2026-05-14T15:34:41-05:00 2025-06-30 351178661 BLUE & CO LLC 2650 EASTPOINT PKWY SUITE 300 LOUISVILLE KY 40223 990 2024-07-01 370661202 FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION FAIR 6168422611 303 NW 11TH STREET FAIRFIELD IL 62837 DAVID ANDREW FLEMER JR CEO 6168422611 2026-05-14 1 0 EMILIE M KNIERIEM CPA P01330194 5029923500 2026-05-14 2024 2025-03-06 01:10:19Z JIM BASCH 303 NW 11TH STREET FAIRFIELD IL 62837 49396414 0 X FAIRFIELDMEMORIAL.ORG X 1948 IL THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 11 10 460 11 0 0 822570 47957 45160074 48528777 70992 102825 2242187 635415 48295823 49314974 130396 60864 0 0 29039974 28888525 0 0 0 24436769 22063506 53607139 51012895 -5311316 -1697921 55359234 51331074 32593217 33776082 22766017 17554992 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 0 0 37728160 60864 49154376 AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008, THE HOSPITAL OPENED A RURAL HEALTH CLINIC. TODAY IT OPERATES RURAL HEALTH CLINICS PROVIDING MEDICAL AND BEHAVIORAL HEALTH SERVICES IN FAIRFIELD, CISNE, AND CARMI, AS WELL AS, OPERATING OUTPATIENT SURGICAL SPECIALTY CLINICS, TO INCLUDE GENERAL SURGERY, WOUND CARE, AND PAIN MANAGEMENT. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE TO ALL PERSONS WITHOUT REGARD TO AND DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, RELIGION (CREED), GENDER, GENDER SEX EXPRESSION, AGE, NATIONAL ORIGIN (ANCESTRY), PHYSICAL OR MENTAL DISABILITY, MARITAL STATUS, GENDER IDENTITY, SEXUAL ORIENTATION, SOCIAL ECONOMIC STATUS, ETHNICITY, CULTURE, LANGUAGE, MILITARY STATUS, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIRFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITIES WE SERVE. THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL FINANCIAL ASSISTANCE POLICY. 37728160 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 42 0 1 460 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X JIM BASCH CFO 6188478260 303 NW 11TH FAIRFIELD IL 62837 PATRICK MOLT MD PRESIDENT/CMO 5.00 0.00 X X 364 0 0 JOEY HUNGERFORD VICE PRESIDENT (END 06/25) 1.75 0.00 X X 0 0 0 ANITA POND SECRETARY/TREASURER 1.75 0.00 X X 0 0 0 MICHAEL COPELAND DIRECTOR 1.75 0.00 X 0 0 0 DONNA MASTERSON DIRECTOR 1.75 0.00 X 0 0 0 D JAMIE POLLARD DIRECTOR 1.75 0.00 X 0 0 0 MATTHEW SENG DIRECTOR 1.75 0.00 X 0 0 0 DOUG WILSON DIRECTOR 1.75 0.00 X 0 0 0 JOSH SCOTT DIRECTOR 1.75 0.00 X 0 0 0 JARED FLORENCE DIRECTOR 1.75 0.00 X 0 0 0 CRAIG SELF DIRECTOR 1.75 0.00 X 0 0 0 KATHERINE BUNTING CEO 40.00 0.00 X 204297 0 2728 DANA TAYLOR COO 50.00 0.00 X 137498 0 8504 RACHEL EWING CNO (END 06/25) 50.00 0.00 X 108118 0 10784 KRISTIN BOLDT INTERIM CFO (END 08/24) 50.00 0.00 X 107999 0 7120 MICHAEL COOPER CEO (BEG 07/24) 40.00 0.00 X 122877 0 11121 JIM BASCH CFO (BEG 08/24-11/24, 06/25) 40.00 0.00 X 249901 0 0 WILLIAM GILES CFO (08/24-06/25) 40.00 0.00 X 44697 0 1807 JENNIFER GILPIN CNO (BEG 06/25) 40.00 0.00 X 0 0 0 KORY BLANK ORTHOPEDIC SURGEON 40.00 0.00 X 692880 0 21051 ARUNIMA SAXENA PHYSICIAN 40.00 0.00 X 350735 0 15202 LAUREN WILLIAMS PHYSICIAN 40.00 0.00 X 414027 0 12487 CHRISTOPHER BALLARD PHYSICIAN 40.00 0.00 X 351410 0 22667 KIMBERLY KING CRNA/PAIN MANAGEMENT PROVIDER 40.00 0.00 X 373196 0 20730 3157999 0 134201 34 0 1 0 DR RODNEY BEELER 2142 KETTLES HILL CT EVANSVILLE IN 47725 ER PHYSICIAN 459211 DR DOUGLAS FRANKEL 407 S MARKET STREET MARION IL 62959 ER PHYSICIAN 416523 DR MARK ROTICH 1401 DANIELLE CT MARION IL 62959 ER PHYSICIAN 388611 DR JAMES GRUBER 2025 ST MEINRAD ROAD ST MEINRAD IN 47577 ER PHYSICIAN 342562 DR JASIRI KENNEDY 11817 BORDEN ROAD HERALD CA 956389707 ER PHYSICIAN 280478 6 8500 20470 18987 47957 NET PATIENT REVENUE 622110 43444719 43444719 CLINIC REVENUE 622110 5070777 5070777 MEDICAL RECORDS FEE 622110 13281 13281 48528777 102573 102573 282243 81440 200803 200803 200803 252 0 252 252 252 CAFETERIA & CATERING 722514 274893 265077 9816 REBATES 900099 6261 6261 153458 153458 434612 49314974 49154376 0 112641 X 18380 18380 42484 42484 1131603 846976 284627 236538 177043 59495 20715217 15504808 5210409 171431 128312 43119 5048272 3778502 1269770 1585464 1186679 398785 110949 110949 319009 319009 11870 11870 7017105 5524216 1492889 70020 20490 49530 37102 10857 26245 2825951 939114 1886837 72131 21108 51023 842791 594478 248313 3023717 3023717 742869 742869 MEDICAL SUPPLIES AND DR 4956938 4348717 608221 MEDICAID ASSESSMENT TAX 1178250 1178250 CAFETERIA EXPENSES 347738 235646 112092 DUES AND SUBSCRIPTIONS 250987 73447 177540 256079 74936 181143 51012895 37728160 13284735 0 259111 430531 1685342 2130445 10867020 8752912 337 347 1307600 1301929 801830 584487 76961263 38832601 40436233 38128662 1761 1761 55359234 51331074 5858258 7861664 25599592 25127494 177721 300000 957646 486924 32593217 33776082 X 22563471 17352446 202546 202546 22766017 17554992 55359234 51331074 X -1697921 -3513104 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11870 11870 0 PART II-B, LINE 1: FMH PAID FOR IHA MEMBERSHIP DUES IN FYE 2025. THE PORTION OF MEMBERSHIP DUES ATTRIBUTABLE TOWARDS LOBBYING EXPENDITURES WERE 44.60%. 474079 474079 47006455 20599468 26406987 1318626 897978 420648 28162103 17335155 10826948 38128662 ESTIMATED THIRD PARTY SETTLEMENTS 486924 486924 X 49396414 81440 81440 49314974 0 49314974 51094335 81440 81440 51012895 0 51012895 PART X, LINE 2: THE HOSPITAL HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501 OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATD BUSINESS TAXABLE INCOME. THE HOSPITAL FILES TAX RETURNS IN THE U.S. FEDERAL JURISDICTION. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES 81,440. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES 81,440. 1 1 X 1 X 1 X 1 1 0 1 1 270904 270904 0.00530 10647924 7869619 2778305 0.05450 10918828 7869619 3049209 0.05980 24819 24819 0.00050 258799 258799 0.00510 283618 283618 0.00560 11202446 7869619 3332827 0.06540 1 5839549 0 6197328 18079264 -11881936 X 1 1 1 1 FAIRFIELD MEMORIAL HOSPITAL 303 NW 11TH STREET FAIRFIELD IL 62837 WWW.FAIRFIELDMEMORIAL.ORG 0000679 X X X X FAIRFIELD MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 25 1 0 0 1 X WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ X 1 25 1 WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X 1 X WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ X WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ X WWW.FAIRFIELDMEMORIAL.ORG/ASSISTANCE/FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X X 1 X 0 0 FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL. THESE INCLUDED THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL), MEMBERS OF THE MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL AND/OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS. THE MEDICALLY UNDERSERVED ARE MEMBERS OF A POPULATION WHO EXPERIENCE HEALTH DISPARITIES, ARE AT RISK OF NOT RECEIVING ADEQUATE MEDICAL CARE AS A RESULT OF BEING UNINSURED OR UNDERINSURED, AND/OR EXPERIENCING BARRIERS TO HEALTHCARE DUE TO GEOGRAPHIC, LANGUAGE, FINANCIAL, AND OTHER BARRIERS. MEMBERS OF THE CHNA STEERING COMMITTEE, ALONG WITH THOSE WHO PARTICIPATED IN FOCUS GROUPS, AND THE NEEDS INDENTIFICATION AND PRIORITIZATION PROCESS, WERE CHOSEN BASED ON THEIR UNIQUE EXPERTISE AND EXPERIENCE, INFORMED PERSPECTIVE, AND INVOLVEMENT WITH THE COMMUNITY. THE CHNA STEERING COMMITTEE MEMBERS INCLUDED:-HEALTHCARE PROVIDERS-COMMUNITY LEADERS-COMMUNITY SERVICE PROVIDERS-SCHOOL LEADERS-PUBLIC HEALTH REPRESENTATIVES-OTHER RELEVANT STAKEHOLDERS FAIRFIELD MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE IMPLEMENTATION STRATEGY WAS DEVELOPED THROUGH A FACILITATED MEETING INVOLVING KEY ADMINISTRATIVE STAFF OF FAIRFIELD MEMORIAL HOSPITAL IN MAY 2025. THE GROUP REVIEWED THE NEEDS ASSESSMENT PROCESS COMPLETED TO THAT POINT AND CONSIDERED THE PRIORITIZED SIGNIFICANT NEEDS AND SUPPORTING DOCUMENTS. THEY ALSO EVALUATED INTERNAL AND EXTERNAL RESOURCES THAT COULD POTENTIALLY ADDRESS THE CURRENT PRIORITIZED NEEDS.THE GROUP THEN CONSIDERED EACH OF THE PRIORITIZED NEEDS. FOR EACH PRIORITY AREA, FMH HAS IDENTIFIED THE ACTIONS IT INTENDS TO TAKE, ALONG WITH THE ANTICIPATED IMPACT OF THESE ACTIONS, THE RESOURCES IT PLANS TO COMMIT TO THESE ACTIONS, AND THE EXTERNAL COLLABORATORS TO COOPERATE WITH TO ADDRESS THE NEEDS.THE PLAN WILL BE EVALUATED THROUGH PERIODIC REVIEWS OF MEASURABLE OUTCOME INDICATORS, IN CONJUNCTION WITH ANNUAL REVIEWS AND REPORTING. THE GROUP ASSESSED THE NEEDS WITH THE FOLLOWING STRATEGIES:1. PRIORITY #1: ACCESS TO MENTAL HEALTH: IMPROVE ACCESS TO, AND KNOWLEDGE OF, MENTAL HEALTH SERVICES.ACTIONS TO ADDRESS THE HEALTH NEED:- PROMOTION OF THE RESOURCES AVAILABLE AT FMH EMPLOYS ONE PSYCHIATRIC NURSE PRACTITIONER- DEVELOP A CAMPAIGN FOR THE COMMUNITY THAT ADDRESSES THE STIGMA ASSOCIATED WITH SEEKING MENTAL HEALTH TREATMENT- PARTNER WITH SCHOOLS TO INCREASE AWARENESS OF AVAILABLE RESOURCES AND HELP NORMALIZE THE NEED FOR MENTAL HEALTH SERVICES WHEN NECESSARY- PROVIDE "LUNCH AND LEARN" EDUCATIONAL OFFERINGS TO THE COMMUNITY ON TOPICS RELATED TO MENTAL HEALTH, SUCH AS WORK-LIFE BALANCE, DEPRESSION, AND ANXIETY- CONTINUE RECRUITING ADDITIONAL MENTAL HEALTH PROVIDERS2. PRIORITY #2: WORKFORCE DEVELOPMENT/YOUTH: DEVELOP RELATIONSHIPS WITH SCHOOLS TO IMPROVE STUDENTS' KNOWLEDGE OF HEALTH TOPICS, INCLUDING HEALTH CAREERS. ACTIONS TO ADDRESS THE HEALTH NEED:- INVESTIGATE WAYS TO COLLABORATE WITH SCHOOLS TO PROVIDE STUDENTS WITH EDUCATION ON HEALTH LIVING. THIS CAN INCLUDE MENTAL, PHYSICAL, AND SEXUAL HEALTH.- EDUCATE STUDENTS ON THE RESOURCES THAT ARE AVAILABLE IN THIS COMMUNITY THAT CAN ASSIST WITH HEALTHY LIVING- EDUCATE STUDENTS ON HEALTH CAREER OPPORTUNITIES AT FMH- OFFER JOB SHADOWING OPPORTUNITIES FOR STUDENTS TO GAIN A DEEPER UNDERSTANDING OF HEALTH CAREERS3. PRIORITY #3: HEALTH IMPROVEMENT: DEVELOP EDUCATIONAL OFFERINGS AND SUPPORT TO HELP PEOPLE ENHANCE THEIR KNOWLEDGE OF WAYS TO IMPROVE THEIR HEALTH. ACTIONS TO ADDRESS THE HEALTH NEED: - USING LIVE AND PODCAST VENUES, CREATE EDUCATIONAL PROGRAMMING THAT MEETS BASIC HEALTH EDUCATIONAL NEEDS AS WELL AS ADVANCED ON SELECTED TOPICS- FOCUS ON THE RESOURCES AVAILABLE IN THE COMMUNITY AND HOW TO HELP PEOPLE ACCESS THEM. - FOCUS ON CONNECTING INTERNAL AND EXTERNAL RESOURCES THROUGH THE CARE COORDINATION AND DISCHARGE PLANNING TEAMS TO ENSURE THAT WHEN PEOPLE ARE DISCHARGED, THEY HAVE BEEN LINKED TO THE RESOURCES THEY REQUIRE.- FOCUS ON CONTROLLING HYPERTENSION THROUGH EDUCATION AND HEALTHY LIFESTYLE ACTIVITIES- FOCUS EDUCATION ON SMOKING AND VAPING CESSATION WITH STUDENTS AND THE COMMUNITY - CREATE PROGRAMS FOR HEALTHY LIVING AND EXERCISE THAT ARE EITHER LOW- OR NO-COST. POTENTIALLY PARTNER WITH THE PARKS AND RECREATION WITHIN THE COMMUNITY - REACH OUT TO THE MINISTRIAL ALLIANCE OR CHURCHES TO SHARE RESOURCES AND ASSESS THEIR NEEDS. CONSIDER OFFERING SCREENINGS AND EDUCATION TO THEIR CONGREGANTS.- COLLABORATE WITH COMMUNITY BUSINESSES TO OFFER EDUCATIONAL PROGRAMS AND SCREENINGS FOR EMPLOYEES- INVESTIGATE THE FORMATION OF SUPPORT GROUPS FOR PEOPLE WITH HEALTH CONDITIONS SUCH AS DIABETES- LEVERAGE THE NEW LABORATORY TESTING PLATFORMS FOR SEXUALLY TRANSMITTED INFECTIONS (STIS). 4 1 - HORIZON HEALTHCARE 213 NW 10TH STREET STE A FAIRFIELD IL 62837 OUTPATIENT RURAL HEALTH CLINIC 2 - HORIZON HEALTHCARE CISNE MEDICAL CLINIC 413 PARK STREET CISNE IL 62823 OUTPATIENT RURAL HEALTH CLINIC 3 - HORIZON HEALTHCARE CARMI MEDICAL CLINIC 1103 W MAIN STREET CARMI IL 62821 OUTPATIENT RURAL HEALTH CLINIC 4 - FMH URGENT CARE CLINIC 303 NW 11TH STREET FAIRFIELD IL 62837 OUTPATIENT RURAL HEALTH CLINIC PART I, LINE 3C: AS PART OF ITS MISSION, FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION PROVIDES CHARITY CARE TO PATIENTS WHO LACK THE ABILITY TO PAY. THE DETERMINATION OF THE ABILITY TO PAY MAY TAKE INTO ACCOUNT A NUMBER OF FINANCIAL VARIABLES, INCLUDING BUT NOT LIMITED TO: INCOME LEVEL, FAMILY SIZE, AND AMOUNT OF HOSPITAL CHARGES IN ORDER TO DETERMINE ELIGIBILITY FOR THE LEVELS OF FINANCIAL ASSISTANCE. IN CERTAIN EXTRAORDINARY CASES WHERE THESE FACTORS MAY NOT ACCURATELY REFLECT THE PATIENT'S ABILITY TO PAY, THE PATIENT FINANCIAL SERVICES DIRECTOR ALONG WITH THE CFO MAY REVIEW AND DETERMINE IF ADDITIONAL FINANCIAL ASSISTANCE IS MERITED. PART I, LINE 7: THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM THE FILED 6/30/2025 COST REPORT TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H. PART III, LINE 2: FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION CALCULATED BAD DEBT EXPENSE AT COST. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H, PART III LINE 9B. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. PART III, LINE 3: BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY. THEREFORE, 25% OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III, LINE 3 AT COST. PART III, LINE 4: SEE PAGES 10-12 IN THE ATTACHED AUDITED FINANCIAL STATEMENTS. PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED OR PROVIDED BY POLICY) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION IS COMMITTED TO SERVING PATIENTS, REGARDLESS OF ABILITY TO PAY OR IF THE PAYMENTS TO BE RECEIVED WILL BE LESS THAN THE COST TO PROVIDE THE SERVICE, AS IS THE CASE FOR MEDICARE AND MEDICAID PATIENTS. THE MEDICARE ALLOWABLE COSTS REPORTED ON LINE 6 OF PART III HAVE BEEN CALCULATED BY USING THE MEDICARE COST TO CHARGE RATIO. THE AMOUNT IS COMPARED TO TOTAL MEDICARE PAYMENTS RECEIVED. SHOULD THERE BE A SHORTFALL, IT WOULD BE TREATED AS A COMMUNITY BENEFIT AS IT REFLECTS UN-REIMBURSED COSTS FOR PROVIDING MEDICAL SERVICES TO THE MEDICARE RESIDENTS OF THE COMMUNITY. THE FYE 2025 COST REPORT WAS USED TO CALCULATE THE MEDICARE SHORTFALL. PART III, LINE 9B: FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON CHARITY CARE ELIGIBLE. THE PROCEDURE FOR COLLECTION ON PATIENT ACCOUNTS IS AS FOLLOWS: SELF-PAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT.IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS, THE ACCOUNT IS TRANSFERRED TO EARLY-OUT DEPARTMENT FOR A FOLLOW UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS PATIENTS SEVERAL PAYMENT ALTERNATIVES, INCLUDING CASH/CHECK FOR THE FULL AMOUNT, CREDIT CARD, SHORT TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCE. SPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR. IF PAYMENT OR SATISFACTORY PAYMENT ARRANGEMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS:DAY 1 - 1ST NOTICEDAY 7-14 - FIRST PHONE CALL IS MADE; AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE 90 DAYS DAY 75 - DEMAND NOTICE DAY 90 - ACCOUNT IS SENT TO COLLECTIONS. ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY, AND ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT. PART VI, LINE 2: THE DETERMINATION OF CURRENT AND FUTURE HEALTHCARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS: EXISTENCE OR NON EXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER," COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, COMMUNITY BASED NEEDS ASSESSMENT, GOVERNMENT AGENCIES, OTHER HEALTHCARE PROVIDERS THAT WOULD ENABLE THE FILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSICIAN INPUT, AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES. THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITAL'S SENIOR LEADERSHIP AND INCORPORATED INTO THE STRATEGIC PLANNING PROCESS. PART VI, LINE 3: SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF THE FINANCIAL ASSISTANCE PROGRAM. THE HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. THE SOCIAL SERVICES DEPARTMENT SPEAKS TO ALL INPATIENTS ABOUT THE PROGRAM. PART VI, LINE 4: FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATION OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE, GENDER, INCOME, ETHNIC ORIGIN, INSURANCE COVERAGE, OR ABILITY TO PAY. WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 34,606 BASED OFF OF THE REPORT AREA DEFINED IN THE MOST CURRENT 2025 CHNA. THE AVERAGE HOUSEHOLD INCOME FOR THE SERVICE MARKET AREA, BASED ON THE LATEST 5-YEAR AMERICAN COMMUNITY SURVEY ESTIMATES, WAS $69,666. THE IL STATE AVERAGE HOUSEHOLD INCOME IS $108,873. THE AVERAGE HOUSEHOLD SIZE IN THE AREA, AT 2.28, IS LOWER THAN BOTH THE STATE OF IL AND THE UNITED STATES. THE UNEMPLOYMENT RATE WAS 3.9%, WHICH IS UNDER BOTH THE STATE OF IL AND THE UNITED STATES UNEMPLOYMENT RATE AVERAGES. 15% OF HOUSEHOLDS ARE BELOW THE POVERTY LEVEL, OR ROUGHLY 2,220 HOUSEHOLDS. PART VI, LINE 5: FAIRFIELD MEMORIAL HOSPITAL HAS A COMMUNITY BOARD, MADE UP OF MEMBERS FROM DIFFERENT OCCUPATIONS IN THE COMMUNITY, INCLUDING MEDICAL, EDUCATION, LOCAL BUSINESSES, FARMING INDUSTRY AND BANKING. PART VI, LINE 6: EFFECTIVE APRIL 1, 2024, THE HOSPITAL ENTERED INTO A MANAGEMENT SERVICES AGREEMENT (THE "AGREEMENT") WITHDEACONESS REGIONAL HEALTHCARE NETWORK, LLC ("DEACONESS"), AS AFFILIATE OF DEACONESS HEALTH SYSTEM. AS ARESULT, THE HOSPITAL'S ARTICLES OF INCORPORATION AND BY-LAWS WERE AMENDED TO PROVIDE FOR TWO REPRESENTATIVESOUT OF ELEVEN ON THE HOSPITAL'S BOARD OF DIRECTORS TO BE APPOINTED BY DEACONESS.UNDER THE AGREEMENT, SUPPORT PROVIDED TO THE HOSPITAL CONSISTS OF MANAGEMENT PERSONNEL, FACILITYPLANNING, STRATEGIC PLANNING, RECRUITING, AND SEVERAL OTHER SUPPORT AND OVERSIGHT SERVICES. THE INITIAL TERMOF THE AGREEMENT IS FOR A FIVE-YEAR PERIOD, WHICH CAN BE EXTENDED IF SO DESIRED. THE AGREEMENT CAN BETERMINATED BY EITHER PARTY WITH A 365-DAY NOTICE WITHOUT RECOURSE ANY TIME AFTER THE FIRST ANNIVERSARY OFTHE EFFECTIVE DATE. AFTER THE SECOND ANNIVERSARY OF THE EFFECTIVE DATE, THE AGREEMENT CAN BE TERMINATEDWITH 180-DAY WRITTEN NOTICE. IF THE AGREEMENT IS TERMINATED BY THE HOSPITAL WITHIN THE INITIAL FIVE-YEARTERM, THE HOSPITAL WILL BE ASSESSED A PENALTY IN THE AMOUNT OF $1,400,000 TO BE PAYABLE TO DRHNI. UNDERTHE AGREEMENT, THE HOSPITAL REIMBURSES DRHNI THE DIRECT COST OF MANAGEMENT PERSONNEL, EMERGENCYROOM COVERAGE, CERTAIN IT COSTS, AS WELL AS VARIOUS SUPPLIES AND TRAINING RELATED COSTS ON A MONTHLY BASIS,IN ADDITION TO A MANAGEMENT AGREEMENT FEE. PART VI, LINE 7, REPORTS FILED WITH STATES IL 1 1 0 SCHOLARSHIPS 2 42484 PART I, LINE 2: SCHOLARSHIPS ARE AWARDED IN A FIELD THAT FMH HAS IDENTIFIED A NEED FOR. THE SCHOLARSHIPS ARE PAID EITHER UPON PRESENTATION OF THE COMPLETED DIPLOMA AND RECEIPTS, OR FMH WILL PAY THE SCHOOL OR UNIVERSITY DIRECTLY. X X X 0 0 0 0 0 0 0 0 0 KORY BLANK ORTHOPEDIC SURGEON 599781 0 93099 0 0 0 6900 0 14151 0 713931 0 0 0 LAUREN WILLIAMS PHYSICIAN 389944 0 24083 0 0 0 0 0 12487 0 426514 0 0 0 KIMBERLY KING CRNA/PAIN MANAGEMENT PROVIDER 308798 0 64398 0 0 0 6900 0 13830 0 393926 0 0 0 CHRISTOPHER BALLARD PHYSICIAN 300536 0 50874 0 0 0 6900 0 15767 0 374077 0 0 0 ARUNIMA SAXENA PHYSICIAN 327614 0 23121 0 0 0 0 0 15202 0 365937 0 0 0 JIM BASCH CFO (BEG 08/24-11/24, 06/25) 249901 0 0 0 0 0 0 0 0 0 249901 0 0 0 KATHERINE BUNTING CEO 204297 0 0 0 0 0 0 0 2728 0 207025 0 0 0 BRADLEY AUGUST SON-IN-LAW OF CEO 111415 COMPENSATION 0 MELINDA BUNTING DAUGHTER-IN-LAW TO CEO 33850 COMPENSATION 0 ALLISSA KEOUGHAN DAUGHTER OF BOARD MEMBER 45984 COMPENSATION 0 DIANNA SENG SPOUSE OF BOARD MEMBER 33118 COMPENSATION 0 REBECCA BUNTING GRANDDAUGHTER OF CEO 12171 COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 3 BEGINNING IN APRIL 2024, FAIRFIELD MEMORIAL HOSPITAL ("FMH") AFFILIATED WITH DEACONESS REGIONAL HEALTHCARE NETWORK ILLINOIS, LLC THROUGH A MANAGEMENT SERVICES AGREEMENT. IN THIS AFFILIATION MANAGEMENT SERVICES AGREEMENT, THEY EMPLOY THE CEO AND CFO TO HELP MANAGE THE ORGANIZATION. TWO MEMBERS OF DEACONESS ALSO SERVE ON THE BOARD OF DIRECTORS FOR FMH. DEACONESS PROVIDES ASSISTANCE IN THE EVALUATION OF OFFICERS, PROVIDES ADMINISTRATIVE RESOURCES, CONSULTING SERVICES, AND ASSISTS WITH REGULATORY ISSUES AND EDUCATION. FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWS THE 990 AFTER IT IS COMPLETED, PRIOR TO BEING FINALIZED. ONCE REVIEWED, IT IS GIVEN TO THE CEO FOR REVIEW. AFTER THE DOCUMENT IS REVIEWED BY THE CEO, IT IS AVAILABLE FOR THE BOARD TO REVIEW. THE 990 PREPARERS ARE NOTIFIED THAT THE DOCUMENT IS APPROVED AND READY TO BE FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES A CONFLICT OF INTEREST POLICY, TO REVIEW AND SIGN STATING THEY HAVE READ, AND DISCLOSED ANY CONFLICT OF INTERESTS; ALL SIGNED DOCUMENTS ARE KEPT ON FILE WITH THE ADMINISTRATION OFFICE. FORM 990, PART VI, SECTION B, LINE 15 LINE 15A: THE CEO AND CFO SALARIES ARE DETERMINED BY THE BOARD OF DIRECTORS AND DEACONESS REGIONAL HEALTHCARE NETWORK, LLC. MARKET SURVEYS AND CONSIDERATION OF YEARS OF EXPERIENCE AND RESPONSIBILITIES ARE FACTORED INTO DETERMINING THE COMPENSATION. THIS PROCESS IS REVIEWED ANNUALLY BY THE BOARD AND COMPENSATION COMMITTEE, AND IS DOCUMENTED WITHIN THE BOARD MINUTES. LINE 15B: COMPENSATION FOR ALL OTHER OFFICERS OF THE ORGANIZATION IS DETERMINED BY THE BOARD OF DIRECTORS BASED ON WEIGHTED PERFORMANCE APPRAISALS. THIS PROCESS IS REVIEWED ANNUALLY AND IS DOCUMENTED WITHIN THE HR ANNUAL EVALUATION FORMS. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS AND THE FEDERAL FORM 990 ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,994,620. MANAGEMENT AND GENERAL EXPENSES 1,425,141. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,419,761. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,109,924. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,109,924. COLLECTION FEES: PROGRAM SERVICE EXPENSES 28,027. MANAGEMENT AND GENERAL EXPENSES 67,748. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 95,775. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 2,166,285. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,166,285. DIAGNOSTIC MAMMOGRAPHY SERVICES: PROGRAM SERVICE EXPENSES 225,360. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 225,360. FORM 990, PART XI, LINE 9: ADJUSTMENT FOR CHANGE IN BEGINNING BALANCE THIRD PARTY RECEIVABLES -3,513,104. FAIRFIELD MEMORIAL HOSPITAL FOUNDATION 303 NW 11TH ST FAIRFIELD IL 62837 371185754 SUPPORT THE HOSPITAL IL 501(C)(3) LINE 12B, II N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0