2011-11-15T12:11:19-06:00 2010-12-31 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 2000 INDIANAPOLIS IN 462045108 990 2010-01-01 356001540 GOSHEN HOSPITAL ASSOCIATION INC GOSH 5745352665 200 HIGH PARK AVENUE GOSHEN IN 46526 AMY FLORIA 5745352665 2011-11-15 1 SHAWNA M JIMENEZ 3174648600 2010 2016-03-07 17:11:31Z IU HEALTH GOSHEN HOSPITAL JAMES DAGUE 2024 S MAIN ST GOSHEN IN 46526 190297429 0 X WWW.GOSHENHEALTH.COM X 1946 IN TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES. 15 11 1357 332 0 0 831884 175927 168187524 184695165 -4006460 1380192 1834479 4046145 166847427 190297429 169000 203000 0 0 67504438 70200359 0 0 0 93013190 104312949 160686628 174716308 6160799 15581121 176858376 196983221 64550691 66823409 112307685 130159812 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 147686776 203000 186979682 GOSHEN HOSPITAL ASSOCIATION, INC. 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 DETAILTHE 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 PROVIDE CARE IN AN INNOVATIVE AND DYNAMIC ENVIRONMENT. THE HOSPITAL HAS 123 PATIENT BEDS AND OVER 145 PHYSICIANS ON ITS MEDICAL STAFF IN NEARLY 22 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 2010. 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, 2011.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 2% 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 2010, THE HOSPITAL PROVIDED OVER $203,000 TO 49 ORGANIZATIONS. SINCE ITS INCEPTION IN 1998, THE COMMUNITY BENEFIT FUND HAS GIVEN OVER $1.4 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 2010, THE HOSPITAL EXTENDED CHARITY CARE TO OVER 1,286 PATIENTS TOTALING $5.9 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. 147686776 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 103 0 1 1357 1 0 0 0 0 0 0 0 0 0 0 X 15 11 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 X X 688361 0 4928 LINDA BAXLEY 1.00 X 0 0 0 JESSE BERGER 1.00 X 0 0 0 RAO BETINA MD 1.00 X 0 0 0 DERALD BONTRAGER 1.00 X 0 0 0 EDWARD BOYTS MD 1.00 X 0 227209 7393 DANIEL BRUETMAN MD 1.00 X 0 509412 9819 RANDY CRIPE 1.00 X 0 0 0 KEVIN DEARY 1.00 X 0 0 0 CHRISTOPHER GRAFF 1.00 X 0 0 0 DAVID KORONKIEWICZ DO 1.00 X 0 0 0 DON OGLE 1.00 X 0 0 0 JACKIE PARK 1.00 X 0 0 0 KAREN PLETCHER 1.00 X 0 0 0 MARTHA SUZIE YEAGER 1.00 X 0 0 0 AMY FLORIA 40.00 X 297250 0 5058 RANDY CHRISTOPHEL 40.00 X 427249 0 6551 ALAN WELDY 40.00 X 355387 0 3311 POOPALASINGHAM POOVENDRAN 40.00 X 557214 0 9706 RANDALL CAMMENGA 40.00 X 364255 0 7662 JOSEPH GAGLIARDI 40.00 X 346564 0 2471 MIN YAN 40.00 X 332728 0 2538 MARIA GARCIA 40.00 X 297548 0 1040 3666556 736621 60477 32 0 1 0 GERIG SURGICAL 303 SOUTH MAIN STREET MISHAWAKA IN 46544 ON CALL SERVICES 1097782 VARIAN MEDICAL SYSTEMS 70140 NETWORK PLACE CHICAGO IL 406731701 MAINTENANCE CONTRACTS 513612 GLOBAL PHYSICS SOLUTIONS PO BOX 809153 CHICAGO IL 606809153 PHYSICS SERVICES 428403 MICHIANA LINEN SERVICES 600 EAST BOULEVARD ELKHART IN 46514 LAUNDRY SERVICES 313670 ELKHART GENERAL HOSPITAL PO BOX 1329 ELKHART IN 46515 LAUNDRY SERVICES 220162 11 16700 159227 175927 PATIENT CARE 621110 184695165 184695165 184695165 1380192 1380192 812454 812454 812454 812454 FOOD SERVICE REVENUE 721000 949174 949174 OTHER ONCOLOGY REV MIS 621500 226037 226037 FINANCE CHARGES 561000 194861 194861 1863619 1863619 3233691 190297429 186979682 0 3141820 203000 203000 1768247 1768247 52198297 35078254 17120043 2704850 1758153 946697 9878396 6420957 3457439 3650569 2372870 1277699 51821 51821 191239 191239 53257 53257 13767379 13767379 3226835 3226835 2723219 2723219 859355 859355 1722374 1722374 683221 683221 2216347 2216347 7036926 7036926 10022573 10022573 1304457 1304457 DRUGS AND MEDICAL SUPPL 35708600 35708600 0 0 BAD DEBT 17552818 17552818 0 0 REPAIRS & MAINTENANCE 4384235 4384235 0 0 DUES & SUBSCRIPTIONS 299035 299035 0 0 2509258 2509258 174716308 147686776 27029532 0 7372491 6293820 9844800 16068380 24506410 25361491 -86357 523731 4040433 5275839 1677762 2730703 182113219 88094427 93533230 94018792 35198195 45879836 213366 110922 558046 719707 176858376 196983221 15206079 18463427 47734007 46386972 1610605 1973010 64550691 66823409 X 111965931 129697959 341754 461853 112307685 130159812 176858376 196983221 X 15581121 2271006 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6872683 6872683 84393259 24741253 59652006 490753 134617 356136 86858833 63218557 23640276 3497691 3497691 94018792 BOARD DESIGNATED FUNDS 44703865 F CANCER CENTER INVESTMENT 1175971 F 45879836 ASSET RETIREMENT OBLIGATION 225857 DEFERRED COMPENSATION 664217 DEFERRED MEDICAL MALPRACTICE 270482 INTEREST RATE SWAP 812454 1973010 1 1 X 1 X 1 X 1 1 1 0 1 1 2421842 2421842 0.01390 14774478 14774478 0.08460 17196320 17196320 0.09850 448638 448638 0.00260 105951 105951 0.00060 223264 223264 0.00130 246035 246035 0.00140 1023888 1023888 0.00590 18220208 18220208 0.10440 8525 8525 0.00000 11811 11811 0.00010 57411 57411 0.00030 15460 15460 0.00010 362 362 0.00000 3993 3993 0.00000 97562 97562 0.00050 1 7214208 605587 32166519 38907271 -6740752 X 1 1 5 1 IU HEALTH GOSHEN HOSPITAL

200 HIGH PARK AVENUE GOSHEN IN 46526

X X X 2 IU HEALTH GOSHEN

200 HIGH PARK AVENUE GOSHEN IN 46526

X 3 NEW PARIS MEDICAL CLINIC

2018 SOUTH MAIN STREET GOSHEN IN 46526

X 4 INDIANA LAKES MANAGED CARE

200 HIGH PARK AVENUE GOSHEN IN 46526

X 5 THE RETREAT WOMEN'S HEALTH CENTER

1135 PROFESSIONAL DRIVE GOSHEN IN 46526

X NA 1 PART I, LINE 7: A COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, WAS USED TO DETERMINE COSTS FOR LINES A THROUGH C REPORTED IN THE TABLE. PART III, LINE 4: A DETAILED COLLECTION POLICY IS FOLLOWED. BAD DEBT COSTS ARE BASED UPON MANAGEMENT'S ASSESSMENT OF EXPECTED COLLECTIONS TAKING INTO CONSIDERATION BUSINESS AND ECONOMIC CONDITIONS. THESE ALLOWANCES ARE PERIODICALLY REVIEWED FOR ACCURACY AND IF ANY FURTHER ACTIONS ARE REQUIRED. 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 BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTIONINDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON ESTIMATED COLLECTIONS BY PAYOR CATEGORY AND AGING. THE RESULTS OF THESE ESTIMATES ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN ADDITION, THE SYSTEM HAS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES. 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 CFO OF IU HEALTH GOSHEN HOSPITAL 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. 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 145 PHYSICIANS ON ITS MEDICAL STAFF IN NEARLY 22 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: GOSHEN HOSPITAL ASSOCIATION, INC. SERVES THE NORTHERN INDIANA AREA IN ELKHART COUNTY. ACCORDING TO THE 2010 CENSUS, THE POPULATION OF ELKHART COUNTY IS 197,559. THE MEDIAN INCOME FOR A HOUSEHOLD IN ELKHART COUNTY BASED ON THE 2010 CENSUS IS $43,531 AND THE MEDIAN INCOME FOR A FAMILY IS $54,549. APPROXIMATELY 9.6% OF FAMILIES AND 12.95% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 21.8% OF THOSE UNDER THE AGE 18 AND 6.5% OF THOSE AGE 65 AND OVER. THE RACIAL MAKEUP OF THE COUNTY WAS ABOUT 82.9% WHITE, 5.7% AFRICAN AMERICAN, AND 11.4% OTHER RACES. 14.1% OF THE POPULATION IS HISPANIC OR LATINO OR ANY RACE. PART VI, LINE 6: 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 7: 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 PO BOX 843 GOSHEN IN 46257 350933555 501(C)(3) 10000 MEDICAL/DENTAL BENEFITS BOYS AND GIRLS CLUB OF GREATER GOSHEN INC PO BOX 614 GOSHEN IN 46257 351033735 501(C)(3) 10000 GIRLS IN FOCUS INITIATIVE CAPS - CHILD AND PARENT SERVICES 1000 WEST HIVELY AVENUE ELKHART IN 46517 350888765 501(C)(3) 5000 HEALTHY FAMILIES PROGRAM ELKHART COUNTY AMERICAN RED CROSS 721 RIVERVIEW AVENUE ELKHART IN 46516 350909968 501(C)(3) 10000 BASIC AID TRAINING COURSE EXPENSES FAMILY CHRISTIAN DEVELOPMENT CENTER PO BOX 227 NAPPANEE IN 46550 351979463 501(C)(3) 5000 MEDICINE ASSISTANCE PROGRAM FAMILY SERVICES OF ELKHART COUNTY INC IFIT 101 E HIVELY AVENUE ELKHART IN 46517 350868079 501(C)(3) 5000 ELKHART COUNTY WOMEN'S SHELTER COUNSELING SERVICES GOSHEN COLLEGE DEPARTMENT OF NURSING 1700 SOUTH MAIN STREET GOSHEN IN 46526 352158366 501(C)(3) 10000 NURSING SCHOLARSHIPS HISPANICLATINO HEALTH COALITION OF ELKHART CO 323 STOCKER COURT ELKHART IN 46516 320039221 501(C)(3) 10000 ANNUAL HEALTH FAIR INDIANA UNIVERSITY SCHOOL OF MEDICINE - SOUTH BEND 1234 N NOTRE DAME AVENUE SOUTH BEND IN 46617 356018940 501(C)(3) 10000 CLINICAL TRAINING AND MEDICAL EDUCATION PROGRAMS LACASA INC 202 N COTTAGE AVENUE GOSHEN IN 46528 351554538 501(C)(3) 5000 HOME OWNERSHIP CENTER MAPLE CITY HEALTH CARE CENTER 213 MIDDLEBURY GOSHEN IN 46528 351749398 501(C)(3) 20000 HEALTH CARE COST ASSISTANCE THE PARENT SOURCE 2600 OAKLAND AVENUE ELKHART IN 46517 351070041 501(C)(3) 10000 INCREASING ACCESS PROGRAM UNITED CANCER SERVICES OF ELKHART COUNTY INC 23971 US HWY 33 ELKHART IN 46517 351091429 501(C)(3) 10000 JOURNEY THROUGH TREATMENT PROGRAM 13 0 OTHER INFORMATION: PART IV: THE ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE U.S. CONSISTS OF REQUIRING THE COMPLETIONG OF A FOLLOW-UP REPORT FORM WITH THE SUBSEQUENT GRANT FUND APPLICATIONS. X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 JAMES DAGUE 465821 0 187598 0 34942 0 0 0 4928 0 693289 0 0 0 EDWARD BOYTS MD 0 141472 0 85737 0 0 0 0 0 7393 0 234602 0 0 DANIEL BRUETMAN MD 0 384294 0 81542 0 43576 0 0 0 9819 0 519231 0 0 AMY FLORIA 194909 0 64270 0 38071 0 0 0 5058 0 302308 0 0 0 RANDY CHRISTOPHEL 288142 0 98360 0 40747 0 0 0 6551 0 433800 0 0 0 ALAN WELDY 245582 0 73991 0 35814 0 0 0 3311 0 358698 0 0 0 POOPALASINGHAM POOVENDRAN 464080 0 34692 0 58442 0 0 0 9706 0 566920 0 0 0 RANDALL CAMMENGA 257813 0 83077 0 23365 0 0 0 7662 0 371917 0 0 0 JOSEPH GAGLIARDI 252525 0 75962 0 18077 0 0 0 2471 0 349035 0 0 0 MIN YAN 297205 0 0 0 35523 0 0 0 2538 0 335266 0 0 0 MARIA GARCIA 261674 0 0 0 35874 0 0 0 1040 0 298588 0 0 0 PART I, LINE 1A TAX INDEMNIFICATION AND GROSS-UP PAYMENTS GOSHEN HOSPITAL ASSOCIATION, INC. GROSSED UP THE TAXABLE VALUE OF AUTOMOBILES FOR 4 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 GOSHEN HOSPITAL ASSOCIATION, INC. PAID FOR COUNTRY CLUB DUES FOR 5 OF THE OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES LISTED IN FORM 990, PART VII. ALL REIMBURSEMENTS ARE CONSIDERED TAXABLE INCOME TO THE EMPLOYEES. PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED CONTRIBUTIONS TO A NON-QUALIFIED DEFERRED COMPENSATION PLAN: RANDY CHRISTOPHEL - 25,188 JAMES DAGUE - 87,639 AMY FLORIA - 17,331 ALAN WELDY - 20,867 RANDALL CAMMENGA - 22,315 JOSEPH GAGLIARDI - 20,942 PRESS GANEY SEE PART V 181252 SEE PART V 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: PRESS GANEY(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION:LINDA BAXLEY IS A DIRECTOR OF GOSHEN HOSPITAL AND EMPLOYEE OF PRESS GANEY(C) AMOUNT OF TRANSACTION: $ 181,252(D) DESCRIPTION OF TRANSACTION: CONDUCTING PATIENT SATISFACTION SURVEY(E) SHARING OF ORGANIZATION REVENUES? = NO FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE EMPLOYEES OF GOSHEN HEALTH SYSTEM OR ITS RELATED ORGANIZATIONS, AND SERVE ON OTHER RELATED GOSHEN HEALTH SYSTEM BOARDS: JAMES DAGUE EDWARD BOYTS DANEL BRUETMAN KEVIN DEARY AMY FLORIA RANDY CHRISTOPHEL ALAN WELDY FORM 990, PART VI, SECTION A, LINE 6 GOSHEN HEALTH SYSTEM, INC. IS THE SOLE MEMBER OF GOSHEN HOSPITAL ASSOCIATION, INC. FORM 990, PART VI, SECTION A, LINE 7A GOSHEN HEALTH SYSTEM, INC., AS THE SOLE MEMBER OF GOSHEN HOSPITAL ASSOCIATION, INC. 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 GOSHEN HEALTH SYSTEM, INC. 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 THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS 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. THE DISCLOSURES ARE 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 GOSHEN HOSPITAL ASSOCIATION, INC. WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,383,860. EQUITY TRANSFERS -1,084,541. INTEREST RATE SWAP -148,410. RELEASE OF UNSPENT GRANT FUNDS 120,099. ROUNDING -2. TOTAL TO FORM 990, PART XI, LINE 5: 2,271,006. FORM 990, PART XII, LINE 2A-2D: THE FINANCIAL STATEMENTS OF GOSHEN HOSPITAL ASSOCIATION, INC. WERE AUDITED ON A CONSOLIDATED BASIS. THE AUDIT COMMITTEE HAS BEEN DELEGATED AUTHORITY TO OVERSEE THE AUDIT OF THE FINANCIAL STATEMENTS. 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