TY 2012 Form 990

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
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	1,244,625	1,244,625
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	3,960,874	2,772,612	1,188,262
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	156,347	109,443	46,904
9	Other employee benefits .......	1,292,413	904,689	387,724
10	Payroll taxes ...........	370,572	259,400	111,172
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........	35,900		35,900
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........
12	Advertising and promotion ....
13	Office expenses .......
14	Information technology ......
15	Royalties ..
16	Occupancy ...........
17	Travel ............	6,790	4,753	2,037
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	96,099	67,269	28,830
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	452,582	452,582
23	Insurance ..............
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	SUPPLIES	729,051	510,336	218,715
b	DRUGS	296,402	296,402
c	EQUIPMENT & MAINTENANCE	265,772	186,040	79,732
d	PURCHASED SERVICES	258,801	181,161	77,640
e	All other expenses	882,745	653,747	228,998
25	Total functional expenses. Add lines 1 through 24e	10,048,973	7,643,059	2,405,914	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 .............	71,038	1	84,211
2	Savings and temporary cash investments .........		2
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	2,447,617	4	1,826,751
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5
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
			6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	177,576	8	166,386
9	Prepaid expenses and deferred charges ..........	14,399	9	15,771
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	5,616,994
b	Less: accumulated depreciation .....	10b	3,842,498	1,972,987	10c	1,774,496
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 .....		12
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........	250,000	15	478,500
16	Total assets. Add lines 1 through 15 (must equal line 34)......	4,933,617	16	4,346,115
	17	Accounts payable and accrued expenses .........	1,408,515	17	1,295,800
18	Grants payable .................		18
19	Deferred revenue ................	365,445	19	254,877
20	Tax-exempt bond liabilities .............		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
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..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	897,258	23	749,235
24	Unsecured notes and loans payable to unrelated third parties ....		24
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....................	750,861	25	513,701
26	Total liabilities. Add lines 17 through 25.........	3,422,079	26	2,813,613
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	1,511,538	27	1,532,502
28	Temporarily restricted net assets ...........		28
29	Permanently restricted net assets ...........		29
	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 ...........	1,511,538	33	1,532,502
34	Total liabilities and net assets/fund balances ........	4,933,617	34	4,346,115

- TIN:

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

HARDIN COUNTY GENERAL HOSPITAL

Employer identification number

37-0702309

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 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

HARDIN COUNTY GENERAL HOSPITAL

Employer identification number

37-0702309

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 .................	17,000		17,000
b	Buildings ................	1,760,326	1,174,630	585,696
c	Leasehold improvements ............
d	Equipment ................	3,839,668	2,667,868	1,171,800
e	Other .................
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				1,774,496

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) THIRD-PARTY PAYORS				478,500








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				478,500

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes
LINE OF CREDIT		336,585
LEASE PAYABLE		164,886
THIRD-PARTY PAYORS		12,230






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		513,701
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	10,069,937
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	10,069,937
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	10,069,937

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1	10,048,973
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	10,048,973
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	10,048,973

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
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	THERE WERE NO UNCERTAIN TAX POSITIONS IDENTIFIED AND RECORDED AS A LIABILITY UPON THE ADOPTION OF ASC TOPIC 740-10-25 OR AT MARCH 31, 2013.

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

HARDIN COUNTY GENERAL HOSPITAL

Employer identification number

37-0702309

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 125.000 %

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 %

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? ..........

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

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		(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) ..	416,225		416,225	4.140 %
b	Medicaid (from Worksheet 3, column a) ....	1,843,905	1,816,689	27,216	0.270 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	2,260,130	1,816,689	443,441	4.410 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4) ..
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)
j	Total. Other Benefits ..
k	Total. Add lines 7d and 7j .	2,260,130	1,816,689	443,441	4.410 %

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
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

548,262

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. ......

274,131

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).....

4,649,277

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

4,614,313

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

34,964

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	HARDIN COUNTY GENERAL HOSPITAL PO BOX 2467 ROSICLARE,IL62982	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)

	HARDIN COUNTY GENERAL 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....................

Yes

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 13

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

Yes

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

Yes

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 ........

Yes

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: 100.0% 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: 400.0% 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	Yes
	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
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	THE HOSPITAL USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2 RATIO OF PATIENT CARE COSTTOCHARGES INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H PART III LINE 9B PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED BASED ON THE HOSPITALS EXPERIENCE WITH ALL ITS PATIENTS THEY ESTIMATE THAT IT IS LIKELY THAT UP TO 50 OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY THEREFORE 50 OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III LINE 3 AT COST THE PROVISION FOR BAD DEBTS IS CLEARLY OUTLINED ON THE STATEMENT OF OPERATIONS THE PROVISION FOR BAD DEBTS REPRESENTS UNCOMPENSATED CARE FOR PATIENTS OF WHICH A MAJORITY ARE UNINSURED OR UNDERINSURED BUT DID NOT APPLY FOR OR QUALIFY FOR CHARITY CARE
MEDICARE EXPLANATION	PART III LINE 8	THE HOSPITAL USED THE MOST RECENT COST REPORT FISCAL YEAR 2013 TO DETERMINE THE UNPAID COST OF MEDICARE UNPAID COST OF MEDICARE REPRESENTS THE COST OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM IN EXCESS OF PAYMENTS FOR THOSE SERVICES IRS REVENUE RULING 69545 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 THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	COLLECTION PRACTICES AND BAD DEBT REFERRAL AUPON ADMISSION AND REGISTRATION THE PATIENTS PAY STATUS IS DETERMINED AND RECORDED IE INSURED OR UNINSURED INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE IS DISTRIBUTED AND POSTED TO ALL PATIENTS IN THE WAITING AREAS BIF AN INDIVIDUAL IS DEEMED TO BE UNINSURED A BILL WITH THE HOSPITAL TELEPHONE NUMBER ADDRESS BRIEF EXPLANATION OF SERVICES TOTAL BILL AND INFORMATION ABOUT THE AVAILABILITY OF AN ITEMIZED BILL AND FINANCIAL ASSISTANCE IS MAILED WITHIN 30 DAYS OF DATE OF SERVICE CIN THE EVENT THE PATIENT IS DEEMED INSURED COPAYMENTS AND DEDUCTIBLES MAY BE REQUESTED AT TIME OF SERVICE CHARGES ARE POSTED AND BILLS ARE SUBMITTED TO ALL AVAILABLE INSURANCES UPON RECEIPT OF EXPLANATION OF BENEFITS OR REMITTANCE ADVICE FROM INSURANCE COMPANY ANY BALANCE REMAINING ON ACCOUNT IS PLACED IN PRIVATE PAY CLASS AND SENT AN INITIAL BILL IN THE SAME MANNER AS STEP B FOR UNINSURED NONCOVERED OR DENIED SERVICES WILL BE DEEMED AS UNINSURED SERVICES DWHEN OUTSTANDING BILLS ARE 60 DAYS OLD A SECOND STATEMENT IS MAILED WITH FINANCIAL ASSISTANCE INFORMATION INCLUDED EA THIRD STATEMENT IS MAILED AT THE END OF AN ADDITIONAL 30 DAYS WITH INFORMATION CONCERNING FINANCIAL ASSISTANCE DISCOUNTS AND PAYMENT PLANS AVAILABLE AFTER 30 MORE DAYS A FINAL DEMAND NOTICE IS MAILED 120 DAYS TOTAL AT THIS POINT THE CREDIT MANAGER ATTEMPTS TO CONTACT CUSTOMER BY PHONE AND DETERMINES WHETHER THE BILL IS COLLECTIBLE FIF AT ANY TIME DURING THE TIME OF REGISTRATION OR THROUGH THE ENTIRE COLLECTION PROCESS THE CUSTOMER NOTIFIES THE HOSPITAL ABOUT THE NEED FOR FINANCIAL ASSISTANCE THE CREDIT MANAGER WILL PROMPTLY RESPOND WITH THE PROPER APPLICATION IN 2 DAYS IF CONTACTED BY TELEPHONE AND 10 DAYS IN WRITING THE APPLICANT HAS UP TO 120 DAYS FROM THE DATE OF SERVICE TO COMPLETE THE APPLICATION AND SUBMIT IT TO THE HOSPITAL THE APPLICATION WILL BE REVIEWED FOR THE FOLLOWING 1 ELIGIBILITY REQUIRES PROOF OF NEED WHICH INCLUDES ESTIMATED VALUE OF HOUSEHOLD ASSETS LISTING OF MONTHLY OBLIGATIONS AND EXPENSES COPIES OF PAYCHECK STUBS UNEMPLOYMENT CHECKS IRS OR STATE INCOME TAX RETURNS OR ANY OTHER PROOF REQUESTED THE NUMBER OF PEOPLE IN AN ADULT PATIENTS HOUSEHOLD INCLUDES THE PATIENT THE PATIENTS SPOUSE AND ANY DEPENDENTS OR ANYONE LISTED ON THE TAX RETURN AS A DEPENDENT A WRITTEN EXPLANATION IS REQUIRED STATING THE REASON THE PATIENT IS UNABLE TO PROVIDE THE REQUESTED DOCUMENTATION VERIFYING INCOME MONTHLY EXPENSES ANDOR HOW EXPENSES ARE BEING PAID 2PERSONS MUST APPLY FOR AND BE DENIED ASSISTANCE FROM THE ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES THE HOSPITAL WILL ASSIST THE PATIENT IN THEIR APPLICATION FOR PUBLIC AID ONCE THE INFORMATION IS COMPILED AND REVIEWED BY THE CREDIT MANAGER AND A DETERMINATION IS MADE THAT THE FINANCIAL ASSISTANCE APPLICATION MEETS THE CRITERIA IT WILL BE FORWARDED TO ADMINISTRATION FOR REVIEW PROMPT DETERMINATION OF ELIGIBILITY WILL BE BASED ON INCOME LEVEL SET BY THE CURRENT DEPARTMENT OF HEALTH AND HUMAN SERVICES POVERTY GUIDELINES THE PATIENT WILL RECEIVE NOTICE AS TO THE APPROVAL OR DENIAL OF FINANCIAL ASSISTANCECHARITY CARE THE PATIENT WILL ALSO BE NOTIFIED ABOUT ANY DISCOUNTS OR PAYMENT PLANS THAT MIGHT BE AVAILABLE THE APPROVED APPLICATION IS VALID FOR THE YEAR APPLIED IN AND MUST BE RENEWED ANNUALLY 3HCGH RESERVES THE RIGHT TO PROVIDE FINANCIAL ASSISTANCE BASED ON REASONABLE JUDGMENT THE CIRCUMSTANCES FOR WHICH ASSISTANCE MAY BE PROVIDED ARE AEXPIRED PATIENTS WITH NO ESTATE BHOMELESS CRESIDENT OF SHELTER FACILITIES DRAPE VICTIM OR VICTIM OF VIOLENT CRIMES EUNEMPLOYED WITH NO BENEFITS FINABILITY TO CONTACT AS A RESULT OF BAD ADDRESS AND TELEPHONE NUMBER GNONCOVERED OR DENIED SERVICES 4HCGH HAS MADE DETERMINATION THAT PATIENTS RECEIVING THE FOLLOWING SERVICES WILL AUTOMATICALLY QUALIFY FOR 100 ASSISTANCE WITHOUT APPLICATION AMEDICAID PATIENTS DETERMINED TO BE MEDICAID QUALIFIED AFTER THE ONE YEAR TIMELY FILING PERIOD VERIFIED THROUGH HFS BMEDICAID SMALL BALANCES OF 1000 OR LESS 5HCGH UTILIZES THE FEDERAL POVERTY GUIDELINES PUBLISHED ANNUALLY BY THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE OR COMMUNITY BENEFITS ALL PATIENTS WHOSE INCOME IS LESS THAN OR EQUAL TO 125 OF THE FPL AND HAVE BEEN APPROVED FOR ASSISTANCE WILL RECEIVE 100 REDUCTION PARTIAL FINANCIAL ASSISTANCE IS PROVIDED FOR THE FOLLOWING INCOME LEVELS 2 XS FPL 50 REDUCTION IN CHARGES 3 XS FPL 30 REDUCTION OR 135 OF COST TO CHARGE RATIO WHICHEVER IS MORE MAXIMUM THAT CAN BE COLLECTED IS 25 OF INCOME 4XS FPL 10 REDUCTION IN CHARGES G AFTER REASONABLE HOSPITAL COLLECTION EFFORTS ARE MADE THE CREDIT MANAGER WILL DETERMINE IF THE UNPAID BALANCE IS SENT TO THE COLLECTION AGENCY THE FOLLOWING CRITERIA WILL NORMALLY BE USED TO ESTABLISH WHETHER AN ACCOUNT IS SENT TO COLLECTION OR ASCERTAINED AS A BAD DEBT OR AN ALLOWABLE MEDICARE BAD DEBT 1 SMALL DEBIT BALANCES FOR TEN DOLLARS 1000 ARE AUTOMATIC WRITEOFFS 2 BALANCES LOWER THAN FIFTY DOLLARS 5000 PER INDIVIDUAL PATIENT ACCOUNT WILL POSSIBLY RECEIVE ADDITIONAL COLLECTION EFFORTS BUT WILL NOT BE SENT TO THE COLLECTION AGENCY 3 ALL ACCOUNTS SUBJECT TO BE SENT TO COLLECTION AGENCY WILL FIRST BE CHECKED FOR PUBLIC AID ELIGIBILITY 4 ONCE AN ACCOUNT BECOMES A BAD DEBT OR GOES TO THE COLLECTION AGENCY THEY ARE COMPILED MONTHLY AND REVIEWED BY THE ADMINISTRATOR AND THE BOARD OF DIRECTORS AFTER APPROVAL THEY ARE WRITTEN OFF OF ACCOUNTS RECEIVABLE 5 IF A PAYMENT IS MADE TO AN ACCOUNT AFTER AR REMOVAL A CREDIT TO BAD DEBT IS MADE AND IN THE CASE OF A MEDICARE BAD DEBT A CREDIT TO MEDICARE WILL BE MADE MONTHLY AND TO THE CURRENT YEARS COST REPORT 6 ONCE AN ACCOUNT IS SENT TO COLLECTION AGENCY ALL ACCOUNTS THEY DEEM UNCOLLECTIBLE OR SURPASSES ONE YEAR AFTER THE DATE OF SERVICE WHICHEVER COMES FIRST UNLESS THERE WAS ACTIVITY ON THE ACCOUNT WITHIN THE LAST NINETY DAYS WILL BE RETURNED TO THE HOSPITAL AND CONSIDERED UNCOLLECTIBLE H MEDICARE ALLOWABLE BAD DEBTS ARE ESTABLISHED AFTER MEDICARE BILLS ARE SENT AND REMITTANCE ADVICES ARE RECEIVED INCLUDING SECONDARY INSURANCE SUPPLEMENTS AND PUBLIC AID CRITERIA FOR AN ALLOWABLE BAD DEBT INCLUDE 1 THE DEBT MUST BE RELATED TO COVERED SERVICE AND DERIVED FROM DEDUCTIBLE AND COINSURANCE AMOUNTS ONLY APPLICABLE TO PAYMENT SYSTEMS BASED ON COSTSBILLED ON A UB NOT A FEE SCHEDULE PAYMENT DEDUCTIBLE OR COINSURANCE NONCOVERED OR DENIED SERVICES CANNOT BE RECOVERED AS A MEDICARE BAD DEBT 2 ONCE A PERSON IS PROVEN TO BE INDIGENT A PUBLIC ASSISTANCE VOUCHER RECEIVED FOR PROOF OF BILLING THE BAD DEBT CAN BE IMMEDIATELY WRITTEN OFF OTHERWISE REASONABLE COLLECTION EFFORTS THE SAME AS ALL OTHER PAY CLASSES MUST BE MADE IN SOME CASES A MEDICARE BAD DEBT MAY BE TAKEN IF THE PATIENT CAN BE DETERMINED TO BE SELFPAY INDIGENT THAT IS NOT QUALIFIED FOR PUBLIC ASSISTANCE BUT INDIGENT BASED ON US HEALTH AND HUMAN SERVICES FEDERAL POVERTY GUIDELINES IN THE EVENT OF A DEATH A COPY OF THE DEATH CERTIFICATE IS REQUIRED AND PROOF OF NO ESTATE ESTABLISHED COURTHOUSE VERIFICATION NORMAL COLLECTION EFFORTS WILL BE MADE FOR A MINIMUM OF 120 DAYS 3 COLLECTIONS EFFORTS WILL BE MADE FOR A MINIMUM OF 120 DAYS FROM THE DATE OF THE INITIAL BILL AND SENT TO COLLECTION AGENCY BASED ON PRIVATE PAY COLLECTION EFFORTS ONLY AFTER THEY HAVE BEEN RETURNED FROM COLLECTION AGENCY AND DEEMED UNCOLLECTIBLE WILL THEY BE CLAIMED AS A MEDICARE BAD DEBT DOCUMENTATION OF THE PROVIDERS COLLECTION EFFORTS SHOULD BE KEPT IN THE PATIENTS FILE IN THE FORM OF BILLS FOLLOWUP LETTERS AND TELEPHONE AND PERSONAL CONTACTS 4 THE DEBT SHOULD BE CONSIDERED UNCOLLECTIBLE WHEN CLAIMED AS WORTHLESS AND SOUND BUSINESS JUDGMENT ESTABLISHED THAT THERE IS NO LIKELIHOOD OF RECOVERY AT ANY TIME IN THE FUTURE 5 ONCE AN ACCOUNT IS VERIFIED AS AN ALLOWABLE BAD DEBT IT IS SUBMITTED MONTHLY TO THE ADMINISTRATOR AND THE BOARD OF DIRECTORS FOR APPROVAL AND LISTED IN THE FOLLOWING MANNER BENEFICIARYS NAME BENEFICIARYS ACCOUNT NUMBER DATE OF THE FIRST BILL SENT TO THE PATIENT DATE OF WRITEOFF OF THE BAD DEBT AMOUNT WRITTEN OFF AS BAD DEBT DEDUCTIBLE AND COINSURANCE AMOUNTS CHARGED TO THE BENEFICIARY AND DATE OF SERVICE
NEEDS ASSESSMENT	PART VI	THE CURRENT AND FUTURE HEALTHCARE NEEDS OF THE COMMUNITIES SERVED BY HARDIN COUNTY GENERAL HOSPITAL ARE DETERMINED BY VARIOUS METHODS THE MANAGEMENT TEAM OF HARDIN COUNTY GENERAL HOSPITAL USES A LOGIC MODEL AS PART OF THE STRATEGIC PLAN THIS PROCESS IDENTIFIES AREAS OF SERVICE THAT MAY BE NONEXISTENT AND RESULTS IN PRIORITIZING NEEDS WITH TIMELINES THE MANAGEMENT TEAM WHICH INCLUDES THE ADMINISTRATOR AND HOSPITAL DEPARTMENT HEADS MEET MONTHLY TO IDENTIFY PRIORITIES AND ONGOING ISSUES REVIEW RESOURCES AND DETERMINE SERVICES THAT CAN BE IMPROVED OR ADDED THE BOARD OF DIRECTORS OF HARDIN COUNTY GENERAL HOSPITAL IS MADE UP OF REPRESENTATIVES FROM THE SERVICE AREA AND MEETS MONTHLY TO REVIEW FINANCIALS BE INFORMED OF HOSPITAL ACTIVITIES AND ASSESS THE NEEDS OF THE COMMUNITY HCGH PROFESSIONAL ADVISORY COMMITTEES FOR BOTH CRITICAL ACCESS HOSPITAL AND RURAL HEALTH CLINIC MEET ANNUALLY TO REVIEW AND ANALYZE THE OPERATIONS AND THE COMMUNITY NEEDS OF THE THOSE ORGANIZATIONS THESE COMMITTEES INCLUDE MEMBERS OF ADMINISTRATION MEDICAL STAFF A BOARD MEMBER AND A MEMBER OF THE COMMUNITY NOT EMPLOYED BY THE HOSPITAL INTERNAL SATISFACTION SURVEYS FOR THE PUBLIC ARE DISTRIBUTED AND REVIEWED QUARTERLY IN THE QUALITY IMPROVEMENT MEETINGS AND THE BOARD OF DIRECTORS MEETINGS PERIODICALLY HOSPITAL FOCUS GROUPS ARE APPOINTED TO ADDRESS ONGOING CONCERNS THAT WILL IMPROVE CARE TO THE COMMUNITY
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	INFORMATION REGARDING THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM IS POSTED IN THE EMERGENCY ROOM AND LOBBY EVERY STATEMENT SENT TO PRIVATE PAY PATIENTS HAS VERBIAGE ABOUT CONTACTING THE HOSPITAL ABOUT THE FINANCIAL ASSISTANCE PROGRAM ALL PRIVATE PAY INPATIENTS ARE VISITED BY THE FINANCIAL ASSISTANCE REPRESENTATIVE AND ALL PRIVATE PAY EMERGENCY ROOM PATIENTS ARE AUTOMATICALLY MAILED A CHARITY PROGRAM APPLICATION IN ADDITION THE FINANCIAL ASSISTANCE PROGRAM IS POSTED ON THE HOSPITAL WEBSITE ILHCGHORG AND AN APPLICATION IS AVAILABLE FOR PRINTING
COMMUNITY INFORMATION	PART VI	HARDIN COUNTY GENERAL HOSPITAL IS A 25 BED NONPROFIT CRITICAL ACCESS HOSPITAL LOCATED IN SOUTHERN ILLINOIS HARDIN COUNTY THE HOSPITAL IS LOCATED IN A RURAL HEALTH CARE PROFESSIONAL SHORTAGE AREA AS DETERMINED FOR PURPOSES OF SECTION 1886D 3D OF THE SOCIAL SECURITY ACT QUALIFIES AS A STATE DISPROPORTIONATE SHARE FACILITY UNDER THE REQUIREMENTS OF MEDICAID AND IS BEING PAID UNDER THE MEDICARE COST REIMBURSEMENT SYSTEM HARDIN COUNTY GENERAL HOSPITAL IS LICENSED BY ILLINOIS DEPARTMENT OF PUBLIC HEALTH AND IS A MEMBER OF THE ILLINOIS HOSPITAL AND HEALTH SYSTEMS ASSOCIATION THE CLOSEST MEDICAL FACILITY TO US IS 31 MILES AWAY LOCATED IN HARRISBURG IL SALINE COUNTY HARDIN COUNTY GENERAL HOSPITALS ORGANIZATIONAL STRUCTURE CONSISTS OF AN EIGHT MEMBER BOARD OF DIRECTORS COMPRISED OF RESIDENTS OF THE COMMUNITY CHIEF OF STAFF AND HOSPITAL ADMINISTRATOR THE MANAGEMENT TEAM CONSISTS OF THE ADMINISTRATOR AND SEVEN DEPARTMENT HEADS WITH DEPARTMENTAL SUPERVISORS BEING UNDER THE DIRECTION OF INDIVIDUAL DEPARTMENT HEADS OUR SCOPE OF SERVICES IS A COMPOSITE OF ALL HOSPITAL DEPARTMENTS PATIENT CARE SERVICES ARE DELIVERED THROUGH AN ORGANIZED AND SYSTEMATIC PROCESS DESIGNED TO ENSURE THE DELIVERY OF SAFE EFFECTIVE TIMELY CARE AND TREATMENT THESE SERVICES ARE PLANNED COORDINATED PROVIDED DELEGATED AND SUPERVISED BY PROFESSIONAL HEALTH CARE PROVIDERS THAT FUNCTION COLLABORATIVELY TO ACHIEVE POSITIVE PATIENT OUTCOMES THE FULL SCOPE OF PATIENT CARE IS PROVIDED ONLY BY THOSE PROFESSIONALS WHO ARE ALSO COMPETENT TO ASSESS PATIENTS AND PLAN OF CARE BASED ON FINDINGS FROM THAT ASSESSMENT SCOPE OF SERVICES INCLUDE 24 HOUR EMERGENCY ROOM COVERAGE BY 3 PHYSICIANS AND 1 ONE FAMILY NURSE PRACTITIONERBOARD CERTIFIED WE CURRENTLY HAVE 7 SEVEN NURSES THAT ARE ACLS CERTIFIED 5 FIVE ARE TRAUMA NURSE CERTIFIED AND 8 NURSES THAT HAVE PEDIATRIC ADVANCED LIFE SUPPORT PALS CERTIFICATION OTHER SCOPE OF SERVICES INCLUDE LABORATORY PROVIDES DIAGNOSTIC STUDIES ON INPATIENTS AND OUTPATIENTS THE PATIENT POPULATION SERVED MAY VARY FROM PEDIATRIC TO GERIATRIC PHARMACY INCLUDES MEDICATION DISTRIBUTION DRUG MONITORING PATIENT ASSESSMENT AND PATIENT EDUCATION RESPIRATORY UPON PHYSICIANS ORDER EVALUATES CARDIOPULMONARY FUNCTION PERFORM PRESCRIBED TREATMENTS AND ASSESSES EFFECTIVENESS OF TREATMENT SETS UP AND MAINTAINS VENTILATORS WITH PARAMETERS ORDERED BY THE PHYSICIAN RADIOLOGY PROVIDES DIAGNOSTIC STUDIES ON INPATIENTS AND OUTPATIENTS SERVICES INCLUDE BARIUM STUDIES CHEST AND ABDOMEN EXTREMITIES AND ULTRASOUND SPIRAL CT STUDIES MRI MAMMOGRAPHY BONE DENSITY REHABILITATION THERAPY PROCEDURES INCLUDE EVALUATION WHEEL CHAIR FUNCTIONAL CAPACITY TENS ROM IS KINETIC EXPRESSIVE AND RECEPTIVE LANGUAGE ORAL MOTOR MOBILIZATION TRANSFER AN GAIT TRAINING BODY MECHANICS INSTRUCTION OCCUPATIONAL THERAPY SPEECH THERAPY SOCIAL SERVICESDISCHARGE PLANNING SERVICES INCLUDE CRISIS INTERVENTION SITUATIONAL COUNSELING ASSESSMENT LINKAGE TO OTHER RESOURCES AND NURSING IN ACCORDANCE WITH THE ILLINOIS NURSING ACT OF 1987 THE TARGET POPULATION BASED ON OUR DEMOGRAPHICS FROM THE 2012 U S CENSUS BUREAU IS APPROXIMATELY 8530 RESIDENTS THIS IS THE PRIMARY TARGET GROUP OF POPE AND HARDIN COUNTIES THAT WE SERVE AN AVERAGE OF 21 OF OUR TARGET POPULATION IS 65 YEARS OF AGE AND OVER AS COMPARED TO 13 OF THE U S AVERAGE AGE DISTRIBUTION UNDER 18 YEARS OF AGE IS 204 FOR HARDIN COUNTY AND 18 FOR POPE COUNTY WITH STATE OF ILLINOIS BEING 24 UNDER 18 YEARS OF AGE MEDIAN INCOME FOR THESE TWO COUNTIES AVERAGES 33625 WITH STATE AVERAGE OF 55735 ECONOMICALLY AN AVERAGE OF 18 OF OUR POPULATION IS BELOW THE POVERTY LEVEL THE UNEMPLOYMENT RATE FOR OUR TARGET POPULATION IS APPROXIMATELY 13 AS COMPARED TO THE STATE OF ILLINOIS WHICH IS 95 SEASONALLY ADJUSTED THE CURRENT DELIVERY SYSTEM IS THE PROVISION OF NEEDED HEALTH CARE TO ANYONE REQUESTING SERVICES REGARDLESS OF THEIR FINANCIAL STATUS WHETHER IT IS INPATIENT OUTPATIENT OR EMERGENCY SERVICES OUR INPATIENT CENSUS FOR FYE 2013 WAS A TOTAL OF 495 ACUTE CARE DISCHARGES 63 SWING BED SKILLED LEVEL DISCHARGES 279 OBSERVATION BED DISCHARGES FOR 911 DISCHARGES OUTPATIENT SERVICES FOR THE SAME FISCAL YEAR END TOTALS 17385 PATIENTS SERVED WHICH INCLUDES OVER 5000 EMERGENCY ROOM DISCHARGES OUR CHARITY CARE VISITS FOR FYE 2013 TOTALED 1119 WHICH RESULTED IN A LOSS OF 642320 GROSS CHARGES IN CHARITY CARE HARDIN COUNTY GENERAL HOSPITAL ACCEPTS PATIENTS REGARDLESS OF ABILITY TO PAY AND IS AN EQUAL OPPORTUNITY EMPLOYER HCGH SUBSIDIZES THE COUNTY AMBULANCE SERVICE AS WELL AS EMA EMERGENCY MANAGEMENT AGENCY THE HOSPITAL PROVIDED FREE WATER FOOD AND TRANSPORTATION FOR PATIENTS WHO WERE STRANDED WHILE VISITING THE AREA FOR A LOCAL EVENT HARDIN COUNTY GENERAL HOSPITAL SERVES AS A TRAINING SITE FOR LPN STUDENTS FROM A LOCAL COMMUNITY COLLEGE CNA TRAINING THROUGH THE LOCAL HIGH SCHOOLS CLINICALS FOR LABORATORY CLINICALS FOR RADIOLOGY THROUGH REND LAKE COMMUNITY COLLEGE JOB SHADOWING FOR HIGH SCHOOL STUDENTS INTERESTED IN PURSUING A CAREER IN THE MEDICAL FIELD WE ALSO SERVE AS A TRAINING SITE FOR MID LEVELS AS NEEDED THROUGH AREA UNIVERSITIES FREE CPR CLASSES ARE CONDUCTED TWICE A YEAR AT THE HOSPITAL FOR MEMBERS OF OUR COMMUNITY AT HCGH CPR TRAINING IS ALSO PROVIDED TO THE TEACHERS AT THE LOCAL SCHOOL CPR CLASSES ARE PROVIDED BY OUR PATIENT EDUCATION DEPARTMENT OUR CHIEF OF STAFF CONDUCTS FREE ACLS TRAINING TWICE A YEAR AT HARRISBURG MEDICAL CENTER HARRISBURG IL HCGH IN CONJUNCTION WITH SOUTHERN SEVEN HEALTH DEPARTMENT CONDUCTS COLORECTAL SCREENINGS ANNUALLY WE PARTICIPATE AND DONATE TIME AND SUPPLIES TO THE ANNUAL AMERICAN CANCER SOCIETY RELAY FOR LIFE OUR HOSPITAL IS INVOLVED 4 FOUR TIMES A YEAR IN THE AMERICAN RED CROSS BLOOD DRIVES BY PROVIDING SPACE AND PERSONNEL FOR THIS EVENT DURING NATIONAL RURAL HEALTH WEEK IN OCTOBER OF 2012 HCGH SPONSORED A 5K WALKRUN WITH FREE T SHIRTS DISTRIBUTED TO THOSE WHO PARTICIPATED DURING THIS EVENT THE RURAL HEALTH CLINIC WHICH CONSISTS OF 2 PRIMARY CARE PHYSICIANS BOARD CERTIFIED AND 3 ADVANCED NURSE PRACTIONERS CONDUCTED AN OPEN HOUSE WITH REFRESHMENTS AND FREE SCREENINGS IE GLUCOSE BLOOD PRESSURE WE ALSO SPONSORED A COAT DRIVE AND CANNED GOODS FOR OUR LOCAL FOOD PANTRIES EDUCATIONAL MATERIALS WERE AVAILABLE FOR THIS EVENT DURING THE SCHOOL YEAR 20122013 OUR SOCIAL SERVICE DEPARTMENT PROVIDED AWARENESS PROGRAMS FOR ONE OF OUR LOCAL HIGH SCHOOLS THIS WAS DONE FOR THE ENTIRE SCHOOL ONCE A MONTH OR EVERY SIX WEEKS TOPICS INCLUDED DRUGALCOHOL ABUSE BULLYING MENTAL HEALTH STRESS THE RURAL HEALTH CLINIC STAFF WENT TO THE LOCAL SCHOOLS TO PERFORM SCHOOL PHYSICALS AT REDUCED RATES THE EDUCATION DEPARTMENT PARTICIPATES MONTHLY IN OUR SENIOR CITIZEN SITES IN THE TWO COUNTY AREAS SHE DOES PRESENTATIONS ON VARIOUS TOPICS AND CONDUCTS FREE BLOOD PRESSURE AND BLOOD SUGAR SCREENINGS
ADDITIONAL INFORMATION	PART VI	THE HOSPITAL PARTICIPATES AND DONATES TIME AND SUPPLIES TO ANNUAL AMERICAN CANCER SOCIETY RELAY FOR LIFE AND PROVIDES SPACE AND PERSONNEL FOR AMERICAN RED CROSS BLOOD DRIVES HARDIN COUNTY GENERAL HOSPITAL ACCEPTS PATIENTS REGARDLESS OF ABILITY TO PAY AND ARE AN EQUAL OPPORTUNITY EMPLOYER HCGH SUBSIDIZES THE COUNTY AMBULANCE SERVICE THE HOSPITAL PROVIDED FREE WATER FOOD AND TRANSPORTATION FOR PATIENTS WHO WERE STRANDED WHILE VISITING THE AREA FOR A LOCAL EVENT HARDIN COUNTY GENERAL SERVES AS A TRAINING SITE FOR LPN AND RN STUDENTS FROM A LOCAL COMMUNITY COLLEGE AND FOR MIDLEVELS WHO ARE WORKING ON CLINICALS THROUGH VANDERBILT UNIVERSITY FREE CPR CLASSES ARE OFFERED TO THE COMMUNITY TWICE PER YEAR AT THE HOSPITAL AND FREE CPR TRAINING WAS PROVIDED TO TEACHERS AT THE LOCAL SCHOOL IT ALSO SERVES AS A LIAISON FOR REFERRING PATIENTS TO COMMUNITY RESOURCES CHURCHES FOOD BANKS FINANCIAL ASSISTANCE ETC AND PARTICIPATES IN THE ANNUAL JOB FAIR AT SOUTHEASTERN ILLINOIS COLLEGE
HARDIN COUNTY GENERAL HOSPITAL LINE NUMBER 1 PART V LINE 3	PART V LINE 3	THIS ASSESSMENT HAS EXPLORED THE INSULAR NEEDS OF THE IDENTIFIED GROUPS BY SPECIFICALLY SEEKING INPUT FROM PERSONS WITH KNOWLEDGE OF THE SPECIFIC HEALTH CONCERNS INPUT WAS ALSO SOUGHT FROM MEMBERS OF THE COMMUNITY CHARGED PROFESSIONALLY WITH ADVANCING THE HEALTH AND EDUCATION OF THE COMMUNITY AND ALL ITS MEMBERS THOSE CONSULATED INCLUDE HOSPITAL EXECUTIVE STAFF AND AN INTERNAL WORKING GROUP THE REFERENCED COMMUNITY AND OUTSIDE RESOURCES INCLUDE 1 HARDIN COUNTY HOSPITAL ASSESSMENT 2 THE ROBERT WOOD JOHNSON FOUNDATION COUNTY HEALTH RANKINGS ROADMAPS 2012 RANKINGS ILLINOIS 3 2012 US CENSUS BUREAU
HARDIN COUNTY GENERAL HOSPITAL LINE NUMBER 1 PART V LINE 20D	PART V LINE 20D	THE HOSPITAL USED 10 WHICH IS AN AVERAGE OF ALL OF THEIR COMMERCIAL NEGOTIATED CONTRACTS

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

HARDIN COUNTY GENERAL HOSPITAL

Employer identification number

37-0702309

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? .........

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

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)DR MARCOS SUNGAPHYSICIAN	(i) (ii)	576,557			8,874		585,431
(2)DR ELADIO CHATTOPHYSICIAN	(i) (ii)	481,497			9,815		491,312

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 (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

HARDIN COUNTY GENERAL HOSPITAL

Employer identification number

37-0702309

Identifier	Return Reference	Explanation
AMENDED RETURN EXPLANATION	FORM 990, PAGE 1, ITEM B	THE FORM 990 WAS AMENDED TO COMPLETE SCHEDULE H PART V, COMMUNITY HEALTH NEEDS ASSESSMENT SECTION LINES 1 THROUGH 8C AND ATTACH HARDIN COUNTY GENERAL HOSPITAL'S IMPLEMENTATION STRATEGY.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	BOARD MEMBERS ARE PROVIDED A COPY OF THE FORM 990 FOR THEIR REVIEW AND COMMENT BEFORE IT IS FILED.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	EACH DIRECTOR AND KEY EMPLOYEE IS GIVEN A QUESTIONNAIRE THAT INCLUDES ASKING THEM TO DISCLOSE ANY APPLICABLE CONFLICTS OF INTEREST. THIS IS DONE ON AN ANNUAL BASIS AND ENFORCEMENT IS DONE ON A PER INCIDENT BASIS, WITH ALL ASPECTS OF THE CONFLICT TAKEN INTO CONSIDERATION.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	BOARD OF DIRECTORS PERFORMS A FORMAL REVIEW PROCESS USING REGIONAL WAGE DATA FOR COMPARABLE SIZE FACILITIES.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	BOARD OF DIRECTORS PERFORMS A FORMAL REVIEW PROCESS USING WAGE DATA FROM COMPARABLE SIZE FACILITIES.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.

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:

1	Briefly describe the organization’s mission or most significant activities: PROVIDER OF HEALTH CARE SERVICES.
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	6
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	151
6	Total number of volunteers (estimate if necessary) .............	6
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	537,651	223,698
9	Program service revenue (Part VIII, line 2g) .........	10,564,307	9,245,092
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	7,624	3,868
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	612,232	597,279
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	11,721,814	10,069,937
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	7,270,491	7,024,831
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	3,895,561	3,024,142
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	11,166,052	10,048,973
19	Revenue less expenses. Subtract line 18 from line 12.......	555,762	20,964
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	4,933,617	4,346,115
21	Total liabilities (Part X, line 26).............	3,422,079	2,813,613
22	Net assets or fund balances. Subtract line 21 from line 20.....	1,511,538	1,532,502

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 7,643,059 including grants of $ ) (Revenue $ 9,248,960 )
	HARDIN COUNTY GENERAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGN, HANDICAP, AGE, OR ABILITY TO PAY. HARDIN COUNTY GENERAL HOSPITAL RECORDED 2,476 ADULT AND CHILDREN PATIENT DAYS AND 17,385 OUTPATIENT VISITS. THE EMERGENCY ROOM TREATED APPROXIMATELY 5,514 PATIENTS. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES AND FURTHER THAT THE MISSION IS TO SERVE THE COMMUNTIY WITH RESPECT TO PROVIDING QUALITY HEALTHCARE.

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 expenses7,643,059

(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) DR MARCOS SUNGA........................................................................ PHYSICIAN	68.00 .......................	X		X	576,557	0	8,874
(2) MR ROBY WILLIAMS........................................................................ CEO	45.00 .......................	X	X		123,960	0	4,958
(3) WILLIAM VERNON........................................................................ PRESIDENT	1.00 .......................	X			0	0	0
(4) WENDELL ROBINSON........................................................................ TREASURER	1.00 .......................	X			0	0	0
(5) DON JOYNER........................................................................ BOARD MEMBER	1.00 .......................	X			0	0	0
(6) KATHLEEN E ROBINSON........................................................................ BOARD MEMBER	1.00 .......................	X			0	0	0
(7) EK DOWNEY........................................................................ VICE PRESIDE	1.00 .......................	X			0	0	0
(8) GARY GROSS........................................................................ BOARD MEMBER	1.00 .......................	X			0	0	0
(9) JANIE PARKER........................................................................ CFO	45.00 .......................		X		62,611	0	2,505
(10) DR ELADIO CHATTO........................................................................ PHYSICIAN	58.00 .......................			X	481,497	0	9,815

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,244,625	26,152

(A) Name and business address	(B) Description of services	(C) Compensation
ALLIANCE HEALTHCARE35 E WACKER DR 1880CHICAGOIL60601	PORTABLE MRI	105,145




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 1

				(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

f	All other contributions, gifts, grants, and similar amounts not included above1f		223,698

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			223,698
			Business Code
2a	PROGRAM SERVICE REVENUE			9,245,092	9,245,092
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			9,245,092
3	Investment income (including dividends, interest, and other similar amounts).......			3,868	3,868
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss)..........
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..
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...
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..
Miscellaneous Revenue			Business Code
11a	EHR INCENTIVE			536,598			536,598
b	REBATES			36,260			36,260
c	SITE FEES			10,677			10,677
d	All other revenue ....			13,744			13,744
e	Total. Add lines 11a–11d ......			597,279
12	Total revenue. See Instructions......			10,069,937	9,248,960		597,279


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			71,038	1	84,211
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			2,447,617	4	1,826,751
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5
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
					6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			177,576	8	166,386
9	Prepaid expenses and deferred charges ..........			14,399	9	15,771
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	5,616,994
b	Less: accumulated depreciation .....	10b	3,842,498	1,972,987	10c	1,774,496
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			250,000	15	478,500
16	Total assets. Add lines 1 through 15 (must equal line 34)......			4,933,617	16	4,346,115
17	Accounts payable and accrued expenses .........			1,408,515	17	1,295,800
18	Grants payable .................				18
19	Deferred revenue ................			365,445	19	254,877
20	Tax-exempt bond liabilities .............				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
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..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			897,258	23	749,235
24	Unsecured notes and loans payable to unrelated third parties ....				24
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....................			750,861	25	513,701
26	Total liabilities. Add lines 17 through 25.........			3,422,079	26	2,813,613
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			1,511,538	27	1,532,502
28	Temporarily restricted net assets ...........				28
29	Permanently restricted net assets ...........				29
	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 ...........			1,511,538	33	1,532,502
34	Total liabilities and net assets/fund balances ........			4,933,617	34	4,346,115