2013-11-08T13:35:01-06:00 2012-12-31 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 2000 INDIANAPOLIS IN 462045108 990 2012-01-01 356001540 GOSHEN HOSPITAL ASSOCIATION INC GOSH 5745742665 200 HIGH PARK AVENUE GOSHEN IN 46526 AMY FLORIA 5745352661 2013-11-08 1 SHAWNA M JIMENEZ P01222873 3174648600 2012 2016-02-25 16:41:14Z IU HEALTH GOSHEN HOSPITAL RANDAL CHRISTOPHEL 200 HIGH PARK AVENUE GOSHEN IN 46526 229625584 0 X WWW.IUHEALTH.ORG/GOSHEN X 1946 IN TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES. 12 8 1440 355 -185089 -185089 158830 126834 200406955 219847588 5421558 2802296 3656377 6848866 209643720 229625584 260500 208000 0 0 76970083 79425542 0 0 0 117865606 107837862 195096189 187471404 14547531 42154180 207700119 253624903 69536171 68217308 138163948 185407595 X THE MISSION OF IU HEALTH GOSHEN HOSPITAL IS TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES, THROUGH EXCEPTIONAL PEOPLE DOING EXCEPTIONAL WORK. 0 0 156003187 208000 224732005 IU HEALTH GOSHEN HOSPITAL IS A NON-DENOMINATIONAL NON-FOR-PROFIT ORGANIZATION PROVIDING HEALTH CARE SERVICES FOR THE GENERAL PUBLIC AS WELL AS CHARITY WITHIN THE COMMUNITY. SEE SCHEDULE O FOR ADDITIONAL DETAIL.THE MISSION OF IU HEALTH GOSHEN HOSPITAL IS TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICE, THROUGH EXCEPTIONAL PEOPLE DOING EXCEPTIONAL WORK.THE HOSPITAL'S VALUES INCLUDE: COMPASSION - AND COMMITMENT TO SERVICE WITH EMPATHY. ACCOUNTABILITY - WITH INTEGRITY AND ACTION. RESPECT - THROUGH TREATING OTHERS AS YOU WISH TO BE TREATED. EXCELLENCE - IN ALL WE DO.BUILDING UPON OUR HERITAGE AND VALUES, IU HEALTH GOSHEN HOSPITAL WILL DELIVER EXCEPTIONAL HEALTHCARE IN AN INTEGRATED MODEL TO THE COMMUNITIES WE SERVE, ACHIEVING PREEMINENCE WITH COMMITMENT TO QUALITY, LEADERSHIP, AND INNOVATION. BY 2015, WE WILL ACHIEVE ALL ELEMENTS OF THIS VISION BY FOCUSING ON THE FOLLOWING KEY AREAS:- PROVIDING HIGH-QUALITY CARE WITH COMPASSION, VALUE AND STATE-OF-THE-ART TECHNOLOGY;- CREATING AN ENVIRONMENT THAT FOSTERS THE HIGHEST LEVEL OF ENTHUSIASM, COMMITMENT, COLLABORATION AND SATISFACTION;- STRATEGICALLY RESPONDING TO OUR DIVERSE COMMUNITY'S CHANGING HEALTHCARE NEEDS, WITH INCREASING EMPHASIS ON WELLNESS; AND- HELPING OUR COMMUNITIES TO BE THE "BEST PLACES" TO LIVE AND WORK.AS A COMMUNITY HOSPITAL, IU HEALTH GOSHEN HOSPITAL IS DEDICATED TO MEETING THE SPECIFIC HEALTH CARE NEEDS OF OUR COMMUNITIES. AS A COMMUNITY LEADER, THE HOSPITAL IS COMMITTED TO PROVIDING CARE IN AN INNOVATIVE AND DYNAMIC ENVIRONMENT. THE HOSPITAL HAS 123 PATIENT BEDS AND OVER 142 PHYSICIANS ON ITS MEDICAL STAFF IN NEARLY 25 SPECIALTIES. THESE PHYSICIANS, TOGETHER WITH OTHER DEDICATED PROFESSIONALS, PROVIDE A WIDE RANGE OF SERVICES INCLUDING THE FOLLOWING: ACUTE MEDICAL & SURGICAL, EMERGENCY, HOME HEALTH, RADIOLOGY, LABORATORY, CANCER CARE, BARIATRICS, WOMEN'S HEALTH, PAIN MANAGEMENT, SLEEP STUDIES, REHABILITATION, PATIENT AND COMMUNITY HEALTH EDUCATION AND PROFESSIONAL EDUCATION.IU HEALTH GOSHEN HOSPITAL HAS CONSISTENTLY MET NATIONAL QUALITY STANDARDS. THE HOSPITAL COMPOSITE SCORES FOR PUBLICLY REPORTED QUALITY MEASURES IN THE AREAS OF ACUTE MYOCARDIAL INFARCTION, PNEUMONIA, HEART FAILURE, SURGICAL CARE IMPROVEMENT PROJECT, AND HOSPITAL OUTPATIENT EXCEED 95% IN 2012. IN ADDITION, HEALTHCARE EXCEL (QUALITY IMPROVEMENT ORGANIZATION FOR INDIANA) REPORTED THAT THE HOSPITAL WAS ABOVE OUR PEER GROUP AND OVERALL STATE PERFORMANCE IN ALL AREAS OF OUR PUBLICLY REPORTED MEASURES FOR THE 4 QUARTERS ENDING MARCH 31, 2012.THE AMERICAN NURSES CREDENTIALING CENTER'S (ANCC) MAGNET RECOGNITION PROGRAM FOR EXCELLENCE IN NURSING SERVICES HAS DESIGNATED IU HEALTH GOSHEN HOSPITAL AS A MAGNET HOSPITAL. DESIGNATED HOSPITALS HAVE SUCCESSFULLY CREATED A WORK ENVIRONMENT THAT NURSES FIND BOTH PERSONALLY AND PROFESSIONALLY REWARDING, ADVANCING THE PRACTICE OF NURSING AND IMPROVING PATIENT OUTCOMES. RESEARCH SHOWS THAT MAGNET HOSPITALS ARE MORE EFFECTIVE AT ATTRACTING AND KEEPING QUALITY NURSES. IU HEALTH GOSHEN HOSPITAL IS AMONG AN ELITE GROUP OF ONLY 7% OF HOSPITALS IN THE NATION TO BE RE-DESIGNATED AS A MAGNET FACILITY AND THE ONLY FACILITY IN THE REGION.THE GOSHEN CENTER FOR CANCER CARE IS ACCREDITED BY THE COMMISSION ON CANCER OF THE AMERICAN COLLEGE OF SURGEONS (COC). RECEIVING CARE AT A COC-APPROVED CENTER FOR CANCER CARE ASSURES THAT PATIENTS WILL HAVE ACCESS TO:- QUALITY CARE CLOSE TO HOME.- COMPREHENSIVE CARE OFFERING A RANGE OF STATE-OF-THE ART SERVICES AND EQUIPMENT.- A MULTIDISCIPLINARY TEAM APPROACH TO COORDINATE THE BEST TREATMENT OPTIONS AVAILABLE TO CANCER PATIENTS.- PARTICIPATION IN CANCER CLINICAL TRIALS, EDUCATION AND SUPPORT.- LIFELONG PATIENT FOLLOW-UP THROUGH A CANCER REGISTRY THAT COLLECTS DATA ON TYPE AND STAGE OF CANCERS AND TREATMENT RESULTS.- ONGOING MONITORING AND IMPROVEMENT IN CARE.THE CENTER FOR CANCER CARE IS A LEADER IN INNOVATIVE CANCER TREATMENT. WE WERE AMONG THE FIRST TO ADOPT A COMPREHENSIVE, MULTIDISCIPLINARY APPROACH TO CANCER TREATMENT. WE OFFER HOLISTIC PROGRAMS FOR STRENGTHENING MINDS AS WELL AS BODIES, PLACE A PREMIUM ON FAMILY INVOLVEMENT AND SPIRITUAL NEEDS, AND ENCOURAGE PATIENTS TO PLAY A DECISION-MAKING ROLE IN TREATMENT SELECTION. THE CENTER FOR CANCER CARE HAS SPECIALLY TRAINED SURGICAL ONCOLOGISTS, A BREAST SURGEON, MEDICAL ONCOLOGIST, A RADIATION ONCOLOGIST, NATUROPATHIC PRACTITIONERS AND HIGHLY DISTINGUISHED MAGNET DESIGNATED NURSES.IU HEALTH GOSHEN HOSPITAL IMPROVES THE HEALTH AND WELL-BEING OF ITS COMMUNITIES BY PROVIDING COMMUNITY WELLNESS AND EDUCATION PROGRAMS. THROUGH LOCAL PARTNERSHIPS, THE HOSPITAL IDENTIFIES HEALTH ISSUES AND CREATES PROGRAMS TO ENSURE OUR COMMUNITY IS THE HEALTHIEST PLACE TO LIVE, WORK AND RAISE A FAMILY. THE FIRST OF THESE PROGRAMS COVER CPR, EMS, DIABETES, CHILDBIRTH, FITNESS, NUTRITION, COMMUNITY EDUCATION AND HEALTH SCREENINGS AND ELKHART COUNTY CHILDHOOD OBESITY INITIATIVE. THE CPR CLASS IS FOR ANYONE - PROFESSIONALS OR PRIVATE CITIZENS - WHO WANT TO KNOW HOW TO PERFORM LIFE-SAVING CARDIOPULMONARY RESUSCITATION; FIRST AID CLASSES ARE ALSO OFFERED. EMS TRAINING IS AVAILABLE FOR PERSONS INTERESTED IN BECOMING EMERGENCY MEDICAL TECHNICIANS OR FIREFIGHTERS. THE DIABETES EDUCATION HELPS PEOPLE DELAY THE ONSET AND SLOW THE PROGRESSION OF COMPLICATIONS FROM THIS DISEASE. IT INCLUDES SEMINARS, SUPPORT GROUPS, CONSULTATIONS AND SCREENINGS. CHILDBIRTH EDUCATION PREPARES EXPECTANT MOTHERS AND THEIR FAMILIES DURING THIS SIGNIFICANT TIME IN THEIR LIFE. CLASSES REVIEW MANY ASPECTS OF CHILDBIRTH INCLUDING LABOR REHEARSAL, CESAREAN DELIVERIES, SINGLE-TEEN ISSUES, BREAST FEEDING AND A CLASS JUST FOR SIBLINGS. IN ADDITION TO VARIOUS COMMUNITY WELLNESS AND EDUCATION PROGRAMS, IU HEALTH GOSHEN HOSPITAL PROVIDES A FULL-SERVICE RESOURCE FOR COMPREHENSIVE HEALTH INFORMATION AND ASSISTANCE. NURSE ON CALL (NOC) IS FULL-SERVICE, MULTI-LINGUAL HEALTH INFORMATION, REFERRAL AND NURSE TRIAGE TELEPHONE SERVICE AVAILABLE 24 HOURS A DAY, 7 DAYS WEEK. NOC IS STAFFED BY SPECIALLY TRAINED, KNOWLEDGEABLE AND EXPERIENCED REGISTERED NURSES. THIS FREE SERVICE PROVIDES MEDICAL GUIDANCE WHEN SICK OR INJURED, INFORMATION ON PHYSICIANS IN THE AREA, REFERRALS TO COMMUNITY RESOURCES AND REGISTRATION FOR CLASSES AND EVENTS. ANNUALLY, IU HEALTH GOSHEN HOSPITAL MAKES CONTRIBUTIONS TO WELL-DESERVING ORGANIZATIONS FROM GOSHEN AND THE SURROUNDING COMMUNITIES. THE HOSPITAL SUPPORTS AREA NON-PROFIT AGENCIES THAT SHARES ITS MISSION, VISION AND VALUES THROUGH THE COMMUNITY BENEFIT FUND. THE PROGRAM IS AN EFFORT TO FURTHER THE IMPACT THESE ORGANIZATIONS CAN MAKE AND INCREASE THE NUMBER OF BENEFICIAL PROGRAMS AVAILABLE TO THE COMMUNITY. IN 2012, THE HOSPITAL PROVIDED OVER $208,000 TO 57 ORGANIZATIONS. SINCE ITS INCEPTION IN 1998, THE COMMUNITY BENEFIT FUND HAS GIVEN OVER $1.9 MILLION IN GRANT MONEY. IU HEALTH GOSHEN HOSPITAL PROVIDES HEALTH CARE SERVICES TO ALL MEMBERS OF THE COMMUNITIES REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL OFFERS FINANCIAL ASSISTANCE TO THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR BILL AND WHO ARE UNABLE TO QUALIFY FOR ASSISTANCE THROUGH FEDERAL AND STATE GOVERNMENT ASSISTANCE PROGRAMS. PATIENTS ARE ASKED TO COMPLETE A FINANCIAL AID APPLICATION TO DETERMINE THEIR ELIGIBILITY FOR FINANCIAL ASSISTANCE. THE HOSPITAL PROVIDES THE ASSISTANCE OF A FINANCIAL ADVOCATE TO HELP PATIENTS COMPLETE THIS APPLICATION AND TO INVESTIGATE OTHER FORMS OF AVAILABLE ASSISTANCE. IN 2012, THE HOSPITAL EXTENDED CHARITY CARE TO OVER 3,955 PATIENTS TOTALING $9.3 MILLION. IU HEALTH GOSHEN HOSPITAL ALSO PARTNERS WITH A LOCAL FINANCIAL INSTITUTION TO PROVIDE A FLEXIBLE AND AFFORDABLE FINANCING SOLUTION FOR A PATIENT'S MEDICAL CARE.IU HEALTH GOSHEN HOSPITAL RECEIVED THE GOLD PERFORMANCE ACHIEVEMENT AWARD BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION'S NCDR ACTION REGISTRY (2011) - ONE OF ONLY 167 HOSPITALS NATIONWIDE TO EARN THE DISTINCTION. IU HEALTH GOSHEN HOSPITAL WAS NAMED AMONG "100 BEST PLACES TO WORK IN HEALTHCARE" BY HOSPITAL REVIEW MAGAZINE IN 2012.IU HEALTH GOSHEN HOSPITAL WAS RECOGNIZED IN 2011 BY THE AMERICAN COLLEGE OF SURGEONS THROUGH THEIR NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM AS ONE OF 26 HOSPITALS ACHIEVING EXEMPLARY PERFORMANCE FOR SURGICAL PATIENT CARE.IU HEALTH GOSHEN HOSPITAL HAS BEEN NAMED AN ACCREDITED HEART FAILURE INSTITUTE BY THE NATIONAL HEALTHCARE ACCREDITATION COLLOQUIUM. 156003187 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 131 0 1 1440 1 1 1 0 0 0 0 0 0 0 0 0 X 12 8 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X DIRECTOR OF FINANCE 5745352665 200 HIGH PARK AVENUE GOSHEN IN 46526 JAMES DAGUE 40.00 1.00 X X 1301376 0 909574 RANDY CHRISTOPHEL 40.00 1.00 X X 531555 0 108161 LINDA BAXLEY 1.00 0.00 X X 0 0 0 DERALD BONTRAGER 1.00 1.00 X X 0 0 0 RANDY CRIPE 1.00 0.00 X 0 0 0 KEVIN DEARY 1.00 0.00 X 0 0 0 DON OGLE 1.00 0.00 X 0 0 0 MARTHA SUZIE YEAGER 1.00 0.00 X 0 0 0 KAREN PLETCHER 1.00 0.00 X 0 0 0 DAN NAFZIGER MD 1.00 40.00 X 0 157948 15616 DANIEL BERGER MD 1.00 40.00 X 0 204518 21697 KAREN SMITH 1.00 0.00 X 0 0 0 JODY NEER MD 1.00 40.00 X 0 375228 32561 SUSAN STIFFNEY 1.00 0.00 X 0 0 0 RAO BETINA MD 1.00 0.00 X 0 0 0 JESSE BERGER 1.00 0.00 X 0 0 0 EDWARD BOYTS MD 1.00 40.00 X 0 206096 27926 CHRISTOPHER GRAFF 1.00 0.00 X 0 0 0 AMY FLORIA 40.00 1.00 X 346891 0 33436 RANDALL CAMMENGA MD 40.00 1.00 X 422534 0 32731 ALAN WELDY 40.00 1.00 X 432856 0 30311 POOPALASINGHAM POOVENDRAN 40.00 0.00 X 583979 0 33301 MIN YAN 40.00 0.00 X 369015 0 31395 MARIA GARCIA 40.00 0.00 X 293989 0 29342 PAMELA KARSEN 40.00 0.00 X 290908 0 27543 XI ZEE WANG 40.00 0.00 X 253968 0 30924 4827071 943790 1364518 40 0 1 0 HEALTHTRAN LLC PO BOX 712460 CINCINNATI OH 452712460 COLLEAGUE DRUG BENEFIT 1242673 GERIG SURGICAL ASSOCIATES PC 2006 SOUTH MAIN STREET STE A GOSHEN IN 46526 ON CALL SERVICES 948795 QUEST DIAGNOSTICS PO BOX 12989 CHICAGO IL 60693 LAB SERVICES 663456 LANDAUER MEDICAL PHYSICS PO BOX 809153 CHICAGO IL 606809153 CONSULTING SERVICES 396200 VENTURE INTERNATIONAL LLC PO BOX 461 HUDSONVILLE MI 49426 CONSULTING SERVICES 208505 14 126834 126834 PATIENT CARE 621110 219847588 219847588 219847588 2802296 -185089 2987385 1028204 0 1028204 1028204 1028204 FOOD SERVICE REVENUE 721000 936245 936245 FINANCE CHARGES 561000 232643 232643 OTHER ONCOLOGY REV MIS 621500 189173 189173 4462601 4462601 5820662 229625584 224732005 -185089 4951834 X 208000 208000 3035212 3035212 57697999 39476587 18221412 2111223 1372295 738928 12608042 8201830 4406212 3973066 2582493 1390573 1410147 3443 1406704 302426 2862 299564 5229 5229 61262 61262 26095617 26095617 4172083 4172083 884549 884549 1343674 1343674 968526 968526 713648 713648 1964383 1964383 9661063 9661063 10533210 10533210 1510444 1510444 DRUGS AND MED. SUPPLIES 38801228 38801228 0 0 REPAIRS & MAINTENANCE 5567396 5567396 0 0 EQUIPMENT RENTAL 1899106 1899106 0 0 UTILITIES 1792826 1792826 0 0 151045 151045 187471404 156003187 31468217 0 12472332 24428555 11282149 12511479 27017971 29335784 860326 1292423 4577268 6005926 2555123 4232372 209175133 106626380 100484922 102548753 47774955 71931547 675073 1338064 207700119 253624903 22615615 22783313 44970675 43481171 1949881 1952824 69536171 68217308 X 137554991 184767777 608957 639818 0 0 138163948 185407595 207700119 253624903 X 42154180 4467998 301733 319736 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5229 5229 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENSES REPRESENT THE PORTION OF DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION THAT IS SPECIFICALLY ALLOCABLE TO LOBBYING. 2988795 3883888 6872683 95917748 30608078 65309670 377004 113748 169703 321049 102771345 75848599 26922746 3122605 3122605 102548753 BOARD DESIGNATED FUNDS 70390365 F CANCER CENTER INVESTMENT 1541182 F 71931547 ASSET RETIREMENT OBLIGATION 202334 DEFERRED COMPENSATION 482650 DEFERRED MALPRACTICE CLAIMS 292977 INTEREST RATE SWAP 974863 1952824 1 1 X 1 X 1 X 1 1 1 0 1 1 3878331 3878331 0.02070 22895509 22944254 -48745 0.00000 26773840 22944254 3829586 0.02070 937064 66866 870198 0.00460 226231 35649 190582 0.00100 665950 665950 0.00360 1829245 102515 1726730 0.00920 28603085 23046769 5556316 0.02990 6613 6613 0.00000 51079 51079 0.00030 75 102 7105 7105 0.00000 15533 15533 0.00010 75 102 80330 80330 0.00040 1 8439410 994631 39166512 45206412 -6039900 X 1 1 1 1 IU HEALTH GOSHEN HOSPITAL

200 HIGH PARK AVENUE GOSHEN IN 46526

WWW.IUHEALTH.ORG/GOSHEN X X X IU HEALTH GOSHEN HOSPITAL 1 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X 1 0 X X 1 X 0 0 4 IU HEALTH GOSHEN

200 HIGH PARK AVENUE GOSHEN IN 46526

CLINIC THE RETREAT WOMEN'S HEALTH CENTER

1135 PROFESSIONAL DRIVE GOSHEN IN 46526

CLINIC INDIANA LAKES MANAGED CARE

2018 SOUTH MAIN STREET GOSHEN IN 46526

HEALTH CARE MANAGEMENT NEW PARIS MEDICAL CLINIC

2018 SOUTH MAIN STREET GOSHEN IN 46526

CLINIC PART I, LINE 7: IN 2012, GOSHEN HOSPITAL ASSOCIATION, INC. RECEIVED RETROACTIVE MEDICAID PAYMENTS FROM THE HOSPITAL ASSESSMENT FEE ("HAF") PROGRAM. THIS RETROACTIVE PAYMENT REPRESENTED TWELVE MONTHS OF MEDICAID REIMBURSEMENT FOR 2012 ALONG WITH SIX ADDITIONAL MONTHS OF REIMBURSEMENT RELATED TO TAX YEAR 2011 CLAIMS. AS A RESULT OF THE RETROACTIVE MEDICAID PAYMENTS RECEIVED FROM THE HAF PROGRAM, GOSHEN HOSPITAL ASSOCIATION, INC.'S COMMUNITY BENEFIT PERCENTAGE IS 2.99% IN 2012 COMPARED TO 7.65% IN 2011. PART III, LINE 2: GOSHEN HOSPITAL ASSOCATION, INC.'S ANALYSIS AND ASSESSMENT OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND RELATED BAD DEBT EXPENSE USES A RECEIPTS "LOOK-BACK" METHOD UTILIZING HISTORICAL PAYMENT DATA ON ACCOUNTS, INCLUDING CONTRACTUAL ADJUSTMENTS FOR PAYER DISCOUNTS, AS WELL AS PATIENT PAYMENTS, SUCH AS CO-PAYS AND DEDUCTIBLES, TO ESTABLISH ANTICIPATED COLLECTABILITY RATES FOR ACCOUNTS RECEIVABLE WITHIN EACH PAYER CATEGORY. PART III, LINE 3: GOSHEN HOSPITAL ASSOCATION, INC. ESTIMATED THE POSSIBLE AMOUNT OF CHARITY CARE WITHIN BAD DEBT EXPENSE BY REVIEWING ACCOUNTS THAT WERE INTERNALLY CODED AS HAVING BEEN PROVIDED A FINANCIAL ASSISTANCE APPLICATION, BUT THAT WAS NOT COMPLETED BY THE PATIENT OR GUARANTOR, IN WHICH THE ACCOUNT WAS SUBSEQUENTLY WRITTEN OFF TO BAD DEBT. PART III, LINE 4: THE FOLLOWING NARRATIVE ADDRESSES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS WHICH IS INCLUDED IN THE FOOTNOTES IN THE FINANCIAL STATEMENTS FOR IU HEALTH: THE PROVISION FOR UNCOLLECTED PATIENT ACCOUNTS, FOR ALL PAYORS, IS RECOGNIZED WHEN SERVICES ARE PROVIDED BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, TAKING INTO CONSIDERATION BUSINESS AND ECONOMIC CONDITIONS, CHANGES AND TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON ACCOUNTS RECEIVABLE PAYOR COMPOSITION AND AGING, THE SIGNIFICANCE OF INDIVIDUAL PAYORS TO OUTSTANDING ACCOUNTS RECEIVABLE BALANCES, AND HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY, AS ADJUSTED FOR COLLECTION INDICATORS. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR UNCOLLECTED PATIENT ACCOUNTS AND THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. IN ADDITION, THE INDIANA UNIVERSITY HEALTH SYSTEM FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES. PATIENT ACCOUNTS THAT ARE UNCOLLECTED, INCLUDING THOSE PLACED WITH COLLECTION AGENCIES, ARE INITIALLY CHARGED AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IN ACCORDANCE WITH COLLECTION POLICIES OF THE INDIANA UNIVERSITY HEALTH SYSTEM AND, IN CERTAIN CASES, ARE RECLASSIFIED TO CHARITY CARE IF DEEMED TO OTHERWISE MEET FINANCIAL ASSISTANCE POLICIES OF THE INDIANA UNIVERSITY HEALTH SYSTEM. PART III, LINE 8: ACTUAL MONTH TO DATE AND YEAR TO DATE REVENUES, CONTRACTUALS, REVENUE AND ACCOUNTS RECEIVABLE RELATED RATIOS, AND REVENUE RELATED STATISTICS (DAYS, DISCHARGES, ETC.) ARE COMPARED TO BUDGET AND PRIOR YEAR AMOUNTS ON A MONTHLY BASIS BY THE CFO OF GOSHEN HOSPITAL'S DEPARTMENT HEADS AND FINANCIAL REPRESENTATIVES. ADDITIONALLY, ACTUAL CONTRACTUAL ALLOWANCE AS A PERCENTAGE OF GROSS ACCOUNTS RECEIVABLE AND CONTRACTUAL PROVISION AS A PERCENTAGE OF GROSS PATIENT CHARGES COMPARED TO BUDGETED AND PRIOR YEAR AMOUNTS ARE MONITORED. THIS IS DONE AS PART OF THE HOSPITAL'S MONTHLY CLOSE PROCESS. EXPLANATIONS TO VARIANCES (OR NON-VARIANCES WHEN EXPECTED) ARE RESEARCHED AND PROVIDED BY THE APPROPRIATE PERSONNEL AND REVIEWED WITH MANAGEMENT OF THE HOSPITAL. THE FINANCE DEPARTMENT ALSO CONSIDERS THESE KEY PERFORMANCE INDICATORS WHEN DEVELOPING THEIR ESTIMATES OF CONTRACTUAL ALLOWANCES TO ENSURE RECORDED AMOUNTS APPEAR REASONABLE BASED ON ACTUAL DATA AVAILABLE.FINANCIAL REPRESENTATIVES PREPARE AND UPDATE THE CONTRACTUAL ALLOWANCE MODEL A MINIMUM OF THREE TIMES THROUGHOUT THE YEAR AS A BASIS FOR ALL THIRD PARTY PAYORS BASED ON ACTUAL STATISTICS (E.G. DISCHARGES, DAYS, ETC.) AND ON CURRENT REIMBURSEMENT RATES. THE MODEL ANALYZES PATIENT RECEIVABLES AND CONTRACTUAL ALLOWANCE BY PAYOR AND BY PATIENT STATUS. THE MODEL ESTIMATES THE COLLECTABILITY OF PATIENT ACCOUNTS BASED ON HISTORICAL COLLECTION RATES. FINANCE COLLEAGUES ALSO UPDATE THE MODEL TO ACCOUNT FOR CHANGES IN REIMBURSEMENT RULES. AFTER THE MODEL IS PREPARED, IT IS REVIEWED BY THE CHIEF FINANCIAL OFFICER FOR APPROPRIATENESS AND REASONABLENESS.CONTRACTUAL ALLOWANCE CALCULATIONS ARE RECONCILED TO THE GENERAL LEDGER ON A MONTHLY BASIS. ONCE THE CALCULATION IS PREPARED, THE FINANCE DEPARTMENT ADJUSTS THE GENERAL LEDGER ACCOUNTS. PART III, LINE 9B: FINANCIAL ASSISTANCE IS GRANTED TO THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR BILL AND WHO ARE UNABLE TO QUALIFY FOR ASSISTANCE THROUGH FEDERAL AND STATE GOVERNMENT ASSISTANCE PROGRAMS. IF AFTER INSURANCE REIMBURSEMENT ADDITIONAL ASSISTANCE IS NEEDED, ALL PATIENTS MAY OBTAIN FINANCIAL ASSISTANCE IF THE INCOME CRITERIA ARE MET. ALL FINANCIAL ASSISTANCE APPLICATIONS ARE BASED ON POLICY GUIDELINES. UNINSURED PATIENTS ARE REQUIRED TO PROVIDE DOCUMENTATION AND AN APPLICATION. WHEN APPROVED, THE ADJUSTMENT IS APPLIED TO THE PATIENT'S ACCOUNT. FOR PATIENTS WHO DO NOT QUALIFY FOR CHARITY CARE OF FINANCIAL ASSISTANCE, PAYMENT PLANS AND LUMP SUM SETTLEMENTS ARE AVAILABLE. IU HEALTH GOSHEN HOSPITAL ALSO PARTNERS WITH A LOCAL FINANCING INSTITUTION TO PROVIDE A FLEXIBLE AND AFFORDING FINANCING SOLUTION. IU HEALTH GOSHEN HOSPITAL PART V, SECTION B, LINE 12H: FAMILY SIZE IS ANOTHER FACTOR IN DETERMINING DISCOUNTS GRANTED TO PATIENTS. PART VI, LINE 2: AS A COMMUNITY HOSPITAL, IU HEALTH GOSHEN HOSPITAL IS DEDICATED TO MEETING THE SPECIFIC HEALTH CARE NEEDS OF OUR COMMUNITY. THE HOSPITAL HAS 123 PATIENT BEDS AND OVER 142 PHYSICIANS ON ITS MEDICAL STAFF IN NEARLY 25 SPECIALTIES. THESE PHYSICIANS, TOGETHER WITH OTHER DEDICATED PROFESSIONALS, PROVIDE A WIDE RANGE OF SERVICES INCLUDING THE FOLLOWING: ACUTE MEDICAL & SURGICAL, EMERGENCY, HOME HEALTH, RADIOLOGY, LABORATORY, CANCER CARE, BARIATRICS, WOMEN'S HEALTH, PAIN MANAGEMENT, SLEEP STUDIES, REHABILITATION, PATIENT AND COMMUNITY HEALTH EDUCATION AND PROFESSIONAL EDUCATION.THE CENTER FOR CANCER CARE IS A LEADER IN INNOVATIVE CANCER TREATMENT. WE WERE AMONG THE FIRST TO ADOPT A COMPREHENSIVE, MULTIDISCIPLINARY APPROACH TO CANCER TREATMENT. WE OFFER HOLISTIC PROGRAMS FOR STRENGTHENING MINDS AS WELL AS BODIES, PLACE A PREMIUM ON FAMILY INVOLVEMENT AND SPIRITUAL NEEDS, AND ENCOURAGE PATIENTS TO PLAY A DECISION-MAKING ROLE IN TREATMENT SELECTION. THE CENTER FOR CANCER CARE HAS SPECIALLY TRAINED SURGICAL ONCOLOGISTS, A BREAST SURGEON, MEDICAL ONCOLOGISTS, A RADIATION ONCOLOGIST, NATUROPATHIC PRACTITIONERS AND HIGHLY DISTINGUISHED MAGNET DESIGNATED NURSES.IU HEALTH GOSHEN HOSPITAL IMPROVES THE HEALTH AND WELL-BEING OF ITS COMMUNITIES BY PROVIDING COMMUNITY WELLNESS AND EDUCATION PROGRAMS. THROUGH LOCAL PARTNERSHIPS, THE HOSPITAL IDENTIFIES HEALTH ISSUES AND CREATES PROGRAMS TO ENSURE OUR COMMUNITY IS THE HEALTHIEST PLACE TO LIVE, WORK AND RAISE A FAMILY. THE FIRST OF THESE PROGRAMS COVER CPR, EMS, DIABETES, CHILDBIRTH, FITNESS, NUTRITION, COMMUNITY EDUCATION AND HEALTH SCREENINGS AND ELKHART COUNTY CHILDHOOD OBESITY INITIATIVE. THE CPR CLASS IS FOR ANYONE - PROFESSIONALS OR PRIVATE CITIZENS - WHO WANT TO KNOW HOW TO PERFORM LIFE-SAVING CARDIOPULMONARY RESUSCITATION; FIRST AID CLASSES ARE ALSO OFFERED. EMS TRAINING IS AVAILABLE FOR PERSONS INTERESTED IN BECOMING EMERGENCY MEDICAL TECHNICIANS OR FIREFIGHTERS. THE DIABETES EDUCATION HELPS PEOPLE DELAY THE ONSET AND SLOW THE PROGRESSION OF COMPLICATIONS FROM THIS DISEASE. IT INCLUDES SEMINARS, SUPPORT GROUPS, CONSULTATIONS AND SCREENINGS. CHILDBIRTH EDUCATION PREPARES EXPECTANT MOTHERS AND THEIR FAMILIES DURING THIS SIGNIFICANT TIME IN THEIR LIFE. CLASSES REVIEW MANY ASPECTS OF CHILDBIRTH INCLUDING LABOR REHEARSAL, CESAREAN DELIVERIES, SINGLE-TEEN ISSUES, BREAST FEEDING AND A CLASS JUST FOR SIBLINGS. IN ADDITION TO VARIOUS COMMUNITY WELLNESS AND EDUCATION PROGRAMS, IU HEALTH GOSHEN HOSPITAL PROVIDES A FULL-SERVICE RESOURCE FOR COMPREHENSIVE HEALTH INFORMATION AND ASSISTANCE. NURSE ON CALL (NOC) IS FULL-SERVICE, MULTI-LINGUAL HEALTH INFORMATION, REFERRAL AND NURSE TRIAGE TELEPHONE SERVICE AVAILABLE 24 HOURS A DAY, 7 DAYS WEEK. NOC IS STAFFED BY SPECIALLY TRAINED, KNOWLEDGEABLE AND EXPERIENCED REGISTERED NURSES. THIS FREE SERVICE PROVIDES MEDICAL GUIDANCE WHEN SICK OR INJURED, INFORMATION ON PHYSICIANS IN THE AREA, REFERRALS TO COMMUNITY RESOURCES AND REGISTRATION FOR CLASSES AND EVENTS. PART VI, LINE 3: UNINSURED PATIENTS ARE SCREENED DURING THE PRE-REGISTRATION PROCESS FOR ELIGIBILITY IN THE HEALTHY INDIANA PLAN AND FOR ANY OTHER KNOWN SOURCES OF FINANCIAL ASSISTANCE. ALL REGISTRATION LOCATIONS HAVE FINANCIAL ASSISTANCE FORMS AVAILABLE FOR SELF-PAY PATIENTS TO COMPLETE AND WILL HAVE INFORMATION ON THE CRITERIA AND PROCESS FOR APPLYING FOR FINANCIAL ASSISTANCE. APPLICATIONS ARE ALSO PROVIDED TO ANY PATIENTS WITH A BALANCE DUE WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE. COUNSELORS ARE AVAILABLE TO PATIENTS TO AID IN THE APPLICATION PROCESS INCLUDING THE COLLECTION OF INFORMATION TO COMPLETE THE APPLICATION. PAYMENT OPTIONS AND INFORMATION ON FINANCIAL ASSISTANCE IS AVAILABLE ON THE HOSPITAL'S WEBSITE. PATIENTS MAY DOWNLOAD A PRELIMINARY APPLICATION, AND THE PATIENT AGREEMENT ASSOCIATED WITH FINANCIAL ASSISTANCE FROM THE WEBSITE. THIS INFORMATION IS AVAILABLE IN ENGLISH AND SPANISH. PART VI, LINE 4: IU HEALTH GOSHEN HOSPITAL SERVES THE NORTHERN INDIANA AREA IN ELKHART COUNTY. ACCORDING TO THE 2012 CENSUS, THE POPULATION OF ELKHART COUNTY IS 199,619. THE MEDIAN INCOME FOR A HOUSEHOLD IN ELKHART COUNTY BASED ON THE 2012 CENSUS IS $47,308 AND THE MEDIAN INCOME FOR A FAMILY IS $54,285. APPROXIMATELY 10.1% OF FAMILIES AND 15.7% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 24.0% OF THOSE UNDER THE AGE 18 AND 7.8% OF THOSE AGE 65 AND OVER. THE RACIAL MAKEUP OF THE COUNTY WAS ABOUT 76.7% WHITE, 6.0% AFRICAN AMERICAN, AND 18.7% OTHER RACES. 4.0% OF THE POPULATION IS HISPANIC OR LATINO. PART VI, LINE 5: ALL OF THE HOSPITAL'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. A MAJORITY OF THE BOARD MEMBERS ARE INDEPENDENT OF THE ORGANIZATION. THE GOVERNING BODY APPROVES MEDICAL STAFF PRIVILEGES AS INDICATED IN THE ORGANIZATION'S CREDENTIALING AND PRIVILEGING POLICIES AND AS RECOMMENDED BY THE MEDICAL EXECUTIVE COMMITTEE OF THE HOSPITAL. THE HOSPITAL'S GOVERNING BODY APPROVES THE ANNUAL OPERATING BUDGET FOR THE HOSPITAL AND THE EXPENDITURE OF CAPITAL FUNDS ABOVE CERTAIN DOLLAR AMOUNTS. THE GOVERNING BODY ALSO PARTICIPATES IN STRATEGIC PLANNING INITIATIVES TO DETERMINE GOALS OBJECTIVES FOCUSED ON PATIENT CARE FOR THE COMMUNITY. PART VI, LINE 6: HOSPITAL MANAGEMENT PROVIDES IU HEALTH WITH THE HOSPITAL'S ANNUAL OPERATING BUDGET AND KEY STRATEGIC OBJECTIVES. IN ADDITION, THE HOSPITAL MANAGEMENT PROVIDES IU HEALTH WITH VARIOUS KEY METRICS INVOLVING PATIENT SATISFACTION, PATIENT QUALITY AND COLLEAGUE SATISFACTION. IU HEALTH REVIEWS THE DATA TO ENSURE KEY INITIATIVES ARE FOCUSED TOWARDS THE PROMOTING AND MEETING THE HEALTHCARE NEEDS OF THE COMMUNITIES. IN ADDITION, THE HOSPITAL COLLABORATES WITH IU HEALTH TO PROVIDE NECESSARY NURSING EDUCATION AND PHYSICIAN RECRUITMENT TO ASSIST IN MEETING THE HEALTH NEEDS OF THE COMMUNITY. REPORTS FILED WITH STATES PART VI, LINE 7 IN 1 BASHOR CHILDREN'S HOME 62226 COUNTY ROAD 15 GOSHEN IN 46526 350933555 501(C)(3) 7500 OPERATING SUPPORT BOYS & GIRLS CLUB OF GREATER GOSHEN INC 102 WEST LINCOLN SUITE 240 GOSHEN IN 46526 351033735 501(C)(3) 15000 OPERATING SUPPORT CENTER FOR HEALING & HOPE 423 E JEFFERSON STREET GOSHEN IN 46528 020560511 501(C)(3) 5000 OPERATING SUPPORT COUNCIL ON AGING OF ELKHART COUNTY INC 230 E JACKSON BLVD ELKHART IN 46516 510178910 501(C)(3) 5000 OPERATING SUPPORT ELKHART COUNTY HEALTH DEPARTMENT-HEALTHY BEGINNINGS 1400 HUDSON STREET ELKHART IN 46516 350909968 GOV'T ENTITY 5000 OPERATING SUPPORT ELKHART COUNTY PROSECUTOR'S OFFICE 301 SOUTH MAIN STREET SUITE 100 ELKHART IN 46516 356000142 GOV'T ENTITY 5000 OPERATING SUPPORT FAMILY CHRISTIAN DEVELOPMENT CENTER 151 S LOCKE STREET NAPPANEE IN 46550 351979463 501(C)(3) 5000 OPERATING SUPPORT FAMILY SERVICES OF ELKHART COUNTY INC 101 EAST HIVELY AVE ELKHART IN 46517 350868079 501(C)(3) 5000 OPERATING SUPPORT LACASA INC 202 N COTTAGE AVE GOSHEN IN 46528 351554538 501(C)(3) 5000 OPERATING SUPPORT LAGRANGE COUNTY COUNCIL ON AGING PO BOX 107 LAGRANGE IN 46761 237455893 501(C)(3) 5000 OPERATING SUPPORT MAPLE CITY HEALTH CARE CENTER 213 MIDDLEBURY STREET GOSHEN IN 46528 351749398 501(C)(3) 20000 OPERATING SUPPORT NORTHERN INDIANA HISPANIC HEALTH COALITION NIHHC 444 N NAPPANEE ST ELKHART IN 46514 320039221 501(C)(3) 7500 OPERATING SUPPORT OAKLAWN PSYCHIATRIC CENTER 330 LAKEVIEW DRIVE GOSHEN IN 46527 351070041 501(C)(3) 10000 OPERATING SUPPORT UNITED CANCER SERVICES OF ELKHART COUNTY INC 23971 US HIGHWAY 33 ELKHART IN 46530 351091429 501(C)(3) 15000 OPERATING SUPPORT GOSHEN COLLEGE 1700 S MAIN GOSHEN IN 46526 352158366 501(C)(3) 10000 OPERATING SUPPORT GOSHEN HIGH SCHOOL 401 LINCOLNWAY EAST GOSHEN IN 46526 356002423 GOV'T ENTITY 5000 OPERATING SUPPORT THE WINDOW INC 223 S MAIN ST GOSHEN IN 46526 351427937 501(C)(3) 5000 OPERATING SUPPORT 17 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE U.S. CONSISTS OF REQUIRING THE COMPLETION OF A FOLLOW-UP REPORT FORM WITH SUBSEQUENT GRANT FUND APPLICATIONS. X X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 JAMES DAGUE 110908 0 314750 0 875718 0 908208 0 1366 0 2210950 0 0 0 RANDY CHRISTOPHEL 332857 0 99225 0 99473 0 99561 0 8600 0 639716 0 0 0 DAN NAFZIGER MD 0 51751 0 100652 0 5545 0 15319 0 297 0 173564 0 0 DANIEL BERGER MD 0 107120 0 86148 0 11250 0 19322 0 2375 0 226215 0 0 JODY NEER MD 0 303933 0 41555 0 29740 0 24495 0 8066 0 407789 0 0 EDWARD BOYTS MD 0 141097 0 64199 0 800 0 20158 0 7768 0 234022 0 0 AMY FLORIA 237438 0 80112 0 29341 0 24495 0 8941 0 380327 0 0 0 RANDALL CAMMENGA MD 299166 0 89412 0 33956 0 24495 0 8236 0 455265 0 0 0 ALAN WELDY 316800 0 102343 0 13713 0 24495 0 5816 0 463167 0 0 0 POOPALASINGHAM POOVENDRAN 563498 0 0 0 20481 0 24495 0 8806 0 617280 0 0 0 MIN YAN 300786 0 25800 0 42429 0 24495 0 6900 0 400410 0 0 0 MARIA GARCIA 282151 0 800 0 11038 0 24495 0 4847 0 323331 0 0 0 PAMELA KARSEN 215414 0 67437 0 8057 0 24495 0 3048 0 318451 0 0 0 XI ZEE WANG 212568 0 800 0 40600 0 24495 0 6429 0 284892 0 0 0 PART I, LINE 1A TAX INDEMNIFICATION AND GROSS-UP PAYMENTS IU HEALTH GOSHEN HOSPITAL GROSSED UP THE TAXABLE VALUE OF AUTOMOBILES FOR 3 OF THE OFFICERS LISTED IN FORM 990, PART VII AND INCLUDED THE AMOUNT IN THE EMPLOYEES' W-2 AS ADDITIONAL COMPENSATION. HEALTH OR SOCIAL CLUB DUES IU HEALTH GOSHEN HOSPITAL PAID FOR COUNTRY CLUB DUES FOR 4 OF THE OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES LISTED IN FORM 990, PART VII. ALL REIMBURSEMENTS ARE CONSIDERED TAXABLE INCOME TO THE EMPLOYEES. SUPPLEMENTAL INFORMATION PART III PART I, LINE 4A: AS PER OUR EMPLOYMENT AGREEMENT, UPON A QUALIFYING TERMINATION DEFINED AS AN INVOLUNTARY SEPARATION FROM SERVICE OTHER THAN FOR CAUSE, THE EMPLOYEE IS ENTITLED TO SEVERANCE PAY BASED UPON YEARS OF SERVICE. THE TERMS AND CONDITIONS TO RECEIVE SEVERANCE PAYMENTS REQUIRE THE EMPLOYEE TO SIGN A RELEASE OF CLAIMS FORM THAT COVERS ALL SITUATIONS SURROUNDING THE EMPLOYEE'S EMPLOYMENT AND SEPARATION FROM IU HEALTH GOSHEN. JAMES DAGUE $475,821 SUPPLEMENTAL INFORMATION PART III PART I, LINE 4B: ALL EMPLOYEES AND AMOUNTS LISTED ARE VOLUNTARY DEFERRALS OR COMPANY CONTRIBUTIONS TO VARIOUS NON-QUALIFIED DEFERRED COMPENSATION PLANS ORGANIZED UNDER CODE SECTION 457(F). THE EXACT PURPOSE OF EACH PLAN VARIES BUT THEY INCLUDE: COMPENSATION LIMITATION MAKE-UP PLANS, VOLUNTARY DEFERRAL PLANS, DEFERRAL OF A PORTION OF INCENTIVE BONUS TYPE PLANS, ETC. RANDY CHRISTOPHEL $27,838 JAMES DAGUE $103,389 FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE EMPLOYEES OF IU HEALTH GOSHEN HOSPITAL OR ITS RELATED ORGANIZATIONS, AND SERVE ON OTHER RELATED TAXABLE BOARDS: JAMES DAGUE RANDY CHRISTOPHEL AMY FLORIA ALAN WELDY FORM 990, PART VI, SECTION A, LINE 6 IU HEALTH GOSHEN IS THE SOLE MEMBER OF IU HEALTH GOSHEN HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A IU HEALTH GOSHEN AS THE SOLE MEMBER OF IU HEALTH GOSHEN HOSPITAL HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B ITEMS THAT REQUIRE APPROVAL OF IU HEALTH GOSHEN INCLUDE ANY AMENDMENT OF THE OPERATING AGREEMENT, DISSOLUTION OF THE ORGANIZATION OR THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND THE AUDIT COMMITTEE IN OCTOBER FOR REVIEW AND QUESTIONS BEFORE THE RETURN IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER COMPLETES AN ANNUAL DISCLOSURE OF KNOWN OR POTENTIAL CONFLICTS. EACH DISCLOSURE IS REVIEWED BY THE VP-LEGAL. ADDITIONALLY WHEN AGENDA ITEMS ARE DISCUSSED AT MEETINGS IT IS ASKED IF THERE ARE ANY KNOWN OR POTENTIAL CONFLICTS OF INTEREST, AND CONFLICTED PARTIES MUST RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT COMMITTEE APPROVES THE COMPENSATION WHICH IS DETERMINED TO BE REASONABLE BASED UPON INDEPENDENT COMPARABILITY DATA PROVIDED BY AN INDEPENDENT CONSULTANT. APPROVAL OF AMOUNTS ARE DOCUMENTED IN THE MINUTES. FORM 990, PART VI, SECTION C, LINE 19 IU HEALTH GOSHEN HOSPITAL WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 314,447. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 314,447. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,315,341. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,315,341. OUTSIDE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 23,465,829. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 23,465,829. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: EQUITY TRANSFERS 308,190. INTEREST RATE SWAP 11,546. NAPPANEE CLINIC LLC 200 HIGH PARK AVENUE GOSHEN IN 46526 201068334 HEALTHCARE IN 0 0 GHS INDIANA LAKES MANAGED CARE ORG LLC 200 HIGH PARK AVENUE GOSHEN IN 46526 351946663 HEALTHCARE IN -266451 365203 N/A PILR INC 200 HIGH PARK AVE GOSHEN IN 46526 204294750 DEVELOPMENT IN 0 0 GHS CLARIAN TRANSPLANT INSTITUTE INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 134350599 HEALTHCARE IN 501(C)(3) 9 IUH 1 GOSHEN HEALTH SYSTEM INC 200 HIGH PARK AVE GOSHEN IN 46526 351974765 HEALTHCARE IN 501(C)(3) 11 I IUH 1 HEALTHLINC INC 714 S ROGERS ST BLOOMINGTON IN 47402 263571507 HEALTHCARE IN 501(C)(3) 9 IUHB 1 INDIANA RADIOLOGY PARTNERS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 201017034 HEALTHCARE IN 501(C)(3) 3 IUH 1 INDIANA UNIVERSITY HEALTH INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351955872 HEALTHCARE IN 501(C)(3) 3 N/A 0 IU HEALTH ARNETT FOUNDATION INC 2600 GREENBUSH ST LAFAYETTE IN 47904 356079797 FUNDRAISING IN 501(C)(3) 11 I IUHA 1 IU HEALTH ARNETT INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 263162145 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH BALL MEMORIAL HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 350867958 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH BALL MEMORIAL PHYSICIANS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351925641 HEALTHCARE IN 501(C)(3) 9 IUHBMH 1 IU HEALTH BEDFORD INC 2900 W 16TH ST BEDFORD IN 47421 237042323 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH BLACKFORD HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 010646166 HEALTHCARE IN 501(C)(3) 3 IUHBMH 1 IU HEALTH BLOOMINGTON INC PO BOX 1149 BLOOMINGTON IN 47403 351720796 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH BMH FOUNDATION INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 311111784 FUNDRAISING IN 501(C)(3) 11 I IUHBMH 1 IU HEALTH CARE ASSOCIATES INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351747218 HEALTHCARE IN 501(C)(3) 9 IUH 1 IU HEALTH LAPORTE HOSPITAL INC PO BOX 250 LAPORTE IN 46352 351125434 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH LAPORTE PHYSICIANS INC PO BOX 250 LAPORTE IN 46352 311070868 HEALTHCARE IN 501(C)(3) 3 IUHLH 1 IU HEALTH MORGAN HOSPITAL INC 2209 JOHN R WOODEN DR MARTINSVILLE IN 46151 273533027 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH NORTH HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351932442 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH PAOLI HOSP FOUNDATION INC PO BOX 499 PAOLI IN 47454 310992486 FUNDRAISING IN 501(C)(3) 11 III-O IUHP 1 IU HEALTH PAOLI INC PO BOX 499 PAOLI IN 47454 352090919 HEALTHCARE IN 501(C)(3) 3 IUHB 1 IU HEALTH TIPTON HOSPITAL INC 1000 S MAIN ST TIPTON IN 46072 262772226 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH WEST HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351814660 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU HEALTH WHITE MEMORIAL HOSPITAL INC 720 S SIXTH ST MONTICELLO IN 47960 273532963 HEALTHCARE IN 501(C)(3) 3 IUH 1 IU MEDICAL GROUP FOUNDATION INC 340 W 10TH ST NO FS5100 INDIANAPOLIS IN 46202 201093251 FUNDRAISING IN 501(C)(3) 11 II N/A 0 METHODIST HEALTH FOUNDATION INC 1800 N CAPITOL AVE INDIANAPOLIS IN 46202 356043086 FUNDRAISING IN 501(C)(3) 11 I IUH 1 METHODIST HEALTH GROUP INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 350876390 HEALTHCARE IN 501(C)(3) 11 III-FI N/A 0 METHODIST MEDICAL GROUP INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351945384 HEALTHCARE IN 501(C)(3) 3 IUH 1 METHODIST OCCUP HEALTH CENTERS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351844176 HEALTHCARE IN 501(C)(3) 3 IUH 1 METHODIST RESEARCH INSTITUTE INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 352023710 HEALTHCARE IN 501(C)(3) 11 I IUH 1 MH HEALTHCARE INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351766531 HEALTHCARE IN 501(C)(3) 3 MMG 1 MORGAN CO MEM HOSP FOUNDATION INC 2209 JOHN R WOODEN DR MARTINSVILLE IN 46151 352035162 FUNDRAISING IN 501(C)(3) 11 II IUHMH 1 MORGAN CO MEM HOSP GUILD INC 2209 JOHN R WOODEN DR MARTINSVILLE IN 46151 310886844 FUNDRAISING IN 501(C)(3) 11 III-FI IUHMH 1 MORGAN HEALTH SERVICES INC 1949 HOSPITAL DR MARTINSVILLE IN 46151 351968564 HEALTHCARE IN 501(C)(3) 3 IUHMH 1 WHITE CO MEM HOSP FOUNDATION INC PO BOX 952 MONTICELLO IN 47960 351671806 FUNDRAISING IN 501(C)(3) 11 III-O IUHWMH 1 UNIVERSITY FAMILY PHYSICIANS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 237427350 HEALTHCARE IN 501(C)(3) 9 IUHCA 1 REHABILITATION HOSPITAL OF INDIANA INC 4141 SHORE DRIVE INDIANAPOLIS IN 46254 351786005 HEALTHCARE IN 501(C)(3) 3 IUH 1 RHI FOUNDATION INC 4141 SHORE DRIVE INDIANAPOLIS IN 46254 351932349 FUNDRAISING IN 501(C)(3) 11 I RHI 1 BALL OUTPATIENT SURGERY CENTER LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 270275794 HEALTHCARE IN N/A BELTWAY SURGERY CENTERS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 352072586 HEALTHCARE IN N/A BLOOMINGTON ENDOSCOPY CENTERS LLC PO BOX 1149 BLOOMINGTON IN 47402 352117943 HEALTHCARE IN N/A BMH OUTPATIENT SURGERY SERVICES LLC 2401 W UNIVERSITY AVE MUNCIE IN 47303 204567998 HEALTHCARE IN N/A BOSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 454147343 HEALTHCARE IN N/A CARDINAL HEALTH INITIATIVES LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 300102702 PURCHASING IN N/A CHV FUND I LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 262523206 VENTURE CAPITAL IN N/A CHV FUND MANAGEMENT LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 262523151 VENTURE CAPITAL IN N/A CLARIAN HEALTH NETWORK LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 352055030 HEALTHCARE IN N/A CTF INTERNATIONAL GROWTH PORTFOLIO 280 CONGRESS ST STE 500 BOSTON MA 02210 200231923 INVESTMENTS MA N/A EAGLE HIGHLANDS SURGERY CENTER LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 352259204 HEALTHCARE IN N/A EHSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 454147879 HEALTHCARE IN N/A HEALTH VENTURE MANAGEMENT LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 205740218 MANAGEMENT IN N/A IEC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 454148032 HEALTHCARE IN N/A INDIANA ENDOSCOPY CENTERS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 208398421 HEALTHCARE IN N/A BSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 452314634 HEALTHCARE IN N/A MID-AMERICA SURGERY CENTER LLC 2401 W UNIVERSITY AVE MUNCIE IN 47303 352002953 HEALTHCARE IN N/A ROC SURGERY LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 271497960 HEALTHCARE IN N/A ROCS HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 454148369 HEALTHCARE IN N/A SENATE STREET SURGERY CENTER LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 421709357 HEALTHCARE IN N/A SSSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM AL 35244 454148167 HEALTHCARE IN N/A CARDINAL HEALTH ALLIANCE LLC 2401 W UNIVERSITY AVE MUNCIE IN 47303 351966281 MANAGED CARE IN N/A BMH MEDICAL PAVILION ASSOCIATION INC 2525 W UNIVERSITY AVE MUNCIE IN 47303 351858408 CONDO MANAGEMENT IN N/A C 0 CARDINAL HEALTH VENTURES INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 351611424 MANAGEMENT IN N/A C 0 CHV CAPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 260752507 VENTURE CAPITAL IN N/A C 0 IU HEALTH ACO INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 454421020 HEALTHCARE IN N/A C 0 IU HEALTH BOARD DESIGNATED TRUST 400 HOWARD ST SAN FRANCISCO CA 94105 306309021 INVESTMENTS IN N/A T 0 IU HEALTH NTGI S&P500 FUND CF PO BOX 804358 CHICAGO IL 60680 306298263 INVESTMENTS IN N/A T 0 IU HEALTH PLANS INC 1776 MERIDIAN ST STE 300 INDIANAPOLIS IN 46202 262127080 HMO IN N/A C 0 IU HEALTH RISK PURCHASING GROUP INC 151 MEETING ST STE 301 CHARLESTON SC 29401 260202446 INSURANCE IN N/A C 0 IU HEALTH RISK RETENTION GROUP INC 151 MEETING ST STE 301 CHARLESTON SC 29401 201107674 INSURANCE SC N/A C 0 IU HEALTH SOUTHERN IN PHYSICIANS INC PO BOX 1149 BLOOMINGTON IN 47402 351913875 HEALTHCARE IN N/A C 0 IUH ASSURANCE LTD 720 W BAY RD PO BOX 69 GRAND CAYMAN CJ 980395429 INSURANCE CJ N/A C 0 OCC-HEALTH REVENUE SYSTEMS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 203308057 WORK COMP PPO IN N/A C 0 PARKMOR DRUG INC 200 HIGH PARK AVE GOSHEN IN 46526 351394980 PHARMACY SALES IN GHS C 490662 3184510 1.00000 1 RADIATION ONCOLOGY RESOURCES INC 200 HIGH PARK AVE GOSHEN IN 46526 262008424 HEALTHCARE IN GHS C -763735 308944 1.00000 1 SCANS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 453080392 HEALTHCARE IN N/A C 0 UNIVERSITY HEALTH MANAGEMENT INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 272891143 MANAGEMENT IN N/A C 0 UNIVERSITY HEALTH MGMT (CHINA) INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 273891311 MANAGEMENT IN N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 GOSHEN HEALTH SYSTEM INC O 11108698 FMV GOSHEN HEALTH SYSTEM INC R 9661063 FMV GOSHEN HEALTH SYSTEM INC S 10223739 FMV