2013-02-15T09:26:09-06:00 2012-06-30 450250958 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2011-07-01 370684691 MEMORIAL HOSPITAL ASSOCIATION MEMO 2173573131 PO BOX 160 CARTHAGE IL 62321 TERESA SMITH 2173573131 2013-02-01 1 CARMEN KRANTZ P00031958 5635561790 2013-01-30 2011 2016-03-07 17:11:31Z ADA BAIR PO BOX 160 CARTHAGE IL 62321 20956454 0 X WWW.MHTLC.ORG X 1947 IL MEMORIAL HOSPITAL PROVIDES CLINICAL CARE, DIAGNOSTIC, TREATMENT, AND WELLNESS SERVICES 12 11 250 140 0 0 90503 182129 19131716 20578220 420642 128503 42721 45594 19685582 20934446 0 1400 0 0 9434373 9795338 0 0 0 10087383 10743270 19521756 20540008 163826 394438 34046684 34024764 22583172 22335409 11463512 11689355 X MEMORIAL HOSPITAL IS COMMITTED TO IMPROVING HEALTH BY PROVIDING EDUCATION AND WELLNESS PROGRAMS AND INNOVATIVE SERVICES AT ALL THE STAGES OF LIFE. 0 0 17844217 1400 20579022 MEMORIAL HOSPITAL IS DEDICATED TO MAINTAINING AND IMPROVING THE HEALTH OF ALL PEOPLE IN THE HANCOCK COUNTY AREA. GOVERNED BY A BOARD OF DIRECTORS, WE SERVE AS A VITAL SAFETY NET, SERVING OUR COMMUNITIES WITH ACCESS TO QUALITY HEALTHCARE SERVICES. MEMORIAL HOSPITAL PROVIDES MANY TYPES OF COMMUNITY BENEFIT CARE. COMMUNITY BENEFIT CARE INCLUDES CHARITY CARE, COMMUNITY HEALTH FAIRS, LECTURES, AND FREE HEALTH SCREENINGS, DEMONSTRATING OUR COMMITMENT TO IMPROVING THE OVERALL HEALTH OF THE RESIDENTS OF THE HANCOCK COUNTY AREA.IN FY 2012, THE HOSPITAL HAD 2,664 PATIENT DAYS WITH 600 ADMISSIONS AND 601 DISCHARGES. THERE WERE 4,282 EMERGENCY ROOM VISITS, 16,577 PROVIDER BASED PHYSICIAN CLINIC VISITS, AND 10,699 RURAL HEALTH PHYSICIAN CLINIC VISITS.WE ARE ALWAYS COMMITTED TO PROVIDING COMPASSIONATE CARE TO EVERY MEMBER OF OUR COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY.TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE ORGANIZATION PROVIDES CARE TO PATIENTS AND RESIDENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. REVENUE FROM SERVICES TO THESE PATIENTS AND RESIDENTS IS RECORDED IN THE ACCOUNTING SYSTEM AT THE ESTABLISHED RATES, BUT THE ORGANIZATION DOES NOT PURSUE COLLECTION OF THE AMOUNTS. THE RESULTING ADJUSTMENTS ARE RECORDED AS ADJUSTMENTS TO PATIENT AND RESIDENT SERVICE REVENUE, DEPENDING ON THE TIMING OF THE CHARITY DETERMINATION.THE ILLINOIS LEGISLATURE PASSED A BILL TITLED THE "HOSPITAL UNINSURED PATIENT DISCOUNT ACT." EFFECTIVE APRIL 1, 2009, THIS ACT REQUIRES HOSPITALS TO PROVIDE CERTAIN MANDATED DISCOUNTS FROM CHARGES TO THE UNINSURED IN ILLINOIS. CHARGES ARE TO BE DISCOUNTED AT 135% OF COST. FURTHERMORE, A HOSPITAL MAY NOT COLLECT MORE THAN 25% OF AN UNINSURED FAMILY'S GROSS INCOME IN ANY ONE YEAR.THE ORGANIZATION MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE AMOUNTS OF CHARGES FOREGONE, BASED ON ESTABLISHED RATES, WERE $349,621 FOR THE YEAR ENDED JUNE 30, 2012. THE ESTIMATED COSTS OF THE CHARGES FOREGONE, BASED UPON AN OVERALL COST-TO-CHARGE RATIO CALCULATION, FOR THE YEAR END JUNE 30, 2012, WERE $192,000. IN ADDITION, THE ORGANIZATION PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS, AND FOR SOME SERVICES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE ORGANIZATION ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 17844217 1 1 0 0 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 90 0 1 250 1 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 IL X JANET FLEMING 2173573131 PO BOX 160 CARTHAGE IL 62321 X TERRY POPE 3.00 X X 0 0 0 MATT DICKINSON 3.00 X X 0 0 0 DENNIS RANKIN 3.00 X X 0 0 0 DAN ASBURY 3.00 X 0 0 0 CAROL GRONEWOLD 3.00 X 0 0 0 LUANN HAAS 3.00 X 0 0 0 KATHY HOLST 3.00 X 0 0 0 LARRY MCCLINTOCK 3.00 X 0 0 0 DR EDWARD MCKENNEY 3.00 X 144920 800 0 SHARON MORRISON 3.00 X 0 0 0 PEGGY LATHEROW 3.00 X 0 0 0 CHARLES GILBERT 3.00 X 0 0 0 ANGELA POLLOCK 3.00 X 0 0 0 ADA BAIR 40.00 X 180171 0 9207 TERESA SMITH 40.00 X 109555 0 14660 CHRISTOPHER JONES MD 40.00 X 288512 0 25982 PHILIP A CAROPRESO MD 40.00 X 272299 0 15455 DOUGLAS HEIGHTON MD 40.00 X 190241 0 25060 DAVID SMITH MD 40.00 X 187594 0 4822 JEFFREY LEON MD 40.00 X 166806 0 29162 1540098 800 124348 12 0 1 0 CPSI PO BOX 850309 MOBILE AL 36695 COMPUTER SOFTWARE SERVICE 282096 MCDONOUGH DISTRICT HOSPITAL 525 E GRANT STREET MACOMB IL 61455 LAB CONTRACT SERVICES 232684 EMCARE INC 7032 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 ER PHYSICIAN SERVICES 176277 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 HEALTHCARE CONSULTING SERVICE 172315 DIAMOND HEALTHCARE CORP PO BOX 85050 RICHMOND VA 23261 GEROPHYS & CARDIO REHAB SERVICE 171577 7 35731 52114 94284 182129 PATIENT SERVICE REVENU 622110 17374737 17374737 CLINIC REVENUE 621111 2885394 2885394 SUPPORTING REVENUE 900099 206023 206023 EQUITY IN ADVANCE PHYS 900099 77269 77269 EQUITY IN SHERRICK HOM 900099 34797 34797 20578220 128503 128503 42008 2000 10359 0 31649 2000 33649 33649 22276 35731 11133 11143 11143 1318 516 802 802 20934446 20579022 0 173295 400 400 1000 1000 474458 145000 329458 7731045 6795255 935790 1039968 907057 132911 549867 466764 83103 76000 76000 7785 7785 54105 54105 3164866 2552894 611972 67046 67046 463500 251186 212314 429400 429400 67562 57616 9946 62809 59102 3707 1213079 1213079 1930281 1930281 455720 455720 MEDICAL SUPPLIES 1440208 1440208 BAD DEBT EXPENSE 1128818 1128818 PROVIDER TAX 168153 168153 13938 10437 3501 20540008 17844217 2695791 0 199241 469647 134713 74350 2847107 4161575 134740 230154 239608 157051 134298 27949991 7642075 21967860 20307916 6774818 6966260 644226 666292 32992 38971 923782 965847 34046684 34024764 1392735 1692895 19645000 19255000 870276 816679 450161 395835 225000 175000 22583172 22335409 X 11188472 11495953 251674 170036 23366 23366 11463512 11689355 34046684 34024764 X 394438 -168595 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 8882 4359 1306 11935 0 4160911 106105 286338 3980678 3468333 936413 243835 4160911 23366 3444967 3468333 23366 23366 0.99500 0.00500 0 0 189215 504757 693972 23033720 4620219 18413501 3857004 2966486 890518 365295 55370 309925 20307916 ESTIMATED HEALTH CLAIMS PAYABLE 175000 175000 PART IV, LINE 1B: MEMORIAL HOSPITAL AUXILIARY USES THE HOSPITAL'S FEIN BUT HAS ITS OWN CHECKING ACCOUNT. THE AUXILIARY ACCOUNT BALANCES WERE NOT INCLUDED IN THE FINANICAL STATEMENTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: AN ENDOWMENT FUND WITH THE INCOME TO BE USED FOR THE BENEFIT OF MEMORIAL HOSPITAL ASSOCIATION. $23,366 IS REQUIRED TO BE RETAINED PERMANENTLY, EITHER BY EXPLICIT DONOR STIPULATION OR BY UPMIFA. BOARD DESIGNATED FUNDS ARE TO BE USED FOR FACILITY AND EQUIPMENT UPGRADES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL BELIEVES THAT THEY HAVE APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING THEIR ANNUAL FILING REQUIREMENTS, AND AS SUCH, DO NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO THEIR EXEMPT PURPOSE, IF APPLICABLE. GALA 27016 20615 6401 3632 1000 1414 BARN DANCE 26371 15116 11255 279 633 1788 2387 53387 35731 17656 279 4265 2788 3801 11133 6523 1 1 X 1 X 125.000000000000 1 X 1 1 1 0 1 1 192000 192000 0.00990 4718755 2169930 2548825 0.13130 4910755 2169930 2740825 0.14120 45263 45263 0.00230 15104 15104 0.00080 1511085 1093565 417520 0.02150 1571452 1093565 477887 0.02460 6482207 3263495 3218712 0.16580 415 415 0.00000 7239 7239 0.00040 777 777 0.00000 17253 17253 0.00090 36326 36326 0.00190 62010 62010 0.00320 0 1128818 395086 7530492 7454542 75950 X 1 1 1 1 MEMORIAL HOSPITAL ASSOCIATION

1454 NORTH COUNTY ROAD 2050 CARTHAGE IL 62321

X X X X 2 RHCS - MIDWEST FAMILY MEDICAL CARE & WOMEN & FAMILY MEDICAL GROUP MEMORIAL HOSPITAL ASSOCIATION 1 1 1 125.000000000000 1 200.000000000000 1 X X X X 1 1 X X X 1 0 1 X 0 1 4 BOWEN FAMILY PRACTICE

209 E 5TH STREET BOWEN IL 62316

AMBULATORY ACUTE CARE FACILITY MEMORIAL MEDICAL NAUVOO CLINIC

1370 MULHOLLAND STREET NAUVOO IL 62321

FAMILY MEDICAL CLINIC EVERGREEN CENTER

630 LOCUST STREET CARTHAGE IL 62321

BEHAVIORAL HEALTH SERVICES ADVANCE PHYSICAL THERAPY

620 WABASH STREET CARTHAGE IL 62321

PHYSICAL THERAPY REHABILITATION PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT INFORMATION IS SHARED IN MEMORIAL HOSPITAL'S ANNUAL REPORT AND AVAILABLE ON THEIR WEBSITE. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST TO CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES AND HEALTH PROFESSIONS EDUCATION, LINES 7E AND 7F, ARE REPORTED BASED ON A CALCULATION OF AN AVERAGE SALARY MULTIPLIED BY THE NUMBER OF HOURS WORKED FOR EACH INDIVIDUAL. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $1,128,818. PART II: OUR EMPLOYEES VOLUNTEER EACH YEAR TO MANY WORTHY COMMUNITY PROGRAMS INCLUDING SERVING ON COMMUNITY COORDINATED COALITION COMMITTEES OFFERING EDUCATIONAL EVENTS TO THE COMMUNITY, PARTICIPATING IN MANY LOCAL WALKS/EVENTS SUCH AS THE RELAY FOR LIFE, AND SUPPORTING DISASTER READINESS PLANNING, AMONG HUNDREDS OF OTHER ACTIVITIES. IN FISCAL YEAR 2012 EMPLOYEES ATTENDED SEVERAL BOARD MEETINGS OF ORGANIZATIONS THAT SUPPORT AND IMPROVE COMMUNITY HEALTH AND TRANSPORTATION SERVICES. THE HOSPITAL WAS INVOLVED IN REVITALIZATION PROJECTS BY WORKING IN GARDENS. THE HOSPITAL ALSO HELD A POVERTY DEMONSTRATION TO HIGH SCHOOL STUDENTS, PROVIDED TOURS TO CHILDREN, AND SPONSORED A HIGH SCHOOL JOB SHADOW DAY. THE ORGANIZATION WAS INVOLVED WITH OTHER COMMUNITY BOARDS TO PLAN AND DISCUSS NEW PROSPECTIVE BUSINESSES OR INDUSTRIES THAT COULD POTENTIALLY COME TO THE AREA TO HELP WITH POVERTY AND UNEMPLOYMENT.MEMORIAL HOSPITAL EMPLOYEES SERVE A VITAL ROLE IN LOCAL WORKFORCE DEVELOPMENT AND YOUTH MENTORING IN THE HEALTH CAREERS. IN TOTAL, OUR EMPLOYEES PROVIDED OVER 6,000 HOURS OF HANDS-ON MENTORING WITH AREA STUDENTS, SOME INTERESTED IN HEALTH CAREERS, AND SOME THROUGH OUR INVOLVEMENT WITH THE SCHOOL CO-OP PROGRAM. MEMORIAL HOSPITAL ALSO HAS PARTNERSHIPS WITH KIRKSVILLE SCHOOL OF OSTEOPATHIC MEDICINE AND CARL SANDBURG SCHOOL OF NURSING. IN ADDITION, WE ALSO HOST HIGH SCHOOL LEADERSHIP GROUPS. PART III, LINE 4: ACCOUNTS ARE NOT WRITTEN OFF TO BAD DEBT UNTIL ALL PAYMENTS ON THE ACCOUNT ARE APPLIED INCLUDING ALL THIRD PARTY PAYMENTS, CONTRACTUAL ALLOWANCES, AND DISCOUNTS. ANY FINANCIAL ASSISTANCE OR CHARITY CARE IS RECORDED AS AN ADJUSTMENT TO PATIENT SERVICE REVENUE AND IS NOT WRITTEN OFF TO BAD DEBT. WE REALIZE SOME PATIENTS MAY QUALIFY FOR FINANCIAL ASSISTANCE BUT DO NOT COMPLETE THE REQUIRED PAPERWORK. WE TRY TO WORK WITH THESE PATIENTS TO PROVIDE THEM WITH SOME FORM OF FINANCIAL ASSISTANCE OR OTHER PAYMENT ARRANGEMENTS, BUT WHEN PATIENTS ARE ABLE TO PAY AND DO NOT, THEIR BALANCES ARE WRITTEN OFF TO BAD DEBT. PAYMENTS RECEIVED ON AN ACCOUNT PREVIOUSLY WRITTEN OFF TO BAD DEBT REDUCES BAD DEBT EXPENSE.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON A PERCENTAGE OF APPLICATIONS DENIED FOR FAILURE TO COMPLETE REQUIRED INFORMATION. FINANCIAL STATEMENT FOOTNOTE: THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS, RESIDENTS, AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT AND RESIDENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND RESIDENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. THESE AMOUNTS DO NOT INCLUDE FEE SCHEDULE AMOUNTS. PART III, LINE 9B: MEMORIAL HOSPITAL DOES NOT PURSUE COLLECTION ACTIVITIES FOR PATIENTS THAT QUALIFY FOR CHARITY CARE OR PATIENTS THAT HAVE SET UP PAYMENT ARRANGEMENTS FOR THEIR ACCOUNTS. MEMORIAL HOSPITAL DOES NOT CHARGE INTEREST ON PATIENTS WITH PAYMENT ARRANGEMENTS. ALSO, COLLECTION ACTIVITIES ARE NOT PURSUED FOR PATIENTS THAT ARE IN THE PROCESS OF APPLYING FOR CHARITY CARE AND PATIENTS WAITING FOR APPROVAL OR DENIAL FROM PUBLIC AID. ANY PERSONAL PORTION DUE AFTER FINANCIAL ASSISTANCE IS ESTABLISHED WOULD FOLLOW NORMAL COLLECTION PROCEDURES. MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 13G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS POSTED IN THE REGISTRATION AREAS, EMERGENCY ROOM, WAITING ROOMS, AND ADMISSIONS OFFICES. BROCHURES WITH THE SUMMARY ARE INCLUDED WITH ALL ADMISSIONS PACKAGES. BILLING STATEMENTS INCLUDE A TELEPHONE NUMBER FOR FINANCIAL ASSISTANCE SUPPORT. MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 19D: THE HOSPITAL DID NOT USE ANY OF THESE METHODS TO DETERMINE THE AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. WHEN INDIVIDUALS QUALIFY FOR FINANCIAL ASSISTANCE THEY ARE GIVEN A DISCOUNT OR 100% WRITE-OFF OF THEIR BILL. THE DISCOUNT AND WRITE-OFF IS APPLIED DIRECTLY TO GROSS CHARGES. ALL INDIVIDUALS WITHOUT INSURANCE RECEIVE THE ILLINOIS UNINSURED DISCOUNT ACT DISCOUNT. ALSO, PROMPT PAY DISCOUNTS ARE OFFERED TO ALL PATIENTS. MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 20: THE HOSPITAL DID NOT REDUCE THE GROSS CHARGE BY ONE OF THE APPROVED METHODS. IN THE CURRENT FISCAL YEAR ALL PATIENTS THAT QUALIFIED FOR CHARITY RECEIVED A 100% WRITE-OFF ON THEIR ACCOUNT, THEREFORE NO PATIENTS WHO WERE ELIGIBLE FOR ASSISTANCE WERE CHARGED MORE THAN THE AMOUNTS GENERALLY BILLED TO INDIVIDUALS WHO HAD INSURANCE. MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 21: ONE OF THE 501(R) APPROVED METHODS FOR DISCOUNTING GROSS CHARGES WAS NOT USED FOR FINANCIAL ASSISTANCE ELIGIBLE PATIENTS, HOWEVER, NO PATIENT WAS BILLED AND REQUIRED TO PAY GROSS CHARGES. THE FINANCIAL ASSISTANCE POLICY ADJUSTMENT WAS APPLIED DIRECTLY TO GROSS CHARGES. THE HOSPITAL IS CURRENTLY LOOKING AT IMPLEMENTING EITHER THE "LOOK-BACK METHOD" OR THE "PROSPECTIVE MEDICARE METHOD." PART VI, LINE 2: MEMORIAL HOSPITAL, BASED ON ITS MISSION, WANTS TO ENSURE THAT THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES ARE MET. THE HOSPITAL HAS MEDICAL CLINICS LOCATED THROUGHOUT HANCOCK COUNTY TO IMPROVE ACCESS TO HEALTH CARE SERVICES TO OUR PATIENTS. THE BOARD ALSO HAS FOUR COMMITTEES; FINANCE, PLANNING, QUALITY AND COMMUNITY HEALTH, AND MARKETING COMMITTEES THAT HAVE COMMUNITY REPRESENTATION TO ENSURE THAT INPUT IS OBTAINED FROM THE COMMUNITY WHEN CONSIDERING THE HEALTH CARE NEEDS OF THOSE WE SERVE. COMMUNITY INPUT ON DESIRED SERVICES IS OBTAINED THROUGH PATIENT SATISFACTION SURVEYS THAT ARE INITIATED BY THE INPATIENT UNIT, EMERGENCY DEPARTMENT, AND MEDICAL CLINICS THAT PROVIDE A LINE OF COMMUNICATION TO IDENTIFY ADDITIONAL HEALTH CARE SERVICES THAT COMMUNITY DESIRES. PART VI, LINE 3: MEMORIAL HOSPITAL STRIVES TO PROVIDE A REWARDING AND HEALING PROCESS TO OUR PATIENTS, PLUS AN AFFORDABLE, COMFORTABLE PROCESS TO MEET THEIR FINANCIAL OBLIGATIONS. MEMORIAL HOSPITAL INFORMS THEIR PATIENTS INDIVIDUALLY UPON ADMISSION ABOUT THE ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS, AND PROVIDES THE PATIENT WITH INFORMATION REGARDING THE ORGANIZATION'S CHARITY CARE POLICY.OUR COLLECTION AND FINANCIAL ASSISTANCE POLICIES AND APPLICATIONS ARE ON OUR WEBSITE. WE ALSO PROVIDE FINANCIAL COUNSELING TO ANY PATIENT. WE POST OUR CHARITY CARE POLICY AND INFORMATION REGARDING FEDERAL, STATE, AND LOCAL PROGRAMS AT ALL OUR REGISTRATION AREAS. BROCHURES ARE DISTRIBUTED REGARDING FINANCIAL ASSISTANCE WITH ALL ADMISSION PACKAGES.BILLING STATEMENTS HAVE FINANCIAL ASSISTANCE SUPPORT TELEPHONE NUMBERS AT THE BOTTOM OF EACH STATEMENT. OUR THIRD PARTY BILLING SERVICE PROVIDES COUNSELING TO OUR PATIENTS REGARDING AVAILABLE FINANCIAL ASSISTANCE IF THERE IS A NEED. PART VI, LINE 4: MEMORIAL HOSPITAL ASSOCIATION IS AN 18-BED CRITICAL ACCESS HOSPITAL LOCATED IN CARTHAGE, IL. CARTHAGE IS A CITY IN HANCOCK COUNTY, ILLINOIS. IT IS LOCATED IN WESTERN ILLINOIS ALONG THE MISSISSIPPI RIVER. THE NEAREST CITY WITH A POPULATION > 50,000 IS PEORIA, IL. THE POPULATION OF CARTHAGE WAS 2,447 AT THE 2010 CENSUS. MEMORIAL HOSPITAL SERVES THE COUNTY OF HANCOCK IN THE STATE OF ILLINOIS. HANCOCK COUNTY IS A RURAL COMMUNITY WITH THE MEDIAN INCOME OF $42,857 COMPARED TO $55,735 IN THE STATE OF ILLINOIS. IN THE YEARS 2005-2009 13% OF THE POPULATION WAS IN POVERTY. THE UNEMPLOYMENT RATE FOR 2010 WAS 10.2%, COMPARED TO 9.1% FOR THE U.S. AVERAGE. THE MOST COMMON INDUSTRIES ARE AGRICULTURE, TRANSPORTATION, AND HEALTH CARE. THE NEAREST HOSPITAL IS KEOKUK AREA HOSPITAL ABOUT 15 MILES AWAY ON THE IOWA SIDE OF THE MISSISSIPPI RIVER. PART VI, LINE 5: MEMORIAL HOSPITAL IS DEDICATED TO IMPROVING HEALTH BY PROVIDING EDUCATION AND WELLNESS PROGRAMS AND INNOVATIVE SERVICES AT ALL THE STAGES OF LIFE FOR RESIDENTS OF HANCOCK COUNTY. THE HOSPITAL IS GOVERNED BY A 12-MEMBER, VOLUNTEER BOARD OF DIRECTORS THAT REPRESENT KEY AREAS WITHIN HANCOCK COUNTY AS WELL AS THE MEDICAL STAFF. AS A CRITICAL ACCESS HOSPITAL, MEMORIAL HOSPITAL IS AN 18-BED FACILITY THAT PROVIDES GENERAL MEDICAL, SURGICAL SERVICES ALONG WITH OBSTETRICS AND AN ARRAY OF OUTPATIENT SERVICES FOR THE COMMUNITY. SPECIALTY CLINICS ARE ALSO PROVIDED LOCALLY IN THE AREAS OF CARDIOLOGY, ONCOLOGY, NEUROLOGY, OPHTHALMOLOGY, PODIATRY, ORTHOPEDIC, PULMONOLOGY, AND SLEEP APNEA SO THAT OUR PATIENTS DON'T HAVE TO TRAVEL FAR TO RECEIVE NEEDED HEALTH CARE SERVICES. THESE SPECIALTY PHYSICIANS ARE MEMBERS OF THE HOSPITAL'S MEDICAL STAFF ALONG WITH OTHER PROVIDERS THAT DESIRE TO SERVE MEMBERS OF OUR SERVICE AREA. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. WITH THE SUPPORT OF THE COMMUNITY, MEMORIAL HOSPITAL BUILT A NEW 18-BED HOSPITAL THAT WAS OCCUPIED IN AUGUST, 2009. THE FACILITY PROVIDES UP-TO-DATE, DIAGNOSTIC EQUIPMENT AND SERVICES WITH A CAPITAL BUDGET ALSO PRESENTED AND APPROVED ON AN ANNUAL BASIS TO ENSURE THAT NEEDED EQUIPMENT IS OBTAINED TO MEET THE EXPECTATIONS OF OUR PATIENTS. MEMORIAL HOSPITAL OPERATES AN EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF ABILITY TO PAY.THE HOSPITAL ALSO PARTICIPATES IN SEVERAL HEALTH CARE EVENTS THROUGHOUT THE YEAR PROVIDING FREE SERVICES AS WELL AS A LISTING OF SERVICES THAT ARE OFFERED THROUGH THE HOSPITAL, CLINICS, AND SPECIALTY CLINICS. THIS INCLUDES, BUT IS NOT LIMITED TO, HEALTH FAIRS, BLOOD PRESSURE SCREENINGS, AND DIABETIC EDUCATION. MEMORIAL HOSPITAL SPONSORS THE BLOODMOBILE AND PROVIDES LANGUAGE ASSISTANCE SERVICES. X 1 1 X X X X 0 0 0 0 0 0 0 0 0 ADA BAIR 180015 0 0 0 156 0 0 0 9207 0 189378 0 0 0 CHRISTOPHER JONES MD 277963 0 10500 0 49 0 0 0 25982 0 314494 0 0 0 PHILIP A CAROPRESO MD 268619 0 0 0 3680 0 0 0 15455 0 287754 0 0 0 DOUGLAS HEIGHTON MD 175099 0 15000 0 142 0 0 0 25060 0 215301 0 0 0 DAVID SMITH MD 187457 0 0 0 137 0 0 0 4822 0 192416 0 0 0 JEFFREY LEON MD 162767 0 4000 0 39 0 0 0 29162 0 195968 0 0 0 PART I, LINE 1A DR. PHILIP CAROPRESO HAS A TRAVEL ALLOWANCE THAT IS REIMBURSED TO HIM FOR MILEAGE TO AND FROM WORK. IT IS A STANDARD AMOUNT PAID MONTHLY, WITHOUT ANY SPECIFIC TRIP REPORTING REQUIRED. WESTERN ILLINOIS ECONOMIC DEVELOPMENT AUTHORITY 352256539 958362AT2 2008-08-22 9972195 FACILITY/EQUIP UPGRADES & REFUND REVENUE BONDS SERIES 2007 ISSUED 12/27/07 0 0 0 WESTERN ILLINOIS ECONOMIC DEVELOPMENT AUTHORITY 352256539 958362AU9 2008-09-16 10385000 NEW FACILITY AND EQUIPMENT UPGRADES 0 0 0 1130000 9972195 193445 9778750 2009 1 0 1 1 10777128 392128 207014 10177986 2009 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 0 0 0 0 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 11: THE OTHER SPENT PROCEEDS WERE USED TO CURRENTLY REFUND BONDS ON AUGUST 22, 2008. SCHEDULE K, PART I, ROW B, COLUMN (E) AND PART II, LINE 3, COLUMN (B): THE DIFFERENCE BETWEEN PART I, ROW B, COLUMN (E) AND PART II, LINE 3, COLUMN (B) IS THE INTEREST EARNED ON THE BOND PROCEEDS DURING THE CONSTRUCTION PHASE. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE PRESIDENT, THE VICE PRESIDENT, THE SECRETARY/TREASURER AND SUCH ADDITIONAL MEMBERS AS THE BOARD APPOINTS AND THE CHIEF EXECUTIVE OFFICER AND ANY OTHER LEADERSHIP TEAM MEMBERS DEEMED APPROPRIATE BY THE OFFICERS OF THE BOARD. THE CHIEF EXECUTIVE OFFICER AND ANY LEADERSHIP TEAM MEMBERS SHALL NOT HAVE THE RIGHT TO VOTE UPON ANY ACTION BEING TAKEN. THE EXECUTIVE COMMITTEE MEETS ONLY IN THE EVENT THAT THE BOARD IS UNABLE TO TAKE NECESSARY ACTION, HAS AN AGENDA FOR EACH MEETING, KEEPS MINUTES OF ITS MEETINGS, AND MAILS A COPY OF THE MINUTES OF EACH MEETING TO EACH MEMBER OF THE BOARD OF DIRECTORS WITHIN TWENTY-FOUR (24) HOURS OF THE ADJOURNMENT OF THE MEETING. THE PRIMARY PURPOSE OF THE EXECUTIVE COMMITTEE IS TO CARRY OUT CRITICAL TASKS FOR EFFECTIVE BOARD FUNCTIONING, INCLUDING, BUT NOT LIMITED TO, CHIEF EXECUTIVE OFFICER MANAGEMENT PERFORMANCE, MANAGEMENT COMPANY PERFORMANCE, IF APPLICABLE, AND PROVIDING ASSISTANCE TO THE BOARD IN SITUATIONS REQUIRING ACTION WHEN IT IS IMPOSSIBLE OR IMPRACTICAL TO CONVENE A FULL BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATION HAS ONE CLASS OF MEMBERS. ANY INDIVIDUAL OR ORGANIZATION THAT CONTRIBUTES ONE HUNDRED DOLLARS ($100.00) OR MORE, UPON APPLICATION IS ENTITLED TO RECEIVE LIFE MEMBERSHIP IN THE CORPORATION. SUCH MEMBERSHIPS ARE NOT TRANSFERABLE. THE MEMBERSHIP OF THIS CORPORATION IS UNLIMITED. FORM 990, PART VI, SECTION A, LINE 7A MEMORIAL HOSPITAL ASSOCIATION HAS ASSOCIATION MEMBERS WHO ARE PRESENTED WITH A SLATE OF OFFICERS AND BOARD MEMBERS AT THE ANNUAL MEETING. THE ASSOCIATION VOTES BY PROXY TO ELECT THESE OFFICERS AND BOARD MEMBERS. EACH MEMBER IS ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS. NO PERSON WHOSE NAME DOES NOT APPEAR ON THE LIST OF MEMBERS KEPT BY THE SECRETARY-TREASURER IS ENTITLED TO VOTE AND THERE IS NO CUMULATIVE VOTING. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE FINANCE COMMITTEE AND THEN BY THE BOARD OF DIRECTORS BEFORE IT IS FILED. THE FINAL RETURN IS REVIEWED AND SIGNED BY THE CFO. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST STATEMENT UPON HIRING OR BECOMING A BOARD MEMBER. THE DISCLOSURE IS UPDATED AT THE ANNUAL ASSOCIATION MEETING. ANY POSSIBLE CONFLICT OF INTEREST IS DISCLOSED TO THE OTHER BOARD MEMBERS AND MADE A MATTER OF RECORD THROUGH AN ANNUAL PROCEDURE AND ALSO WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. DISCLOSURES ARE REVIEWED BY THE BOARD OF DIRECTORS AND ANY MEMBER FOR WHOM CONFLICTS HAVE BEEN IDENTIFIED LEAVE THE ROOM AND ABSTAIN FROM VOTING. APPROPRIATE DOCUMENTATION OF THE HANDLING OF THE CONFLICT IS KEPT TO PROTECT THE INTERESTED PARTY AND MEMORIAL HOSPITAL ASSOCIATION. ADDITIONALLY, THE COMPLIANCE OFFICER MEETS WITH THE COMPLIANCE COMMITTEE OF THE BOARD. ANY ISSUES IDENTIFIED ARE LOGGED AND FOLLOWED UP BY THE COMPLIANCE OFFICER. FORM 990, PART VI, SECTION B, LINE 15A SALARY SURVEYS ARE REVIEWED ANNUALLY TO ENSURE ALL POSITIONS INDIVIDUALLY ARE WITHIN THE MARKET RATE. SURVEYS ARE USED FROM THE LOCAL AREA (BLESSING SURVEY) AND LSN & QHR (COMPARABLE ORGANIZATION SURVEYS). THE EXECUTIVE COMMITTEE DETERMINES THE SALARY FOR THE CEO. EACH BOARD MEMBER DOES AN INDEPENDENT PERFORMANCE REVIEW OF THE CEO, WHICH IS COMPILED AND USED BY THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE USES THE ILLINOIS HOSPITAL ASSOCIATION SALARY SURVEY AS A GUIDE FOR COMPENSATION USING THE HIGH, MIDDLE, AND LOW RANGES FOR SIMILAR SIZE ORGANIZATIONS. MEASURES SUCH AS REVENUE, PERFORMANCE OF THE CEO, AND BUDGETARY CONSTRAINTS ARE ALL FACTORS THAT ARE CONSIDERED WHEN REVIEWING THE CEO'S SALARY. THE MOST RECENT REVIEW OF SALARY OCCURRED IN JANUARY 2012. THE SALARY FOR THE CFO IS DETERMINED BY THE CEO USING THE BLESSING SURVEY AND THE ILLINOIS HOSPITAL ASSOCIATION SURVEY AS A GUIDE FOR SIMILAR ORGANIZATIONS BASED ON THE LOCAL AREA. THE MOST RECENT REVIEW OF SALARY OCCURRED IN JANUARY 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL ARE ALSO REQUIRED TO BE ATTACHED TO THE FORM 990. FORM 990, PAGE 7, PART VII: THE FOLLOWING INDIVIDUALS DEVOTED TIME PROVIDING SERVICES TO THESE RELATED ORGANIZATIONS: HANCOCK COUNTY NURSING HOME ASSOCIATION DAN ASBURY 1 HOUR PER WEEK LUANN HAAS 1 HOUR PER WEEK PEGGY LATHEROW 1 HOUR PER WEEK MATT DICKINSON 1 HOUR PER WEEK CAROL GRONEWOLD 1 HOUR PER WEEK KATHY HOLST 1 HOUR PER WEEK LARRY MCCLINTOCK 1 HOUR PER WEEK EDWARD MCKENNEY 1 HOUR PER WEEK SHARON MORRISON 1 HOUR PER WEEK TERRY POPE 1 HOUR PER WEEK DENNIS RANKIN 1 HOUR PER WEEK ANGELA POLLOCK 1 HOUR PER WEEK CHARLES GILBERT 1 HOUR PER WEEK ADA BAIR 3 HOURS PER WEEK TERESA SMITH 3 HOURS PER WEEK ADVANCE PHYSICAL THERAPY LARRY MCCLINTOCK 1 HOUR PER WEEK SHERRICK HOME HEALTH LARRY MCCLINTOCK 1 HOUR PER WEEK HANCOCK COUNTY SLF, LLP DAN ASBURY 1 HOUR PER WEEK LUANN HAAS 1 HOUR PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -165,542. CHANGE IN MEMORIAL HOSPITAL AUXILIARY'S ASSETS -3,053. TOTAL TO FORM 990, PART XI, LINE 5: -168,595. HANCOCK COUNTY NURSING HOME ASSOCIATION PO BOX 160 CARTHAGE IL 62321 370902248 PROVIDE EDUCATION AND WELLNESS PROGRAMS AND INNOVATIVE SERVICES IL 501(C)(3) LINE 3 MEMORIAL HOSPITAL ASSOCIATION 1 ADVANCE PHYSICAL THERAPY 620 WABASH STREET CARTHAGE IL 62321 113655886 PHYSICAL THERAPY REHABILITATION IL MEMORIAL HOSPITAL ASSOCIATION RELATED 88805 35598 0 1 0.50000 HANCOCK COUNTY SLF LLP 403 S ADAMS CARTHAGE IL 62321 204445121 ASSISTED LIVING FACILITY IL N/A HANCOCK AREA MEDICAL SUPPLY DBA SHERRICK HOME HEALTH 525 MAIN ST CARTHAGE IL 62321 371180373 HOME HEALTH IL MEMORIAL HOSPITAL ASSOCIATION C 564160 494197 1.00000 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 1 HANCOCK COUNTY NURSING HOME ASSOCIATION J 107461 GENERAL LEDGER ADVANCE PHYSICIAL THERAPY R 58518 GENERAL LEDGER ADVANCE PHYSICAL THERAPY I 90000 GENERAL LEDGER