FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION (EIN 37-0661202)
- Tax period
- 2011-07-01 to 2012-06-30
- Filed
- 2013-02-11
- IRS object ID
- 201320429349301142
- Schema version
- 2011v1.5
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-02-11T14:28:47-06:00 | Timestamp |
| Tax Period End Date | 2012-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KERBER ECK & BRAECKEL LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1116 W MAIN ST | AddressLine1 |
| City | CARBONDALE | City |
| State | IL | State |
| ZIP Code | 629012335 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 370661202 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL ASSOC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | FAIR | NameControl |
| Phone | 6188422611 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1 |
| City | FAIRFIELD | City |
| State | IL | State |
| ZIP Code | 62837 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | MIKE BROWN | Name |
| Title | CFO | Title |
| Phone | 6188422611 | Phone |
| Date Signed | 2013-02-11 | DateSigned |
| Authorize Third Party | true | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | MARK DALLAS | Name |
| Phone | 6185291040 | Phone |
| Date Prepared | 2013-02-11 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-03-07 17:11:31Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | KATHERINE BUNTING | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1 |
| City | FAIRFIELD | City |
| State | IL | State |
| ZIP Code | 62837 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 26468188 | GrossReceipts |
| Group Return For Affiliates | false | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.FAIRFIELDMEMORIAL.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1943 | YearFormation |
| State Legal Domicile | IL | StateLegalDomicile |
| Activity Or Mission Description | THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 9 | NbrIndependentVotingMembers |
| Total Nbr Employees | 391 | TotalNbrEmployees |
| Total Nbr Volunteers | 53 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Contributions Grants Prior Year | 562877 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 563381 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 26610429 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 25564158 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 16971 | InvestmentIncomePriorYear |
| Investment Income Current Year | 12363 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 215530 | OtherRevenuePriorYear |
| Other Revenue Current Year | 328286 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 27405807 | TotalRevenuePriorYear |
| Total Revenue Current Year | 26468188 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 13539909 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 12636087 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 13129510 | OtherExpensePriorYear |
| Other Expenses Current Year | 13911946 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 26669419 | TotalExpensesPriorYear |
| Total Expenses Current Year | 26548033 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 736388 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -79845 | RevenuesLessExpensesCY |
| Total Assets BOY | 25126899 | TotalAssetsBOY |
| Total Assets EOY | 25545808 | TotalAssetsEOY |
| Total Liabilities BOY | 12441200 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 12939954 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 12685699 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 12605854 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. | MissionDescription |
| Significant New Program Services | false | SignificantNewProgramServices |
| Significant Change | false | SignificantChange |
| Expense | 26548033 | Expense |
| Revenue | 25982807 | Revenue |
| Description | AS A NON-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL HOSPITAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008 THE HOPSITAL OPENED AN OUTPATIENT PHYSICIAN CLINIC. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORGIN, HANDICAP, AGE OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY AND IN FY 2012 THIS AMOUNTED TO APPROXIMATELY 2,078,404. | Description |
| Total Program Service Expense | 26548033 | TotalProgramServiceExpense |
| Described In501 C3 | true | DescribedIn501C3 |
| Schedule B Required | false | ScheduleBRequired |
| Political Activities | false | PoliticalActivities |
| Lobbying Activities | false | LobbyingActivities |
| Subject To Proxy Tax | false | SubjectToProxyTax |
| Donor Advised Funds | false | DonorAdvisedFunds |
| Conservation Easements | false | ConservationEasements |
| Collections Of Art | false | CollectionsOfArt |
| Credit Counseling | false | CreditCounseling |
| Term Or Permanent Endowments | false | TermOrPermanentEndowments |
| Report Land Bldg Equip | true | ReportLandBldgEquip |
| Report Invest Oth Securities | false | ReportInvestOthSecurities |
| Report Prog Rel Invest | false | ReportProgRelInvest |
| Report Other Assets | false | ReportOtherAssets |
| Report Other Liabilities | true | ReportOtherLiabilities |
| Report Fin48 Footnote | true | ReportFin48Footnote |
| Independent Audit Financial Stmt | true | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | false | ConsolidatedAuditFinancialStmt |
| School | false | School |
| Foreign Office | false | ForeignOffice |
| Foreign Activities | false | ForeignActivities |
| More Than5000 K To Organizations | false | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividuals |
| Professional Fundraising | false | ProfessionalFundraising |
| Fundraising Activities | false | FundraisingActivities |
| Gaming | false | Gaming |
| Hospital | true | Hospital |
| Financial Stmt Attached | true | FinancialStmtAttached |
| Grants To Organizations | false | GrantsToOrganizations |
| Grants To Individuals | false | GrantsToIndividuals |
| Schedule J Required | true | ScheduleJRequired |
| Tax Exempt Bonds | false | TaxExemptBonds |
| Excess Benefit Transaction | false | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | false | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | false | LoanToOfficerOrDQP |
| Grant To Related Person | false | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | false | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | false | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | false | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | false | DeductibleNonCashContributions |
| Deductible Contributions Of Art | false | DeductibleContributionsOfArt |
| Terminated | false | Terminated |
| Partial Liquidation | false | PartialLiquidation |
| Disregarded Entity | false | DisregardedEntity |
| Related Entity | true | RelatedEntity |
| Related Org Controlled Entity | false | RelatedOrgControlledEntity |
| Transaction Related Entity | false | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | false | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | false | ActivitiesConductedPartnership |
| Schedule O Required | true | ScheduleORequired |
| Number Forms Transmitted With1096 | 20 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 391 | NumberOfEmployees |
| Employment Tax Returns Filed | true | EmploymentTaxReturnsFiled |
| Unrelated Business Income | false | UnrelatedBusinessIncome |
| Foreign Financial Account | false | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTrans |
| Taxable Party Notification | false | TaxablePartyNotification |
| Non Deductible Contributions | false | NonDeductibleContributions |
| Quid Pro Quo Contributions | false | QuidProQuoContributions |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | false | FundsToPayPremiums |
| Premiums Paid | false | PremiumsPaid |
| Form8899 Filed | false | Form8899Filed |
| Form1098 C Filed | false | Form1098CFiled |
| Indoor Tanning Services | false | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 9 | NumberIndependentVotingMembers |
| Family Or Business Relationship | false | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | false | DelegationOfManagementDuties |
| Changes To Organizing Docs | false | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuse |
| Members Or Stockholders | false | MembersOrStockholders |
| Election Of Board Members | false | ElectionOfBoardMembers |
| Decisions Subject To Approval | false | DecisionsSubjectToApproval |
| Minutes Of Governing Body | true | MinutesOfGoverningBody |
| Minutes Of Committees | true | MinutesOfCommittees |
| Officer Mailing Address | false | OfficerMailingAddress |
| Local Chapters | false | LocalChapters |
| Form990 Provided To Governing Body | true | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | true | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | true | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | true | RegularMonitoringEnforcement |
| Whistleblower Policy | true | WhistleblowerPolicy |
| Document Retention Policy | true | DocumentRetentionPolicy |
| Compensation Process CEO | true | CompensationProcessCEO |
| Compensation Process Other | true | CompensationProcessOther |
| Investment In Joint Venture | false | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | IL | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | MIKE BROWN | NamePerson |
| Telephone Number | 6188422611 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH ST | AddressLine1 |
| City | FAIRFIELD | City |
| State | IL | State |
| ZIP Code | 62837 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (18 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer | Highest Compensated EmployeeHighestCompensatedEmployee | FormerFormer |
|---|---|---|---|---|---|---|---|---|
| PATRICK MOLT MD | ||||||||
| TRUSTEE | 10.00 | X | 35275 | 0 | 0 | |||
| MARTY HEFLIN | ||||||||
| SECRETARY/TR | 5.00 | X | 0 | 0 | 0 | |||
| JAMIE POLLARD | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| MIKE ST LEDGER | ||||||||
| PRESIDENT | 10.00 | X | 0 | 0 | 0 | |||
| SANDY SIMPSON | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| DONNA SULLIVAN | ||||||||
| TRUSTEE | 4.00 | X | 0 | 0 | 0 | |||
| RENA TALBERT | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| DALE WARREN | ||||||||
| VICE PRESIDE | 2.00 | X | 0 | 0 | 0 | |||
| JARED VAUGHN | ||||||||
| TRUSTEE | 4.00 | X | 0 | 0 | 0 | |||
| KATHY BUNTING | ||||||||
| CEO | 40.00 | 191421 | 0 | 4747 | X | |||
| MIKE BROWN | ||||||||
| CFO | 40.00 | 124073 | 0 | 2883 | X | |||
| ANN IGNAS | ||||||||
| CNO | 40.00 | 83312 | 0 | 3561 | X | |||
| CHRIS BALLARD | ||||||||
| PHYSICIAN | 40.00 | 310272 | 0 | 23050 | X | |||
| WESLEY THOMPSON | ||||||||
| PHYSICIAN | 40.00 | 308288 | 0 | 22992 | X | |||
| KYLE KAKAC | ||||||||
| PHYSCIAN | 40.00 | 299114 | 0 | 22963 | X | |||
| ALEX KING | ||||||||
| CRNA | 40.00 | 223659 | 0 | 21457 | X | |||
| KIM KING | ||||||||
| CRNA | 40.00 | 199867 | 0 | 4891 | X | |||
| CINDY MEAGHER | ||||||||
| CNO | 40.00 | 79396 | 0 | 2055 | X | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1854677 | TotalReportableCompFromOrg |
| Total Other Compensation | 108599 | TotalOtherCompensation |
| Number Individuals GT100 K | 9 | NumberIndividualsGT100K |
| Formers Listed | true | FormersListed |
| Total Comp GT150 K | true | TotalCompGT150K |
| Compensation From Other Sources | false | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| AMERISOURCE BERGEN DRUG COMPANY | |||||
| PO BOX 27550 | CHICAGO | IL | 606731275 | PHARMACEUTICALS | 855299 |
| WAY-FAIR NURSING & REHABILITATION CE | |||||
| 305 NW 11TH ST | FAIRFIELD | IL | 62837 | DIETARY | 733595 |
| ARAMARK UNIFORM SERVICE | |||||
| PO BOX 329 | EVANSVILLE | IN | 47701 | LAUNDRY | 436033 |
| DR RODNEY BEELER | |||||
| 2142 KETTLES HILL COURT | EVANSVILLE | IN | 47725 | ER PHYSICIAN | 356558 |
| GATEWAY ENTERPRISES | |||||
| 915 OLIVE STREET 1613 | ST LOUIS | MO | 631011458 | ER PHYSICANS | 354298 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 12 | NumberOfContractorsGT100K |
| Government Grants | 469168 | GovernmentGrants |
| All Other Contributions | 94213 | AllOtherContributions |
| Total Contributions | 563381 | TotalContributions |
Program Service Revenue ProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | NET PATIENT SERVICE REVENUE | Description |
| Total Revenue Column | 25564158 | TotalRevenueColumn |
| Related Or Exempt Function Income | 25564158 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 25564158 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 12363 | TotalRevenueColumn |
| Related Or Exempt Function Income | 12363 | RelatedOrExemptFunctionIncome |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 212914 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 212914 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 212914 | TotalRevenueColumn |
| Related Or Exempt Function Income | 212914 | RelatedOrExemptFunctionIncome |
Other Revenue Misc OtherRevenueMisc (2 entries)
| DescriptionDescription | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|
| CAFETERIA SERVICES | 107248 | 107248 |
| MEDICAL RECORDS FEES | 8124 | 8124 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 115372 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 26468188 | TotalRevenueColumn |
| Related Or Exempt Function Income | 25904807 | RelatedOrExemptFunctionIncome |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 398806 | Total |
| Program Services | 398806 | ProgramServices |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 10040707 | Total |
| Program Services | 10040707 | ProgramServices |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 128066 | Total |
| Program Services | 128066 | ProgramServices |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1361159 | Total |
| Program Services | 1361159 | ProgramServices |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 707349 | Total |
| Program Services | 707349 | ProgramServices |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 18200 | Total |
| Program Services | 18200 | ProgramServices |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 27750 | Total |
| Program Services | 27750 | ProgramServices |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4304920 | Total |
| Program Services | 4304920 | ProgramServices |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 104576 | Total |
| Program Services | 104576 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2333650 | Total |
| Program Services | 2333650 | ProgramServices |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 823891 | Total |
| Program Services | 823891 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 173130 | Total |
| Program Services | 173130 | ProgramServices |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 471791 | Total |
| Program Services | 471791 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1326586 | Total |
| Program Services | 1326586 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 274792 | Total |
| Program Services | 274792 | ProgramServices |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices |
|---|---|---|
| BAD DEBT | 1493828 | 1493828 |
| DRUGS | 959993 | 959993 |
| REPAIRS AND MAINTENANCE | 631600 | 631600 |
| FOOD | 438781 | 438781 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 528458 | Total |
| Program Services | 528458 | ProgramServices |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 26548033 | Total |
| Program Services | 26548033 | ProgramServices |
| Management And General | 0 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 995 | BOY |
| EOY | 995 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2880033 | BOY |
| EOY | 2717565 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3947887 | BOY |
| EOY | 4984323 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 310892 | BOY |
| EOY | 301993 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 160276 | BOY |
| EOY | 102527 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 33657600 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 17329255 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 17023606 | BOY |
| EOY | 16328345 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 300800 | BOY |
| EOY | 300800 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 502410 | BOY |
| EOY | 809260 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 25126899 | BOY |
| EOY | 25545808 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2686492 | BOY |
| EOY | 2574522 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 9441454 | BOY |
| EOY | 9419829 | EOY |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayable
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 56800 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 313254 | BOY |
| EOY | 888803 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12441200 | BOY |
| EOY | 12939954 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11856105 | BOY |
| EOY | 11877535 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 829025 | BOY |
| EOY | 727750 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 569 | BOY |
| EOY | 569 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12685699 | BOY |
| EOY | 12605854 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 25126899 | BOY |
| EOY | 25545808 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | -79845 | ReconcilationRevenueExpenses |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | false | AccountantCompileOrReview |
| FS Audited | true | FSAudited |
| Audit Committee | true | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | false | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Disclosed Orgs Legal Control | false | DisclosedOrgsLegalControl |
| Disclosed For Charitable Purposes | false | DisclosedForCharitablePurposes |
| Written Policy Monitoring | false | WrittenPolicyMonitoring |
| Sect170h Requirements Satisfied | false | Sect170hRequirementsSatisfied |
| Solicited Assets For Sale | false | SolicitedAssetsForSale |
| Agent Trustee Etc | false | AgentTrusteeEtc |
| Included On FS | false | IncludedOnFS |
| Endowments Held By Unrelated Orgs | false | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | false | EndowmentsHeldByRelatedOrgs |
| Are Related Orgs Listed Schedule R | false | AreRelatedOrgsListedScheduleR |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 421395 | OtherCostOrOtherBasis |
| Book Value | 421395 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 19031974 | OtherCostOrOtherBasis |
| Depreciation | 6398850 | Depreciation |
| Book Value | 12633124 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 14172971 | OtherCostOrOtherBasis |
| Depreciation | 10916240 | Depreciation |
| Book Value | 3256731 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 31260 | OtherCostOrOtherBasis |
| Depreciation | 14165 | Depreciation |
| Book Value | 17095 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 16328345 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | THIRD PARTY REIMBURSEMENT PROGRAMS | Description |
| Amount | $888,803 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 888803 | TotalOfAmounts |
| Total Revenue | 26468188 | TotalRevenue |
| Total Expenses | 26548033 | TotalExpenses |
| Excess Or Deficit For Year | -79845 | ExcessOrDeficitForYear |
| Excess Or Deficit Per FS | -79845 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 26468188 | TotRevenueEtcAuditedFinclStmt |
| Revenue Subtotal | 26468188 | RevenueSubtotal |
| Total Revenue Per Form990 | 26468188 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 26548033 | TotExpensesEtcAuditedFinclStmt |
| Expenses Subtotal | 26548033 | ExpensesSubtotal |
| Total Expenses Per Form990 | 26548033 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | LIABILITY UNDER FIN 48 FOOTNOTE | Identifier |
| Return Reference | SCHEDULE D, PAGE 3, PART X | ReturnReference |
| Explanation | THERE WERE NO UNCERTAIN TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY UPON THE ADOPTION OF ASC TOPIC 740-10-25 OR AT JUNE 30, 2012. | Explanation |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | true | CharityCarePolicy |
| Written Policy | true | WrittenPolicy |
| FPG Reference Free Care | true | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | true | FPGReferenceDiscountedCare |
| Pcent300 | X | Pcent300 |
| Free Disc Care Medically Indigent | true | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | true | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | true | ExpensesExceededBudget |
| Unable To Provide Care | false | UnableToProvideCare |
| Annual Community Benefit Report | true | AnnualCommunityBenefitReport |
| Report Publically Available | true | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 821301 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 821301 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03090 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1093954 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1030731 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 63223 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00240 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1915255 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1030731 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 884524 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03330 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 35135 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 35135 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00130 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 35135 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 35135 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00130 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1950390 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1030731 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 919659 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03460 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | true | BadDebtExpenseReported |
| Bad Debt Expense | $590,301 | BadDebtExpenseAmount |
| Amount Attributable To | 147575 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 10906406 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 12881992 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -1975586 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | true | WrittenDebtCollectionPolicy |
| Provision For Charity Care | true | ProvisionForCharityCare |
| Number Of Hospital Facilities | 2 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA (2 entries)
| Facility NumberFacilityNumber | Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Licensed HospitalLicensedHospital | General Medical And SurgicalGeneralMedicalAndSurgical | Critical Access HospitalCriticalAccessHospital | Er24 HoursEr24Hours | OtherOther |
|---|---|---|---|---|---|---|---|---|---|
| FAIRFIELD MEMORIAL HOSPITAL | |||||||||
| 1 | 303 NW 11TH ST | FAIRFIELD | IL | 62837 | X | X | X | X | |
| HORIZON HEALTHCARE | |||||||||
| 2 | 1021 HARDING ST | FAIRFIELD | IL | 62837 | OUTPATIENT PHYSCIAN CLINIC | ||||
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB (2 entries)
| Hospital Facility NumberHospitalFacilityNumber | Eligibility Criteria ExplainedEligibilityCriteriaExplained | Uses FPG FreeUsesFPGFree | FPG Free PercentFPGFreePercent | Uses FPG DiscountedUsesFPGDiscounted | FPG Discount PercentFPGDiscountPercent | Explains BasisExplainsBasis | Income LevelIncomeLevel | Asset LevelAssetLevel | Medical IndigencyMedicalIndigency | Explains Application MethodExplainsApplicationMethod | Includes Publicity MeasuresIncludesPublicityMeasures | Posted On WebsitePostedOnWebsite | Attached To InvoicesAttachedToInvoices | Posted In Emergency RoomPostedInEmergencyRoom | Posted In Admission OfficePostedInAdmissionOffice | Available On RequestAvailableOnRequest | Other PublicityOtherPublicity | Actions On NonpaymentActionsOnNonpayment | Permit Report To Credit AgencyPermitReportToCreditAgency | Permit LawsuitPermitLawsuit | Collection ActivitiesCollectionActivities | Report To Credit AgencyReportToCreditAgency | LawsuitLawsuit | Notify Upon AdmissionNotifyUponAdmission | Notify Before DischargeNotifyBeforeDischarge | Notified All PatientsNotifiedAllPatients | Documented DeterminationDocumentedDetermination | Nondiscrim Emergency Care PolicyNondiscrimEmergencyCarePolicy | Used Other MethodUsedOtherMethod | Amounts Generally BilledAmountsGenerallyBilled | Gross ChargesGrossCharges |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FAIRFIELD MEMORIAL HOSPITAL | |||||||||||||||||||||||||||||||
| 1 | true | true | 200.0 | true | 300.0 | true | X | X | X | true | true | X | X | X | X | X | X | true | X | X | true | X | X | X | X | X | X | true | X | false | false |
| HORIZON HEALTHCARE | |||||||||||||||||||||||||||||||
| 2 | true | true | 200.0 | true | 300.0 | true | X | X | X | true | true | X | X | X | X | X | X | true | X | X | true | X | X | X | X | X | X | true | X | false | false |
Form990 Schedule H Part VI Form990ScheduleHPartVI (14 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE | PART I LINE 7 COLUMN F | 1493828 |
| COSTING METHODOLOGY EXPLANATION | PART I LINE 7 | THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2 RATIO OF PATIENT CARE COSTTOCHARGES INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H |
| BAD DEBT EXPENSE EXPLANATION | PART III LINE 4 | THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H PART III LINE 9B PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED BASED ON THE HOSPITALS EXPERIENCE WITH ALL ITS PATIENTS THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY THEREFORE 25 OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III LINE 3 AT COST FOLLOWING IS NOTE C UNCOMPENSATED CARE AND COMMUNITY BENEFIT COPIED DIRECTLY FROM THE AUDITED FINANCIAL STATEMENTS IN SUPPORT OF ITS MISSION THE HOSPITAL VOLUNTARILY PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITALS CHARITY CARE CRITERIA BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE THEY ARE NOT REPORTED IN NET PATIENT SERVICES REVENUE CHARGES EXCLUDED FROM REVENUE UNDER THE HOSPITALS CHARITY CARE POLICY WERE APPROXIMATELY 2078000 AND 1556000 FOR 2012 AND 2011 IN ADDITION THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENTREIMBURSED PUBLIC AID PROGRAMS SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS AND MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED THE HOSPITALS TOTAL COST OF UNCOMPENSATED CARE RELATING TO THESE SERVICES AND OTHER SERVICES ARE AS FOLLOWS CHARITY CARE 821301 STATE MEDICAID AND OTHER PUBLIC PROGRAMS 63223 UNCOLLECTIBLE ACCOUNTS 590301 THE UNCOMPENSATED CARE COST OF STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS IS DETERMINED BY COMPUTING THE COST OF PROVIDING THAT CARE LESS AMOUNTS PAID BY THE PROGRAM IN ADDITION TO THE ABOVE COST OF UNCOMPENSATED CARE THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFILLED COMMUNITY NEEDS MANY OF THESE ACTIVITIES ARE SPONSORED WITH KNOWLEDGE THAT THEY WILL NOT BE SELFSUPPORTING OR FINANCIALLY VIABLE |
| MEDICARE EXPLANATION | PART III LINE 8 | UNPAID COST OF MEDICARE REPRESENTS THE COST DETERMINED USING THE OVERALL COST TO CHARGE RATIO OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM IN EXCESS OF PAYMENTS FOR THOSE SERVICES IRS REVENUE RULING 69545 WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFTIS INCLUDING MEDICARE THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT |
| COLLECTION PRACTICES EXPLANATION | PART III LINE 9B | THE FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS BOTH CHARITY CARE ELIGIBLE AND NONCHARITY CARE PATIENTS THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE AS FOLLOWS SELFPAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS THE ACCOUNT IS TRANSFERRED TO OUR EARLYOUT DEPARTMENT FOR A FOLLOWUP STATEMENTPHONE CALL TO THE PATIENT THE HOSPITAL OFFERS THE PATIENTS SEVERAL PAYMENT ALTERNATIVES 1 CASHCHECK FOR THE FULL AMOUNT 2 MASTERCARDVISADISCOVER 3 SHORTTERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCE SPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR IF PAYMENT OR SATISFACTORY PAYMENT ARRANGMENTS AS OUTLINED ABOVE ARE NOT MADE THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS DAY 1 1ST NOTICE SENT DAY 714 FIRST PHONE CALL IS MADE AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLYOUT 90 DAY PERIOD DAY 75 DEMAND NOTICE IS SENT DAY 90 ACCOUNT IS SENT TO COLLECTIONS ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY AND ANY ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT BALANCE |
| NEEDS ASSESSMENT | PART VI | GENERALLY SPEAKING THE DETERMINATION OF CURRENT AND FUTURE HEALTH CARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS EXISTENCE OR NONEXISTENCE OF SERVICES OPPORTUNITY SUPPLY DEMONSTRATED NEED VOICE OF THE CUSTOMER AND OR COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES GOVERMENT AGENCIES AND OTHER HEALTH CARE PROVIDERS THAT WOULD ENABLE THE FILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKETING MARKET RESEARCH CUSTOMER SURVEYS PHYSCIAN INPUT AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITALS SENIOR LEADERSHIP AND INCORPORATED INTO STRATEGIC PLANNING PROCESSES |
| PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE | PART VI | SIGNS ARE POSTED IN THE FACILITY THE PATIENTS BILL INFORMS THEM OF FINANCIAL ASSISTANCE PROGRAM OUR HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION SOCIAL SERVICE DEPARTMENT SPEAKS TO INPATIENTS ABOUT THE PROGRAM |
| COMMUNITY INFORMATION | PART VI | FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATIONS OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE GENDER INCOME ETHIC ORGIN INSURANCE COVERAGE OR ABILITY TO PAY WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 16760 THE MEDIAN HOUSEHOLD INCOME IN 2011 WAS 39207 WHICH WAS 77 OF ILLINOIS AVERAGE AND 78 OF THE US AVERAGE THE PERCENTAGE OF INDIVIDUALS BELOW POVERTY LEVEL WAS 143 |
| LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED | PART VI | ILLINOIS |
| ADDITIONAL INFORMATION | PART VI | STUDY FINDINGS SHOWED THAT FAIRFIELD MEMORIAL HOSPITAL ECONOMIC IMPACT IN ONE YEAR FOR 2009 BASED ON COMMUNITY BENFIT STUDY DONE IN 2009 WERE THE FOLLOWING EMPLOYED 356 POEPLE GENERATED SALARIES AND BENEFITS OF 13539909 INVESTED 2218116 IN CAPITAL EXPEDITURES GENERATED 56780973 OF ECONOMIC ACTIVITY US DEPARTMENT OF COMMERCE GENERATED 24032877 OF HOUSEHOLD EARNINGSUS DEPARTMENT OF COMMERCE CREATED APPROXIMATELY 1240 JOBS IN WAYNE COUNTY OUTSIDE OF HEALTHCARE THESE NUMBERS CLEARLY DEMONSTATE THAT FAIRFIELD MEMORIAL HOSPITAL WILL BE A MAJOR FACTOR IN FUTURE ECONOMIC DEVELOPMENT IN WAYNE COUNTY |
| FAIRFIELD MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 13G | PART V LINE 13G | THE POLICY IS VERBALLY DISCUSSED WITH ALL SELFPAY PATIENTS |
| FAIRFIELD MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 19D | PART V LINE 19D | IF A PATIENT APPLIES FOR FINANCIAL ASSISTANCE AND THEY ARE APPROVED THE BILL IS REDUCED TO ZERO IF THE PATIENT QUALIFIES FOR THE PATIENT DISCOUNT ACT THEN THE CURRENT ASSIGNED PERCENTAGE IS CHARGED IF NEITHER APPLY THEN THE PATIENT IS OFFERED A 20 DISCOUNT IF PAID IN FULL OR AN OFFER OF REASONABLE INTEREST FREE PAYMENTS ARE SET UP |
| HORIZON HEALTHCARE LINE NUMBER 2 PART V LINE 13G | PART V LINE 13G | POLICY IS VERBALLY DISCUSSED WITH ALL SELFPAY PATIENTS |
| HORIZON HEALTHCARE LINE NUMBER 2 PART V LINE 19D | PART V LINE 19D | IF A PATIENT APPLIES FOR FINANCIAL ASSISTANCE AND THEY ARE APPROVED THE BILL IS REDUCED TO ZERO IF THE PATIENT QUALIFIES FOR THE PATIENT DISCOUNT ACT THEN THE CURRENT ASSIGNED PERCENTAGE IS CHARGED IF NEITHER APPLY THEN THE PATIENT IS OFFERED A 20 DISCOUNT IF PAID IN FULL OR AN OFFER OF REASONABLE INTEREST FREE PAYMENTS ARE SET UP |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | X | CompensationCommittee |
| Independent Consultant | X | IndependentConsultant |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | false | SeverancePayment |
| Supplemental Nonqual Retire Plan | false | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | false | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | false | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | false | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | false | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | false | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | false | AnyNonFixedPayments |
| Initial Contract Exception | false | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (7 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Deferred Comp Filing OrgDeferredCompFilingOrg | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Total Compensation Filing OrgTotalCompensationFilingOrg |
|---|---|---|---|
| KATHY BUNTING | |||
| 191421 | 890 | 3857 | 196168 |
| CHRIS BALLARD | |||
| 310272 | 22127 | 923 | 333322 |
| WESLEY THOMPSON | |||
| 308288 | 22069 | 923 | 331280 |
| KYLE KAKAC | |||
| 299114 | 22040 | 923 | 322077 |
| ALEX KING | |||
| 223659 | 20534 | 923 | 245116 |
| KIM KING | |||
| 199867 | 4001 | 890 | 204758 |
| CINDY MEAGHER | |||
| 79396 | 1605 | 450 | 81451 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (7 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| EXPLANATION ON VOLUNTEERS AND TYPES OF SERVICES OR BENEFITS | FORM 990, PAGE 1, PART I, LINE 6 | VOLUNTEERS ARE PART OF THE HOSPITAL AUXILIARY WHO RUN FUNDRAISERS ON BEHALF OF THE HOSPITAL AND OPERATE THE GIFT SHOP. |
| FIRST ACCOMPLISHMENT DESCRIPTION | FORM 990, PAGE 2, PART III, LINE 4A | COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY AND IN FY 2012 THIS AMOUNTED TO APPROXIMATELY 2,078,404. |
| ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 | FORM 990, PAGE 6, PART VI, LINE 11B | THE FORM 990 WAS REVIEWED BY THE CFO AND FINANCE COMMITTEE. AFTER THE FINANCE COMMITTEE IT WAS TAKEN TO THE FULL BOARD FOR APPROVAL. |
| ENFORCEMENT OF CONFLICTS POLICY | FORM 990, PAGE 6, PART VI, LINE 12C | ANNUALLY EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES THE CONFLICT OF INTEREST POLICY WITHIN IT TO REVIEW AND SIGN THAT THEY HAVE READ THE POLICY AND HAVE NO COMFLICTS. ALL SIGNED DOCUMENTS ARE KEPT ON FILE IN ADMINISTRATION OFFICE. |
| COMPENSATION PROCESS FOR TOP OFFICIAL | FORM 990, PAGE 6, PART VI, LINE 15A | THE CEO'S COMPENSATION PROCESS INVOLVES ALLIANT, THE HOSPITAL'S MANAGEMENT COMPANY, BRINGING EVALUATION TIME SALARY INFORMATION FOR OTHER ALLIANT HOSPITALS WHICH INCLUDE HOSPITAL'S IN THE FOLLOWING STATES: ILLINOIS, KENTUCKY, AND INDIANIA; AS WELL AS SALARY INFORMATION FOR CEO'S FROM OTHER HOSPITAL'S IN RELEVANT SIZE (IN REVENUES) TO FMH. THE SALARY COMPARISON INFORMATION IS PRESENTED TO THE PERSONNEL COMMITTEE OF THE BOARD IN WHICH THEY REVIEW THE INFORMATION AND ESTABLISH THE RATE FOR THE CEO. |
| COMPENSATION PROCESS FOR OFFICERS | FORM 990, PAGE 6, PART VI, LINE 15B | MARKET WAGE DATA FOR THE HEALTHCARE INDUSTRY IS REVIEWED FOR COMPARABLE RATES FROM THREE SALARY SURVEYS INCLUDING ALLIANT AS ONE. THE CEO DETERMINES THE AMOUNTS FOR THE OFFICERS. |
| GOVERNING DOCUMENTS DISCLOSURE EXPLANATION | FORM 990, PAGE 6, PART VI, LINE 19 | COPIES OF THE ORGANIZATIONS GOVERING DOCUMENTS, CONFLICT IF INTEREST POLICIES, FINANCIAL STATEMENTS, AND THE FEDERAL FORM 990 TAX RETURN ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRFIELD MEMORIAL HOSPITAL FOUNDAT | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 303 NW 11TH STREET | AddressLine1 |
| City | FAIRFIELD | City |
| State | IL | State |
| ZIP Code | 62837 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 371185754 | EIN |
| Primary Activities | SUPPORT | PrimaryActivities |
| Legal Domicile State | IL | LegalDomicileState |
| Exempt Code Section | 501C3 | ExemptCodeSection |
| Public Charity Status | 11B | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Controlled Org | false | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | false | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | false | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | false | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | false | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | false | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | false | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | false | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | false | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | false | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | false | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | false | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | false | SharingOfFacilities |
| Sharing Of Paid Employees | false | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | false | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | false | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | false | OtherTransferToOtherOrg |
| Other Transfer From Other Org | false | OtherTransferFromOtherOrg |
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