TY 2011 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
ELMER TOLIVER PSC 14412 SMUGGLERS NOTCH FORT WAYNE,IN46814	MEDICAL	289,140
RAINMAKER PRODUCTION SERVICES LLC 17062 CEDAR CREEK LANE NOBLSEVILLE,IN46060	MEDICAL	287,692
INSIGHT HEALTH CORP PO BOX 847689 DALLAS,TX75284	MEDICAL	133,700
SHAW DO SERVICES LLC 18017 CHERRY WOOD LANE HOMEWOOD,IL60430	MEDICAL	132,532
DONALD W HUNSBERGER MD PO BOX 37 MONTPELIER,IN47359	MEDICAL	102,048
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 5

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	800	800
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 ....	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	5,464,711	4,641,922	822,789
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	115,244	115,244
9	Other employee benefits .......	717,399	711,432	5,967
10	Payroll taxes ...........	388,088	328,904	59,184
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	0
c	Accounting ...........	4,861		4,861
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	0
g	Other ..........	5,376,349	5,128,247	248,102
12	Advertising and promotion ....	15,772		15,772
13	Office expenses .......	162,254	110,614	51,640
14	Information technology ......	5,123	2,514	2,609
15	Royalties ..	0
16	Occupancy ...........	449,474	119,080	330,394
17	Travel ............	17,506	10,209	7,297
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	66,479		66,479
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	1,271,855	1,271,855
23	Insurance ..............	126,746	1,320	125,426
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	2,841,548	2,841,548
b	DRUGS AND MEDICAL SUPPLIES	1,114,131	1,114,131
c	INSTITUTIONAL DUES/LICENSES	17,560	17,560
d	UBI TAX	5,421		5,421
e
f	All other expenses	150,354	99,759	50,595
25	Total functional expenses. Add lines 1 through 24f	18,311,675	16,515,139	1,796,536	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 if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	518,120	1	675
2	Savings and temporary cash investments .......	0	2	0
3	Pledges and grants receivable, net .........	0	3	0
4	Accounts receivable, net .........	1,425,540	4	1,802,840
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 ..............	142,464	8	181,023
9	Prepaid expenses and deferred charges ............	45,167	9	54,877
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	20,714,857
b	Less: accumulated depreciation. .....	10b	8,883,878	12,948,642	10c	11,830,979
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 ......	0	12	0
13	Investments—program-related. See Part IV, line 11 ..	47,664	13	57,817
14	Intangible assets .........	10,833	14	834
15	Other assets. See Part IV, line 11 ...........	14,585	15	1,587,433
16	Total assets. Add lines 1 through 15 (must equal line 34)...	15,153,015	16	15,516,478
	17	Accounts payable and accrued expenses .	2,007,837	17	984,867
18	Grants payable ..........	0	18	0
19	Deferred revenue ..........	177	19	42,410
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 ..	4,000,010	23	2,400,347
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.....	540,296	25	1,031,985
26	Total liabilities. Add lines 17 through 25.....	6,548,320	26	4,459,609
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	8,604,695	27	11,056,869
28	Temporarily restricted net assets .....	0	28	0
29	Permanently restricted net assets .....	0	29	0
	Organizations that do not follow SFAS 117, check here 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 .....	8,604,695	33	11,056,869
34	Total liabilities and net assets/fund balances .....	15,153,015	34	15,516,478

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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.

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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

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.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

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).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2011. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2010. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

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.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2011. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

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:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2011

Name of organization

INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... 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

Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
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	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3

Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

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

(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

(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

(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

(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:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

2,082

Total. Add lines 1c through 1i ...............................

2,082

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
Schedule C, Part II-B	Line 1i - Other Activities	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2011 in the amount of $7,101 and $6,580, respectively. Each membership organization notified IU Health Blackford Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 24.42%, or $1,734 of 2011 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The IHA used 5.29%, or $348 of the 2011 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The total membership dues paid to these organizations by IU Health Blackford Hospital during 2011 that were attributable to lobbying expenditures was $2,082.

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

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 .......

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? ............

Yes No

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? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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.


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

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

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)? ....................................

Yes No

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.

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.

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

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:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

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

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

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):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

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?........

Yes No

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.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

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 ....
b	Contributions ........
c	Net investment earnings, gains, and losses ...
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the year end balance (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

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		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	190,324		190,324
b	Buildings ................	14,859,870	4,868,656	9,991,214
c	Leasehold improvements ............
d	Equipment ................	5,388,593	3,863,185	1,525,408
e	Other .................	246,070	152,037	124,033
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				11,830,979

Schedule D (Form 990) 2011

Page 3

Part VII

InvestmentsOther 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.)

Part VIII

InvestmentsProgram 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.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) EST. THIRD PARTY SETTLEMENTS				1,587,433








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,587,433

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Book value
Federal Income Taxes		0
INTERCOMPANY PAYABLES (NET)		931,374
SELF-INSURANCE LIABILITIES		29,122
INTEREST RATE SWAP LIABILITIES		71,489






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		1,031,985
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

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
Schedule D, Part X - Other Liabilities	Line 2 - FIN 48 (ASC 740) Footnote	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") 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 in 2011 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:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....

Yes

If "Yes," was it a written policy? .......................

Yes

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.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

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.

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:

Yes

100% 150% 200% Other

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: ............

Yes

200% 250% 300% 350% 400% Other 650 %

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.

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"? ..............

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......

Yes

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?...............

Did the organization prepare a community benefit report during the tax year?...........

Yes

If "Yes," did the organization make it available to the public? ...............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

	(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) ..		0	987,552	0	987,552	6.380 %
b Medicaid (from Worksheet 3, column a) .....		6,614	2,284,828	915,359	1,369,469	8.850 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .		0	0	0	0	0 %
dTotal Financial Assistance and Means-Tested Government Programs .....		6,614	3,272,380	915,359	2,357,021	15.230 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	15	1,561	39,726	1,250	38,476	0.250 %
f Health professions education (from Worksheet 5) ..	2	28	29,686	0	29,686	0.190 %
g Subsidized health services (from Worksheet 6) ..		0	0	0	0	0 %
h Research (from Worksheet 7)		0	0	0	0	0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	3	0	7,918	0	7,918	0.050 %
jTotal Other Benefits ...	20	1,589	77,330	1,250	76,080	0.490 %
kTotal. Add lines 7d and 7j. ..	20	8,203	3,349,710	916,609	2,433,101	15.720 %

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	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing		0	0	0	0 %
2	Economic development	1	0	95	95	0 %
3	Community support	2	0	7,510	7,510	0.050 %
4	Environmental improvements		0	0	0	0 %
5	Leadership development and training for community members		0	0	0	0 %
6	Coalition building	1	4,438	5,563	5,563	0.040 %
7	Community health improvement advocacy	1	70	432	432	0 %
8	Workforce development		0	0	0	0 %
9	Other		0	0	0	0 %
10	Total	5	4,508	13,600	13,600	0.090 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense........

1,048,531

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....

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

Enter total revenue received from Medicare (including DSH and IME).....

7,266,829

Enter Medicare allowable costs of care relating to payments on line 5.....

6,542,517

Subtract line 6 from line 5. This is the surplus or (shortfall)........

724,312

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

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.......................

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

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		Other (Describe)
1	IU HEALTH BLACKFORD HOSPITAL 410 PILGRIM BOULEVARD HARTFORD CITY,IN47348	X	X	X	X

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)

IU HEALTH BLACKFORD HOSPITAL

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: 200.% If "No," explain in Part VI the criteria the hospital facility used.

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: 650.% 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

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

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

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
Schedule H, Part I - Financial Assistance	Line 3c	N/A
Schedule H, Part I - Financial Assistance	Line 6a - Community Benefit Report Prepared by Related Organization	Indiana University Health Blackford Hospital, Inc.'s ("IU Health Blackford Hospital") community benefits and investments are included in the Indiana University Health ("IU Health") Community Benefit Report which is made available to the public on its website at www.iuhealth.org. The Community Benefit report is also distributed to numerous key organizations throughout the State of Indiana to broadly share IU Health's community benefit efforts and investments statewide, and is available by request through the Indiana State Department of Health or IU Health. IU Health Blackford Hospital community benefit information is also included in the Indiana University Health Ball Memorial Hospital, Inc. ("IU Health Ball Memorial Hospital") Community Benefit Report and is made available to the public on the IU Health Blackford Hospital and IU Health Ball Memorial Hospital websites at iuhealth.org/blackford and iuhealth.org/ball-memorial. The report is also printed and widely distributed to community leaders and at community events such as health fairs and information programs attended by the public. It is also available upon request.
Schedule H, Part I - Financial Assistance	Line 7, Column (f) - Bad Debt Expense	The amount of bad debt expense included on Form 990, Part IX, Line 25, column (A), but subtracted for purposes of calculating the percentage of total expense is $2,841,548.
Schedule H, Part I - Financial Assistance	Line 7 - Total Community Benefit Expense	Percentage of Total Expenses listed on Schedule H, Part I, Line 7, Column (f) is calculated based on Net Community Benefit Expense. The Percentage of Total Expenses calculated based on Total Community Benefit Expense is 21.65%.
Schedule H, Part I - Financial Assistance	Line 7g - Subsidized Health Services	Indiana University Health Blackford Hospital, Inc. does not include any costs associated with physician clinics as subsidized health services.
Schedule H, Part II - Community Building Activities	Promotion of Health in Communities Served	In 2011, Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") provided expertise and resources to local community initiatives that addressed community factors related to health improvement. Outreach activities included participation in community disaster-readiness programs; financial support for preschool initiatives within the local school system; assistance for a community food drive; and collaborative partnerships to improve community health through the Blackford County Wellness Coalition. IU Health Blackford Hospital employees also participated in a Kindergarten reading program for local children, and participated in the construction of enhanced playground facilities at schools in neighboring Delaware County. As part of the IU Health system, IU Health Blackford leaders participate in a wide array of community-building activities that address the underlying quality of life in the communities IU Health serves. Hospitals throughout the IU Health system invest in economic development efforts in their communities which results in collaborations through coalitions across the state, with like-minded organizations that address key issues, and advocates for improvements in the health status of vulnerable populations. In 2011, IU Health spent over 1.2 million dollars, serving more than 77,000 individuals as a statewide organization. Specifically, IU Health Blackford Hospital invested over $13,600 serving nearly 4,500 people in the Blackford County community.
Schedule H, Part III - Bad Debt, Medicare, & Collection Practices	Line 4 - Bad Debt Expense	The provision for uncollected patient accounts is based upon management's assessment of historical and expected net collections considering business and economic conditions, changes and trends in health care coverage, and other collection indicators. Periodically, management assesses the adequacy of the allowance for uncollectible accounts based upon accounts receivable payor composition and aging, and historical write-off experience by payor category, as adjusted for collection indicators. The results of the review are then used to make any modifications to the provision for uncollected patient accounts and the allowance for uncollectible accounts. In addition, Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") follows established guidelines for placing certain past due patient balances with collection agencies. Patient accounts that are uncollected, including those placed with collection agencies, are initially charged against the allowance for uncollectible accounts in accordance with collection policies of IU Health Blackford Hospital and, in certain cases, are reclassified to charity care if deemed to otherwise meet charity care and financial assistance policies of IU Health Blackford Hospital. The bad debt expense reported on Line 2 is calculated under the cost to charge ratio methodology. IU Health Blackford Hospital provides health care services through various programs that are designed, among other matters, to enhance the health of the community and improve the health of low-income patients. In addition, IU Health Blackford Hospital provides services intended to benefit the poor and underserved, including those persons who cannot afford health insurance because of inadequate resources or are uninsured or underinsured.
Schedule H, Part III - Bad Debt, Medicare, & Collection Practices	Line 8 - Medicare Shortfall	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford 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 Blackford Hospital's Medicare Cost Report. "Allowable costs" for Medicare Cost Report purposes are not reflective of all costs associated with IU Health Blackford Hospital's participation in Medicare programs. For example, the Medicare Cost Report excludes certain costs such as billed physician services, the costs of Medicare Parts C and D, fee schedule reimbursed services, and durable medical equipment services. Inclusion of all costs associated with IU Health Blackford Hospital's participation in Medicare programs would significantly increase the Medicare shortfall reported on Schedule H, Part III, Line 7.
Schedule H, Part III - Bad Debt, Medicare, & Collection Practices	Line 9b - Written Debt Collection Policy and Financial Assistance	If a patient cannot satisfy standard payment expectations, a financial assistance screening process for alternative sources of balance resolution is completed. Those resolutions may include: a discount on charges; Medicaid enrollment, interest-free loan or application for charity care. If a patient does not apply for charity care but meets the charity care guidelines established by Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital"), IU Health Blackford Hospital will waive charges and treat the cost of services as charity care.
Schedule H, Part VI - Supplemental Information	Line 2 - Needs Assessment	Communities are multifaceted and so are their health needs. Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") understands that the health of individuals and communities are shaped by various social and environmental factors, along with health behaviors and additional influences. IU Health Blackford Hospital assesses the health care needs of the communities it serves by utilizing the detailed community needs assessments undertaken by organizations such as the Blackford County Health Department, the Indiana State Department of Health, the Centers for Disease Control and Prevention and the United Way.
Schedule H, Part VI - Supplemental Information	Line 3 - Patient Education of Eligibility for Assistance	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") goes to great lengths to ensure patients know that IU Health Blackford Hospital treats all patients regardless of their ability to pay. IU Health Blackford Hospital shares financial assistance information with patients during the admission process, billing process and online. Helping patients understand that financial support for their care is a part of IU Health Blackford Hospital's commitment to its mission. IU Health Blackford Hospital's financial assistance policy exists to serve those in need by providing financial relief to patients who ask for assistance after care has been provided. During the admissions process, opportunities for financial assistance are discussed with patients who are identified as a self-pay patient, or requests assistance information. The patient is also provided with an Admissions Packet that provides information regarding IU Health Blackford Hospital's financial assistance program. Financial counselors are onsite to assist financial concerns or questions during the patient's stay. Patient Financial Services - Customer Service representatives can help patients apply for financial assistance, understand their bills, explain what they can expect during the billing process, accept payment (if needed), update their insurance or payor information, and update their address or other demographics. A summary of the financial assistance policy is printed on the back of each patient statement, while the financial assistance application is mailed to all uninsured IU Health Blackford Hospital patients at the conclusion of their treatment along with a summary of the incurred charges. Additionally, on the back of each patient statement is a phone number that will allow patients the ability to request financial assistance. Uninsured patients are also made aware of this process at the time of registration. The Indiana University Health, Inc. ("IU Health") statewide system, of which IU Health Blackford Hospital is included, website (iuhealth.org) has a page dedicated to financial assistance and offers an online application and phone numbers for customer service representatives to assist with the application process. IU Health Blackford Hospital has an expansive financial assistance program, which aligns with IU Health's policy and utilizes the federal poverty guidelines to determine eligibility; making access to quality care within a patient's reach. The IU Health Financial Assistance policy provides the following support to patients that qualify. " Free care for those earning up to 200 percent of federal poverty guidelines; " Discounted care on a sliding scale for families earning from 200 to 400 percent of federal poverty guidelines; and " Discounted care on a sliding scale for uninsured families earning from 400 to 650 percent of federal poverty guidelines, and " Financial assistance to patients whose health insurance coverage, if any, does not provide full coverage for all of their medical expenses and whose medical expenses would make them indigent if they were forced to pay full charges. Patients are guided through their course of care with particular sensitivity, reviewing changing circumstances and allowing for financial assistance at any point during the relationship and billing process with the patient. For those inpatients that may qualify for the Medicaid program and have not applied, IU Health Blackford Hospital financial counselors will assist patients with the Medicaid application. If a patient does not apply for financial assistance, but meets the financial assistance guidelines established by IU Health Blackford Hospital, IU Health Blackford Hospital will waive charges and treat the cost of services as financial assistance.
Schedule H, Part VI - Supplemental Information	Line 4 - Community Information	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") serves patients primarily from Blackford County (75%) and four surrounding counties (Grant, Delaware, Jay, and Wells) (25%). Blackford County has a higher rate of unemployment and a lower median household income than the Indiana state and national averages. The county is adversely affected by a combination of chronic health conditions, low educational attainment, and the low availability of higher paying jobs. Of the five counties primarily served by IU Health Blackford Hospital, all are expected to decrease in total population and increase in the number of residents 65 years of age or older, except for Wells and Jay Counties, respectively. Additionally, approximately 79% of inpatient and outpatient cases in 2011 were covered by government-sponsored health care plans (Medicare and Medicaid, 73% and 5%, respectively).
Schedule H, Part VI - Supplemental Information	Line 5 - Promotion of Community Health	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") was founded in 1923 to provide care to the residents of Hartford City and surrounding towns. In 2005, the hospital opened a new campus, featuring a 15-bed hospital with all private rooms, a new attached medical office building and new ambulance garage. The 55,000 square foot facility, which is designated by Medicare as a critical access hospital, is designed on a single floor for easy navigation. To receive the distinction of critical access, a hospital must be considered the necessary provider of services in a rural area. IU Health Blackford Hospital is an affiliate of the Indiana University Health, Inc. ("IU Health") statewide healthcare system, and prepares and submits its own community benefits plan relative to the local community. It is also part of a three-prong community outreach strategy in place with the academic medical center downtown Indianapolis, suburban Indianapolis and statewide entities as priority areas of focus and effort. IU Health considers its community benefit plan as part of an overall vision for strengthening Indiana's healthcare safety net. IU Health Blackford Hospital promotes the health of the community by maintaining a variety of inpatient and outpatient health services that include an emergency department, CT radiology services, MRI radiology, additional radiology services, sleep lab services, medical/surgical inpatient services, surgery inpatient and outpatient services, cardiac rehab services, respiratory therapy services, laboratory services, a pain clinic, a specialty clinic, and an ambulance service. Some of these services operate at a loss in order to ensure the comprehensive services are available to the county. The hospital operates a paramedic level ambulance service that operates throughout the county, with ambulance garages in Montpelier and Hartford City. The ambulance service responds to all medical 911 calls and operates without any governmental subsidy. Throughout the year, IU Health Blackford Hospital offers a variety of educational programs and sponsors a number of health improvement support groups. Classes such as CPR training, smoking cessation, diabetic nutrition classes, and others that positively impact the health of the community are offered throughout the year.
Schedule H, Part VI - Supplemental Information	Line 6 - Affiliated Health Care System	Indiana University Health Blackford Hospital, Inc.'s (IU Health Blackford Hospital") Board of Directors is composed of 8 members, of which substantially all are community members. A majority of the board members reside in IU Health Blackford Hospital's primary service area. IU Health Blackford Hospital also extends medical staff privileges to all qualified physicians in the community. IU Health Blackford Hospital is a part of the Indiana University Health, Inc. ("IU Health") statewide healthcare system which continues to broaden its reach and positive impact throughout the state of Indiana. IU Health is Indiana's most comprehensive healthcare system. A unique partnership with Indiana University School of Medicine, one of the nation's leading medical schools, gives patients access to innovative treatments and therapies. IU Health is comprised of hospitals, physicians and allied services dedicated to providing preeminent care throughout Indiana and beyond. A collaborative partnership with IU Health and Indiana University School of Medicine, IU Health Physicians is comprised of more than 500 board-certified or board-eligible physicians, 70 locations statewide and more than 1,000 staff, including 170 advanced practice providers. National Recognition: - Eight clinical programs ranked among the top 50 national programs in U.S. News & World Report's 2010-11 Edition of America's Best Hospitals. - Ten specialty programs at Riley Hospital for Children at IU Health ranked among the top 30 children's hospitals in the nation. - Six hospitals designated as Magnet hospital systems by the American Nurses Credentialing Center recognizing excellence in nursing care. - Named to the 2012-2013 U.S. News & World Report's Best Hospitals Honor Roll, their highest distinction. Education and Research: As an academic health center, IU Health works in partnership with Indiana University School of Medicine to train physicians, blending breakthrough research and treatments with the highest quality of patient care. Research conducted by Indiana University School of Medicine faculty gives IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. The IU Health statewide healthcare system consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health, IU Health West Hospital, IU Health North Hospital, IU Health Blackford, IU Health Blackford Hospital, IU Health Bloomington Hospital, IU Health Paoli Hospital, IU Health Bedford Hospital, IU Health Tipton Hospital, IU Health La Porte Hospital, IU Health Starke Hospital, and IU Health Goshen Hospital. In July of 2011, IU Health Morgan Hospital and IU Health White Hospital also became a member of IU Health. In December of 2011, IU Health opened its newest location, IU Health Saxony Hospital in Fishers, Indiana. Although each IU Health healthcare system hospital prepares and submits its own community benefits plan relative to the local community, IU Health considers its community benefit plan as part of an overall vision for strengthening Indiana's overall health. A comprehensive community outreach strategy and community benefit plan is in place that encompasses the academic medical center downtown Indianapolis, suburban Indianapolis and statewide entities around priority areas that focus on health improvement efforts statewide. IU Health is keenly aware of the positive impact it can have on the communities of need in the state of Indiana by focusing on the most pressing needs in a systematic and strategic way. After taking a careful look into IU Health's communities we serve, and by utilizing the detailed community needs assessments undertaken by public health officials and community partners, IU Health identified the following community health needs. Obesity Prevention To improve the lifestyle of Indiana residents, IU Health has utilized best practice methods to attack obesity in our communities. IU Health is working to improve access to nutritious foods and physical activity in low-income neighborhoods, in addition to providing traditional health education and public advocacy efforts. With these initiatives, IU Health strives to prevent chronic diseases such as obesity and diabetes and increase the awareness of the importance of making healthy choices, since Thirty-six percent of Hoosier adults are overweight and 29.5% are obese, costing the nation billions of dollars each year to treat these chronic health conditions. Garden on the Go: Year-round mobile produce delivery program, that aims to increase access to affordable, fresh fruits & vegetables for the city's most disadvantaged neighbors. By the end of December 2011, Garden on the Go served thousands of Indianapolis community members, reaching a total of 8281 residents! Indy Urban Acres: 8-acre organic urban farm that supplies low-income Hoosiers with healthy fruits and vegetables. Produce grown at this site is given to Gleaners Food Bank. In just two months of harvest, more than 1400 pounds of produce was grown on .5 acres and delivered to Gleaners Food Bank. Riley School Gardens: In an effort to increase access to nutritious foods and reduce the incidence of obesity among youth, Riley Hospital for Children at Indiana University Health partnered with Keep Indianapolis Beautiful (KIB) and Indianapolis Public Schools (IPS) to establish school gardens at 10 IPS schools throughout the city. IU Health Bucks: IU Health Bucks is an incentive program designed to increase produce consumption among underserved populations using state-issued Farmers Market Vouchers. Participants who spent their state-issued vouchers at the North United Methodist Church Farmers' Market in Indianapolis received additional IU Health "Market Money" to spend on produce. 233 low-income families participated in the pilot program, spending $3,500 on healthy, local produce. Walk Indiana: IU Health contributes resources for the implementation of a unique non-competitive walking marathon held in Muncie, Indiana. The program emphasizes walking as a lifestyle choice to enhance health and fitness. Community walking groups were offered during spring and summer months to help community members prepare for the main event held in September. IU Health staff members provided free blood pressure screenings and health information at each training session. Nearly 500 individuals participated in the Walk Indiana event in September, 2011. Access to Affordable Healthcare One of the first steps to improved health outcomes is having access to healthcare resources. To show its commitment to providing affordable healthcare access, IU Health treats all patients regardless of their ability to pay. IU Health is also working to raise awareness and work to identify individuals within our communities that have barriers to care and connect these individuals with better access and consistency of healthcare resources to meet their needs. Injury Prevention IU Health strives to create safe communities by helping to reduce preventable injuries such as bicycle, motor vehicle, and fall related injuries, as injuries are the leading cause of death for people 1 - 44 years old. The CDC reports 160,000 people die and 50 million people are injured each year, costing over $80 billion in medical costs. IU Health works to provide the necessary to tools, such as helmets and education to communities of need to prevent injuries for youth and adults. Additionally, IU Health supports the advocacy of policies, such as the texting while driving ban, to help provide infrastructure to instill the awareness of injury prevention in our communities. Bicycle Helmet Safety Campaign: Outfitted 4,042 children statewide (ages 6-14) with free, properly fitted bicycle helmets and provided bicycle safety education. This initiative resulted in a 37% increase in helmet usage post-activation. IU Health Child Passenger Safety Campaign: On National Seat Check Saturday, IU Health launched a statewide campaign to decrease the incidence of children traveling unrestrained or restrained incorrectly. CPS Technicians distributed 122 free car seats and found that 85% of the 205 car seats inspected were installed improperly. CICOA Aging and In-Home Solutions: Safe at Home Event - targeted homeowners over the age of 65 or persons of any age with a disability to make their homes safe and accessible for daily living. Volunteers made safety modifications to 22 homes including securing grab bars in bathrooms, installing handrails and banisters on steps, repairing steps, and installing comfort height toilets. K-12 Education In 2011, IU Health partnered with the United Way to implement a Kindergarten readiness program for at-risk children called Kindergarten Countdown. IU Health's significant investment in this program allowed hundreds of soon-to-be students to receive necessary vaccinations and screenings as well as attend a 4-week summer camp to enhance their school readiness. With I
STATE FILING OF COMMUNITY BENEFIT REPORT	990 SCHEDULE H, PART VI	IN,

Schedule H (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Part I

Questions Regarding Compensation

Yes

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.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

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....

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? ....

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.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

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:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? ........

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.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

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 ............

Yes

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 .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

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
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable 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
(1) MICHAEL E HALEY	(i) (ii)	0 472,485	0 142,703	0 273,672	0 20,652	0 25,003	0 934,515	0 0
(2) HAROLD L BERFIEND	(i) (ii)	0 285,714	0 48,094	0 10,643	0 9,800	0 13,623	0 367,874	0 0
(3) STEVEN J WEST	(i) (ii)	0 126,712	0 14,641	0 6,156	0 5,845	0 14,252	0 167,606	0 0
(4) CHARLES L CARROLL MD	(i) (ii)	155,918 0	0 0	0 0	3,899 0	0 0	159,817 0	0 0
(5) THOMAS M LEE MD	(i) (ii)	127,308 169,014	0 3,260	0 1,569	6,125 6,125	0 18,437	133,433 198,405	0 0

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 - Questions Regarding Compensation	Line 3 - Compensation of the Organization's CEO/Executive Director	Steven J. West, the President of Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital"), is compensated as an employee of Indiana University Health Ball Memorial Hospital, Inc. ("IU Health Ball Memorial Hospital") for his services performed at IU Health Blackford Hospital. IU Health Ball Memorial Hospital has a process in place to determine the compensation of IU Health Blackford Hospital's President. This process includes the use of a written employment contract, the terms of which are determined based upon a compensation survey/study conducted by an independent compensation consultant with review and approval by IU Health Ball Memorial Hospital's compensation committee and board of directors.
Schedule J, Part I - Questions Regarding Compensation	Line 4b - Supplemental Nonqualified Retirement Plan	Harold L. Berfiend participates in a 457(f) executive supplemental benefit plan of Indiana University Health Ball Memorial Hospital, Inc., provisions of which are designed to retain its critical employees. The plan provides for an additional retirement benefit for service through normal retirement or other key dates. If the executive leaves prior to retirement or other key dates, the benefit may be forfeited or reduced. Harold L. Berfiend has an amount included in column c, deferred compensation, representing the current year increase in the accrued benefit and/or current contributions. No amount was actually paid to this executive during the year. Michael E. Haley participates in a supplemental executive retirement plan of Indiana University Health, Inc., the provisions of which are designed to retain its critical employees. The plan provides for an additional retirement benefit for service through normal retirement or other key dates. If the executive leaves prior to retirement or other key dates, the benefit may be forfeited or reduced. Michael E. Haley has an amount included in column c, deferred compensation, representing the current year increase in the accrued benefit and/or current contributions. No amount was actually paid to this executive during the year.
Schedule J, Part I - Questions Regarding Compensation	Line 7 - Non-Fixed Payments	Amounts disclosed in Column B(ii) include a long-term and short-term incentive for certain executives and short-term incentive for other employees. Although these plans are based on a fixed formula that has been approved by the Board of Directors based upon certain qualitative and quantitative factors and goals, all discretionary incentive plans must be approved by the Board of Directors prior to any incentive payout.

Schedule J (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Identifier	Return Reference	Explanation
Part VI, Section A - Governing Body and Management	Line 2 - Family or Business Relationships	Michael E. Haley serves on the board of directors of Cardinal Health Ventures, Inc. Additionally, Michael E. Haley and Harold L. Berfiend serve as officers of Cardinal Health Ventures, Inc. No additional compensation is provided. Michael E. Haley and Harold L. Berfiend serve on the board of managers of Ball Outpatient Surgery Center, LLC. No additional compensation is provided.
Part VI, Section A - Governing Body and Management	Lines 6, 7a and 7b - Members or Stockholders	Line 6: Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") has one class of membership and the sole member is Indiana University Health Ball Memorial Hospital, Inc. ("IU Health Ball Memorial Hospital"). Line 7a: The Board of Directors may consist of no fewer than 3 and no more than 13 members and shall be at least 70% representing the local community. Five directors shall be "Community Directors" and shall be appointed by IU Health Ball Memorial Hospital subject to the recommendation of the Nominating Committee. All Community Directors shall be residents of Blackford County. Two directors shall be appointed by IU Health Ball Memorial Hospital to represent the Corporate Member. One director shall be appointed by the Board of Directors from a slate of three candidates nominated by the Commissioners. Line 7b: Notwithstanding any other provisions of the Articles of Incorporation, the following matters require the approval of IU Health Ball Memorial Hospital prior to implementation: -Approve the Governing Documents of the Hospital. -Appoint, upon the recommendation of the Board of the Hospital, or remove, with or without cause, the members of the Board of Directors of the Hospital. Removal does not require a recommendation of the Hospital's Board; provided, however, that IU Health Ball Memorial Hospital will not remove without cause one or more Community Directors prior to consulting with the remaining members of the Board, or remove without cause the County Director prior to consulting with the remaining members of the Board and the Blackford County Commissioners. -Approve the incurrence of debt of the Hospital within limits delegated to the Board of Directors from time to time by IU Health Ball Memorial Hospital -Approve and recommend the formation of legal entities, the sale, transfer or substantial change in use of all or substantially all of the assets of the Hospital or the divestiture, dissolution, closure, merger, consolidation or change in the Corporate Member of the Hospital. -Approve the transfer or encumbrance of the assets of the Hospital, except in the ordinary course of business. -Subject to approval by Indiana University Health, Inc., approve the capital and operating budgets for Hospital.
Part VI, Section A - Governing Body and Management	Line 11b - Form 990 Provided to Governing Body	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") has established the following process for the review of the Form 990 and related schedules before it is filed: The Chief Financial Officer of Indiana University Health Ball Memorial Hospital, Inc. reviewed and approved the Form 990 and related schedules. After the review and approval from the Chief Financial Officer, a complete final copy, as filed with the Internal Revenue Services, of the Form 990 and related schedules was made available to each board member on a secure intranet site. Each member was informed of the availability of the Tax Department to answer any questions
Part VI, Section B - Policies	Lines 12, 13, 14, and 16b	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") is part of the Indiana University Health, Inc. ("IU Health") system. As the sole member and controlling parent of Indiana University Health Ball Memorial Hospital, Inc., the sole member and controlling parent of IU Health Blackford Hospital, IU Health and its Board of Directors have mandated that certain policies be followed to ensure greater standardization throughout the system. Thus, IU Health Blackford Hospital's Board of Directors was not required to separately adopt a conflict of interest, whistleblower, document retention and destruction and joint venture policies because IU Health's Board of Directors had already adopted and required these policies to be followed by its subsidiaries.
Part VI, Section B - Policies	Line 12c - Conflict of Interest Policy	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") has a Conflict of Interest Policy, the purpose of which is to protect IU Health Blackford Hospital's interests when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer, director, or employee. Each employee that is manager level or above, including officers and directors, is required to annually sign a statement which affirms that such person (1) has received a copy of the conflict of interest policy; (2) has read and understands the policy; (3) has agreed to comply with the policy; and (4) understands and acknowledges that the Corporation is a tax-exempt organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. If an interest is disclosed, the form requires that the discloser's supervisor sign the form to indicate his/her knowledge and approval of the interest. The form is then submitted to Corporate Compliance for review. If the disclosure is by the President, it is reviewed by the board chairman for approval. If the disclosure is by a member of the board of directors, the IU Health Ball Memorial Hospital's General Counsel/Chief Compliance Officer reviews the disclosures and determines whether to consent. Board members with a conflict of interest cannot participate in any decision related to that conflict. Breach of the conflict of interest policy, including failure to complete and update the questionnaire and failure to disclose an interest that should be disclosed, may subject an individual to disciplinary action, including dismissal.
Part VI, Section B - Policies	Line 15 - Process for Determining Compensation	The President/Top Management Official for Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") is employed by Indiana University Health Ball Memorial Hospital, Inc. ("IU Health Ball Memorial Hospital"). Indiana University Health, Inc. ("IU Health"), as the sole member and controlling parent of IU Health Ball Memorial Hospital, has implemented the following process for determining compensation: 1. The Board of Directors has established a Committee on Personnel and Compensation. The individuals on this Committee are made up of individuals who are on the Board and who do not have a conflict of interest with Indiana University Health, Inc. ("IU Health"). There are no physicians or employees on this Committee. This Committee develops and reviews annually the executive compensation philosophy, market analysis as to comparability and reasonableness. One of the purposes of this Committee is to review, approve and make recommendations regarding executive compensation and benefits to the IU Health Board. As deemed appropriate, this Committee also reviews the same detail with the Committee on Finance. The Committee on Finance is represented by certain members of the Board as well. 2. Each year the Committee on Personnel and Compensation engages an outside compensation consulting firm to conduct a compensation and benefits study for all senior vice presidents and above. The current compensation advisor is the Hay Group. Hay Group performs an independent compensation survey. The relevant comparability data includes: compensation and benefit levels paid by similarly situated organizations (both governmental and tax exempt) for functionally comparable positions as well as the availability of similar services in the geographic area. The Committee reviews the entire compensation package including: base compensation, short term and long term incentive plans, basic health and welfare benefits, qualified and nonqualified plans as well as any additional fringe benefits. Further, Hay Group will provide recommendations based upon the reasonable compensation information as it relates to salary increases, bonuses and benefits that are consistent with the compensation philosophy of the Committee. A separate analysis using the same methodology is done for the President. 3. The Committee reviews the salary survey and, if appropriate, makes recommendations on increases in salary and any changes in bonuses or benefits. The Committee's goal is to ensure that the total compensation and benefits package is reasonable based upon the independent data provided by Hay Group. The Committee votes on any changes in compensation or benefits. This review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval of compensation. 4. The Board reviews the report prepared by the Hay Group as well as the recommendations of the Committee on Personnel and Compensation as to changes in compensation approved by the Committee. As requested, the Committee on Finance also provides its review of recommendations on changes in executive compensation and benefits. This review, discussion and vote are documented in the minutes. 5. The Board then reviews the recommendations provided by the Committee on Personnel and Compensation and votes on the changes as well. No additional compensation or benefits are paid to the executives until the changes have been approved by the Committee and the Board. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval of compensation. The IU Health's General Counsel prepares a formal written opinion reviewing the compensation and benefits approval process, comparing that process to the Intermediate Sanctions Test of IRC Section 4958 and, if the facts warrant, provides comments regarding the compensation and benefits approval process as this relates to meeting the requirements for a rebuttable presumption of reasonableness as provided in the Intermediate Sanctions Test. 6. After the end of each year, the Committee and Board also reviews the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executive and the Board. These achievements may also be reviewed with the Committee on Finance. The Board, at its discretion, may approve bonus payments based upon the achievement of the goals and the compensation survey. The discussion and vote of the Committee and Board is documented in the minutes for each such meeting. The bonuses are not paid until approval is made by the Board. 7. The Committee on Personnel and Compensation and Audit Committee also review the required Form 990 disclosures related to executive compensation and benefits as well as compensation practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. IU Health Blackford Hospital has a yearly process in place to determine the compensation for the other officers and key employees. IU Health Blackford Hospital uses an independent compensation consultant who utilizes a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. The independent compensation consultant provides IU Health Blackford Hospital with recommended compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Management decisions with regard to determining compensation are subject to the review and approval of the Compensation Committee and Board of Directors.
Part VI, Section C - Disclosure	Line 19 - Public Disclosure	Indiana University Health Blackford Hospital, Inc.'s ("IU Health Blackford Hospital") Articles of Incorporation are available for public inspection through the Indiana Secretary of State's web-site. IU Health Blackford Hospital's conflict of interest procedures are disclosed on the Form 990, Schedule O. IU Health Blackford Hospital is a consolidated subsidiary in the consolidated financial statements for Indiana University Health, Inc. ("IU Health"). The consolidated financial statements for IU Health are available to the public through its bond filings.
Part VII, Section A - Governing Body and Management	Line 1a, Column (B) - Average hours per week	Michael E. Haley is the President for Indiana University Health Ball Memorial Hospital, Inc. ("IU Health Ball Memorial Hospital") and devotes 55 hours per week. Harold L. Berfiend was the CFO and COO during different portions of 2011 for IU Health Ball Memorial Hospital and devoted 55 hours per week. Steven J. West is the President for Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital"), but is paid by IU Health Ball Memorial Hospital, the tax-exempt parent organization for IU Health Blackford Hospital for this position. He devotes 55 hours per week. Thomas M. Lee, M.D. is a physician for Indiana University Health Ball Memorial Physicians, Inc. and devotes 35 hours a week.
Part XI - Reconciliation of Net Assets	Line 5 - Other Changes in Net Assets or Fund Balances	During 2011, Indiana University Health Blackford Hospital, Inc. recorded the following other changes in net assets or fund balances: Unrealized Gain/(Loss) on Investments: -16,455 Book/Tax Differences - Partnerships: 20,187
Form 5471 - Information Return of U.S. Persons With Respect	To Certain Foreign Corporations	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") (FEIN: 35-0867958) 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 IU Health Blackford Hospital, Inc. 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:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
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 BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

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

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
(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	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		No
(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 BLOOMINGTON INC PO BOX 1149 BLOOMINGTON,IN47403 35-1720796	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(14) IU HEALTH BMH FOUNDATION INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 31-1111784	FUNDRAISING	IN	501(C)(3)	11 I	IUHBMH	Yes
(15) IU HEALTH CARE ASSOCIATES INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1747218	HEALTHCARE	IN	501(C)(3)	9	IUH	Yes
(16) IU HEALTH LAPORTE HOSPITAL INC PO BOX 250 LAPORTE,IN46352 35-1125434	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(17) IU HEALTH LAPORTE PHYSICIANS INC PO BOX 250 LAPORTE,IN46352 31-1070868	HEALTHCARE	IN	501(C)(3)	3	IUHLH	Yes
(18) IU HEALTH MORGAN HOSPITAL INC 2209 JOHN R WOODEN DR MARTINSVILLE,IN46151 27-3533027	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(19) IU HEALTH NORTH HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1932442	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(20) IU HEALTH PAOLI HOSP FOUNDATION INC PO BOX 499 PAOLI,IN47454 31-0992486	FUNDRAISING	IN	501(C)(3)	11 III-O	IUHP	Yes
(21) IU HEALTH PAOLI INC PO BOX 499 PAOLI,IN47454 35-2090919	HEALTHCARE	IN	501(C)(3)	3	IUHB	Yes
(22) IU HEALTH TIPTON HOSPITAL INC 1000 S MAIN ST TIPTON,IN46072 26-2772226	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(23) IU HEALTH WEST HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1814660	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(24) IU HEALTH WHITE MEMORIAL HOSPITAL INC 720 S SIXTH ST MONTICELLO,IN47960 27-3532963	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,IN46204 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

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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) BALL OUTPATIENT SURGERY CENTER LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 27-0275794	HEALTHCARE	IN	BOSCH	N/A	0	0		No	0		No	0 %
(2) BELTWAY SURGERY CENTERS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 35-2072586	HEALTHCARE	IN	IUHSC	N/A	0	0		No	0		No	0 %
(3) BLOOMINGTON ENDOSCOPY CENTERS LLC PO BOX 1149 BLOOMINGTON,IN47402 35-2117943	HEALTHCARE	IN	IUHB	N/A	0	0		No	0		No	0 %
(4) BMH OUTPATIENT SURGERY SERVICES LLC 2401 W UNIVERSITY AVE MUNCIE,IN47303 20-4567998	HEALTHCARE	IN	IUHBMH	N/A	0	0		No	0		No	0 %
(5) BOSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4147343	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(6) CARDINAL HEALTH INITIATIVES LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 30-0102702	PURCHASING	IN	IUHBMH	RELATED	51,714	37,627		No	5,277		No	4.750 %
(7) CHV FUND I LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 26-2523206	VENTURE CAPITAL	IN	IUH	N/A	0	0		No	0		No	0 %
(8) CHV FUND MANAGEMENT LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 26-2523151	VENTURE CAPITAL	IN	CHV	N/A	0	0		No	0		No	0 %
(9) CLARIAN HEALTH NETWORK LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-2055030	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(10) CLARIAN HEALTH NORTH LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 43-1980602	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(11) CLARIAN HEALTH WEST LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 43-1980611	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(12) CTF INTERNATIONAL GROWTH PORTFOLIO 280 CONGRESS ST STE 500 BOSTON,MA02210 20-0231923	INVESTMENTS	MA	IUH	N/A	0	0		No	0		No	0 %
(13) EAGLE HIGHLANDS SURGERY CENTER LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 35-2259204	HEALTHCARE	IN	EHSCH	N/A	0	0		No	0		No	0 %
(14) EHSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4147879	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(15) HEALTH VENTURE MANAGEMENT LLC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 20-5740218	MANAGEMENT	IN	IUH	N/A	0	0		No	0		No	0 %
(16) IEC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4148032	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(17) INDIANA ENDOSCOPY CENTERS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 20-8398421	HEALTHCARE	IN	IECH	N/A	0	0		No	0		No	0 %
(18) INDIANA LAKES MANAGED CARE ORG LLC 310 S MAIN ST GOSHEN,IN46526 35-1946663	HEALTHCARE	IN	GHS	N/A	0	0		No	0		No	0 %
(19) IUH SURGERY CENTERS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-2314634	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(20) MID-AMERICA SURGERY CENTER LLC 2401 W UNIVERSITY AVE MUNCIE,IN47303 35-2002953	HEALTHCARE	IN	CDHV	N/A	0	0		No	0		No	0 %
(21) ROC SURGERY LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 27-1497960	HEALTHCARE	IN	ROCSH	N/A	0	0		No	0		No	0 %
(22) ROCS HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4148369	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(23) SENATE STREET SURGERY CENTER LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 42-1709357	HEALTHCARE	IN	SSSCH	N/A	0	0		No	0		No	0 %
(24) SSSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4148167	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(25) THE HEALTHCARE GROUP LLC 1776 MERIDIAN ST STE 300 INDIANAPOLIS,IN46202 35-2067373	MANAGED CARE	IN	IUH	N/A	0	0		No	0		No	0 %

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)
(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	CJ	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

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

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 . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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 RISK RETENTION GROUP INC	Q	79,558	FMV
(2) CARDINAL HEALTH INITIATIVES LLC	R	61,750	FMV
(3)
(4)
(5)
(6)

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)	(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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

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

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: Promote wellness and improve the health status of the people of East Central Indiana and surrounding areas through patient care, health education and medical research.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	8
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	5
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	198
6	Total number of volunteers (estimate if necessary) ....	6	68
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	5,277
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	1,499

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	301,542	171,976
9	Program service revenue (Part VIII, line 2g) .........	18,594,021	20,446,759
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	7,729	46,514
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	228,027	94,868
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	19,131,319	20,760,117
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	750	800
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)	6,803,724	6,685,442
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	13,420,815	11,625,433
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	20,225,289	18,311,675
19	Revenue less expenses. Subtract line 18 from line 12.......	-1,093,970	2,448,442
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	15,153,015	15,516,478
21	Total liabilities (Part X, line 26).............	6,548,320	4,459,609
22	Net assets or fund balances. Subtract line 21 from line 20.....	8,604,695	11,056,869

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 16,515,139 including grants of $ 800 ) (Revenue $ 20,446,759 )
	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital") is a community hospital that serves the needs of area residents without regard to their ability to pay. IU Health Blackford Hospital provides unsurpassed care to the people of Blackford County, and boasts a specialty clinic, outpatient surgical services, and a paramedic-level ambulance service. At IU Health Blackford Hospital, patients and their loved ones experience superior care in a familiar community atmosphere.

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 expenses$ 16,515,139

(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
(A) Name and Title
(1) JOHN K JACKSON CHAIRMAN	5.0	X			0	0	0
(2) J NOLAN WILLMAN VICE CHAIRMAN	5.0	X			0	0	0
(3) GARY L RHOTON DIRECTOR	5.0	X			0	0	0
(4) MARK W TOWNSEND DIRECTOR	5.0	X			0	0	0
(5) MICHAEL E HALEY DIRECTOR	5.0	X			0	888,860	45,655
(6) HAROLD L BERFIEND DIRECTOR	5.0	X			0	344,451	23,423
(7) STEVEN J WEST DIRECTOR/PRESIDENT	55.0	X	X		0	147,509	20,097
(8) LARRY D GARRETT DIRECTOR/SECRETARY/TREASURER	5.0	X	X		0	0	0
(9) CHARLES L CARROLL MD PHYSICIAN	55.0			X	155,918	0	3,899
(10) THOMAS M LEE MD PHYSICIAN	25.0			X	127,308	173,843	30,687
(11) DEBRA L MCKINNIE RN RN ADMIN. SUPERVISOR	55.0			X	103,466	0	12,267

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	386,692	1,554,663	136,028

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		171,976

f	All other contributions, gifts, grants, and similar amounts not included above1f
g	Noncash contributions included in lines 1a-1f:$ 0
h	Total. Add lines 1a-1f.......			171,976
			Business Code
2a	NET PATIENT SERVICE REVENUE		621,111	20,372,351	20,372,351	0	0
b	INCOME (LOSS) FROM PARTNERSHIPS		900,099	51,714	46,437	5,277	0
c	RENT FROM RELATED 501(C)(3) ORGS.		532,000	22,694	22,694	0	0
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			20,446,759
3	Investment income (including dividends, interest
	and other similar amounts).....			48			48
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross rents	7,400
b	Less: rental expenses	0
c	Rental income or (loss)	7,400
d	Net rental income or (loss).......			7,400			7,400
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		92,932
b	Less: cost or other basis and sales expenses		46,466
c	Gain or (loss)		46,466
d	Net gain or (loss)..........			46,466			46,466
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..			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...			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..			0
Miscellaneous Revenue			Business Code
11a	CAFETERIA/FOOD SERVICE		722,210	73,398	0	0	73,398
b	VENDING		900,099	1,626	0	0	1,626
c	ALL OTHER REVENUE		900,099	12,444	0	0	12,444
d	All other revenue ....
e	Total. Add lines 11a–11d ......			87,468
12	Total revenue. See Instructions....			20,760,117	20,441,482	5,277	141,382


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			518,120	1	675
2	Savings and temporary cash investments .......			0	2	0
3	Pledges and grants receivable, net .........			0	3	0
4	Accounts receivable, net .........			1,425,540	4	1,802,840
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 ..............			142,464	8	181,023
9	Prepaid expenses and deferred charges ............			45,167	9	54,877
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	20,714,857
b	Less: accumulated depreciation. .....	10b	8,883,878	12,948,642	10c	11,830,979
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 ......			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			47,664	13	57,817
14	Intangible assets .........			10,833	14	834
15	Other assets. See Part IV, line 11 ...........			14,585	15	1,587,433
16	Total assets. Add lines 1 through 15 (must equal line 34)...			15,153,015	16	15,516,478
17	Accounts payable and accrued expenses .			2,007,837	17	984,867
18	Grants payable ..........			0	18	0
19	Deferred revenue ..........			177	19	42,410
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 ..			4,000,010	23	2,400,347
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.....			540,296	25	1,031,985
26	Total liabilities. Add lines 17 through 25.....			6,548,320	26	4,459,609
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			8,604,695	27	11,056,869
28	Temporarily restricted net assets .....			0	28	0
29	Permanently restricted net assets .....			0	29	0
	Organizations that do not follow SFAS 117, check here 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 .....			8,604,695	33	11,056,869
34	Total liabilities and net assets/fund balances .....			15,153,015	34	15,516,478