TY 2012 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
ELMER TOLIVER PSC, 14412 SMUGGLERS NOTCHFORT WAYNEIN46814	MEDICAL	258,443
SHAW DO SERVICES LLC, 18017 CHERRY WOOD LNHOMEWOODIL60430	MEDICAL	176,371
INSIGHT HEALTH CORP, PO BOX 847689DALLASTX75284	MEDICAL	123,431


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 3

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	4,248	4,248
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 ....	183,434		183,434
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	5,970,444	5,393,435	577,009
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	204,966	185,157	19,809
9	Other employee benefits .......	972,795	878,780	94,015
10	Payroll taxes ...........	439,116	387,312	51,804
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	35		35
c	Accounting ...........	15,549		15,549
d	Lobbying ...........	2,011		2,011
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	4,309,555	4,171,247	138,308
12	Advertising and promotion ....	15,113		15,113
13	Office expenses .......	151,500	112,086	39,414
14	Information technology ......	57,462	56,636	826
15	Royalties ..	0
16	Occupancy ...........	451,624	437,239	14,385
17	Travel ............	9,174	5,911	3,263
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	36,380		36,380
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	1,196,628	1,173,022	23,606
23	Insurance ..............	156,721	117,491	39,230
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	BAD DEBT	1,444,264	1,444,264	0	0
b	DRUGS AND MEDICAL SUPPLIES	1,172,097	1,172,097	0	0
c	INSTITUTIONAL DUES/LICENSES	17,593	17,593	0	0
d	NONCAPITALIZED EQUIPMENT	1,483	1,483	0	0
e	All other expenses	1,208,652	1,132,672	75,980
25	Total functional expenses. Add lines 1 through 24e	18,020,844	16,690,673	1,330,171	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 Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	675	1	600
2	Savings and temporary cash investments .........	0	2	12,794
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	1,802,840	4	2,884,931
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	181,023	8	173,225
9	Prepaid expenses and deferred charges ..........	54,877	9	88,170
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,093,625
b	Less: accumulated depreciation .....	10b	10,116,580	11,830,979	10c	10,977,045
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 .....	57,817	13	55,773
14	Intangible assets ...............	834	14	0
15	Other assets. See Part IV, line 11 ...........	1,587,433	15	779,415
16	Total assets. Add lines 1 through 15 (must equal line 34)......	15,516,478	16	14,971,953
	17	Accounts payable and accrued expenses .........	984,867	17	1,780,175
18	Grants payable .................	0	18	0
19	Deferred revenue ................	42,410	19	6,621
20	Tax-exempt bond liabilities .............	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other 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 ..	2,400,347	23	800,351
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....................	1,031,985	25	1,528,095
26	Total liabilities. Add lines 17 through 25.........	4,459,609	26	4,115,242
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	11,056,869	27	10,856,711
28	Temporarily restricted net assets ...........	0	28	0
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........	11,056,869	33	10,856,711
34	Total liabilities and net assets/fund balances ........	15,516,478	34	14,971,953

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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

2012

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 described in 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. See section 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 - Non-functionally integrated

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. 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—2011. If the organization did not check a 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—2012. 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—2011. 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) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

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 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. 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—2011. 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) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

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

2012

Name of the 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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

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) (2012)

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

2012

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, Part V, 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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

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 SchCMd Bullet

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 SchCMd Bullet

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) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable 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) 2012

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

2,011

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

2,011

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, line 5; Part II-A (affiliated group list); Part II-A, line 2; 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 2012 in the amount of $7,047 and $5,104, 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 24.60%, or $1,733 of 2012 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The IHA used 5.44%, or $278 of the 2012 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 2012 that were attributable to lobbying expenditures was $2,011.

Schedule C (Form 990 or 990EZ) 2012

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

2012

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 section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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 XIII, 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

Using the organization’s acquisition, 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 XIII.

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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (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 current year end balance (line 1g, column (a)) 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 XIII 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 ................	14,859,871	5,559,575	9,300,296
c	Leasehold improvements ............	0
d	Equipment ................	5,154,285	3,940,407	1,213,878
e	Other .................	889,145	616,598	272,547
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				10,977,045

Schedule D (Form 990) 2012

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) INTERCOMPANY RECEIVABLES (NET)				779,415








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				779,415

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes		0
SELF-INSURANCE LIABILITIES		30,713
INTEREST RATE SWAP LIABILITIES		9,449
DUE TO THIRD-PARTY PAYORS		1,315,163
PENSION AND OTHER RETIREMENT LIABILITIES		171,000
ALL OTHER LIABILITIES		1,770




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		1,528,095
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI 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 XIII.) ............	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 XIII.) ...........	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 XII 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 XIII.) ............	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 XIII.) ............	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 XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, 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. 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 2012 under GAAP as IU Health does not have any material tax contingencies that required disclosures in the footnotes.

Schedule D (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Part I

Financial Assistance 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) as a factor in determining 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 as a factor in determining 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 used factors other than FPG in determining 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, as a factor in determining 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

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..		7,213	1,340,629	0	1,340,629	8.090 %
b	Medicaid (from Worksheet 3, column a) ....		6,433	3,270,236	2,091,878	1,178,358	7.110 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .		13,646	4,610,865	2,091,878	2,518,987	15.200 %
Other Benefits		15	3,050	64,794	2,951	61,843	0.370 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	15	3,050	64,794	2,951	61,843	0.370 %
f	Health professions education (from Worksheet 5) ..	1	41	24,756	0	24,756	0.150 %
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	3	517	2,788	0	2,788	0.020 %
j	Total. Other Benefits ..	19	3,608	92,338	2,951	89,387	0.540 %
k	Total. Add lines 7d and 7j .	19	17,254	4,703,203	2,094,829	2,608,374	15.740 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing	1	40	1,763	0	1,763	0.010 %
2	Economic development
3	Community support	2	48	5,248	0	5,248	0.030 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	1	1,554	8,063	0	8,063	0.050 %
7	Community health improvement advocacy	1	58	784	0	784
8	Workforce development
9	Other
10	Total	5	1,700	15,858	0	15,858	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. Explain in Part VI the methodology used by the organization to estimate this amount. ......

496,682

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

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

8,188,282

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

7,505,308

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

682,974

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(owned 10% or more by officers, directors, trustees, key employees, and physicians—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) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	IU HEALTH BLACKFORD HOSPITAL 410 PILGRIM BLVD HARTFORD CITY,IN47348 IUHEALTH.ORG/BLACKFORD/	X	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	IU HEALTH BLACKFORD HOSPITAL
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Did the hospital facility make its CHNA report widely available to the public? .............

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	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.
11	Used FPG to determine eligibility for providing discounted care?.................	11	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.
12	Explained the basis for calculating amounts charged to patients?.................	12	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	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 website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	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?.......	15	Yes
16	Check all of the following 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)
17	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?..........	17		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)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

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.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

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) 2012

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; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
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.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

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 the IU Health Blackford Hospital and IU Health Ball Memorial Hospital websites at iuhealth.org/blackford and iuhealth.org/ball-memorial and also the IU Health statewide website iuhealth.org/getstrong. 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 $1,444,264.
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 28.37%.
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 2012, 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; child car seat safety programs, disease support groups, 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. As part of the IU Health system, IU Health hospitals and their leadership 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. IU Health contributed nearly $2 million to community-building activities in 2012, serving over 52,600 people statewide. Specifically, IU Health Blackford Hospital invested nearly $16,000 serving 1700 people in the Blackford community. Additionally, through IU Health's team member community benefit service program, Strength That Cares, team members across the state made a difference in the lives of thousands of Hoosiers. In 2012, team members: - Built 25 Habitat for Humanity home panels throughout Indiana. Three of those homes were given to victims of the Henryville, Indiana tornado. - Impacted the lives of just over 400 at-risk children by serving as camp or reading buddies in IU Health's Kindergarten Countdown program to prepare at-risk children for their first day of kindergarten.
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 2012. However, in years in which it does experience a Medicare shortfall, the Medicare shortfall that would be 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. IU Health Blackford Hospital's Medicare shortfall is attributable to reimbursements that are less than the cost of providing patient care and services to Medicare beneficiaries and does not include any amounts that result from inefficiencies or poor management. IU Health Blackford Hospital accepts all Medicare patients knowing that there may be shortfalls; therefore it has taken the position that the shortfall should be counted as part of its community benefit. Additionally, it is implied in Internal Revenue Service Revenue Ruling 69-545 that treating Medicare patients is a community benefit. Revenue Ruling 69-545, which established the community benefit standard for nonprofit hospitals, states that if a hospital serves patients with governmental health benefits, including Medicare, then this is an indication that the hospital operates to promote the health of the community.
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 assessed the healthcare needs of the areas 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	Blackford County comprises the majority of the IU Health Blackford Hospital community. It accounts for all of the primary service area (PSA) population, and 79% of the inpatient discharge population of the total community. Blackford County has higher rates of unemployment than the state of Indiana and the national average. The median household income of Blackford County is also below the Indiana state average and the national average. The county is adversely affected by a combination of chronic health conditions, low educational attainment, and the low availability of higher paying jobs. Service Area Counties: Blackford, Grant, Delaware, Jay, and Wells - Service area population in 2010: 249,387 - 79% of the IU Health Blackford's inpatient discharge population resides in Blackford County - Of the five service area counties, all except Wells County are expected to decrease in total population by 2015 - Although population is expected to decrease for all of the service area counties across almost all of the age cohorts, the 65+ population is projected to increase substantially by 2015 for all counties. - The 2011 poverty rate in Blackford County was ranked 27th highest in Indiana. - in 2012, 4% of inpatient discharges were for patients with Medicaid, 85% were for patients with Medicare, and 2% were for uninsured/self-pay patients
Schedule H, Part VI - Supplemental Information	Line 5 - Promotion of Community Health	Indiana University Health Blackford Hospital is a 15-bed, 55,000 square foot Medicare-designated critical access hospital, providing care to the people of Hartford City and surrounding communities. The Hospital campus features all-private rooms, an attached medical office building and an ambulance garage. 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 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 & effort. IU Health considers its community benefit plan as part of an overall vision for strengthening Indiana's healthcare safety net. The 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 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, the 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. In 2012, Blackford Hospital invested over $58,000 in community health improvement services, serving over 3,000 community members in their region.
Schedule H, Part VI - Supplemental Information	Line 6 - Affiliated Health Care System	IU Health Blackford Hospital's Board of Directors is composed of eight members, with six of those members being residents of Blackford County. IU Health Blackford Hospital maintains an open medical staff, to which all local qualified physicians may choose to be members. In addition, a number of physicians from near-by communities, in a variety of specialties, are members of the IU Health Blackford Hospital medical staff. IU Health Blackford Hospital is a part of the IU Health statewide healthcare system which continues to broaden its reach and positive impact throughout the state of Indiana. Indiana University 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. 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. IU Health 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 Ball Memorial, 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 in Fishers, Indiana. Although each IU Health 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 nations 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. Garden on the Go reported 18,998 transactions to thousands of community members in underserved neighborhoods across Marion County in 2012. For just $7, Garden on the Go shoppers can purchase one pound of green beans, one pound of bananas, one pound of tomatoes, three pounds of potatoes, a bunch of greens, a head of lettuce, a couple of apples and a couple of oranges. In 2012, Garden on the Go received the Indiana State Health Commissioner Award for Excellence in Public Health. The award is given to programs that contribute to promoting, protecting and providing for the health of the people of Indiana. 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 2012, 1,000 people benefited from Indy Urban Acres produce. The amount of fruits and vegetables generated by the farm and donated to Gleaners totaled 35,619 pounds. To learn about gardening and the importance of good nutrition, 1,000 children from the Indy Parks summer program visited Indy Urban Acres in 2012. The food pantry at IPS #14 serves 40-50 families each week. The produce from Indy Urban Acres helps provide fresh fruits and vegetables and expand the pantry's food supply, making it possible to better serve everyone who visits each week. Food pantry patrons enjoy sharing their recipes of dishes that use fresh produce. 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 working 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. Community access to healthcare efforts at IU Health Blackford Hospital include the following programs: Dermatologists and dermatology staff members from the IU Health Blackford Hospital Outpatient Clinic performed free skin cancer screenings for the community in May 2012. Thirty-four people were screened, and 16 were referred for further evaluation. More than 200 people attended the IU Health Blackford Hospital Community Health Fair in April. Those attending the fair took advantage of free and reduced-cost lab testing for cholesterol lipid profiles, complete blood count, chemistry profile and blood glucose. Prostate cancer screening tests were available for men. Information on breast health, colonoscopy education, infection prevention and healthy eating habits was provided to participants. 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. Falls Prevention for Older Adults Each year, one in three adults age 65 and older experiences a fall. In 2011, falls were responsible for nearly 8,000 visits to IU Health emergency departments across the state. IU Health strives to reduce the number of injuries due to falls among the older adult population by offering two unique programs. In 2012 IU Health partnered with CICOA Aging & In-Home Solutions and other area agencies on aging to conduct Safe at Home, a half-day event to assist older adults in making their homes safe and accessible for daily living. Program Highlights and Impact include: 1) Five hundred IU Health and other community volunteers made simple home modifications, such as installing bathroom grab bars, building ramps and repairing stairs to help decrease risk of accidents in the home. 2) During the October event, 128 seniors in seven IU Health communities across Indiana benefited from Safe at Home. IU Health Blackford Hospital serves as the lead agency of the Blackford County Safe Kids chapter, which works to prevent childhood injuries in the local community. The chapter hosted two car seat safety checks, and in 2012, funds were used to promote Halloween safety. K-12 Education Edu
STATE FILING OF COMMUNITY BENEFIT REPORT	990 SCHEDULE H, PART VI	IN,

Schedule H (Form 990) 2012

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

2012

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 of 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 filing organization used 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2012

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 (E) amounts for that individual.

(A) Name and Title		(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 and Title		(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)HAROLD L BERFIENDDIRECTOR (01/01 - 05/19)	(i) (ii)	0 255,645	0 43,609	0 183,272	0 17,004	0 17,283	0 516,813	0 0
(2)MICHAEL E HALEYDIRECTOR	(i) (ii)	0 479,675	0 148,262	0 104,660	0 21,020	0 29,936	0 783,553	0 0
(3)LORI A LUTHERDIRECTOR (07/26 - 12/31)	(i) (ii)	0 188,982	0 10,000	0 30,227	0 8,487	0 8,571	0 246,267	0 0
(4)STEVEN J WESTDIRECTOR/PRESIDENT	(i) (ii)	124,943 0	25,017 0	6,871 0	7,764 0	18,839 0	183,434 0	0 0
(5)CHARLES L CARROLL DOPHYSICIAN	(i) (ii)	170,534 0	0 0	0 0	4,263 0	0 0	174,797 0	0 0
(6)THOMAS M LEE MDPHYSICIAN	(i) (ii)	103,583 172,477	0 103,137	0 1,548	0 11,556	0 23,395	103,583 312,113	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Schedule J, Part I - Questions Regarding Compensation	Line 1b - Gross-Up Payments and Personal Services	Executive physicals were provided for certain board members, including Lori A. Luther, free of charge.
Schedule J, Part I - Questions Regarding Compensation	Line 3 - Compensation of the Organization's CEO/Executive Director	Steven J. West, the CEO 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 CEO. 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. For Harold L. Berfiend, $137,176 is included in column b(iii), other reportable compensation, representing the amount received under his vested 457(f) supplemental executive benefit plan. 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., 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) 2012

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

2012

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 Board of Commissioners of Blackford County. 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 COO/CFO of Indiana University Health Ball Memorial Hospital, Inc. reviewed and approved the Form 990 and related schedules. After the review and approval from the COO/CFO, a complete final copy, as filed with the Internal Revenue Service, 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	During different parts of 2012, Thomas M. Lee, M.D. devoted 55 hours per week as a Physician of Indiana University Health Blackford Hospital, Inc. and Physician of Indiana University Health Ball Memorial Physicians, Inc.
Part IX - Statement of Functional Expenses	Line 11g - Other Fees for Services	Line 11g includes amounts paid for the following: Shared Services/Professional Fees - $4,309,555

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

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

2012

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" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) 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" to 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 entity?
(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) CLARIAN TRANSPLANT INSTITUTE INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 13-4350599	HEALTHCARE	IN	501(C)(3)	9	IUH	Yes
(2) GOSHEN HEALTH SYSTEM INC 200 HIGH PARK AVE GOSHEN,IN46527 35-1974765	HEALTHCARE	IN	501(C)(3)	11 I	IUH	Yes
(3) GOSHEN HOSPITAL ASSOCIATION INC 200 HIGH PARK AVE GOSHEN,IN46527 35-6001540	HEALTHCARE	IN	501(C)(3)	3	GHS	Yes
(4) HEALTHLINC INC 714 S ROGERS ST BLOOMINGTON,IN47402 26-3571507	HEALTHCARE	IN	501(C)(3)	9	IUHB	Yes
(5) INDIANA RADIOLOGY PARTNERS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 20-1017034	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(6) INDIANA UNIVERSITY HEALTH INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1955872	HEALTHCARE	IN	501(C)(3)	3	NA		No
(7) IU HEALTH ARNETT FOUNDATION INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-6079797	FUNDRAISING	IN	501(C)(3)	11 I	IUHA	Yes
(8) IU HEALTH ARNETT INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 26-3162145	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(9) IU HEALTH BALL MEMORIAL HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-0867958	HEALTHCARE	IN	501(C)(3)	3	IUH		No
(10) IU HEALTH BALL MEMORIAL PHYSICIANS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1925641	HEALTHCARE	IN	501(C)(3)	9	IUHBMH	Yes
(11) IU HEALTH BEDFORD INC 2900 W 16TH ST BEDFORD,IN47421 23-7042323	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(12) IU HEALTH BLOOMINGTON INC PO BOX 1149 BLOOMINGTON,IN47403 35-1720796	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(13) IU HEALTH BMH FOUNDATION INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 31-1111784	FUNDRAISING	IN	501(C)(3)	11 I	IUHBMH	Yes
(14) IU HEALTH CARE ASSOCIATES INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1747218	HEALTHCARE	IN	501(C)(3)	9	IUH	Yes
(15) IU HEALTH LAPORTE HOSPITAL INC PO BOX 250 LAPORTE,IN46352 35-1125434	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(16) IU HEALTH LAPORTE PHYSICIANS INC PO BOX 250 LAPORTE,IN46352 31-1070868	HEALTHCARE	IN	501(C)(3)	3	IUHLH	Yes
(17) IU HEALTH MORGAN HOSPITAL INC 2209 JOHN R WOODEN DR MARTINSVILLE,IN46151 27-3533027	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(18) IU HEALTH NORTH HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1932442	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(19) IU HEALTH PAOLI HOSP FOUNDATION INC PO BOX 499 PAOLI,IN47454 31-0992486	FUNDRAISING	IN	501(C)(3)	11 III-O	IUHP	Yes
(20) IU HEALTH PAOLI INC PO BOX 499 PAOLI,IN47454 35-2090919	HEALTHCARE	IN	501(C)(3)	3	IUHB	Yes
(21) IU HEALTH TIPTON HOSPITAL INC 1000 S MAIN ST TIPTON,IN46072 26-2772226	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(22) IU HEALTH WEST HOSPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1814660	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(23) IU HEALTH WHITE MEMORIAL HOSPITAL INC 720 S SIXTH ST MONTICELLO,IN47960 27-3532963	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(24) IU MEDICAL GROUP FOUNDATION INC 340 W 10TH ST NO FS5100 INDIANAPOLIS,IN46202 20-1093251	FUNDRAISING	IN	501(C)(3)	11 II	NA		No
(25) METHODIST HEALTH FOUNDATION INC 1800 N CAPITOL AVE INDIANAPOLIS,IN46204 35-6043086	FUNDRAISING	IN	501(C)(3)	11 I	IUH	Yes
(26) METHODIST HEALTH GROUP INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-0876390	HEALTHCARE	IN	501(C)(3)	11 III-FI	NA		No
(27) METHODIST MEDICAL GROUP INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1945384	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(28) METHODIST OCCUP HEALTH CENTERS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1844176	HEALTHCARE	IN	501(C)(3)	3	IUH	Yes
(29) METHODIST RESEARCH INSTITUTE INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-2023710	HEALTHCARE	IN	501(C)(3)	11 I	IUH	Yes
(30) MH HEALTHCARE INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1766531	HEALTHCARE	IN	501(C)(3)	3	MMG	Yes
(31) MORGAN CO MEM HOSP FOUNDATION INC 2209 JOHN R WOODEN DR MARTINSVILLE,IN46151 35-2035162	FUNDRAISING	IN	501(C)(3)	11 II	IUHMH	Yes
(32) 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
(33) MORGAN HEALTH SERVICES INC 1949 HOSPITAL DR MARTINSVILLE,IN46151 35-1968564	HEALTHCARE	IN	501(C)(3)	3	IUHMH	Yes
(34) IU HEALTH WHITE MEMORIAL FOUNDATION PO BOX 952 MONTICELLO,IN47960 35-1671806	FUNDRAISING	IN	501(C)(3)	11 III-O	IUHWMH	Yes
(35) UNIVERSITY FAMILY PHYSICIANS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 23-7427350	HEALTHCARE	IN	501(C)(3)	9	IUHCA	Yes
(36) REHABILITATION HOSPITAL OF INDIANA INC 4141 SHORE DR INDIANAPOLIS,IN46254 35-1786005	HEALTHCARE	IN	501(C)(3)	3	MHH	Yes
(37) RHI FOUNDATION INC 4141 SHORE DR INDIANAPOLIS,IN46254 35-1932349	FUNDRAISING	IN	501(C)(3)	11 I	RHI	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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	BSCH	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	54,953	35,580		No	3,445		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) 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 %
(11) EHSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4147879	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(12) 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 %
(13) IEC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4148032	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(14) INDIANA ENDOSCOPY CENTERS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 20-8398421	HEALTHCARE	IN	IECH	N/A	0	0		No	0		No	0 %
(15) BSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-2314634	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(16) MID-AMERICA SURGERY CENTER LLC 2401 W UNIVERSITY AVE MUNCIE,IN47303 35-2002953	HEALTHCARE	IN	CDHV	N/A	0	0		No	0		No	0 %
(17) ROC SURGERY LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 27-1497960	HEALTHCARE	IN	ROCSH	N/A	0	0		No	0		No	0 %
(18) ROCS HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4148369	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(19) 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 %
(20) SSSC HOLDINGS LLC 3000 RIVERCHASE GALLERIA STE 500 BIRMINGHAM,AL35244 45-4148167	HEALTHCARE	IN	IUH	N/A	0	0		No	0		No	0 %
(21) CARDINAL HEALTH ALLIANCE LLC 1776 MERIDIAN ST STE 300 INDIANAPOLIS,IN46202 35-2067373	MANAGED CARE	IN	IUHBMH	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" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets		Yes	No
(1) BMH MEDICAL PAVILION ASSOCIATION INC 2525 W UNIVERSITY AVE MUNCIE,IN47303 35-1858408	CONDO MANAGEMENT	IN	IUHBMH	C	0	0	0 %	Yes
(2) CARDINAL HEALTH VENTURES INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 35-1611424	MANAGEMENT	IN	IUHBMH	C	0	0	0 %	Yes
(3) CHV CAPITAL INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 26-0752507	VENTURE CAPITAL	IN	IUH	C	0	0	0 %	Yes
(4) IU HEALTH ACO INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 45-4421020	HEALTHCARE	IN	IUH	C	0	0	0 %	Yes
(5) IU HEALTH BOARD DESIGNATED TRUST 400 HOWARD ST SAN FRANCISCO,CA94105 30-6309021	INVESTMENTS	IN	IUH	T	0	0	0 %	Yes
(6) IU HEALTH NTGI S&P500 FUND CF PO BOX 804358 CHICAGO,IL60680 30-6298263	INVESTMENTS	IN	IUH	T	0	0	0 %	Yes
(7) IU HEALTH PLANS INC 1776 MERIDIAN ST STE 300 INDIANAPOLIS,IN46202 26-2127080	HMO	IN	IUH	C	0	0	0 %	Yes
(8) IU HEALTH RISK PURCHASING GROUP INC 151 MEETING ST STE 301 CHARLESTON,SC29401 26-0202446	INSURANCE	IN	IUH	C	0	0	0 %	Yes
(9) IU HEALTH RISK RETENTION GROUP INC 151 MEETING ST STE 301 CHARLESTON,SC29401 20-1107674	INSURANCE	SC	IUH	C	0	0	0 %	Yes
(10) IU HEALTH SOUTHERN IN PHYSICIANS INC PO BOX 1149 BLOOMINGTON,IN47402 35-1913875	HEALTHCARE	IN	IUHB	C	0	0	0 %	Yes
(11) IUH ASSURANCE LTD PO BOX 69 SOLARIS AVE.,GRAND CAYMAN CJ 98-0395429	INSURANCE	CJ	IUH	C	0	0	0 %	Yes
(12) OCC-HEALTH REVENUE SYSTEMS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 20-3308057	WORK COMP PPO	IN	MOHC	C	0	0	0 %	Yes
(13) PARKMOR DRUG INC 1501 S MAIN ST GOSHEN,IN46526 13-1394980	PHARMACY SALES	IN	GHS	C	0	0	0 %	Yes
(14) PILR INC 200 HIGH PARK AVE GOSHEN,IN46526 20-4294750	DEVELOPMENT	IN	GHS	C	0	0	0 %	Yes
(15) RADIATION ONCOLOGY RESOURCES INC 200 HIGH PARK AVE GOSHEN,IN46526 26-2008424	HEALTHCARE	IN	GHS	C	0	0	0 %	Yes
(16) SCANS INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 45-3080392	HEALTHCARE	IN	CHVF1	C	0	0	0 %	Yes
(17) UNIVERSITY HEALTH MANAGEMENT INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 27-2891143	MANAGEMENT	IN	CHV	C	0	0	0 %	Yes
(18) UNIVERSITY HEALTH MGMT (CHINA) INC 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 27-3891311	MANAGEMENT	IN	CHV	C	0	0	0 %	Yes
(19) PROTEUO FUND LP PO BOX 31106 89 NEXUS WAY,GRAND CAYMAN CJ 98-1075227	INVESTMENTS	CJ	IUH	C	0	0	0 %	Yes

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

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 or (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 Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

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

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

Yes

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

Yes

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

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

Yes

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

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

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

Yes

s 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-s)	(c) Amount involved	(d) Method of determining amount involved
(1) INDIANA UNIVERSITY HEALTH INC	M	343,968	FMV
(2) INDIANA UNIVERSITY HEALTH INC	O	630,572	FMV
(3) IU HEALTH RISK RETENTION GROUP INC	R	111,508	FMV
(4) CARDINAL HEALTH INITIATIVES LLC	S	57,000	FMV

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) 2012

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	209
6	Total number of volunteers (estimate if necessary) .............	6	52
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	3,445
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	2,100

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	171,976	64,581
9	Program service revenue (Part VIII, line 2g) .........	20,446,759	17,645,439
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	46,514	15,712
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	94,868	100,753
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	20,760,117	17,826,485
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	800	4,248
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)	6,685,442	7,770,755
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–24e)....	11,625,433	10,245,841
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	18,311,675	18,020,844
19	Revenue less expenses. Subtract line 18 from line 12.......	2,448,442	-194,359
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	15,516,478	14,971,953
21	Total liabilities (Part X, line 26).............	4,459,609	4,115,242
22	Net assets or fund balances. Subtract line 21 from line 20.....	11,056,869	10,856,711

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 16,690,673 including grants of $ 4,248 ) (Revenue $ 17,645,439 )
	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 expenses16,690,673

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(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........................................................................ CHAIR	5.0 .......................0.0	X	X		0	0	0
(2) J NOLAN WILLMAN........................................................................ VICE-CHAIR	5.0 .......................0.0	X	X		0	0	0
(3) HAROLD L BERFIEND........................................................................ DIRECTOR (01/01 - 05/19)	5.0 .......................55.0	X			0	482,526	34,287
(4) LARRY D GARRETT........................................................................ DIR./SEC./TRE. (01/01 - 05/29)	5.0 .......................0.0	X			0	0	0
(5) MICHAEL E HALEY........................................................................ DIRECTOR	5.0 .......................55.0	X			0	732,597	50,956
(6) KRISTIE B JENNERJAHN........................................................................ DIRECTOR (05/30 - 12/31)	5.0 .......................0.0	X			0	0	0
(7) LORI A LUTHER........................................................................ DIRECTOR (07/26 - 12/31)	5.0 .......................55.0	X			0	229,209	17,058
(8) GARY L RHOTON........................................................................ DIRECTOR	5.0 .......................0.0	X			0	0	0
(9) MARK W TOWNSEND MD........................................................................ DIRECTOR	5.0 .......................0.0	X			0	0	0
(10) STEVEN J WEST........................................................................ DIRECTOR/PRESIDENT	55.0 .......................0.0	X	X		156,831	0	26,603
(11) CHARLES L CARROLL DO........................................................................ PHYSICIAN	55.0 .......................0.0			X	170,534	0	4,263
(12) ELIZABETH A DROEGE MD........................................................................ PHYSICIANS	55.0 .......................0.0			X	136,935	0	7,202
(13) THOMAS M LEE MD........................................................................ PHYSICIAN	55.0 .......................55.0			X	103,583	277,162	34,951

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	567,883	1,721,494	175,320

				(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		64,581

f	All other contributions, gifts, grants, and similar amounts not included above1f

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			64,581
			Business Code
2a	NET PATIENT SERVICE REVENUE		621111	16,958,414	16,958,414	0	0
b	ELECTRONIC HEALTH RECORDS INCENTIVE		900099	609,060	609,060	0	0
c	INCOME (LOSS) FROM PARTNERSHIPS		900099	54,956	51,511	3,445	0
d	SHARED SERVICES		541900	23,009	23,009	0	0
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			17,645,439
3	Investment income (including dividends, interest, and other similar amounts).......			712			712
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents	8,400
b	Less: rental expenses
c	Rental income or (loss)	8,400	0
d	Net rental income or (loss).......			8,400			8,400
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		15,000
b	Less: cost or other basis and sales expenses
c	Gain or (loss)		15,000
d	Net gain or (loss)..........			15,000			15,000
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		721110	69,656	0	0	69,656
b	VENDING		900099	1,459	0	0	1,459
c	ALL OTHER REVENUE		900099	21,238	0	0	21,238
d	All other revenue ....
e	Total. Add lines 11a–11d ......			92,353
12	Total revenue. See Instructions......			17,826,485	17,641,994	3,445	116,465


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			675	1	600
2	Savings and temporary cash investments .........			0	2	12,794
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			1,802,840	4	2,884,931
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			181,023	8	173,225
9	Prepaid expenses and deferred charges ..........			54,877	9	88,170
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,093,625
b	Less: accumulated depreciation .....	10b	10,116,580	11,830,979	10c	10,977,045
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 .....			57,817	13	55,773
14	Intangible assets ...............			834	14	0
15	Other assets. See Part IV, line 11 ...........			1,587,433	15	779,415
16	Total assets. Add lines 1 through 15 (must equal line 34)......			15,516,478	16	14,971,953
17	Accounts payable and accrued expenses .........			984,867	17	1,780,175
18	Grants payable .................			0	18	0
19	Deferred revenue ................			42,410	19	6,621
20	Tax-exempt bond liabilities .............			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other 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 ..			2,400,347	23	800,351
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....................			1,031,985	25	1,528,095
26	Total liabilities. Add lines 17 through 25.........			4,459,609	26	4,115,242
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			11,056,869	27	10,856,711
28	Temporarily restricted net assets ...........			0	28	0
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........			11,056,869	33	10,856,711
34	Total liabilities and net assets/fund balances ........			15,516,478	34	14,971,953