2013-05-06T11:56:43-05:00 2012-06-30 351178661 BLUE & CO LLC ONE AMERICAN SQUARE 2200 INDIANAPOLIS IN 46282 990 2011-07-01 350985964 LITTLE COMPANY OF MARY HOSPITAL OF INDIANA INC LITT 8129962345 800 WEST NINTH STREET JASPER IN 47546 RANDALL RUSSELL 8129960507 2013-05-06 1 KEISHA CORSO CPA P00852354 3176334705 2011 2016-03-07 17:11:31Z MEMORIAL HOSPITAL & HEALTH CARE CTR RANDALL RUSSELL 800 WEST NINTH STREET JASPER IN 47546 165742056 0 X WWW.MHHCC.ORG X 1950 IN PROVIDE HEALTH SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. 12 9 1534 285 106637 63517 651769 464789 147163536 159856793 1296860 1188690 2508040 2973110 151620205 164483382 136707 112164 0 0 75183427 80602109 0 0 0 68732289 77310876 144052423 158025149 7567782 6458233 200080236 204189958 75929324 75902067 124150912 128287891 X WE, THE BOARD, PHYSICIANS, STAFF, VOLUNTEERS AND AUXILIARY OF MEMORIAL HOSPITAL AND HEALTH CARE CENTER WILL PROVIDE EXCELLENT HEALTH CARE SERVICES TO THE PEOPLE OF THE COMMUNITIES WE SERVE. WE WILL PLEDGE OURSELVES TO CARE FOR EACH INDIVIDUAL IN A MANNER THAT REFLECTS THE PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL HEALING MINISTRY OF JESUS CHRIST. WE WILL WORK TOGETHER TO CREATE AN ATMOSPHERE OF MUTUAL RESPECT, DIGNITY, COMPASSION AND JOY. WE WILL EFFECTIVELY AND EFFICIENTLY UTILIZE OUR RESOURCES IN PROVIDING HEALTH CARE. WE WILL BE GUIDED BY THE NEEDS OF THOSE WE SERVE AND AS NEEDS CHANGE, WE WILL CHANGE. WE WILL "BE FOR OTHERS!" 0 0 140212563 112164 160730152 GENERAL PRIMARY ACUTE CARE HOSPITAL EXPENSES INCURRED IN PROVIDING EXCELLENT HEALTH CARE SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. SEE FORM 990, SCHEDULE H FOR ADDITIONAL SERVICES PROVIDED TO THE COMMUNITY. 140212563 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 1 0 0 0 1 182 0 1 1534 1 1 1 0 0 0 0 0 0 0 0 0 X 12 9 1 0 0 0 1 0 1 1 1 0 0 0 1 1 1 1 1 1 1 0 IN X RANDALL RUSSELL 8129960506 800 WEST NINTH STREET JASPER IN 47546 SR ADRIAN DAVIS 30.00 X 0 0 897 ROBERT DISINGER 30.00 X 0 0 0 KENNETH SENDELWECK 1.00 X 0 0 0 SR RENEE CUNNINGHAM 1.00 X 0 0 12368 STANLEY TRETTER MD 40.00 X 187857 0 19115 SCOTT BECKMAN MD 1.00 X 0 0 0 DOUGLAS BIES MD 40.00 X 487583 0 14561 ROBERT EHRHARD MD 1.00 X 18000 0 0 BRENDA STALLINGS 1.00 X 0 0 0 JOSEPH STEURER 1.00 X 0 0 0 MICHAEL UEBELHOR 1.00 X 0 0 0 SR SHARON ANN WALSH 1.00 X 0 0 0 WILLIAM RUBINO 1.00 X 0 0 0 SR KATHLEEN MCINTYRE 1.00 X 0 0 0 RAYMOND SNOWDEN 40.00 X X 445418 0 38570 LISA ARVESEN 40.00 X X 168909 0 17691 E KYLE BENNETT 40.00 X X 275682 0 20092 JOHN DILLON 40.00 X X 166906 0 14041 TONYA HEIM 40.00 X X 180958 0 10319 DR ROBERT MANDAL 40.00 X 856018 0 0 DR MICHAEL RUFF 40.00 X 486330 0 13531 DR PATRICK LILLY 40.00 X 472641 0 38839 DR NEIL MARTIN 40.00 X 463922 0 17709 DR SOHAIL QADIR 40.00 X 456740 0 12129 4666964 0 229862 75 0 1 0 AMERICAN RED CROSS - RIVER 29 SOUTH STOCKWELL ROAD EVANSVILLE IN 47714 HEALTH SERVICES 1004515 HARRELL-FISH INC 2010 VERNAL PIKE BLOOMINGTON IN 47402 MECHANICAL CONTRACTORS 841160 VANTAGE ONCOLOGY TREATMENT PO BOX 15040 IN 47716 EVANSVILLE IN 47716 ONCOLOGY SERVICES 837121 STREICHER CONSTRUCTION INC 2296 MILL STREET JASPER IN 47547 CONSTRUCTION SERVICES 825282 WEATHERBY LOCUMS INC 6451 NORTH FEDERAL HWY STE 800 FT LAUDERDALE FL 33308 LOCUM TENUM SERVICES 654500 45 49806 414983 464789 NET PATIENT SERVICE RE 900099 159856793 159856793 159856793 1354986 1354986 778469 594809 183660 183660 183660 430018 67551 621732 42133 -191714 25418 -166296 -166296 LABORATORY SERVICES 621500 105228 105228 LINEN SERVICES REVENUE 812300 715 715 CLINICAL ENGINEERING R 811000 694 694 2682813 873359 1809454 2789450 164483382 160730152 106637 3181804 112164 112164 2060967 1828490 232477 62929752 55831276 7098476 2292217 2033655 258562 9101056 8074457 1026599 4218117 3742313 475804 101561 90105 11456 46826 41544 5282 10962409 9725849 1236560 294517 261295 33222 26728353 23713395 3014958 8052874 7144510 908364 706744 627023 79721 2363545 2096937 266608 9633731 8547046 1086685 1071782 950885 120897 BAD DEBTS 8182647 7259644 923003 HOSPITAL ASSESSMENT FEE 5622569 4988343 634226 DUES & SUB. 381075 338090 42985 3162243 2805542 356701 158025149 140212563 17812586 0 38473639 38243872 18102387 20838628 1242511 3830227 2319909 2534372 1331653 1640610 177172131 92387543 82121322 84784588 54402742 50276393 1606069 1516264 480004 525004 200080236 204189958 12331440 12859496 52304666 50793353 11293218 12249218 75929324 75902067 X 124150912 128287891 124150912 128287891 200080236 204189958 X 6458233 -2321254 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 694781 694781 73230720 28503275 44727445 98619950 63884268 34735682 4626680 4626680 84784588 THIRD PARTY PAYABLE 4453007 PENSION LIABILITY 7796211 12249218 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY IF THE CORPORATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE CORPORATION, AND HAS CONCLUDED THAT AS OF JUNE 30, 2012 AND 2011, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, XII, AND XIII ARE NOT REQUIRED AS THE ORGANIZATION IS PART OF A CONSOLIDATED FINANCIAL STATEMENT. THE CONSOLIDATED FINANCIAL STATEMENTS ARE AUDITED BY AN INDEPENDENT ACCOUNTING FIRM AND PREPARED IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES. 1 1 1 X 1 X 1 1 0 1 1 2919695 2919695 0.01950 12864660 11306114 1558546 0.01040 15784355 11306114 4478241 0.02990 1285580 1285580 0.00860 1285580 1285580 0.00860 17069935 11306114 5763821 0.03850 0 0 107278 107278 0.00070 0 0 52510 52510 0.00040 0 387806 387806 0.00260 46368 46368 0.00030 593962 593962 0.00400 1 8182647 36497372 35936483 560889 X 1 1 1 1 MEMORIAL HOSPITAL & HEALTH CARE CENTER

800 W 9TH ST JASPER IN 47546

X X X MEMORIAL HOSPITAL & HEALTH CARE CENTER 1 1 X X X X X X X X X 11 1 0 1 X X X X X X X X X 0 1 1 200.000000000000 1 400.000000000000 1 X X X X X X X X 1 1 X X X X 1 0 1 X 0 1 24 MEMORIAL HOSPITAL SLEEP CENTER

721 W 13TH ST STE 202 JASPER IN 47546

DIAGNOSIS AND TREATMENT CENTER DALE FAMILY MEDICINE

4 W VINE ST DALE IN 47523

PHYSICIAN OFFICE FERDINAND FAMILY MEDICINE

115 S MAIN ST FERDINAND IN 47532

PHYSICIAN OFFICE LOOGOOTEE FAMILY MEDICINE

105 COOPER ST LOOGOOTEE IN 47553

PHYSICIAN OFFICE MARTIN COUNTY HEALTH CENTER

229 HIGH ST SHOALS IN 47581

PHYSICIAN OFFICE MEMORIAL FAMILY CARE

709 W 9TH ST JASPER IN 47546

PHYSICIAN OFFICE JASPER NEUROLOGY

721 W 13TH ST STE 221 JASPER IN 47546

PHYSICIAN OFFICE PETERSBURG FAMILY MEDICINE

1003 E ILLINOIS ST PETERSBURG IN 47567

PHYSICIAN OFFICE ENT

251 S TRUMAN RD JASPER IN 47546

PHYSICIAN OFFICE WOUND CARE CENTER

507 E 19TH ST HUNTINGBURG IN 47542

TREATMENT CENTER SANTA CLAUS FAMILY MEDICINE

92 W CHRISTMAS BLVD SANTA CLAUS IN 47579

PHYSICIAN OFFICE MEDICAL PRACTICE MGMT AND SUPPORT SRVS

800 W 9TH ST JASPER IN 47546

MANAGEMENT AND SUPPORT SERVICES WOMELDORF

721 W 13TH ST STE 205 JASPER IN 47546

PHYSICIAN OFFICE LANGE FUHS CANCER CENTER - MEDICAL ONCOL

800 W 9TH ST JASPER IN 47546

TREATMENT CENTER HUNTINGBURG URGENT CARE

507 E 19TH ST HUNTINGBURG IN 47542

URGENT CARE CENTER JASPER PEDIATRICS

721 W 13TH ST STE 321 JASPER IN 47546

PHYSICIAN OFFICE HOLLAND FAMILY MEDICINE

303 MERIDIAN ST HOLLAND IN 47541

PHYSICIAN OFFICE HUNTINGBURG CLINIC

407 E 22ND ST HUNTINGBURG IN 47542

CLINIC DR MUNNING

721 W 13TH ST STE 102 JASPER IN 47546

PHYSICIAN OFFICE FRENCH LICK FAMILY MEDICINE

522 SOUTH MAPLE ST FRENCH LICK IN 47432

PHYSICIAN OFFICE DR RICHARD D'MELLO

721 W 13TH ST STE 225 JASPER IN 47546

PHYSICIAN OFFICE DR SOHAIL QADIR

721 W 13TH ST STE 225 JASPER IN 47546

PHYSICIAN OFFICE CULLEN MEDICAL PROFESSIONALS

2005 STATE ST STE A WASHINGTON IN 47501

PHYSICIAN OFFICE DR CHARLES TOLLETT JR

407 E 22ND ST HUNTINGBURG IN 47542

PHYSICIAN OFFICE PART I, LINE 3C: A PATIENT MAY QUALIFY FOR PARTIAL FINANCIAL ASSISTANCE IF THE PATIENT'S HOUSEHOLD INCOME IS BETWEEN 200% AND 400% OF THE FEDERAL POVERTY GUIDELINES. PART I, LINE 7G: THE ORGANIZATION DOES NOT PROVIDE ANY SUBSIDIZED HEALTH SERVICES ATTRIBUTABLE TO PHYSICIAN CLINICS. PART I, L7 COL(F): TOTAL BAD DEBT EXPENSE OF $8,182,647 INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A) HAS BEEN EXCLUDED FROM THE DENOMINATOR FOR THE PERCENTAGE CALCULATION PER IRS INSTRUCTIONS. PART II: PROGRAMS WERE OFFERED AT LOW OR DISCOUNTED PRICES. SOME SERVICES SUCH AS SCREENING RESULT SESSIONS OR SUPPORT GROUPS WERE OFFERED FREE TO PARTICIPANTS. THE FOLLOWING IS A LIST OF SERVICES PROVIDED THROUGH THE COMMUNITY RELATIONS DEPARTMENT.HEALTH SCREENINGS INCLUDING WEIGHT, BMI, WAIST CIRCUMFERENCE, BLOOD PRESSURE, LIPID PROFILE, CHEMISTRY PANEL, TOBACCO STATUS, GLUCOSE, PSA AND COLON KITS: 7527 PARTICIPATED AT 62 DIFFERENT LOCATIONS. 1244 PSA'S WERE PERFORMED WHICH INCLUDED THE ANNUAL PSA SCREENING FOR MEN 50 AND OLDER, 533 COLON KITS DISTRIBUTED. 68 BODY FAT ANALYSES AND 71 CARBON MONOXIDE SCREENINGS WERE PERFORMED. HEALTH RISK APPRAISALS WERE PROVIDED FOR PARTICIPANTS IN HEALTH SCREENINGS WITH 2387 COMPLETED.2982 PARTICIPANTS ATTENDED SCREENING RESULT SESSIONS TO LEARN ABOUT THE IMPORTANCE OF THEIR SCREENING RESULTS AT THE VARIOUS WORK-SITES. THE LOW-COST SCREENING FEE INCLUDES THESE GROUP RESULTS SESSIONS. SMOKING CESSATION PROGRAMS AND PRESENTATIONS WERE PROVIDED FOR THE COMMUNITY AND COMPANY WORK-SITES AT NO COST WITH ONE WEEK OF NICOTINE PATCHES AWARDED FOR COMPLETION THANKS TO A GRANT FROM THE DUBOIS COUNTY SUBSTANCE ABUSE COUNCIL AND MEMORIAL HOSPITAL SPONSORSHIP FOR 27 PARTICIPANTS. AMERICAN CANCER SOCIETY AND THE INDIANA TOBACCO PREVENTION AND CESSATION COUNCIL ALSO PROVIDED EDUCATION MATERIALS AT NO CHARGE. MEMORIAL HOSPITAL PROVIDED STAFF TO PROMOTE AND TEACH THE CLASSES.12 PARTICIPANTS WERE TAUGHT STRESS MANAGEMENT SKILLS THROUGH THE SPEAKERS BUREAU SERVICES.1145 HOSPITAL EMPLOYEES AND LOCAL COMPANY PARTICIPANTS PARTICIPATED IN WELLNESS CHECK-INS TO MONITOR BLOOD PRESSURE AND WEIGHT ON A REGULAR BASIS AT THE WORK-SITE.261 MEMORIAL HOSPITAL EMPLOYEES PARTICIPATED IN WELLNESS CALENDARS AND LOGS AT NO CHARGE.WE PROVIDED WELLNESS COACHING FOR 40 INDUSTRY PARTICIPANTS. THE COMPANIES PAID A FEE FOR THIS SERVICE. HOSPITAL EMPLOYEES PARTICIPATED FOR FREE. CANCER EDUCATION INFORMATION AND HEALTH EDUCATION INFORMATION WAS DISTRIBUTED AT NO COST TO PARTICIPANTS AT SCREENINGS AND THROUGH EMPLOYEE WELLNESS PROGRAMS.NUTRITION AND HEALTH DISPLAYS WERE PROVIDED FOR 409 PARTICIPANTS.197 PARTICIPANTS ATTENDED COMMUNITY HEALTH EDUCATION DISPLAYS AT NO COST INCLUDING EXHIBITS AT THE ODON HEALTH FAIR AND THE SENIOR FAIR HELD IN PIKE COUNTY.749 PARTICIPATED IN WELLNESS PROGRAMS AT NO CHARGE AS A PART OF THE SPEAKERS BUREAU SERVICE OR THE HOSPITAL.MATERNITY CENTER PROGRAMS WERE OFFERED INCLUDING THE CHILDBIRTH AND CHILDBIRTH REFRESHER CLASSES, BREAST-FEEDING, GETTING READY FOR BABY BROTHER OR SISTER, PAPA PAGERS PARTICIPANTS AT NO CHARGE. 469 PARTICIPANTS ATTENDED THE VARIOUS CHILDBIRTH, BREAST-FEEDING, AND GETTING READY FOR BABY BROTHER AND SISTER CLASSES. THESE PROGRAMS ARE FREE TO THOSE DELIVERING THEIR BABIES AT MEMORIAL HOSPITAL. THE FERTILITY CARE (NATURAL FAMILY PLANNING) PROGRAM WAS OFFERED TO COUPLES, WITH 47 SESSIONS PROVIDED FOR A SMALL FEE. PROGRAMS ARE AVAILABLE AT REDUCED RATE FOR THOSE UNABLE TO PAY FOR THE SERVICES.MEDIC FIRST AID, CPR PROGRAMS, HEARTSAVER FIRST AID, AED, AND BLOOD BORNE PATHOGENS CLASSES, WERE PROVIDED FOR 728 INDUSTRY WORKERS, SCOUT TROOPS, SCHOOLS AND THE GENERAL PUBLIC FOR A FEE.THE LANGE-FUHS CANCER CENTER CONDUCTED THE MAN TO MAN PROGRAM, THE LOOK GOOD, FEEL BETTER PROGRAM, MEN'S GROUP AND WOMEN'S GROUP, AND THE CELEBRATE LIFE PROGRAM TO AREA CANCER PATIENTS AT NO COST.THE BARIATRIC FORUM AND SUPPORT GROUP WERE OFFERED MONTHLY AT NO COST.VARIOUS MEMORIAL HOSPITAL DEPARTMENTS PROVIDED MONTHLY SUPPORT GROUPS FOR FAMILIES WITH ALZHEIMER'S DISEASE AND DEMENTIA, HEART DISEASE, AND PARKINSON'S DISEASE. THE DIABETES EDUCATION STAFF PROVIDED FREE MONTHLY SUPPORT GROUPS FOR THOSE WITH DIABETES. THE PASTORAL CARE DEPARTMENT PROVIDED TWO 5-WEEK PROGRAMS FOR THOSE SUFFERING WITH GRIEF.SUPERSITTER (BABYSITTING) CLASSES WERE OFFERED FOR A FEE TO 15 YOUTH TO LEARN ABOUT SAFE BABYSITTING PRACTICES. SCHOOL HEALTH FAIRS REACHED 156 YOUTH TEACHING THEM WAYS TO IMPROVE THEIR HEALTH.619 PARTICIPANTS ATTENDED WELLNESS CLASSES AND LUNCH AND LEARN PROGRAMS SPONSORED BY THEIR EMPLOYER, INCLUDING MEMORIAL HOSPITAL EMPLOYEES AND OTHER COMMUNITY PROGRAMS OFFERED BY THE HOSPITAL. PROGRAMS WERE FREE TO HOSPITAL EMPLOYEES.92 ENROLLED IN THE CHOOSE 8 TO LOSE WEIGHT PROGRAM. THE WELBORN BAPTIST FOUNDATION PROVIDED SOME FUNDING AND MEMORIAL HOSPITAL SPONSORED THE REMAINING COSTS FOR AN 8-MONTH WEIGHT MANAGEMENT AND FITNESS PROGRAM FOR FOUR GROUPS IN JASPER, HUNTINGBURG, AND DALE. 36 PARTICIPATED IN THE FITNESS CLASSES AS A PART OF THE CHOOSE 8 PROGRAM. A COMMUNITY FITNESS-TRACKING PROGRAM WAS OFFERED TO THE PUBLIC WITH 528 PARTICIPANTS ENROLLED. THERE WAS NO CHARGE FOR THIS PROGRAM.57 PARTICIPANTS TOOK PART IN THE GEAR UP TO WEIGHT DOWN PROGRAM OFFERED TO THE PUBLIC A LOCAL COMPANY FOR A FEE. MEMORIAL HOSPITAL EMPLOYEES PARTICIPATED FREE. 239 PARTICIPATED IN WEIGHT CHALLENGES AT LOCAL COMPANIES AND AT MEMORIAL HOSPITAL. EMPLOYEES OF MEMORIAL HOSPITAL PARTICIPATED FREE. MANY PARTICIPATED IN THE MONTHLY FITNESS CLASSES HELD AT THE HOSPITAL WITH 1506 INDIVIDUAL VISITS TO CLASSES. CLASSES INCLUDED WEEKLY STEP IT AWAY, THREE WEEKLY CLASSES OF ZUMBA, WEEKLY CLASS OF ABSOLUTE ABS, FIT IT IN CLASSES, CORPORATE FIT IT IN PROGRAMS, AND THE GET FIT 55+. 200 PARTICIPATED IN THE FREE FITNESS DEMONSTRATION HELD AT THE COMMUNITY ANNUAL SENIOR EDUCATIONAL EVENT. A HEALTH AND LIFELINE BOOTH WAS ALSO PROVIDED AT THE EVENT. 185 OTHERS ATTENDED FREE FITNESS DEMONSTRATIONS PROVIDED BY THE COMMUNITY EDUCATION STAFF. THE LIFELINE HOME EMERGENCY RESPONSE SYSTEM MAINTAINED BY THE COMMUNITY RELATIONS DEPARTMENT BEGAN THE FISCAL YEAR WITH 220 SUBSCRIBERS. A MONTHLY FEE IS CHARGED FOR USING THE LIFELINE UNITS. SERVICE CALLS, TEST CALLS, SUBSCRIBER/RESPONDER UPDATES, INSTALLATIONS, AND REPAIR CALLS ARE PROVIDED AS A PART OF THE FEE. THE SERVICE PROVIDES AN OPPORTUNITY FOR INDIVIDUALS TO STAY IN THEIR HOMES IN A SAFE ENVIRONMENT TO HELP MAINTAIN THEIR INDEPENDENCE. SUBSCRIBERS REFERRED THROUGH GENERATIONS RECEIVE DISCOUNTED SERVICES.FREE MONTHLY WELLNESS TIPS HAVE BEEN PROVIDED FOR THE AREA CHAMBER OF COMMERCE AND 14 LOCAL BUSINESSES TO SHARE WITH THEIR MEMBERS/EMPLOYEES.COMMUNITY EDUCATION STAFF PARTICIPATED IN LOCAL COMMUNITY COMMITTEES INCLUDING THE DUBOIS COUNTY SUBSTANCE ABUSE COUNCIL, THE HOSPITAL ERGONOMIC COMMITTEE, THE DUBOIS COUNTY PARTNERSHIP SENIOR FOCUS COMMITTEE, LANGE-FUHS CANCER CENTER FUN DAY COMMITTEE, THE NEW TOBACCO LAW EDUCATION PROGRAM PLANNING COMMITTEE, AND THE HOSPITAL CANCER COMMITTEE WITH OVER 43 HOURS OF STAFF TIME DONATED. FREE WELLNESS INFORMATION WAS PROVIDED QUARTERLY TO AREA INDUSTRIES TO USE IN NEWSLETTERS AND ON BULLETIN BOARDS TO IMPROVE THE HEALTH OF THEIR EMPLOYEES. TWO ARTICLES ON SMOKING CESSATION AND TOBACCO WERE PROVIDED FOR AREA AGENCIES AND LOCAL COMPANIES AT NO COST TO CREATE AWARENESS AND REDUCE THE USE OF TOBACCO. PART III, LINE 4: SECTION A. BAD DEBT EXPENSE. LINE 2 FOOTNOTE TO ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE: NOT APPLICABLE. PART III, LINE 4: SECTION A. BAD DEBT EXPENSE. LINE 3 EXPLANATION FOR RATIONAL FOR INCLUDING OTHER BAD DEBT AMOUNT IN COMMUNITY BENEFIT: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY AND EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED JUNE 30, 2011: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: THE ORGANIZATION'S WRITTEN DEBT COLLECTION POLICY INCLUDES PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED DURING THE FOLLOW-UP PERIOD AFTER A PATIENT IS DISCHARGED AND INCLUDES SPECIFIC INSTRUCTIONS FOR SELF-PAY WHO MAY QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 3: THE ASSESSMENT INVOLVED REPRESENTATIVES FROM 45 ORGANIZATIONS AND COMMUNITIES HELPING TO IDENTIFY THE HEALTH NEEDS OF DUBOIS COUNTY. THE COMMITTEE CONDUCTED A SERIES OF FOCUS GROUP MEETINGS AND SURVEYS TO PROVIDE AN OPPORTUNITY AND FORUM FOR COMMUNITY REPRESENTATIVES TO PARTICIPATE IN IDENTIFYING HEALTH NEEDS. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 7: AT THIS TIME, WE HAVE NOT EXPANDED OPTIONS FOR UN- AND UNDERINSURED PATIENTS. WE CONTINUE TO PROVIDE SERVICES AT MEMORIAL FAMILY CARE BASED ON A SLIDING FEE SCHEDULE. ALSO, THE HOSPITAL CONTINUES TO PROVIDE FINANCIAL ASSISTANCE TO ALL PATIENTS BASED ON FAMILY INCOME. WE ARE NOT ACTIVELY RECRUITING A DERMATOLOGIST. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY DETERMINED, DURING THE YEAR, THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE BY USING THE AVERAGE OF THE HOSPITAL'S TOP THREE (BY VOLUME) NEGOTIATED INSURANCE RATES. MEMORIAL HOSPITAL & HEALTH CARE CENTER PART V, SECTION B, LINE 21: NON-MEDICALLY NECESSARY SERVICES INCLUDING COSMETIC PROCEDURES ARE NOT ELIGIBLE FOR DISCOUNTED CHARGES OR FINANCIAL ASSISTANCE. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH THE USE OF HOSPITAL COMMITTEES DEVELOPING STRATEGIC PLANS FOR THE HOSPITAL TO PROVIDE QUALITY CARE TO THE COMMUNITY MEMBERS. PART VI, LINE 3: IF DURING PATIENT FINANCIAL SERVICES' FINANCIAL COUNSELING OR COLLECTION PROCESS, IT APPEARS THAT AN INDIVIDUAL MAY NOT HAVE THE FINANCIAL RESOURCES TO PAY FOR SERVICES NOT COVERED BY A THIRD PARTY PAYOR, THEN A FINANCIAL DISCLOSURE FORM SHOULD BE COMPLETED BY THE PATIENT. IN ADDITION, OTHER MEMBERS OF THE HOSPITAL STAFF MAY IDENTIFY INDIVIDUALS WHO MAY QUALIFY FOR CHARITY CARE. THE INFORMATION IS FORWARDED TO THE PATIENT FINANCIAL SERVICES DEPARTMENT. APPROPRIATE SIGNAGE IS VISIBLE IN THE HOSPITAL AND ALL HOSPITAL-OWNED FACILITIES, SPECIFICALLY IN PATIENT ACCESS AREAS, CREATING AWARENESS FOR THE FINANCIAL ASSISTANCE PROGRAM AND THE FINANCIAL ASSISTANCE THAT IS AVAILABLE. IN ADDITION THE HOSPITAL HAS ANNOUNCED A NEW PAYMENT PLAN WHICH ALLOWS PATIENTS TO PAY FOR THEIR HOSPITAL SERVICES AT 0% INTEREST OVER A 25-MONTH PERIOD. REGARDLESS OF INSURANCE COVERAGE, CREDIT HISTORY OR EMPLOYMENT, THE HOSPITAL WILL REFER PATIENTS AUTOMATICALLY TO THE CAREPAYMENT OPTION IF THEY HAVE A BALANCE ON THEIR HOSPITAL ACCOUNT TWO MONTHS AFTER RECEIVING THEIR FIRST STATEMENT. THROUGH A PRE-APPROVED APPLICATION PROCESS, THE PATIENT WILL RECEIVE A 0% INTEREST HOSPITAL-SPONSORED LOYALTY CARD WITH A MINIMUM OF 4% OF THE BALANCE OR $25. PART VI, LINE 4: AS A REGIONAL HEALTH CENTER, THE STAFF PROVIDES A COMPREHENSIVE RANGE OF MEDICAL CARE FOR RESIDENTS OF DUBOIS AND SURROUNDING COUNTIES INCLUDING MORE THAN 7,700 INPATIENTS AND 230,000 OUTPATIENTS. PART VI, LINE 5: THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSE BY PROMOTING HEALTH OF THE COMMUNITY THROUGH THE FOLLOWING: THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. ANY SURPLUS FUNDS ARE APPLIED DIRECTLY OR INDIRECTLY TO IMPROVE PATIENT CARE SERVICES. ALSO, THE ORGANIZATION OPERATES UNDER THE PREMISE OF AN OPEN MEDICAL STAFF WITH REGARD TO QUALIFIED PHYSICIANS IN THE 9 COUNTY COMMUNITY IT SERVES, HOWEVER IT DOES NOT ACTIVELY PURSUE THOSE PHYSICIANS WHO HAVE NOT APPROACHED THE ORGANIZATION REGARDING THESE PRIVILEGES. PART VI, LINE 6: NOT APPLICABLE. THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 IN 1 STUDENT LOAN BUY BACK PROGRAM TO OFFSET EDUCATIONAL EXPENSES FOR CRITICALLY NEEDED HEALTH CARE FIELDS. 32 51175 TUITION REIMBURSEMENT PROGRAM FOR THE COST OF TUITION AND BOOKS. 24 50138 SCHOLARSHIP PROGRAM TO ASSIST STAFF MEMBERS PURSUING AN UNDERGRADUATE DEGREE TO WORK IN DEFINED CRITICAL SHORTAGE AREAS. 11 10851 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: FOR THE STUDENT LOAN BUY-BACK PROGRAM APPLICATIONS ARE SUBMITTED TO THE HUMAN RESOURCE DEPARTMENT; AND REVIEWED FOR DENIAL OR APPROVAL. FOR THE TUITION REIMBURSMENT PROGRAM APPLICATIONS MUST BE APPROVED BY THE DIRECTORS IN CHARGE OF THE EMPLOYEE BEFORE SUBMITTING TO HUMAN RESOURCE DEPARTMENT FOR APPROVAL. IN ADDITION GRADES MUST BE SUBMITTED TO THE HUMAN RESOURCE DEPARTMENT FOR GRADE VERIFICATION. FOR THE SCHOLARSHIP PROGRAM THE SCHOLARSHIP COMMITTEE EXERCISES AUTHORITY IN THE SELECTION PROCESS AND RECIPIENTS MUST RE-APPLY EACH SEMESTER. PART III, ELIGIBILITY AND PROCEDURES FOR STUDENT LOAN BUY-BACK, TUITION REIMBURSEMENT, AND SCHOLARSHIP PROGRAMS: STUDENT LOAN BUY-BACK PROGRAM - POLICY STATEMENT: MEMORIAL HOSPITAL AND HEALTH CARE CENTER STRIVES TO BE PROACTIVE IN RECRUITING, ASSISTING, AND ENCOURAGING QUALIFIED INDIVIDUALS TO ENTER INTO CRITICALLY NEEDED HEALTH CARE FIELDS. THIS PROGRAM WAS DESIGNED TO OFFSET EDUCATIONAL EXPENSES BY REIMBURSING APPROVED MONTHLY STUDENT LOAN OBLIGATIONS IN TRADE FOR TIME WORKED AT MEMORIAL HOSPITAL AND HEALTH CARE CENTER. STUDENT LOAN BUY-BACK PROGRAM - PROCEDURE: 1. THE STUDENT LOAN BUY-BACK BENEFIT IS AVAILABLE TO EMPLOYEES RECRUITED BY MEMORIAL HOSPITAL AND HEALTH CARE CENTER FOR CRITICAL SHORTAGE AREAS WHO HAVE EXISTING LOANS. THIS BENEFIT MAY NOT BE USED IN CONJUNCTION WITH THE TUITION REIMBURSEMENT PROGRAM. 2. THE STUDENT LOAN MONIES MUST BE BORROWED BY THE EMPLOYEE FOR OBTAINING A FORMALIZED DEGREE IN A CRITICAL SHORTAGE AREA AS DEFINED BY THE HOSPITAL. EACH POTENTIAL EMPLOYEE MUST HAVE MADE HIS OR HER OWN ARRANGEMENTS FOR THE STUDENT LOAN FINANCING THROUGH AN APPROPRIATE LENDING INSTITUTION. THE HOSPITAL WILL IN NO WAY BE SIGNATORY OR BE HELD RESPONSIBLE FOR THE FINANCIAL CONTRACT OBTAINED THROUGH A LENDING INSTITUTION. 3. THE APPLICATION TITLED "STUDENT BUY-BACK APPLICATION" FOR QUALIFIED INDIVIDUALS MUST BE COMPLETED AND SUBMITTED TO THE HUMAN RESOURCE DEPARTMENT. IT SHALL BE THE RESPONSIBILITY OF HUMAN RESOURCES TO NOTIFY THE EMPLOYEE OF DENIAL OR APPROVAL. 4. THE ACTIVE LOAN BALANCE AT THE TIME OF APPLICATION WILL BE USED TO CALCULATE STUDENT LOAN BUY-BACK. 5. ELIGIBILITY FOR BUY-BACK PAYMENTS COMMENCES AT THE BEGINNING OF THE MONTH FOLLOWING COMPLETION OF THE 60 DAY INTRODUCTORY PERIOD. EMPLOYEES WITH A PRN STATUS ARE NOT ELIGIBLE TO PARTICIPATE IN THE STUDENT LOAN BUY-BACK PROGRAM. BUY-BACK PAYMENTS CEASE IMMEDIATELY WITH TERMINATION. 6. SHOULD AN EMPLOYEE REDUCE TO LESS THAN FULL TIME STATUS (1.0 FTE) THEN THE EMPLOYEE'S MAXIMUM REIMBURSEMENT WILL BE REDUCED PROPORTIONATELY(I.E. A .8 FTE WILL QUALIFY FOR 80% OF THE ALLOWABLE MONTHLY AND TOTAL REIMBURSEMENT AMOUNT). THE EMPLOYEE WILL BE REQUIRED TO COMPLETE A NEW APPLICATION AT THE TIME OF STATUS CHANGE. 7. IF AN INDIVIDUAL IS GIVEN ANY DISCIPLINARY ACTION, THE LOAN BUY-BACK PAYMENT WILL NOT BE MADE FOR THE MONTH IN WHICH THE DISCIPLINARY ACTION OCCURRED AND CONTINUATION OF THE BENEFIT WILL BE REVIEWED. 8. THE MAXIMUM AMOUNT FOR LOAN BUY-BACK WILL BE $250.00 PER MONTH FOR A TOTAL OF 24 MONTHS. 9. THE CRITICAL SHORTAGE AREAS WILL BE IDENTIFIED BY THE ADMINISTRATIVE STAFF OF MEMORIAL HOSPITAL AND THE HUMAN RESOURCE DEPARTMENT WILL HAVE THE LIST AVAILABLE UPON REQUEST. 10. SHOULD A POSITION BE REMOVED FROM THE CRITICAL SHORTAGE LIST, ANY APPROVED APPLICATION FOR THE STUDENT LOAN BUY-BACK SHALL CONTINUE TO BE VALID AND APPROVED EACH YEAR SO LONG AS ALL OTHER CRITERIA ARE MET. 11. STUDENT LOAN BUY-BACK PAYMENTS WILL BE MADE DIRECTLY TO THE EMPLOYEE. THE EMPLOYEE WILL CONTINUE TO BE RESPONSIBLE FOR THEIR OWN PAYMENTS TO THE LENDING INSTITUTION(S). 12. THE EMPLOYEE IS RESPONSIBLE FOR OBTAINING A LETTER STATING THE PURPOSE OF THE LOAN, AMOUNT OF THE LOAN, THE DATE OF ISSUANCE AND THE SIGNATURE OF THE LOAN OFFICER. TUITION REIMBURSEMENT PROGRAM: TUITION REIMBURSEMENT PROGRAM - POLICY STATEMENT: MEMORIAL HOSPITAL AND HEALTH CARE CENTER STRIVES TO PROVIDE A WORKING ENVIRONMENT DESIGNED TO ATTRACT, REWARD AND RETAIN QUALIFIED PERSONNEL. TUITION REIMBURSEMENT IS DEFINED AS THE COST OF TUITION AND BOOKS ONLY FOR CLASSES TAKEN IN PURSUANCE OF AN UNDERGRADUATE DEGREE AT AN ACCREDITED INSTITUTION OF HIGHER EDUCATION. TUITION REIMBURSEMENT PROGRAM - PROCEDURE: 1. ELIGIBILITY: EMPLOYEES MUST BE EMPLOYED AS A REGULAR EMPLOYEE AUTHORIZED TO WORK WEEKEND OPTION OR AT LEAST 64 HOURS PER PAY PERIOD FOR SIX CONSECUTIVE MONTHS. THE SIX MONTH REQUIREMENT IS WAIVED FOR EMPLOYEES TAKING ACADEMIC COURSES TOWARD A DEGREE FOR A CRITICAL SHORTAGE AREA. IF ACADEMIC COURSES ARE RECOMMENDED BY THE DIRECTOR OR VICE PRESIDENT AT THE TIME OF HIRE, THE EMPLOYEE MAY ENROLL IN THE CLASS BEFORE SIX MONTHS OF EMPLOYMENT IS COMPLETED; HOWEVER, TUITION REIMBURSEMENT MAY NOT BE RECEIVED BEFORE SIX MONTHS OF EMPLOYMENT HAS BEEN COMPLETED. THE PROGRAM OF STUDY MUST: (A) BENEFIT THE HOSPITAL, AND EITHER (B) BE RELATED TO THE EMPLOYEE'S PRESENT JOB, OR (C) ENHANCE THE EMPLOYEE'S POTENTIAL FOR ADVANCEMENT TO A POSITION TO WHICH THE EMPLOYEE CAN REASONABLY BE EXPECTED TO BE PROMOTED WITHIN MEMORIAL HOSPITAL AND HEALTH CARE CENTER. TUITION REIMBURSEMENT WILL BE CONSIDERED FOR GRADUATE COURSES IF THE APPLICABLE VICE PRESIDENT OF MEMORIAL HOSPITAL AND HEALTH CARE CENTER REQUESTS THE EMPLOYEE TO CONTINUE HIS/HER EDUCATION TO MEET JOB REQUIREMENTS OF THE CURRENT JOB, TO MEET QUALIFICATIONS OF A PLANNED PROMOTION OR SERVES A BUSINESS PURPOSE OF THE HOSPITAL. INDIVIDUAL SEMINARS AND WORKSHOPS ARE NOT COVERED UNDER THIS POLICY. CERTIFICATE PROGRAMS ARE ONLY COVERED IF COLLEGE CREDIT AND LETTER GRADES ARE PROVIDED FOR CLASSES TAKEN BY THE EMPLOYEE. THE COURSE(S) MUST BE ATTENDED DURING NON-WORKING HOURS OR DIRECTOR/VICE PRESIDENT APPROVAL IS REQUIRED FOR SCHEDULE CHANGES IF NEEDED TO ATTEND CLASSES. THIS ACCOMMODATION MAY NOT BE POSSIBLE IN SOME AREAS. THE HOSPITAL EXPECTS EACH EMPLOYEE INVOLVED IN THE TUITION REIMBURSEMENT PROGRAM TO CONTINUE TO FUNCTION AT AN ACCEPTABLE LEVEL OF PERFORMANCE. A LETTER GRADE OF C (OR EQUIVALENT) OR BETTER MUST BE OBTAINED FOR UNDERGRADUATE COURSES. A GRADE OF B (OR EQUIVALENT) OR BETTER MUST BE ATTAINED FOR GRADUATE CLASSES. GRADES AND CHECK REQUESTS FOR TUITION REIMBURSEMENT MUST BE RECEIVED BY THE HUMAN RESOURCES DEPARTMENT WITHIN TWO WEEKS AFTER GRADES ARE RECEIVED. 2. BENEFITS - FOR CLASSES TAKEN FOR ALL JOB TITLES THAT ARE NOT LISTED AS CRITICAL SHORTAGE: FULL TIME (72 HOURS OR MORE PER PAY PERIOD) UNDERGRADUATE - 90% WITH A MAXIMUM OF $3,000 GRADUATE - 90% WITH A MAXIMUM OF $5,000 PART TIME (WEEKEND OPTION OR MINIMUM OF 64 HOURS PER PAY PERIOD) UNDERGRADUATE - 70% WITH A MAXIMUM OF $2,000 GRADUATE - 70% WITH A MAXIMUM OF $3,000 3. BENEFITS - FOR CLASSES TAKEN FOR JOB TITLES THAT ARE LISTED AS CRITICAL SHORTAGE: FULL TIME (MINIMUM OF 72 HOURS PER PAY PERIOD) UNDERGRADUATE - 90% WITH A MAXIMUM OF $4,000 PART TIME (WEEKEND OPTION OR MINIMUM OF 64 HOURS PER PAY PERIOD) 70% WITH A MAXIMUM OF $4,000 4. APPLICATION PROCEDURE: EMPLOYEES THAT MEET ELIGIBILITY REQUIREMENTS MUST COMPLETE A TUITION REIMBURSEMENT REQUEST FORM. ALL REQUESTS MUST INCLUDE DIRECTOR RECOMMENDATIONS. THE PRESIDENT AND THE DIRECTOR OF HUMAN RESOURCES HAVE THE AUTHORITY FOR THE FINAL APPROVAL OF EACH INDIVIDUAL REQUEST FOR TUITION REIMBURSEMENT. IN CASES WHERE EMPLOYEES HAVE HAD WRITTEN COUNSELING/DISCIPLINARY ACTION WITHIN THE LAST TWELVE MONTHS, TUITION REIMBURSEMENT MAY NOT BE APPROVED. REQUESTS RECEIVED MAY BE DENIED AND THE EMPLOYEE WILL BE ADVISED TO APPLY FOR THE NEXT CLASS SESSION. AFTER CLASS COMPLETION, VERIFICATION OF A LETTER GRADE (OR EQUIVALENT)FOR EACH CLASS MUST BE SUBMITTED TO THE HUMAN RESOURCES DEPARTMENT WITHIN TWO WEEKS OF RECEIPT OF GRADES. REIMBURSEMENT WILL NOT BE OBTAINED WITHOUT GRADE VERIFICATION. IF AN EMPLOYEE WHO HAS RECEIVED TUITION REIMBURSEMENT TERMINATES EMPLOYMENT AT MEMORIAL HOSPITAL (VOLUNTARY OR INVOLUNTARY) OR IF AN EMPLOYEE REDUCES EMPLOYMENT STATUS TO BELOW .6 FTE ALL TUITION REIMBURSEMENT RECEIVED WITHIN THE LAST 24 MONTHS PRIOR TO DATE OF TERMINATION OR STATUS REDUCTION WILL BE REPAID TO MEMORIAL HOSPITAL AND HEALTH CARE CENTER. REPAYMENT IS DUE WITHIN 30 DAYS OF TERMINATION DATE OR STATUS REDUCTION. A STATEMENT AGREEING TO THIS ARRANGEMENT WILL BE SIGNED BY EACH EMPLOYEE AT THE TIME APPLICATION IS MADE. SCHOLARSHIP PROGRAM: SCHOLARSHIP PROGRAM - POLICY STATEMENT: IN AN EFFORT TO PROMOTE PERSONAL AND PROFESSIONAL GROWTH OF STAFF, MEMORIAL HOSPITAL AND HEALTH CARE CENTER PROVIDES A SCHOLARSHIP PROGRAM TO ASSIST STAFF MEMBERS PURSUING AN UNDERGRADUATE DEGREE AT AN ACCREDITED INSTITUTION OF HIGHER EDUCATION TO WORK IN DEFINED CRITICAL SHORTAGE AREAS. SCHOLARSHIP PROGRAM - PROCEDURE: 1. ELIGIBILITY: SCHOLARSHIP APPLICANTS MUST BE EMPLOYED BY MEMORIAL HOSPITAL AND HEALTH CARE CENTER PRIOR TO APPLYING FOR THE SCHOLARSHIP. WEEKEND OPTION EMPLOYEES ARE NOT ELIGIBLE TO PARTICIPATE IN THE SCHOLARSHIP PROGRAM. EMPLOYEES WITH WRITTEN COUNSELING/DISCIPLINARY ACTION WITHIN THE LAST TWELVE MONTHS WILL NOT BE ELIGIBLE FOR THE SCHOLARSHIP PROGRAM. THE HOSPITAL EXPECTS EACH EMPLOYEE INVOLVED IN THE SCHOLARSHIP PROGRAM TO CONTINUE TO FUNCTION AT AN ACCEPTABLE LEVEL OF PERFORMANCE. THE PROGRAM OF STUDY MUST BENEFIT SPECIFICALLY DEFINED CRITICAL SHORTAGE AREAS WITHIN THE HOSPITAL, AS DETERMINED BY THE SCHOLARSHIP COMMITTEE. THE NUMBER OF SCHOLARSHIPS FOR CRITICAL SHORTAGE AREAS WILL BE DETERMINED ANNUALLY. EMPLOYEES THAT MEET ELIGIBILITY REQUIREMENTS MUST COMPLETE AN APPLICATION FORM AND SUBMIT IT TO THEIR DEPARTMENT DIRECTOR. DIRECTOR RECOMMENDATIONS MUST ACCOMPANY ALL APPLICATIONS SENT TO THE HUMAN RESOURCES DEPARTMENT. THE SCHOLARSHIP COMMITTEE WILL EXERCISE AUTHORITY IN THE SELECTION PROCESS. MEMBERS OF THIS COMMITTEE INCLUDE THE PRESIDENT/CEO, TWO VICE PRESIDENTS, THE DIRECTOR OF HUMAN RESOURCES, AND A DIRECTOR FROM ALL THREE DIVISIONS. SCHOLARSHIP RECIPIENTS ARE REQUIRED TO MAINTAIN A 0.8 FTE WORK STATUS. BENEFITS WILL BE CONSISTENT WITH EMPLOYEE STATUS. CREDIT HOURS WILL BE APPLIED WEEKLY TOWARDS THE STUDENT'S WEEKLY REQUIRED HOURS. EXAMPLE: A STUDENT WITH NINE CREDIT HOURS WEEKLY WOULD BE REQUIRED TO WORK 23 HOURS PER WEEK AT THE HOSPITAL. IN THIS EXAMPLE, THE STUDENT WOULD WORK 24 HOURS AT THE HOSPITAL, AS STAFFING WILL NOT BE ADJUSTED MID-SHIFT TO RELEASE STUDENTS EARLY FROM THEIR RESPONSIBILITIES. COURSE(S) WILL BE ATTENDED DURING NON-WORKING HOURS IN COORDINATION WITH STUDENT'S DEPARTMENT DIRECTOR WHO WILL SCHEDULE THEIR HOSPITAL HOURS AS NEEDED FOR DEPARTMENTAL COVERAGE, WHILE NOT INTERFERING WITH HOURS OF CLASS. STUDENTS MUST SUPPLY A CLASS SCHEDULE TO THEIR DIRECTOR AS SOON AS AVAILABLE TO ENABLE THE SCHEDULING PROCESS. AFTER CLASS COMPLETION, VERIFICATION OF A LETTER GRADE (OR EQUIVALENT) FOR EACH CLASS MUST BE SUBMITTED TO THE HUMAN RESOURCES DEPARTMENT WITHIN TWO WEEKS OF RECEIPT OF GRADES. A GRADE POINT AVERAGE OF 2.5 OR GREATER MUST BE MAINTAINED TO REMAIN IN GOOD STANDING. IF A STUDENT'S GPA DROPS BELOW 2.5, THE INDIVIDUAL WILL NOT BE ELIGIBLE TO REMAIN IN THE SCHOLARSHIP PROGRAM AND MUST APPLY FOR AN OPEN POSITION IN THE HOSPITAL TO CONTINUE THEIR EMPLOYMENT. SCHOLARSHIP RECIPIENTS MUST RE-APPLY FOR EACH SEMESTER TO VERIFY ELIGIBILITY BASED ON GRADES AND WORK PERFORMANCE. IF A SCHOLARSHIP RECIPIENT TERMINATES EMPLOYMENT AT MEMORIAL HOSPITAL (VOLUNTARY OR INVOLUNTARY), REDUCES EMPLOYMENT STATUS TO BELOW .8 FTE, OR DOES NOT MAINTAIN SATISFACTORY PERFORMANCE, ALL SCHOLARSHIP ASSISTANCE RECEIVED WITH THE LAST 24 MONTHS PRIOR TO DATE OF TERMINATION, STATUS REDUCTION, OR DISCIPLINARY ACTION WILL BE REPAID TO MEMORIAL HOSPITAL AND HEALTH CARE CENTER. RE-PAYMENT IS DUE WITHIN 30 DAYS OF THIS DATE. STATEMENT AGREEING TO THIS ARRANGEMENT WILL BE SIGNED BY EACH EMPLOYEE EACH TIME APPLICATION IS MADE. 2. BENEFITS: SCHOLARSHIP RECIPIENTS WILL BE PAID MINIMUM WAGE PER CREDIT HOUR TO BE APPLIED TO THEIR 0.8 FTE COMMITMENT. NO ADDITIONAL HOURS WILL BE PAID TO COMPLETE HOMEWORK, CLINICAL HOURS, OR SPECIAL ASSIGNMENTS. CORRESPONDENCE COURSES WILL BE PAID AT MINIMUM WAGE PER CREDIT HOUR FOR A MAXIMUM OF 16 WEEKS. THE STUDENT WILL BE PAID AT THEIR REGULAR HOURLY RATE FOR HOURS WORKED IN THE FACILITY. SCHOLARSHIP ASSISTANCE DOES NOT APPLY WHEN SCHOOL IS NOT IN SESSION. SCHOLARSHIP RECIPIENTS ARE ALSO ELIGIBLE TO APPLY FOR TUITION. X X X 1 1 X X X X 0 1 0 0 0 1 0 0 0 STANLEY TRETTER MD 187857 0 0 0 0 0 3572 0 15543 0 206972 0 0 0 DOUGLAS BIES MD 487583 0 0 0 0 0 3846 0 10715 0 502144 0 0 0 RAYMOND SNOWDEN 445418 0 0 0 0 0 29154 0 9416 0 483988 0 0 0 LISA ARVESEN 168909 0 0 0 0 0 10485 0 7206 0 186600 0 0 0 E KYLE BENNETT 275682 0 0 0 0 0 6217 0 13875 0 295774 0 0 0 JOHN DILLON 166906 0 0 0 0 0 4966 0 9075 0 180947 0 0 0 TONYA HEIM 180958 0 0 0 0 0 3002 0 7317 0 191277 0 0 0 DR ROBERT MANDAL 856018 0 0 0 0 0 0 0 0 0 856018 0 0 0 DR MICHAEL RUFF 486330 0 0 0 0 0 2916 0 10615 0 499861 0 0 0 DR PATRICK LILLY 472641 0 0 0 0 0 22625 0 16214 0 511480 0 0 0 DR NEIL MARTIN 463922 0 0 0 0 0 7171 0 10538 0 481631 0 0 0 DR SOHAIL QADIR 456740 0 0 0 0 0 4900 0 7229 0 468869 0 0 0 PART I, LINE 1A MEMORIAL HOSPITAL HAS AN EXECUTIVE PERQUISITE PROGRAM WHICH INCLUDES REIMBURSEMENT FOR ALLOWABLE APPROVED PERQUISITE EXPENSES. REIMBURSEMENT MADE AS PART OF THE EXECUTIVE PERQUISITE PROGRAM IS REFLECTED ON THE EXECUTIVE'S W-2 FORM. HOSPITAL AUTHORITY OF THE CITY OF JASPER 351692946 471641AA8 2008-05-20 15000000 SEE BELOW 0 0 0 2090000 15000000 214398 70302 14715300 2008 0 0 1 1 0 1 1 1 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 SR R CUNNINGHAM SEE BELOW 266986 SEE BELOW 0 SR A DAVIS SEE BELOW 266986 SEE BELOW 0 MIKE UEBELHOR SEE BELOW 127764 SEE BELOW 0 SCHEDULE L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: SISTER R. CUNNINGHAM AND SISTER A. DAVIS(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: BOARD MEMBERS OF MEMORIAL HOSPITAL.(D) DESCRIPTION OF TRANSACTION: SISTERS RENEE CUNNINGHAM AND ADRIAN DAVIS PROVIDE NURSING SERVICES TO THE HOSPITAL AND SERVE AS BOARD MEMBERS. THE HOSPITAL PAYS AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS $266,986 AS A SPONSORSHIP FOR THE SISTERS. THE SISTERS DO NOT ACCEPT COMPENSATION AS THEY HAVE TAKEN A VOW OF POVERTY. SISTER ADRIAN DAVIS PASSED AWAY MAY 2012. THE AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS IS THE CORPORATE MEMBER FOR THE HOSPITAL.(A) NAME OF PERSON: MIKE UEBELHOR(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: BOARD MEMBER OF MEMORIAL HOSPITAL AND OWNER OF UEBELHOR DEVELOPMENT.(D) DESCRIPTION OF TRANSACTION: MIKE UEBELHOR IS A PART OWNER OF UEBELHOR DEVELOPMENTS, WHICH IS THE LESSOR OF THE ORGANIZATION'S URGENT CARE BUILDING IN HUNTINGBERG, IN. THE HOSPITAL PAID $127,764 IN LEASE PAYMENTS AND PROPERTY TAX PAYMENTS TO UEBELHOR DEVELOPMENTS IN THE CURRENT YEAR. FORM 990, PART VI, SECTION A, LINE 2 MR. BENNETT, SISTER DAVIS, MR. DISINGER, MR. RUBINO, MR. SENDELWECK AND MR. SNOWDEN HAVE A BUSINESS RELATIONSHIP AS THEY ARE ALL BOARD MEMBERS FOR THE MEMORIAL HOSPITAL FOUNDATION TOGETHER. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF THE CORPORATION ARE THE PROVIDENCE LEADER AND COUNCIL MEMBERS OF THE AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY THE MEMBERS: TO ESTABLISH/APPROVE THE MISSION/PHILOSOPHY OF THE CORPORATION; TO ADOPT, AMEND OR REPEAL THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; TO FIX THE NUMBER OF DIRECTORS OF THE CORPORATION AND APPOINT THE CORPORATION'S BOARD OF DIRECTORS; TO REMOVE ANY MEMBER OF THE BOARD OF THE CORPORATION; TO APPOINT AND REMOVE THE PRESIDENT/CEO OF THE CORPORATION; TO APPOINT AND REMOVE THE CHAIRPERSON OF THE BOARD OF DIRECTORS; TO APPROVE FOR THE CORPORATION, THE ACQUISITION OF ASSETS, THE INCURRENCE OF INDEBTEDNESS OR THE LEASE, SALE, TRANSFER, ASSIGNMENT, OR ENCUMBERING OF THE ASSETS IN AN AMOUNT SET FROM TIME TO TIME BY THE MEMBERS; TO APPROVE THE MERGER, DISSOLUTION, AFFILIATION, OR CORPORATE RESTRUCTURING OF THE CORPORATION AND ANY SUBSIDIARY OF THE CORPORATION; TO ACCEPT A GIFT OR LEGACY IMPOSING A PERMANENT OR CONTINUING OBLIGATION ON THE CORPORATION; TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS; AND TO APPOINT THE AUDITORS OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS MADE AVAILABLE FOR THE BOARD OF DIRECTORS FOR REVIEW UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD CHAIRPERSON EVALUATES SITUATIONS WHERE POSSIBLE CONFLICTS MAY EXIST, AND TRIES TO DISCUSS THESE SITUATIONS WITH BOARD MEMBERS BEFORE DISCUSSIONS MAY TAKE PLACE AT THE BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE, COMPOSED OF THE EXECUTIVE COMMITTEE OF THE BOARD MINUS THE CEO, REVIEWS EXTERNAL SURVEY INFORMATION PROVIDED BY AN INDEPENDENT COMPENSATION CONSULTANT, AND VOTES ON ANY COMPENSATION AND BENEFIT CHANGES FOR THE CEO AND APPROVES THE SAME FOR OTHER MEMBERS OF ADMINISTRATIVE STAFF. THESE ACTIONS ARE DOCUMENTED IN MEETING MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,325,479. CHANGE IN PENSION -995,775. TOTAL TO FORM 990, PART XI, LINE 5: -2,321,254. OVERSIGHT OF THE AUDIT PART XI, LINE 2C THE FINANCE COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS; NO PROCESSES HAVE CHANGED FROM THE PRIOR YEAR. THE AUDITORS ARE SELECTED BY THE COUNCIL MEMBERS OF THE AMERICAN PROVIDENCE OF LITTLE COMPANY OF MARY SISTERS. BARRETT HEALTHCARE CORP OF SW INDIANA 800 WEST 9TH ST JASPER IN 47546 352039829 HEALTHCARE IN 0 3094009 N/A MEMORIAL HOSPITAL FOUNDATION INC 800 WEST NINTH STREET JASPER IN 47546 351359445 BENEFIT MEMORIAL HOSPITAL & HEALTH CARE CENTER IN 501(C)(3) LINE 11A, I MEMORIAL HOSPITAL AND HEALTH CARE CENTER 0 0 0 1 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 MEMORIAL HOSPITAL FOUNDATION INC C 49805 FAIR VALUE