TY 2021 Form 990EZ

Form990EZ

Department of the Treasury
Internal Revenue Service

Short Form
Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)

Do not enter social security numbers on this form as it may be made public.

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

OMB No. 1545-0047

2021

Open to Public
Inspection

Check if applicable:

Address change

Name change

Initial return

Final return/terminated

Amended return

Application pending

C Name of organization
MEDICAL STAFF MEMORIAL HOSPITAL OF
UNION COUNTY

Number and street (or P. O. box, if mail is not delivered to street address)500 LONDON AVENUE
Room/suite

City or town, state or province, country, and ZIP or foreign postal code MARYSVILLE, OH43040

D Employer identification number

31-0671145

E Telephone number

(937) 644-6115

F Group Exemption
Number bullet

Part ⅢStatement of Program Service Accomplishments (see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III . .	Expenses (Required for section 501(c)(3) and 501(c)(4) organizations; optional for others.)
What is the organization's primary exempt purpose? TO PROVIDE A MECHANISM FOR ACCOUNTABILITY TO THE BOARD THROUGH DEFINED ORGANIZATIONAL COMPONENTS AND POSITIONS FOR THE APPROPRIATENESS OF PATIENT CARE SERVICES AND THE PROFESSIONAL AND ETHICAL CONDUCT OF EACH PRACTITIONER APPOINTED TO THE MEDICAL STAFF OR OTHERWISE GRANTED CLINICAL PRVILEGES AT THE HOSPITAL, TO THE END THAT PATIENT CARE PROVIDED AT THE HOSPITAL IS MAINTAINED AT THAT LEVEL OF QUALITY AND EFFICIENCY WHICH IS COMMENSURATE WITH, OR SUPERIOR TO, GENERALLY RECOGNIZED STANDARDS OF CARE.
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 TO SERVE AS THE COLLEGIAL BODY THROUGH WHICH PRACTITIONERS MAY OBTAIN PREROGATIVES AND CLINICAL PRIVILEGES AT THE HOSPITAL, TO PROVIDE AN APPROPRIATE EDUCATIONAL SETTING, TO PROVIDE AN ORDERLY AND SYSTEMATIC MEANS BY WHICH STAFF APPOINTEES CAN GIVE INPUT TO THE BOARD AND HOSPITAL PRESIDENT, TO INITIATE AND MAINTAIN THE MEDICAL STAFF BYLAWS AND RELATED MANUALS AND DEPARTMENTAL POLICIES FOR SELF-GOVERNING OF THE MEDICAL STAFF. (Grants $ 5,700) If this amount includes foreign grants, check here ...			28a	52,609
29 (Grants $ ) If this amount includes foreign grants, check here ...			29a
30 (Grants $ ) If this amount includes foreign grants, check here ...			30a
31 Other program services (describe in Schedule O) ................ (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a)..........	32	52,609

(a) Name and title	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC) (if not paid, enter -0-)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation
CHARLES MUNCRIEF PRESIDENT	15.00	0
DELIA HERZOG VICE PRESIDE	13.00	0
VINCE BRINKMAN SEC/TREAS	7.50	0
MATTHEW HAZELBAKER DOC CHAIR	7.00	0
JEFFREY HAZEL DOS CHAIR	7.50	0
MICHAEL JORDAN DOS VICE CHA	6.00	0
JUSTIN KRUEGER DOM CHAIR	7.50	0
SHAHRUKH HASHMI DOM VICE CHA	6.00	0
TRISTA SCHRICKEL OB CHAIR	4.50	0

Yes

Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II .......................

Is the organization a school as described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ..

49a

Did the organization make any transfers to an exempt non-charitable related organization?......

49a

If "Yes," was the related organization a section 527 organization?................

49b

Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and title of each employee	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation

Total number of other employees paid over $100,000 ............. bullet

Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and business address of each independent contractor	(b) Type of service	(c) Compensation

Return Reference	Explanation
FORM 990-EZ, PART I, LINE 16	EXPENSES MEETING EXPENSES 2,209 DIRECTOR STIPENDS 42,200 GIFTS 2,500 TOTAL 46,909
FORM 990-EZ, PART III	TO PROVIDE A MECHANISM FOR ACCOUNTABILITY TO THE BOARD THROUGH DEFINED ORGANIZATIONAL COMPONENTS AND POSITIONS FOR THE APPROPRIATENESS OF PATIENT CARE SERVICES AND THE PROFESSIONAL AND ETHICAL CONDUCT OF EACH PRACTITIONER APPOINTED TO THE MEDICAL STAFF OR OTHERWISE GRANTED CLINICAL PRVILEGES AT THE HOSPITAL, TO THE END THAT PATIENT CARE PROVIDED AT THE HOSPITAL IS MAINTAINED AT THAT LEVEL OF QUALITY AND EFFICIENCY WHICH IS COMMENSURATE WITH, OR SUPERIOR TO, GENERALLY RECOGNIZED STANDARDS OF CARE.
FORM 990-EZ, PART III, LINE 28	TO SERVE AS THE COLLEGIAL BODY THROUGH WHICH PRACTITIONERS MAY OBTAIN PREROGATIVES AND CLINICAL PRIVILEGES AT THE HOSPITAL, TO PROVIDE AN APPROPRIATE EDUCATIONAL SETTING, TO PROVIDE AN ORDERLY AND SYSTEMATIC MEANS BY WHICH STAFF APPOINTEES CAN GIVE INPUT TO THE BOARD AND HOSPITAL PRESIDENT, TO INITIATE AND MAINTAIN THE MEDICAL STAFF BYLAWS AND RELATED MANUALS AND DEPARTMENTAL POLICIES FOR SELF-GOVERNING OF THE MEDICAL STAFF.

Return Reference

Explanation

FORM 990-EZ, PART I, LINE 16

EXPENSES MEETING EXPENSES 2,209 DIRECTOR STIPENDS 42,200 GIFTS 2,500 TOTAL 46,909

FORM 990-EZ, PART III

TO PROVIDE A MECHANISM FOR ACCOUNTABILITY TO THE BOARD THROUGH DEFINED ORGANIZATIONAL COMPONENTS AND POSITIONS FOR THE APPROPRIATENESS OF PATIENT CARE SERVICES AND THE PROFESSIONAL AND ETHICAL CONDUCT OF EACH PRACTITIONER APPOINTED TO THE MEDICAL STAFF OR OTHERWISE GRANTED CLINICAL PRVILEGES AT THE HOSPITAL, TO THE END THAT PATIENT CARE PROVIDED AT THE HOSPITAL IS MAINTAINED AT THAT LEVEL OF QUALITY AND EFFICIENCY WHICH IS COMMENSURATE WITH, OR SUPERIOR TO, GENERALLY RECOGNIZED STANDARDS OF CARE.

FORM 990-EZ, PART III, LINE 28

TO SERVE AS THE COLLEGIAL BODY THROUGH WHICH PRACTITIONERS MAY OBTAIN PREROGATIVES AND CLINICAL PRIVILEGES AT THE HOSPITAL, TO PROVIDE AN APPROPRIATE EDUCATIONAL SETTING, TO PROVIDE AN ORDERLY AND SYSTEMATIC MEANS BY WHICH STAFF APPOINTEES CAN GIVE INPUT TO THE BOARD AND HOSPITAL PRESIDENT, TO INITIATE AND MAINTAIN THE MEDICAL STAFF BYLAWS AND RELATED MANUALS AND DEPARTMENTAL POLICIES FOR SELF-GOVERNING OF THE MEDICAL STAFF.

1	Contributions, gifts, grants, and similar amounts received ....................	1
2	Program service revenue including government fees and contracts ................	2
3	Membership dues and assessments .............................	3	42,000
4	Investment income ....................................	4
5a	Gross amount from sale of assets other than inventory .......	5a
b	Less: cost or other basis and sales expenses ............	5b
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......	5c
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000)	6a
b	Gross income from fundraising events (not including $ of contributions from fundraising events reported on line 1) (attach Schedule G if the			sum of such gross income and contributions exceeds $15,000) ..	6b
c	Less: direct expenses from gaming and fundraising events ...	6c
d	Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)	6d
7a	Gross sales of inventory, less returns and allowances ......	7a
b	Less: cost of goods sold .............	7b
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........	7c
8	Other revenue (describe in Schedule O) ....................	8
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ..............	9	42,000

18	Excess or (deficit) for the year (Subtract line 17 from line 9) ............	18	-10,609
19	Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
	end-of-year figure reported on prior year’s return) .................	19	121,338
20	Other changes in net assets or fund balances (explain in Schedule O) ...........	20
21	Net assets or fund balances at end of year. Combine lines 18 through 20 ..........	21	110,729

Sign Here

	Signature of officer	Date

	Type or print name and title

10	Grants and similar amounts paid (list in Schedule O) ................	10	5,700
11	Benefits paid to or for members ......................	11
12	Salaries, other compensation, and employee benefits ................	12
13	Professional fees and other payments to independent contractors ............	13
14	Occupancy, rent, utilities, and maintenance ...................	14
15	Printing, publications, postage, and shipping ...................	15
16	Other expenses (describe in Schedule O) ...................	16	46,909
17	Total expenses. Add lines 10 through 16 .................	17	52,609

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