Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2011 and ending 12-31-2011
BCheck if applicable:
CName of organization
Indiana University Health White Memorial
Hospital Inc
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
720 South Sixth Street
 
Room/suite
City or town, state or country, and ZIP + 4
Monticello, IN47960
D Employer identification number

27-3532963
E Telephone number

G Gross receipts $ 15,201,688
F Name and address of principal officer:
STEPHANIE LONG CEO
720 SOUTH SIXTH STREET
MONTICELLO,IN47960
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
N/A
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 2010
M State of legal domicile: IN
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: Improve the health status of all people throughout White County, Indiana and surrounding areas by delivering quality, compassionate, and cost-effective health services.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 9
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 6
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 301
6 Total number of volunteers (estimate if necessary) .... 6 26
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b  
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 647,066
9 Program service revenue (Part VIII, line 2g) ......... 0 14,270,776
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 0 0
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 0 283,846
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 0 15,201,688
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 0 5,705,159
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 0 8,583,215
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 0 14,288,374
19 Revenue less expenses. Subtract line 18 from line 12....... 0 913,314
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 0 45,573,468
21 Total liabilities (Part X, line 26)............. 0 38,810,806
22 Net assets or fund balances. Subtract line 21 from line 20..... 0 6,762,662
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: Improve the health status of all people throughout White County, Indiana and surrounding areas by delivering quality, compassionate, and cost-effective health services.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 13,392,390 including grants of $ 0 ) (Revenue $ 14,270,776 )
Indiana University Health White Memorial Hospital, Inc operates a 25 bed critical access hospital providing quality health care to patients without regard to their origin, gender, or ability to pay. Total inpatient admissions during the year were 663 with 18,566 outpatient procedures performed.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 13,392,390
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see list of attachments
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
42
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
301
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
9
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
6
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
 
No
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IN
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
CARA BREIDSTER
2550 GREENBUSH STREET
lafeyette,IN47904
(765) 838-6203
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Kathleen Altman
Vice President
 2.0 X   X       1,800   0
(2) Janet Johnson Faker
Secretary
 2.0 X   X       1,800 0 0
(3) Larry Pampel DDS
Chairman
 2.0 X   X       1,800 0 0
(4) Dean Fleck
Board Member
 2.0 X           1,800 0 0
(5) Gary Cooley
Board Member
 2.0 X           1,800 0 0
(6) Reg Shireman
Board Member
 2.0 X           1,800 0 0
(7) Randy Mitchell
Board Member
 2.0 X           1,800 0 0
(8) Alfonso Gatmaitan
BOARD MEMBER
 2.0 X           0 535,935 122,401
(9) James Bien MD
Board Member
 2.0 X           0 311,368 351,065
(10) NORMAN G TABLER JR
BOARD MEMBER THROUGH 6/30/11
 1.0 X           0 616,835 669,125
(11) MARVIN G PEMBER
BOARD MEMBER THROUGH 6/30/11
 1.0 X           0 1,010,382 3,467,627
(12) SCOTT M BLACK
BOARD MEMBER THROUGH 6/30/11
 1.0 X           0 279,631 46,752
(13) Walter Soptelean
CFO beg. 7/1/11
 50.0     X       43,903 0 3,656
(14) Stephanie Long
CEO
 50.0     X       83,571 0 3,675
(15) Mary Minier
COO
 50.0     X       47,362 0 2,001
(16) Robin Smith
CNO
 50.0     X       37,926 0 1,862


Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 225,362 2,754,151 4,668,164
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Monticello Emergency Care LLC
PO Box 1937 Dept L-174
INDIANAPOLIS,IN46205 		ER Physicians 440,667
Henney Frederic
810 S Sixth Street
MONTICELLO,IN47960 		Anesthesia Services 212,300
Monticello Medical Center
826 N Sixth Street
MONTICELLO,IN47960 		On-Call MED SERVICES 137,214
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet3
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 9,000
e Government grants (contributions)1e 638,066
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 647,066
Program Service Revenue Business Code
2a NET PATIENT SERVICE REVENUE 622,110 14,185,180 14,185,180    
b AFFILIATE RENT INCOME 531,120 85,596 85,596    
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 14,270,776
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 0      
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 157,168  
b Less: rental expenses    
c Rental income or (loss) 157,168  
d Net rental income or (loss).......MediumBullet 157,168     157,168
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss)    
d Net gain or (loss)..........MediumBullet 0      
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a MISCELLANEOUS INCOME 900,099 126,678     126,678
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet 126,678
12 Total revenue. See Instructions....MediumBullet 15,201,688 14,270,776   283,846
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 236,556   236,556  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 32,979   32,979  
7 Other salaries and wages 4,606,243 4,201,191 405,052  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 119,646 99,590 20,056  
9 Other employee benefits ....... 377,707 618,332 -240,625  
10 Payroll taxes ........... 332,028 292,235 39,793  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 46,180   46,180  
c Accounting ........... 73,837   73,837  
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 1,741,533 1,653,461 88,072  
12 Advertising and promotion .... 34,559 34,559    
13 Office expenses ....... 2,339,991 2,310,545 29,446  
14 Information technology ...... 151,603 151,603    
15 Royalties .. 0      
16 Occupancy ........... 0      
17 Travel ............ 30,791 27,512 3,279  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 3,798 3,278 520  
20 Interest ........... 394,533 394,533    
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 767,920 767,920    
23 Insurance .............. 155,838 13,842 141,996  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a BAD DEBT 1,872,385 1,872,385    
b ALL OTHER EXPENSES 970,247 951,404 18,843  
c
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 14,288,374 13,392,390 895,984 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 0 1 0
2 Savings and temporary cash investments ....... 0 2 6,236,953
3 Pledges and grants receivable, net ......... 0 3 0
4 Accounts receivable, net ......... 0 4 3,008,518
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 0 5 0
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L .......... 0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 0 8 640,565
9 Prepaid expenses and deferred charges ............ 0 9 190,637
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 35,400,725
b Less: accumulated depreciation. ..... 10b 767,736 0 10c 34,632,989
11 Investments—publicly traded securities .......... 0 11 863,806
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 0 15 0
16 Total assets. Add lines 1 through 15 (must equal line 34)... 0 16 45,573,468
Liabilities 17 Accounts payable and accrued expenses . 0 17 4,931,789
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 9,157,643
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 0 25 24,721,374
26 Total liabilities. Add lines 17 through 25..... 0 26 38,810,806
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 0 27 6,507,775
28 Temporarily restricted net assets ..... 0 28 156,140
29 Permanently restricted net assets ..... 0 29 98,747
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 0 33 6,762,662
34 Total liabilities and net assets/fund balances ..... 0 34 45,573,468
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
15,201,688
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
14,288,374
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
913,314
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
0
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
5,849,348
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
6,762,662
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
Yes
 
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
Yes
 
Form 990 (2011)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Indiana University Health White Memorial
Hospital Inc 		Employer identification number

27-3532963
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Indiana University Health White Memorial
Hospital Inc 		Employer identification number

27-3532963
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Indiana University Health White Memorial
Hospital Inc 		Employer identification number

27-3532963
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 152,745      
b Contributions ........        
c Net investment earnings, gains, and losses ... -12,566      
d Grants or scholarships ..... 6,348      
e Other expenditures for facilities
and programs ........ 		       
f Administrative expenses ....        
g End of year balance ...... 133,831      
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet0 %
b
Permanent endowment SchDMd Bullet74.720 %
c
Temporarily restricted endowment SchDMd Bullet25.280 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
Yes
 
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   972,779 972,779
b Buildings ................ 55,400 30,630,549 421,128 30,264,821
c Leasehold improvements ............        
d Equipment ................   3,605,565 338,667 3,266,898
e Other .................   136,432 7,941 128,491
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 34,632,989
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
INTER-COMPANY PAYABLE 24,721,374








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 24,721,374
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Intended uses of the organization's endowment funds Schedule D, Part V, Question 4 The net income of the endowment funds will be used for the improvement and maintenance of the hospital through the purchase of equipment or improvements which will be of long-lasting benefit to the hospital and the community. Part X Line 2 Indiana University Health White Memorial, Inc is a subsidiary in the consolidated financial statements of Indiana University Health, Inc. ("IU Health"). IU Health adopted FIN 48 in 2007. No disclosures were required under GAAP as IU Health does not have any material tax contingencies that required disclosures in the footnotes.
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		  211 274,901   274,901 2.210 %
b Medicaid (from Worksheet 3, column a) .....   1,663 1,625,114 732,432 892,682 7.190 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .            
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		  1,874 1,900,015 732,432 1,167,583 9.400 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		11 788 21,899 4,414 21,687 0.170 %
f Health professions education
(from Worksheet 5) .. 		3 11 8,964   8,964 0.070 %
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....   13 9,200     0.070 %
jTotal Other Benefits ... 14 812 40,063 4,414 30,651 0.310 %
kTotal. Add lines 7d and 7j. .. 14 2,686 1,940,078 736,846 1,198,234 9.710 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense........
2
299,171
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
0
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
5,991,131
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
5,389,240
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
601,891
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 Indiana University Health White Memorial
720 S Sixth St
Monticello,IN47960 		X X     X   X    
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Indiana University Health White Memorial
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 100%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 200.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?  
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
Part I, Line 3c   THE Federal Poverty Guidelines are used to determine eligibility. SUBSIDIZED HEALTH SERVICES PART I, LINE 7G: INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL, INC. DOES NOT INCLUDE ANY COSTS ASSOCIATED WITH PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES. BAD DEBT EXPENSE PART I, LINE 7, COLUMN F: THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE COMMUNITY BENEFIT PERCENTAGE OF TOTAL EXPENSES IS $1,872,385. Part I, Line 7 Percentage of total expenses listed on Schedule H, Part I, Line 7, is calculated based on net community benefit expense. The percentage of total expenses calculated based on total community benefit expense is 10.34%. Part III, Line 4 The provision for uncollected patient accounts is based upon Management's assessment of historical and expected net collections considering business and economic conditions, changes in trends in health care coverage, and other collection indicators. In addition, Management assesses the adequacy of the allowance for uncollectable accounts based upon accounts receivable balances, and historical write-off experience by payor category, as adjusted for collection indicators. The results of this assessment are then used to make any modifications to the provision for uncollectible accounts. Indiana University White Memorial Hospital follows established guidelines for collection practices. Patient accounts that are uncollected and placed with collection agencies, are charged against the allowance for uncollectable accounts and in accordance with collection policies of Indiana University Health White Memorial Hospital. Part III, Line 8 INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL DID NOT HAVE A MEDICARE SHORTFALL FOR 2011. HOWEVER, IN YEARS IN WHICH IT DOES EXPERIENCE A MEDICARE SHORTFALL, THE MEDICARE SHORTFALL reported on Schedule H, Part III, Line 7 is calculated in accordance with the Form 990 instructions, using "allowable costs" from IU Health White Memorial Hospital's Medicare cost report. "Allowable costs" for medicare cost report purposes 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 cost of Medicare Part C & D, fee schedule reimbursed services. Inclusion of all costs associated with IU Health White Memorial Hospitals participation in Medicare programs would result in a significant Medicare shortfall reported on schedule H part III line 7. IU Health White Memorial Hospital's shortfall is attributable to reimbursements that are less than the cost of providing patient care and services to Medicare beneficiaries and does not include any amounts that result from insufficiencies or poor management. IU Health White accepts all Medicare patients knowing there may be shortfalls; therefore it has taken the position that the shortfall should be accounted as part of the community benefit. Collection Practices Part III, Line 9b If a patient cannot satisfy standard payment expectations, financial screening is completed for alternative sources of balance resolution. This financial screening may include; a discount on charges, Enrollment in Medicaid or another type of government assistance program, an interest-free payment plan, a low interest loan, or an application for charity care. If a patient meets the charity care guidelines, Indiana University Health White Memorial Hospital will waive charges and treat the costs of services as charity care. Needs Assessment Part VI Line 2 Indiana University Health White Memorial Hospital assesses the health care needs of the community it serves by utilizing detailed community needs assessments prepared by organizations such as Indiana Hospital Association, North Central Nursing Clinics, as well as other local departments or chapters for example, the White County Department of Health, and the local United Way Chapter. Indiana University Health White Memorial Hospital strives to garner community input while aligning our programs, design of community health needs and visible opportunities to demonstrate we provide benefits that respond to meet community needs. Patient Education of Eligibility for Assistance Part VI Line 3 During the patient registration process, patient education of eligibility for assistance is discussed with patients who are identified as self-pay and/or patients who may be billed for services. Many assistance programs are available under federal, state, or local government programs. Since a complex set of variables does define the uninsured patients we treat, Indiana University Health White Memorial Hospital provides an extension to our patients by offering an on-site service (ClaimAid) who is able to assist patients through an eligibility screening and enrollment process. This has proven to be both needed and beneficial for the patients Indiana University Health White Memorial Hospital serves as it provides assistance with collecting the required documentation. Additionally, Indiana University Health White Memorial Hospital shows its commitment to providing affordable healthcare access by treating all patients regardless of their ability to pay. In order to provide consistency and awareness to individuals, information related to the hospital's financial assistance program is provided during the registration process, through the assistance of a ClaimAid advocate, through the billing process, and is provided on the hospital website. Medical care meeting financial assistance guidelines is discounted on a sliding scale according to the Federal Poverty Guidelines. The hospital explains and helps patients apply for financial assistance. Financial assistance is provided at any point during the billing process with the patient. Utmost respect and sensitivity is provided to all patients through the course of care and the billing process. Community Information Part VI, Line 4 Indiana University Health White Memorial Hospital is located in White County, a county located in northwest Indiana. White County includes ZIP codes within the towns of Monticello, Norway, Reynolds, Wolcott, Brookston, Buffalo, Burnettsville, Chalmers, Idaville, and Monon. Based on the most recent Census Bureau (2010) statistics, White County's population is 24,643 persons with approximately 51% being female and 49% male. The county's population estimates by race are 93.8% White, 7.1% Hispanic or Latino, 0.28% Black, 0.4% Asian, 0.3% American Indian or Alaska Native, and 1.88% persons reporting two or more races. At almost 14%, the 65+ population is expected to grow the fastest among all White County age cohorts between 2010 and 2015. In general, an older population can produce increased demand for healthcare services and a potential increase in the prevalence of certain chronic conditions. Promotion of Community Health Part VI, Line 5 Indiana University Health White invests in its community to improve the quality of health of community members and has participated in a variety of community-based building activities that address the quality of life in the communities it serves. Indiana University Health White Memorial Hospital invested by spending .. in community initiatives which provided both resources and expertise. Additionally, Indiana University Health White Memorial established and/or participated in community outreach activities such as; Job fairs, a workforce development program, counseling and education related to nutrition, tobacco cessation classes, child passenger safety and car seat program with free inspection and car seats provided, injury prevention class related to fall injuries, and cholesterol and blood pressures testing. Indiana University Health White Memorial Hospital contributes to a variety of community service initiatives. Health and Safety Fair Blood Pressure Readings Child Safety Car Seat Safety Fire Safety Water Safety Nutrition Stress Management Smoking Cessation Bicycle Safety - Bicycle Helmets Poison Control Weather Safety Skin Protection and Sun Damage Public Education Safe Sitter Classes CPR Classes Organ/Tissue Donation Awareness Advanced Directives Education Childbirth Classes Child Abuse/Shaken-infant Syndrome Child Development Classes High School Awareness for dangers of Alcohol use Participation in Every 15-minutes Technically Advance Professional (TAP) training-Provides adults with a plan to achieve their goals in becoming a healthcare professional Medication Assistance Program - Staffed and provided in Hospital Scholarships for local School Systems High School Prom Sponsor Little League Sponsor County 4-H Fair Sponsor Mitten Tree - provides hats, mittens, gloves and scarves for local children Special Olympic Sponsor and participant Chamber of Commerce Member Good Neighbor by providing free community meeting rooms with Wi-Fi, projector, screen, and LCD Televisions. Healthcare Provider Trainin
Schedule H (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) Alfonso Gatmaitan (i)
(ii)		 0
393,762 		0
131,088 		0
11,085 		0
93,663 		0
28,738 		0
658,336 		0
0
(2) James Bien MD (i)
(ii)		 0
250,707 		0
42,200 		0
18,461 		0
325,000 		0
26,065 		0
662,433 		0
0
(3) NORMAN G TABLER JR (i)
(ii)		 0
359,104 		0
155,627 		0
102,104 		0
15,819 		0
653,306 		0
1,285,960 		0
0
(4) MARVIN G PEMBER (i)
(ii)		 0
436,425 		0
262,280 		0
311,677 		0
20,390 		0
3,447,237 		0
4,478,009 		0
290,387
(5) SCOTT M BLACK (i)
(ii)		 0
223,402 		0
46,155 		0
10,074 		0
20,505 		0
26,247 		0
326,383 		0
0











Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
SCHEDULE J, PART I, LINE 4B   MARVIN G. PEMBER AND NORMAN G. TABLER, JR. PARTICIPATE IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN, PROVISIONS OF WHICH ARE DESIGNED TO RETAIN THESE 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. FOR MARVIN G. PEMBER AND NORMAN G. TABLER, JR., $290,387 AND $52,611 IS INCLUDED IN COLUMN B(III), OTHER REPORTABLE COMPENSATION, REPRESENTING THE AMOUNT RECEIVED UNDER THEIR VESTED SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN.
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Phil Prescott SEE PART V 32,979 employment   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L, Part IV - Business Transactions Involving Interested Persons   Phil Prescott IS A FAMILY MEMBER OF KATHLEEN ALTMAN, WHO SERVES ON THE BOARD OF DIRECTORS OF IU HEALTH WHITE.
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Identifier Return Reference Explanation
Form 990 Part III Line 2   Indiana University Health White Memorial Hospital, Inc was incorporated on September 24, 2010 for the purpose of acquiring operational control of White County Memorial Hospital, a hospital owned and previously operated by White County, Indiana and its board of commissioners. Indiana University Health White Memorial Hospital, Inc did not begin operational control of the hospital until the acquistion was completed in 2011. As a result, Indiana University Health White Memorial Hospital, Inc. did not have any activity until 7/1/2011, therefore, the 2011 return includes activity from 7/1/2011 through 12/31/2011. Form 990, Part V, Line 6 Indiana University Health White Memorial Hospital is provided services and benefits of volunteers who make up the Indiana University Health White Memorial Hospital Auxiliary. This group, made up of 27 volunteers, serve in a variety of capacities for the hospital. Volunteer service examples include; providing week-end hours serving at main registration acting as a welcome desk to assist patients families and visitors guidance and locations of departments within the hospital, in the forms, assisting with labeling supply items on a routine schedule, sewing and making puppets for children admitted to the hospital or treated in out-patient areas, as well as perform fundraising events with proceeds funding hospital equipment purchases. Form 990, Part VI, Section A, Line 2 Business Relationships Norman G. Tabler, Jr. is an officer and serves on the Board of Directors of Indiana University health plans, Inc. MArvin G. Pember served on the Board of Directors of Indiana University health plans, Inc. during a portion of 2011. No additional compensation is provided. Form 990, Part VI, Section A, Line 4 On July 1, 2011 White County Memorial Hospital was acquired by Indiana University Health, and subsequently began operations as Indiana University Health White Memorial Hospital. Form 990, Part VI, Section A, Line 6 Indiana University health White Memorial Hospital has one member which is Indiana University Health. Form 990, Part VI, Line 7a The member has the right to appoint all of the Directors, provided that without consent of the then-current Board, the member may not alter the requirement that at least 75% of the directors must reside in White County. Form 990, Part VI, Section A, Line 7B Notwithstanding, any other provisions of the articles of incorporation or any provision of IU Health White Memorial Hospitals bylaws, the following actions require the approval of IU Health prior to implementation: Approval of any proposed amendment to the Corporations Articles of Incorporation or Bylaws Approval of any unbudgeted operating or capital budget items or deviations, including any issuance or guarantee of unbudgeted debt, greater than the budgeted amount by more than a) $250,000 per fiscal year per budget line item and B) $750,000 per fiscal year in the aggregate Approval of any encumbrance, sale or conveyance of assets in excess of 5%, on a cumulative basis, of the corporations Net Book Value, during any fiscal year Approval of the corporations annual capital and operating budgets APPROVAL OF ANY STRATEGIC PLAN FOR THE CORPORATION, INCLUDING ANY AMENDMENTS TO A STRATEGIC PLAN APPROVAL OF ANY ENCUMBRANCE, SALE, OR CONVEYANCE OF ASSETS IN EXCESS OF 5%, ON A CUMULATIVE BASIS, OF THE CORPORATION'S NET BOOK VALUE, DURING ANY FISCAL YEAR 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 CHIEF EXECUTIVE OFFICER, UPON A RECOMMENDATION OF THE BOARD THE DISSOLUTION OF THE CORPORATION OR ANY OF ITS AFFILIATES
Form 990, Part VI, Section A, Line 8B   Not applicable. IU Health White Memorial Hospital did not have to contemporaneously document any meetings by a committee, because it did not have any committees with the authority to act on behalf of the board of directors. Form 990, Part VI, Section B, Line 11B The Form 990 and related schedules are reviewed by the Chief Financial Officer. The form 990 and related schedules are presented and made available to each board member via an online website. Part VI, Section B. Policies Line 12c Conflict of Interest Policy: Indiana University Health White Memorial Hospital understands that regular and consistent monitoring is essential to ensure compliance with its Conflict of Interest Policy. Health care should be provided to patients in a manner consistent with our mission, vision, and values. Our responsibility is to ensure that a high standard of individual, organizational, ethical and legal standards is maintained. To assist in this development, IU Health White Memorial has established training and ongoing education for all staff members. This includes but is not limited to: New employee orientation, where each new employee receives and reviews detailed information outlining the Corporate Compliance Program and specifics relevant to his or her job functions. Dedicated time is spent discussing rules, regulations, including conflict of interest. This orientation is provided to reinforce the desired ethical culture which embraces quality care for our patients and the communities we serve. Mandatory Education is conducted each year. All employees are required to review and complete this training which includes testing related to corporate compliance. Compliance training is evaluated on an annual basis by the Corporate Compliance Committee. The Corporate Compliance Committee currently consists of the hospital Corporate Compliance Officer, the Privacy Officer, the Security Officer and the Business Office Director. In addition, each Indiana University Health White Memorial Hospital, at the level of Manager or above, as well as Officers must complete, sign and submit a Questionnaire to the Compliance Officer. The completion and signature contained on Indiana University Health White Memorial Hospitals Conflict of Interest questionnaire, affirms that each level of Manager or above, as well as Officers, have received and read said policy, has been provided direct interaction with the compliance officer to discuss the policy, has agreed to comply with the policy, and understands and acknowledges the organizations requirements which includes discloser of any transaction or arrangement that might benefit the private interest of an employee, Manager or Officer. BOARD MEMBERS WITH A CONFLICT OF INTEREST CANNOT PARTICIPATE IN ANY DECISION RELATED TO THAT CONFLICT. Form 990, Part VI, Section B, Lines 15a annd 15b The process in place to determine the compensation of the IU Health White Memorial Hospitals Chief Executive Officer, Chief Operating Officer, and Chief Nursing Officer includes a compensation survey or study conducted by an Independent compensation consultant, reviewed with the IU Health White Memorial Hospitals board of directors and human resources. The CEO has a written contract, subject to approval by the board. Due to IU Health White Memorial Hospital beginning operations in July 1, 2011, a formal review by an independent compensation consultant and review by the board did not occur in 2011, but in the second quarter of 2012. Form 990, Part VI, Section C, Line 19 IU Health White Memorial Hospital, Incs governing documents are available to the public through the Indiana Secretary of State website. IU Health White Memorial Hospitals conflict of interest policy is described on Form 990, Schedule O. See description Part VI, Section B, Line 12C. IU Health White memorial Hospital is a consolidated subsidiary in the consolidated financial statements for Indiana University Heath, Inc. The consolidated financial statements for Indiana University Health, Inc. are available to the public through its bond filings. Form 990, Part VII: ALFONSO GATMAITAN IS THE PRESIDENT AND CEO OF IU HEALTH ARNETT AND DEVOTES 53 HOURS PER WEEK. JAMES BIEN, MD IS Vice President of Quality and Patient Safety FOR IU HEALTH ARNETT AND DEVOTES 48 HOURS PER WEEK. JEFFREY NAGY IS CHIEF FINANCIAL OFFICER OF IU HEALTH ARNETT AND DEVOTES 48 HOURS PER WEEK. NORMAN G. TABLER, JR. IS THE SENIOR VP - GENERAL COUNSEL & CCO/SECRETARY OF IU HEALTH AND DEVOTES 55 HOURS/WEEK. MARVIN G. PEMBER IS THE EXECUTIVE VP AND CFO OF IU HEALTH AND DEVOTES 55 HOURS PER WEEK. SCOTT BLACK IS THE VP OF BUSINESS DEVELOPMENT AT IU HEALTH AND DEVOTES 55 HOURS PER WEEK. FORM 990, PART XI LINE 5 OTHER CHANGES IN NET ASSETS INCLUDES A NET UNREALIZED LOSS ON INVESTMENTS ($5,606), AND THE NET VALUE OF NET ASSETS TRANSFERRED FROM WHITE COUNTY MEMORIAL HOSPITAL, $5,854,954. Form 990, Part XII, Line 2C: Oversight of Audit: The Board of Directors assumes responsibility for oversight of the audit of the financial statements. The financial statements are part of the consolidated audit for Indiana University Health, Inc. Form 5471 - Information Return of U.S. Persons With Respect To Certain Foreign Corporations Indiana University Health White Memorial (FEIN: 27-3532963) constructively owned a controlled foreign corporation in 2011 through its affiliate, Indiana University Health, Inc. (FEIN: 35-1955872). Pursuant to IRC Section 6038, the 2011 controlled foreign corporation filing requirement of Entity Name was fulfilled on the 2011 Form 5471 filed on its behalf by: Indiana University Health, Inc. FEIN: 35-1955872 950 N. Meridian Street, Suite 800 Indianapolis, IN 46204 The 2011 Form 5471 for Indiana University Health, Inc. was filed at the following IRS processing center: Ogden, UT 84201-0012
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Indiana University Health White Memorial
Hospital Inc
Employer identification number

27-3532963
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity







(1) TWIN LAKES MEDICAL OFFICE BUILDING LLC
810 SOUTH SIXTH STREET
MOTICELLO,IN47960
20-5299511 		Office Bldg IN 242,764 8,004,191 IUHWMH
 










Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) Ball Memorial Hospital Auxiliary Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-6025400 		Healthcare IN 501(c)(3) 11 III-FI IUHBMH
 
Yes
 
(2) Clarian Transplant Institute Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
13-4350599 		Healthcare IN 501(c)(3) 9 IUH
 
Yes
 
(3) Goshen Health System Inc

200 High Park Ave

Goshen,IN46527
35-1974765 		Healthcare IN 501(c)(3) 11 I IUH
 
Yes
 
(4) Goshen Hospital Association Inc

200 High Park Ave

Goshen,IN46527
35-6001540 		Healthcare IN 501(c)(3) 3 GHS
 
Yes
 
(5) HealthLinc Inc

714 S Rogers St

Bloomington,IN47402
26-3571507 		Healthcare IN 501(c)(3) 9 IUHB
 
Yes
 
(6) Indiana Radiology Partners Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
20-1017034 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(7) Indiana University Health Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1955872 		Healthcare IN 501(c)(3) 3 NA
 
 
No
(8) IU Health Arnett Foundation Inc

2600 Greenbush St

Lafayette,IN47904
35-6079797 		Fundraising IN 501(c)(3) 11 I IUHA
 
Yes
 
(9) IU Health Arnett Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
26-3162145 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(10) IU Health Ball Memorial Hospital Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-0867958 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(11) IU Health Ball Memorial Physicians Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1925641 		Healthcare IN 501(c)(3) 9 IUHBMH
 
Yes
 
(12) IU Health Bedford Inc

2900 W 16th St

Bedford,IN47421
23-7042323 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(13) IU Health Blackford Hospital Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
01-0646166 		Healthcare IN 501(c)(3) 3 IUHBMH
 
Yes
 
(14) IU Health Bloomington Inc

PO Box 1149

Bloomington,IN47403
35-1720796 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(15) IU Health BMH Foundation Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
31-1111784 		Fundraising IN 501(c)(3) 11 I IUHBMH
 
Yes
 
(16) IU Health Care Associates Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1747218 		Healthcare IN 501(c)(3) 9 IUH
 
Yes
 
(17) IU Health LaPorte Hospital Inc

PO Box 250

LaPorte,IN46352
35-1125434 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(18) IU Health LaPorte Physicians Inc

PO Box 250

LaPorte,IN46352
31-1070868 		Healthcare IN 501(c)(3) 3 IUHLH
 
Yes
 
(19) IU Health Morgan Hospital Inc

2209 John R Wooden Dr

Martinsville,IN46151
27-3533027 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(20) IU Health North Hospital Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1932442 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(21) IU Health Paoli Hosp Foundation Inc

PO Box 499

Paoli,IN47454
31-0992486 		Fundraising IN 501(c)(3) 11 III-O IUHP
 
Yes
 
(22) IU Health Paoli Inc

PO Box 499

Paoli,IN47454
35-2090919 		Healthcare IN 501(c)(3) 3 IUHB
 
Yes
 
(23) IU Health Tipton Hospital Inc

1000 S Main St

Tipton,IN46072
26-2772226 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(24) IU Health West Hospital Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1814660 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(25) IU Medical Group Foundation Inc

340 W 10th St No FS5100

Indianapolis,IN46202
20-1093251 		Fundraising IN 501(c)(3) 11 II NA
 
 
No
(26) Methodist Health Foundation Inc

1800 N Capitol Ave

Indianapolis,IN46202
35-6043086 		Fundraising IN 501(c)(3) 11 I IUH
 
Yes
 
(27) Methodist Health Group Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-0876390 		Healthcare IN 501(c)(3) 11 III-FI NA
 
 
No
(28) Methodist Medical Group Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1945384 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(29) Methodist Occup Health Centers Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1844176 		Healthcare IN 501(c)(3) 3 IUH
 
Yes
 
(30) Methodist Research Institute Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-2023710 		Healthcare IN 501(c)(3) 11 I IUH
 
Yes
 
(31) MH Healthcare Inc

950 N Meridian St Ste 800

Indianapolis,IN46204
35-1766531 		Healthcare IN 501(c)(3) 3 MMG
 
Yes
 
(32) Morgan Co Mem Hosp Foundation Inc

2209 John R Wooden Dr

Martinsville,IN46151
35-2035162 		Fundraising IN 501(c)(3) 11 II IUHMH
 
Yes
 
(33) Morgan Co Mem Hosp Guild Inc

2209 John R Wooden Dr

Martinsville,IN46151
31-0886844 		Fundraising IN 501(c)(3) 11 III-FI IUHMH
 
Yes
 
(34) Morgan Health Services Inc

1949 Hospital Dr

Martinsville,IN46151
35-1968564 		Healthcare IN 501(c)(3) 3 IUHMH
 
Yes
 
(35) White Co Mem Hosp Foundation Inc

PO Box 952

Monticello,IN47960
35-1671806 		Fundraising IN 501(c)(3) 11 III-O IUHWMH
 
Yes
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) Ball Outpatient Sur Ctr LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
27-0275794 		Healthcare IN BOSCH
  		N/A                
(2) Beltway Surgery Centers LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
35-2072586 		Healthcare IN IUHSC
  		N/A                
(3) Bloomington Endo Centers LLC

PO Box 1149
Bloomington,IN47402
35-2117943 		Healthcare IN IUHB
  		N/A                
(4) BMH Outpat Surg Svcs LLC

2401 W University Ave
Muncie,IN47303
20-4567998 		Healthcare IN IUHBMH
  		N/A                
(5) BOSC Holdings LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
45-4147343 		Healthcare IN IUH
  		N/A                
(6) Cardinal Health Init LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
30-0102702 		Purchasing IN IUHBMH
  		N/A                
(7) CHV Fund I LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
26-2523206 		Venture Capital IN IUH
  		N/A                
(8) CHV Fund Management LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
26-2523151 		Venture Capital IN CHV
  		N/A                
(9) Clarian Health Network LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
35-2055030 		Healthcare IN IUH
  		N/A                
(10) Clarian Health North LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
43-1980602 		Healthcare IN IUH
  		N/A                
(11) Clarian Health West LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
43-1980611 		Healthcare IN IUH
  		N/A                
(12) CTF International Growth Port

280 Congress St Ste 500
Boston,MA02210
20-0231923 		Investments MA IUH
  		N/A                
(13) Eagle High Surg Center LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
35-2259204 		Healthcare IN EHSCH
  		N/A                
(14) EHSC Holdings LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
45-4147879 		Healthcare IN IUH
  		N/A                
(15) Health Venture Management LLC

950 N Meridian St Ste 800
Indianapolis,IN46204
20-5740218 		Management IN IUH
  		N/A                
(16) IEC Holdings LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
45-4148032 		Healthcare IN IUH
  		N/A                
(17) Indiana Endoscopy Centers LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
20-8398421 		Healthcare IN IECH
  		N/A                
(18) IN Lakes Manag Care Org LLC

310 S Main St
Goshen,IN46526
35-1946663 		Healthcare IN GHS
  		N/A                
(19) IUH Surgery Centers LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
45-2314634 		Healthcare IN IUH
  		N/A                
(20) Mid-America Surg Ctr LLC

2401 W University Ave
Muncie,IN47303
35-2002953 		Healthcare IN CDHV
  		N/A                
(21) ROC Surgery LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
27-1497960 		Healthcare IN ROCSH
  		N/A                
(22) ROCS Holdings LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
45-4148369 		Healthcare IN IUH
  		N/A                
(23) Senate St Surgery Center LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
42-1709357 		Healthcare IN SSSCH
  		N/A                
(24) SSSC Holdings LLC

3000 Riverchase Galleria Ste 500
Birmingham,AL35244
45-4148167 		Healthcare IN IUH
  		N/A                
(25) The Healthcare Group LLC

1776 Meridian St Ste 300
Indianapolis,IN46202
35-2067373 		Managed Care IN IUH
  		N/A                
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) BMH Medical Pavilion Association Inc
2525 W University Ave
Muncie,IN47303
35-1858408 		Condo Management IN IUHBMH
  		C      
(2) Cardinal Health Ventures Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
35-1611424 		Management IN IUHBMH
  		C      
(3) CHV Capital Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
26-0752507 		Venture Capital IN IUH
  		C      
(4) IU Health ACO Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
45-4421020 		Healthcare IN IUH
  		C      
(5) IU Health Board Designated Trust
400 Howard St
San Francisco,CA94105
30-6309021 		Investments IN IUH
  		T      
(6) IU Health NTGI S&P500 Fund CF
PO Box 804358
Chicago,IL60680
30-6298263 		Investments IN IUH
  		T      
(7) IU Health Plans Inc
1776 Meridian St Ste 300
Indianapolis,IN46202
26-2127080 		HMO IN IUH
  		C      
(8) IU Health Risk Purchasing Group Inc
151 Meeting St Ste 301
Charleston,SC29401
26-0202446 		Insurance IN IUH
  		C      
(9) IU Health Risk Retention Group Inc
151 Meeting St Ste 301
Charleston,SC29401
20-1107674 		Insurance SC IUH
  		C      
(10) IU Health Southern IN Physicians Inc
PO Box 1149
Bloomington,IN47402
35-1913875 		Healthcare IN IUHB
  		C      
(11) IUH Assurance Ltd
720 W Bay Rd PO Box 69
Grand Cayman    
CJ
98-0395429 		Insurance IN IUH
  		C      
(12) Occ-Health Revenue Systems Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
20-3308057 		Work Comp PPO IN MOHC
  		C      
(13) Parkmor Drug Inc
1501 S Main St
Goshen,IN46526
13-1394980 		Pharmacy Sales IN GHS
  		C      
(14) PILR Inc
200 High Park Ave
Goshen,IN46526
20-4294750 		Development IN GHS
  		C      
(15) Radiation Oncology Resources Inc
200 High Park Ave
Goshen,IN46526
26-2008424 		Healthcare IN GHS
  		C      
(16) SCANS Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
45-3080392 		Healthcare IN CHVF1
  		C      
(17) University Health Management Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
27-2891143 		Management IN CHV
  		C      
(18) University Health Mgmt (China) Inc
950 N Meridian St Ste 800
Indianapolis,IN46204
27-3891311 		Management IN CHV
  		C      
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
Yes
 
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) IU Health Arnett

 i 78,624 FMV
(2) IU Health Home Care

 i 6,972 FMV
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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