2025-11-13T14:22:59+00:00 2024-12-31 990 2024-01-01 273532963 Indiana University Health White Memorial Hospital Inc INDI 3179634842 950 N MERIDIAN STREET 1200 INDIANAPOLIS IN 46204 Michael L Craig VP & CFO 8123539171 2025-11-13 2024 2025-03-06 01:10:19Z MARY E MINIER 950 N MERIDIAN STREET 1200 INDIANAPOLIS IN 46204 56071671 false X SEE SCHEDULE O X 2010 IN Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. 14 8 239 82 0 450514 390382 52436755 53137100 2303837 2495125 25791 30855 55216897 56053462 10271 18728 0 12974189 14397584 0 0 33945991 34742819 46930451 49159131 8286446 6894331 81819030 69027768 24738686 5033308 57080344 63994460 Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. false false 47038676 18728 52783023 INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL, INC. ("IU HEALTH WHITE MEMORIAL HOSPITAL"), LOCATED IN MONTICELLO, INDIANA, IS A 25-BED CRITICAL ACCESS HOSPITAL THAT OFFERS A COMPREHENSIVE RANGE OF SERVICES TO CARE FOR ITS PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. ALL PATIENT ROOMS ARE PRIVATE AND BOAST WARM COLORS AND NATURAL LIGHT TO ENHANCE COMFORT AND HEALING. A FAMILY-FRIENDLY ENVIRONMENT OFFERS PULLOUT BEDS FOR OVERNIGHT STAYS AND WIRELESS INTERNET ACCESS. AS PART OF ITS COMMITMENT TO THE COMMUNITY, THE HOSPITAL OFFERS SEVERAL PROGRAMS TO BENEFIT RESIDENTS IN THE MONTICELLO AREA. 289184 0 324499 IU HEALTH WHITE MEMORIAL HOSPITAL LEASES PHYSICIAN OFFICE AND CLINIC SPACE TO RELATED TAX-EXEMPT ORGANIZATIONS. 26359 0 29578 OUR NETWORK OF PHARMACIES OFFERS THE CONVENIENCE OF ONE-STOP SHOPPING. WE PROVIDE EXPERT CARE AND HELP PATIENTS MAKE THE BEST USE OF THEIR MEDICATIONS. 47354219 true true false true false false false false false true true false false true true true false true false false false false false false false false true true true false true false false false false false false false false true false false false false false false true true true false false true 0 0 239 true false false false false false false false false false false false false X 14 8 false false false false true true true true true false false false true true true true true true false false false false IN X CRAIG J JONES 3179634842 950 N MERIDIAN STREET SUITE 800 INDIANAPOLIS IN 46204 GARY D HENRIOTT DIRECTOR/CHAIR 2.0 5.0 X X 0 9000 0 PHILIP LIST Director (Part Year) / Legal Counsel Secretary (Part Year) 10.0 45.0 X X 0 273073 57009 AMANDA WHITLOCK DIRECTOR 2.0 4.0 X 0 6000 0 BEN HARPENAU DIRECTOR 2.0 4.0 X 0 6000 0 ERIKA UGIANSKIS MD DIRECTOR 2.0 53.0 X 0 922291 78678 JESSE MOORE DIRECTOR 2.0 4.0 X 0 5000 0 JOHNNY PARK DIRECTOR 2.0 4.0 X 0 5000 0 MARK BUONO MD Director 2.0 53.0 X 0 826411 68190 MICHELE S SAYSANA MD DIRECTOR (Part Year) 2.0 53.0 X 0 629341 29763 RUBAN NIRMALAN MD DIRECTOR 2.0 53.0 X 0 996753 68129 SHAN SHERIDAN DIRECTOR 2.0 4.0 X 0 6000 0 UMESH PATEL DIRECTOR 2.0 4.0 X 0 5000 0 WILLIAM Y LI MD DIRECTOR 2.0 53.0 X 0 197724 30637 YINGKEI HUI MD Director (Part Year) 2.0 4.0 X 0 38657 2974 ARTHUR VASQUEZ PRESIDENT (WCR) 10.0 45.0 X 0 848653 170264 MICHAEL L CRAIG CFO (Part Year) 5.0 50.0 X 0 375821 65857 TODD A WILLIAMS CFO (Part Year)/TREASURER (WCR) 10.0 45.0 X 0 440215 66454 WHITNEY A AIKEN Legal Counsel Secretary (Part Year) 10.0 45.0 X 0 182473 32904 KISHAN PATEL MD VP-Chief Physician Executive (WCR) 10.0 45.0 X 0 473047 66999 KOREEN C KYHNELL VP - HUMAN RESOURCES (WCR) 10.0 45.0 X 0 259251 70000 ROXANNE WICKLUND CNO (WCR) 10.0 45.0 X 0 357547 65710 DARA WERT SUPERVISOR, HOUSE 50.0 0 X 142829 44643 43586 MARY E MINIER COO (Frankfort and White) 35.0 20.0 X 204528 0 43382 RENEA SMITH CNO (Frankfort and White) 30.0 20.0 X 208926 0 13555 SAMANTHA K BARNETT Clinical Nurse 50.0 0.0 X 223882 20605 47659 SHARON M MCILVAIN Clinical Nurse 50.0 0 X 176453 0 53524 CARA L BREIDSTER FORMER OFFICER 0.0 55.0 X 0 351618 66113 CHRISTOPHER A MANSFIELD MD FORMER KEY EMPLOYEE 10.0 45.0 X 0 655505 66999 DEREK E EMPIE FORMER OFFICER 0.0 55.0 X 0 430208 77430 MARY C DREWES FORMER Highest Compensated Employee 0.0 50.0 X 0 301506 30592 956618 8667342 1316408 true true false 0 47619 336763 6000 390382 Net Patient Service Revenue 622110 52783023 52783023 Rent from Related 501(c)(3) Orgs. 532000 324499 324499 Pharmacy 446110 29578 29578 0 0 0 0 53137100 2513334 2513334 28232 28232 0 28232 28232 18209 0 -18209 -18209 -18209 All Other Revenue 900099 2623 2623 0 0 0 0 2623 56053462 53137100 0 2525980 X 18728 18728 0 0 0 0 51062 49340 1722 11503852 11115952 387900 412781 398862 13919 1625747 1570928 54819 804142 777027 27115 2128 2128 13390141 12497708 892433 0 675251 629922 45329 81551 40776 40775 1766290 1766290 12212 11392 820 852406 852406 2015404 1920455 94949 241771 241771 Drugs and Medical Supplies 11151100 11151100 Hospital Assessment Fee 3113237 3113237 Bad Debt 1410882 1410882 Other Expenses 15036 14315 721 15410 14899 511 0 49159131 47354219 1804912 0 49833620 0 34351 87916 5381875 5869145 0 0 0 0 900336 1323885 68607 153238 44228859 20735639 25438448 23493220 0 0 161793 38100364 81819030 69027768 2525807 2685540 0 0 22212879 2347768 24738686 5033308 X 56898948 63793279 181396 201181 57080344 63994460 81819030 69027768 X 6894331 19785 X false true true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 2128 2128 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY IU Health White Memorial Hospital paid institutional membership dues to the American Hospital Association ("AHA"), Indiana Hospital Association ("IHA"), and 340B Health during 2024 in the amount of $5,240, $3,262, and $1,029, respectively. Each membership organization notified IU Health White Memorial Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 32.00%, or $1,677 of 2024 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The IHA used 11.78%, or $384 of the 2024 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. 340B Health used 6.50%, or $67 of the 2024 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The total membership dues paid to these organizations by IU Health White Memorial Hospital during 2024 that were attributable to lobbying expenditures was $2,128. 181396 19785 201181 169142 12254 181396 204188 -35046 169142 186774 17414 204188 237034 7690 57950 186774 0.0 0.0 1.0 false false 954570 954570 30277094 10859916 19417178 12840561 9731512 3109049 156634 144211 12423 23493220 Intercompany Receivables (Net) 37912302 Interest in Net Assets of Foundations 188062 38100364 0 Federal Income Taxes 0 Intercompany Payables (Net) 0 Due to Third-Party Payers 2308802 Self-Insurance Liabilities 31619 Operating Lease Liabilities 7347 2347768 X 0 0 0 0 0 0 0 0 0 0 0 0 Schedule D, Part V, Line 4 Intended uses of endowment funds RESTRICTED NET ASSETS ARE GENERALLY RESTRICTED FOR INDIGENT AND OTHER PATIENT CARE SERVICES, MEDICAL EDUCATION AND RESEARCH PROGRAMS, AND MEDICAL SUPPLIES AND EQUIPMENT. Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote IU Health White Memorial Hospital is a subsidiary in IU Health's Consolidated Audited Financial Statements. The Internal Revenue Service has determined that Indiana University Health and certain of its affiliated entities are tax-exempt organizations as defined in Section 501(c)(3) of the Internal Revenue Code (IRC). Indiana University Health and its tax-exempt affiliates are, however, subject to federal and state income taxes on unrelated business income under the provisions of IRC Section 511. Deferred income taxes which, as of December 31, 2024, and 2023, have no net carrying value, reflect the net tax effect of temporary differences between the carrying amounts of assets and liabilities for financial reporting and the amounts used for income tax purposes. As of December 31, 2024, and 2023, the Indiana University Health System had gross deferred tax assets of $110,705,348, and $141,386,173, respectively, relating to net operating loss carryovers. Indiana University Health White Memorial Hospital, Inc.'s portion of the December 31, 2024, and 2023 deferred tax assets is $0 and $0 respectively. Management determined that a full valuation allowance at December 31, 2024 and 2023 was necessary to reduce the deferred tax assets to the amount that would more likely than not be realized. Based on the weight of the evidence, if it is more likely than not that some portion or all of the deferred tax assets will not be realized, a valuation allowance to reduce the deferred tax assets is recorded. The decrease in the gross deferred tax asset and the valuation allowance for the current year is $30,681,000. At December 31, 2024, Indiana University Health System has available net operating loss carryforwards of $445,118,000, Indiana University Health White Memorial Hospital, Inc.'s portion is $0. Net operating losses generated from 2005 through 2017 will expire between 2025 and 2037. Net operating losses generated after 2017 do not expire. true true X true X 300 false 2798 1703825 1703825 0.03568 4020 8659000 5579901 3079099 0.06449 0 0.0 0 6818 10362825 5579901 4782924 0.10017 2 1303 941230 333905 607325 0.01272 1 5 5000 5000 0.00010 1 718 655228 614076 41152 0.00086 0 0.0 2 16871 16871 0.00035 6 2026 1618329 947981 670348 0.01404 6 8844 11981154 6527882 5453272 0.11421 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0 0 0 0 0.0 false 319836 14546290 14175038 371252 X true true 1 1 IU HEALTH WHITE MEMORIAL HOSPITAL 720 SOUTH SIXTH STREET MONTICELLO IN 47960 https://iuhealth.org/find-locations/iu-health-white-memorial-hospital 22-005034-1 X X X X IU HEALTH WHITE MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 24 true false false true X HTTPS://IUHEALTH.ORG/IN-THE-COMMUNITY/COMMUNITY-BENEFIT true 25 true HTTPS://IUHEALTH.ORG/IN-THE-COMMUNITY/COMMUNITY-BENEFIT false true X 300.0 0.0 X X X X X X X true true X X X true X HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE X HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE X HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 3E IU HEALTH'S 2024 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) REPORTS INCLUDE PRIORITIZED DESCRIPTIONS OF SIGNIFICANT HEALTH NEEDS IN THE COMMUNITY. THE CHNA REPORTS IDENTIFIED THE FOLLOWING NEEDS TO BE ADDRESSED: - Access to healthcare services - Aging population and needs of older adults - Behavioral health (mental health and substance abuse) - Chronic disease prevention and management - Maternal and infant health and child well-being - Smoking, vaping and tobacco use - Social determinants of health (SDOH) Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - IU HEALTH WHITE MEMORIAL HEALTH. IU Health White Memorial Hospital The defined community per the most recent CHNA conducted in the current tax year (i.e., 2024) is White County, Indiana, where the hospital resides. This CHNA relies on multiple data sources and community input gathered in January through June of 2024. The CHNA process was completed when the CHNA was made widely available to the public on December 19, 2024. Primary data summary IU Health White Memorial Hospital obtained the insight and views of those who live in and service White County through community meetings (including those having public health expertise), a survey sent to those who were unable to attend the community meetings and a survey sent to internal healthcare providers and other team members from IU Health White Memorial Hospital. People and organizations representing a broad range of sectors, services and groups in the community were invited to attend. See Appendix C for a list of the organizations and community members that participated in the community input process Community meetings In June 2024, IU Health facilitated two community meetings to receive input on the health needs in White County. The meetings were attended by 33 people in total. These meetings followed the same format as those meetings held in Carroll County. Highlights of the discussion during the community meetings include many, if not all, of the 2021 CHNA significant community health needs. Suggested additions to the list include aging population and the needs of older adults; access to safe and affordable housing; transportation; access to healthy foods; and access to quality childcare. Additional highlights of the 2024 discussion include: - Social isolation is an issue, especially for older adults - The lack of transportation impacts who gets services - Available community resources cannot keep up with demand - Identifying and assisting individuals-and families- experiencing homelessness or that have inadequate or poor housing is needed as well as ongoing support for local organizations such as LTHC's Homeless Services (Lafayette Transitional Housing Center) - There is a growing number of young people caring for themselves and needing community support (e.g., Boys and Girls Club and Monon and North White) - More after-school programs are needed for outlying county schools - There is a desire to see community members increase their use of gyms, trails and other available resources that support physical activity - Vaping is a concern in the community - The needs of the community are like other rural communities - Addressing mental health and barriers to accessing services (e.g., shortage of providers and stigma) is vital - There is continued support for local services that seek to increase access to healthcare, including the mobile integrated health program and urgent care - More flexibility in the offering of healthcare services (e.g., hours) For those unable to attend the community meetings, a separate survey was distributed to receive their input on comparable questions posed during those meetings. Seven people responded to the survey. These findings were combined with those of the community meeting participants. This process identified the following needs as most significant for White County, which are not listed in any order: - Access to healthcare services - Access to mental health services - Access to treatment for substance use disorders - Aging population and older adults - Maternal and infant health Community meeting and survey participants Individuals from organizations representing different sectors and groups within the local community participated in the community input process. Participants included community members and representatives from the following organizations: - Alliance Bank - Bank of Wolcott - Carroll/White County REMC - City of Monticello - Food Finders Food Bank - Frontier School Corporation - IU Health - IU Health White Memorial Hospital - Jordan Manufacturing - Koppelmann Real Estate - LightStream - Mental Health American Wabash Valley Region - Monticello Fire Department - Monticello Parks Department - Monticello Public Library - North Central Nursing Clinic - North White School Corporation - Purdue Center for Rural and Migrant Health - Purdue Extension - Purdue Extension of White County - Purdue University - Terra Drive Systems - Town of Brookston - Town of Monon - Upper Room Youth Center (Carroll County) - White County Area Planning - White County Commissioner - White County Council on Aging - White County Economic Development - White County Health Department - White County United Way/United Council on Opioids - YMCA Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - IU HEALTH WHITE MEMORIAL HEALTH. In February 2025, IU Health's board of directors approved the implementation strategy for IU Health White Memorial Hospital to respond to the needs identified in their 2024 CHNA. IU Health White Memorial Hospital would address these community health needs in 2025-2027: * Access to healthcare services * Aging population and needs of older adults * Behavioral health (mental health and substance use) * Chronic disease prevention and management * Maternal and infant health and child well-being * Smoking, vaping and tobacco use * Social determinants of health IU Health White Memorial Hospital would address all the community health needs identified in the 2024 CHNA. In 2024, IU Health White Memorial Hospital addressed needs identified in the 2021 CHNA using the 2022-2024 implementation strategy plan adopted in April 2022. The hospital, along with community partners, prioritized and determined which of the significant needs identified in the CHNA could be adequately addressed by current or future initiatives, programs, resources, and collaborations. The 2022-2024 implementation strategy outlined how IU Health White Memorial Hospital planned to address significant needs including initiatives, strategies, internal/external collaborators, anticipated impact, and hospital resources. Significant Needs Hospital Addressed Below was the progress of the implementation strategy by significant need and its respective initiative(s). The hospital was addressing the following significant needs between 2022 and 2024: Access to Healthcare Services; Behavioral Health; Maternal and Infant Health and Child Well-being; and Social Determinants of Health. Access to Healthcare Services Supported Mobile Integrated Health Program (MIH)/Community Paramedicine Program. In 2024, the Mobile Integrated Health/Community Paramedicine Program received 50 referrals from IU Health White Memorial Hospital. Supported community members accessing healthcare services regardless of their ability to pay. The hospital provided financial assistance to patients each year that included discounts, full charity, and personal hardship reductions. IU Health Patient Financial Counselors were certified Indiana Navigators. They assisted patients and families with information and helped them with applications for various health coverage programs. In 2024, the counselors served 88 people at IU Health White Memorial Hospital. Created a pipeline, targeting youth and adults, for future healthcare leaders to access local opportunities. During 2024, IU Health team members visited multiple locations across the region speaking to more than 99 individuals about healthcare career pathways. Provided IU Health Arnett Primary Care Walk-in Clinic in Monticello. IU Health Arnett Primary Care Walk-in Clinic in Monticello completed 6,797 appointments in 2024. Launched Integrated Social Work Initiative in IU Health clinical settings. Virtual Integrated Social Work (VISW) assisted providers and patients with urgent complex situations such as abuse and neglect concerns, domestic violence, housing insecurity, and social barriers to care. This team of licensed social workers and coordinators were skilled in assessing and identifying social determinants of health (SDOH), providing resources, and making recommendations unique to the patient and their circumstances. ISW provided urgent medical social worked services through an iPad cart to all primary care and pediatric primary care practices throughout the system. The SDOH screener PRAPARE was live in 73 primary care practices. ISW Social Determinants of Health Coordinators provided resources and supported to patients with urgent needs identified in the screener. There was a total of 7,715 referrals in 2024. Of those referrals, 765 referrals made to ISW included patients seen at IU Health Arnett, IU Health Frankfort and IU Health White Memorial Hospitals. Behavioral Health Supported community access strategies to prevent opioid overdose in the community. IU Health team members participated in the White County United Council on Opioids, a local task force that addresses prevention, treatment and recovery resources in White County. IU Health provided sponsorship and attended the White County Youth Summit where more than 50 White County youth discussed strategies about substance abuse in White County. IU Health provided funding for the Comeback Recovery Cafe, White County's only Recovery Cafe/Support Network. Further implemented the Virtual Care Peer Recovery Coaching Program (provided patients who had substance use concerns with virtual behavioral health services). The Virtual Peer Recovery Coach program was discontinued in February 2023 as IU Health assessed and evolved its behavioral health services based on the needs of patients and the communities it serves. Since 2018, this program had served 15 IU Health and two non-IU Health emergency department patients who struggled with substance use disorder through support to aid in recovery. IU Health continues to serve patients with a need for this service through the Virtual Behavioral Health team. Developed hospital and community infrastructure for crisis care to support community members with behavioral health concerns. In 2024, IU Health awarded one community-based organization funding to host #WoW Talk Teen Cafe's to address the youth mental health crisis happening in the region. This location hosted 12 cafes with 31 unique participants. Further implemented the emergency department (ED) virtual care program (provided patients virtual access to behavioral health services). Virtual Integrated Behavioral Health (VIBH) provided urgent psychiatric assessment for patients experiencing behavioral health crises, such as suicidal ideation, homicidal ideation, psychosis, and substance abuse disorders. A team of behavioral health professionals provided consultation through iPad carts located in emergency departments, urgent cares, and ambulatory care locations. In 2024, there were over 10,000 visited of which 1,989 visited included patients seeking care in the emergency departments in the West Central Region (which included IU Health White Memorial Hospital). This program was financially supported by the parent hospital, IU Health Inc., but was offered to and impacted patients in this hospital's defined community. Provided comprehensive suicide prevention through the Zero Suicide Initiative. The program was live in all 92 IU Health Primary Care Practices around the state (including those located in IU Health White Memorial's defined community). Patients were screened for suicidal ideation. Virtual Integrated Behavioral Health (VIBH) expanded behavioral health access to patients and providers across the state. VIBH provided urgent psychiatric assessment for patients that experienced behavioral health crises, such as suicidal ideation, homicidal ideation, psychosis, and substance abuse disorders. Maternal and Infant Health and Child Well-being Provided support and expertise to the Fetal Infant Mortality Review Team. The Fetal Infant Mortality Review Team no longer reviews cases from White County. Supported the White/Carroll County Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program. In 2024, the White County WIC Program served approximately 1,190 clients. During World Breastfeeding Week, they hosted an event and distributed educational information and IU Health Diaper Bags, filled with burp cloths, diapers, and wipes to approximately 28 people. Provided increased access to local healthcare services. IU Health White Memorial served 101 OBGYN patients in 2024. IU Health supported the White County Mobile Integrated Health program delivered by the Monticello Fire Department. In 2022, the MIH program received additional funding to add a maternal health specialist to their team with their program being named Project Sprout. Unfortunately, during 2024 the Project Sprout coordinator left that position. Distributed Safe Sleep education in the community. The White/Carroll County WIC program offered Safe Sleep education to program participants. Schedule H, Part V, Section B, Line 11 Facility , 2 Facility , 2 - IU HEALTH WHITE MEMORIAL HEALTH (CONTINUED). Social Determinants of Health Provided fiscal support to organizations addressing social determinants of health. In 2024, the IU Health Community Outreach and Engagement Committee provided funding to the Purdue University Family Health Clinics to support their mobile outreach program to provide support and supplies to families in White County. The committee also provided funding support to the Monticello Fire Department to help provide support for EMS education. Established strategic collaborative relationships with local community-based organizations that addressed social determinants of health. IU Health had coordinated service projects through IU Health Serves including 2 mobile food pantries, playground painting at North White Elementary School, fleece-hand tie blankets, feminine hygiene kits, and tobacco cessation kits for IU Health White Memorial's Tobacco Cessation program. Supported career pathway development program. During 2024, IU Health team members visited multiple locations across the region speaking to 99 individuals about healthcare career pathways. Supported Bridging the Gap. The Bridging the Gap program was paused due to system level initiatives around language services. Significant Needs Hospital Did Not Address IU Health White Memorial Hospital addressed all the significant health needs identified in the 2021 Community Health Needs Assessment. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - IU HEALTH WHITE MEMORIAL HOSPITAL. IN ADDITION TO FPG, IU HEALTH WHITE MEMORIAL HOSPITAL MAY TAKE INTO CONSIDERATION A PATIENT'S INCOME AND/OR ABILITY TO PAY IN CALCULATION OF A FINANCIAL ASSISTANCE AWARD. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - IU HEALTH WHITE MEMORIAL HOSPITAL. IU Health White Memorial Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. Financial Assistance due to Financial Hardship A. To be eligible for Financial Assistance due to financial Hardship under this Policy, a patient or guarantor must: a. Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; b. Be an Indiana Resident as defined in this Policy; and B. If Uninsured, consult with a member of IU Health's Financial Counseling department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. C. Financial Assistance due to financial Hardship is only available for Qualifying Care, as defined in this Policy. D. The FPL income threshold under this section is as follows: - If one or more adults and zero dependents are in the household, the FPL Income Threshold is 200%. - If two or more adults and one or more dependents are in the household, the FPL Income Threshold is 250%. - If one adult and one or more dependents are in the household, the FPL Income Threshold is 300%. *In some instances, an adult will also qualify as a dependent. When this occurs, IU Health will treat the adult as a dependent for purposes of the FPL calculation. 2. Financial Assistance due to Personal Hardship A. In order to be eligible for Financial Assistance due to personal Hardship under this Policy, a patient or guarantor must: a. Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; b. Be an Indiana Resident as defined in this Policy; and c. If Uninsured, consult with a member of IU Health's Financial Counseling department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. B. An Uninsured or Underinsured patient or their guarantor may be eligible for Financial Assistance if the Household's outstanding Patient Responsibility exceeds 5% of the patient's or their guarantor's annual household income. C. If approved, the Household's balance will be reduced to 5% of the patient or guarantor's annual household income. 3. Eligibility Period A. If approved for Financial Assistance by IU Health under Sections IV.E-F, the patient will be guaranteed financial assistance for treatment related to the underlying condition, for which the patient was originally screened and approved, through the remainder of the calendar year. B. As a condition of extending the ongoing Financial Assistance, the patient must comply with requests from IU Health to verify that the patient continues to meet the conditions for qualification. 4. Appeals and Assistance Granted By the Financial Assistance Committee A. The Financial Assistance Committee will review and make determinations on all requests for appeals related to Financial Assistance. If a patient or guarantor seeks to appeal a Financial Assistance Determination, a request must be submitted, along with any additional information or requested supporting documentation, if applicable. B. The Financial Assistance Committee will review requests for and may grant additional Financial Assistance, including but not limited to, the following: a. Assistance to patients who are seeking treatment that can only be provided in Indiana by IU Health or who would benefit from continued medical services from IU Health for continuity of care; b. Care approved by an IU Health Chief Medical Officer (CMO), Chief Executive Officer (CEO) or Chief Financial Off icer (CFO) of an IU Health facility or region, including medically necessary non-elective services for which no payment source can be identified; c. Care provided when it is known no payment source exists; d. Care provided, due to medical urgency, for which a payer denies payment; e. International humanitarian aid; and f. Other care identified by the Financial Assistance Committee that fulfills the IU Health Mission. C. All decisions of the Financial Assistance Committee are final. 5. Presumptive Eligibility A. A Financial Assistance Application is not required to receive Financial Assistance under this Presumptive Eligibility section. B. IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and the patient received Qualifying Care, as defined in this Policy. a. Medicaid (any state) b. Indiana Children's Special Health Care Services c. Healthy Indiana Plan d. Patients who are awarded Hospital Presumptive Eligibility (PE) e. Patients approved for the Eskenazi Health Advantage program f. A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. C. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. a. IU Health may also periodically conduct a similar review on patient balances not placed with a collection agency, and presumptively quality patients for Financial Assistance. D. Financial Assistance may additionally be granted in the following circumstances: a. If the patient or their guarantor is found to have filed a petition for bankruptcy. b. If the patient is deceased and found to have no estate. c. If the patient is deceased and was under 21 years of age at the time of death. 6. Exhaustion of Alternate Sources of Assistance A. Patients may be required to exhaust all other state and federal healthcare coverage assistance programs prior to receiving Financial Assistance due to financial or personal Hardship under this Policy including, but not limited to, Medicaid. B. Patients who may be eligible for coverage under an applicable health insurance policy must exhaust all insurance benefits. a. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. b. IU Health may request patients show proof that such a claim was properly submitted to the appropriate insurance provider before awarding Financial Assistance. C. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award. D. In the event Financial Assistance has already been granted in the above circumstances, IU Health reserves the right to reverse the Financial Assistance Determination in an amount equal to the amount IU Health would be entitled to receive had no Financial Assistance been awarded. 7. Patient Assets A. There are situations where a patient or their guarantor may have significant income or assets available to pay for healthcare services such as a legal settlement. The Financial Assistance Committee may evaluate the income or assets in determining financial Hardship. B. IU Health may require a list of all property owned by the patient or guarantor and adjust a Financial Assistance Determination as a result. Schedule H, Part V, Section B, Line 16 Facility , 1 Facility , 1 - IU HEALTH WHITE MEMORIAL HOSPITAL. IU Health White Memorial Hospital takes several other measures to broadly publicize its FAP within the community. These measures include the following: 1. Post this Policy, a Plain Language Summary of this Policy, and the Financial Assistance Application on its website. 2. Provide patients with a Plain Language Summary of this Policy during registration and/or discharge. 3. Post conspicuous displays in appropriate acute care settings such as emergency departments and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 4. Include a conspicuous written notice on all patient post-discharge billing statements notifying the patient about this Policy and the telephone number of the Customer Service Department which can assist patients with questions regarding this Policy. 5. Make available Customer Service representatives via telephone during normal business hours. 6. Mail copies of this Policy, a Plain Language Summary of this Policy, and a Financial Assistance Application to patients or their guarantor free of charge upon request. 7. Broadly communicate this Policy as a part of its general outreach efforts. 8. Educate patient-facing team members on this Policy and the process for referring patients to the program. 3 IU HEALTH WHITE MEMORIAL HOSPITAL REHABILITATION 720 S 6TH ST MONTICELLO IN 47960 REHABILITATION SERVICES IU HEALTH WHITE MEMORIAL HOSPITAL RADIOLOGY 720 S 6TH ST MONTICELLO IN 47960 RADIOLOGY IU HEALTH WHITE MEMORIAL HOSPITAL LAB 720 S 6TH ST MONTICELLO IN 47960 LAB Schedule H, Part I, Line 6a C.B Report Prepared by a related Org IU Health White Memorial Hospital's community benefit and other investments, encompassing its total community investment, are included in the IU Health Community Benefit Report which is prepared on behalf of and includes IU Health and its related hospital entities in the State of Indiana. The IU Health Community Benefit Report is made available to the public on IU Health's website at https://iuhealth.org/in-the-community. The IU Health Community Benefit Report is also distributed to numerous key organizations throughout the State of Indiana in order to broadly share the IU Health Statewide System's community benefit efforts. It is also available by request through the Indiana State Department of Health or IU Health. Schedule H, Part I, Line 7c TOTAL COMMUNITY BENEFIT EXPENSE Schedule H, Part I, Line 7, Column (f), Percent of Total Expense, is based on column (e) Net Community Benefit Expense. The percent of total expense based on column (c) Total Community Benefit Expense, which does not include direct offsetting revenue, is 25.09%. Schedule H, Part I, Line 7f PERCENT OF TOTAL EXPENSE The amount of bad debt expense included on Form 990, Part IX, Line 25, column (A), but subtracted for purposes of calculating the percentage of total expense on Line 7, column (f) is $1,410,882. Schedule H, Part II PROMOTION OF HEALTH IN COMMUNITIES SERVED IU Health White Memorial Hospital supports and/or participates in a variety of community-building activities that address the non-medical, root causes of health problems in the communities it serves. IU Health White Memorial Hospital and its related hospital entities across the state of Indiana ("IU Health Statewide System") investments include economic development efforts across the state, workforce development opportunities, collaborate with like-minded organizations through coalitions that address key issues, and advocate for improvements in the health status of vulnerable populations. Some of these activities meet the definition of community benefit and have been reported as such. In 2024, IU Health White Memorial Hospital supported the following community building activities to promote the health of the community: Community Support: IU Health White Memorial Hospital administrators provided five $1,000 scholarships to local high school students totaling to $5,000. Schedule H, Part I, Line 7g DESCRIBE SUBSIDIZED HEALTH SERVICE COSTS FROM PHYSICIAN CLINIC IU HEALTH WHITE INCLUDES COSTS ASSOCIATED WITH PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES, BUT IS NOT ABLE TO SEGREGATE THE COSTS ASSOCIATED WITH PHYSICIAN CLINICS. Schedule H, Part I, Line 3c Eligibility criteria for free or discounted care IU Health White Memorial Hospital uses several factors other than federal poverty guidelines ("FPG") in determining eligibility for free care under its FAP. These factors include the following: 1. Financial Assistance due to Financial Hardship A. To be eligible for Financial Assistance due to financial Hardship under this Policy, a patient or guarantor must: a. Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; b. Be an Indiana Resident as defined in this Policy; and B. If Uninsured, consult with a member of IU Health's Financial Counseling department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. C. Financial Assistance due to financial Hardship is only available for Qualifying Care, as defined in this Policy. D. The FPL income threshold under this section is as follows: - If one or more adults and zero dependents are in the household, the FPL Income Threshold is 200%. - If two or more adults and one or more dependents are in the household, the FPL Income Threshold is 250%. - If one adult and one or more dependents are in the household, the FPL Income Threshold is 300%. *In some instances, an adult will also qualify as a dependent. When this occurs, IU Health will treat the adult as a dependent for purposes of the FPL calculation. 2. Financial Assistance due to Personal Hardship A. In order to be eligible for Financial Assistance due to personal Hardship under this Policy, a patient or guarantor must: a. Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; b. Be an Indiana Resident as defined in this Policy; and c. If Uninsured, consult with a member of IU Health's Financial Counseling department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. B. An Uninsured or Underinsured patient or their guarantor may be eligible for Financial Assistance if the Household's outstanding Patient Responsibility exceeds 5% of the patient's or their guarantor's annual household income. C. If approved, the Household's balance will be reduced to 5% of the patient or guarantor's annual household income. 3. Eligibility Period A. If approved for Financial Assistance by IU Health under Sections IV.E-F, the patient will be guaranteed financial assistance for treatment related to the underlying condition, for which the patient was originally screened and approved, through the remainder of the calendar year. B. As a condition of extending the ongoing Financial Assistance, the patient must comply with requests from IU Health to verify that the patient continues to meet the conditions for qualification. 4. Appeals and Assistance Granted By the Financial Assistance Committee A. The Financial Assistance Committee will review and make determinations on all requests for appeals related to Financial Assistance. If a patient or guarantor seeks to appeal a Financial Assistance Determination, a request must be submitted, along with any additional information or requested supporting documentation, if applicable. B. The Financial Assistance Committee will review requests for and may grant additional Financial Assistance, including but not limited to, the following: a. Assistance to patients who are seeking treatment that can only be provided in Indiana by IU Health or who would benefit from continued medical services from IU Health for continuity of care; b. Care approved by an IU Health Chief Medical Officer (CMO), Chief Executive Officer (CEO) or Chief Financial Off icer (CFO) of an IU Health facility or region, including medically necessary non-elective services for which no payment source can be identified; c. Care provided when it is known no payment source exists; d. Care provided, due to medical urgency, for which a payer denies payment; e. International humanitarian aid; and f. Other care identified by the Financial Assistance Committee that fulfills the IU Health Mission. C. All decisions of the Financial Assistance Committee are final. 5. Presumptive Eligibility A. A Financial Assistance Application is not required to receive Financial Assistance under this Presumptive Eligibility section. B. IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and the patient received Qualifying Care, as defined in this Policy. a. Medicaid (any state) b. Indiana Children's Special Health Care Services c. Healthy Indiana Plan d. Patients who are awarded Hospital Presumptive Eligibility (PE) e. Patients approved for the Eskenazi Health Advantage program f. A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. C. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. a. IU Health may also periodically conduct a similar review on patient balances not placed with a collection agency, and presumptively quality patients for Financial Assistance. D. Financial Assistance may additionally be granted in the following circumstances: a. If the patient or their guarantor is found to have filed a petition for bankruptcy. b. If the patient is deceased and found to have no estate. c. If the patient is deceased and was under 21 years of age at the time of death. 6. Exhaustion of Alternate Sources of Assistance A. Patients may be required to exhaust all other state and federal healthcare coverage assistance programs prior to receiving Financial Assistance due to financial or personal Hardship under this Policy including, but not limited to, Medicaid. B. Patients who may be eligible for coverage under an applicable health insurance policy must exhaust all insurance benefits. a. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. b. IU Health may request patients show proof that such a claim was properly submitted to the appropriate insurance provider before awarding Financial Assistance. C. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award. D. In the event Financial Assistance has already been granted in the above circumstances, IU Health reserves the right to reverse the Financial Assistance Determination in an amount equal to the amount IU Health would be entitled to receive had no Financial Assistance been awarded. 7. Patient Assets A. There are situations where a patient or their guarantor may have significant income or assets available to pay for healthcare services such as a legal settlement. The Financial Assistance Committee may evaluate the income or assets in determining financial Hardship. B. IU Health may require a list of all property owned by the patient or guarantor and adjust a Financial Assistance Determination as a result. Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 1410882 Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount METHODOLOGY USED TO EST. BAD DEBT EXP. THE AMOUNT REPORTED ON LINE 2 AS BAD DEBT IS REPORTED AT COST, AS CALCULATED USING THE COST TO CHARGE RATIO METHODOLOGY. Schedule H, Part III, Line 3 Bad Debt Expense Methodology IU Health White Memorial Hospital will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: 1. Medicaid (any state) 2. Indiana Children's Special Health Care Services 3. Healthy Indiana Plan 4. Patients who are awarded Hospital Presumptive Eligibility (HPE) 5. A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health White Memorial Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: a) If the patient or their guarantor is found to have filed a petition for bankruptcy. b) If the patient is deceased and found to have no estate. c) If the patient is deceased and was under 21 years of age at the time of death. Due to this comprehensive methodology, IU Health White Memorial Hospital does not believe any amount of bad debt is attributable to patients who may be eligible under the financial assistance policy and no portion of bad debt is included as community benefit. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote IU HEALTH'S CONSOLIDATED FINANCIAL STATEMENTS, FOOTNOTE 5, ADDRESSES BAD DEBT EXPENSE AS FOLLOWS: The Indiana University Health System does not require collateral or other security from its patients, substantially all of whom are residents of the State, for the delivery of health care services. However, consistent with industry practice, the Indiana University Health System routinely obtains assignment of (or is otherwise entitled to receive) patients' benefits payable under their health insurance programs, plans, or policies (e.g., Medicare, Medicaid, managed care payers, and commercial insurance policies). The Indiana University Health System uses a portfolio approach to account for categories of patient contracts as a collective group, rather than recognizing revenue on an individual contract basis. The portfolios consist of major payer classes for inpatient revenue and outpatient revenue. Based on the historical collection trends and other analysis, the Indiana University Health System believes that revenue recognized by utilizing the portfolio approach approximates the revenue that would have been recognized if an individual contract approach were used. In support of its mission, the Indiana University Health System provides care to uninsured and underinsured patients. The Indiana University Health System provides charity care to patients who lack the financial resources to pay for their medical care. Financial assistance is available to qualifying uninsured and underinsured patients receiving care at an Indiana University Health System hospital location. Under its financial assistance policy, the Indiana University Health System provides medically necessary care to uninsured patients. Financial assistance up to the full amount of patient financial responsibility is available for uninsured and underinsured patients receiving care via the emergency department, direct admission from a physician's office, or transfer from another hospital. The federal poverty level (FPL) thresholds are used when determining the level of financial assistance based on household makeup. Households without dependents are eligible for assistance if household income is less than or equal to 200% FPL, two adults and at least one dependent are eligible if household income is less than or equal to 250% FPL, and households with one adult and at least one dependent are eligible if household income is less than or equal to 300% FPL. Qualifying individuals with medical bills totaling more than 20% of annual household income, regardless of FPL, qualify for catastrophic assistance and are eligible for a reduction in patient financial responsibility to 5% of annual household income or Amounts Generally Billed, whichever is less. Since the Indiana Health System does not pursue collection of these amounts, the discounted amounts are not reported as patient service revenue. The Indiana University Health System uses presumptive eligibility screening procedures for some forms of financial assistance and recognizes net patient service revenue on services provided to self-pay patients at the discounted rate at the time services are rendered. The estimated cost of charity care, using the consolidated cost to charge ratio, was $201,699,000 and $95,909,000 in 2024 and 2023, respectively. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs IU HEALTH WHITE MEMORIAL HOSPITAL DID NOT HAVE A MEDICARE SHORTFALL FOR 2024. IU HEALTH WHITE MEMORIAL HOSPITAL'S MEDICARE REIMBURSEMENTS, HOWEVER, ARE NORMALLY LESS THAN THE COST OF PROVIDING PATIENT CARE AND SERVICES TO MEDICARE BENEFICIARIES AND DO NOT INCLUDE ANY AMOUNTS THAT RESULT FROM INEFFICIENCIES OR POOR MANAGEMENT. IU HEALTH WHITE MEMORIAL HOSPITAL ACCEPTS ALL MEDICARE PATIENTS KNOWING THAT THERE MAY BE SHORTFALLS; THEREFORE IT HAS TAKEN THE POSITION THAT ANY SHORTFALL SHOULD BE COUNTED AS PART OF ITS COMMUNITY BENEFIT. ADDITIONALLY, IT IS IMPLIED IN INTERNAL REVENUE SERVICE REVENUE RULING 69-545 THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE AMOUNT REPORTED ON SCHEDULE H, PART III, LINE 6 IS CALCULATED, IN ACCORDANCE WITH THE FORM 990 INSTRUCTIONS, USING "ALLOWABLE COSTS" FROM THE IU HEALTH WHITE MEMORIAL HOSPITAL MEDICARE COST REPORT. "ALLOWABLE COSTS" FOR MEDICARE COST REPORT PURPOSES, HOWEVER, ARE NOT REFLECTIVE OF ALL COSTS ASSOCIATED WITH IU HEALTH WHITE MEMORIAL HOSPITAL'S PARTICIPATION IN MEDICARE PROGRAMS. FOR EXAMPLE, THE MEDICARE COST REPORT EXCLUDES CERTAIN COSTS SUCH AS BILLED PHYSICIAN SERVICES, THE COSTS OF MEDICARE PARTS C AND D, FEE SCHEDULE REIMBURSED SERVICES, AND DURABLE MEDICAL EQUIPMENT SERVICES. INCLUSION OF ALL COSTS ASSOCIATED WITH IU HEALTH WHITE MEMORIAL HOSPITAL'S PARTICIPATION IN MEDICARE PROGRAMS WOULD SIGNIFICANTLY REDUCE THE MEDICARE SURPLUS REPORTED ON SCHEDULE H, PART III, LINE 7. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance IU Health White Memorial Hospital's FAP and Written Debt Collection Policy describe the collection practices applicable to patients, including those who may qualify for financial assistance. 1. Financial Assistance Application Financial Assistance Applications must include the following documentation: - All sources of Income for the last three (3) months. - Most recent three (3) months of pay stubs or Supplemental Security Income via Social Security. - Most recent three (3) statements from checking and savings accounts, certificates of deposit, stocks, bonds and money market accounts. - Most recent state and Federal Income Tax forms including Schedules C, D, E, and F. In the event the patient or guarantor's income does not warrant the filing of a federal tax statement, the individual may submit a notarized affidavit attesting to the foregoing. - Most recent W-2 statement. - For patients or members of the Household who are currently unemployed, Wage Inquiry from WorkOne. - If applicable, divorce/dissolution decrees and child custody order. Patients or their guarantors wishing to apply for Financial Assistance due to Financial Hardship are encouraged to submit an Application within ninety (90) days of discharge. Patients or their guarantors may submit an Application up to two-hundred and forty (240) days from the date of their initial post-discharge billing statement from IU Health, however, accounts may be subject to Extraordinary Collection Actions (ECA) as soon as one-hundred and twenty (120) days after receipt of the initial post-discharge billing statement. Patients or their guarantors submitting an incomplete Financial Assistance Application will receive written notification of the Application's deficiency upon discovery by IU Health. The Application will be pended for a period of forty-five (45) days from the date the notification is mailed. IU Health will suspend any ECA until the Application is complete or the expiration of the forty-five (45) day period. Patients with limited English proficiency may request a copy of this Policy, a Financial Assistance Application, and a Plain Language Summary in one of the below languages: - Arabic; - Burmese; - Burmese - Falam; - Burmese - Hakha Chin; - Mandarin/Chinese; or - Spanish The patient, and/or their representative, such as the patient's physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a Financial Assistance Application be mailed to a patient's primary mailing address free of charge. IU Health maintains the confidentiality of all Financial Assistance Applications and supporting documentation. IU Health will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance Application. 2. Financial Assistance Determinations IU Health will inform patients or guarantors of the results of their Application by providing the patient or guarantor with a Financial Assistance Determination within ninety (90) days of receiving a completed Application and all requested documentation. A patient's Financial Assistance Application and Financial Assistance Determination are specific to each date(s) of service and approved related encounters. If a patient or guarantor is granted less than full charity assistance and the patient or guarantor provides additional information for reconsideration, Revenue Cycle Services may amend a prior Financial Assistance Determination. 3. Extraordinary Collection Actions IU Health may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patient's eligibility for assistance under this Policy. Reasonable efforts include the following: - IU Health will notify the patient of this Policy at least thirty (30) days prior to initiating an ECA. - IU Health will not initiate an ECA for at least one-hundred and twenty (120) days after the patient's initial post-discharge billing statement. - IU Health will review all Financial Assistance Applications received up to and including two-hundred and forty (240) days after the patient's initial post-discharge billing statement. IU Health will cease any ECAs it has initiated upon receipt of a Financial Assistance Application until a Financial Assistance Determination is made under this policy. - If an Application is Approved, IU Health will issue a revised statement, issue refunds, and make reasonable efforts to reverse ECAs as necessary. IU Health and its third-party collection agencies may initiate an ECA against a patient or their guarantor in accordance with this Policy and 26 C.F.R. § 1.501(r). ECAs may include the following: - Selling a patient or their guarantor's outstanding financial responsibility to a third party. - Reporting adverse information about the patient or their guarantor to consumer credit reporting agencies or credit bureaus. - Deferring or denying, or requiring a payment before providing, medically necessary care because of a patient or their guarantor's nonpayment of one or more bills for previously provided care covered under this Policy. - Actions requiring a legal or judicial process, including but not limited to placing a lien on a patient's or their guarantor's property, foreclosing on a patient's or their guarantor's real property, attaching or seizing a patient's or their guarantor's bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantor's arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantor's wages When it is necessary to engage in such action, IU Health and its third party collection agencies, will engage in fair, respectful and transparent collections activities. 4. Refunds Patients eligible for Financial Assistance under this Policy who remitted payment to IU Health in excess of their Patient Responsibility will be alerted to the overpayment as promptly after discovery as is reasonable given the nature of the overpayment. Patients with an outstanding account balance due on a separate account will have their refund applied to the outstanding balance. Patients without an outstanding account balance described above will be issued a refund check for their overpayment as soon as technically feasible. Schedule H, Part V, Section B, Line 16a FAP website - IU HEALTH WHITE MEMORIAL HOSPITAL: Line 16a URL: HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE; Schedule H, Part V, Section B, Line 16b FAP Application website - IU HEALTH WHITE MEMORIAL HOSPITAL: Line 16b URL: HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE; Schedule H, Part V, Section B, Line 16c FAP plain language summary website - IU HEALTH WHITE MEMORIAL HOSPITAL: Line 16c URL: HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE; Schedule H, Part VI, Line 2 Needs assessment Though IU Health White Memorial Hospital believes its CHNA process is comprehensive, the CHNA is done on a triennial basis. Between CHNA cycles, IU Health White Memorial Hospital gathers data and information to monitor the most current needs of the community. Additional sources of data and information include: * IU Health data analytics and information service teams; * Secondary data sources from Federal, state, and local entities with a focus on health behaviors, health outcomes, and social determinants of health; * Obtaining community organization and governmental agency perspectives; priority population perspectives; and other healthcare and hospital perspectives; * Reports that share findings and recommendations on certain populations within the community and/or health behaviors, health outcomes, or social determinants of health; * Evidence informed sources; and * Team member participation in partnering efforts (e.g., coalitions, advisory committees, task forces, etc.). The regular review of these sources of data and information rarely impact what the significant needs are between CHNA cycles. However, it does help influence the types or level of interventions to address the significant needs; prioritize resources to those groups or neighborhoods experiencing health disparities in the community; identify funding opportunities to support interventions; and strengthen or mobilize partnerships to improve health. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance IU Health White Memorial Hospital takes several measures to inform its patients of the FAP and FAP-eligibility. These measures include the following: 1. Post this Policy, a Plain Language Summary of this Policy, and the Financial Assistance Application on its website. 2. Provide patients with a Plain Language Summary of this Policy during registration and/or discharge. 3. Post conspicuous displays in appropriate acute care settings such as emergency departments and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 4. Include a conspicuous written notice on all patient post-discharge billing statements notifying the patient about this Policy and the telephone number of the Customer Service Department which can assist patients with questions regarding this Policy. 5. Make available Customer Service representatives via telephone during normal business hours. 6. Mail copies of this Policy, a Plain Language Summary of this Policy, and a Financial Assistance Application to patients or their guarantor free of charge upon request. 7. Broadly communicate this Policy as a part of its general outreach efforts. 8. Educate patient-facing team members on this Policy and the process for referring patients to the program. Schedule H, Part VI, Line 4 Community information IU HEALTH WHITE MEMORIAL HOSPITAL IS LOCATED IN WHITE COUNTY, INDIANA, A COUNTY LOCATED IN CENTRAL NORTHWEST INDIANA. WHITE COUNTY INCLUDES ZIP CODES WITHIN THE TOWNS OF BROOKSTON, BURNETTSVILLE, CHALMERS, MONON, MONTICELLO, REYNOLDS, AND WOLCOTT. BASED ON THE MOST RECENT CENSUS BUREAU (2024) STATISTICS, WHITE COUNTY'S POPULATION IS 24,833, 49.9% are female and 50.1% are male. Schedule H, Part VI, Line 5 Promotion of community health IU Health White Memorial Hospital is a subsidiary of IU Health, a tax-exempt healthcare organization, whose Board of Directors is composed of members, of which the majority are independent community members. IU Health White Memorial Hospital extends medical staff membership and clinical privileges to medical and allied health providers who meet the credentialing qualifications as well as any additional standards and rules set forth by its Board for medical staff appointment (in accordance with Indiana state law). Information on privileging and credentialing, including applying for membership, for IU Health White Memorial Hospital can be accessed on the IU Health website. A nondiscrimination clause is explicitly stated in IU Health White Memorial Hospital credentialing process. IU Health, in conjunction with the IU School of Medicine, trains the next generation of physicians in an exceptional environment. Blending breakthrough research and treatments with the highest quality of patient care. In addressing the identified community priorities, IU Health White Memorial Hospital has partnered with a number of high quality, engaged community organizations and initiatives to help make health and wellness improvement a reality. Schedule H, Part VI, Line 6 Affiliated health care system Indiana University Health White Memorial Hospital is part of Indiana University Health ("IU Health "the healthcare system"), which is Indiana's most comprehensive healthcare system. A unique partnership with the Indiana University School of Medicine ("IU School of Medicine"), one of the nation's leading medical schools, gives patients access to innovative treatments and therapies. The healthcare system is comprised of hospitals, physicians and allied services dedicated to providing preeminent patient care and community health improvement throughout Indiana. IU Health's affiliate hospitals are divided into six regions that serve communities in Northwest, Northeast, Central and Southern Indiana. The 15 hospitals in the healthcare system include IU Health Inc. (i.e., the IU Health Academic Health Center consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health and IU Health Saxony Hospital); IU Health Arnett; IU Health Ball;; IU Health Bloomington Hospital; IU Health Frankfort; IU Health Jay; IU Health North Hospital; IU Health Paoli Hospital; IU Health Tipton Hospital; IU Health West Hospital; and IU Health White Memorial Hospital. Each affiliate hospital in the healthcare system, along with community partners, conducted, and adopted its own community health needs assessment (CHNA) and implementation strategy. IU Health considered the sum of these CHNAs and the implementation strategies part of a system wide vision of making Indiana one of the healthiest states in the nation. The healthcare system and its affiliate hospitals are keenly aware of the positive impact it can have on improving the health of communities throughout the state of Indiana by investing in local, community-based initiatives as well as system-level strategies. The healthcare system includes an Academic Health Center (i.e., IU Health Inc.), a regional academic health center (i.e., IU Health Bloomington Hospital) and several affiliate hospitals (IU Health Arnett and IU Health Ball) that work in partnership with the IU School of Medicine to train physicians, blending breakthrough research and treatments with the highest quality of patient care throughout IU Health. Each year, more than 1,000 residents and fellows received training in affiliate hospitals. Research conducted by IU School of Medicine faculty gave IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. To further promote the health of the communities served by IU Health, the system-level Community Health Division partnered with state and local community-based organizations, community coalitions and governmental agencies to focus on innovative models of care; community alliances and partnerships; anchor institution and advocacy strategies; and social determinants of health. All affiliate hospitals in the healthcare system identified and addressed significant needs unique to the communities they serve. However, some needs were common in communities served by multiple or all affiliate hospitals in the healthcare system and aligned with system priority areas, warranting a system-level strategy. The Community Health Division, along with additional internal partners such as the Office of Health Excellence Research and Engagement (HERE) and the IU Health Foundation, planed and provided technical assistance for system-level strategies that addressed these common needs including tobacco and nicotine cessation, infant and maternal health, hypertension, and social determinants of health. For example, the Community Health Division has launched a community health worker initiative throughout the system in outpatient and inpatient sites that did community outreach as part of the WeCare and iHEART initiatives. Each affiliate hospital collaborated with the Community Health Division to align and activate local resources to support local and system strategies. This benefits the community each affiliate hospital served and worked towards a statewide impact (system-level) on health outcomes. As part of the Community Health Division, the Community Outreach and Engagement Program's IU Health Serves initiative, a system-level team member volunteer program, sought to positively impact the health of communities IU Health affiliate hospitals serve and foster a culture of engagement and social responsibility. Each affiliate hospital coordinated the different initiatives of the program, including Days of Service. This was the largest volunteer event of the year, consisting of projects designed to engage each affiliate hospitals' team members in activities that address local, significant needs. The $200 million Community Impact and Investment (CII) Fund was established in 2018 by IU Health to financially support high-impact community investing. The focus of these efforts addressed key social and environmental factors that impact different groups in the communities IU Health serves. Each affiliate hospital and its team members were eligible to pursue this grant opportunity with a community organization. Schedule H, Part VI, Line 7 State filing of community benefit report IN true City of Monticello 225 N Main St Monticello IN 47960 356001121 Government 7500 Community Benefit 1 0 Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds ALTHOUGH IU HEALTH WHITE MEMORIAL DOES NOT MONITOR THE USE OF GRANT FUNDS ONCE DISTRIBUTED, THROUGH DUE DILIGENCE THE ORGANIZATION HAS REASONABLY CONFIRMED THAT THE ENTITIES TO WHICH THE CONTRIBUTIONS ARE MADE ARE HIGHLY REPUTABLE IN THE COMMUNITY AND USE THE FUNDS FOR THE PURPOSES INTENDED. X X X X false true false false false false false true false PHILIP LIST Director (Part Year) / Legal Counsel Secretary (Part Year) 0 229388 0 35768 0 7917 0 10430 0 46579 0 330082 0 0 MARK BUONO MD Director 0 775682 0 47165 0 3564 0 9812 0 58378 0 894601 0 0 WILLIAM Y LI MD DIRECTOR 0 165299 0 30103 0 2322 0 7749 0 22888 0 228361 0 0 RUBAN NIRMALAN MD DIRECTOR 0 489535 0 506408 0 810 0 12204 0 55925 0 1064882 0 0 MICHELE S SAYSANA MD DIRECTOR (Part Year) 0 557155 0 70619 0 1567 0 6373 0 23390 0 659104 0 0 ERIKA UGIANSKIS MD DIRECTOR 0 589922 0 26945 0 305424 0 13800 0 64878 0 1000969 0 0 CARA L BREIDSTER FORMER OFFICER 0 309988 0 39308 0 2322 0 12104 0 54009 0 417731 0 0 DEREK E EMPIE FORMER OFFICER 0 373567 0 55399 0 1242 0 13800 0 63630 0 507638 0 0 WHITNEY A AIKEN Legal Counsel Secretary (Part Year) 0 160510 0 16829 0 5134 0 7459 0 25445 0 215377 0 0 MICHAEL L CRAIG CFO (Part Year) 0 329178 0 43079 0 3564 0 13500 0 52357 0 441678 0 0 ARTHUR VASQUEZ PRESIDENT (WCR) 0 591884 0 254900 0 1869 0 116832 0 53432 0 1018917 0 0 TODD A WILLIAMS CFO (Part Year)/TREASURER (WCR) 0 378983 0 58910 0 2322 0 13176 0 53278 0 506669 0 0 CHRISTOPHER A MANSFIELD MD FORMER KEY EMPLOYEE 0 568986 0 85709 0 810 0 13800 0 53199 0 722504 0 0 KOREEN C KYHNELL VP - HUMAN RESOURCES (WCR) 0 219439 0 36618 0 3194 0 8298 0 61702 0 329251 0 0 KISHAN PATEL MD VP-Chief Physician Executive (WCR) 0 410604 0 61633 0 810 0 13800 0 53199 0 540046 0 0 ROXANNE WICKLUND CNO (WCR) 0 287317 0 63372 0 6858 0 11533 0 54177 0 423257 0 0 MARY C DREWES FORMER Highest Compensated Employee 0 261979 0 38306 0 1221 0 4434 0 26158 0 332098 0 0 SAMANTHA K BARNETT Clinical Nurse 148416 17799 72087 2806 3379 0 9172 824 36427 1236 269481 22665 0 0 SHARON M MCILVAIN Clinical Nurse 136051 0 35378 0 5024 0 7351 0 46173 0 229977 0 0 0 MARY E MINIER COO (Frankfort and White) 164975 0 35314 0 4239 0 8075 0 35307 0 247910 0 0 0 RENEA SMITH CNO (Frankfort and White) 181578 0 27348 0 0 0 937 0 12618 0 222481 0 0 0 DARA WERT SUPERVISOR, HOUSE 114706 44643 23030 0 5093 0 3955 1103 37425 1103 184209 46849 0 0 Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation IU HEALTH WHITE MEMORIAL HOSPITAL'S REGIONAL PRESIDENT IS EMPLOYED BY IU HEALTH, INC. IU HEALTH, INC., IU HEALTH WHITE MEMORIAL HOSPITAL, AND OTHER RELATED ENTITIES HAVE A PROCESS IN PLACE TO DETERMINE THE COMPENSATION FOR THE OTHER OFFICERS AND KEY EMPLOYEES. IU HEALTH HUMAN RESOURCES USES MARKET DATA FROM MULTIPLE COMPENSATION EXPERTS/VENDORS WHO UTILIZE A VARIETY OF METHODS AND PROCEDURES TO OBTAIN COMPENSATION RANGES FOR COMPARABLE OFFICER AND EMPLOYEE POSITIONS. THIS MARKET DATA AND MULTIPLE OTHER FACTORS (INCLUDING MARKET PAY BENCHMARKS, INTERNAL EQUITY, CANDIDATE/EMPLOYEE QUALIFICATIONS & PERFORMANCE, AND BUSINESS NEEDS) ARE USED TO RECOMMEND COMPENSATION RANGES FOR ITS OFFICERS AND OTHER EMPLOYEES, WHICH ARE THEN USED AS A GUIDE FOR SETTING REASONABLE COMPENSATION BY MANAGEMENT. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan ARTHUR VASQUEZ PARTICIPATES IN AN IU HEALTH SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN, PROVISIONS OF WHICH ARE DESIGNED TO RETAIN ITS CRITICAL EMPLOYEES. THE PLAN PROVIDES FOR AN ADDITIONAL RETIREMENT BENEFIT FOR SERVICE THROUGH NORMAL RETIREMENT OR OTHER KEY DATES. IF THE EXECUTIVE LEAVES PRIOR TO RETIREMENT OR OTHER KEY DATES, THE BENEFIT MAY BE FORFEITED OR REDUCED. Arthur Vasquez has AN AMOUNT INCLUDED IN COLUMN C, DEFERRED COMPENSATION, REPRESENTING THE CURRENT YEAR UNVESTED CONTRIBUTIONS MADE UNDER THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. THESE AMOUNTS WERE NOT PAID TO THE EXECUTIVES DURING THE YEAR. Schedule J, Part I, Line 7 Non-fixed payments AMOUNTS DISCLOSED IN COLUMN B(II) INCLUDE A LONG-TERM INCENTIVE FOR CERTAIN EXECUTIVES. ALTHOUGH THESE PLANS ARE BASED ON A FIXED FORMULA THAT HAS BEEN APPROVED BY THE BOARD OF DIRECTORS BASED UPON CERTAIN QUALITATIVE AND QUANTITATIVE FACTORS AND GOALS, ALL DISCRETIONARY INCENTIVE PLANS MUST BE APPROVED BY THE TALENT MANAGEMENT AND EXECUTIVE COMPENSATION COMMITTEE AND BOARD OF DIRECTORS PRIOR TO ANY INCENTIVE PAYOUT. Kameron Kyhnell Son of IU White Memorial Hospital Inc. Key Employee Koreen Kyhnell 51062 TOTAL TAXABLE AND NONTAXABLE COMPENSATION FOR EMPLOYMENT IN THE NORMAL COURSE OF BUSINESS. false LINE J - WEB SITE HTTPS://IUHEALTH.ORG/FIND-LOCATIONS/IU-HEALTH-WHITE-MEMORIAL-HOSPITAL SECTION B, LINES 12, 13, 14, AND 16B - POLICIES IU HEALTH WHITE MEMORIAL HOSPITAL IS PART OF THE IU HEALTH SYSTEM. AS THE SOLE MEMBER AND CONTROLLING PARENT OF IU HEALTH WHITE MEMORIAL HOSPITAL, IU HEALTH AND ITS BOARD OF DIRECTORS HAVE MANDATED THAT CERTAIN POLICIES BE FOLLOWED TO ENSURE GREATER STANDARDIZATION THROUGHOUT THE SYSTEM. THUS, IU HEALTH WHITE MEMORIAL HOSPITAL'S BOARD OF DIRECTORS WAS NOT REQUIRED TO SEPARATELY ADOPT A CONFLICT OF INTEREST, WHISTLEBLOWER, DOCUMENT RETENTION AND DESTRUCTION AND JOINT VENTURE POLICIES BECAUSE IU HEALTH'S BOARD OF DIRECTORS HAD ALREADY ADOPTED AND REQUIRED THESE POLICIES TO BE FOLLOWED BY ITS SUBSIDIARIES. Form 990, Part VI, Line 6 Classes of members or stockholders THE SOLE MEMBER OF IU HEALTH WHITE MEMORIAL HOSPITAL, INC. IS INDIANA UNIVERSITY HEALTH, INC. ("IU HEALTH"), A 501(C)(3) TAX-EXEMPT ORGANIZATION. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body THE BOARD OF DIRECTORS OF THE IU HEALTH WHITE MEMORIAL HOSPITAL SHALL CONSIST OF UP TO FOURTEEN (14) VOTING MEMBERS ALL APPOINTED BY IU HEALTH, WHO SHALL INCLUDE UP TO TWO (2) DIRECTORS WHO RESIDE IN WHITE COUNTY AND FOUR (4) PHYSICIAN REPRESENTATIVES FROM THE WEST CENTRAL REGION. THE PHYSICIAN DIRECTORS WILL BE IDENTIFIED THROUGH A NOMINATION PROCESS DEVELOPED BY THE WEST CENTRAL REGION AND SUBMITTED TO IU HEALTH FOR CONSIDERATION AND APPROVAL. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders THE FOLLOWING ARE SUBJECT TO IU HEALTH'S APPROVAL: - ANY PROPOSED AMENDMENT TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS; - ADOPTION OF THE CORPORATION'S ANNUAL CAPITAL AND OPERATING BUDGETS; - APPROVAL OF ANY UNBUDGETED OPERATING OR CAPITAL BUDGET ITEMS OR DEVIATIONS, INCLUDING ANY ISSUANCE OR GUARANTEE OF ANY UNBUDGETED DEBT; - APPROVAL OF ANY STRATEGIC PLAN FOR THE CORPORATION, INCLUDING ANY AMENDMENTS TO A STRATEGIC PLAN; - APPROVAL OF ANY ENCUMBRANCE, SALE OR CONVEYANCE OF ASSETS; - ANY MERGER, CONSOLIDATION, JOINT VENTURE OR AFFILIATION INVOLVING THE CORPORATION OR ANY OF ITS AFFILIATES AND ANY OTHER ENTITY; - APPOINTMENT AND REMOVAL OF THE CORPORATION'S PRESIDENT AND OTHER OFFICERS; - CONSTRUCTION, ACQUISITION OR LEASE OF HOSPITAL BUILDINGS; - PROJECTS OR CONTRACTS THAT REQUIRE MEMBER APPROVAL IN ACCORDANCE WITH THE MEMBER'S RESOLUTION AND POLICY GOVERNING SYSTEM-WIDE CONTRACT EXECUTION AUTHORITY AND PAYMENT APPROVAL LIMITS; AND - THE DISSOLUTION OF THE CORPORATION OR ANY OF ITS AFFILIATES. Form 990, Part VI, Line 11b Review of form 990 by governing body THE CFO REVIEWED AND APPROVED THE FORM 990. FOLLOWING THE CFO'S REVIEW AND APPROVAL, A COMPLETE COPY OF THE FORM 990 WAS MADE AVAILABLE TO EACH BOARD MEMBER PRIOR TO ITS FILING. EACH MEMBER WAS ALSO INFORMED OF THE AVAILABILITY OF IU HEALTH'S TAX DEPARTMENT TO ANSWER ANY QUESTIONS. Form 990, Part VI, Line 12c Conflict of interest policy IU HEALTH White Memorial Hospital FOLLOWS IU HEALTH'S CONFLICT OF INTEREST POLICY. IU HEALTH'S CONFLICT OF INTEREST POLICY INCLUDES THE FOLLOWING PROVISIONS: ALL IU HEALTH EMPLOYEES, ASSOCIATES, COLLEAGUES AND CONTRACTED PERSONNEL, INCLUDING EMPLOYED PHYSICIANS AND PAID MEDICAL DIRECTORS ("IU HEALTH REPRESENTATIVES") ARE COVERED BY AND SUBJECT TO ITS CONFLICT OF INTEREST POLICY. IU HEALTH REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE POLICY THROUGH THE FOLLOWING PROCEDURES: (A) ON AN ANNUAL BASIS, EACH IU HEALTH REPRESENTATIVE AT THE LEVEL OF MANAGER OR ABOVE, TOGETHER WITH EVERY OTHER PERSON DESIGNATED BY THE CORPORATE COMPLIANCE DEPARTMENT ("DEPARTMENT"), MUST COMPLETE, SIGN AND SUBMIT A CONFLICT OF INTEREST QUESTIONNAIRE ("QUESTIONNAIRE") TO THE DEPARTMENT. GOVERNING BOARD MEMBERS, COMMITTEE MEMBERS, CORPORATE OFFICERS, MEDICAL STAFF AND RESEARCHERS MUST COMPLY WITH THE ADMINISTRATIVE REQUIREMENTS NOTED IN THE RESPECTIVE POLICIES AND PROCEDURES RELATIVE TO THOSE AREAS. (B) AN IU HEALTH REPRESENTATIVE MUST SUPPLEMENT A QUESTIONNAIRE IN WRITING, IF AFTER COMPLETION OF THE ORIGINAL QUESTIONNAIRE, A SITUATION ARISES, OR MAY REASONABLY BE EXPECTED TO ARISE, THAT WOULD CHANGE ANY ANSWER OR INFORMATION ON THE ORIGINAL QUESTIONNAIRE IF THE SITUATION HAD EXISTED OR BEEN ANTICIPATED AT THE TIME OF COMPLETION OF THE ORIGINAL QUESTIONNAIRE. (C) IF A FULLY AND PROPERLY COMPLETED QUESTIONNAIRE REVEALS FACTS OR OTHER INFORMATION THAT MIGHT REASONABLY INDICATE A CONFLICT OF INTEREST OR VIOLATION OF THE POLICY, THE IU HEALTH REPRESENTATIVE COMPLETING THE QUESTIONNAIRE MUST SECURE APPROVAL BY HIS/HER SUPERVISOR, EVIDENCED IN WRITING. (D) THE DEPARTMENT WILL REVIEW EACH QUESTIONNAIRE AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS AND, IF SO, WHETHER AND HOW IT SHOULD OR MAY BE ELIMINATED, AVOIDED OR MANAGED IN ORDER TO COMPLY WITH THE SPIRIT OF THE POLICY AND WITH THE BEST INTERESTS OF IU HEALTH AND ITS PATIENTS. IN MAKING THE DETERMINATION, THE CORPORATE COMPLIANCE DEPARTMENT MAY CONSULT WITH THE IU HEALTH REPRESENTATIVE'S SUPERVISOR AND OTHER APPROPRIATE INDIVIDUALS AND GROUPS. (E) THE SCOPE OF THE POLICY IS NOT LIMITED TO THOSE WHO ARE REQUIRED TO COMPLETE QUESTIONNAIRES. IF AN IU HEALTH REPRESENTATIVE IS INVOLVED IN A SITUATION OR RELATIONSHIP THAT WOULD CONSTITUTE A VIOLATION OF THE POLICY IN THE ABSENCE OF DISCLOSURE AND APPROVAL AS DESCRIBED ABOVE, THEN THE IU HEALTH REPRESENTATIVE MUST DISCLOSE THE MATTER TO HIS/HER SUPERVISOR, SECURE HIS/HER SUPERVISOR'S APPROVAL IN WRITING, AND DISCLOSE THE MATTER TO THE DEPARTMENT. OTHERWISE, THE IU HEALTH REPRESENTATIVE IS IN VIOLATION OF THE POLICY AND SUBJECT TO CORRECTIVE ACTION, UP TO AND INCLUDING TERMINATION. (F) THE CHIEF COMPLIANCE OFFICER, IN CONSULTATION WITH ONSITE COMPLIANCE PERSONNEL, MAY FROM TIME TO TIME APPOINT STANDING OR AD HOC COMMITTEES TO ASSIST IN RESOLVING ISSUES THAT ARISE UNDER PROVISIONS OF THE POLICY. Form 990, Part VI, Line 19 Required documents available to the public IU HEALTH WHITE MEMORIAL HOSPITAL ARTICLES OF INCORPORATION ARE AVAILABLE FOR PUBLIC INSPECTION THROUGH THE INDIANA SECRETARY OF STATE'S WEBSITE. IU HEALTH WHITE MEMORIAL HOSPITAL CONFLICT OF INTEREST PROCEDURES ARE DISCLOSED ON THE FORM 990, SCHEDULE O. IU HEALTH WHITE MEMORIAL HOSPITAL IS A SUBSIDIARY IN IU HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS. IU HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE AVAILABLE FOR PUBLIC INSPECTION THROUGH ITS BOND FILINGS AND AS AN ATTACHMENT TO IU HEALTH'S FORM 990 AS WELL AS IU HEALTH WHITE MEMORIAL HOSPITAL'S FORM 990. Form 990, Part IX, Line 11g Other Fees Intercompany fees - Total Expense: 12367366, Program Service Expense: 11543592, Management and General Expenses: 823774, Fundraising Expenses: ; Contract service - Total Expense: 674136, Program Service Expense: 628881, Management and General Expenses: 45255, Fundraising Expenses: ; Professional fees - Total Expense: 270328, Program Service Expense: 252181, Management and General Expenses: 18147, Fundraising Expenses: ; Consulting - Total Expense: 7736, Program Service Expense: 7217, Management and General Expenses: 519, Fundraising Expenses: ; Other Fees - Total Expense: 70575, Program Service Expense: 65837, Management and General Expenses: 4738, Fundraising Expenses: ; Form 990, Part XI, Line 9 Other changes in net assets or fund balances CHANGE IN TEMP RESTRICTED NET ASSETS - -6484; Change in interest in Net Assets of Foundation - 26269; Total - 19785; INDIANA HEALTH INFO EXCHANGE INC 846 N SENATE AVE INDIANAPOLIS IN 46202 364550324 HEALTHCARE 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