TY 2019 Form 990

(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)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) JEFFREY C BIRD MD...................................................................... DIRECTOR/PRES.(ECR)	10.0 ................. 45.0	X	X				0	675,023	122,854
(2) KEVIN W SCHREIBER M...................................................................... PHYSICIAN	5.0 ................. 50.0				X		20,280	441,929	48,858
(3) THOMAS M LEE MD...................................................................... PHYSICIAN	2.0 ................. 53.0				X		2,880	416,537	47,910
(4) Peter M Voss MD...................................................................... CMO (ECR)	10.0 ................. 45.0			X			0	372,104	42,519
(5) LORI A LUTHER...................................................................... COO	10.0 ................. 45.0			X			0	370,838	41,320
(6) JUDITH COLEMAN...................................................................... FORMER Officer	5.0 ................. 50.0					X	0	314,630	38,369
(7) JONATHAN W VANATOR...................................................................... CFO (ECR)	10.0 ................. 45.0		X				0	308,658	41,978
(8) CHARLES L CARROLL D...................................................................... PHYSICIAN	5.0 ................. 50.0				X		15,000	301,567	18,075
(9) MICHELLE R ALTOBELLA...................................................................... SECRETARY	10.0 ................. 45.0		X				0	257,421	45,230
(10) DAVID W HYATT...................................................................... DIRECTOR/PRESIDENT	20.0 ................. 35.0	X	X				0	252,760	46,569
(11) CARLA C COX RN...................................................................... VP & CNO (ECR)	10.0 ................. 45.0			X			0	250,658	36,602
(12) Ann M McGuire...................................................................... VP-Human Resources Regional	10.0 ................. 45.0			X			0	203,736	22,805
(13) RODNEY J STEVENS RN...................................................................... Former Key Employee	45.0 ................. 10.0					X	199,890	0	23,538
(14) BETTIE A CALDWELL...................................................................... TREASURER	10.0 ................. 45.0		X				0	124,209	18,151
(15) Jan Blake...................................................................... Blackford COO/CNO	55.0 ................. 0.0				X		110,098	0	28,173
(16) Monica R Gaither...................................................................... Admin-Assoc-Nursing	55.0 ................. 0.0				X		111,873	0	20,632
(17) DANIEL E BORGENHEIMER...................................................................... DIRECTOR	5.0 ................. 0.0	X					0	0	0

- 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.
right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

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 12, 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 agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

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 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

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) 2019

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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—2018. 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—2019. 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—2018. 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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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—2018. 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) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d 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 12a or 12b 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) 2019

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) 2019

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 (explain in Part VI). 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) 2019

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 2019 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-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

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) 2019

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.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

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. Don't 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 isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC

Part I Contributors	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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

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) (2019)

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

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 (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

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) 2019

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) 2016	(b) 2017	(c) 2018	(d) 2019	(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) 2019

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|No

(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

230

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

230

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 Indiana Hospital Association ("IHA") during 2019 in the amount of $3,515. Each membership organization notified IU Health Blackford Hospital that a portion of the dues it paid were used for lobbying purposes. The IHA used 6.53%, or $230 of the 2019 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The total membership dues paid to this organization by IU Health Blackford Hospital during 2019 that was attributable to lobbying expenditures was $230.

Return Reference

Explanation

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

IU Health Blackford Hospital paid institutional membership dues to Indiana Hospital Association ("IHA") during 2019 in the amount of $3,515. Each membership organization notified IU Health Blackford Hospital that a portion of the dues it paid were used for lobbying purposes. The IHA used 6.53%, or $230 of the 2019 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The total membership dues paid to this organization by IU Health Blackford Hospital during 2019 that was attributable to lobbying expenditures was $230.

Schedule C (Form 990 or 990EZ) 2019

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.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

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 7/25/06, 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 FASB 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 FASB 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 FASB 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) 2019

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

Term 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	9,594,663	5,413,082
c	Leasehold improvements	0
d	Equipment ....	4,504,982	3,105,104	1,399,878
e	Other .....	288,908	25,381	263,527
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				7,266,811

Schedule D (Form 990) 2019

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
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
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)INTERCOMPANY RECEIVABLES (NET)				2,606,869
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				2,606,869

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
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	1,854,474
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) 2019

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 is a subsidiary in IU Health's Consolidated Audited Financial Statements. The Internal Revenue Service (IRS) has determined that IU Health and certain of its affiliated entities are tax-exempt organizations as defined in Section 501(c)(3) of the Internal Revenue Code (IRC). IU Health and its tax-exempt affiliates are, however, subject to federal and state income taxes on unrelated business income under the provision of IRC Section 511. The Tax Cuts and Jobs Act (TCJA) was enacted on December 22, 2017. For tax-exempt entities, TCJA requires organizations to pay an excise tax on compensation above certain thresholds and record income or losses for tax determination purposes from unrelated business activities on an activity-by-activity basis, among other provisions. Proposed regulations and interim guidance, necessary for implementation, have been issued on most aspects of TCJA. It is expected that proposed regulations will be issued as final regulations by the IRS in 2020. As of and for the year ended December 31, 2019, Indiana University Health has made reasonable estimates of the provision for income taxes, the compensation excise tax, and the effects, if any, on existing deferred tax balances based on accounting guidance included in Accounting Standards Codification (ASC) 740, Income Taxes. Indiana University Health will continue to refine its calculations in future periods, as additional regulations and guidance are issued by the IRS. Deferred income taxes that, as of December 31, 2019 and 2018, have no net carrying value reflect the net tax effect of temporary differences between the carrying amounts of assets and liabilities for financial reporting and the amounts used for income tax purposes. As of December 31, 2019 and 2018, the Indiana University Health System had gross deferred tax assets of $143,157,000 and $119,965,000, respectively, primarily relating to net operating loss carryovers. Management determined that a full valuation allowance at December 31, 2019 and 2018 was necessary to reduce the deferred tax assets to the amount that would more likely than not be realized. Based on the weight of the evidence, if it is more likely than not that same portion or all of the deferred tax assets will not be realized, a valuation allowance to reduce the deferred tax assets is recorded. The change in valuation allowance for the current year is $23,192,000. At December 31, 2019, the Indiana University Health System has available net operating loss carryforwards of $575,596,000. Net operating losses generated from 1999 through 2017 will expire between 2020 and 2037. Net operating losses generated after 2017 do not expire. Certain subsidiaries of Indiana University Health are taxable entities. The tax expense and liabilities of these subsidiaries are not material to the consolidated financial statements.

Schedule D (Form 990) 2019

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

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

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: . . . . . . . .

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? . . . . . .

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .		780	631,262		631,262	3.380 %
b	Medicaid (from Worksheet 3, column a) . . . . .		1,348	3,861,655	1,257,623	2,604,032	13.940 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .		2,128	4,492,917	1,257,623	3,235,294	17.320 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	11	6,473	205,083	2,828	202,255	1.080 %
f	Health professions education (from Worksheet 5) . . .	2	78	45,884		45,884	0.250 %
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	36	1,379		1,379	0.010 %
j	Total. Other Benefits . .	14	6,587	252,346	2,828	249,518	1.340 %
k	Total. Add lines 7d and 7j .	14	8,715	4,745,263	1,260,451	3,484,812	18.660 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

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	1	12	2,225	2,225	0.010 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	1	419	1,390	1,390	0.010 %
7	Community health improvement advocacy	1	22	2,067	2,067	0.010 %
8	Workforce development
9	Other
10	Total	3	453	5,682	5,682	0.030 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare 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. ......

751,323

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).....

8,538,611

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

8,139,900

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

398,711

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) 2019

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?1Name, 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 SEE PART V, SECTION C 19-005101-1	X	X	X	X

Schedule H (Form 990) 2019

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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

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 19

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) 2019

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 0.%

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)

Was widely publicized 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):
SEE PART V, SECTION C

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)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

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

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	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 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 nonpayment?..................................

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

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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

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

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

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)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

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

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

Yes

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 a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

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) 2019

Page 8

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, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 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 A, Line 1 - Website address	IU Health Blackford Hospital's website address is: https://iuhealth.org/find-locations/iu-health-blackford-hospital
Schedule H, Part V, Section B, Line 3e - Prioritized Health Needs	IU Health Blackford Hospital's 2018 Community Health Needs Assessment (CHNA) report includes a prioritized description of significant health needs in the community. The CHNA report identified the following eight needs as priorities for IU Blackford Hospital: - Access to healthcare services - Aging population and needs of seniors - Drug and substance abuse - Maternal and infant health and child wellbeing - Mental health - Obesity and diabetes - Smoking and tobacco usage - Social determinants of health
Schedule H, Part V, Section B, Line 5 - Input from Community	In conducting its most recent Community Health Needs Assessment ("CHNA") IU Health Blackford Hospital took into account input from persons who represent the broad interests of the communities it serves. Primary data were gathered in two different methodologies for this assessment: Community Meetings and a Community Survey. For purposes of this CHNA, IU Health Blackford Hospital's community is defined as Blackford County, Indiana. This county accounted for 74.4 percent of the hospital's inpatient cases in 2016. Community Meetings - Blackford County On May 24, 2018, a meeting of community representatives was held at the City Hall Building in Harford City, the county seat of Blackford County. The meeting was attended by 24 community members invited by IU Health because they represent important community organizations and sectors such as: local health departments, police/fire departments, non-profit organizations, local business, health care providers, mayors/local policymakers, faith-based organizations, parks and recreation departments, and schools. Through this meeting, IU Health sought a breadth of perspectives on the community's health needs. The specific organizations represented at the meeting are listed below. - 3M Hartford City - AMVETS Post 23 - Blackford Community Foundation - Blackford County Health Department - Blackford County Schools - Blackford County Sheriff's Department - Blackford Economic Development - Hartford City - Hartford City Kiwanis Club - Hester Hollis Concern Center - IU Health - IU Health Blackford Hospital - Indiana State Government - LifeStream - Mayor's Office, Hartford City - Meridian Health Services - Plexus Worldwide - Purdue Extension The meeting began with a presentation that discussed the goals and status of the CHNA process and the purpose of the community meeting. Then, secondary data were presented, along with a summary of the most unfavorable community health indicators. For the community served by IU Health Blackford Hospital, those indicators were (in alphabetical order): - Air pollution - Cancer incidence and mortality rates - Maternal and Child Health: Low birthweight births, preterm births, and smoking during pregnancy - Mental health and supply of mental health providers - Motor vehicle accidents - Obesity and physical inactivity - Preventable hospital admissions - Teen pregnancy Meeting participants then were asked to discuss whether the identified, unfavorable indicators accurately identified the most significant community health issues and were encouraged to add issues that they believed were significant. Several issues were added, such as: transportation challenges, substance abuse and overdoses, and the needs of seniors. During the meeting, a range of other topics was discussed, including: - The need to enhance services for seniors, including transportation options - The community's need for more primary care physicians - Whether air pollution has contributed to comparatively high rates of lung (and other types of) cancer - The undersupply of options for indoor exercise and recreation - Concerns regarding the projected population decrease and the need to keep young people in the community - The need for a collective impact model to collaborate and provide a central resource for accessing information about health and services - The importance of learning directly from community members about their needs, rather than developing services based on what could be inaccurate assumptions After discussing the needs identified through secondary data and adding others to the list, each participant was asked through a voting process to identify "three to five" they consider to be most significant. From this process, the group identified the following needs as most significant in the community served by IU Health Blackford Hospital: - Substance abuse - Mental health, including the shortage of mental health workers and psychiatrists - The need to provide health education to enhance health literacy - The need to reduce or eliminate barriers to collaboration among community organizations, including the lack of sharing information about available resources to residents and other organizations - Parental factors, including a lack of participation in available programs designed to address a variety of social and health-related issues in households Community Survey To inform the CHNA, a community survey was conducted by the Indiana Hospital Collaborative. Across Indiana, 9,161 completed questionnaires were received by all participating hospitals in the Indiana Hospital Collaborative, for an overall response rate of 11.6 percent; 5,030 questionnaires were received from the 17 Indiana counties served by one or more IU Health hospitals. For IU Health Blackford Hospital, surveys were received from 296 community households. According to the responses, these households included 530 adults. The community survey indicates that substance use and abuse, obesity, chronic diseases, and poverty represent top concerns in the community served by IU Health Blackford Hospital.
Schedule H, Part V, Section B, Line 7a - CHNA Website	A copy of IU Health Blackford Hospital's CHNA is available on its website at the following URL: https://iuhealth.org/in-the-community/community-benefit
Schedule H, Part V, Section B, Line 10a - Implementation Strategy Website	A copy of IU Health Blackford Hospital's CHNA is available on its website at the following URL: https://iuhealth.org/in-the-community/community-benefit
Schedule H, Part V, Section B, Line 11 - Addressing Identified Needs	In conjunction with the CHNA, IU Health Blackford Hospital's Board adopted an implementation strategy in April 2019 related to the 2018 CHNA. 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. IU Health Blackford Hospital will address the following community health needs between 2019 and 2021: - Access to Healthcare Services - Aging Population and Needs of Seniors - Drug and Substance Abuse (including Opioids and Alcohol) - Maternal and Infant Health and Child Wellbeing - Mental Health - Obesity and Diabetes - Smoking and Tobacco Usage - Social Determinants of Health IU Health uses the term "Behavioral Health" to refer to Mental Health and Drug and Substance Abuse (including Opioids and Alcohol). Access to Healthcare IU Health Blackford Hospital's implementation strategy to address the identified need of Access to Healthcare includes the following: - Recruit new primary care, obstetric and mental health medical doctors to practice in East Central Indiana. - Utilize IU Health's internal recruitment resources. - Leverage IU Health's Ball Memorial Residency Programs for potential recruits. - Maintain and update facilities' plan and initiatives to support incoming practices. - Provide two family medicine directors and a resident rotation at a subsidized rate to local federally qualified health center (FQHC) Open Door Health Services to expand obstetrics capacity to serve low-income residents. Aging Population and Needs of Seniors IU Health Blackford Hospital's implementation strategy to address the identified need of Aging Population and Needs of Seniors include the following: - Support communication, organization and facilitation of local collaboration to advance new food policy, food waste reduction, and food access. - Facilitate organization recruitment and engagement using the collective impact model around improved nutrition, increased physical activity and tobacco cessation. - Organize workgroups and develop partner tools for audience engagement. - Build and maintain Healthy Community Alliance (HCA) website and other communication tools to support partner engagement. - Engage local partners to recruit low-income families to participate. - Provide opportunities for families to learn about nutrition value of fresh produce, physical activity and tobacco cessation. - Offer IU Health Bucks to participants so they may fully engage in farmers' market experience. - Investigate potential partnership levels and investments with community-building activities related to food access, housing, aging population, behavioral health and education. Behavioral Health (includes Drug & Substance Abuse and Mental Health) IU Health Blackford Hospital's implementation strategy to address the identified need of Behavioral Health includes the following: - Provide structured therapeutic recovery program. - Apply for grant funding to expand virtual IOP to serve other East Central Region facilities. - Assist in the establishment of a community network of existing substance use disorders (SUD) related concerns. - Provide access to peer recovery coaches, advanced practice nursing and psychiatry for emergency department (ED) patients who need help with substance use disorders (SUD) related concerns. - Provide prescription medication disposal kiosks at IU Health East Central Region facilities. - Investigate potential partnership levels and investments with community-building activities related to food access, housing, aging population, behavioral health and education. - Provide Perinatal Coordinator to facilitate and collaborate within the hospital and with outside physician offices and community agencies to enhance efforts to decrease infant mortality in the IU Health East Central Region. Maternal and Infant Health and Child Wellbeing IU Health Blackford Hospital's implementation strategy to address the identified need of Maternal and Infant Health and Child Wellbeing include the following: - Provide two family medicine directors and a resident rotation at a subsidized rate to local federally qualified health center (FQHC) Open Door Health Services to expand obstetrics capacity to serve low-income residents. Obesity and Diabetes IU Health Blackford Hospital's implementation strategy to address the identified need of Obesity and Diabetes include the following: - Support communication, organization and facilitation of local collaboration to advance new food policy, food waste reduction, and food access. - Facilitate organization recruitment and engagement using the collective impact model around improved nutrition, increased physical activity and tobacco cessation. - Organize workgroups and develop partner tools for audience engagement. - Build and maintain Healthy Community Alliance (HCA) website and other communication tools to support partner engagement. - Engage local partners to recruit low-income families to participate. - Provide opportunities for families to learn about nutrition value of fresh produce, physical activity and tobacco cessation. - Offer IU Health Bucks to participants so they may fully engage in farmers' market experience. Smoking and Tobacco Usage IU Health Blackford Hospital's implementation strategy to address the identified need of Smoking and Tobacco Usage include the following: - Facilitate organization recruitment and engagement using the collective impact model around improved nutrition, increased physical activity and tobacco cessation. - Organize workgroups and develop partner tools for audience engagement. - Build and maintain Healthy Community Alliance (HCA) website and other communication tools to support partner engagement. - Educate staff regarding "Ask, Advise, Refer" process to refer patients and family members to the Indiana Tobacco Quitline. - Provide Perinatal Coordinator to facilitate and collaborate within the hospital and with outside physician offices and community agencies to enhance efforts to decrease infant mortality in the IU Health East Central Region. - Engage local partners to recruit low-income families to participate. - Provide opportunities for families to learn about nutrition value of fresh produce, physical activity and tobacco cessation. - Offer IU Health Bucks to participants so they may fully engage in farmers' market experience. Social Determinants of Health IU Health Blackford Hospital's implementation strategy to address the identified need of Social Determinants of Health include the following: - Investigate potential partnership levels and investments with community-building activities related to food access, housing, aging population, behavioral health and education. IU Health Blackford Hospital will address all community health needs based on their 2018 Community Health Needs Assessment. There were no identified needs that will not be addressed.
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. IU Health Blackford Hospital's Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Health's Individual Solutions department to determine if healthcare coverage may be obtained from a government insurance/assistance product or from the Health Insurance Exchange Marketplace. 2. Alternate Sources of Assistance When technically feasible, a patient will exhaust all other state and federal assistance programs prior to receiving an award from IU Health Blackford Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health Blackford Hospital's 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 the proper 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. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health Blackford Hospital reserves the right to reverse the award in an amount equal to the amount IU Health Blackford Hospital would be entitled to receive had no Financial Assistance been awarded. 3. Alternate Methods of Eligibility Determination IU Health Blackford Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an Extraordinary Collection Action ("ECA"). Said accounts may be eligible for assistance under the FAP based on the patient's individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health Blackford Hospital will deem patients/guarantors to be presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied his/her required co-pay/deductible: - Indiana Children's Special Health Care Services - Medicaid - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the Federal Poverty Level 4. Additional Considerations Financial Assistance may be granted to a deceased patient's 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. 5. Non-Emergent Services Down Payment Uninsured Patients presenting for scheduled or other non-emergent services will not be charged more than the Amounts Generally Billed ("AGB") for their services. Patients will receive an estimated AGB cost of their care prior to IU Health Blackford Hospital rendering the services and will be asked to pay a down-payment percentage of the AGB adjusted cost prior to receiving services. In the event a patient is unable to fulfill the down-payment, their service may be rescheduled for a later date as medically prudent and in accordance with all applicable federal and state laws and/or regulations. 6. Emergency Services Non-Refundable Deposit This section will be implemented with a strict adherence to Emergency Medical Treatment and Active Labor Act ("EMTALA") and IU Health Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health Blackford Hospital's Emergency Department, via transfer from another hospital facility, or direct admission, will be responsible for a one-hundred dollar ($100.00) non-refundable deposit for services rendered. Patients/guarantors will be responsible for any copays and/or deductibles required by their plan prior to full Financial Assistance being applied. Uninsured Patients wishing to make an application for Financial Assistance greater than the AGB must fulfill their non-refundable deposit prior to IU Health Blackford Hospital processing said application. Uninsured Patients making payments toward their outstanding non-refundable deposit balance will have said payments applied to their oldest application on file, if applicable.
Schedule H, Part V, Section B, Line 16a - FAP Website address	IU Health Blackford Hospital's FAP is available at the following URL: https://iuhealth.org/pay-a-bill/financial-assistance
Schedule H, Part V, Section B, Line 16b - FAP Application Website	IU Health Blackford Hospital's FAP is available at the following URL: https://iuhealth.org/pay-a-bill/financial-assistance
Schedule H, Part V, Section B, Line 16c - FAP PLS Website	A plain language summary of the FAP, including translated copies, is available on the following website: https://iuhealth.org/pay-a-bill/financial-assistance
Schedule H, Part V, Section B, Line 16j - 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. Conspicuous public displays will be 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 will include a conspicuous written notice on all patient billing statements that notifies the patient about the availability of this Policy, and the telephone number of its Customer Service Department which can assist patients with any questions they may have regarding this Policy. 3. IU Health Blackford Hospital Customer Service representatives will be available via telephone Monday through Friday, excluding major holidays, from 8:00 a.m. to 7:00 p.m. Eastern Time to address questions related to this Policy. 4. IU Health Blackford Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health Blackford Hospital will educate its patient facing team members of the FAP and the process for referring patients to the Program.

Schedule H (Form 990) 2019

Page 9

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?3
Name and address		Type of Facility (describe)
1	IU Health Blackford Hospital Radiology 410 Pligrim Blvd Hartford City,IN47348	Diagnostic and Other Outpatient
2	IUH Blackford Physical Therapy and Rehab 410 Pligrim Blvd Hartford City,IN47350	Diagnostic and Other Outpatient
3	IU Health Blackford Pharmacy 400 Pligrim Blvd Hartford City,IN47349	Pharmacy
4
5
6
7
8
9
10

Schedule H (Form 990) 2019

Page 10

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 care under its FAP. These factors include the following: 1. Indiana Residency Requirement Financial Assistance will only be made available to residents of the State of Indiana and those eligible for assistance under 42 U.S.C.A. 1396b(v). IU Health Blackford Hospital will employ the same residency test as set forth in Indiana Code 6-3-1-12 to define an Indiana resident. The term Resident includes any individual who was domiciled in Indiana during the taxable year, or any individual who maintains a permanent place of residence in Indiana and spends more than one hundred eight-three (183) days of the taxable year in Indiana. Patients residing in the state of Indiana while attending an institution of higher education may be eligible for assistance under the FAP if they meet the aforementioned residency test and are not claimed as a dependent on a parent's or guardians' federal income tax return. 2. IU Health Blackford Hospital's Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Health Blackford Hospital's Individual Solutions department to determine if healthcare coverage may be obtained from a government insurance/assistance product or from the Health Insurance Exchange Marketplace. 3. Uninsured Patients All Uninsured Patients presenting for services at IU Health Blackford Hospital eligible under the FAP will not be charged more than the AGB as described in the FAP. 4. Services Rendered by Individual Providers The FAP does not cover services rendered by individual providers. A full listing of providers and services not covered by the FAP is available at https://iuhealth.org/pay-a-bill/financial-assistance and is updated on a quarterly basis. 5. Alternate Sources of Assistance When technically feasible, a patient will exhaust all other state and federal assistance programs prior to receiving an award from IU Health Blackford Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health Blackford Hospital's 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 the proper 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. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health Blackford Hospital reserves the right to reverse the award in an amount equal to the amount IU Health Blackford Hospital would be entitled to receive had no Financial Assistance been awarded. 6. Alternate Methods of Eligibility Determination IU Health Blackford Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an ECA. Said accounts may be eligible for assistance under the FAP based on the patient's individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health Blackford Hospital will deem patients/guarantors to be presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied his/her required co-pay/deductible: - Indiana Children's Special Health Care Services - Medicaid - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the Federal Poverty Level 7. Additional Considerations Financial Assistance may be granted to a deceased patient's 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. 8. Patient Assets IU Health Blackford Hospital may consider patient/guarantor Assets in the calculation of a patient's true financial burden. A patient's/guarantor's primary residence and one (1) motor vehicle will be exempted from consideration in most cases. A patient's primary residence is defined as the patient's principal place of residence and will be excluded from a patient's extraordinary asset calculation so long as the patient's equity is less than five-hundred thousand dollars ($500,000) and the home is occupied by the patient/guarantor, patient's/guarantor's spouse or child under twenty-one (21) years of age. One (1) motor vehicle may be excluded as long as the patient's equity in the vehicle is less than fifty-thousand dollars ($50,000). IU Health Blackford Hospital reserves the right to request a list of all property owned by the patient/guarantor and adjust a patient's award of Financial Assistance if the patient demonstrates a claim or clear title to any extraordinary Asset not excluded from consideration under the above guidance. 9. Non-Emergent Services Down Payment Uninsured Patients presenting for scheduled or other non-emergent services will not be charged more than the AGB for their services. Patients will receive an estimated AGB cost of their care prior to IU Health Blackford Hospital rendering the services and will be asked to pay a down-payment percentage of the AGB adjusted cost prior to receiving services. In the event a patient is unable to fulfill the down-payment, their service may be rescheduled for a later date as medically prudent and in accordance with all applicable federal and state laws and/or regulations. 10. Emergency Services Non-Refundable Deposit This section will be implemented with a strict adherence to EMTALA and IU Health Blackford Hospital Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health Blackford Hospital's Emergency Department, via transfer from another hospital facility, or direct admission, will be responsible for a one-hundred dollar ($100.00) non-refundable deposit for services rendered. Patients/guarantors will be responsible for any copays and/or deductibles required by their plan prior to full Financial Assistance being applied. Uninsured Patients wishing to make an application for Financial Assistance greater than the AGB must fulfill their non-refundable deposit prior to IU Health Blackford Hospital processing said application. Uninsured Patients making payments toward their outstanding non-refundable deposit balance will have said payments applied to their oldest application on file, if applicable.
Schedule H, Part I, Line 6a - C.B. Report Prepared by a Related Org.	IU Health Blackford Hospital's 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 Health's website at https://iuhealth.org/in-the-community/community-benefit 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 System's 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 $1,714,176. Bad debt expense is reported at cost based on the cost-to-charge ratio. Derived from worksheet 2, ratio of patient care cost-to-charges.
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 25.41%.
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 Health's support of the following organizations and initiatives that focus on some of the root causes of the health issues, such as lack of education, employment and poverty: - Healthy Community Alliance of East Central Indiana - Community and Family Services - Hartford City Growers and Makers Market - Blackford Community Schools - Purdue Extension - United Way - Blackford County 4H - Blackford County Chamber of Commerce Additionally, through the IU Health Statewide System's team member community benefit service program, "IU Health Serves," 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 $751,323 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 3 - Est. Bad Debt Attr. to Patients Under FAP	An uninsured patient and/or guarantor who was admitted through an eligible facility's emergency department via a direct admission from a physician's office, or transfer from another hospital facility, and whose household income is less than or equal to 200% of the federal poverty level may be eligible for full charity assistance after the successful completion of the financial assistance application and satisfaction of his/her non-refundable deposit. To capture all patients who are potentially eligible for financial assistance under the IU Health Financial Assistance Policy, IU Health will deem patients/guarantors to be presumptively eligible for financial assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied the required co-pay/deductible: 1. Indiana Children's Special Healthcare Services 2. Medicaid 3. Healthy Indiana Plan 4. Patients who are awarded hospital presumptive eligibility 5. Enrolled in a state and/or federal program that verifies the patient's gross household income in less than or equal to 200% of the federal poverty level (FPL). IU Health also conducts a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for extraordinary collection actions. Said accounts may be eligible for assistance under the financial assistance policy based on the patient's individual scoring criteria and are not included in bad debt, due to this comprehensive methodology, IU Health does not believe any amount of bad debt is attributable to patients who may be eligible under the financial assistance policy and no portion of bad debt is included as community benefit.
Schedule H, Part III, Line 4 - Bad Debt Expense	IU Health's consolidated financial statements, Footnote 4, addresses bad debt expense as follows: The Indiana University Health System does not require collateral or other security from its patients, substantially all of whom are residents of the State, for the delivery of health care services. However, consistent with industry practice, the Indiana University Health System routinely obtains assignment of (or is otherwise entitled to receive) patients' benefits payable under their health insurance programs, plans or policies (e.g., Medicare, Medicaid, managed care payers, and commercial insurance policies). The Indiana University Health System uses a portfolio approach to account for categories of patient contracts as a collective group, rather than recognizing revenue on an individual contract basis. The portfolios consist of major payer classes for inpatient revenue and outpatient revenue. Based on the historical collection trends and other analysis, the Indiana University Health System believes that revenue recognized by utilizing the portfolio approach approximates the revenue that would have been recognized if an individual contract approach were used. In support of its mission, the Indiana University Health System provides care to uninsured and underinsured patients. The Indiana University Health System provides charity care to patients who lack financial resources and are deemed to be medically indigent. Under its financial assistance policy, the Indiana University Health System provides medically necessary care to uninsured patients with inadequate financial resources at charitable discounts equivalent to the amounts generally billed, and it provides eligibility for full charity for emergent encounters for uninsured patients who earn less than 200% of the federal poverty level and who meet application criteria. Patients whose liability is deemed catastrophic relative to their annual household income are also eligible for reduced charges. Since the Indiana University Health System does not pursue collection of these amounts, the discounted amounts are not reported as patient service revenue. The Indiana University Health System uses presumptive eligibility screening procedures for free care and recognizes net patient service revenue on services provided for self-pay patients at the discounted rate at the time of service are rendered. The estimated cost of charity care, using the consolidated cost to charge ratio, was $96,693,000 and $94,886,000 in 2019 and 2018.
Schedule H, Part III, Line 8 - Medicare Shortfall	IU Health Blackford Hospital did not have a Medicare shortfall for 2019. IU Health Blackford Hospital's 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 Health's participation in Medicare programs. For example, the Medicare Cost Report excludes certain costs such as billed physician services, the costs of Medicare Parts C and D, fee schedule reimbursed services, and durable medical equipment services. Inclusion of all costs associated with IU Health Blackford Hospital's participation in Medicare programs would significantly 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 Hospital's FAP and Written Debt Collection 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 are encouraged to submit a Financial Assistance Application within ninety (90) days of their discharge. Patients or their guarantors may submit an application up to two-hundred and forty (240) days from the date of their first billing statement from IU Health, however, accounts may be subject to ECA as soon as one hundred and twenty (120) days after having received their first billing statement. Patients or their guarantors submitting an incomplete application will receive written notification of the application's deficiency upon discovery by IU Health. The application will be pended for a period of forty-five (45) days from the date the notification is mailed. IU Health will suspend any ECA until the application is complete, or the patient fails to cure any deficiencies in their application in the allotted period. Patients with limited English proficiency may request to have a copy of the FAP, a FAP Application, and FAP Plain Language Summary in one of the below languages: - Arabic - Burmese - Burmese-Falam - Burmese-Hakha Chin - Mandarin/Chinese - Spanish The patient, and/or their representative, such as the patient's physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a FAP Application to be mailed to a patient's primary mailing address free of charge. IU Health Blackford Hospital keeps all applications and supporting documentation confidential. Patients applying for assistance under the FAP will be required to complete a Financial Assistance Application. Patients must include the following documentation with their Financial Assistance Application: - All sources of Income for the last three (3) months; - Most recent three (3) months of pay stubs or Supplemental Security Income via Social Security; - Most recent three (3) statements from checking and savings accounts, certificates of deposit, stocks, bonds and money market accounts; - Most recent state and Federal Income Tax forms including schedules C, D, E, and F. In the event a patient's and/or guarantor's income does not warrant the filing of a federal tax return, the patient may submit a notarized affidavit attesting to the foregoing; - Most recent W-2 statement; - For patients or members of the Household who are currently unemployed, Wage Inquiry from WorkOne; and - If applicable, divorce/dissolution decrees and child custody order 2. Eligibility Determination IU Health Blackford Hospital will inform 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 charity assistance and the patient or guarantor provides additional information for reconsideration, IU Health 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 must 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 patient's Financial Assistance Application and eligibility determination are specific to each individual date(s) of service and related encounters. 3. Extraordinary Collection Actions IU Health Blackford Hospital may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patient's eligibility for assistance under the FAP. IU Health Blackford Hospital and its third-party collection agencies may initiate ECA against a patient or their guarantor in accordance with this Policy and 26 C.F.R. 1.501(r). Said ECA may include the following: - Selling a patient's or their guarantor's outstanding financial responsibility to a third party. - Reporting adverse information about the patient or their guarantor to consumer credit reporting agencies or credit bureaus. - Deferring or denying, or requiring a payment before providing, medically necessary care because of a patient's or their guarantor's nonpayment of one or more bills for previously provided care covered under the FAP. - Actions requiring a legal or judicial process, including but not limited to placing a lien on patient's or their guarantor's property, foreclosing on a patient's or their guarantor's real property attaching or seizing a patient's or their guarantor's bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantor's arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantor's wages. When it is necessary to engage in such action, IU Health Blackford Hospital and its third party collection agencies, will engage in fair, respectful and transparent collections activities. Patients or guarantors currently subject to an ECA who have not previously applied for Financial Assistance may apply for assistance up to two-hundred and forty (240) days of the date of their first billing statement from IU Health Blackford Hospital. IU Health Blackford Hospital and their third-party collection agencies will suspend any ECA engaged on a patient or their guarantor while an Application is being processed and considered. 4. Refunds Patients eligible for assistance under the FAP who remitted payment to IU Health Blackford Hospital in excess of their patient responsibility will be alerted to the overpayment as promptly after discovery as is reasonable given the nature of the overpayment. Patients with an outstanding account balance on a separate account not eligible for assistance under the FAP will have their refund applied to the outstanding balance. Patients without an outstanding account balance described above will be issued a refund check for their overpayment as soon as technically feasible.
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 conducting a community health needs assessment (CHNA). For the 2018 CHNA, IU Health Blackford Hospital conducted the community survey data collection in collaboration with Indiana University, University of Evansville and the Indiana Hospital Collaborative, including Community Health Network, Franciscan Alliance, St. Vincent Health and other hospital partners. After completion of the CHNA, IU Health Blackford Hospital reviewed secondary data, findings from other community health assessments of area served by the hospital, input obtained from individuals who participated in community meetings, input obtained from key stakeholders, and a community survey to identify and analyze the needs identified by each source. The top health needs of the IU Health Blackford Hospital community are those that are supported by multiple data sources. Additionally, the effectiveness of an intervention for each need and IU Health's 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 established a FAP to provide Financial Assistance to Uninsured Patients. IU Health Blackford Hospital is committed to ensuring its patients are compliant with all provisions of the Patient Protection & Affordable Care Act. To that end, IU Health Blackford Hospital will make a good faith effort to locate and obtain health insurance coverage for patients prior to considering patients for coverage under the FAP. IU Health Blackford Hospital takes several measures to inform its patients of the FAP and FAP-eligibility. These measures include the following: 1. Conspicuous public displays will be 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 will include a conspicuous written notice on all patient billing statements that notifies the patient about the availability of this Policy, and the telephone number of its Customer Service Department which can assist patients with any questions they may have regarding this Policy. 3. IU Health Customer Service representatives will be available via telephone Monday through Friday, excluding major holidays, from 8:00 a.m. to 7:00 p.m. Eastern Time to address questions related to this Policy. 4. IU Health Blackford Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health Blackford Hospital will educate its patient facing team members of the FAP and the process for referring patients to the Program.
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 (2019) statistics, Blackford County's population is 11,758 persons with approximately 50.6% being female and 49.4% male. The county's population estimates by race are 95.4% White, 1.8% Hispanic or Latino, 0.8% Black, 0.4% Asian, 0.3% American Indian or Alaska Native, and 1.6% persons reporting two or more races. Blackford County has relatively low levels of educational attainment. The level of education most of the population has achieved is a high school degree (89.4%). As of 2019, 13.6% of the population had a bachelor's degree or higher.
Schedule H, Part VI, Line 5 - Promotion of Community Health	During 2019, IU Health Blackford Hospital's promotion of community health included the following highlights: IU Health Blackford Hospital hosted their annual community health fair on Saturday, October 12, 2019 at IU Health Blackford Hospital 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. IU Health Blackford Hospital participates as a supporting partner in a three-county health coalition focused on obesity prevention and tobacco cessation as a means to reduce the impact of chronic disease including cancer and heart disease. More than 150 organizations are partners in the "Healthy Community Alliance of East Central Indiana" coalition and each pledges to influence audiences to make positive choices regarding improved nutrition, increased physical activity or tobacco cessation. Coalition partners report a collective total audience size of more than 50,000 people. As an additional obesity prevention initiative, IU Health Blackford Hospital partners with the Hartford City Growers and Makers Market and other community partners to offer "families at the farmers market." This program consists of three monthly Saturday workshops that offer a wellness-based presentation on utilizing tasty natural herbs, ideal healthy recipes for children, or a diabetes component, grocery shopping tips are often a part of the educational lectures, including a better understanding of nutritional labels and food storage. Participating families also receive free "IU Health Bucks" to shop for produce in the farmers market. In 2019, 7 families participated in the program.
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 Indiana's most comprehensive healthcare system. With hospitals, physician offices and allied services, IU Health provides access to a full range of specialty and primary care services for adults and children. A unique partnership with Indiana University School of Medicine - one of the nation's leading medical schools - gives patients access to groundbreaking research and innovative treatments to complement high-quality care. National Recognition - Eight hospitals designated as Magnet by the American Nurses Credentialing Center recognizing excellence in nursing care. - IU Health Medical Center is honored to be nationally ranked by U.S. News & World Report for the 22nd year in a row. According to the U.S. News rankings, IU Health Medical Center is the No. 1 ranked hospital in Indiana and Indianapolis and the only nationally ranked adult hospital in the state. For 2019-2020, IU Health Medical Center was rated as high performing nationally in five specialties, with a sixth specialty achieving a top 50 national ranking: - Cancer - high performing - Gastroenterology - ranked 45th in nation - Nephrology - high performing - Neurology & Neurosurgery - high performing - Urology - high performing Besides IU Health Medical Center, IU Health has three other hospitals among the 10 top ranked hospitals in Indiana: . IU Health Ball Memorial Hospital - 5th . IU Health Arnett Hospital - 8th . IU Health Bloomington Hospital - 8th The annual rankings, now in their 30th year, are designed to assist patients and their doctors in making informed decisions about where to receive care for challenging health conditions or for common elective procedures. 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. Each year, more than 1,000 residents and fellows receive training in IU Health hospitals. Research conducted by IU School of Medicine faculty gives IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. In 2017, IU Health and the IU School of Medicine announced that they would invest $150 million over five years in the Strategic Research Initiative, a new research collaboration that has enhanced the institutions' joint capabilities in fundamental scientific investigation, translational research and clinical trials. The initial focus is on projects in the fields of neuroscience, cancer and cardiovascular disease with the goal to fund transformative proposals that will fundamentally change our understanding of these diseases and lead to important new therapies for patients. The three target research areas represent research strengths at IU School of Medicine, key strategic service lines for IU Health, and important medical needs in a time of an aging population and rising healthcare costs: - Cancer: One of the initiative's primary goals is to enable the IU Health Melvin and Bren Simon Cancer Center to attain the National Cancer Institute's top status of "comprehensive," which would recognize it as one of the top-tier cancer centers in the nation. This designation was achieved in August 2019 making the center the only NCI-designated Comprehensive Cancer Center in Indiana and one of just 51 in the nation. - Neuroscience: The neurosciences research program tackles a broad range of brain injuries, neurodegenerative disorders and neurodevelopmental disorders. - Cardiovascular: The cardiovascular research initiative develops a comprehensive program for the study and treatment of heart failure, from newborns to older adults. A top priority is developing a cardiovascular genetics program. The Strategic Research Initiative provides patients with access to internationally renowned physicians and to new therapies developed through translational research and clinical trials, and will make use of the latest genetic tools to develop personalized therapies that are more effective for individuals and efficient for healthcare providers. 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 Indiana's 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 Frankfort Hospital - IU Health Jay Hospital - IU Health North Hospital - IU Health Paoli 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 Indiana's overall health. A comprehensive community outreach strategy and community benefit plan is in place that encompasses the academic medical center downtown Indianapolis, suburban Indianapolis and statewide entities around priority areas that focus on health improvement efforts statewide. IU Health is keenly aware of the positive impact it can have on the communities of need in the state of Indiana by focusing on the most pressing needs in a systematic and strategic way. In 2019, IU Health provided over $700 million of dollars in total community benefit and served more than one million individuals. Some ways we address our community health priorities as a system include: IU Health Day of Service The annual IU Health Days of Service is a high-impact event aimed at engaging IU Health team members in activities that address an identified community priority. Each year, more than 2,000 IU Health team members volunteer during the Days of Service. 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 2019, 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. Twenty-four local organizations are benefitting from grants awarded by IU Health. In 2019, IU Health Community Outreach and Engagement awarded more than $900,000 to community organizations and institutions which-like IU Health-are addressing the health needs of the community. These needs include access to affordable healthcare, behavioral health and substance abuse, healthy weight and nutrition and social determinants of health. The grants, administered by the IU Health Foundation, were awarded to the following: Access to Affordable Healthcare - Covering Kids and Families (https://www.ckfindiana.org/) received $25,000 to assist in increasing health insurance enrollment and retention. - LifeSmart Youth (https://lifesmartyouth.org/) received $50,000 toward a new initiative called Tween Education & Access to Community Health (TEACH), which aims to help advance racial health equity and access to care by providing culturally-relevant, medically-accurate reproductive health education to 4,000 Black and Latin youth ages 8 - 12 (grades 4 - 7) in Marion County schools and summer camps. Behavioral Health and Substance Abuse: - Volunteers of America Ohio & Indiana's (https://www.voaohin.org/) (VOAOHIN) Fresh Start Recovery Center received a $75,000 grant to provide residential addiction treatment to pregnant women and mothers. It also allows up to two children ages 5 and under to live with their mother while they receive services. - Goodwill Foundation of Central and Southern Indiana (https://www.goodwillindy.org/foundation/) received $75,000 to help Goodwill Education Initiatives (GEI) Resilience Initiative support resilience work across 15 Excel Center locations by leveraging groundbreaking research on neuroplasticity-the ability of the brain to reorganize itself-and to train staff and students on enhancing their resilience and mitigating the effects of trauma. - Additional grant winners: - Reach for Youth (https://www.reachforyouth.org/) - Lutheran Foundation (https://thelutheranfoundation) - Indy Public Safety Foundation (https://indypsf.org/) Healthy Weight and Nutrition - United Way of Central Indiana, Inc.'s (https://uwci.org/) initiative Jump IN for Healthy Kids received a $50,000 grant to address the epidemic of childhood obesity with a s

Schedule H (Form 990) 2019

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

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 on 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 on 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 nonfixed
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) 2019

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)
1MICHELLE R ALTOBELLA SECRETARY	(i) (ii)	0 ------------- 209,945	0 ------------- 46,778	0 ------------- 698	0 ------------- 17,244	0 ------------- 27,986	0 ------------- 302,651	0 ------------- 0
2JEFFREY C BIRD MD DIRECTOR/PRES.(ECR)	(i) (ii)	0 ------------- 470,693	0 ------------- 176,646	0 ------------- 27,684	0 ------------- 100,293	0 ------------- 22,561	0 ------------- 797,877	0 ------------- 0
3LORI A LUTHER COO	(i) (ii)	0 ------------- 306,078	0 ------------- 42,196	0 ------------- 22,564	0 ------------- 18,075	0 ------------- 23,245	0 ------------- 412,158	0 ------------- 0
4JONATHAN W VANATOR CFO (ECR)	(i) (ii)	0 ------------- 270,283	0 ------------- 37,835	0 ------------- 540	0 ------------- 18,075	0 ------------- 23,903	0 ------------- 350,636	0 ------------- 0
5CARLA C COX RN VP & CNO (ECR)	(i) (ii)	0 ------------- 218,913	0 ------------- 28,577	0 ------------- 3,168	0 ------------- 16,465	0 ------------- 20,137	0 ------------- 287,260	0 ------------- 0
6CHARLES L CARROLL DO PHYSICIAN	(i) (ii)	14,976 ------------- 301,091	24 ------------- 476	0 ------------- 0	856 ------------- 17,219	0 ------------- 0	15,856 ------------- 318,786	0 ------------- 0
7KEVIN W SCHREIBER MD PHYSICIAN	(i) (ii)	19,401 ------------- 422,768	22 ------------- 478	857 ------------- 18,683	960 ------------- 20,910	1,184 ------------- 25,804	22,424 ------------- 488,643	0 ------------- 0
8RODNEY J STEVENS RN Former Key Employee	(i) (ii)	150,671 ------------- 0	18,078 ------------- 0	31,141 ------------- 0	11,346 ------------- 0	12,192 ------------- 0	223,428 ------------- 0	0 ------------- 0
9THOMAS M LEE MD PHYSICIAN	(i) (ii)	2,091 ------------- 302,463	742 ------------- 107,263	47 ------------- 6,811	124 ------------- 17,950	205 ------------- 29,631	3,209 ------------- 464,118	0 ------------- 0
10JUDITH COLEMAN FORMER Officer	(i) (ii)	0 ------------- 259,644	0 ------------- 43,864	0 ------------- 11,122	0 ------------- 18,075	0 ------------- 20,294	0 ------------- 352,999	0 ------------- 0
11DAVID W HYATT DIRECTOR/PRESIDENT	(i) (ii)	0 ------------- 220,323	0 ------------- 29,686	0 ------------- 2,751	0 ------------- 16,500	0 ------------- 30,069	0 ------------- 299,329	0 ------------- 0
12Peter M Voss MD CMO (ECR)	(i) (ii)	0 ------------- 308,299	0 ------------- 42,483	0 ------------- 21,322	0 ------------- 18,075	0 ------------- 24,444	0 ------------- 414,623	0 ------------- 0
13Ann M McGuire VP-Human Resources Regional	(i) (ii)	0 ------------- 163,445	0 ------------- 21,801	0 ------------- 18,490	0 ------------- 13,245	0 ------------- 9,560	0 ------------- 226,541	0 ------------- 0

Schedule J (Form 990) 2019

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 President	IU Health Blackford's Regional President is employed by IU Health, Inc. IU Health Blackford's President is employed by IU Health Ball Memorial Hospital. IU Health, IU Health Ball and other related organizations have a process in place for determining the compensation for the officers and key employees. IU Health human resources uses market data from multiple compensation experts/vendors who utilize a variety of methods and procedures to obtain compensation ranges for comparable officers and employee positons. This market data and multiple other factors (include market pay benchmarks, internal equity, candidate/employee qualifications and performance, and other business needs) are used to recommend compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Please see schedule O for additional details.
Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan	Jeffrey C. Bird M.D. 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. Jeffrey C. Bird M.D. has an amount included in column C, deferred compensation, representing the current year unvested contributions made under the supplemental retirement plan. No amount was actually paid to Jeffrey C. Bird M.D. during the year.
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 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) 2019

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

INDIANA UNIVERSITY HEALTH BLACKFORD
HOSPITAL INC

Employer identification number

01-0646166

Return Reference	Explanation
Form 990, Page 1, Item J - Website address	IU Health Blackford Hospital's website address is: https://iuhealth.org/find-locations/iu-health-blackford-hospital Part VI, Section A, Line 2 - Family or Business Relationships Certain officers, directors or key employees of Indiana University Health, Inc. (IU Health) may also serve on the boards or as officers of other related or unrelated organizations. As noted below, no additional compensation was provided to these individuals for their service to related organizations. Related for-profit organization: Cardinal Health Ventures, Inc. Type of Relationship: Business Director or Officer: Peter M. Voss, M.D., Jeffrey C. Bird, M.D., and John D. Littler Jeffrey C. Bird, M.D. also served as an Officer. Part VI, Section A, Line 4 - Changes to the Governing Documents On May 16, 2019, Article IV, Section 4.9, Board Member Attendance of Indiana University Health Blackford's by-laws were amended to include the ability to grant excused absence.
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. - 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. - Approve the mission and vision statements for the Hospital.
Part VI, Section B, Line 11b - Review of Form 990	The CFO reviewed and approved the Form 990. 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 Health's 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 Health's Conflict of Interest Policy. IU Health's 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 Representative's 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 supervisor's 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 15A & 15B - Process for Determining Comp	The Regional President are employed by IU Health. IU Health's process for determining compensation is as follows: (1) The Board of Directors ("Board") has established a Talent Management and Executive Compensation Committee ("TMECC"), the purpose of which includes reviewing and making recommendations regarding executive (Senior Vice Presidents and above) pay and benefits (collectively referred to as "compensation") on an annual basis. The TMECC is made up of members of the Board that are neither physicians nor employees and do not otherwise have a conflict of interest regarding any of IU Health's compensation arrangements. The TMECC reviews an executive's entire compensation package including base salary, short-term and long-term incentives, health and welfare benefits, qualified and nonqualified retirement plans, as well as any additional fringe benefits. As deemed appropriate, the Committee on Finance, which is also made up of members of the Board, may also review executive compensation and benefits. (2) The TMECC engages an independent compensation consulting firm on an annual basis to conduct a compensation analysis for its executive group, which consists of employees at the level of senior vice president and above. The current compensation advisor is SullivanCotter. SullivanCotter performs its analysis in the form of a compensation survey ("survey") that includes relevant comparability data for compensation 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. SullivanCotter then prepares a survey report and provides recommendations to the TMECC, if deemed appropriate, on changes in executive compensation. A separate analysis using the same methodology is done for the President and Chief Executive Officer. (3) The TMECC then reviews SullivanCotter's report and recommendations and, if appropriate, votes on whether to recommend any changes in executive compensation to the Board. The TMECC will only recommend changes to the Board if they are consistent with the Board's philosophy on compensation matters and are deemed reasonable based upon the independent analysis provided by SullivanCotter. The TMECC's review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval. (4) The Board then reviews the report prepared by SullivanCotter as well as the recommendations of the TMECC as to any changes in executive compensation. As deemed appropriate, the Committee on Finance may also provide its review of the TMECC's recommendations on any changes in executive compensation. This review and discussion are documented in the minutes. (5) The Board then votes on whether to accept the TMECC's recommendations on any changes in executive compensation. Changes in executive compensation are made if approved by the TMECC and Board on an annual basis, or as necessary throughout the year. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval. IU Health's General Counsel also prepares a formal written opinion reviewing the executive compensation approval process, comparing it to the Intermediate Sanctions Test of IRC Section 4958. If warranted, IU Health's General Counsel may also provide comments regarding the executive compensation approval process as it 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 TMECC and Board also review the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executives 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. The discussion and vote of the TMECC 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 TMECC and Audit Committee also review Form 990 disclosures related to executive compensation as well as the organization's practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. IU Health Blackford Hospital's President is an employee of IU Health Ball Memorial Hospital. IU Health Ball, IU Health Blackford, and other related entities have a process in place to determine the compensation for its officers and key employees. IU Health Human Resources uses market data from multiple compensation experts/vendors who utilize a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. This market data and multiple other factors (including market pay benchmarks, internal equity, candidate/employee qualifications & performance, and business needs) are used to recommend compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management.
Part VI, Section C, Line 19 - Public Disclosure	IU Health Blackford Hospital's 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 subsidiary in IU Health's Consolidated Audited Financial Statements. IU Health's Consolidated Audited Financial Statements are available for public inspection through its bond filings and as an attachment to IU Health's Form 990.
Form 990, Part VII - ACRONYM DESCRIPTION	The acronym for the East Central Region, (ECR), is used throughout Form 990, most notably in Part VII and in Schedule J.
FORM 990 PART IX LINE 11G	DESCRIPTION:PROF. FEES/SHARED SERVICES TOTAL FEES:9787548

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

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)	10	IUH	Yes
(2)Indiana Health Info Exchange Inc 846 N Senate Ave Indianapolis,IN46202 36-4550324	Healthcare	IN	501(c)(3)	12 I	NA		No
(3)Indiana University Health Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1955872	Healthcare	IN	501(c)(3)	3	NA		No
(4)IU Health Arnett Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 26-3162145	Healthcare	IN	501(c)(3)	3	IUH	Yes
(5)IU Health Ball Memorial Hospital Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-0867958	Healthcare	IN	501(c)(3)	3	IUH	Yes
(6)IU Health Ball Memorial Physicians Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1925641	Healthcare	IN	501(c)(3)	10	IUHBMH		No
(7)IU Health Bedford Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 23-7042323	Healthcare	IN	501(c)(3)	3	IUH	Yes
(8)IU Health Bloomington Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1720796	Healthcare	IN	501(c)(3)	3	IUH	Yes
(9)IU Health BMH Foundation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 31-1111784	Fundraising	IN	501(c)(3)	12 I	IUHBMH		No
(10)IU Health Care Associates Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1747218	Healthcare	IN	501(c)(3)	10	IUH	Yes
(11)IU Health Frankfort Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 81-5174295	Healthcare	IN	501(c)(3)	3	IUH	Yes
(12)IU Health Jay Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 82-2736786	Healthcare	IN	501(c)(3)	3	IUH	Yes
(13)IU Health Morgan Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 27-3533027	Healthcare	IN	501(c)(3)	10	IUH	Yes
(14)IU Health North Hospital Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1932442	Healthcare	IN	501(c)(3)	3	IUH	Yes
(15)IU Health Paoli Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-2090919	Healthcare	IN	501(c)(3)	3	IUH	Yes
(16)IU Health Plans NFP Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 46-3803873	Insurance	IN	501(c)(4)	N/A	IUH	Yes
(17)IU Health Tipton Hospital Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 26-2772226	Healthcare	IN	501(c)(3)	3	IUH	Yes
(18)IU Health West Hospital Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1814660	Healthcare	IN	501(c)(3)	3	IUH	Yes
(19)IU Health White Memorial Hospital Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 27-3532963	Healthcare	IN	501(c)(3)	3	IUH	Yes
(20)IU Medical Group Foundation Inc 340 W 10th St No FS5100 Indianapolis,IN46202 20-1093251	Fundraising	IN	501(c)(3)	12 II	NA		No
(21)IUHLP Liquidation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-1125434	Healthcare	IN	501(c)(3)	10	IUH	Yes
(22)IUHLP-P Liquidation Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 31-1070868	Healthcare	IN	501(c)(3)	10	IUHLP	Yes
(23)MDwise Marketplace Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 46-5270582	Insurance	IN	501(c)(4)	N/A	IUH	Yes
(24)MDwise Network Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 47-2619552	Insurance	IN	501(c)(4)	N/A	IUH	Yes
(25)IU Health Foundation Inc 1633 N Capitol Ave Ste 1200 Indianapolis,IN46202 35-6043086	Fundraising	IN	501(c)(3)	12 I	IUH	Yes
(26)Methodist Health Group Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 35-0876390	Healthcare	IN	501(c)(3)	12 III-FI	NA		No
(27)Methodist Occup Health Centers Inc 950 N Meridian St Ste 300 Indianapolis,IN46204 35-1844176	Healthcare	IN	501(c)(3)	3	IUH	Yes
(28)Riley Cheer Guild Inc 705 Riley Hospital Dr Indianapolis,IN46202 35-6018517	Fundraising	IN	501(c)(3)	12 III-FI	NA		No
(29)University Family Physicians Inc 950 N Meridian St Ste 800 Indianapolis,IN46204 23-7427350	Healthcare	IN	501(c)(3)	10	IUHCA	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2019

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) BOSC LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 27-0275794	Healthcare	IN	NA
(2) BSC LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 35-2072586	Healthcare	IN	NA
(3) BOSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4147343	Healthcare	IN	NA
(4) BSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-2314634	Healthcare	IN	NA
(5) CHV Fund I LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 26-2523206	Venture Capital	IN	NA
(6) CHV Fund II Mgt LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 37-1717823	Venture Capital	IN	NA
(7) CHV Fund II LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 80-0902337	Venture Capital	IN	NA
(8) CHV Fund Mgmt LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 26-2523151	Venture Capital	IN	NA
(9) Health Vntr Mgmt LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 20-5740218	Management	IN	NA
(10) IEC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4148032	Healthcare	IN	NA
(11) IN Endo Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 20-8398421	Healthcare	IN	NA
(12) ROC Surgery LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 27-1497960	Healthcare	IN	NA
(13) ROCS Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4148369	Healthcare	IN	NA
(14) Sen St Surg Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 42-1709357	Healthcare	IN	NA
(15) SSSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4148167	Healthcare	IN	NA
(16) Egl Hig Srg Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 35-2259204	Healthcare	IN	NA
(17) EHSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 45-4147879	Healthcare	IN	NA
(18) EWASC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 47-3087761	Healthcare	IN	NA
(19) IUH EWA Srg Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 47-3102482	Healthcare	IN	NA
(20) IUH Sax Srg Ctr LLC 569 Brookwood Village Ste 901 Birmingham,AL35244 27-5271091	Healthcare	IN	NA
(21) SSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 46-4472887	Healthcare	IN	NA
(22) IUH FORT WAYNE LLC 950 N Meridian St Ste 800 Indianapolis,IN46204 83-1224627	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 Insurance Company 950 N Meridian St Ste 800 Indianapolis,IN46204 81-1097215	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 950 N Meridian St Ste 300 Indianapolis,IN46204 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) Proteuo Fund LP PO BOX 31106 89 NEXUS WAY CAMANA BAY,GRAND CAYMAN CJ 98-1075227	Investments	CJ	NA	C			Yes
(16) SCANS Inc 950 N MERIDIAN ST STE 800 INDIANAPOLIS,IN46204 45-3080392	Healthcare	IN	NA	C			Yes
(17) Ontario Place Business Park Owners Assoc 1208 W White River Blvd Muncie,IN47303 26-4249298	Condo Management	IN	NA	C			Yes

Schedule R (Form 990) 2019

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

Yes

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

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 RISK RETENTION GROUP INC	R	61,487	FMV
(2) IU HEALTH CARE ASSOCIATES INC	L	61,335	FMV
(3) IU HEALTH CARE ASSOCIATES INC	M	101,411	FMV
(4) IU HEALTH JAY HOSPITAL INC	L	77,010	FMV
(5) IUH Ball Memorial Physicians Inc	M	1,660,420	FMV

Schedule R (Form 990) 2019

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) 2019

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) 2019

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 2019 (Part V, line 2a) ......	5	132
6	Total number of volunteers (estimate if necessary) .............	6	35
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 39 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	0	35,270
9	Program service revenue (Part VIII, line 2g) .........	18,049,392	18,624,801
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	93,731	147,810
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	79,325	114,203
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	18,222,448	18,922,084
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	325	95
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)	7,759,200	5,625,782
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)....	12,170,777	14,764,123
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	19,930,302	20,390,000
19	Revenue less expenses. Subtract line 18 from line 12.......	-1,707,854	-1,467,916
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	15,158,490	12,114,937
21	Total liabilities (Part X, line 26).............	4,234,272	2,658,635
22	Net assets or fund balances. Subtract line 21 from line 20.....	10,924,218	9,456,302

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 15,681,961 including grants of $ 95 ) (Revenue $ 18,519,287 )
	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 $ 65,211 including grants of $ 0 ) (Revenue $ 77,010 )
	IU Health Blackford Hospital leases physician and clinic space to related tax-exempt organizations. IU Health Blackford receives revenue from a related 501(c)(3) entity for shared services.

4c	(Code: ) (Expenses $ 24,137 including grants of $ 0 ) (Revenue $ 28,504 )
	IU Health Blackford received revenue from a related 501(c)(3) entity for shared services.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses15,771,309

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	460,021	4,290,070	643,583

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)		(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
(18) JOHN K JACKSON........................................................................ CHAIR (Partial Year)	5.0 .......................5.0	X	0	0	0
(19) JOHN D LITTLER........................................................................ CHAIR	5.0 .......................10.0	X	0	0	0

(A) Name and business address	(B) Description of services	(C) Compensation
ALLIANCE HEALTHCARE SERVICES, 100 BAYVIEW CIRCLE STE 400 NEWPORT BEACH,CA92658	MEDICAL	130,875




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	35,270
e	Government grants (contributions)		1e

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

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		35,270

		Business Code
2a	NET PATIENT SERVICE REVENUE	622110	18,519,287	18,519,287	0	0
b	SHARED SERVICES	541900	77,010	77,010	0	0
c	RENT FROM RELATED 501(C)(3) ORGS.	532000	28,504	28,504	0
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		18,624,801

3 Investment income (including dividends, interest, and othersimilar amounts) ......			107,810	0	0	107,810
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		1,200	6a
b	Less: rental expenses			6b
c	Rental income or (loss)	0	1,200	6c
d	Net rental income or (loss).......			1,200	0	0	1,200
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	40,000		7a
b	Less: cost or other basis and sales expenses			7b
c	Gain or (loss)	40,000		7c
d	Net gain or (loss).........			40,000	0	0	40,000
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a	0
b	Less: direct expenses ...		8b	0
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a	0
b	Less: direct expenses ...		9b	0
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
			10a	0
b	Less: cost of goods sold ..		10b	0
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	CAFETERIA/FOOD SERVICE		721110	59,300	0	0	59,300
b	VENDING		900099	1,471	0	0	1,471
c	ALL OTHER REVENUE		900099	52,232	0	0	52,232
d	All other revenue ....
e	Total. Add lines 11a–11d ......			113,003
12	Total revenue. See instructions.....			18,922,084	18,624,801	0	262,013

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	95	95
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. 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 ...........	223,428	196,222	27,206
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........	576,427	506,239	70,188
7	Other salaries and wages........	3,607,614	3,168,335	439,279
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	150,393	132,080	18,313
9	Other employee benefits .......	749,284	658,048	91,236
10	Payroll taxes ...........	318,636	279,837	38,799
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	0
c	Accounting ...........	7,350		7,350
d	Lobbying ...........	230		230
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)	9,787,548	6,053,264	3,734,284	0
12	Advertising and promotion ....	3,881		3,881
13	Office expenses .......	50,881	22,490	28,391
14	Information technology ......	9,282	7,232	2,050
15	Royalties ..	0
16	Occupancy ...........	499,798	498,860	938
17	Travel ............	8,352	3,120	5,232
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	170	170
20	Interest ...........	0
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	873,215	856,646	16,569
23	Insurance ...	129,703	30,201	99,502
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	1,714,176	1,714,176	0	0
b	DRUGS AND MEDICAL SUPPLIES	1,092,362	1,092,362	0	0
c	INSTITUTIONAL DUES/LICENSES	3,826	3,826	0	0
d	HOSPITAL ASSESSMENT FEE	480,568	480,568	0	0
e	All other expenses	102,781	67,538	35,243
25	Total functional expenses. Add lines 1 through 24e	20,390,000	15,771,309	4,618,691	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 ........			0	1	0
2	Savings and temporary cash investments .........			4,774,511	2	344
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			2,004,576	4	1,928,080
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				0	6	0
7	Notes and loans receivable, net ...........			0	7	0
8	Inventories for sale or use ............			237,532	8	245,169
9	Prepaid expenses and deferred charges ......			109,628	9	67,664
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	19,991,959
b	Less: accumulated depreciation	10b	12,725,148	8,032,243	10c	7,266,811
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	2,606,869
16	Total assets. Add lines 1 through 15 (must equal line 33)...			15,158,490	16	12,114,937

17	Accounts payable and accrued expenses .....	1,264,067	17	804,161
18	Grants payable ...	0	18	0
19	Deferred revenue .........	43,509	19	0
20	Tax-exempt bond liabilities .........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
		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	2,926,696	25	1,854,474
26	Total liabilities. Add lines 17 through 25..	4,234,272	26	2,658,635

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	10,924,218	27	9,456,302
28	Net assets with donor restrictions ...........	0	28	0
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	10,924,218	32	9,456,302
33	Total liabilities and net assets/fund balances ........	15,158,490	33	12,114,937