TY 2015 Form 990

- 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.
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Attach to Form 990 or Form 990-EZ.
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Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 (Form 990 or 990-EZ))

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 in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ..............

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

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.)..
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 section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2015. 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—2014. 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—2015. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. 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 VI 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) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.) ..
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 section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. 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—2014. 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) 2015

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2015 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2015	(iii) Distributable Amount for 2015
1 Distributable amount for 2015 from Section C, line 6
2 Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2015:
a
b
c
d From 2013.......
e From 2014.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2015 distributable amount
i Carryover from 2010 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2015 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2015 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2016. Add lines 3j and 4c.
8 Breakdown of line 7:
a
b
c Excess from 2013.......
d From 2014.......
e From 2015.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

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.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) 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), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions 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 an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled 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 totaling $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 its Form 990PF, Part I, line 2, 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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 3

Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC		Employer identification number 01-0646166

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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 4


Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC			Employer identification number 01-0646166
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ 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) (2015)

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

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), 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-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(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) 2015

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 on 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

1,342

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

1,342

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

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Schedule C, Part II-B, Line 1i - Other Activities	IU Health Blackford Hospital paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2015 in the amount of $5,281 and $2,727, 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 22.80%, or $1,204 of the 2015 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The IHA used 5.05%, or $138 of the 2015 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 2015 that were attributable to lobbying expenditures was $1,342.

Return Reference

Explanation

Schedule C, Part II-B, Line 1i - Other Activities

IU Health Blackford Hospital paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2015 in the amount of $5,281 and $2,727, 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 22.80%, or $1,204 of the 2015 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The IHA used 5.05%, or $138 of the 2015 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 2015 that were attributable to lobbying expenditures was $1,342.

Schedule C (Form 990 or 990EZ) 2015

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," on 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.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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" on Form 990, Part IV, line 6.

			(a) Donor advised funds	(b) Funds and other accounts

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of 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" on 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, 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" on 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)

Revenue included on 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:

Revenue included on 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) 2015

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" on 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


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?

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" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the 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 on 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" on 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.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land ...	190,324		190,324
b	Buildings	15,007,745	7,411,013	7,596,732
c	Leasehold improvements
d	Equipment ...	5,170,282	4,010,023	1,160,259
e	Other ...	299,428	279,081	20,347
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				8,967,662

Schedule D (Form 990) 2015

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11b. 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
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
INTERCOMPANY PAYABLES (NET)	242,834
SELF-INSURANCE LIABILITIES	25,885
DUE TO THIRD-PARTY PAYORS	2,115,825
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	2,384,544
2. Liability for uncertain tax positions. 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) 2015

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 (losses) 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. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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

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.

Return Reference	Explanation
Schedule D, Part X, Line 2 - FIN 48 (ASC 740) Footnote	IU Health Blackford Hospital is a subsidiary in the consolidated financial statements of Indiana University Health, Inc. ("IU Health"). IU Health adopted FIN 48 in 2007. No disclosures were required in 2015 under GAAP as IU Health does not have any material tax contingencies that required disclosures in the footnotes.

Schedule D (Form 990) 2015

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" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used 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? . . . . . .

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) . . .		1,375	790,403		790,403	5.470 %
b	Medicaid (from Worksheet 3, column a) . . . . .		2,391	2,660,341	347,885	2,312,486	16.000 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .		3,766	3,450,744	347,885	3,102,889	21.470 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	14	2,851	121,383	3,540	117,843	0.820 %
f	Health professions education (from Worksheet 5) . . .	2	30	22,143	15	22,128	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) . . . .	1		1,837		1,837	0.010 %
j	Total. Other Benefits . .	17	2,881	145,363	3,555	141,808	0.980 %
k	Total. Add lines 7d and 7j .	17	6,647	3,596,107	351,440	3,244,697	22.450 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015

Schedule H (Form 990) 2015

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	2	167	1,803	1,803	0.010 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	2	1,540	7,599	7,599	0.050 %
7	Community health improvement advocacy	1	61	4,511	4,511	0.030 %
8	Workforce development
9	Other
10	Total	5	1,768	13,913	13,913	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. ......

437,436

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).....

8,458,493

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

7,639,052

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

819,441

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) 2015

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, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	IU HEALTH BLACKFORD HOSPITAL 410 PILGRIM BLVD HARTFORD CITY,IN47348 HTTP://IUHEALTH.ORG/BLACKFORD/ 15-005101-1	X	X	X	X

Schedule H (Form 990) 2015

Page 4

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 letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

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 12......................

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 significant 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 Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 15

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

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 (list url): SEE PART V, SECTION C

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 15

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): SEE PART V, SECTION C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, 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) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

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

Yes

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.% and FPG family income limit for eligibility for discounted care of 400.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

SEE PART V, SECTION C

The FAP application form was widely available on a website (list url):

SEE PART V, SECTION C

A plain language summary of the FAP was widely available on a website (list url):

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

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 all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

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 individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

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

Yes

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (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 individuals regarding the individuals’ bills

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

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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 Section C)

Other (describe in Section C)

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 Section C)

During the tax year, did the hospital facility charge any FAP-eligible individual 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 Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Schedule H, Part V, Section B, Line 5 - Input from Community	IU Health Blackford's approach to gathering qualitative data for its CHNA consisted of a multi-component approach to identify and verify community health needs for the IU Health Blackford Hospital service area. This included the following components: 1. Hosting a community conversation focus group with public health officials and community leaders in attendance to discuss the healthcare needs of the service area and what role IU Health Blackford Hospital could play in addressing the identified needs. 2. Surveying the community at large through the hospital's website, with special effort to gather input from low income, uninsured, or minority groups. To obtain a more complete picture of the factors that play into the Blackford County community's health, input from local health leaders was gathered through a focus group session lasting three hours. IU Health Blackford Hospital representatives mailed letters and made follow-up telephone calls inviting public health officials and community leaders to attend the focus group discussion, paying special attention to including organizations that represent the interest of low-income, minority and uninsured individuals. The goal of soliciting these leaders' feedback was to gather insights into the quantitative data that may not be easily identified from the secondary statistical data alone. Leaders provide insights into the quantitative data and looked for needs not easily identified from the data. Attendees who participated in the focus group included: Robyn Clamme - Nurse, Blackford County Health Department Scot Croner - Superintendent, Blackford County Schools Ben Hodgin - Mayor, City of Blackford Ted Leas - Regional President, Citizens State Bank Carol Robles - Administrator/Co-Owner, Hearts with Integrity Lori Skidmore - Family Practice Physician, Health Officer, Blackford County Health Department Steve West - CEO, IU Health Blackford Hospital Upon arrival to the focus group, participants were asked to list five health needs, which should be prioritized in their opinion, for the Blackford County community served by IU Health Blackford Hospital. These responses were collected and aggregated into a comprehensive list of identified needs to be further discussed later in the session and ranked for severity of need within the community. IU Health Blackford Hospital facilitators then provided participants with a presentation featuring the mission of IU Health Blackford Hospital, current outreach priorities, and local health data, including demographics, insurance information, poverty rates, county health rankings, causes of death, physical activity, chronic conditions, preventive behaviors, and community needs index. Upon completion of the data presentation, IU Health Blackford Hospital facilitated a discussion on the comprehensive list of identified needs from earlier in the session. The objective of this method was intended to inspire candid discussions prior to a second identification of five prioritized health needs by each participant. The votes on the five prioritized health needs were tallied and final input from the group was encouraged during this process in order to validate the previously identified needs. Following additional discussion, participants were also asked to address what they thought the role of the IU Health Blackford Hospital could be in meeting the local health needs.
Schedule H, Part V, Section B, Line 7a - CHNA Website	A copy of IU Healths CHNA is available on its website at the following URL: http://iuhealth.org/about-iu-health/in-the-community/
Schedule H, Part V, Section B, Line 10a - Implementation Strategy Website	A copy of IU Healths CHNA implementation strategy is available on its website at the following URL: http://iuhealth.org/about-iu-health/in-the-community/
Schedule H, Part V, Section B, Line 11 - Addressing Identified Needs	IU Health Blackford Hospital prioritized and determined which of the community health needs identified in its most recently conducted CHNA were most critical for it to address by using the Hanlon Method of prioritization. This method prioritizes identified needs based upon the prevalence and severity of the need and the effectiveness of interventions available to address the needs. Based upon the Hanlon Method of prioritization, IU Health Blackford Hospital selected the following five needs to be addressed: - Obesity - Infant Health Factors - Mental Health and Substance Abuse - Tobacco and Smoking - Access to Healthcare Obesity IU Health Blackford Hospital's implementation strategy to address the identified need of Obesity includes the following: - Evaluate continuation of IU Health strong school grants to increase the amount of daily physical activity of students - Research investment in farm to table, community gardens, and other food initiatives to provide access to healthy and affordable food - Work with community partners to develop a broad-based collective impact model health coalition targeted to improved nutrition and increased physical activity - Introduce IUH providers to YMCA Diabetes Prevention program - Support for YMCA 7th and 8th Grade free membership initiative - Expand community programming offerings, including video modules for education, walking track promotion at events - Support for walking programs and initiatives including Walk Indiana Infant Health Factors IU Health Blackford Hospital's implementation strategy to address the identified need of infant health factors includes the following: - Provide expertise and resources for continued operation of Fetal Infant Mortality Review Program and Community Action Teams related to infant health - Offer Pack-n-play infant beds plus Halo Sleep sacks in conjunction with educational programming to families at risk for unsafe sleep practices - Collaborate with community partners to promote ABC's of safe sleep in key locations - Introduce IUH pre-natal practitioners to the Nurse Family Partnership Program - Provide two family medicine doctors and a resident rotation at a subsidized local federally qualified health center open door health services to expand obstetrics capacity to serve low income residents Mental Health and Substance Abuse IU Health Blackford Hospital's implementation strategy to address the identified need of mental health and substance abuse includes the following: - Examine expansion of the academic health center's teen texting pilot project to other IU Health communities and more fully develop current relationships with Mental Health of America Indiana and the National Alliance on Mental Illness - Research new partnerships with statewide community organizations, state and county government offices providing evidence-based programs and services - Family Medicine Residency SBIRT screening. SBIRT is an approach to the delivery of early intervention and treatment to people with substance abuse disorders and those at risk of developing these disorders - Provide support for substance abuse teaching in schools, particularly middle schools and Pride Team initiatives - Elevate involvement with the Delaware County Prevention Council Tobacco and Smoking IU Health Blackford Hospital's implementation strategy to address the identified need of tobacco and smoking includes the following: - Work with community partners to develop a broad based collective impact model health coalition targeted to reduced tobacco use - Widely publicize 1-800-QUIT-NOW line to patients and families, prepare additional handouts specific to certain populations (i.e. parents with newborns) Access to Healthcare IU Health Blackford Hospital's implementation strategy to address the identified need of access to healthcare includes the following: - Continue to identify collaborative partners and coordinate efforts, leveraging resources - Investigate impact of coordinating and promoting health education - Healthcare education and health insurance enrollment assistance to community members in low-income neighborhoods - Explore strategies to access affordable healthcare including providing vaccinations and health screenings - Leverage resources to expand office/clinic hours at partnering clinics - Investigate potential of advanced community screenings that tie back to a physician navigator, or financial navigator at the event - Explore additional opportunities for a specialty clinic at Blackford Hospital Also, based upon the Hanlon Method of prioritization, the following identified community health needs were not chosen as one of the needs to be addressed: - Prenatal health - Chronic disease - Injury prevention After completing a gap analysis, IU Health Blackford Hospital determined that the severity of and lack of resources available to address the five needs chosen to be addressed outweighed the severity of and resources available to address the three needs not chosen.
Schedule H, Part V, Section B, Line 13b - Income Level Other than FPG	In addition to FPG, IU Health Blackford Hospital may take into consideration a patient's income and/or ability to pay in calculation of a financial assistance award.
Schedule H, Part V, Section B, Line 13h - Other FAP Factors	IU Health Blackford Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. Alternate Sources of Assistance When technically feasible, a patient will be required to exhaust all other state and federal assistance programs prior to receiving an award from IU Healths Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowners, must exhaust all insurance benefits prior to receiving an award from IU Healths Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to their insurance provider at the request of IU Health. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award to which IU Health is entitled. Said patients may be asked to complete a financial assistance application. 2. Presumptive Financial Assistance Eligibility Patients who are deemed to be presumptively eligible for Financial Assistance will receive a Financial Adjustment to their final statement balance based on the patients individual scoring criteria. Patients are considered to be presumptively eligible for Financial Assistance if the financial need has been determined by the following third parties: Eskenazi Health, formerly Wishard Memorial Hospital, Project Health, Indiana Childrens Special Health Care Services, Medicaid, Out-of-State Medicaid, Healthy Indiana Plan, or Volunteers in Medicine. Patients are also considered to be presumptively eligible if they are pending Medicaid approval or have a hospital bill with a maximum balance to be determined by the Financial Assistance Committee and who meet certain risk segmentation scoring criteria. 3. Additional Considerations Financial Assistance may be granted to a deceased patients account if said patient is found to have no estate. Additionally, IU Health Blackford Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance application.
Schedule H, Part V, Section B, Line 16a - FAP Website	A copy of IU Health Blackford Hospital FAP is available at the following URL: http://iuhealth.org/patients/my-iu-health/billing-services/financial-assis tance/
Schedule H, Part V, Section B, Line 16b - FAP Application Website	A copy of IU Health Blackford Hospitals FAP Application is available at the following URL: http://iuhealth.org/patients/my-iu-health/billing-services/financial-assis tance/
Schedule H, Part V, Section B, Line 16i - Other Measures to Publicize	IU Health Blackford Hospital takes several other measures to publicize its FAP within the community. These measures include the following: 1. Signs are posted in appropriate acute care settings such as the emergency department and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 2. IU Health Blackford Hospital includes a plain language description of its FAP with all patient bills and statements of services. 3. IU Health Revenue Cycle Services representatives are available via telephone Monday through Friday, excluding major holidays, from 8 a.m. to 7 p.m. (Eastern Time) to address questions related to Financial Assistance. 4. IU Health Revenue Cycle Services educates its patient facing team members of its FAP and the process for referring patients to the Program.
Schedule H, Part V, Section B, Line 22d - Other Determination of Charges	IU Health Blackford Hospital limits the amounts charged for Emergency or other Medically Necessary Services provided to individuals eligible for assistance under its FAP to not more than amounts generally billed to individuals who have insurance coverage for such care. The basis for calculating the amount charged to all patients, including those who are eligible for Financial Assistance, is derived through the use of a chargemaster or physician fee schedule and are uniformly applied. All additional discounts required by insurance contract or IU Health Blackford Hospitals FAP are applied to the chargemaster or physician fee schedule calculated amount. IU Health Blackford Hospital does not use gross charges in the calculation of the amount to charge a Financial Assistance eligible patient.

Schedule H (Form 990) 2015

Page 8

Part VFacility Information (continued)

Section D. 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?1
Name and address		Type of Facility (describe)
1	IUH Blackford Hosp Rehab Services 400 Pilgrim Blvd Ste 100 Hartford City,IN47348	Diagnostic and Other Outpatient
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
Schedule H, Part I, Line 3c - Other Factors Used in Determining Elig.	IU Health Blackford Hospital uses several factors other than Federal Poverty Guidelines ("FPGs") in determining eligibility for free or discounted care under its FAP. These factors include the following: 1. Indiana Residency Requirement IU Health Blackford Hospital only makes Financial Assistance available to residents of the State of Indiana. IU Health Blackford Hospital employs the same residency test as set forth in Indiana Code 6-3-1-12 to define as resident any individual who was domiciled in Indiana during the taxable year, or any individual who maintains a permanent place of residence in this state and spends more than one hundred eighty-three (183) days of the taxable year in Indiana. 2. Alternate Sources of Assistance When technically feasible, patients must exhaust all other state and federal assistance programs prior to receiving an award from IU Health Blackford Hospitals Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowners, must exhaust all insurance benefits prior to receiving an award from IU Health Blackford Hospitals Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to their insurance provider at the request of IU Health Blackford Hospital. Eligible patients who receive medical care from IU Health Blackford Hospital as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award to which IU Health Blackford Hospital is entitled. Said patients may be asked to complete a financial assistance application. 3. Presumptive Financial Assistance Eligibility Patients who are deemed to be presumptively eligible for Financial Assistance will receive a Financial Adjustment to their final statement balance based on the patients individual scoring criteria. Patients are considered to be presumptively eligible if the financial need has been determined by the following third parties: Eskenazi Health, formerly Wishard Memorial Hospital, Project Health, Indiana Childrens Special Health Care Services, Medicaid, Out-of-State Medicaid, Healthy Indiana Plan, or Volunteers in Medicine. Patients may also be considered presumptively eligible if they are pending Medicaid approval or have a hospital bill with a maximum balance to be determined by the Financial Assistance Committee and who meet certain risk segmentation scoring criteria. 4. Additional Considerations Financial Assistance may be granted to a deceased patients account if said patient is found to have no estate. IU Health Blackford Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance Application. A patients income and/or ability to pay may be taken into consideration in the calculation of a financial assistance award. 5. Patient Assets IU Health Blackford Hospital will consider patient Assets in the calculation of a patients true financial burden. A patients primary residence and one (1) motor vehicle will be exempted from consideration in most cases. IU Health Blackford Hospital will apply the definitions set for in Indiana Administrative Code 405 IAC 2-3-15 to define a patients primary residence and motor vehicle. A patients primary residence is defined as the patients principal place of residence. The patients primary residence will be excluded from a patients extraordinary asset calculation so long as the patients equity is less than five-hundred thousand dollars ($500,000) and the home is not occupied by the patients spouse or child under twenty-one (21) years of age. One (1) motor vehicle, regardless of its fair market value, may be excluded in limited circumstances defined in Indiana Administrative Code 405 IAC 2-3-15(d)(6). IU Health Blackford Hospital reserves the right to adjust a patients Federal Poverty Level ("FPL") if the patient demonstrates a claim or clear title to any extraordinary Asset not excluded from consideration under the above guidance. IU Health Blackford Hospital will not seek the title to discovered Assets without the express authorization of the Financial Assistance Committee.
Schedule H, Part I, Line 6a - C.B. Report Prepared by a Related Org.	IU Health Blackford Hospitals community benefit and other investments, encompassing its total community investment, are included in the IU Health Community Benefit Report which is prepared on behalf of and includes IU Health and its related hospital entities in the State of Indiana ("IU Health Statewide System"). The IU Health Community Benefit Report is made available to the public on IU Healths website at http://iuhealth.org/communitybenefit/. The IU Health Community Benefit Report is also distributed to numerous key organizations throughout the State of Indiana in order to broadly share the IU Health Statewide Systems community benefit efforts. It is also available by request through the Indiana State Department of Health or IU Health.
Schedule H, Part I, 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 $1,234,996.
Schedule H, Part I, Line 7 - Total Community Benefit Expense	Schedule H, Part I, Line 7, Column (f), Percent of Total Expense, is based on column (e) Net Community Benefit Expense. The percent of total expense based on column (c) Total Community Benefit Expense, which does not include direct offsetting revenue, is 24.88%.
Schedule H, Part II - Promotion of Health in Communities Served	IU Health Blackford Hospital is a subsidiary of IU Health. IU Health participates in a variety of community-building activities that address the social determinants of health in the communities it serves. IU Health and its related hospital entities across the State of Indiana ("IU Health Statewide System") invest in economic development efforts across the state, collaborate with like-minded organizations through coalitions that address key issues, and advocate for improvements in the health status of vulnerable populations. This includes making contributions to community-building activities by providing investments and resources to local community initiatives that addressed economic development, community support and workforce development. Several examples include IU Healths support of the following organizations and initiatives that focus on some of the root causes of health issues, such as lack of education, employment and poverty: - Blackford County Health Communities Coalition - Early Learning Indiana - Starfish Initiative - United Way Additionally, through the IU Health Statewide Systems team member community benefit service program, "Strength That Cares", team members across the state make a difference in the lives of thousands of Hoosiers every year.
Schedule H, Part III, Line 2 - Methodology Used to Est. Bad Debt Exp.	The bad debt expense of $437,436 reported on Schedule H, Part III, Line 2 is reported at cost, as calculated using the cost to charge ratio methodology.
Schedule H, Part III, Line 4 - Bad Debt Expense	IU Health Blackford Hospital is a subsidiary in the consolidated financial statements of IU Health. IU Health's bad debt expense footnote is as follows: The provision for uncollectible accounts, for all payors, is recognized when services are provided based upon managements assessment of historical and expected net collections, taking into consideration 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, the significance of individual payors to outstanding accounts receivable balances, and historical write-off experience by payor category, as adjusted for collection indicators. The results of this review are then used to make any modifications to the provision for uncollectible accounts and the allowance for uncollectible accounts. In addition, the Indiana University Health System 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 the Indiana University Health System and, in certain cases, are reclassified to charity care if deemed to otherwise meet financial assistance policies of the Indiana University Health System.
Schedule H, Part III, Line 8 - Medicare Shortfall	IU Health Blackford Hospital did not have a Medicare shortfall for 2015. IU Health Blackford Hospitals Medicare reimbursements, however, are normally less than the cost of providing patient care and services to Medicare beneficiaries and do 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 any 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. The amount reported on Schedule H, Part III, Line 6 is calculated, in accordance with the Form 990 instructions, using "allowable costs" from the IU Health Medicare Cost Report. "Allowable costs" for Medicare Cost Report purposes, however, are not reflective of all costs associated with IU Healths 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 Hospitals participation in Medicare programs would significantly reduce the Medicare surplus reported on Schedule H, Part III, Line 7.
Schedule H, Part III, Line 9b - Written Debt Collection Policy	IU Health Blackford Hospitals FAP and Bad Debt Referral Policy describe the collection practices applicable to patients, including those who may qualify for financial assistance. 1. Financial Assistance Application Patients or their guarantors wishing to apply for Financial Assistance must submit a Financial Assistance Application within twenty-one (21) days of receiving their first billing statement from IU Health Blackford Hospital. Individuals other than the patient, such as the patients physician, family members, community or religious groups, social services or hospital personnel may request a Financial Assistance Application to be mailed to a patients primary mailing address free of charge. IU Health Blackford Hospital keeps all applications and supporting documentation confidential. 2. Eligibility Determination IU Health Blackford Hospital informs patients or guarantors of the results of their application by providing the patient or guarantor with a Financial Assistance Determination within ninety (90) days of receiving a completed Application and all requested documentation. If a patient or guarantor is granted less than full assistance and the patient or guarantor provides additional information for reconsideration, Revenue Cycle Services may amend a prior Financial Assistance Determination. If a patient or guarantor seeks to appeal the Financial Assistance Determination further, a written request may be submitted, along with the supporting documentation, to the Financial Assistance Committee for additional review/reconsideration. All decisions of the Financial Assistance Committee are final. A patients Financial Assistance Application and eligibility determination will remain in effect for three-hundred-sixty-five (365) days from the date of receipt of a completed application. 3. Extraordinary Collection Actions IU Health Blackford Hospital only implements its "Bad Debt Referral Policyother Extraordinary Collection Action after it has made reasonable efforts to determine whether the patient account is eligible for assistance under its FAP. When it is necessary to engage in such action, IU Health Blackford Hospital, and its contracted third parties, will engage in fair, respectful and transparent collections activities. Patients or guarantors who have not applied for Financial Assistance and whose accounts have been engaged in Extraordinary Collection Actions may request Financial Assistance, complete an Application with requested documentation, and be considered for a reduction in their bill if it is within the two-hundred-forty (240) days of receiving their first billing statement. IU Health Blackford Hospital may also suspend collection activity on an account while an Application is being processed and considered. IU Health Blackford Hospital and its collection agencies will not provide assistance after an account has entered into legal proceedings without first obtaining written consent from its Financial Assistance Committee. The award of Financial Assistance may be subject to successful completion of a payment plan. In the event a patient or guarantor who is receiving Financial Assistance fails to complete the terms of their payment plan, IU Health Blackford Hospital reserves the right to submit the unadjusted account balance, less any amount previously paid by the patient, to an Extraordinary Collection Action.
Schedule H, Part VI, Line 2 - Needs Assessment	Communities are multifaceted and so are their health needs. IU Health Blackford Hospital understands that the health of individuals and communities are shaped by various social and environmental factors, along with health behaviors and additional influences. IU Health Blackford Hospital assesses the health care needs of the communities it serves by utilizing the detailed community needs assessments undertaken by organizations such as the Blackford County Health Department, the Indiana State Department of Health, the Centers for Disease Control and Prevention and the United Way. After completion of the CHNA, IU Health Blackford Hospital reviewed the information gathered from community leader focus groups, community input surveys and statistical data. The needs identified were analyzed and ranked using the Hanlon method of prioritization to determine the prevalence and severity of community health needs and which ones were most critical. Additionally, the effectiveness of an intervention for each need and IU Healths ability to impact positive change was evaluated.
Schedule H, Part VI, Line 3 - Patient Education of Eligibility for Assist.	IU Health Blackford Hospital is committed to serving the healthcare needs of all of its patients regardless of their ability to pay for such services. To assist in meeting those needs, IU Health Blackford Hospital has adopted a Financial Assistance Policy that provides Financial Assistance to eligible patients receiving Emergency or Medically-Necessary Services. This policy was developed and is utilized to determine a patients financial ability to pay for services. IU Health Blackford Hospital goes to great lengths to publicize its financial assistance policy and ensure that patients know they will be treated regardless of their ability to pay. IU Health Blackford Hospital shares financial assistance information with patients throughout their entire episode of care and beyond including the admissions process, billing process, and online. 1. Admissions Process IU Health Blackford Hospital educates all patient facing team members on its Financial Assistance Policy and the process for referring patients to the program. During the admissions process, opportunities for financial assistance are discussed with patients who are identified as self-pay (uninsured) or if they request assistance information. The patient is also provided with an Admissions Packet that outlines information regarding IU Health Blackford Hospitals financial assistance program. Financial counselors are onsite to assist with financial concerns or questions during the patients stay. Patient Financial Services Customer Service representatives are also available after the patients stay to 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 demographic information. 2. Billing Process IU Health Blackford Hospital includes a plain language summary of its Financial Assistance Policy with all patient bills and statements of services. The plain language summary includes contact information allowing patients the ability to request financial assistance. Additionally, a Financial Assistance Application is mailed to all IU Health Blackford Hospital patients with a patient balance due after insurance. IU Health Revenue Cycle Services representatives are available via telephone Monday through Friday, excluding major holidays, from 8 a.m. to 7 p.m. (Eastern Time) to address questions related to Financial Assistance. Customer Service team members will also mail paper applications to a patient at their request. 3. Online IU Health Blackford Hospitals Financial Assistance Policy and Financial Assistance Application are available on its website at http://iuhealth.org/patients/my-iu-health/billing-services/financial-assis tance/. The website also includes contact information for customer service representatives to assist with the application process.
Schedule H, Part VI, Line 4 - Community Information	IU Health Blackford Hospital is located in Blackford County, Indiana, a county located in east-central Indiana. Its service areas include Blackford, Grant, Delaware, Jay, and Wells counties. Blackford County includes ZIP codes within the towns of Hartford City and Montpelier. Based on the most recent Census Bureau (Estimated 2014) statistics, Blackford Countys population is 12,401 persons with approximately 50% being female and 50% male. The countys population estimates by race are 94.5% White, 1.6% Hispanic or Latino, 1.3% Black, 0.5% Asian, 0.8% American Indian or Alaska Native, and 1.3% persons reporting two or more races. Blackford County has a high degree of high school completion but a comparatively low level of college attendance, compared with the United States. Based on data for 2013 from the American Community Survey, In Blackford County, among adults age 25 and above, 13.5% did not complete high school; 50.8% stopped school with a high school diploma or equivalent. Just over a quarter (25.4%) have some college, including those with an associates degree. And just over 1 in 8 (13.4%) have a bachelors degree or higher. Nationally, 86.4% of adults have completed high school; in Blackford County, it is nearly 90%. However, nationally, 28.9% of adults over 25 have a bachelors degree, compared with 13.4% in the county.
Schedule H, Part VI, Line 5 - Promotion of Community Health	During 2015, IU Health Blackford Hospital's promotion of community health included the following highlights: IU Health Blackford Hospital hosted their annual Community Health Fair on November 7, 2015 at Northside Elementary School in Hartford City. Residents of Blackford County and the surrounding areas came out to visit with local medical professionals, receive health and wellness screenings, see activity demonstrations and enjoy family entertainment. The one-day event, sponsored by IU Health Blackford Hospital, focused on specific health needs, including cardiac services, cancer, and diabetes. Heart failure and stroke screenings were offered to visitors, along with free or reduced-cost lab work. Visitors also enjoyed karate and self-defense demonstrations from the Blackford County YMCA, and a childrens chorale. In addition, IU Health Blackford Hospital partnered with the Blackford County YMCA to form the Blackford Community Walking Club. The Club kicked off with weekly Thursday walks from August-October on the athletic track at Blackford High School. A typical gathering of 10-12 people each week participated including seniors all the way to small children taking part with their mothers.
Schedule H, Part VI, Line 6 - Affiliated Health Care System	IU Health Blackford Hospital is part of the IU Health Statewide System. The IU Health Statewide System is Indianas most comprehensive healthcare system. A unique partnership with the IU School of Medicine, one of the nations 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 - Six hospitals designated as Magnet by the American Nurses Credentialing Center recognizing excellence in nursing care. - Ten clinical programs ranked among the top 50 national programs in U.S. News & World Reports 2015-16 edition of Americas Best Hospitals. - Ten out of ten specialty programs at Riley Hospital for Children at IU Health ranked among the top 50 childrens hospitals in the nation. Education and Research As an academic health center, IU Health works in partnership with the IU School of Medicine to train physicians, blending breakthrough research and treatments with the highest quality of patient care. Research conducted by IU School of Medicine faculty gives IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. Collaborative Strategic Research Initiative Conceived by IU Health and the IU School of Medicine in 2012, the Strategic Research Initiative aims to enhance the institutions joint capabilities in fundamental scientific investigation, translational research and clinical trials targeting innovative treatments for disease. The two organizations committed to invest $150 million over five years to this new research collaboration. Established in 2013, the Center for Innovation and Implementation Science is partially supported by the Strategic Research Initiative. The new center, launched by the IU School of Medicine and the Indiana Clinical and Translational Sciences Institute, focuses on increasing efficacy and reducing costs at IU Health. With oversight of four specialized research and discovery units managed by IU School of Medicine researchers, the center will address problems with the potential to reduce costs or generate new revenue estimated at $5 million per year or more. IU Health Statewide System IU Health is a part of the IU Health Statewide System which continues to broaden its reach and positive impact throughout the state of Indiana. IU Health is Indianas most comprehensive academic health center and consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health, and IU Health Saxony Hospital. Other hospitals in the IU Health Statewide System include the following: - IU Health Arnett Hospital - IU Health Ball Memorial Hospital - IU Health Bedford Hospital - IU Health Blackford Hospital - IU Health Bloomington Hospital - IU Health Goshen Hospital - IUHLP Liquidation, Inc. f/k/a IU Health La Porte Hospital - IU Health Morgan Hospital - IU Health North Hospital - IU Health Paoli Hospital - IU Health Starke Hospital - IU Health Tipton Hospital - IU Health West Hospital - IU Health White Memorial Hospital Although each hospital in the IU Health Statewide System prepares and submits its own community benefits plan relative to the local community, the IU Health Statewide System considers its community benefit plan as part of an overall vision for strengthening Indianas 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. Some ways we address our community health priorities as a system include: IU Health Day of Service The annual IU Health Day of Service is a high-impact, one-day event aimed at engaging IU Health team members in activities that address an identified community need. Tackling the issue of obesity in the communities IU Health serves, the seventh annual Day of Service in 2015 focused on leaving behind key physical assets to help meet a statewide need for more venues for physical activity and recreation. During the 2015 Day of Service: - More than 2,200 team members and 6,000 volunteer hours were dedicated by IU Health team members - Created 3 miles of walking trails - Revitalized 18 parks and trailheads - Mounted 7 swing sets - Distributed hundreds of bicycles and bicycle helmets to elementary schools Kindergarten Countdown As one of IU Healths signature programs and collaboration with United Way, Kindergarten Countdown helps hundreds of soon-to-be kindergartners improve their readiness for school. In addition to providing health screenings and vaccinations to students, the program offers assistance to parents in registering their kindergartners for school. Kindergarten Countdown summer camps are designed to provide at-risk youngsters the basic skills they need to succeed in their first year of school. From "Get Ready to Read" pre- and post-tests, campers in the IU Health camps achieved a 21 percent average increase in scores from the beginning of the four-week camp to the end. The program also creates positive impact by increasing awareness of kindergarten readiness, improving parent engagement and strengthening relationships between volunteers and team members at hospitals, schools and community organizations. IU Health recognizes that in some cases we dont have all the expertise or resources to address the needs of the community and other organizations are better suited to tackle some of the specific needs of the community. IU Health, therefore, provided financial support to like-minded non-profit organizations that are working to improve the health of the community in our identified priorities of need. Clinical Research Clinical trials are conducted at the following IU Health partners: - Methodist Cancer Center Research Group - IU Simon Cancer Center - Methodist Research Institute - Indiana Clinical and Translational Sciences Institute (Indiana CTSI) - IU Health Arnett Clinical Research - IU Health Arnett Cancer Care - IU Health Goshen Center for Cancer Care - IU Health Ball Memorial Cancer Center - IU Health Ball Memorial Hospital - IU Health Bloomington Hospital - Riley Hospital for Children at IU Health Methodist Research Institute ("MRI") The Biorepository at MRI, under IRB approval, collects human biological materials (blood, bone, tissue, urine) vital for medical research to provide the best way to study a variety of diseases and their potential treatments. Basic science researchers at MRI publish the results of their innovative grant-supported research in prestigious peer-reviewed journals. Their work has been recognized both nationally and internationally as they participate in system-wide collaborative efforts within IU Health as well as with the IU School of Medicine. Community Health Initiatives With investments in high-quality and impactful initiatives to address community health needs statewide; IU Health is helping Indiana residents improve their health and their quality of life. In 2015, IU Health impacted many people statewide through presentations, health risk screenings, health education programs, and additional health educational opportunities made available to the community, especially to our community members in the greatest need of such services. Examples of the types of programming and investment we make in community outreach areas include: Access to 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 works 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. Some ways that these IU Health hospitals address Access to Healthcare include: - Public Assistance Enrollment - Veggies and Vaccines - Indiana University Student Outreach Clinic - Indianapolis Public Schools Student Athlete Physicals - Fishers Fire Department QR Code Magnet Program for Immediate Access to Patient Medical Records - Partnership for a Healthy Hamilton County Nutrition and Healthy Weight To improve the lifestyle of Indiana residents, IU Health has utilized innovative and 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 chr

Schedule H (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization
INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number
01-0646166

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient

that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance

(1) YMCA OF MUNCIE
500 S MULBERRY ST
MUNCIE,IN47305

35-0868215

501(C)(3)

42,000

N/A

GENERAL SUPPORT

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

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

Cat. No. 50055P

Schedule I (Form 990) 2015

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a) Type of grant or assistance	(b) Number of recipients	(c) Amount of cash grant	(d) Amount of non-cash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of non-cash assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)

Part IV

Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Return Reference	Explanation
Schedule I, Part I, Line 2 - Org's. Proc. for Mon. the Use of Grant Funds	Although IU Health Blackford Hospital does not monitor the use of grant funds once distributed, through due diligence the organization has reasonably confirmed that the entities to which the contributions are made are highly reputable in the community and use the funds for the purposes intended.

Schedule I (Form 990) 2015

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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

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 on 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
directors, trustees, officers, including 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 on 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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on 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," on line 5a or 5b, describe in Part III.

For persons listed on 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," on line 6a or 6b, describe in Part III.

For persons listed on 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 on 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" on 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) 2015

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 on 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 in column(B) reported as deferred on 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)
1STEVEN J WESTDIRECTOR/PRESIDENT	(i) (ii)	0 ------------- 142,933	0 ------------- 18,508	0 ------------- 1,851	0 ------------- 6,675	0 ------------- 11,006	0 ------------- 180,973	0 ------------- 0
2MICHAEL E HALEYDIRECTOR	(i) (ii)	0 ------------- 516,190	0 ------------- 148,735	0 ------------- 113,510	0 ------------- 10,600	0 ------------- 26,239	0 ------------- 815,274	0 ------------- 0
3JUDITH L COLEMANCFO	(i) (ii)	0 ------------- 191,515	0 ------------- 13,763	0 ------------- 1,703	0 ------------- 7,386	0 ------------- 27,283	0 ------------- 241,650	0 ------------- 0
4JEFFREY C BIRD MDCMO	(i) (ii)	0 ------------- 334,215	0 ------------- 25,430	0 ------------- 2,322	0 ------------- 10,685	0 ------------- 26,537	0 ------------- 399,189	0 ------------- 0
5ELIZABETH A DROEGE MDPHYSICIAN	(i) (ii)	296,741 ------------- 0	4,871 ------------- 0	21,564 ------------- 0	11,870 ------------- 0	21,818 ------------- 0	356,864 ------------- 0	0 ------------- 0
6THOMAS M LEE MDPHYSICIAN	(i) (ii)	107,031 ------------- 215,626	22,659 ------------- 45,648	788 ------------- 1,588	4,201 ------------- 8,463	8,911 ------------- 17,952	143,590 ------------- 289,277	0 ------------- 0
7LORI A LUTHERFORMER TREASURER	(i) (ii)	0 ------------- 295,488	0 ------------- 23,814	0 ------------- 3,335	0 ------------- 10,600	0 ------------- 8,794	0 ------------- 342,031	0 ------------- 0

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation
Schedule J, Part I, Line 3 - Comp. of the Org.'s CEO/Executive Director	IU Health Blackford Hospitals President is an employee of IU Health Ball Memorial Hospital. IU Health, as the sole member and controlling parent of IU Health Ball Memorial Hospital, has implemented a process for determining the compensation of IU Health Blackford Hospitals CEO/Executive Director. IU Healths process for determining compensation includes the use of a compensation survey/study conducted by an independent compensation consultant with review and approval by the Committee on Personnel and Compensation and the Board of Directors. Please see Schedule O for additional details.
Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan	Michael E. Haley participates in an IU Health supplemental executive retirement plan, provisions of which are designed to retain its critical employees. The plan provides for an additional retirement benefit for services 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 $88,717 included in column b(iii), other reportable compensation, representing the current year vested amounts received under the supplemental executive retirement plan.
Schedule J, Part I, 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) 2015

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Return Reference	Explanation
Part VI, Section A, Line 2 - Family or Business Relationships	Michael E. Haley and Jeffrey C. Bird, M.D. both served on the board of managers of Ball Outpatient Surgery Center, LLC. No additional compensation was provided to these individuals for their service.
Part VI, Section A, Line 4 - Signfiant Changes to Gov. Documents	IU Health Blackford Hospital amended their bylaws in 2015 as the board of directors is now considered a regional board with IU Health Ball Memorial Hospital, the sole member of IU Health Blackford Hospital. The amended bylaws state: The Board of Directors shall consist of such number of members not fewer than three (3) nor more than five (5) in number as shall time to time be fixed by resolution of IU Health Ball Memorial Hospital. To be eligible for Board membership a Director candidate shall satisfy the selection criteria and personal characteristics as may be established by IU Health Ball Memorial Hospital from time to time. Composition of the Board of Directors shall be consistent with the following criteria: (i) two (2) members appointed by IU Health Ball Memorial Hospital shall be representatives of the local community; and (ii) one (1) to three (3) members appointed by IU Health Ball Memorial Hospital shall be at-large representatives. In addition the bylaws included the following changes: - Annual meeting defined as being held each year within six (6) months after the close of the fiscal year of the hospital - Notice of all annual and special meetings of the Corporate member shall now be given at least ten (10) days notice as opposed to five (5) previously - Now a provision detailing what constitutes a quorum - Now a provision detailing voting procedures by proxy
Part VI, Section A, Lines 6, 7a and 7b - Members or Stockholders	Line 6: IU Health Blackford Hospital has one class of membership and the sole member is IU Health Ball Memorial Hospital, a wholly owned subsidiary of IU Health. Line 7a: The Board of Directors shall consist of such number of members not fewer than three (3) nor more than five (5) in number. Composition of the Board of Directors shall be consistent with the following criteria: two (2) members appointed by IU Health Ball Memorial Hospital shall be representatives of the local community and one (1) to three (3) members appointed by IU Health Ball Memorial Hospital shall be at-large representatives 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 IU Health, approve the capital and operating budgets for Hospital.
Part VI, Section B, Line 11b - Review of Form 990	The CFO and IU Health Ball Memorial Hospitals Audit Committee reviewed and approved the Form 990. Following their review and approval, a complete copy of the Form 990 was made available to each board member prior to its filing. Each member was also informed of the availability of IU Healths Tax Department to answer any questions.
Part VI, Section B, Lines 12, 13, 14, and 16b - Policies	IU Health Blackford Hospital is part of the IU Health system. As the sole member and controlling parent of IU 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 Hospitals Board of Directors was not required to separately adopt a conflict of interest, whistleblower, document retention and destruction and joint venture policies because IU Healths Board of Directors had already adopted and required these policies to be followed by its subsidiaries.
Part VI, Section B, Line 12c - Conflict of Interest Policy	IU Health Blackford Hospital follows IU Healths Conflict of Interest Policy. IU Healths Conflict of Interest Policy includes the following provisions: All IU Health employees, associates, colleagues and contracted personnel, including employed physicians and paid medical directors ("IU Health Representatives") are covered by and subject to its Conflict of Interest Policy. IU Health regularly and consistently monitors and enforces compliance with the policy through the following procedures: (a) On an annual basis, each IU Health Representative at the level of Manager or above, together with every other person designated by the Corporate Compliance Department ("Department"), must complete, sign and submit a Conflict of Interest Questionnaire ("Questionnaire") to the Department. Governing board members, committee members, corporate officers, medical staff and researchers must comply with the administrative requirements noted in the respective policies and procedures relative to those areas. (b) An IU Health Representative must supplement a Questionnaire in writing, if after completion of the original Questionnaire, a situation arises, or may reasonably be expected to arise, that would change any answer or information on the original Questionnaire if the situation had existed or been anticipated at the time of completion of the original Questionnaire. (c) If a fully and properly completed Questionnaire reveals facts or other information that might reasonably indicate a Conflict of Interest or violation of the policy, the IU Health Representative completing the questionnaire must secure approval by his/her supervisor, evidenced in writing. (d) The Department will review each Questionnaire and determine whether a Conflict of Interest exists and, if so, whether and how it should or may be eliminated, avoided or managed in order to comply with the spirit of the policy and with the best interests of IU Health and its patients. In making the determination, the Corporate Compliance Department may consult with the IU Health Representatives supervisor and other appropriate individuals and groups. (e) The scope of the policy is not limited to those who are required to complete Questionnaires. If an IU Health Representative is involved in a situation or relationship that would constitute a violation of the policy in the absence of disclosure and approval as described above, then the IU Health Representative must disclose the matter to his/her supervisor, secure his/her supervisors approval in writing, and disclose the matter to the Department. Otherwise, the IU Health Representative is in violation of the policy and subject to corrective action, up to and including termination. (f) The Chief Compliance Officer, in consultation with onsite Compliance personnel, may from time to time appoint standing or ad hoc committees to assist in resolving issues that arise under provisions of the policy.
Part VI, Section B, Line 15 - Process for Determining Comp.	IU Health Blackford Hospitals President is an employee of IU Health Ball Memorial Hospital. IU Health, as the sole member and controlling parent of IU Health Ball Memorial Hospital, has implemented the following process for determining compensation of IU Health Blackford Hospitals CEO/Top Management Official: (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 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 Chief Executive Officer. (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 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.
Part VI, Section C, Line 19 - Public Disclosure	IU Health Blackford Hospitals 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 IU Health, Inc. The consolidated financial statements for IU Health are available to the public through its bond filings.
Part VII, Section A, Line 1a, Column (B) - Average Hours Per Week	Thomas M. Lee, M.D. was an employee of IU Health Blackford Hospital during a portion of 2015 in which he devoted an average of 55 hours per week. He was also an employee of IU Health Ball Memorial Physicians during a portion of 2015 in which he devoted an average of 55 hours per week.
FORM 990 PART IX LINE 11G	DESCRIPTION:SHARED SERVICES/PROF. FEES TOTAL FEES:5287068

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

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" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (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" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled 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 Incorporated 950 N Meridian St Ste 800 Indianapolis,IN46204 26-3571507	Healthcare	IN	501(c)(3)	9	IUHB	Yes
(5)Indiana Health Info Exchange Inc 846 N Senate Ave Indianapolis,IN46202 36-4550324	Healthcare	IN	501(c)(3)	11 I	NA		No
(6)Indiana Radiology Partners Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 20-1017034	Healthcare	IN	501(c)(3)	3	IUH	Yes
(7)Indiana University Health Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1955872	Healthcare	IN	501(c)(3)	3	NA		No
(8)IU Health Arnett Foundation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-6079797	Fundraising	IN	501(c)(3)	11 I	IUHA	Yes
(9)IU Health Arnett Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 26-3162145	Healthcare	IN	501(c)(3)	3	IUH	Yes
(10)IU Health Ball Memorial Hospital Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-0867958	Healthcare	IN	501(c)(3)	3	IUH	Yes
(11)IU Health Ball Memorial Physicians Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1925641	Healthcare	IN	501(c)(3)	9	IUHBMH	Yes
(12)IU Health Bedford Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 23-7042323	Healthcare	IN	501(c)(3)	3	IUH	Yes
(13)IU Health Bloomington Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1720796	Healthcare	IN	501(c)(3)	3	IUH	Yes
(14)IU Health BMH Foundation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 31-1111784	Fundraising	IN	501(c)(3)	11 I	IUHBMH	Yes
(15)IU Health Care Associates Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1747218	Healthcare	IN	501(c)(3)	9	IUH	Yes
(16)IU Health Goshen Foundation Inc 200 High Park Ave Goshen,IN46527 46-2565300	Fundraising	IN	501(c)(3)	11 I	GHS	Yes
(17)IUHLP Liquidation Inc PO Box 250 LaPorte,IN46352 35-1125434	Healthcare	IN	501(c)(3)	3	IUH	Yes
(18)IUHLP-P Liquidation Inc PO Box 250 LaPorte,IN46352 31-1070868	Healthcare	IN	501(c)(3)	3	IUHLH	Yes
(19)IU Health Morgan Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 27-3533027	Healthcare	IN	501(c)(3)	3	IUH	Yes
(20)IU Health North Hospital Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1932442	Healthcare	IN	501(c)(3)	3	IUH	Yes
(21)IU Health Paoli Hosp Foundation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 31-0992486	Fundraising	IN	501(c)(3)	9	IUHP	Yes
(22)IU Health Paoli Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-2090919	Healthcare	IN	501(c)(3)	3	IUHB	Yes
(23)IU Health Plans NFP Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 46-3803873	Insurance	IN	501(c)(4)	N/A	IUH	Yes
(24)IU Health Tipton Hospital Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 26-2772226	Healthcare	IN	501(c)(3)	3	IUH	Yes
(25)IU Health West Hospital Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1814660	Healthcare	IN	501(c)(3)	3	IUH	Yes
(26)IU Health White Mem Hosp Fndtn Inc PO Box 952 Monticello,IN47960 35-1671806	Fundraising	IN	501(c)(3)	11 III-FI	IUHWMH	Yes
(27)IU Health White Memorial Hospital Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 27-3532963	Healthcare	IN	501(c)(3)	3	IUH	Yes
(28)IU Medical Group Foundation Inc 340 W 10th St No FS5100 Indianapolis,IN46202 20-1093251	Fundraising	IN	501(c)(3)	11 II	NA		No
(29)LaPorte Hospital Foundation Inc PO Box 250 LaPorte,IN46352 31-0952775	Fundraising	IN	501(c)(3)	11 I	NA		No
(30)MDwise Marketplace Inc 1200 Madison Ave Indianapolis,IN46225 46-5270582	Insurance	IN	501(c)(4)	N/A	IUH	Yes
(31)MDwise Network Inc 1200 Madison Ave Indianapolis,IN46225 47-2619552	Insurance	IN	501(c)(4)	N/A	IUH	Yes
(32)Methodist Health Foundation Inc 1800 N Capitol Ave Indianapolis,IN46202 35-6043086	Fundraising	IN	501(c)(3)	11 I	IUH	Yes
(33)Methodist Health Group Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-0876390	Healthcare	IN	501(c)(3)	11 III-FI	NA		No
(34)Methodist Medical Group Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1945384	Healthcare	IN	501(c)(3)	3	IUH	Yes
(35)Methodist Occup Health Centers Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1844176	Healthcare	IN	501(c)(3)	3	IUH	Yes
(36)Methodist Research Institute Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-2023710	Healthcare	IN	501(c)(3)	11 I	IUH	Yes
(37)MH Healthcare Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1766531	Healthcare	IN	501(c)(3)	3	MMG	Yes
(38)Morgan Co Mem Hosp Foundation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-2035162	Fundraising	IN	501(c)(3)	11 II	IUHMH	Yes
(39)Morgan Co Mem Hosp Guild Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 31-0886844	Fundraising	IN	501(c)(3)	11 III-FI	IUHMH	Yes
(40)Morgan Health Services Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1968564	Healthcare	IN	501(c)(3)	3	IUHMH	Yes
(41)Rehabilitation Hospital of Indiana Inc 4141 Shore Dr Indianapolis,IN46254 35-1786005	Healthcare	IN	501(c)(3)	3	MHH	Yes
(42)RHI Foundation Inc 4141 Shore Dr Indianapolis,IN46254 35-1932349	Fundraising	IN	501(c)(3)	11 I	RHI	Yes
(43)The Cheer Guild of Riley Hos for Child 705 Riley Hospital Dr Indianapolis,IN46202 35-6018517	Fundraising	IN	501(c)(3)	11 III-FI	NA		No
(44)Tipton Co Health Care Foundation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 31-1231905	Fundraising	IN	501(c)(3)	11 I	IUHTH	Yes
(45)University Family Physicians Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 23-7427350	Healthcare	IN	501(c)(3)	9	IUHCA	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2015

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Ball Outpatient Sur Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 27-0275794	Healthcare	IN	NA
(2) Beltway Surgery Centers LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 35-2072586	Healthcare	IN	NA
(3) Bloomington Endo Center LLC PO Box 550 Bloomington,IN47402 35-2117943	Healthcare	IN	NA
(4) BOSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4147343	Healthcare	IN	NA
(5) BSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-2314634	Healthcare	IN	NA
(6) CHV Fund I LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 26-2523206	Venture Capital	IN	NA
(7) CHV Fund II Management LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 37-1717823	Venture Capital	IN	NA
(8) CHV Fund II LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 80-0902337	Venture Capital	IN	NA
(9) CHV Fund Management LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 26-2523151	Venture Capital	IN	NA
(10) Clarian Health Network LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 35-2055030	Healthcare	IN	NA
(11) Eagle High Surg Center LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 35-2259204	Healthcare	IN	NA
(12) EHSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4147879	Healthcare	IN	NA
(13) EWASC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 47-3087761	Healthcare	IN	NA
(14) Health Venture Management LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 20-5740218	Management	IN	NA
(15) IEC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4148032	Healthcare	IN	NA
(16) Indiana Endoscopy Centers LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 20-8398421	Healthcare	IN	NA
(17) IUH EWA Surgery Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 47-3102482	Healthcare	IN	NA
(18) IUH Saxony Surgery Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 27-5271091	Healthcare	IN	NA
(19) ROC Surgery LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 27-1497960	Healthcare	IN	NA
(20) ROCS Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4148369	Healthcare	IN	NA
(21) Senate St Surgery Center LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 42-1709357	Healthcare	IN	NA
(22) SSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 46-4472887	Healthcare	IN	NA
(23) SSSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4148167	Healthcare	IN	NA

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(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	NA	C			Yes
(2) Cardinal Health Ventures Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1611424	Management	IN	NA	C			Yes
(3) CHV Capital Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 26-0752507	Venture Capital	IN	NA	C			Yes
(4) IU Health 457(B) Plan 1100 N Market St Wilmington,DE19890 47-6948347	Investments	IN	NA	T			Yes
(5) IU Health ACO Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4421020	Healthcare	IN	NA	C			Yes
(6) IU Health Board Designated Trust 400 Howard St San Francisco,CA94105 30-6309021	Investments	IN	NA	T			Yes
(7) IU Health NTGI S&P500 Fund CF PO Box 804358 Chicago,IL60680 30-6298263	Investments	IN	NA	T			Yes
(8) IU Health Plans Holding Company Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 46-3794815	Insurance	IN	NA	C			Yes
(9) IU Health Plans NFP Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 46-3803873	Insurance	IN	NA	C			Yes
(10) IU Health Plans Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 26-2127080	HMO	IN	NA	C			Yes
(11) IU Health Risk Purchasing Group Inc 151 Meeting St Ste 301 Charleston,SC29401 26-0202446	Insurance	IN	NA	C			Yes
(12) IU Health Risk Retention Group Inc 151 Meeting St Ste 301 Charleston,SC29401 20-1107674	Insurance	SC	NA	C			Yes
(13) IU Health Southern IN Physicians Inc PO Box 1149 Bloomington,IN47402 35-1913875	Healthcare	IN	NA	C			Yes
(14) IUH Assurance SPC Ltd PO BOX 69 94 SOLARIS AVE CAMANA BAY,GRAND CAYMAN CJ 98-0395429	Insurance	CJ	NA	C			Yes
(15) Occ-Health Revenue Systems Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 20-3308057	Work Comp PPO	IN	NA	C			Yes
(16) Parkmor Drug Inc 1501 S Main St Goshen,IN46526 13-1394980	Pharmacy Sales	IN	NA	C			Yes
(17) PILR Inc 200 High Park Ave Goshen,IN46526 20-4294750	Development	IN	NA	C			Yes
(18) Proteuo Fund LP PO BOX 31106 89 NEXUS WAY CAMANA BAY,GRAND CAYMAN CJ 98-1075227	Investments	CJ	NA	C			Yes
(19) Radiation Oncology Resources Inc 200 High Park Ave Goshen,IN46526 26-2008424	Healthcare	IN	NA	C			Yes
(20) SCANS Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 45-3080392	Healthcare	IN	NA	C			Yes
(21) Univ Hlth (Shanghai) Mgt Con Co Ltd 88 CENTURY AVE SHANGHAI CH	Management	CH	NA	C			Yes
(22) University Health Management Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 27-2891143	Management	IN	NA	C			Yes
(23) University Health Mgmt (China) Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 27-3891311	Management	IN	NA	C			Yes

Schedule R (Form 990) 2015

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on 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) .......................

Yes

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

Yes

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) ............................

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) IU HEALTH CARE ASSOCIATES INC	M	153,158	FMV
(2) IU HEALTH RISK RETENTION GROUP INC	R	145,452	FMV

Schedule R (Form 990) 2015

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI 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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2015

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2015

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	3
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	1
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	153
6	Total number of volunteers (estimate if necessary) .............	6	50
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) .........	21,278	21,889
9	Program service revenue (Part VIII, line 2g) .........	18,978,752	18,302,889
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,158	7,474
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	86,895	100,281
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	19,088,083	18,432,533
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	42,000
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)	6,205,322	6,345,037
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)....	10,029,442	9,299,036
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	16,234,764	15,686,073
19	Revenue less expenses. Subtract line 18 from line 12.......	2,853,319	2,746,460
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	16,570,097	18,689,669
21	Total liabilities (Part X, line 26).............	3,807,287	3,180,399
22	Net assets or fund balances. Subtract line 21 from line 20.....	12,762,810	15,509,270

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 14,831,371 including grants of $ 42,000 ) (Revenue $ 18,302,889 )
	Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital"), located in Hartford City, Indiana, is a 15-bed acute-care and critical access hospital that offers a broad range of services to care for its patients without regard to their ability to pay. IU Health Blackford Hospital features all private rooms, a specialty clinic, cardiac and pulmonary rehabilitation, outpatient surgical services and diagnostic imaging. In addition to providing 24-hour emergency services, the hospital hosts a paramedic-level ambulance service. IU Health Blackford Hospital also serves the community with an annual health fair which includes free and low-cost screenings. The hospital promotes wellness initiatives such as diabetes education, tobacco cessation, childrens safety, after-school health lifestyle initiatives, seniors programming and outreach to local employers with screenings and health information.

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 expenses14,831,371

(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...................................................................... CHAIRMAN	5.0 ................. 5.0	X	X				0	0	0
(2) STEVEN J WEST...................................................................... DIRECTOR/PRESIDENT	5.0 ................. 55.0	X	X				0	163,292	17,681
(3) MICHAEL E HALEY...................................................................... DIRECTOR	5.0 ................. 55.0	X					0	778,435	36,839
(4) MICHAEL L COX...................................................................... VICE CHAIRMAN	5.0 ................. 0.0		X				0	0	0
(5) JUDITH L COLEMAN...................................................................... CFO	0.0 ................. 55.0		X				0	206,981	34,669
(6) JEFFREY C BIRD MD...................................................................... CMO	0.0 ................. 55.0			X			0	361,967	37,222
(7) ELIZABETH A DROEGE MD...................................................................... PHYSICIAN	55.0 ................. 0.0				X		323,176	0	33,688
(8) KEVIN W SCHREIBER MD...................................................................... PHYSICIAN	55.0 ................. 0.0				X		145,010	0	367
(9) THOMAS M LEE MD...................................................................... PHYSICIAN	55.0 ................. 55.0				X		130,478	262,862	39,527
(10) CHARLES L CARROLL DO...................................................................... PHYSICIAN	55.0 ................. 0.0				X		116,338	0	4,654
(11) JOHN C CROSBIE...................................................................... DIRECTOR, SUPPORT SERVICES	55.0 ................. 0.0				X		102,657	0	24,171
(12) LORI A LUTHER...................................................................... FORMER TREASURER	0.0 ................. 55.0					X	0	322,637	19,394

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	817,659	2,096,174	248,212

(A) Name and business address	(B) Description of services	(C) Compensation
ELMER TOLIVER PSC, 1412 SMUGGLERS NOTCH FORT WAYNE,IN46814	MEDICAL	394,018




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

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e	21,889

f	All other contributions, gifts, grants, and similar amounts not included above		1f

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		21,889

			Business Code
2a	NET PATIENT SERVICE REVENUE	621110	18,262,779	18,262,779
b	RENT FROM RELATED 501(C)(3) ORGS.	532000	40,110	40,110
c
d
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			18,302,889

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			7,474			7,474
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		7,400
b	Less: rental expenses
c	Rental income or (loss)	0	7,400
d	Net rental income or (loss)......			7,400			7,400
		(ii) Other	(i) Securities
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).....			0
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			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
Business Code			Miscellaneous Revenue
11a	CAFETERIA/FOOD SERVICE		721110	54,579			54,579
b	VENDING		900099	1,203			1,203
c	ALL OTHER REVENUE		900099	37,099			37,099
d	All other revenue ....
e	Total. Add lines 11a–11d ......			92,881
12	Total revenue. See Instructions......			18,432,533	18,302,889		107,755

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	42,000	42,000
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	5,059,040	4,674,622	384,418
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	204,310	188,785	15,525
9	Other employee benefits .......	721,657	666,821	54,836
10	Payroll taxes ...........	360,030	332,673	27,357
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	0
c	Accounting ...........	0
d	Lobbying ...........	1,342		1,342
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)	5,287,068	5,115,719	171,349	0
12	Advertising and promotion ....	5,624		5,624
13	Office expenses .......	60,097	30,983	29,114
14	Information technology ......	20,085	20,044	41
15	Royalties ..	0
16	Occupancy ...........	477,450	477,257	193
17	Travel ............	4,810	2,714	2,096
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	834	315	519
20	Interest ...........	0
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	888,903	854,101	34,802
23	Insurance ...	163,837	48,282	115,555
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	1,234,996	1,234,996
b	DRUGS AND MEDICAL SUPPLIES	1,003,955	1,003,955
c	INSTITUTIONAL DUES/LICENSES	12,488	12,488
d	ALL OTHER EXPENSES	137,547	125,616	11,931
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	15,686,073	14,831,371	854,702	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).

1	Cash–non-interest-bearing ........			600	1	600
2	Savings and temporary cash investments .........			3,517,754	2	7,434,084
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			2,981,066	4	2,031,924
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 ........			204,831	8	202,216
9	Prepaid expenses and deferred charges ......			65,640	9	53,183
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	20,667,780
b	Less: accumulated depreciation	10b	11,700,118	9,800,206	10c	8,967,662
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 ..			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)...			16,570,097	16	18,689,669

17	Accounts payable and accrued expenses .....	1,233,871	17	784,818
18	Grants payable ...	0	18	0
19	Deferred revenue .........	21,684	19	11,037
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 ..	0	23	0
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	2,551,732	25	2,384,544
26	Total liabilities. Add lines 17 through 25..	3,807,287	26	3,180,399

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	12,762,810	27	15,509,270
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 ...........	12,762,810	33	15,509,270
34	Total liabilities and net assets/fund balances ........	16,570,097	34	18,689,669