2026-08-17T17:48:43-05:00 2025-09-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2024-10-01 350985964 DEACONESS MEMORIAL MEDICAL CENTER INC DEAC 8124822345 800 WEST NINTH STREET JASPER IN 47546 KEITH MILLER CAO 8124822345 2026-08-17 1 1 EMILIE M KNIERIEM CPA P01330194 3176334705 2026-08-17 2024 2025-03-06 01:10:19Z X MEMORIAL HOSPITAL & HEALTH CARE KEITH MILLER 800 WEST NINTH STREET JASPER IN 47546 400829448 0 X SEE SCHEDULE O X 1950 IN PROVIDE HEALTH SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. 15 8 2073 163 28223 6856 252023 2314420 71383448 288391134 2090762 12001449 834020 4241065 74560253 306948068 14456 0 0 0 35746463 131904352 0 0 0 36240156 148203688 72001075 280108040 2559178 26840028 375527229 403731135 104135811 101385062 271391418 302346073 X WE, THE BOARD, PHYSICIANS, STAFF, VOLUNTEERS AND AUXILIARY OF MEMORIAL HOSPITAL AND HEALTH CARE CENTER WILL PROVIDE EXCELLENT HEALTH CARE SERVICES TO THE PEOPLE OF THE COMMUNITIES WE SERVE. WE WILL PLEDGE OURSELVES TO CARE FOR EACH INDIVIDUAL IN A MANNER THAT REFLECTS THE PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL HEALING MINISTRY OF JESUS CHRIST. WE WILL WORK TOGETHER TO CREATE AN ATMOSPHERE OF MUTUAL RESPECT, DIGNITY, COMPASSION AND JOY. WE WILL EFFECTIVELY AND EFFICIENTLY UTILIZE OUR RESOURCES IN PROVIDING HEALTH CARE. WE WILL BE GUIDED BY THE NEEDS OF THOSE WE SERVE AND AS NEEDS CHANGE, WE WILL CHANGE. WE WILL "BE FOR OTHERS!" 0 0 248502433 291878541 GENERAL PRIMARY ACUTE CARE HOSPITAL EXPENSES INCURRED IN PROVIDING EXCELLENT HEALTH CARE SERVICES CONSISTENT WITH THE NEEDS OF THE COMMUNITY. SEE FORM 990, SCHEDULE H FOR ADDITIONAL SERVICES PROVIDED TO THE COMMUNITY. 248502433 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 1 0 1 0 0 0 0 0 1 1 1 0 0 1 158 0 1 2073 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 IN X KEITH MILLER 8129960506 800 WEST NINTH STREET JASPER IN 47546 X KEITH MILLER CAO & INDIANA REGION PRES. 40.00 5.00 X X 287654 0 41313 JIM HUEBNER BOARD CHAIRPERSON 5.00 6.00 X X 0 0 0 BRENT STERNBERG BOARD TREASURER 1.00 0.00 X X 0 0 0 SR RENEE CUNNINGHAM BOARD SECRETARY 30.00 5.00 X X 0 0 0 DONNA BALKA BOARD MEMBER 1.00 0.00 X 0 0 0 CHRISTIAN BLOME BOARD MEMBER 1.00 0.00 X 0 0 0 TONYA HEIM BOARD MEMBER 1.00 0.00 X 0 0 0 MICHAEL KERN BOARD MEMBER 1.00 1.00 X 0 0 0 GARY KEEPES MD BOARD MEMBER 1.00 0.00 X 0 0 0 SHERRIL LUEKEN BOARD MEMBER PARTIAL TERM 1.00 0.00 X 0 0 0 SHAWN MCCOY BOARD MEMBER 1.00 60.00 X 0 2016238 361449 KRISTI NORD MD MED. STAFF PRES. 51.00 0.00 X 363083 0 39340 SOHAIL QADIR MD BOARD MEMBER 51.00 0.00 X 640356 0 38703 LYNN LINGAFELTER BOARD MEMBER 1.00 65.00 X 0 1072960 198379 JAMES PORTER MD BOARD MEMBER 1.00 60.00 X 0 1073178 187360 NICK WERNE MD BOARD MEMBER 51.00 0.00 X 483444 0 37941 BRENDA STALLINGS BOARD TREASURER PARTIAL TERM 1.00 0.00 X X 0 0 0 EDWARD W MILLER VP FINANCE/CFO 40.00 0.00 X 699942 0 12731 GEOFFREY DAY MD PHYSICIAN 50.00 0.00 X 1362411 0 40284 MATTHEW DODARO PHYSICIAN 50.00 0.00 X 1414703 0 40284 JOSHUA LEONARD MD PHYSICIAN 50.00 0.00 X 1309715 0 39806 ADAM DAWKINS MD PHYSICIAN 50.00 0.00 X 1291520 0 39067 JONATHAN DAY MD PHYSICIAN 50.00 0.00 X 1186230 0 56920 E KYLE BENNETT FORMER PRES./CEO 0.00 0.00 X 1245859 0 25569 10284917 4162376 1159146 218 1 1 0 IVORY COAST ANESTHESIA 1765 E NINE MILE RD SUITE 1-229 PENSACOLA FL 32514 ANESTHESIOLOGY 6087128 MEMORIAL HOSPITAL OUTPATIENT SURGERY CTR 600 W 13TH STREET SUITE 100 JASPER IN 47546 OUTPATIENT SURGERY 4268468 CHG COMPANIES INC PO BOX 972651 DALLAS TX 75397 HEALTHCARE STAFFING & RECRUITING 1721465 INDIANA UNIVERSITY DEPT 78920 PO BOX 78000 DETROIT MI 48278 MEDICAL & HEALTHCARE PAYMENTS 1399477 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUM PHYSICIANS 1299488 43 1203518 228176 882726 2314420 PATIENT SERVICE REVENUE 621110 288391134 288391134 288391134 6267433 20330 6247103 433356 182916 250440 250440 250440 99432480 93698464 5734016 5734016 5734016 CAFETERIA REVENUE 722514 476908 476908 LAB REVENUE 541380 7893 7893 GAIN/LOSS ON JOINT VENTURE 900099 -303665 -303665 3809489 3791072 18417 3990625 306948068 291878541 28223 12726884 X 113399597 102631480 10768117 2411982 2061036 350946 9553301 8163287 1390014 6539472 5587973 951499 69344 63842 5502 6100 6100 40531708 37321136 3210572 132981 119160 13821 14012695 13892135 120560 23260552 14335951 8924601 502366 450153 52213 93393 83686 9707 1974881 1163495 811386 13443942 9153188 4290754 587469 526411 61058 HOSPITAL SUPPLIES 37300439 36979527 320912 HAF EXPENSE 13229674 13229674 DUES & SUBSCRIPTIONS 854596 765775 88821 LICENSES & TAXES 146639 131398 15241 2056909 1843126 213783 280108040 248502433 31605607 0 28031777 40536878 26255814 28051624 32500 2592821 1203304 3722988 5537843 3482178 2774513 161547733 22018001 141750501 139529732 162791551 177714082 799226 289044 6100373 8061615 375527229 403731135 23604679 27149618 62055000 56255000 761228 689205 17714904 17291239 104135811 101385062 X 271391418 302346073 271391418 302346073 375527229 403731135 X 26840028 4114627 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 4411 4411 0 PART II-B, LINE 1: LOBBYING EXPENDITURES CONSISTED OF A PORTION OF MEMBERSHIP DUES TO PROFESSIONAL ORGANIZATIONS IN WHICH DEACONESS MEMORIAL MEDICAL CENTER AND ITS EMPLOYEES ARE MEMBERS. THE LOBBYING PORTION OF THE DUES IS NOTED ON THE MEMBERSHIP APPLICATION OR BILLING STATEMENT. 1505629 1505629 104646762 309372 104337390 55395342 21708629 33686713 139529732 RIGHT OF USE LIABILITY 2333825 RELATED PARTY PAYABLE 14957414 17291239 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2025 AND 2024, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE REMAINING CONSOLIDATED SUBSIDIARIES ARE ORGANIZED AS LIMITED LIABILITY COMPANIES, WHEREBY NET TAXABLE INCOME IS TAXED DIRECTLY TO THE MEMBERS OF THE LIMITED LIABILITY COMPANIES. THUS, THE CONSOLIDATED FINANCIAL STATEMENTS DO NOT INCLUDE ANY PROVISION FOR FEDERAL OR STATE INCOME TAXES RELATED TO THESE ENTITIES. THESE ENTITIES HAVE FILED THEIR FEDERAL AND STATE INCOME TAX RETURNS FOR PERIODS THROUGH THEIR MOST RECENT FISCAL YEAR ENDS (PRIMARILY DECEMBER 31, 2024). THESE INCOME TAX RETURNS ARE GENERALLY OPEN TO EXAMINATION BY THE RELEVANT TAXING AUTHORITIES FOR A PERIOD OF THREE YEARS FROM THE LATER OF THE DATE THE RETURN WAS FILED OR ITS DUE DATE (INCLUDING APPROVED EXTENSIONS). 1 1 X 1 X 1 X 1 1 0 1 1 1097657 1097657 0.00390 39867912 29533272 10334640 0.03690 40965569 29533272 11432297 0.04080 2023549 2023549 0.00720 2653213 2653213 0.00950 4400127 4400127 0.01570 9076889 9076889 0.03240 50042458 29533272 20509186 0.07320 1 9759244 114735410 131222701 -16487291 X 1 1 1 MEMORIAL OUTPATIENT SURGERY CENTER LLC HEALTHCARE 0.40000 0.00000 0.07500 2 DUBOIS PSYCH PROPERTIES LLC HEALTHCARE 0.50000 0.00000 0.50000 1 1 DEACONESS MEMORIAL MEDICAL CENTER INC 800 W 9TH ST JASPER IN 47546 WWW.DEACONESSMEMORIAL.COM 26-005102-1 X X X DEACONESS MEMORIAL MEDICAL CENTER INC 1 0 0 1 X X X X X X X X X 23 1 0 0 1 X WWW.DEACONESS.COM/CHNA X 1 24 1 WWW.DEACONESS.COM/CHNA 0 1 X 200.000000000000 350.000000000000 X X X X 1 1 X X X X 1 X HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCE X HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCE X HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCE X X X X X X X 1 X 0 X X X X 1 X 0 0 DEACONESS MEMORIAL MEDICAL CENTER, INC. PART V, SECTION B, LINE 5: ADVISORY COUNCILS: ADVISORY COUNCILS WERE DEVELOPED AND IMPLEMENTED IN 2014 AS A WAY FOR DEACONESS MEMORIAL MEDICAL CENTER TO STAY CONNECTED WITH EACH COUNTY OUTSIDE OF DUBOIS COUNTY. IT WAS IDENTIFIED THERE WERE SEVERAL NEEDS THAT WERE SPECIFIC FOR EACH COUNTY. MEMBERS OF THE DEACONESS MEMORIAL MEDICAL CENTER MANAGEMENT TEAM ARE ASSIGNED TO A COUNTY TO CONTINUE THE COLLABORATION AND TO RECEIVE ONGOING FEEDBACK ON NEEDS AND WHERE DEACONESS MEMORIAL MEDICAL CENTER IS ABLE TO PROVIDE ASSISTANCE. PARTICIPATING IN THESE COUNCILS ARE ECONOMIC DEVELOPMENT DIRECTORS, COUNTY HEALTH NURSES, CHAMBER OF COMMERCE LEADERS, EDUCATORS, EXECUTIVES, PASTORS, EMS, LAW ENFORCEMENT, BUSINESS OWNERS, OTHER HEALTH CARE ORGANIZATION LEADERS, ETC. WITH THE ONGOING ADVISORY COUNCILS, WE ARE ABLE TO PROVIDE QUICK SOLUTIONS FOR EACH AREA. WE CONTINUE TO GATHER FEEDBACK AND NEEDS AND WORK TO ADDRESS EACH COUNTY SPECIFICALLY IN OUR PSA. DEACONESS MEMORIAL MEDICAL CENTER, INC. PART V, SECTION B, LINE 11: DEACONESS MEMORIAL MEDICAL CENTER CONDUCTED ITS MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN 2023, IDENTIFYING FIVE PRIORITY AREAS: MENTAL HEALTH, ACCESS TO HEALTHCARE, DIVERSITY/EQUITY AND INCLUSION, COMMUNITY-FOCUSED HEALTHCARE EDUCATION, AND TRANSPORTATION. THE FOLLOWING DESCRIBES ACTIONS TAKEN IN 2025 TO ADDRESS THESE NEEDS IN ALIGNMENT WITH THE HOSPITAL'S ADOPTED IMPLEMENTATION STRATEGY.PRIORITY 1: MENTAL HEALTHTHE 2023 CHNA IDENTIFIED INCREASED NEED FOR MENTAL HEALTH RESOURCES AS THE TOP COMMUNITY PRIORITY, WITH FOCUS GROUP PARTICIPANTS CITING LACK OF TIMELY TREATMENT AND INSUFFICIENT BEHAVIORAL HEALTH SERVICES ACROSS THE REGION.-CONTINUED PARTNERSHIP WITH IU SCHOOL OF PUBLIC HEALTH TO EXPAND URGENT AND EMERGENT MENTAL HEALTH SERVICES INTO MARTIN, ORANGE, AND PERRY COUNTIES THROUGH IN-OFFICE VISITS AND TELEHEALTH, WITH FUNDING SECURED THROUGH 2029 TO SUPPORT ONGOING EXPANSION INTO ADDITIONAL RURAL AREAS.-WORKED WITH THE DUBOIS COUNTY COMMUNITY FOUNDATION TO SECURE FUNDING THROUGH THE LILLY GIFT VIII, SUPPORTING CONSTRUCTION OF A PARTIAL HOSPITALIZATION PROGRAM SPACE SCHEDULED TO OPEN IN OCTOBER 2026, PROFESSIONAL DEVELOPMENT FOR MENTAL HEALTH PROFESSIONALS, AND A COMMUNITY MENTAL HEALTH FIRST AID TRAINING PROGRAM DELIVERED BY TRAINED WELLNESS COACHES.-COLLABORATED WITH LIFESPRINGS TO SUPPORT THEIR CERTIFICATION AS A CERTIFIED COMMUNITY BEHAVIORAL HEALTH CENTER AND EXPAND THEIR MOBILE CRISIS TEAM INTO DUBOIS AND SURROUNDING COUNTIES, BROADENING ACCESS TO CRISIS SERVICES.-DEVELOPED A CARE TEAM MODEL IN THE EMERGENCY DEPARTMENT TO PROVIDE 24/7 EVALUATION AND ACCESS FOR PATIENTS PRESENTING IN BEHAVIORAL HEALTH CRISIS, AND PARTNERED WITH DUBOIS COUNTY COMMUNITY CORRECTIONS TO PROVIDE URGENT AND EMERGENT OUTPATIENT MENTAL HEALTH ACCESS.-MAINTAINED CO-CHAIR ROLE ON THE DUBOIS COUNTY MENTAL HEALTH COMMITTEE AND SUSTAINED ACTIVE PARTICIPATION IN THE DUBOIS COUNTY PUBLIC HEALTH PARTNERSHIP, SUPPORTING REGIONAL COORDINATION AND COMMUNITY EDUCATION ON ACCESSING EMERGENCY MENTAL HEALTH SERVICES.PRIORITY 2: ACCESS TO HEALTHCARETHE 2023 CHNA IDENTIFIED ACCESS TO PRIMARY CARE AND SPECIALTY CARE AS A SIGNIFICANT COMMUNITY NEED, NOTING LONG WAIT TIMES AND PHYSICIAN SHORTAGES ACROSS DUBOIS, MARTIN, PIKE, AND SPENCER COUNTIES.-ADDED TWO FULL-TIME PRIMARY CARE PHYSICIANS, DR. ZACH CRABTREE AND DR. KENEDI DIVINE, TO MEMORIAL'S SERVICE AREA, DIRECTLY INCREASING PRIMARY CARE CAPACITY FOR PATIENTS ACROSS THE REGION.-EXPANDED OUTPATIENT MENTAL HEALTH ACCESS THROUGH ADDITIONAL FTE ADDITIONS, REDUCING WAIT TIMES AND INCREASING AVAILABILITY OF BEHAVIORAL HEALTH SERVICES.-CONTINUED DEPLOYMENT OF TELEHEALTH SERVICES TO EXTEND CARE ACCESS INTO RURAL AND UNDERSERVED AREAS OF THE PRIMARY SERVICE AREA, CONSISTENT WITH THE IMPLEMENTATION STRATEGY'S FOCUS ON IMPROVING HEALTHCARE ACCESSIBILITY.-SUSTAINED THE IU FAMILY MEDICINE RESIDENCY PROGRAM AS A LONG-TERM PIPELINE STRATEGY FOR GROWING PRIMARY CARE CAPACITY IN SOUTHWESTERN INDIANA.PRIORITY 3: DIVERSITY, EQUITY AND INCLUSIONTHE 2023 CHNA IDENTIFIED GAPS IN CULTURAL COMPETENCY, LANGUAGE ACCESS, AND INCLUSION OF DIVERSE POPULATIONS, WITH FOCUS GROUP PARTICIPANTS NOTING LANGUAGE BARRIERS AND A LACK OF DIVERSE CULTURAL UNDERSTANDING AMONG STAFF AND IN SERVICE DELIVERY.-CONTINUED OFFERING INTERPRETER SERVICES AND ACCESS TO TRANSLATION LANGUAGE LINE ACROSS CLINIC LOCATIONS TO SUPPORT PATIENTS WITH LIMITED ENGLISH PROFICIENCY, CONSISTENT WITH THE LANGUAGE ACCESS RESOURCES NOTED IN APPENDIX D OF THE 2023 CHNA.-PROVIDED CULTURAL COMPETENCY TRAINING OR EDUCATION FOR STAFF TO STRENGTHEN THE ORGANIZATION'S ABILITY TO SERVE A GROWING AND DIVERSE PATIENT POPULATION, INCLUDING THE EXPANDING HISPANIC/LATINO COMMUNITY IN DUBOIS COUNTY.-PROVIDED FINANCIAL SUPPORT TO ALASI (ASOCIACIN LATINOAMERICANA DEL SUR DE INDIANA), A LOCAL NONPROFIT WORKING TO REMOVE BARRIERS FOR LATINO AND IMMIGRANT COMMUNITIES IN DUBOIS COUNTY, SUPPORTING THE HOSPITAL'S EFFORTS TO ADDRESS LANGUAGE ACCESS AND CULTURAL INCLUSION NEEDS-TRAINED STAFF IN AVADE NONVIOLENT CRISIS INTERVENTION, SUPPORTING EQUITABLE AND TRAUMA-INFORMED CARE FOR BEHAVIORAL HEALTH PATIENTS ACROSS ALL BACKGROUNDS.PRIORITY 4: COMMUNITY-FOCUSED HEALTHCARE EDUCATIONTHE 2023 CHNA IDENTIFIED A NEED FOR GREATER COMMUNITY OUTREACH, HEALTH EDUCATION, AND COLLABORATION WITH COMMUNITY PARTNERS TO IMPROVE AWARENESS OF AVAILABLE SERVICES AND SUPPORT POPULATION WELLNESS.-DELIVERED COMMUNITY EDUCATIONAL OFFERINGS TO A BROAD RANGE OF COMMUNITY PARTNERS ACROSS THE PRIMARY SERVICE AREA, SUPPORTING HEALTH LITERACY AND AWARENESS OF AVAILABLE CARE.-PARTICIPATED IN OR SPONSORED COMMUNITY HEALTH EVENTS, SCREENINGS, OR WELLNESS PROGRAMS TO PROMOTE PREVENTIVE CARE AND HEALTHY BEHAVIORS IN THE COMMUNITIES SERVED.-COLLABORATED WITH AREA EMPLOYERS, SCHOOLS, OR FAITH COMMUNITIES TO DELIVER HEALTH EDUCATION PROGRAMMING ALIGNED WITH IDENTIFIED COMMUNITY PRIORITIES SUCH AS CARDIOVASCULAR HEALTH, CANCER SCREENING, AND DIABETES PREVENTION.-SUPPORTED COMMUNITY AWARENESS OF EMERGENCY MENTAL HEALTH SERVICES AVAILABLE THROUGH DEACONESS MEMORIAL MEDICAL CENTER AND THE CARE TEAM MODEL, IN PARTNERSHIP WITH BUSINESS DEVELOPMENT AND COMMUNITY EDUCATION EFFORTS.PRIORITY 5: TRANSPORTATIONTHE 2023 CHNA IDENTIFIED TRANSPORTATION AS A BARRIER TO CARE, PARTICULARLY FOR PATIENTS FOLLOWING DISCHARGE OR TRANSFER AND FOR THOSE IN RURAL AREAS OF THE PRIMARY SERVICE AREA.-CONTINUED TO CONNECT PATIENTS WITH AVAILABLE TRANSPORTATION RESOURCES AND COMMUNITY PROGRAMS TO SUPPORT ACCESS TO FOLLOW-UP CARE AND OUTPATIENT SERVICES.-COORDINATED WITH COMMUNITY PARTNERS, INCLUDING COUNTY AGENCIES OR SOCIAL SERVICES, TO IDENTIFY AND ADDRESS TRANSPORTATION BARRIERS FOR PATIENTS WITH LIMITED MOBILITY OR IN RURAL AREAS.-LEVERAGED TELEHEALTH SERVICES AS A STRATEGY TO REDUCE TRANSPORTATION BURDEN FOR PATIENTS IN OUTLYING COUNTIES, INCLUDING MARTIN, PIKE, SPENCER, ORANGE, AND PERRY COUNTIES. DEACONESS MEMORIAL MEDICAL CENTER, INC. PART V, SECTION B, LINE 15E: WELL FUND IS AVAILABLE TO DEACONESS HEALTH SYSTEM PATIENTS TO ASSIST WITH APPLYING FOR MEDICAID OR EXCHANGE PRODUCTS. DEACONESS MEMORIAL MEDICAL CENTER, INC. PART V, SECTION B, LINE 16J: DEACONESS MEMORIAL MEDICAL CENTER SEEKS OUT THE PATIENTS THAT ARE SELF-PAY AND INTERVIEWS THESE PATIENTS WHILE THEY ARE IN THE FACILITY. THE FINANCIAL ASSISTANCE POLICY IS PROMOTED TO PATIENTS. DEACONESS MEMORIAL MEDICAL CENTER SEEKS OUT THOSE PATIENTS THAT WOULD QUALIFY FOR THE FINANCIAL ASSISTANCE POLICY. COLLECTABILITY SCORING IS ALSO COMPLETED AND ALLOWANCES ARE MADE BASED UPON THESE SCORES. DEACONESS MEMORIAL MEDICAL CENTER, INC. PART V, SECTION B, LINE 24: GROSS CHARGES FOR NON-MEDICALLY NECESSARY SERVICES (ELECTIVE SERVICES) INCLUDING COSMETIC, SURGICAL WEIGHT LOSS, EXPERIMENTAL (NON-FDA APPROVED DEVICES) PROCEDURES, SPECIALTY REPLACEMENT LENSES, HEARING AIDS, SERVICES DENIED BY INSURANCE FOR NO PRIOR AUTHORIZATION OR NON-EMERGENCY SERVICES PROVIDED AS A RESULT OF BEING OUT-OF-NETWORK ARE NOT ELIGIBLE FOR DISCOUNTED CHARGES OR FINANCIAL ASSISTANCE. 22 1 - DEACONES CLINIC FAMILY MEDICINE BRISTOW 26020 STATE ROAD 145 BRISTOW IN 47515 HEALTHCARE 2 - DEACONESS CLINIC & REHAB SERVICES 695 WEST 2ND AVENUE JASPER IN 47546 ORTHOPAEDIC, OCCUPATIONAL HEALTH, REHABILITATION 3 - DEACONESS CLINIC EAR NOSE AND THROAT 251 S TRUMAN RD JASPER IN 47546 EAR, NOSE, THROAT 4 - DEACONESS CLINIC FAMILY MEDICINE 1950 ST CHARLES STREET SUITE 4 JASPER IN 47546 PRIMARY CARE 5 - DEACONESS CLINIC FAMILY MEDICINE & SPECIAL 5066 NORTH 900 EAST MONTGOMERY IN 47558 HEALTHCARE 6 - DEACONESS CLINIC FAMILY MEDICINE 9TH ST 751 WEST 9TH STREET JASPER IN 47546 FAMILY MEDICINE 7 - DEACONESS CLINIC FAMILY MEDICINE DALE 4 WEST VINE STREET PO BOX 599 DALE IN 47523 FAMILY MEDICINE 8 - DEACONESS CLINIC FAMILY MEDICINE FERDINAND 115 SOUTH MAIN STREET PO BOX 280 FERDINAND IN 47532 FAMILY MEDICINE 9 - DEACONESS CLINIC FAMILY MEDICINE FRENCH LI 679 HIGHWAY 145 FRENCHLICK IN 47432 FAMILY MEDICINE 10 - DEACONESS CLINIC FAMILY MEDICINE HOLLAND 303 MERIDIAN STREET PO BOX 212 HOLLAND IN 47541 FAMILY MEDICINE 11 - DEACONESS CLINIC FAMILY MEDICINE HUNTINGBU 407 EAST 22ND STREET HUNTINGBURG IN 47542 HEALTHCARE 12 - DEACONESS CLINIC FAMILY MEDICINE LOOGOOTEE 105 COOPER STREET PO BOX 401 LOOGOOTEE IN 47553 FAMILY MEDICINE 13 - DEACONESS CLINIC FAMILY MEDICINE PETERSBUR 1003 EASTI LLINOIS STREET PO BOX 66 PETERSBURG IN 47567 FAMILY MEDICINE 14 - DEACONESS CLINIC FAMILY MEDICINE RESIDENCY 966 BARTLEY STREET JASPER IN 47546 FAMILY MEDICINE 15 - DEACONESS CLINIC FAMILY MEDICINE SANTA CLA 92 WEST CHRISTMAS BOULEVARD SANTACLAUS IN 47579 FAMILY MEDICINE 16 - DEACONESS CLINIC FAMILY MEDICINE WASHINGTO 600 SOUTH STATE ROAD 57 WASHINGTON IN 47501 HEALTHCARE 17 - DEACONESS CLINIC HEART & VASCULAR JASPER 440 SCOTT ROLEN DRIVE JASPER IN 47546 CARDIOLOGY 18 - DEACONESS CLINIC HUNTINGBURG 507 EAST 19TH STREET HUNTINGBURG IN 47542 WOUND CARE & URGENT CARE 19 - DEACONESS CLINIC JASPER 600 WEST 13TH STREET JASPER IN 47546 OUTPATIENT SURGERY, UROLOGY, NEUROLOGY 20 - DEACONESS CLINIC JASPER 721 WEST 13TH STREET JASPER IN 47546 AUDIOLOGY, BEHAVIORAL, GASTRO, SURGERY, PED., SLEEP, PULMONARY, NEPHRO, PAIN 21 - DEACONESS CLINIC ORTHOPAEDICS ST CHARLES 1900 ST CHARLES STREET JASPER IN 47546 ORTHOPAEDICS 22 - MARTIN COUNTY HEALTH CENTER 229 HIGHSTREET PO BOX 480 SHOALS IN 47581 HEALTHCARE PART I, LINE 3C: A PATIENT MAY QUALIFY FOR PARTIAL FINANCIAL ASSISTANCE IF THE PATIENT'S HOUSEHOLD INCOME IS BETWEEN 200% AND 350% OF THE FEDERAL POVERTY GUIDELINES. PRESUMPTIVE ELIGIBILITY FOR FREE CARE WITH REQUIRED VERIFICATION IS AVAILABLE FOR DECEASED INDIVIDUALS WITH NO ESTATE AND NO SURVIVING SPOUSE; AND, FOR INDIVIDUALS IN HOMELESS SITUATIONS RECEIVING ASSISTANCE FROM SUPPORTIVE SERVICES SUCH AS GOVERNMENTAL, RELIGIOUS OR COMMUNITY SERVICES. PART I, LINE 7: DEACONESS MEMORIAL MEDICAL CENTER CALCULATED THE COST OF FINANCIAL ASSISTANCE AND MEANS-TESTED GOVERNMENT PROGRAMS, USING THE COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO- CHARGES. OTHER BENEFIT AMOUNTS REPORTED ON LINE 7 WERE CALCULATED USING COSTS CHARGED DIRECTLY TO THE INDIVIDUAL PROGRAMS VIA THE FINANCIAL ACCOUNTING SYSTEM. PART I, LINE 7G: $1,714,460 OF LOSSES FROM RURAL HEALTH CLINICS OPERATED BY DEACONESS MEMORIAL MEDICAL CENTER ARE INCLUDED IN SUBSIDIZED HEALTH SERVICES. PART III, LINE 2: DEACONESS MEMORIAL MEDICAL CENTER'S ANALYSIS AND ASSESSMENT OF THE BAD DEBT EXPENSE IS BASED ON THE EVALUATION OF ITS MAJOR PAYOR SOURCES OF REVENUE, THE AGING OF THE ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO ITS SERVICE AREA AND THE HEALTHCARE INDUSTRY. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 3: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY AND EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 4: SEE PAGE 12 OF THE AUDITED FINANCIAL STATEMENTS FOOTNOTE 1 UNDER HEADING "PATIENT SERVICE REVENUE." PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2025: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: THE ORGANIZATION'S WRITTEN DEBT COLLECTION POLICY INCLUDES PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED DURING THE FOLLOW-UP PERIOD AFTER A PATIENT IS DISCHARGED AND INCLUDES SPECIFIC INSTRUCTIONS FOR SELF-PAY WHO MAY QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. PART VI, LINE 2: ADVISORY COUNCILS: ADVISORY COUNCILS WERE DEVELOPED AND IMPLEMENTED IN 2014 AS A WAY FOR DEACONESS MEMORIAL MEDICAL CENTER TO STAY CONNECTED WITH EACH COUNTY OUTSIDE OF DUBOIS COUNTY. IT WAS IDENTIFIED THERE WERE SEVERAL NEEDS THAT WERE SPECIFIC FOR EACH COUNTY. MEMBERS OF THE DEACONESS MEMORIAL MEDICAL CENTER MANAGEMENT TEAM ARE ASSIGNED TO A COUNTY TO CONTINUE THE COLLABORATION AND TO RECEIVE ONGOING FEEDBACK ON NEEDS AND WHERE DEACONESS MEMORIAL MEDICAL CENTER IS ABLE TO PROVIDE ASSISTANCE. PARTICIPATING IN THESE COUNCILS ARE ECONOMIC DEVELOPMENT DIRECTORS, COUNTY HEALTH NURSES, CHAMBER OF COMMERCE LEADERS, EDUCATORS, EXECUTIVES, PASTORS, EMS, LAW ENFORCEMENT, BUSINESS OWNERS, OTHER HEALTH CARE ORGANIZATION LEADERS, ETC. WITH THE ONGOING ADVISORY COUNCILS, WE ARE ABLE TO PROVIDE QUICK SOLUTIONS FOR EACH AREA. WE CONTINUE TO GATHER FEEDBACK AND NEEDS AND WORK TO ADDRESS EACH COUNTY SPECIFICALLY IN OUR PSA. PART VI, LINE 3: THIS IS LISTED ON OUR WEBSITE AT HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCE AND IS POSTED IN EVERY CLINIC OFFICE AND FACILITY. PART VI, LINE 4: DEACONESS MEMORIAL MEDICAL CENTER DEFINES ITS COMMUNITY AS INDIVIDUALS RESIDING IN DUBOIS, MARTIN, PIKE, AND SPENCER COUNTIES IN INDIANA. THE SERVICE AREA HAD AN ESTIMATED POPULATION OF APPROXIMATELY 85,509 BASED ON 2020 U.S. CENSUS DATA AND ENCOMPASSES APPROXIMATELY 1,494 SQUARE MILES, WITH A POPULATION DENSITY OF APPROXIMATELY 57 PERSONS PER SQUARE MILE. THE AREA IS PREDOMINANTLY RURAL. THE POPULATION IS GENERALLY EVENLY DIVIDED BETWEEN MALES AND FEMALES.THE COMMUNITY INCLUDES RESIDENTS ACROSS ALL AGE GROUPS; APPROXIMATELY 19.3% OF RESIDENTS ARE AGE 65 OR OLDER, AND APPROXIMATELY 23.1% ARE UNDER AGE 18. THE POPULATION IS PREDOMINANTLY WHITE (APPROXIMATELY 91.8%), WITH RESIDENTS REPRESENTING OTHER RACIAL BACKGROUNDS AND PERSONS REPORTING MORE THAN ONE RACE. APPROXIMATELY 6.0% OF THE POPULATION IDENTIFIES AS HISPANIC OR LATINO. THESE GEOGRAPHIC AND DEMOGRAPHIC CHARACTERISTICS WERE CONSIDERED IN IDENTIFYING AND ADDRESSING THE HEALTH NEEDS OF THE COMMUNITY SERVED. PART VI, LINE 5: DEACONESS PROMOTED SERVICES AND INFORMATION THAT HELPED US ADDRESS THE GREATEST HEALTH NEEDS OF THE COMMUNITY AS DEFINED BY OUR MOST RECENT CHNA, AS WELL AS ENCOURAGE PEOPLE TO GET THE PREVENTIVE SCREENINGS THEY NEED.DEACONESS HOSTED AND ATTEND PUBLIC EVENTS, SUCH AS OUR ANNUAL ORAL, HEAD AND NECK CANCER SCREENINGS; COLON CANCER SCREENINGS, LOW DOSE CT SCREENINGS AND MORE OUTLINED BELOW. ADDITIONALLY, WE CREATED AND DISTRIBUTED WRITTEN AND VISUAL CONTENT THAT ADDRESSED SPECIFIC ISSUES AND HEALTH CONCERNS FOR OUR COMMUNITY.SOCIAL MEDIA POSTS:BREAST CANCER AWARENESS 10/1/2024WISE CHOICE 10/8/2024MENTAL HEALTH AWARENESS 10/10/2024PRIMARY CARE WEEK 10/11/2024GLOBAL HANDWASHING DAY 10/15/2024NATIONAL MAMMOGRAPHY DAY 10/18/2024MEGA BREAST TOUR 10/18/2024BREAST CANCER SURVIVOR TESTIMONY 10/25/2024BREAST CANCER SURVIVOR TESTIMONY 10/31/2024LUNG CANCER AWARENESS 11/1/2024LUNG CANCER SCREENING 11/8/2024WORLD DIABETES DAY 11/14/2024GREAT AMERICAN SMOKEOUT 11/24/2024WORLD AIDS DAY SCREENING 11/22/2024NO SHAVE NOVEMBER 11/22/2024SAFE TOYS AND GIFTS MONTH 12/2/2024SAFESITTER 12/4/2024HAND HYGIENE 12/6/2024ANXIETY 12/6/2024WHOOPING COUGH (PERTUSSIS) VACCINE AWARENESS 12/10/2024WHOOPING COUGH (PERTUSSIS) VACCINE AWARENESS 12/18/2024CROHN'S DISEASE AWARENESS 12/19/2024WHOOPING COUGH (PERTUSSIS) VACCINE AWARENESS 12/23/2024ANXIETY 1/3/2025WINTER STORM PREPAREDNESS 1/5/2025SLEDDING SAFETY 1/10/2025WEIGHT LOSS 1/10/2025HEAD AND NECK CANCER AWARENESS 1/15/2025LUNG DISEASE SUPPORT 1/16/2025FROSTBITE/HYPOTHERMIA AWARENESS 1/20/2025MOBILE MAMMOGRAM 1/29/2025GO RED FOR WOMEN (HEART DISEASE) 1/31/2025GO RED FOR WOMEN (HEART DISEASE) 2/1/2025AMERICAN HEART MONTH 2/3/2025GO RED FOR WOMEN (HEART DISEASE) 2/5/2025GO RED FOR WOMEN (HEART DISEASE) 2/6/2025HEART ATTACK SIGNS AND SYMPTOMS 2/8/2025IMPELLA HEART PUMP 2/11/2025CARDIAC REHAB 2/15/2025WINTER WEATHER SAFETY 2/18/2025NATIONAL CAREGIVERS DAY 2/21/2025COLON CANCER SCREENING 3/3/2025MEDICARE SEMINAR 3/3/2025NATIONAL KIDNEY MONTH 3/6/2025COLON CANCER AWARENESS MONTH 3/6/2025COLONOSCOPY AWARENESS 3/7/2025KIDNEY HEALTH 3/11/2025WORLD KIDNEY DAY / CHRONIC KIDNEY DISEASE 3/13/2025PULMONARY REHAB EDUCATION 3/15/2025FLU SEASON AWARENESS 3/18/2025KIDNEY DISEASE AWARENESS 3/20/2025AMERICAN DIABETES ALERT DAY 3/20/2025KIDNEY HEALTH 3/25/2025COLON CANCER SCREENING 3/26/2025HEAD AND NECK CANCER AWARENESS 4/1/2025HEAD AND NECK CANCER SCREENINGS 4/7/2025HEAD AND NECK CANCER SCREENINGS 4/15/2025STRESS AND ALCOHOL USE 4/18/2025STROKE AWARENESS MONTH 5/1/2025SPOT A STROKE F.A.S.T. 5/2/2025WORLD OVARIAN CANCER DAY 5/8/2025MENTAL HEALTH AND NURSING 5/9/2025SANE EDUCATION 5/9/2025SKIN CANCER AWARENESS 5/14/2025F.A.S.T. EXPERIENCE 5/14/2025STROKE AWARENESS MONTH 5/21/2025MENTAL HEALTH FOR WOMEN 5/22/2025BLOOD DONATION 5/24/2025CANCER SURVIVORSHIP 6/1/2025MEN'S HEALTH AWARENESS MONTH 6/2/2025MEN'S HEALTH AWARENESS MONTH 6/4/2025MEN'S HEALTH AWARENESS MONTH 6/9/2025MEN'S HEALTH AWARENESS MONTH 6/11/2025MEN'S HEALTH AWARENESS MONTH 6/12/2025MEN'S HEALTH AWARENESS MONTH 6/12/2025WORLD BLOOD DONATION DAY 6/14/2025HEAT SAFETY AWARENESS 6/23/2025MEN'S CANCERS 6/24/2025MEN'S HEALTH AWARENESS MONTH 6/27/2025SUMMER SAFETY 6/28/2025MEN'S HEALTH AWARENESS MONTH 6/30/2025FIREWORKS SAFETY 7/2/2025SKIN HEALTH AWARENESS 7/17/2025PEDIATRIC PHYSICAL THERAPY 7/18/2025HEALTH SAFETY 7/19/2025BLOOD DONATION 7/21/2025INFANT MORTALITY 7/23/2025UV SAFETY AWARENESS 7/25/2025BACK-TO-SCHOOL HEALTH 7/28/2025PEDIATRIC PHYSICAL THERAPY 7/30/2025BACK-TO-SCHOOL HEALTH 7/30/2025WORLD LUNG CANCER DAY 8/1/2025NATIONAL BREASTFEEDING MONTH 8/16/2025BITE THERAPY 9/4/2025WORLD SEPSIS DAY 9/13/2025TIF PROCEDURE FOR GERD 9/17/2025BLOOD DONATION 9/17/2025BREAST CANCER AWARENESS 9/19/2025PROSTATE CANCER DETECTION 9/23/2025COCHLEAR IMPLANTS 9/26/2025MAMMOGRAMS 9/29/2025MEDICATION ASSISTANCE AND FAMILY MEDICINE RESIDENCY CLINIC DEACONESS PROVIDES FREE AND REDUCED CARE WITHIN OUR HOSPITAL BUILDINGS. THROUGH OUR MEDICATION ASSISTANCE PROGRAM (MAP) AND OUR FAMILY PRACTICE RESIDENCY CLINIC, PATIENTS CAN ACCESS THE HIGH QUALITY HEALTH CARE THEY NEED IN CONVENIENT LOCATIONS AND AT A PRICE THEY CAN AFFORD. SIMILARLY, THE MAP FOR DEACONESS MEMORIAL MEDICAL CENTER ASSISTED 963 PATIENTS WITH $5,818,823.94 IN MEDICATION ASSISTANCE.LOCAL SPONSORSHIPSAS A SYSTEM IN FY 24-25, DEACONESS SPONSORED PROGRAMS AND ACTIVITIES FOR MORE THAN 170,000 PEOPLE, CONTRIBUTING $2.1 MILLION IN SUPPORT OF CLUBS, GROUPS, SOCIAL SERVICE ORGANIZATIONS, AND OTHERS STRIVING TO MAKE OUR COMMUNITY A BETTER PLACE. PART VI, LINE 6: DEACONESS MEMORIAL MEDICAL CENTER IS AFFILIATED WITH DEACONESS HEALTH SYSTEM, COOPERATING TO PROVIDE HEALTH CARE SERVICES TO THEIR COMMUNITIES. ADDITIONALLY, THE HOSPITAL DOES PARTICIPATE IN SEVERAL COALITIONS AND COOPERATIVES WITH OTHER PROVIDERS AND OFTEN COLLABORATES WITH THE LARGER SYSTEM IN THE EVANSVILLE AREA TO PROVIDE ACCESS TO SERVICES THE HOSPITAL CANNOT PROVIDE SUCH AS CARDIAC AND NEUROLOGICAL SURGERY. PART VI, LINE 7, REPORTS FILED WITH STATES IN X 0 0 0 1 0 0 0 1 1 1 0 SHAWN MCCOY BOARD MEMBER 0 1238547 0 457318 0 320373 0 316483 0 44966 0 2377687 0 313370 MATTHEW DODARO PHYSICIAN 806756 0 595642 0 12305 0 6900 0 33384 0 1454987 0 0 0 GEOFFREY DAY MD PHYSICIAN 905895 0 455886 0 630 0 6900 0 33384 0 1402695 0 0 0 JOSHUA LEONARD MD PHYSICIAN 886787 0 421962 0 966 0 6900 0 32906 0 1349521 0 0 0 ADAM DAWKINS MD PHYSICIAN 869346 0 421544 0 630 0 6900 0 32167 0 1330587 0 0 0 E KYLE BENNETT FORMER PRES./CEO 346259 0 557501 0 342099 0 5775 0 19794 0 1271428 0 0 0 LYNN LINGAFELTER BOARD MEMBER 0 694891 0 216135 0 161934 0 162333 0 36046 0 1271339 0 158553 JAMES PORTER MD BOARD MEMBER 0 682862 0 213203 0 177113 0 160685 0 26675 0 1260538 0 173123 JONATHAN DAY MD PHYSICIAN 589958 0 595642 0 630 0 6900 0 50020 0 1243150 0 0 0 EDWARD W MILLER VP FINANCE/CFO 383209 0 314307 0 2426 0 6900 0 5831 0 712673 0 0 0 SOHAIL QADIR MD BOARD MEMBER 609750 0 28800 0 1806 0 6900 0 31803 0 679059 0 0 0 NICK WERNE MD BOARD MEMBER 308731 0 174083 0 630 0 5682 0 32259 0 521385 0 0 0 KRISTI NORD MD MED. STAFF PRES. 344042 0 18621 0 420 0 6529 0 32811 0 402423 0 0 0 KEITH MILLER CAO & INDIANA REGION PRES. 274802 0 11670 0 1182 0 7569 0 33744 0 328967 0 0 0 PART I, LINE 1A SOCIAL CLUB DUES ARE PAID FOR SHAWN MCCOY FOR ORGANIZATION BUSINESS ONLY. ANY PERSONAL USE OF THE CLUB MUST BE PAID BY THE EMPLOYEES. PART I, LINE 3 THE FOLLOWING METHODS WERE USED BY DEACONESS HEALTH SYSTEM, A RELATED NON-PROFIT ORGANIZATION, TO DETERMINE THE COMPENSATION FOR THE CEO: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION STUDY OR SURVEY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B SEVERANCE PAYMENTS: E. KYLE BENNETT $339,602 EDWARD MILLER $53,612 NONQUALIFIED PAYMENTS: SHAWN MCCOY $23,000 LYNN LINGAFELTER $23,000 DR. JAMES PORTER $23,000 LYNN LINGAFELTER: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $150,258 SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $158,553 SHAWN MCCOY: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $304,408 SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $313,370 JAMES PORTER: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $148,610 SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $173,123 PART I, LINE 6 COMPENSATION CONTINGENT UPON NET EARNINGS: INCENTIVE COMPENSATION PAYMENTS MADE BY THE ORGANIZATION ARE BASED UPON SUCCESSFUL ACHIEVEMENT OF ESTABLISHED INPATIENT SATISFACTION MEASURES, OUTPATIENT SATISFACTION MEASURES, COMPLIANCE WITH PUBLICLY REPORTED QUALITY INDICATORS, OPERATING MARGIN AS WELL AS OTHER TECHNICAL AND PERSONAL FUNCTIONAL GOALS OF BOTH THE ORGANIZATION AND RELATED ORGANIZATIONS. DEACONESS HOSPITAL'S INCENTIVE COMPENSATION PROGRAMS ARE FORMULATED TO REWARD BEHAVIOR THAT BALANCES PATIENT NEEDS AND EFFICIENT DELIVERY OF PATIENT CARE TO ENSURE THE BEST OUTCOMES ARE ACHIEVED. PART I, LINE 7 PHYSICIANS ARE ELIGIBLE FOR INCENTIVE COMPENSATION. THE PHYSICIAN IS COMPENSATED FOR EACH WORK RVU PERFORMED BY A PHYSICIAN IN A CALENDAR YEAR IN EXCESS OF THE PHYSICIAN'S WORK RVU INCENTIVE THRESHOLD FOR THE CALENDAR YEAR MULTIPLIED BY THE INCENTIVE RVU PAYMENT. DR MATTHEW DODARO TOP 5 HIGHEST COMPENSATED EMPLOYEE SB&A LOAN X 32500 0 1 1 32500 BRENDA STALLINGS SEE PART V 2569050 SEE PART V 0 SCHEDULE L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: A) NAME OF PERSON: BRENDA STALLINGS(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND THE HOSPITAL: BRENDA STALLINGS, MEMORIAL HOSPITAL BOARD MEMBER, IS THE PRESIDENT OF MATRIX INTEGRATION.(D) DESCRIPTION OF TRANSACTION: MATRIX INTEGRATION PROVIDES PROFESSIONAL INFORMATION TECHNOLOGY (IT) SERVICES TO MEMORIAL HOSPITAL. THE HOSPITAL PAID $2,569,050 FOR SERVICES TO MATRIX INTEGRATION IN THE CURRENT YEAR. FORM 990, PART I, SECTION J WWW.DEACONESS.COM/INDIANA/DEACONESS-MEMORIAL-MEDICAL-CENTER FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS DEACONESS HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A DIRECTORS APPOINTED TO THE BOARD ARE SUBJECT TO THE APPROVAL OF THE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B EACH OF THE FOLLOWING MATTERS SHALL REQUIRE THE SPECIFIC APPROVAL OF THE MEMBER, WHICH MAY BE EXERCISED UPON THE MEMBER'S INITIATIVE (EITHER BY ACTION OF THE BOARD OF DIRECTORS OF THE MEMBER OR VIA APPROVED MANAGEMENT AUTHORITY (E.G., VIA AUTHORITY SET FORTH IN THE DIVISION CHARTER, SUBJECT TO APPLICABLE PARAMETERS)) OR BY APPROVAL OF A RECOMMENDATION FROM THE BOARD OF THE CORPORATION: (A) ADOPTION BY THE CORPORATION OF ANNUAL OR LONG-TERM STRATEGIC PLANS, BUSINESS PLANS, CAPITAL BUDGETS AND OPERATING BUDGETS AND, THEREAFTER, ANY ACTION WHICH WILL RESULT IN A SUBSTANTIAL CHANGE IN ANY SUCH PLAN OR BUDGET OR IN THE EXPENDITURES OR REVENUE FORECAST IN ANY SUCH PLAN OR BUDGETS IN EXCESS OF THE APPLICABLE PARAMETERS; (B) ANY CREATION OR SUBSTANTIVE AMENDMENT OF A CONTRACT, LEASE OR OTHER AGREEMENT TO WHICH THE CORPORATION IS A PARTY WHICH INVOLVES AN OBLIGATION, OR A POTENTIAL OBLIGATION, ON THE PART OF THE CORPORATION IN EXCESS OF THE APPLICABLE PARAMETERS; INVOLVES A STRATEGIC AFFILIATION BY THE CORPORATION WITH ONE OR MORE OTHER ENTITIES; OR RELATES TO THE PURCHASE OF INSURANCE OR RELATED ISSUES INVOLVING A MATERIAL CHANGE IN INSURANCE LIMITS, DEDUCTIBLES, COINSURANCE OR OTHER ISSUES INVOLVING THE NATURE OF ANY TYPE OF INSURANCE OR THE CORPORATION'S PROGRAM OF INSURANCE IN EACH CASE EXCEPT WITH RESPECT TO TRANSACTIONS CONSISTENT WITH APPROVED BUDGETS OR APPLICABLE POLICIES; (C) ANY PURCHASE, LEASE AS LESSEE, OR OTHER ACQUISITION BY THE CORPORATION OF ANY BUSINESS, ASSET OR ASSETS AT AN AGGREGATE PRICE IN EXCESS OF THE APPLICABLE PARAMETERS, IN EACH CASE EXCEPT WITH RESPECT TO TRANSACTIONS CONSISTENT WITH APPROVED BUDGETS OR APPLICABLE POLICIES; (D) ANY SALE, LEASE AS LESSOR, EXCHANGE, GIFT, MORTGAGE, ENCUMBRANCE, OPTION OR OTHER DISPOSITION BY THE CORPORATION OF: ANY REAL PROPERTY OR INTEREST THEREIN WITH A VALUE IN EXCESS OF THE APPLICABLE PARAMETERS; OR ANY OTHER ASSET WITH A VALUE IN EXCESS OF THE APPLICABLE PARAMETERS, EXCEPT WITH RESPECT TO TRANSACTIONS CONSISTENT WITH APPROVED BUDGETS OR APPLICABLE POLICIES; (E) ANY RELEASE OR CANCELLATION BY THE CORPORATION OF A CLAIM OR RIGHT OF ACTION AGAINST ANOTHER PARTY IN ANY AMOUNT, OR ANY SETTLEMENT OF LITIGATION, ARBITRATION OR OTHER PROCEEDINGS, IN EXCESS OF THE APPLICABLE PARAMETERS; (F) ANY PLAN OF CONSTRUCTION OR REMODELING INVOLVING AN EXPENDITURE BY THE CORPORATION IN EXCESS OF THE APPLICABLE PARAMETERS; (G) ANY BORROWING BY THE CORPORATION IN EXCESS OF THE APPLICABLE PARAMETERS; (H) ANY LOAN MADE BY THE CORPORATION TO ANOTHER PARTY THAT WOULD CAUSE THE AGGREGATE OF ALL LOANS MADE BY SUCH ENTITY AND ITS SUBSIDIARIES THEN OUTSTANDING TO EXCEED THE APPLICABLE PARAMETERS; (I) ADOPTION BY THE CORPORATION OF ANY INVESTMENT POLICIES, AND ANY MAKING, RETENTION OR DISPOSITION OF AN INVESTMENT BY THE CORPORATION INCONSISTENT WITH SUCH POLICIES; J) ANY SELECTION, REMOVAL, OR CHANGE IN THE COMPENSATION OR OTHER TERMS OF EMPLOYMENT OF THE CAO OR THE OFFICERS OF THE CORPORATION (WITH COMPENSATION FOR INDIVIDUALS SERVING IN EXECUTIVE ROLES FOR THE CORPORATION AT ALL TIMES BEING SUBJECT TO REVIEW AND APPROVAL BY THE BOARD OF DIRECTORS OF THE MEMBER); (K) ANY SUBSTANTIAL CHANGE IN THE EMPLOYEE FRINGE BENEFITS OR PERSONNEL POLICIES OF THE CORPORATION; (I) ANY GENERAL PLAN FOR THE SOLICITATION BY THE CORPORATION OF CHARITABLE CONTRIBUTIONS, OR THE SOLICITATION OR ACCEPTANCE AS A GIFT BY THE CORPORATION OF ANY REAL PROPERTY OR ANY INTEREST THEREIN, EXCEPT FOR ROUTINE FUNDRAISING ACTIVITIES CONTEMPLATED BY A FUNDRAISING PROGRAM PREVIOUSLY APPROVED BY THE MEMBER; (M) ANY REPORT OR APPLICATION TO A PUBLIC OR QUASI-PUBLIC AGENCY OR THIRD PARTY PAYER BY THE CORPORATION; (N) ANY AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION, BYLAWS, OR OTHER ORGANIZATIONAL DOCUMENTS OF THE CORPORATION OR ANY AFFILIATE OF THE CORPORATION (SUBJECT TO THE RESTRICTIONS CONTAINED IN ARTICLE XII HEREOF). (O) ANY MERGER, REORGANIZATION, CONSOLIDATION, CHANGE OF CONTROL, OR DISSOLUTION INVOLVING THE CORPORATION, OR ANY ACTION RELATED TO BANKRUPTCY OR INSOLVENCY INVOLVING THE CORPORATION; (P) ANY AGREEMENT TO INDEMNIFY A PERSON OR PERSONS BY THE CORPORATION OTHER THAN IN THE ORDINARY COURSE OF BUSINESS; (Q) ANY TRANSACTION BY THE CORPORATION INVOLVING A DUALITY OF INTEREST; (R) ANY ACTION OR INACTION BY THE CORPORATION AT VARIANCE WITH THE POLICIES OF THE MEMBER; (S) ANY AGREEMENTS OR AFFILIATIONS INVOLVING THE CORPORATION AND ANY OTHER HOSPITALS OR HEALTH CARE SYSTEMS INVOLVING FINANCIAL COMMITMENTS IN EXCESS OF THE APPLICABLE PARAMETERS; (T) FORMATION OF ANY NEW ENTITY BY THE CORPORATION INVOLVING FINANCIAL COMMITMENTS IN EXCESS OF THE APPLICABLE PARAMETERS; (U) ANY ACQUISITION OF EQUITY OR MEMBERSHIP INTEREST BY THE CORPORATION IN ANOTHER ENTITY INVOLVING FINANCIAL COMMITMENTS IN EXCESS OF THE APPLICABLE PARAMETERS; (V) ANY ISSUANCE OF EQUITY OR MEMBERSHIP INTEREST BY THE CORPORATION WITH A VALUE IN EXCESS OF THE APPLICABLE PARAMETERS; (W) THE CORPORATION ENTERING A NEW LINE OF BUSINESS, OR CEASING OR MATERIALLY ALTERING ANY EXISTING LINE OF BUSINESS, IN EACH CASE INVOLVING A FINANCIAL IMPACT OR COMMITMENT IN EXCESS OF THE APPLICABLE PARAMETERS; (X) HIRING OR CHANGING OUTSIDE FINANCIAL AUDITORS BY THE CORPORATION; (Y) CREATING COMMITTEES OF THE GOVERNING BOARD OF THE CORPORATION OR CHANGING THE PURPOSES, AUTHORITY, SIZE OR COMPOSITION OF ANY EXISTING COMMITTEES; (Z) GUARANTEEING ANY OBLIGATIONS OF ANY OTHER PERSON OR ENTITY BY THE CORPORATION INVOLVING POTENTIAL FINANCIAL OBLIGATIONS IN EXCESS OF THE APPLICABLE PARAMETERS; (AA) ADOPTION OF ANY CHANGES TO THE CHARITY CARE POLICY OF THE CORPORATION EXCEPT TO THE EXTENT CONSISTENT WITH POLICIES PREVIOUSLY APPROVED BY THE MEMBER; (BB) ANY OTHER MATTERS INVOLVING THE CORPORATION AS MAY BE REQUIRED BY LAW TO BE SUBMITTED TO THE MEMBER OR AS TO WHICH THE GOVERNING BOARD OF THE CORPORATION DETERMINES BY RESOLUTION THAT SUBMISSION IS ADVISABLE; AND (CC) SUCH OTHER MATERIAL MATTERS RELATED TO THE CORPORATION AS MAY BE DETERMINED APPROPRIATE FROM TIME TO TIME BY RESOLUTION OF THE BOARD OF THE MEMBER OR BY INCLUSION IN THE CHARTER OF AN OPERATING DIVISION COMMITTEE. FORM 990, PART VI, SECTION B, LINE 11B THE IRS FORM 990 IS PRESENTED TO DHS CFO AND CEO OF THE ORGANIZATION FOR REVIEW. AFTER THIS REVIEW AND ALL QUESTIONS HAVE BEEN ANSWERED, THE FORM 990 IS PRESENTED TO THE BOARD OF DIRECTORS OF DEACONESS HEALTH SYSTEM PRIOR TO FILING. ANY ADDITIONAL QUESTIONS ARE ANSWERED AND THE FILING OF THE FORM IS COMPLETED. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST REVIEW AND COMPLIANCE ACTIVITIES ARE CONDUCTED THROUGHOUT THE YEAR UNDER THE DIRECTION OF DEACONESS HEALTH'S CORPORATE COMPLIANCE OFFICER. UPON APPOINTMENT AND ANNUALLY THEREAFTER, OFFICERS, TRUSTEES, DIRECTORS, AND KEY EMPLOYEES, ALSO KNOWN AS INTERESTED PERSONS, ARE REQUIRED TO COMPLETE THE CONFLICTS OF INTEREST AND/OR THE DISCLOSURE QUESTIONNAIRE. THESE DOCUMENTS SERVE TO ENSURE THAT INTERESTED PERSONS HAVE AN APPROPRIATE AND TIMELY MANNER IN WHICH TO DISCLOSE ANY POTENTIAL CONFLICTS. CONFLICTS ARE CONSIDERED WITH RESPECT TO OUTSIDE INTEREST, INVESTMENTS, OUTSIDE ACTIVITIES, AND BUSINESS INTERESTS AMONG THE INTERESTED PERSONS AS WELL AS THEIR FAMILY MEMBERS ON A PERIODIC BASIS. REVIEWS OCCUR TO ENSURE DEACONESS MEMORIAL MEDICAL CENTER OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSE. SUBJECTS THAT ARE REVIEWED ON A PERIODIC BASIS INCLUDE COMPENSATION, PHYSICIAN RELATIONSHIPS, PARTNERSHIP AND JOINT VENTURE ARRANGEMENTS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR TOP OFFICIALS AND OTHER OFFICERS DEACONESS MEMORIAL MEDICAL CENTER UTILIZES THE DEACONESS HEALTH COMPENSATION COMMITTEE TO APPROVE EXECUTIVE, DIRECTOR AND PHYSICIAN COMPENSATION AS WELL AS EXECUTIVE AND PHYSICIAN BENEFITS PROGRAMS. THE COMPENSATION COMMITTEE IS APPOINTED BY THE BOARD OF DIRECTORS OF DEACONESS HEALTH AND MUST MEET THE INDEPENDENCE REQUIREMENTS OF THE IRS. THE COMMITTEE HAS THE POWER AND AUTHORITY TO: 1) ANNUALLY REVIEW AND APPROVE AND RECOMMEND TO THE BOARD OF DIRECTORS FOR ITS FINAL APPROVAL FOR THE CEO AND EACH OTHER EXECUTIVE OFFICER OF THE SYSTEM ALL ELEMENTS OF EXECUTIVE COMPENSATION 2) MONITOR BROADLY THE STRUCTURE, PHILOSOPHY OR COMPETITIVENESS OF THE SYSTEM'S GENERAL HIRING OR COMPENSATION PRACTICES 3) OVERSEE THE ESTABLISHMENT AND ADMINISTRATION OF THE COMPANY'S BROAD-BASED BENEFIT PLANS AND PROGRAMS 4) REVIEW OR APPROVE SIGNIFICANT AMENDMENTS OR CHANGES TO THE PLANS AND PROGRAMS 5) RETAIN AND TERMINATE ANY COMPENSATION CONSULTANT TO BE USED TO ASSIST IN THE EVALUATION OF DIRECTOR, CEO OR EXECUTIVE OFFICER COMPENSATION 6) SOLE AUTHORITY TO APPROVE THE CONSULTANT'S FEES AND OTHER RETENTION TERMS 7) OBTAIN ADVICE AND ASSISTANCE FROM INTERNAL OR EXTERNAL LEGAL, ACCOUNTING OR OTHER ADVISORS 8) APPROVE ALL PHYSICIAN AND PHYSICIAN RELATED CONTRACTS 9) MAKE REGULAR REPORTS TO THE BOARD FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VII & SCHEDULE J, PART II: WE DO NOT USE A COMMON PAYMASTER. ALL SHARED STAFF AND DUAL-OFFICERS ARE PAID AND W-2'D SOLELY BY DHS. DEACONESS MEMORIAL MEDICAL CENTER REPORTS ALL SUCH COMPENSATION AS RELATED ORGANIZATION COMPENSATION IN PART VII COL (E) AND SCHEDULE J ROW (II). THE INTERCOMPANY ALLOCATION AND SUBSIDY ARE REPORTED AS OPERATIONAL TRANSFERS/ALLOCATIONS, NOT AS DIRECT COMPENSATION BY THE SUBSIDIARY. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 37,321,136. MANAGEMENT AND GENERAL EXPENSES 3,210,572. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 40,531,708. FORM 990, PART XI, LINE 9: INTERCOMPANY TRANSFER 4,114,627. 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