Form990


Department of the TreasuryInternal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
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OMB No. 1545-0047
2021
Open to Public Inspection
A For the 2021 calendar year, or tax year beginning 07-01-2021 , and ending 06-30-2022
BCheck if applicable:
CName of organization
The Ingalls Memorial Hospital
 
 
Doing business as
 
 
Number and street (or P.O. box if mail is not delivered to street address)
One Ingalls Drive
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Harvey, IL60426
D Employer identification number

36-2170866
E Telephone number

G Gross receipts $ 351,131,134
F Name and address of principal officer:
MICHAEL ANTONIADES
One Ingalls Drive
Harvey,IL60426
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.INGALLS.ORG
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. See instructions.
H(c)
Group exemption number MediumBullet  
K Form of organization:  
L Year of formation: 1922
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: INGALLS MEMORIAL HOSPITAL IS A NONPROFIT ACUTE CARE HOSPITAL ORGANIZED FOR THE PURPOSE OF PROVIDING PATIENT CARE, EDUCATION, AND RESEARCH.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 12
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 8
5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) ...... 5 2,645
6 Total number of volunteers (estimate if necessary) ............. 6 58
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 799,429
b Net unrelated business taxable income from Form 990-T, Part I, line 11 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 26,728,626 11,362,917
9 Program service revenue (Part VIII, line 2g) ......... 303,821,660 328,667,723
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 7,329,267 7,831,360
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 2,951,802 2,445,923
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 340,831,355 350,307,923
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 69,750 166,500
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 143,998,787 161,832,244
16a Professional fundraising fees (Part IX, column (A), line 11e) .....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet304,182    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 197,781,277 196,854,273
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 341,849,814 358,853,017
19 Revenue less expenses. Subtract line 18 from line 12....... -1,018,459 -8,545,094
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 491,188,340 479,733,184
21 Total liabilities (Part X, line 26)............. 249,831,648 257,529,322
22 Net assets or fund balances. Subtract line 21 from line 20..... 241,356,692 222,203,862
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2021)
Form 990 (2021)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III..............
1
Briefly describe the organization’s mission: INGALLS MEMORIAL HOSPITAL IS A NONPROFIT ACUTE CARE HOSPITAL ORGANIZED FOR THE PURPOSE OF PROVIDING PATIENT CARE, EDUCATION, RESEARCH, AND ASSISTANCE TO UCM COMMUNITY HEALTH & HOSPITAL DIVISION.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? .....................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ...........................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 188,383,811 including grants of $ 71,500 ) (Revenue $ 219,043,451 )
INGALLS MEMORIAL (IMH) INCLUDES A 400+ CERTIFIED BED HOSPITAL AND A NETWORK OF COMPREHENSIVE OUTPATIENT CENTERS THAT FEATURE A FULL ARRAY OF HIGH-TECH DIAGNOSTIC AND TREATMENT SERVICES. IMH MAKES SURE THAT OUR RESOURCES ARE DIRECTED TO AREAS THAT RESULT IN THE GREATEST BENEFIT TO OUR PATIENTS AND THE COMMUNITY.
4b (Code:   ) (Expenses $ 28,589,279 including grants of $   ) (Revenue $ 44,057,863 )
THE PHARMACY PROVIDES SERVICES TO BOTH OUR INPATIENTS AND INFUSION CENTER PATIENTS. INCLUDED IN THE SERVICES PROVIDED ARE ANTIBIOTIC DOSING, DOSING BASED ON KIDNEY FUNCTION, BLOOD GLUCOSE MANAGEMENT, AND ANTICOAGULANT DOSING AND MONITORING. THE INPATIENT PHARMACY IS OPEN 24/7. WE PROCESS APPROXIMATELY 59,000 MEDICATION ORDERS AND MAKE 3,500 INTERVENTIONS PER MONTH.
4c (Code:   ) (Expenses $ 14,300,560 including grants of $   ) (Revenue $ 18,583,369 )
IMH PERFORMS AN ARRAY OF SURGICAL SERVICES INCLUDING ELECTIVE, NON-ELECTIVE, COMPLEX AND HIGHLY SPECIALIZED PROCEDURES. SURGEONS ON STAFF AT INGALLS SPECIALIZE IN EVERY AREA OF SURGERY, INCLUDING, BUT NOT LIMITED TO CARDIOTHORACIC SURGERY, ORTHOPEDIC SURGERY, NEUROSURGERY, SPINE SURGERY, GENERAL SURGERY, AND VASCULAR SURGERY. IN FY2022 INGALLS PERFORMED 1,277 INPATIENT SURGERIES AND 2,306 AMBULATORY SURGERIES.
(Code:   ) (Expenses $ 91,593,870 including grants of $ 95,000 ) (Revenue $ 49,526,422 )
OTHER PROGRAM SERVICES RELATED TO THE PROVISION OF HEALTHCARE INCLUDE LABORATORY SERVICES, PATIENT FINANCIAL SERVICES, COST OF FACILITIES, MALPRACTICE INSURANCE, AND OTHER SUPPORT SERVICES.
4d Other program services (Describe in Schedule O.)
(Expenses $ 91,593,870 including grants of $ 95,000 ) (Revenue $ 49,526,422 )
4e Total program service expensesMediumBullet322,867,520
Form 990 (2021)
Form 990 (2021)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? See instructions. Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I.............
3
 
No
4
Section 501(c)(3) organizations. 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 IIClick to see attachment.........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Rev. Proc. 98-19? If "Yes," complete Schedule C, Part III..
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I.........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II....
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part III..............
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part V......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X, as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete
Schedule D, Part VI. Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XII......................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States? .....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I. See instructions. ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....Click to see attachment
21
Yes
 
Form 990 (2021)
Form 990 (2021)
Page 4
Part IV
Checklist of Required Schedules (continued)
Yes
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........Click to see attachment
22
Yes
 
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............
24c
 
No
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I ....
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I.......................
25b
 
No
26
Did the organization report any amount on Part X, line 5 or 22 for receivables from or 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? If "Yes," complete Schedule L, Part II...........
26
 
No
27
Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?
If "Yes," complete
Schedule L, Part III.........................
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see the Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................
28a
 
No
b
A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....
28b
 
No
c
A 35% controlled entity of one or more individuals and/or organizations described in line 28a or 28b? If "Yes," complete Schedule L, Part IV.....................
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M .................
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II........................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I............
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1.........................Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ...Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2.............
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations on Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........
Yes
No
1a
Enter the number reported in box 3 of Form 1096. Enter -0- if not applicable ..
1a
213
b
Enter the number of Forms W-2G included on line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
Form 990 (2021)
Form 990 (2021)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance (continued)
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
2,645
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. See instructions.
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................
7a
 
No
b
If "Yes," did the organization notify the donor of the value of the goods or services provided? .....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?........
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources. (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state? .........
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
15
Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see the instructions and file Form 4720, Schedule N.
15
 
No
16
Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.
16
 
No
17
Section 501(c)(21) organizations. Did the trust, any disqualified person, or mine operator engage in any activities that would result in the imposition of an excise tax under section 4951, 4952, or 4953? ..
If "Yes," complete Form 6069.
17
 
 
Form 990 (2021)
Form 990 (2021)
Page 6
Part VI
Governance, Management, and Disclosure. For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
1a
12
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
1b
8
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? .
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .......................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe on Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe on Schedule O how this was done...................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process on Schedule O. See instructions.
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the states with which a copy of this Form 990 is required to be filedMediumBullet
IL
18
Section 6104 requires an organization to make its Form 1023 (1024 or 1024-A, if applicable), 990, and 990-T (section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletJUSTIN KATS150 HARVESTER DRIVE SUITE 300   BURR RIDGE,IL60527 (708) 333-2300
Form 990 (2021)
Form 990 (2021)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See the instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (box 5 of Form W-2, Form 1099-MISC, and/or box 1 of Form 1099-NEC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

See the instructions for the order in which to list the persons above.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC/1099-NEC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) DAVID H ORTH MD
 
CHAIRMAN (THRU 7/1/21)
 1.0
.................
2.0 		X   X       0 0 0
(2) DENNIS IRVIN
 
VICE CHAIRMAN
 1.0
.................
0 		X   X       0 0 0
(3) KEVIN M PURCELL
 
CHAIRMAN
 1.0
.................
2.0 		X   X       0 0 0
(4) RANDY NEISWONGER
 
INTERIM PRESIDENT CHHD
 40.0
.................
7.0 		X   X       544,558 0 71,534
(5) SAMUEL J CUTRARA JR
 
SECRETARY/TREASURER
 1.0
.................
1.0 		X   X       0 0 0
(6) CORRIN STEINHAUER
 
BOARD MEMBER/VP PATIENT CARE & CNO, INGALLS (THRU 4/22/22)
 40.0
.................
0.0 		X           0 421,206 74,053
(7) DOROTHY JONES MD
 
BOARD MEMBER
 1.0
.................
0 		X           0 0 0
(8) ENGIN YILMAZ MD
 
BOARD MEMBER
 1.0
.................
40.0 		X           0 460,274 7,509
(9) FRANCIS ALMEDA MD
 
BOARD MEMBER
 1.0
.................
0 		X           0 0 0
(10) HENRY JOHNSON
 
BOARD MEMBER
 1.0
.................
0 		X           0 0 0
(11) JOHN A FLYNN MD
 
BOARD MEMBER (THRU 9/23/21)
 1.0
.................
43.0 		X           0 793,961 56,645
(12) MARK KOZLOFF MD
 
BOARD MEMBER
 1.0
.................
41.0 		X           0 723,872 33,365
(13) MILDRED WILLIAMS-REID
 
BOARD MEMBER
 1.0
.................
0 		X           0 0 0
(14) NATHANIEL SUTTON
 
BOARD MEMBER
 1.0
.................
1.0 		X           0 0 0
(15) STEPHEN WEBER MD
 
BOARD MEMBER (EFF. 9/23/21)
 1.0
.................
41.0 		X           0 2,100,916 168,562
(16) ANN MCCOLGAN
 
ASSISTANT TREASURER
 1.0
.................
45.0 		    X       0 488,668 81,343
(17) IVAN SAMSTEIN
 
CHIEF FINANCIAL OFFICER
 1.0
.................
48.0 		    X       0 854,927 125,085
Form 990 (2021)
Form 990 (2021)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC/1099-NEC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) TOMASZ SAMEK
 
ASSISTANT SECRETARY
 40.0
.......................2.0 		    X       0 193,752 27,563
(19) DOUGLAS SAEGESSER
 
VP OF FINANCE (THRU 9/8/2021)
 40.0
.......................4.0 		      X     447,895 0 35,479
(20) PAUL DONOHUE
 
VP PHILANTHROPY AND COMMUNITY
 40.0
.......................0 		      X     263,367 0 66,202
(21) KRISTINE SHIELDS
 
OCCUPATIONAL MEDICINE
 40.0
.......................0 		        X   239,119 0 2,948
(22) LISA LIGUE
 
DIRECTOR, REVENUE CYCLE
 40.0
.......................0 		        X   225,911 0 2,859
(23) MARY JO CRANDALL
 
VP OPERATIONS
 40.0
.......................0 		        X   258,048 0 3,230
(24) NEGIN KIYAVASH
 
DIRECTOR OF PHARMACY
 40.0
.......................0 		        X   221,020 0 32,768
(25) POONAM DESAI
 
EXECUTIVE DIRECTOR, AMBULATORY
 40.0
.......................0 		        X   236,760 0 46,332
(26) BRIAN SINOTTE
 
FORMER PRESIDENT CHHD (THRU 5/31/21)
 0.0
.......................0.0 		          X 423,750 0 7,627
(27) GARY GASBARRA
 
INTERIM CFO TIL 6/30/17
 0.0
.......................42.0 		          X 0 610,418 78,815
(28) RICHARD W SILVERIA
 
FORMER CHIEF FINANCIAL OFFICER (THRU 4/22/21)
 0.0
.......................0.0 		          X 0 1,906,873 21,121




1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)...........MediumBullet 2,860,428 8,554,866 943,040
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet133
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
VIZIENT INC

290 E JOHN CARPENTER FREEWAY
IRVING,TX75062 		CONTRACT LABOR 18,966,561
CARDINAL HEALTH VALUELINK

PO BOX 70539
CHICAGO,IL60673 		SUPPLY CHAIN SERVICES 7,152,027
CROTHALL HEALTHCARE

25271 NETWORK PLACE
CHICAGO,IL60637 		HEALTHCARE SUPPORT SERVICES 6,366,566
CERNER HEALTH SERVICES

PO BOX 959156
SAINT LOUIS,MO63195 		IT SUPPORT 5,640,516
SYNERGY BEHAVIORAL HEALTHCARE

1566 W ALGONQUIN ROAD
HOFFMAN ESTATES,IL60192 		BEHAVIORAL HEALTH 5,622,139
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet102
Form 990 (2021)
Form 990 (2021)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII.............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512 - 514
Contributions, Gifts, Grants, and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues..1b  
c Fundraising events..1c  
d Related organizations1d 8,076,881
e Government grants (contributions)1e 3,285,694
f All other contributions, gifts, grants, and similar amounts not included above1f 342
g Noncash contributions included in lines 1a - 1f:$ 1g  
h Total. Add lines 1a-1f.......MediumBullet 11,362,917
Program Service RevenueAmt Business Code
2a NET PATIENT REVENUE 622110 324,687,170 324,687,170    
b RENTAL INCOME 900099 1,560,020 1,560,020    
c LAB SERVICES 621500 799,429   799,429  
d BONUS FROM IPG 900099 850,116 850,116    
e FOOD SERVICE 900099 627,247 627,247    
f All other program service revenue. 143,741 143,741 0 0
g Total. Add lines 2a–2f .....MediumBullet 328,667,723
OtherAmtRevenueAmt 3 Investment income (including dividends, interest, and othersimilar amounts) ......MediumBullet 1,488,525     1,488,525
4 Income from investment of tax-exempt bond proceedsMediumBullet        
5 Royalties...........MediumBullet        
(ii) Personal (i) Real
6a Gross rents   725,752 6a
b Less: rental expenses   823,211 6b
c Rental income or (loss) 0 -97,459 6c
d Net rental income or (loss).......MediumBullet -97,459     -97,459
(ii) Other (i) Securities
7a Gross amount from sales of assets other than inventory   6,342,835 7a
b Less: cost or other basis and sales expenses     7b
c Gain or (loss) 0 6,342,835 7c
d Net gain or (loss).........MediumBullet 6,342,835     6,342,835
8a Gross income from fundraising events (not including $   of contributions reported on line 1c). See Part IV, line 18 ....
8a  
b Less: direct expenses ... 8b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
9a  
b Less: direct expenses ... 9b  
c Net income or (loss) from gaming activities..MediumBullet        
10a Gross sales of inventory, less
returns and allowances ..
10a  
b Less: cost of goods sold .. 10b  
c Net income or (loss) from sales of inventory..MediumBullet        
Business Code Miscellaneous Revenue
11a 340B PROGRAM 900099 746,564 746,564    
b MANAGEMENT FEES 900099 278,568 278,568    
c BANK REBATES 900099 599,516 599,516    
d All other revenue .... 918,734 918,734 0 0
e Total. Add lines 11a–11d ...... MediumBullet 2,543,382
12 Total revenue. See instructions.....MediumBullet 350,307,923 330,411,676 799,429 7,733,901
Form 990 (2021)
Form 990 (2021)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX..............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising
expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 95,000 95,000
2 Grants and other assistance to domestic individuals. See Part IV, line 22 ........... 71,500 71,500
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............    
4 Benefits paid to or for members .......    
5 Compensation of current officers, directors, trustees, and key employees ........... 1,525,207 309,566 911,459 304,182
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........        
7 Other salaries and wages........ 140,171,223 129,163,860 11,007,363  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 2,577,506 2,392,949 184,557  
9 Other employee benefits ....... 10,287,440 9,448,252 839,188  
10 Payroll taxes ........... 7,270,868 6,647,953 622,915  
11 Fees for services (non-employees):        
a Management ...... 3,814,980   3,814,980  
b Legal .........        
c Accounting ........... 210,262   210,262  
d Lobbying ........... 31,559   31,559  
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ...... 573,646   573,646  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) 49,817,937 42,221,720 7,596,217 0
12 Advertising and promotion .... 1,606,202   1,606,202  
13 Office expenses ....... 2,919,640 1,906,871 1,012,769  
14 Information technology ...... 12,320,312 8,774,322 3,545,990  
15 Royalties ..        
16 Occupancy ........... 5,403,794 5,084,143 319,651  
17 Travel ............ 121,035 71,206 49,829  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials .        
19 Conferences, conventions, and meetings ....        
20 Interest ........... 4,131,300 4,131,300    
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .. 14,889,370 14,889,370    
23 Insurance ... 16,208,069 13,525,790 2,682,279  
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 MEDICAL SUPPLIES 59,602,210 59,467,083 135,127  
b PUBLIC ASSESSMENT 17,923,084 17,923,084    
c REPAIRS & MAINTENANCE 5,358,790 4,986,439 372,351  
d LAUNDRY SERVICES 1,297,509 1,289,986 7,523  
e All other expenses 624,574 467,126 157,448 0
25 Total functional expenses. Add lines 1 through 24e 358,853,017 322,867,520 35,681,315 304,182
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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2021)
Form 990 (2021)
Page 11
Part X
Balance Sheet
Check if Schedule O contains a response or note to any line in this Part IX..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ........ 5,220 1 5,220
2 Savings and temporary cash investments ......... 18,384 2 23,814
3 Pledges and grants receivable, net ......   3  
4 Accounts receivable, net ............. 41,878,302 4 41,394,560
5 Loans and other receivables from 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 ...........   7  
8 Inventories for sale or use ............ 6,682,363 8 6,777,269
9 Prepaid expenses and deferred charges ...... 2,484,699 9 2,316,969
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 282,824,199
b Less: accumulated depreciation 10b 86,669,381 182,833,874 10c 196,154,818
11 Investments—publicly traded securities . 148,668,551 11 129,349,004
12 Investments—other securities. See Part IV, line 11 ..... 0 12  
13 Investments—program-related. See Part IV, line 11 .. 0 13  
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 108,616,947 15 103,711,530
16 Total assets. Add lines 1 through 15 (must equal line 33)... 491,188,340 16 479,733,184
Liabilities 17 Accounts payable and accrued expenses ..... 126,726,867 17 144,685,915
18 Grants payable ...   18  
19 Deferred revenue ......... 5,908,645 19 6,330,281
20 Tax-exempt bond liabilities ......... 34,057,540 20 32,143,937
21 Escrow or custodial account liability. Complete Part IV of Schedule D   21  
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 .. 63,087,786 23 61,371,463
24 Unsecured notes and loans payable to unrelated third parties ..   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D 20,050,810 25 12,997,726
26 Total liabilities. Add lines 17 through 25.. 249,831,648 26 257,529,322
Net Assets or Fund Balance Organizations that follow FASB ASC 958, check here MediumBullet and complete lines 27, 28, 32, and 33.
27 Net assets without donor restrictions .......... 238,197,644 27 218,994,374
28 Net assets with donor restrictions ........... 3,159,048 28 3,209,488
Organizations that do not follow FASB ASC 958, check here MediumBullet 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 ........... 241,356,692 32 222,203,862
33 Total liabilities and net assets/fund balances ........ 491,188,340 33 479,733,184
Form 990 (2021)
Form 990 (2021)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
350,307,923
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
358,853,017
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
-8,545,094
4
Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..
4
241,356,692
5
Net unrealized gains (losses) on investments ...............
5
-21,292,427
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
10,684,691
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))
10
222,203,862
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII.............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain on
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
Yes
 
Form 990 (2021)
Form 990 (2021)
Additional Data


Software ID: 21014044
Software Version: 2021v4.2
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990)

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
2021
Open to Public
Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
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.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations ...............................  
g
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 10 above (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
Yes No
Total
 
   
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Cat. No. 11285F
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
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) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (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) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (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  
12
12
 
13
First 5 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
14
14
 
15
15
 
16a
b
17a
b
18
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) 2021

Schedule A (Form 990) 2021
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) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (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) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (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 on 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.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
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.
1
 
 
2
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).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below.
3a
 
 
b
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.
3b
 
 
c
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.
3c
 
 
4a
Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.
4a
 
 
b
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.
4b
 
 
c
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.
4c
 
 
5a
Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer lines 5b and 5c 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).
5a
 
 
b
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?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
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.
6
 
 
7
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) .
7
 
 
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If “Yes,” complete Part I of Schedule L (Form 990).
8
 
 
9a
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.
9a
 
 
b
Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
 
 
c
Did a disqualified person (as defined on 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.
9c
 
 
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
 
 
b
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) 2021

Schedule A (Form 990) 2021
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described on lines 11b and 11c below, the governing body of a supported organization?
11a
 
 
b
A family member of a person described on 11a above?
11b
 
 
c
A 35% controlled entity of a person described on line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.
11c
 
 
Section B. Type I Supporting Organizations
Yes
No
1
Did the officers, 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.
1
 
 
2
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.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
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).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
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?
1
 
 
2
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).
2
 
 
3
By reason of the relationship described in line 2 above, 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.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer lines 2a and 2b below.
Yes
No
a
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.
2a
 
 
b
Did the activities described on line 2a, above 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.
2b
 
 
3
Parent of Supported Organizations. Answer lines 3a and 3b below.
a
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?If "Yes" or "No", provide details in Part VI.
3a
 
 
b
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.
3b
 
 
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
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 0.015 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 0.035 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  
7
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
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 1  
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in
excess of income from activity 		2  
3 Administrative expenses paid to accomplish exempt purposes of supported organizations 3  
4 Amounts paid to acquire exempt-use assets 4  
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) 5  
6 Other distributions (describe in Part VI). See instructions 6  
7Total annual distributions. Add lines 1 through 6. 7  
8 Distributions to attentive supported organizations to which the organization is responsive (provide
details in Part VI). See instructions 		8  
9 Distributable amount for 2021 from Section C, line 6 9  
10 Line 8 amount divided by Line 9 amount 10  
Section E - Distribution Allocations (see instructions) (i)
Excess Distributions 		(ii)
Underdistributions
Pre-2021 		(iii)
Distributable
Amount for 2021
1 Distributable amount for 2021 from Section C, line 6  
2 Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI).
See instructions.		  
3 Excess distributions carryover, if any, to 2021:
a From 2016.......  
b From 2017.......  
c From 2018.......  
d From 2019.......  
e From 2020.......  
fTotal of lines 3a through e  
g Applied to underdistributions of prior years  
h Applied to 2021 distributable amount  
i Carryover from 2016 not applied (see
instructions) 		 
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.  
4Distributions for 2021 from Section D, line 7:
$  
a Applied to underdistributions of prior years  
b Applied to 2021 distributable amount  
c Remainder. Subtract lines 4a and 4b from line 4.  
5 Remaining underdistributions for years prior to
2021, 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 2021. 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 2022. Add lines
3j and 4c. 		 
8 Breakdown of line 7:
a Excess from 2017.....  
b Excess from 2018.....  
c Excess from 2019.....  
d Excess from 2020.....  
e Excess from 2021.....  
Schedule A (Form 990) (2021)

Schedule A (Form 990) 2021
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) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2
Schedule B
(Form 990)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors

Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ






Form 990-PF




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
Special Rules
......... 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) (2021)
Schedule B (Form 990) (2021) Page 2
Name of organization
The Ingalls Memorial Hospital
  		Employer identification number
36-2170866
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


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page 3
Name of organization
The Ingalls Memorial Hospital
  		Employer identification number

36-2170866
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) (2021)
Schedule B (Form 990) (2021)
Page 4
Name of organization
The Ingalls Memorial Hospital
  		Employer identification number

36-2170866
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 $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a)
No. from Part I		 (b) Purpose of gift (c) Use 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 (c) Use 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 (c) Use 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 (c) Use 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) (2021)
Additional Data


Software ID: 21014044
Software Version: 2021v4.2
SCHEDULE C
(Form 990)

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 BulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
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
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV. See instructions for definition of “political campaign activities."

2
Political campaign activity expenditures. See instructions ....................................................................SchCMd Bullet
$  
3
Volunteer hours for political campaign activities. See instructions ..................................................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 ................................SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 .......................SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................
4a
Was a correction made? ......................................................................................................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b...........SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ...................................................................
5
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.
Cat. No. 50084S
Schedule C (Form 990) 2021

Schedule C (Form 990) 2021
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 Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(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? ...................................................................................................................

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) 2018 (b) 2019 (c) 2020 (d) 2021 (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) 2021


Schedule C (Form 990) 2021
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
1
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:
a
Volunteers? ...........................................................................................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........
Yes
 
c
Media advertisements? ...................................................................................................
 
No
 
d
Mailings to members, legislators, or the public? .............................................................................
 
No
 
e
Publications, or published or broadcast statements? ...........................................................
 
No
 
f
Grants to other organizations for lobbying purposes? ..........................................................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? .......................
Yes
 
15,960
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................
 
No
 
i
Other activities? ...................................................................................................................
Yes
 
31,559
j
Total. Add lines 1c through 1i ....................................................................................................
47,519
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 ...........................................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................
 
d
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
No
1
Were substantially all (90% or more) dues received nondeductible by members? ...............................................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................
3
 
 
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."
1
Dues, assessments and similar amounts from members ......................................................................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).
a
Current year .............................................................................................................................
2a
 
b
Carryover from last year ............................................................................................................
2b
 
c
Total ...........................................................................................................................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
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? ......................................................................................................................
4
 
5
Taxable amount of lobbying and political expenditures. See Instructions .........................................
5
 
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 1g DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY The Vice President of Government Affairs for University of Chicago Medicine has contact with legislators and government officials on behalf of Ingalls Memorial Hospital. Topics include Medicare and Medicaid funding and proposed staffing legislation.
Schedule C, Part II-B, Line 1i DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY THE HOSPITAL PAYS DUES TO THE ILLINOIS HEALTH AND HOSPITAL ASSOCIATION. A PORTION OF THESE DUES ARE USED TO SUPPORT LOBBYING BY THE ASSOCIATION FOCUSED ON ADVOCACY AND REPRESENTATION.
Schedule C (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet 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
2021
Open to Public Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
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 ........    
5
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? ............
6
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? ...................................
Part II
Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............
6
Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet $  
8
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)? .............................
9
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.
1a
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.
b
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 $  
2
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:
a
Revenue included on Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
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) 2021

Schedule D (Form 990) 2021
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
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):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
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?...
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
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  
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...
b
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 ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Term endowment SchDMd Bullet  
The percentages on lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) Unrelated organizations .................
3a(i)
 
 
(ii) Related organizations .................
3a(ii)
 
 
b
If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
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 .....   6,464,807 6,464,807
b Buildings ....   172,355,268 35,880,216 136,475,052
c Leasehold improvements        
d Equipment ....   77,116,696 49,000,501 28,116,195
e Other .....   26,887,428 1,788,664 25,098,764
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..SchDMdBullet 196,154,818
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 3
Part VII
Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1) Financial derivatives.........    
(2) Closely-held equity interests........    
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
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)DUE FROM AFFILIATES 100,502,042
(2)RESTRICTED INVESTMENTS - FDN 3,209,488
(3)OTHER LONG TERM ASSETS 0
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 103,711,530
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  
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 12,997,726
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) 2021

Schedule D (Form 990) 2021
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 THE SYSTEM APPLIES ASC TOPIC 740, INCOME TAXES, WHICH CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN A COMPANY'S CONSOLIDATED FINANCIAL STATEMENTS. ASC TOPIC 740 PRESCRIBES A MORE LIKELY THAN NOT RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN. UNDER ASC TOPIC 740, TAX POSITIONS ARE EVALUATED FOR RECOGNITION, DERECOGNITION, AND MEASUREMENT USING CONSISTENT CRITERIA AND PROVIDE MORE INFORMATION ABOUT THE UNCERTAINTY IN INCOME TAX ASSETS AND LIABILITIES. AS OF JUNE 30, 2022 AND 2021, THE SYSTEM DOES NOT HAVE AN ASSET OR LIABILITY RECORDED FOR UNRECOGNIZED TAX POSITIONS. THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE.
Schedule D (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet 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
2021
Open to Public Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
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.
3
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.
a
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:
3a
Yes
 
%
b
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: . . . . . . . .
3b
Yes
 
c
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.
4
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"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
Yes
 
c
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? . . . . . . . . . . . . .
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
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) . . . 		    6,902,992 0 6,902,992 1.92 %
b Medicaid (from Worksheet 3, column a) . . . . .     114,278,532 90,209,841 24,068,691 6.71 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .     0 0 0 0 %
d Total Financial Assistance and Means-Tested Government Programs . . . . . 0 0 121,181,524 90,209,841 30,971,683 8.63 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     419,740 0 419,740 0.12 %
f Health professions education (from Worksheet 5) . . .     1,722,155 483,095 1,239,060 0.35 %
g Subsidized health services (from Worksheet 6) . . . .     0 0 0 0 %
h Research (from Worksheet 7) .     0 0 0 0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     55,684 0 55,684 0.02 %
j Total. Other Benefits . . 0 0 2,197,579 483,095 1,714,484 0.48 %
k Total. Add lines 7d and 7j . 0 0 123,379,103 90,692,936 32,686,167 9.11 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing         0 0 %
2 Economic development         0 0 %
3 Community support         0 0 %
4 Environmental improvements         0 0 %
5 Leadership development and
training for community members		         0 0 %
6 Coalition building         0 0 %
7 Community health improvement advocacy         0 0 %
8 Workforce development         0 0 %
9 Other         0 0 %
10 Total 0 0 0 0 0 0 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
9,932,651
3
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. ......
3
0
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
120,693,314
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
136,673,894
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-15,980,580
8
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:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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 .........................

9b

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 %
1NONE
  		       
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
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) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 INGALLS MEMORIAL HOSPITAL
ONE INGALLS DRIVE
HARVEY,IL60426
WWW.INGALLS.ORG
0001099 		X     X     X      
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
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)
INGALLS MEMORIAL 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): 		1
Yes No
Community Health Needs Assessment
1 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?........................ 1   No
2 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............... 2   No
3 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...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 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 ................. 5 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.................................. 6a   No
b 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. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 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. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): https://www.uchicagomedicine.org/about-us/community/benefit/health-needs-ingalls-memorial/chna
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 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   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c 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) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
INGALLS MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 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):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
(SEE STATEMENT)
b
SEE STATEMENT
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
INGALLS MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
17 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?.................................. 17 Yes  
18 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:
a
b
c
d
e
f
19 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?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 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):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 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?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
INGALLS MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
22 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.
a
b
c
d
23 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? ............................... 23   No
If "Yes," explain in Section C.
24 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? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
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 B, Line 5 Facility , 1 Facility , 1 - THE INGALLS MEMORIAL HOSPITAL. The CHNA process engaged several internal and external stakeholders to collect, curate, and interpret data, and then use that data to prioritize the health needs of the community. IMH also gathered data from public health experts, through incorporating data from the Illinois Department of Public Health. Partners and stakeholder groups also provided insight and expertise around the indicators to be assessed, types of focus group questions to be asked, interpretation of results, and prioritization of areas of highest need. Leaders from the Urban Health Initiative (UHI) worked with Metopio to guide the strategic direction of the CHNA and engage the CHNA Steering Committee, other various internal committees, and workgroups to ensure broad engagement of diverse perspectives across Ingalls. Metopio is a software and services company grounded in the philosophy that communities are connected through places and people. Metopio's visualization tools use data to reveal valuable, interconnected factors that influence outcomes in different locations. The Ingalls Community Benefit Management Team guided the strategic direction of the CHNA while relying on the expertise of community stakeholders throughout the CHNA process. Ingalls' partners and stakeholders provided insight and expertise about the assessment of key indicators, the types of focus group questions, how to interpret results, and how to prioritize the areas of highest need. The Community Benefit Management Team is composed of key staff members with expertise in key areas related to Ingalls' community benefit activities. This group discusses and validates community benefit programs and activities, monitors CHNA policies, provides input on the CHNA strategic implementation plan and strategies, reviews and approves grant funding requests, provides feedback on community engagement activities, and provides input for the Annual Report. The Community Advisory Council (CAC) was established by Ingalls in 2020 and is a representative group of 14 volunteer members who live and/or work in the Ingalls Service Area. The CAC members serve as advisors to Ingalls on issues of interest to the community. The CAC is an essential partner in achieving Ingalls' goals related to broader community interests, community benefit, access to care, and effective community engagement. Specifically, the CAC played a key role in identifying community organizations for our focus groups, disseminating the survey, and ensuring diverse community voices were heard throughout the CHNA process. THE INCLUSION OF PATIENT VOICE IN THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS A CORNERSTONE OF THE PROCESS. PRIMARY DATA FOR THE CHNA WAS COLLECTED THROUGH THE FOLLOWING METHODS: 1) 419 COMMUNITY RESIDENT SURVEYS COMPLETED IN ENGLISH AND SPANISH, IN BOTH ELECTRONIC AND PAPER VERSIONS 2) 4 COMMUNITY RESIDENT FOCUS GROUPS WITH 12 OR FEWER RESIDENTS IN EACH GROUP. TOPICS INCLUDED MENTAL HEALTH, MATERNAL AND CHILD HEALTH, YOUTH HEALTH, AND ADULT HEALTH 3) 8 KEY INFORMANT INTERVIEWS WITH RESIDENTS FROM UNDERSERVED POPULATIONS DURING DEVELOPMENT OF THE STRATEGIC IMPLEMENTATION PLAN, INGALLS CONSULTED SUBJECT MATTER EXPERTS ON INGALLS' HEALTH PRIORITIES. THROUGHOUT OUR CHNA PROCESS, INGALLS WAS ABLE TO TAKE INTO ACCOUNT VARIOUS DIFFERING COMMUNITY VIEWPOINTS.
Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - THE INGALLS MEMORIAL HOSPITAL. IMH contracted with Metopio to complete the 2021-2022 Community Health Needs Assessment. Metopio is a software and services company grounded in the philosophy that communities are connected through places and people. Metopio's visualization tools use data to reveal valuable, interconnected factors that influence outcomes in different locations. Leaders from Ingalls and UHI worked with Metopio to guide the strategic direction of the CHNA and engage the CHNA Steering Committee, other various internal committees, and workgroups to ensure broad engagement of diverse perspectives across Ingalls Memorial.
Schedule H, Part V, Section B, Line 7 Facility , 1 Facility , 1 - INGALLS MEMORIAL HOSPITAL. THE RESULTS OF THE REPORT WERE DISCUSSED AT COMMUNITY MEETINGS, WITH REFERENCE TO THE FULL REPORT'S ELECTRONIC AVAILABILITY ON THE HOSPITAL'S WEBSITE AND PAPER COPIES AVAILABLE IN THE INGALLS MEMORIAL MAIN LOBBY AND THE PROFESSIONAL OFFICE BUILDING FRONT DESKS. KEY EXTERNAL STAKEHOLDERS SUCH AS EXECUTIVE LEADERS AT COMMUNITY BASED ORGANIZATIONS, ELECTED OFFICIALS, AND INDIVIDUAL DONORS WERE SENT ELECTRONIC AND PAPER COPIES OF THE 4 PAGE, INFOGRAPHIC EXECUTIVE SUMMARY- WHICH IS ALSO AVAILABLE ON THE COMMUNITY BENEFIT WEBSITE. THE CHNA WAS MADE WIDELY AVAILABLE TO VARIOUS CHICAGOLAND COMMUNITY NEWS OUTLETS, INCLUDING THE HYDE PARK HERALD, SOUTHLAND JOURNAL, AND CRAIN'S CHICAGO BUSINESS, CHICAGO LEADER AND BLOCK CLUB CHICAGO. A LINK TO THE REPORT WAS ALSO SENT OUT TO A COMMUNITY HEALTH NEWSLETTER LISTSERV WITH OVER 11,000 PEOPLE SUBSCRIBED.
Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - THE INGALLS MEMORIAL HOSPITAL. THE MOST RECENT INGALLS CHNA WAS CONDUCTED IN 2021-2022. THE IMPLEMENTATION STRATEGY FOR THIS CHNA FOR YEARS 2023-2025 WAS ADOPTED BY THE UNIVERSITY OF CHICAGO MEDICAL CENTER'S BOARD OF DIRECTOR'S GOVERNMENT AND COMMUNITY RELATIONS COMMITTEE. THIS COMMITTEE RECEIVED AND REVIEWED THE 2021-2022 CHNA REPORT, FY 2020-2022 EVALUATION REPORT, AND 2023-2025 STRATEGIC IMPLEMENTATION PLAN AND FORMALLY APPROVED ALL THREE DOCUMENTS IN MAY 2022. THE HEALTH PRIORITIES IDENTIFIED IN THE MOST RECENT CHNA WERE: 1. PREVENT AND MANAGE CHRONIC DISEASES: HEART DISEASE, DIABETES, CANCER 2. PROVIDE ACCESS TO CARE AND SERVICES: MATERNAL HEALTH, MENTAL HEALTH 3. REDUCE INEQUITIES CAUSED BY SOCIAL DETERMINANTS OF HEALTH INGALLS WILL ADDRESS THE NEEDS IDENTIFIED IN ITS MOST RECENT CHNA THROUGH EXECUTION OF THE IMPLEMENTATION STRATEGY. INGALLS WILL ADDRESS THE IDENTIFIED NEEDS THROUGH THE FOLLOWING APPROACHES: 1) CARE DELIVERY INITIATIVES. THE CARE DELIVERY INITIATIVES INCLUDE A MYRIAD OF INITIATIVES THAT PROVIDE DIRECT HEALTH AND WELLNESS SERVICES TO COMMUNITY MEMBERS. THESE SERVICES ARE EXECUTED IN MULTIPLE WAYS THAT INCLUDE LEVERAGING INGALLS RESOURCES AND PARTNERING WITH COMMUNITY HEALTH CENTERS AND COMMUNITY-BASED CLINICAL SERVICES. 2) COMMUNITY IMPACT GRANTS. GRANT OPPORTUNITIES ARE PROVIDED TO COMMUNITY-BASED ORGANIZATIONS THAT IMPLEMENT PROGRAMS TO ADDRESS THE INGALLS PRIORITY AREAS WITHIN THE INGALLS SERVICE AREA. 3) COMMUNITY-BASED EDUCATION & OUTREACH. INGALLS OUTREACH AND ENGAGEMENT COMPONENTS ARE DIRECTLY ALIGNED WITH THE HOSPITALS' PRIORITY AREAS, PROMOTING EDUCATION AND AWARENESS TO COMMUNITY MEMBERS IN THE TARGETED SERVICE AREAS. THESE ACTIVITIES ARE INTENDED TO BETTER INFORM AND EDUCATE THE COMMUNITY REGARDING HEALTH PROMOTION AND DISEASE SELF-MANAGEMENT PRACTICES. RATIONALE FOR UNADDRESSED NEEDS: IN ACKNOWLEDGING THE WIDE RANGE OF PRIORITY HEALTH ISSUES THAT EMERGED FROM THE CHNA PROCESS, INGALLS DETERMINED THAT IT COULD ONLY EFFECTIVELY FOCUS ON THOSE WHICH FIT WITHIN THE CURRENT RESOURCES AVAILABLE. WHILE VIOLENCE WAS NOT SELECTED AS A HEALTH PRIORITY AREA FOR FY 2023-2025, IT AFFECTS THE HEALTH STATUS OF THE WHOLE COMMUNITY. CONSEQUENTLY, VIOLENCE WILL BE ADDRESSED IN RELATION TO EACH OF THE PRIORITY HEALTH AREAS BY FOCUSING ON THE SOCIAL INEQUITIES CAUSED BY THE SOCIAL DETERMINANTS OF HEALTH (SDOH) AND BY PROVIDING ACCESS TO MENTAL HEALTH SERVICES. THIS FRAMEWORK RETAINS FOUR OF THE HEALTH PRIORITIES FROM THE FY 2020-2022 STRATEGIC IMPLEMENTATION PLAN: HEART DISEASE, DIABETES, CANCER, AND MATERNAL HEALTH. IN THE FY 2020-2022 SIP, ASTHMA WAS SELECTED AS A PRIORITY HEALTH AREA. DURING THE LAST CYCLE, INGALLS INVESTED RESOURCES TO ADDRESS ASTHMA. AS A RESULT OF THESE EFFORTS (AND OTHER FACTORS), THERE WAS A DECLINE IN ASTHMA EMERGENCY DEPARTMENT (ED) VISITS. CONSEQUENTLY, ASTHMA IS NOT A PRIORITY HEALTH AREA FOR THE FY 2023-2025 SIP. THE HOSPITAL WILL CONTINUE TO INVEST RESOURCES TO SUSTAIN THIS POSITIVE OUTCOME BY SUPPORTING EXISTING PROGRAMS. ADDITIONALLY, INGALLS WILL CONTINUE TO WORK WITH PARTNERS, INCLUDING THE LOCAL PUBLIC HEALTH DEPARTMENTS, COMMUNITY ORGANIZATIONS AND FEDERAL QUALIFIED HEALTH CENTERS TO MEET THE HEALTH NEEDS OF OUR PATIENT SERVICE AREA. PLEASE SEE A REPORT OF INGALLS COMMUNITY ACTIVITIES IN PART VI, LINE 5.
Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - THE INGALLS MEMORIAL HOSPITAL. A PATIENT IS NOT REQUIRED TO PAY MORE THAN 20% OF HIS/HER FAMILY INCOME FOR ALL EMERGENCY AND OTHER MEDICALLY NECESSARY CARE PROVIDED BY IMH IN A 12-MONTH PERIOD. THE MEDICAL INDIGENCY DISCOUNT APPLIES TO ANY PATIENT WHOSE PATIENT BALANCE DUE FOR EMERGENCY AND OTHER MEDICALLY NECESSARY SERVICES EXCEEDS 20% OF HIS/HER ADJUSTED GROSS INCOME IN THE YEAR THAT THE PATIENT RECEIVED CARE.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
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?7
Name and address Type of Facility (describe)
1 INGALLS FAMILY CARE CENTER
1600 TORRENCE AVENUE
CALUMET CITY,IL60409 		URGENT AID, PRIMARY CARE, AND SPECIALIST SERVICES
2 INGALLS FAMILY CARE CENTER
19550 GOVERNORS HIGHWAY
FLOSSMOOR,IL60422 		URGENT AID AND SPECIALIST SERVICES
3 INGALLS FAMILY CARE CENTER
6701 WEST 159TH STREET
TINLEY PARK,IL60477 		URGENT AID, PRIMARY CARE, AND SPECIALIST SERVICES
4 INGALLS CARE CENTER
4742 CAL SAG ROAD
CRESTWOOD,IL60445 		QUICK CARE CENTER AND OCCUPATIONAL HEALTH
5 INGALLS CARE CENTER
16246 PRINCE DRIVE
SOUTH HOLLAND,IL60473 		INDUSTRIAL, MEDICAL REHABILITATION AND PHYSICIAN OFFICES
6 INGALLS WELLNESS CENTER
2920 WELLNESS CENTER
HOMEWOOD,IL60430 		COMPLEMENTARY MEDICINE AND COMMUNITY HEALTH PROGRAMS
7
8
9
10
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
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 AUTOMATIC UNINSURED SELF-PAY DISCOUNT A DISCOUNT OF 80% OF GROSS CHARGES, PROVIDED TO ALL UNINSURED PATIENTS WITHOUT REQUIRING EVIDENCE OF INABILITY TO PAY. THIS DISCOUNT IS DESIGNED TO ENSURE THAT PATIENTS ARE CHARGED AT A RATE GENERALLY COMPARABLE TO THAT APPLIED TO INSURED PATIENTS. 1. THERE IS NO APPLICATION PROCESS FOR THE PATIENT TO RECEIVE THE UNINSURED DISCOUNT. THE DISCOUNT IS APPLIED BASED ON THE ACCOUNT'S SELF-PAY/UNINSURED STATUS. 2. PATIENTS RECEIVING PRE-NEGOTIATED DISCOUNTS FOR HOSPITAL SERVICES WILL NOT BE ELIGIBLE FOR THIS UNINSURED DISCOUNT. 3. IF A PATIENT IS SUBSEQUENTLY APPROVED FOR FINANCIAL ASSISTANCE, THE AUTOMATIC DISCOUNT WILL BE REVERSED SO THAT THE FULL AMOUNT CAN BE RECOGNIZED AS A CHARITY ALLOWANCE. 4. IF A PATIENT SUBSEQUENTLY PROVIDES EVIDENCE OF INSURANCE COVERAGE, THE AUTOMATIC DISCOUNT WILL BE REVERSED AND THE INSURANCE COVERAGE PROVIDED WILL BE BILLED ACCORDINGLY. 5. PATIENT WHO ARE OTHERWISE INSURED AND CHOOSE NOT TO USE THEIR INSURANCE COVERAGE ARE INELIGIBLE FOR THIS AUTOMATIC DISCOUNT.
Schedule H, Part I Line 7 INGALLS UTILIZES A COST TO CHARGE METHODOLOGY. CHARGES ASSOCIATED WITH THE RELATED CATEGORIES ARE THEN USED TO DETERMINE COST RELATED TO SUCH REVENUE.
Schedule H, Part V, Section B, Line 4 THE HOSPITAL IS REPORTING THE TAX YEAR BEGINNING FOR WHICH IT LAST CONDUCTED ITS CHNA. THE CHNA WAS FINALIZED DURING THE TAX YEAR ENDED JUNE 30, 2022.
Schedule H, Part III Line 1 INGALLS FOLLOWS GAAP PRINCIPLES AND UNDER THE NEW REPORTING STANDARD ASC 606, BAD DEBT IS NOW IMPLICIT PRICE CONCESSIONS. THE REPORTING OF BAD DEBT ALSO CONFORMS TO THE UPDATED HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION NO. 15.
Schedule H, Part I Line 5a WHILE INGALLS PROJECTS AN ANTICIPATED AMOUNT OF DISCOUNTED CARE EACH FISCAL YEAR WHEN CREATING ITS ANNUAL BUDGET, NO SPECIFIC LINE ITEM OR LIMIT IS INCLUDED IN THE BUDGET. THE ABSENCE OF A LINE ITEM IN NO WAY LIMITS THE AMOUNT OF DISCOUNTED CARE INGALLS PROVIDES.
Schedule H, Part V, Section B, Line 16a FAP AVAILABLE WEBSITE https://www.uchicagomedicine.org/-/media/pdfs/adult-pdfs/patients-and-visitors/patients/ingalls-financial-assistance/patient-financial-assistance-discounts-and-collections-policy-signed.pdf
Schedule H, Part V, Section B, Line 16b FAP APPLICATION FORM WEBSITE https://www.uchicagomedicine.org/-/media/pdfs/adult-pdfs/patients-and-visitors/patients/ingalls-financial-assistance/financial-assistance-application.pdf
Schedule H, Part V, Section B, Line 16c PLAIN LANGUAGE FAP SUMMARY WEBSITE https://www.uchicagomedicine.org/-/media/pdfs/adult-pdfs/patients-and-visitors/patients/ingalls-financial-assistance/ingalls-financial-assistance-plain-language-summary.pdf
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount THE AMOUNT REPORTED AS BAD DEBT EXPENSE IS DETERMINED BY APPLYING THE RATIO OF COST TO CHARGES (RCC) TO THE TOTAL CHARGES WRITTEN OFF TO BAD DEBT AS REPORTED IN THE AUDITED FINANCIAL STATEMENTS. THE RCC WAS DETERMINED UTILIZING WORKSHEET 2 FROM FORM 990, SCHEDULE H INSTRUCTIONS. THE BASIS FOR THIS COSTING METHODOLOGY IS THE HOSPITAL'S OPERATING EXPENSES (EXCLUDING BAD DEBT) ADJUSTED BY OTHER OPERATING REVENUE AND COMMUNITY BENEFIT EXPENSE DIVIDED BY GROSS PATIENT CHARGES.
Schedule H, Part III, Line 3 Bad Debt Expense Methodology IMH RUNS PRESUMPTIVE ELIGIBILITY FOR FINANCIAL ASSISTANCE WHEN SUFFICIENT INFORMATION CANNOT BE OBTAINED. AS A RESULT, IMH DOES NOT BELIEVE THERE IS ANY BAD DEBT FOR INDIVIDUALS THAT WOULD OTHERWISE QUALIFY FOR ASSISTANCE.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote FOOTNOTE TO FINANCIAL STATEMENTS: IN ACCORDANCE WITH ASC TOPIC 606, REVENUE FROM CONTRACTS WITH CUSTOMERS, THE SYSTEM DOES NOT ADJUST THE PROMISED AMOUNT OF CONSIDERATION FROM PATIENTS AND THIRD-PARTY PAYORS FOR THE EFFECTS OF A SIGNIFICANT FINANCING COMPONENT DUE TO THE EXPECTATION THAT THE PERIOD BETWEEN THE TIME THE SERVICE IS PROVIDED TO A PATIENT AND THE TIME THAT THE PATIENT OR A THIRD-PARTY PAYOR PAYS FOR SERVICE WILL BE ONE YEAR OR LESS. REVENUES ARE RECOGNIZED IN THE AMOUNTS TO WHICH IT EXPECTS TO BE ENTITLED, WHICH ARE THE TRANSACTION PRICES ALLOCATED TO THE DISTINCT SERVICES. THE SYSTEM HAS AGREEMENTS WITH GOVERNMENTAL AND OTHER THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE SYSTEM AT AMOUNTS DIFFERENT FROM ESTABLISHED CHARGES. PAYMENT ARRANGEMENTS FOR MAJOR THIRD-PARTY PAYORS MAY BE BASED ON PROSPECTIVELY DETERMINED RATES, REIMBURSED COST, DISCOUNTED CHARGES, PER DIEM PAYMENTS, OR OTHER METHODS. THE TRANSACTION PRICE IS DETERMINED BASED ON GROSS CHARGES FOR SERVICES PROVIDED, REDUCED BY EXPLICIT PRICE CONCESSIONS PROVIDED TO THIRD-PARTY PAYERS, DISCOUNTS PROVIDED TO UNINSURED PATIENTS IN ACCORDANCE WITH THE FINANCIAL ASSISTANCE PROGRAM, AND IMPLICIT PRICE CONCESSIONS PROVIDED PRIMARILY TO UNINSURED PATIENTS. THE ESTIMATES OF EXPLICIT PRICE CONCESSIONS AND DISCOUNTS ARE BASED ON CONTRACTUAL AGREEMENTS, DISCOUNT POLICIES, AND HISTORICAL EXPERIENCE. THE ESTIMATES OF IMPLICIT PRICE CONCESSIONS ARE BASED ON HISTORICAL COLLECTION EXPERIENCE WITH THESE CLASSES OF PATIENTS USING THE PORTFOLIO APPROACH.
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs THE HOSPITAL BELIEVES THE FULL AMOUNT OF THE SHORTFALL FROM MEDICARE SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE IT SERVES ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY, AND IT CANNOT NEGOTIATE CONTRACTUAL RATES WITH THE MEDICARE PROGRAM. THE HOSPITAL MUST ACCEPT WHAT THE MEDICARE PROGRAM PAYS. THE METHODOLOGY USED IN DETERMINING MEDICARE SHORTFALL REPORTED IN THE COMMUNITY BENEFITS REPORT IS MEDICARE NET PATIENT SERVICE REVENUE LESS MEDICARE CHARGES MULTIPLIED BY THE MEDICARE COST REPORT COST TO CHARGE RATIO.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance INGALLS MEMORIAL HOSPITAL HAS A FIDUCIARY DUTY TO SEEK REIMBURSEMENT FOR SERVICES IT HAS PROVIDED FROM INDIVIDUALS WHO ARE ABLE TO PAY, FROM THIRD PARTY INSURERS WHO COVER THE COST OF CARE, AND FROM OTHER PROGRAMS OF ASSISTANCE FOR WHICH THE PATIENT IS ELIGIBLE. TO DETERMINE WHETHER A PATIENT IS ABLE TO PAY FOR THE SERVICES PROVIDED AS WELL AS TO ASSIST THE PATIENT IN FINDING ALTERNATIVE COVERAGE OPTIONS IF THEY ARE UNINSURED OR UNDERINSURED, THE HOSPITAL FOLLOWS THE FOLLOWING CRITERIA RELATED TO BILLING AND COLLECTING FROM PATIENTS. COLLECTING INFORMATION ON PATIENT HEALTH COVERAGE AND FINANCIAL RESOURCES PATIENT OBLIGATIONS: PRIOR TO THE DELIVERY OF ANY HEALTH CARE SERVICES (EXCEPT FOR CASES THAT ARE AN EMERGENCY OR URGENT CARE SERVICE LEVEL), THE PATIENT IS EXPECTED TO PROVIDE TIMELY AND ACCURATE INFORMATION ON THEIR INSURANCE STATUS, DEMOGRAPHIC INFORMATION, CHANGES TO THEIR FAMILY INCOME OR INSURANCE STATUS, AND INFORMATION ON ANY DEDUCTIBLES OR CO-PAYMENTS THAT ARE OWED BASED ON THEIR EXISTING INSURANCE OR FINANCIAL PROGRAM'S PAYMENT OBLIGATIONS. THE DETAILED INFORMATION WILL INCLUDE: A. FULL NAME, ADDRESS, TELEPHONE NUMBER, DATE OF BIRTH, SOCIAL SECURITY NUMBER (IF AVAILABLE), CURRENT HEALTH INSURANCE COVERAGE OPTIONS, CITIZENSHIP AND RESIDENCY INFORMATION, AND THE PATIENT'S APPLICABLE FINANCIAL RESOURCES THAT MAY BE USED TO PAY THEIR BILL; B. FULL NAME OF THE PATIENT'S GUARANTOR, THEIR ADDRESS, TELEPHONE NUMBER, DATE OF BIRTH, SOCIAL SECURITY NUMBER (IF AVAILABLE), CURRENT HEALTH INSURANCE COVERAGE OPTIONS, AND THEIR APPLICABLE FINANCIAL RESOURCES THAT MAY BE USED TO PAY FOR THE PATIENT'S BILL; AND C. OTHER RESOURCES THAT MAY BE USED TO PAY THEIR BILL, INCLUDING OTHER INSURANCE PROGRAMS, MOTOR VEHICLE OR HOMEOWNERS INSURANCE POLICIES IF THE TREATMENT WAS DUE TO AN ACCIDENT, WORKER'S COMPENSATION PROGRAMS, AND STUDENT INSURANCE POLICIES, AMONG OTHERS. IT IS ULTIMATELY THE PATIENT'S OBLIGATION TO KEEP TRACK OF AND TIMELY PAY THEIR UNPAID HOSPITAL BILL, INCLUDING ANY EXISTING CO-PAYMENTS, CO-INSURANCE, AND DEDUCTIBLES. THE PATIENT IS FURTHER REQUIRED TO INFORM EITHER THEIR CURRENT HEALTH INSURER (IF THEY HAVE ONE) OR THE AGENCY THAT DETERMINED THE PATIENT'S ELIGIBILITY STATUS IN A PUBLIC HEALTH INSURANCE PROGRAM OF ANY CHANGES IN FAMILY INCOME OR INSURANCE STATUS. THE HOSPITAL MAY ALSO ASSIST THE PATIENT WITH UPDATING THEIR ELIGIBILITY IN A PUBLIC PROGRAM WHEN THERE ARE ANY CHANGES IN FAMILY INCOME OR INSURANCE STATUS, BUT ONLY IF THE HOSPITALS MADE AWARE BY THE PATIENT OF FACTS THAT MAY INDICATE A CHANGE IN THE PATIENT'S ELIGIBILITY STATUS. PATIENTS ARE REQUIRED TO NOTIFY THE STATE PUBLIC PROGRAM (OFFICE OF MEDICAID), INFORMATION RELATED TO ANY LAWSUIT OR INSURANCE CLAIM THAT WILL COVER THE COST OF THE SERVICES PROVIDED BY THE HOSPITAL. HOSPITAL OBLIGATIONS: INGALLS MEMORIAL HOSPITAL WILL MAKE ALL REASONABLE AND DILIGENT EFFORTS TO COLLECT THE PATIENT INSURANCE STATUS AND OTHER INFORMATION TO VERIFY COVERAGE FOR THE HEALTH CARE SERVICES TO BE PROVIDED BY INGALLS MEMORIAL HOSPITAL. THESE EFFORTS MAY OCCUR WHEN THE PATIENT IS SCHEDULING THEIR SERVICES, DURING PREREGISTRATION, WHILE THE PATIENT IS ADMITTED IN THE HOSPITAL, UPON DISCHARGE, OR DURING THE COLLECTION PROCESS WHICH MAY OCCUR FOR A REASONABLE TIME FOLLOWING DISCHARGE FROM THE HOSPITAL. THIS INFORMATION WILL BE OBTAINED PRIOR TO THE DELIVERY OF ANY NONEMERGENT AND NON-URGENT HEALTH CARE SERVICES (I.E., ELECTIVE PROCEDURES AND SCHEDULED PROCEDURES). INGALLS MEMORIAL HOSPITAL WILL DELAY ANY ATTEMPT TO OBTAIN THIS INFORMATION DURING THE DELIVERY OF ANY EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) LEVEL EMERGENCY LEVEL OR URGENT CARE SERVICES, IF THE PROCESS TO OBTAIN THIS INFORMATION WILL DELAY OR INTERFERE WITH EITHER THE MEDICAL SCREENING EXAMINATION OR THE SERVICES UNDERTAKEN TO STABILIZE AN EMERGENCY MEDICAL CONDITION. THE HOSPITAL'S REASONABLE AND DILIGENT EFFORTS WILL INCLUDE, BUT ARE NOT LIMITED TO, REQUESTING INFORMATION ABOUT THE PATIENT'S INSURANCE STATUS, CHECKING ANY AVAILABLE PUBLIC OR PRIVATE INSURANCE DATABASES, AND FOLLOWING THE BILLINGS RULES OF A KNOWN THIRD PARTY PAYER. IF THE PATIENT OR GUARANTOR/GUARDIAN IS UNABLE TO PROVIDE THE INFORMATION NEEDED, AND THE PATIENT CONSENTS, THE HOSPITAL WILL MAKE REASONABLE EFFORTS TO CONTACT RELATIVES, FRIENDS, GUARANTOR/GUARDIAN, AND THE THIRD PARTY FOR ADDITIONAL INFORMATION. INGALLS MEMORIAL HOSPITAL WILL ALSO MAKE REASONABLE AND DILIGENT EFFORTS TO INVESTIGATE WHETHER A THIRD PARTY RESOURCE MAY BE RESPONSIBLE FOR THE SERVICES PROVIDED BY THE HOSPITAL, INCLUDING BUT NOT LIMITED TO: (1) A MOTOR VEHICLE OR HOMEOWNER'S LIABILITY POLICY, (2) GENERAL ACCIDENT OR PERSONAL INJURY PROTECTION POLICIES, (3) WORKER'S COMPENSATION PROGRAMS, (4) STUDENT INSURANCE POLICIES, AMONG OTHERS. IN ACCORDANCE WITH APPLICABLE STATE REGULATIONS OR THE INSURANCE CONTRACT, FOR ANY CLAIM WHERE INGALLS MEMORIAL HOSPITAL'S REASONABLE AND DILIGENT EFFORTS RESULTED IN A PAYMENT FROM A PRIVATE INSURER OR PUBLIC PROGRAM, INGALLS MEMORIAL HOSPITAL WILL REPORT THE RECOVERY AND OFF SET IT AGAINST THE CLAIM PAID BY THE PRIVATE INSURER OR PUBLIC PROGRAM.THE HOSPITAL FURTHER MAINTAINS ALL INFORMATION IN ACCORDANCE WITH APPLICABLE FEDERAL AND STATE PRIVACY, SECURITY AND ID THEFT LAWS.
Schedule H, Part V, Section B, Line 16a FAP website - INGALLS MEMORIAL HOSPITAL: Line 16a URL: (SEE STATEMENT);
Schedule H, Part V, Section B, Line 16b FAP Application website - INGALLS MEMORIAL HOSPITAL: Line 16b URL: SEE STATEMENT;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website - INGALLS MEMORIAL HOSPITAL: Line 16c URL: SEE STATEMENT;
Schedule H, Part VI, Line 2 Needs assessment INGALLS ASSESSES THE HEALTH CARE NEEDS OF THE SOUTH SUBURBAN SERVICE AREA THROUGH THE IMPLEMENTATION OF THE CHNA, STAKEHOLDER ENGAGEMENT, AND COMMUNITY IMPACT GRANT OPPORTUNITIES FOR COMMUNITY-BASED ORGANIZATIONS. INGALLS CONDUCTED ITS CHNA BETWEEN APRIL 2021 AND FEBRUARY 2022 USING A PROCESS THAT WAS ADAPTED FROM THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) FRAMEWORK. THIS PLANNING FRAMEWORK FOCUSES ON COMMUNITY ENGAGEMENT, PARTNERSHIP DEVELOPMENT, AND INCLUSION OF THOSE WHO HAVE HISTORICALLY BEEN EXCLUDED FROM THE DECISION-MAKING PROCESS. PRIMARY DATA FOR THE CHNA WAS COLLECTED THROUGH FOUR CHANNELS. > COMMUNITY RESIDENT SURVEYS > COMMUNITY RESIDENT FOCUS GROUPS > HEALTHCARE AND SOCIAL SERVICE PROVIDER FOCUS GROUP > KEY INFORMANT INTERVIEWS THE COMMUNITY RESIDENT SURVEY TOOL WAS DEVELOPED BY INGALLS & UCMC STAFF, INGALLS COMMUNITY ADVISORY COUNCIL AND BASED ON A DESIGN USED BY OTHER PUBLIC HEALTH AGENCIES. THE FINAL SURVEY TOOL INCLUDED 29 QUESTIONS AND ASKED RESPONDENTS TO IDENTIFY HEALTH NEEDS OF YOUTH (0-17 YEARS), ADULTS (18-64 YEARS), AND SENIORS (65+ YEARS). COMMUNITY RESIDENT SURVEYS WERE AVAILABLE ONLINE AND IN PERSON IN BOTH ENGLISH AND SPANISH. COMMUNITY PARTNERS DISTRIBUTED THE SURVEY THROUGH VARIOUS CHANNELS WITH A PARTICULAR EMPHASIS ON SURVEYING TYPICALLY UNDERREPRESENTED POPULATIONS, SUCH AS COMMUNITIES OF COLOR, IMMIGRANTS AND MEMBERS OF THE LGBTQ+ COMMUNITY. INGALLS HELD FOUR FOCUS GROUPS, EACH COVERING A SPECIFIC HEALTH AREA OR POPULATION: > ADULT HEALTH > MATERNAL AND CHILD HEALTH > YOUTH HEALTH > HEALTHCARE AND SOCIAL SERVICE PROVIDERS DUE TO THE COVID-19 PANDEMIC, INGALLS CONDUCTED MOST OF ITS FOCUS GROUPS VIRTUALLY. IN-PERSON AND VIRTUAL FOCUS GROUPS LASTED 90 MINUTES WITH UP TO 12 COMMUNITY MEMBERS IN EACH ONE. IN ADDITION TO THE FOUR GROUPS, THE COMMUNITY BENEFIT MANAGEMENT TEAM IDENTIFIED EIGHT KEY INFORMANTS FOR ONE-ON-ONE INTERVIEWS. KEY INFORMANTS WERE CHOSEN BASED ON THEIR AREA OF EXPERTISE TO FURTHER VALIDATE THEMES THAT EMERGED FROM THE SURVEYS AND FOCUS GROUPS. KEY INFORMANT INTERVIEWS WERE CONDUCTED VIRTUALLY AND EACH LASTED 30 MINUTES. SECONDARY POPULATION HEALTH AND DEMOGRAPHIC DATA WAS COLLECTED FROM A VARIETY OF SOURCES, INCLUDING ILLINOIS HOSPITAL ASSOCIATION (IHA) COMPDATA. INGALLS USED A COMMON SET OF HEALTH INDICATORS TO UNDERSTAND THE PREVALENCE OF MORBIDITY AND MORTALITY IN THE SERVICE AREA. ALL DATA WERE UPLOADED AND ANALYZED USING THE METOPIO DATA PLATFORM. BUILDING ON INGALLS' PAST CHNA, THE DATA PRIORITY SETTING TEAM, WHICH INCLUDED THE DIRECTOR, COMMUNITY RELATIONS & VOLUNTEER SERVICE AT INGALLS, AND STAFF FROM UNIVERSITY OF CHICAGO MEDICINE'S (UCM'S) COMMUNITY BENEFIT AND EVALUATION TEAM, WORKED WITH THE COMMUNITY BENEFIT MANAGEMENT TEAM AND THE COMMUNITY BENEFIT COMMITTEE AS WELL AS SEVERAL WORKGROUPS TO PRIORITIZE HEALTH ISSUES FOR INGALLS NEXT THREE YEARS OF COMMUNITY BENEFIT PROGRAMMING FROM 2020-2022. USING THE CHNA AS A FOUNDATIONAL TOOL, THE DATA PRIORITY SETTING TEAM REVIEWED AND COMPARED THE 2020-2021 INGALLS SERVICE AREA HEALTH OUTCOME DATA TO PREVIOUS HEALTH OUTCOME DATA. NEW DATA AND HEALTH ISSUES THAT WERE WORSE THAN PREVIOUS YEARS WERE SLATED FOR CONSIDERATION. FOR MORE INFORMATION ON INGALL'S SELECTED HEALTH PRIORITY AREAS PLEASE SEE PART V, SECTION B, LINE 11.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance THE HOSPITAL INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THE ELIGIBILITY FOR ASSISTANCE BY POSTING SIGNS THROUGHOUT THE PATIENT REGISTRATION AREAS REGARDING PATIENT PAYMENT OPTIONS. IN ADDITION, PATIENTS ARE INFORMED VIA THE HOSPITAL'S WEBSITE, INDIVIDUAL PATIENT STATEMENTS, AND FINANCIAL COUNSELORS. BELOW ARE SOME ADDITIONAL DETAILS REGARDING HOW THE HOSPITAL INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. SIGNAGE: SIGNS OR SIMILAR WRITTEN NOTICES REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE PROGRAM WILL BE VISIBLE AT ALL HOSPITAL POINTS OF SERVICE TO CREATE AWARENESS OF THE FINANCIAL ASSISTANCE PROGRAM. AT A MINIMUM, SIGNAGE WILL BE POSTED IN THE EMERGENCY DEPARTMENT AND ADMISSION REGISTRATION AREA. ALL PUBLIC INFORMATION AND/OR FORMS REGARDING THE PROVISION OF FINANCIAL ASSISTANCE PROGRAM WILL USE LANGUAGES THAT ARE APPROPRIATE FOR THE SERVICE AREA IN ACCORDANCE WITH THE STATE'S LANGUAGE ASSISTANCE SERVICES ACT. HOSPITAL BILL/INVOICE: PATIENT BILLS OR STATEMENTS INCLUDE A PROMINENT STATEMENT THAT PATIENTS WHO MEET CERTAIN INCOME REQUIREMENTS MAY QUALIFY FOR FINANCIAL ASSISTANCE AND INFORMATION REGARDING HOW A PATIENT MAY APPLY FOR CONSIDERATION UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE FOLLOWING ARE MADE PUBLICLY AVAILABLE VIA THE HOSPITAL'S WEBSITE, https://www.uchicagomedicine.org/patients-visitors/patient-information/billing/financial-assistance-at-ingalls 1. PATIENT BROCHURES 2. FINANCIAL ASSISTANCE POLICY 3. APPLICATION FORMS USED TO DETERMINE A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE. 4. PLAIN LANGUAGE SUMMARY OF FINANCIAL ASSISTANCE POLICY
Schedule H, Part VI, Line 4 Community information INGALLS SERVICE AREA CONSISTS OF A LARGE, MEDICALLY UNDER RESOURCED, LOWER INCOME POPULATION IN SOUTH SUBURBAN COOK COUNTY. BASED ON THE RESULTS OF THE 2021-2022 CHNA, THE INGALLS PATIENT SERVICE AREA (PSA) HAS UNDERGONE SIGNIFICANT POPULATION CHANGES OVER THE LAST DECADE. THE 2015-2019 ESTIMATES FROM THE AMERICAN COMMUNITY SURVEY REVEALED THAT THE INGALLS PSA'S POPULATION DECLINED BY 4.9%, WHILE THE TOTAL POPULATION OF COOK COUNTY INCREASED BY 1.6%, AND SOUTH SUBURBAN COOK COUNTY (SSCC) DECREASED BY 2.2%. THE INGALLS PSA IS COMPRISED OF THORNTON TOWNSHIP, WHICH CONSISTS OF 13 ZIP CODES, 20 CITIES/MUNICIPALITIES. THE INGALLS PSA COMPRISES OF 56,994 RESIDENTS, MANY OF WHOM ARE UNDERSERVED BY INGALLS. SOME OF THE COMMUNITIES IN INGALLS SERVICE AREA HAVE SOME OF THE HIGHEST CHRONIC DISEASE RATES IN SUBURBAN COOK COUNTY. THE POPULATION OF THE INGALLS PSA IS APPROXIMATELY 62.5 PERCENT BLACK, 19.8% Hispanic/Latinx, 14.4% non-Hispanic White, 0.6% Asian & Pacific Islander, 0.1% Native Americans in all three areas, and people identifying as two or more races account for 2.1% in both the Ingalls PSA . IN THE INGALLS PSA, 18.7% OF INDIVIDUALS LIVE BELOW THE FEDERAL POVERTY LEVEL - THIS IS 1.5 TIMES THE STATE LEVEL. THE UNEMPLOYMENT RATE IS 12.9% IN THE INGALLS PSA COMPARED TO 8.9% IN SOUTH SUBURBAN COOK COUNTY AND 5.9% IN ILLINOIS. 12.8% OF RESIDENTS IN INGALLS PSA ARE FOOD INSECURE. 9.1% OF THOSE IN THE INGALLS PSA DO NOT HAVE HEALTH INSURANCE COMPARED TO 6.8% IN SOUTH SUBURBAN COOK COUNTY AND 8.8% IN COOK COUNTY. 31.4% HAVE MEDICAID COVERAGE, WHICH IS 1.5 TIMES THE STATE LEVEL. IN THE INGALLS PSA PREVENTABLE CHRONIC DISEASE HOSPITALIZATION RATES ARE AMONG THE HIGHEST 1% IN ILLINOIS. THESE DISEASES AFFECT BLACK COMMUNITY MEMBERS AT AN UNEQUAL RATE. THE EMERGENCY DEPARTMENT VISIT RATE FOR HYPERTENSION IN THE INGALLS PSA IS AMONG THE HIGHEST IN THE STATE. ADDITIONALLY, THE EMERGENCY DEPARTMENT VISIT RATE FOR HEART FAILURE IS IN THE 90TH PERCENTILE. THE RATE OF DIABETES IS 15% HIGHER IN THE INGALLS PSA THAN IN SOUTH SUBURBAN COOK COUNTY. THE RATE OF OBESITY, WHICH IS A RISK FACTOR FOR TYPE 2 DIABETES, IS NEARLY 35.5% IN THE SERVICE AREA. ON AVERAGE, PEOPLE WHO LIVE IN INGALLS PSA HAVE A MORE ADVANCED STAGE OF CANCER WHEN THEY ARE DIAGNOSED THAN OTHER RESIDENTS IN SOUTH SUBURBAN COOK COUNTY, COOK COUNTY, AND ILLINOIS. IN ADDITION TO THE PREVENTABLE CHRONIC DISEASES, THE INGALLS PSA HAS ONE OF THE HIGHEST BEHAVIORAL HEALTH ED VISIT RATES IN THE STATE FOR ADULTS. INGALLS IS ONE OF THE FEW HOSPITALS LOCATED IN SOUTH SUBURBAN COOK COUNTY.
Schedule H, Part VI, Line 5 Promotion of community health THE UNIVERSITY OF CHICAGO INGALLS MEMORIAL HOSPITAL (INGALLS) IS A COMMUNITY HOSPITAL THAT WORKS WITH ITS COMMUNITY AND PARTNERS TO IMPROVE HEALTH, PREVENT DISEASES AND ADDRESS THE SOCIAL DETERMINANTS OF HEALTH IN ITS SERVICE AREA. COMMUNITY IMPACT GRANTS INGALLS COMMUNITY IMPACT GRANTS PROGRAM PROVIDES NOT-FOR-PROFIT, COMMUNITY-BASED ORGANIZATIONS FUNDING TO SUPPORT HEALTH PROGRAMMING OR A FUNDRAISING EVENT. PRIORITY CONSIDERATION IS GIVEN TO THOSE GRANTS THAT ARE IN LINE WITH INGALLS' STRATEGIC HEALTH PRIORITIES. FUNDING TO COMMUNITY ORGANIZATIONS HELPS THEM EXPAND THEIR CAPABILITIES TO SERVE MORE COMMUNITY MEMBERS. IN FY 2022, INGALLS AWARDED $50,000 IN COMMUNITY IMPACT GRANTS, WHICH WERE USED TO ADDRESS THE HEALTH PRIORITY AREAS. - $25,000 DONATED TO CANCER SUPPORT CENTER TO INCREASE CANCER AWARENESS AND EXPAND ACCESS TO CANCER CARE - $10,000 PROVIDED TO THORNTON TOWNSHIP HIGH SCHOOL TO INTRODUCE STUDENTS TO URBAN FARMING AND ACCESS TO QUALITY FOOD - $15,000 IN FUNDING GIVEN TO BARBARA W. SMITH FAMILY LIFE CENTER TO PROVIDE HEALTH AND WELLNESS PROGRAMMING CHRONIC DISEASES: DIABETES, HEART DISEASE AND CANCER IN 2022, INGALLS OFFERED: - 14 NUTRITION WELLNESS TALKS FOCUSED ON HEART HEALTH, CANCER, DIABETES, AND WEIGHT MANAGEMENT - 106 PEOPLE ATTENDED ACCESS TO MATERNAL HEALTH THE HEALTHY BABY NETWORK (HBN) WAS ESTABLISHED TO ADDRESS THE NUMBER OF WOMEN GIVING BIRTH WHO HAVE NOT RECEIVED PRENATAL CARE. THE LACK OF PRENATAL CARE RESULTS IN PREMATURE BIRTHS, BABIES WITH LOW BIRTH WEIGHTS, INCREASED MORBIDITY AND MORTALITY, AND NUMEROUS OTHER COMPLICATIONS THAT HAVE BEEN EASILY TREATED. IN 2022, 101 PEOPLE ENROLLED IN HBN, 84 OF HBN PARTICIPANTS DELIVERED BABIES, 73 DELIVERIES WERE FULL-TERM BABIES, 72 BABIES HAD A NORMAL BIRTH WEIGHT, AND 100 PEOPLE ATTENDED THE DRIVE THRU BABY SHOWER. INGALLS DEVELOPMENT FOUNDATION THE INGALLS DEVELOPMENT FOUNDATION'S PURPOSE IS TO CONNECT DONORS WITH PHILANTHROPIC INVESTMENT OPPORTUNITIES TO TRANSFORM COMMUNITY MEDICINE IN THE UCHICAGO MEDICINE INGALLS MEMORIAL HOSPITAL SERVICE AREA. IN 2022, THE FOUNDATION PROVIDED: - $2.4 MILLION TO FUND WOOD STREET COMMUNITY HEALTH CORRIDOR. THIS INCLUDED AN OVERALL PLAN TO PROMOTE ECONOMIC DEVELOPMENT IN HARVEY, ILLINOIS. - $18,750 IN COMMUNITY SCHOLARSHIPS FOR 20 HEALTH EDUCATION STUDENTS. -$8,750 IN SUPPORT OF THE INGALLS ROOFTOP GARDEN. FUNDING ALLOWED FOR THE HIRING OF A LOCAL GARDEN COORDINATOR WHO WORKED WITH COMMUNITY MEMBERS IN MAINTENANCE AND HARVESTING EFFORTS. OUTREACH AND SUPPORT - MENTAL HEALTH THE COVID-19 PANDEMIC UNLEASHED THE BRUTAL TRUTH - MENTAL HEALTH IS AS IMPORTANT AS PHYSICAL HEALTH. THE 2021-2022 DATA SHOWED THAT INGALLS MEMORIAL'S SERVICE AREA HAS ONE OF THE HIGHEST BEHAVIORAL HEALTH EMERGENCY ROOM VISIT RATES IN THE STATE FOR ADULTS. TO ADDRESS THE NEED, INGALLS OFFERED FOUR FREE WORKSHOPS ON MENTAL HEALTH, WELLNESS AND SELF-CARE. ADDRESSING FOOD INSECURITY UCHICAGO MEDICINE INGALLS MEMORIAL HOSPITAL OPENED THREE ONSITE FOOD PANTRIES FOR ITS ONCOLOGY PATIENTS. THE PROGRAM DOES NOT REQUIRE INDIVIDUALS TO SIGN FOR EMERGENCY FOOD IF THEY ARE UNCOMFORTABLE. IN 2022, THE NUTRITION STATIONS EXPANDED TO FLOSSMOOR AND TINLEY PARK. IN FY 2022, 300 POUNDS OF FOOD WERE DISTRIBUTED, SERVING 2,705 PATIENTS. COMMUNITY ADVISORY COUNCIL (CAC) THE INGALLS CAC IS COMPRISED OF 14 MEMBERS AND SEEKS COMMUNITY INPUT ON HEALTH ISSUES THAT ARE IMPORTANT TO ITS PRIMARY SERVICE AREA AND SURROUNDING COMMUNITIES. THE COUNCIL TALKS TO THE COMMUNITY TO HELP GUIDE FUTURE DECISIONS FOR RESOURCES OF UCHICAGO MEDICINE INGALLS MEMORIAL HOSPITAL IN HARVEY AND INGALLS AMBULATORY LOCATIONS. COMMUNITY BOARD THE INGALLS BOARD OF DIRECTORS MEMBERSHIP IS COMPRISED OF LOCAL BUSINESS AND COMMUNITY MEMBERS THAT LIVE IN THE CHICAGO AND THE SOUTH SUBURBAN REGION. IN ADDITION TO THE INGALLS PRESIDENT, ONE EMPLOYED PHYSICIAN SERVES AS AN ELECTED BOARD MEMBER. ALL MEMBERS ARE IN COMPLIANCE WITH THE BOARD CONFLICT OF INTEREST POLICY AND ARE REQUIRED TO COMPLETE AN ANNUAL CERTIFICATION AND DISCLOSURE FORM. QUALIFIED PHYSICIANS INGALLS RESPONDS TO REQUESTS FOR APPLICATIONS TO JOIN THE MEDICAL STAFF MADE BY QUALIFIED PHYSICIANS IN THE COMMUNITY. THE INGALLS PROFESSIONAL AFFAIRS COMMITTEE REVIEWS INQUIRIES AND PROVIDES APPLICATIONS TO PHYSICIANS WHO MEET THE MINIMUM QUALIFICATIONS FOR MEDICAL STAFF MEMBERSHIP IF THERE IS A NEED FOR A PARTICULAR SERVICE AND/OR A PATIENT NEED EXISTS WITHIN THE COMMUNITY. STAFF EDUCATION IN FY 2022 INGALLS INVESTED $1.2 MILLION IN MEDICAL EDUCATION. THE INGALLS MEDICAL STAFF SUPPORTS IMPROVEMENTS IN PATIENT CARE AND ONGOING EDUCATION TO THE MEDICAL AND PROFESSIONAL STAFF THROUGH FUNDING OF MEDICAL EDUCATION ACTIVITIES. INGALLS IS ACCREDITED BY THE ILLINOIS STATE MEDICAL SOCIETY TO AWARD CME CATEGORY 1 CREDIT. THE CME COMMITTEE IS RESPONSIBLE FOR OVERSIGHT OF MONTHLY CME ACTIVITIES WHICH ARE SPONSORED BY THE HOSPITAL. BOTH MEDICAL AND PROFESSIONAL (NURSING, QUALITY MANAGEMENT, ETC.) STAFF ARE INVITED AND ENCOURAGED TO ATTEND THE PROGRAMS. TO PROMOTE COMMUNITY HEALTH ACTIVITIES AND PROGRAMS, INGALLS DISTRIBUTES INFORMATION VIA: - EXTERNAL NEWSLETTERS - COMMUNITY PARTNERS - MESSAGE BOARDS - SOCIAL MEDIA PLATFORMS
Schedule H, Part VI, Line 6 Affiliated health care system THE INGALLS MEMORIAL HOSPITAL IS PART OF THE INGALLS HEALTH SYSTEM THAT IS NOW KNOWN AS UCM COMMUNITY HEALTH & HOSPITAL DIVISION, INC. THE INGALLS HEALTH SYSTEM WAS INCORPORATED TO SUPPORT AND ENCOURAGE HEALTH AND HUMAN SERVICES THROUGH THE FOLLOWING AFFILIATES: *THE INGALLS MEMORIAL HOSPITAL *INGALLS HEALTH VENTURES *MEDCENTRIX, INC. *INGALLS DEVELOPMENT FOUNDATION *INGALLS HEALTH COUNCIL *INGALLS HOME CARE *INGALLS PROVIDER GROUP *INGALLS CASUALTY INSURANCE *INGALLS SAME DAY SURGERY, LTD. *INGALLS CARE NETWORK *PRIMARY HEALTHCARE ASSOCIATES, SC* TRULEN INSURANCE SPC LIMITED
Schedule H, Part VI, Line 7 State filing of community benefit report IL
Schedule H (Form 990) 2021
Additional Data


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Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990.
lBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number
36-2170866
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient
that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC section
(if applicable)		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
noncash assistance		 (h) Purpose of grant
or assistance
(1) FAMILY CHRISTIAN HEALTH CENTER
31 W 155TH STREET
CHICAGO,IL60426 		36-4346917 501(C)(3) 25,000       COMMUNITY IMPACT GRANT
(2) CANCER SUPPORT CENTER
2028 ELM RD
HOMEWOOD,IL60430 		36-3880404 501(C)(3) 55,000       COMMUNITY IMPACT GRANT
(3) BARBARA W SMITH FAMILY LIFE CENTER
1130 E 154TH ST
SOUTH HOLLAND,IL60473 		46-3014545 501(C)(3) 15,000       COMMUNITY IMPACT GRANT
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
3
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2021

Schedule I (Form 990) 2021
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of
recipients		 (c) Amount of
cash grant		 (d) Amount of
noncash assistance		 (e) Method of valuation (book,
FMV, appraisal, other)		 (f) Description of noncash assistance
(1) SCHOLARSHIPS 96 71,500   CASH N/A
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Part IV
Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.
Return Reference Explanation
Schedule I, Part I, Line 2 PROCEDURES FOR MONITORING USE OF GRANT FUNDS INGALLS DEVELOPMENT FOUNDATION'S BOARD OF DIRECTORS APPROVES THE GRANTS MADE TO OTHER ORGANIZATIONS. FUNDS ARE THEN TRANSFERRED TO INGALLS MEMORIAL HOSPITAL FOR DISBURSEMENT. ENTITIES RECEIVING GRANT FUNDS MUST PROVIDE A WRITTEN FINAL REPORT AND BUDGET NARRATIVE TO ENSURE THE FUNDS WERE EXPENDED TO ATTAIN GRANT OBJECTIVES.
Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. SCHOLARSHIPS ARE PAID DIRECTLY TO THE EDUCATIONAL INSTITUTIONS IN ORDER TO ENSURE THE FUNDS ARE USED FOR THEIR INTENDED PURPOSE.
Schedule I (Form 990) 2021



Additional Data


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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
2021
Open to Public Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
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 .....
1b
Yes
 
2
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? ....
2
Yes
 
3
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.
4
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:
a
Receive a severance payment or change-of-control payment? .............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
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.
5
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:
a
The organization? ....................
5a
 
No
b
Any related organization? .......................
5b
 
No
If "Yes," on line 5a or 5b, describe in Part III.
6
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:
a
The organization? ..................
6a
 
No
b
Any related organization? ......................
6b
 
No
If "Yes," on line 6a or 6b, describe in Part III.
7
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 ............
7
Yes
 
8
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 ..........................
8
 
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2021

Schedule J (Form 990) 2021
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, 1099-MISC compensation, and/or 1099-NEC (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
(i) Base
compensation 		(ii) Bonus & incentive
compensation 		(iii) Other reportable compensation
1BRIAN SINOTTE
 
FORMER PRESIDENT CHHD (THRU 5/31/21) 		(i)

(ii)		 266,509
-------------
0 		148,065
-------------
0 		9,176
-------------
0 		0
-------------
0 		7,627
-------------
0 		431,376
-------------
0 		0
-------------
0
2RANDY NEISWONGER
 
INTERIM PRESIDENT CHHD 		(i)

(ii)		 423,391
-------------
0 		120,452
-------------
0 		714
-------------
0 		31,927
-------------
0 		39,607
-------------
0 		616,092
-------------
0 		0
-------------
0
3JOHN A FLYNN MD
 
BOARD MEMBER (THRU 9/23/21) 		(i)

(ii)		 0
-------------
633,075 		0
-------------
118,392 		0
-------------
42,494 		0
-------------
23,200 		0
-------------
33,445 		0
-------------
850,606 		0
-------------
0
4MARK KOZLOFF MD
 
BOARD MEMBER 		(i)

(ii)		 0
-------------
508,872 		0
-------------
215,000 		0
-------------
0 		0
-------------
2,474 		0
-------------
30,891 		0
-------------
757,237 		0
-------------
0
5CORRIN STEINHAUER
 
BOARD MEMBER/VP PATIENT CARE & CNO, INGALLS (THRU 4/22/22) 		(i)

(ii)		 0
-------------
308,019 		0
-------------
54,910 		0
-------------
58,277 		0
-------------
32,280 		0
-------------
41,773 		0
-------------
495,259 		0
-------------
0
6STEPHEN WEBER MD
 
BOARD MEMBER (EFF. 9/23/21) 		(i)

(ii)		 0
-------------
1,482,114 		0
-------------
499,641 		0
-------------
119,160 		0
-------------
139,175 		0
-------------
29,387 		0
-------------
2,269,477 		0
-------------
0
7ENGIN YILMAZ MD
 
BOARD MEMBER 		(i)

(ii)		 0
-------------
321,024 		0
-------------
127,250 		0
-------------
12,000 		0
-------------
6,914 		0
-------------
595 		0
-------------
467,783 		0
-------------
0
8GARY GASBARRA
 
INTERIM CFO TIL 6/30/17 		(i)

(ii)		 0
-------------
366,230 		0
-------------
102,416 		0
-------------
141,771 		0
-------------
52,141 		0
-------------
26,674 		0
-------------
689,233 		0
-------------
47,146
9RICHARD W SILVERIA
 
FORMER CHIEF FINANCIAL OFFICER (THRU 4/22/21) 		(i)

(ii)		 0
-------------
250,773 		0
-------------
435,412 		0
-------------
1,220,688 		0
-------------
0 		0
-------------
21,121 		0
-------------
1,927,994 		0
-------------
514,033
10ANN MCCOLGAN
 
ASSISTANT TREASURER 		(i)

(ii)		 0
-------------
279,136 		0
-------------
76,499 		0
-------------
133,033 		0
-------------
40,057 		0
-------------
41,286 		0
-------------
570,011 		0
-------------
26,910
11TOMASZ SAMEK
 
ASSISTANT SECRETARY 		(i)

(ii)		 0
-------------
168,449 		0
-------------
20,815 		0
-------------
4,489 		0
-------------
7,870 		0
-------------
19,692 		0
-------------
221,315 		0
-------------
0
12IVAN SAMSTEIN
 
CHIEF FINANCIAL OFFICER 		(i)

(ii)		 0
-------------
692,648 		0
-------------
125,203 		0
-------------
37,077 		0
-------------
81,600 		0
-------------
43,485 		0
-------------
980,012 		0
-------------
0
13PAUL DONOHUE
 
VP PHILANTHROPY AND COMMUNITY 		(i)

(ii)		 227,276
-------------
0 		36,091
-------------
0 		0
-------------
0 		17,524
-------------
0 		48,678
-------------
0 		329,569
-------------
0 		0
-------------
0
14DOUGLAS SAEGESSER
 
VP OF FINANCE (THRU 9/8/2021) 		(i)

(ii)		 267,351
-------------
0 		63,944
-------------
0 		116,599
-------------
0 		1,180
-------------
0 		34,300
-------------
0 		483,374
-------------
0 		15,859
-------------
0
15MARY JO CRANDALL
 
VP OPERATIONS 		(i)

(ii)		 226,520
-------------
0 		31,528
-------------
0 		0
-------------
0 		3,230
-------------
0 		0
-------------
0 		261,278
-------------
0 		0
-------------
0
16POONAM DESAI
 
EXECUTIVE DIRECTOR, AMBULATORY 		(i)

(ii)		 210,289
-------------
0 		26,471
-------------
0 		0
-------------
0 		2,894
-------------
0 		43,438
-------------
0 		283,092
-------------
0 		0
-------------
0
17NEGIN KIYAVASH
 
DIRECTOR OF PHARMACY 		(i)

(ii)		 194,245
-------------
0 		26,775
-------------
0 		0
-------------
0 		3,005
-------------
0 		29,763
-------------
0 		253,788
-------------
0 		0
-------------
0
18LISA LIGUE
 
DIRECTOR, REVENUE CYCLE 		(i)

(ii)		 200,488
-------------
0 		25,184
-------------
0 		240
-------------
0 		2,859
-------------
0 		0
-------------
0 		228,771
-------------
0 		0
-------------
0
19KRISTINE SHIELDS
 
OCCUPATIONAL MEDICINE 		(i)

(ii)		 205,764
-------------
0 		33,355
-------------
0 		0
-------------
0 		2,948
-------------
0 		0
-------------
0 		242,067
-------------
0 		0
-------------
0
Schedule J (Form 990) 2021

Schedule J (Form 990) 2021
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 1a Tax indemnification and gross-up payments DURING 2021, THE ORGANIZATION PROVIDED A VERY LIMITED NUMBER OF AD HOC TAX-RELATED PAYMENTS. RANDY NEISWONGER RECEIVED TAX RELATED PAYMENTS IN CONNECTION WITH THE PAYMENT OF AN EXECUTIVE LIFE INSURANCE POLICY. ALL TAX-RELATED PAYMENTS ARE INCLUDED IN TAXABLE COMPENSATION, AND ARE CONFIRMED AS BEING REASONABLE WHEN CONSIDERED WITH ALL OTHER FORMS OF COMPENSATION.
Schedule J, Part I, Line 4a Severance or change-of-control payment IN CALENDAR YEAR 2021, RICHARD SILVERIA AND DOUGLAS SAEGESSER RECEIVED SEVERANCE PAYMENTS FOLLOWING THEIR TERMINATION OF EMPLOYMENT ($1,080,964 TO RICHARD SILVERIA AND $116,599 TO DOUGLAS SAEGESSER). SOME OF THESE AMOUNTS WERE PREVIOUSLY REPORTED ON A PRIOR FORM 990 AS DEFERRED COMPENSATION AS SET FORTH IN COLUMN (F) OF PART II.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan CERTAIN INDIVIDUALS LISTED IN SCHEDULE J, PART II PARTICIPATE IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN TO WHICH UCMC MAKES ANNUAL CONTRIBUTIONS. THESE CONTRIBUTIONS ARE AT RISK AND DO NOT BECOME VESTED AND PAYABLE UNLESS AND UNTIL THE INDIVIDUAL SATISFIES A SUBSTANTIAL FUTURE SERVICE REQUIREMENT. THE FOLLOWING INDIVIDUALS HAD CONTRIBUTIONS MADE TO THE PLAN IN JANUARY 2022 FOR CALENDAR YEAR 2021: ANN MCCOLGAN CORRIN STEINHAUER GARY GASBARRA IVAN SAMSTEIN PAUL DONOHUE RANDY NEISWONGER STEPHEN WEBER THE FOLLOWING INDIVIDUALS BECAME VESTED IN, AND WERE TAXED ON, AMOUNTS PREVIOUSLY CREDITED UNDER THE PLAN TO THE INDIVIDUAL FOR SERVICES PROVIDED TO THE ORGANIZATION IN PRIOR YEARS (INCLUDED IN THE 2021 W-2'S): ANN MCCOLGAN - $26,910 GARY GASBARRA - $47,146 STEPHEN WEBER - 119,160 RICHARD SILVERIA AND DOUGLAS SAEGESSER RECEIVED A DISTRIBUTION FROM A SUPPLEMENTAL RETIREMENT PLAN FOLLOWING THEIR TERMINATION OF EMPLOYMENT, IN ACCORDANCE WITH THE GOVERNING PLAN DOCUMENT ($514,033 TO RICHARD SILVERIA AND $15,859 TO DOUGLAS SAEGESSER). THESE DISTRIBUTIONS WERE REPORTED AS TAXABLE INCOME AND ARE INCLUDED IN THE COMPENSATION DISCLOSED IN SCHEDULE J IN THE REPORTED YEAR.
Schedule J, Part I, Line 7 Non-fixed payments NINE PERSONS LISTED IN PART VII, SECTION A, LINE 1A RECEIVED NON-FIXED NON-RECURRING PAYMENTS DURING CALENDAR YEAR 2021. THESE NON-FIXED PAYMENTS ARE RELATED TO PERFORMANCE BONUSES.
Schedule J, Part II TAXABLE INCOME REPORTED IN COLUMN (B) MAY INCLUDE PAYMENTS FROM THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). IN MOST CASES, THESE PAYMENTS WERE EARNED OVER MANY YEARS OF EMPLOYMENT AND THE AMOUNTS HAD PREVIOUSLY BEEN SUBJECT TO VESTING RULES. SERP PAYMENT AMOUNTS EARNED IN PRIOR YEARS WERE PREVIOUSLY REPORTED ON THE FORM 990 AS DEFERRED COMPENSATION AND ARE REPORTED IN THIS 2021 FORM 990 ON SCHEDULE J, PART II, COLUMN (F). AN INDEPENDENT COMPENSATION COMMITTEE OF THE BOARD ANNUALLY REVIEWS THESE BENEFITS IN COMPARISON TO MARKET DATA AND HAS CONCLUDED THAT THESE BENEFITS AND ALL OTHER FORMS OF COMPENSATION PROVIDED TO THESE INDIVIDUALS ARE REASONABLE. The independent compensation committee of the board conducts its review and approval of all executive compensation, including these SERP amounts, in a manner that qualifies for the rebuttable presumption of reasonableness under federal tax law. This is a rigorous review process designed for tax-exempt organizations by the Internal Revenue Service, and it means that the board compensation committee does not have any conflicts of interest, and relies on market data compiled by an independent compensation consultant to support all executive pay as market competitive and reasonable. FOR THE INDIVIDUALS LISTED ON SCHEDULE J, PART II THAT ARE IDENTIFIED AS FORMER OFFICERS OR KEY EMPLOYEES, THE COMPENSATION LISTED IS EITHER THE FAIR MARKET VALUE COMPENSATION PAID TO THEM FOR SERVICES THEY PERFORMED AS ACTIVE EMPLOYEES OF IMH OR A RELATED ORGANIZATION (AND WAS NOT PAID TO THEM DUE TO THEIR FORMERLY HAVING BEEN LISTED AS OFFICERS OR KEY EMPLOYEES), OR COMPENSATION AS A COMBINATION OF SERVICES AND SEVERANCE: RICHARD SILVERIA AND DOUGLAS SAEGESSER.
Schedule J (Form 990) 2021

Additional Data


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Software Version: 2021v4.2

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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax-Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet Attach to Form 990.
SchKMediumBulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number
36-2170866
Part Ⅰ
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer		 (i) Pool
financing
Yes No Yes No Yes No
A ILLINOIS FINANCE AUTHORITY 2017
  		86-1091967 000000000 12-29-2017 41,180,000 REFUNDING 2004 BONDS   X   X   X
Part Ⅱ
Proceeds
A B C D
1 Amount of bonds retired .................. 8,790,000      
2 Amount of bonds legally defeased ..............        
3 Total proceeds of issue .................. 41,180,000      
4 Gross proceeds in reserve funds .............        
5 Capitalized interest from proceeds .............        
6 Proceeds in refunding escrows ...............        
7 Issuance costs from proceeds ............... 349,422      
8 Credit enhancement from proceeds .............        
9 Working capital expenditures from proceeds .............        
10 Capital expenditures from proceeds .............        
11 Other spent proceeds ............. 40,830,578      
12 Other unspent proceeds .............        
13 Year of substantial completion ............. 2017
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue of tax-exempt
bonds (or, if issued prior to 2020, a current refunding issue)? ........ 		X              
15 Were the bonds issued as part of an advance refunding issue of taxable
bonds (or, if issued prior to 2020, an advance refunding issue)? ........ 		  X            
16 Has the final allocation of proceeds been made? .......... X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .................. X              
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2021

Schedule K (Form 990) 2021
Page 2
Part Ⅲ
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? ............... X              
3a Are there any management or service contracts that may result in private business use of bond-financed property? ............. X              
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? X              
c Are there any research agreements that may result in private business use of bond-financed property? .............   X            
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....SchKMediumBullet 0 %      
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government ......... SchKMediumBullet 0 %      
6 Total of lines 4 and 5 ............. 0 %      
7 Does the bond issue meet the private security or payment test? ...   X            
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............   X            
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..        
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............                
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2? ........ 		X              
Part Ⅳ
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...   X            
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? ....... X              
b Exception to rebate? ........   X            
c No rebate due? .........   X            
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate
computation was performed ......
3 Is the bond issue a variable rate issue? .....   X            
Schedule K (Form 990) 2021

Schedule K (Form 990) 2021
Page 3
Part Ⅳ
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X            
b Name of provider ..........  
  		 
  		 
  		 
 
c Term of hedge .........        
d Was the hedge superintegrated? ......                
e Was the hedge terminated? ........                
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?   X            
b Name of provider ..........  
  		 
  		 
  		 
 
c Term of GIC .........        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........                
6 Were any gross proceeds invested beyond an available temporary period?   X            
7 Has the organization established written procedures to monitor the requirements of section 148? ... X              
Part Ⅴ
Procedures To Undertake Corrective Action
--------------------------------------------------------------------------------------------------------------- A B C D
Yes No Yes No Yes No Yes No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? X              
Part Ⅵ
Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).
Return Reference Explanation
Schedule K, Part V BOND POLICY WRITTEN TAX-EXEMPT BOND PROCEDURES WERE ADOPTED ON FEBRUARY 12, 2018.
Schedule K (Form 990) 2021

Additional Data


Software ID: 21014044
Software Version: 2021v4.2

SCHEDULE O
(Form 990)

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
2021
Open to Public
Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
Return Reference Explanation
Form 990, Part III, Line 4d Description of other program services (Expenses $ 91,593,870 including grants of $ 95,000)(Revenue $ 49,526,422) OTHER PROGRAM SERVICES RELATED TO THE PROVISION OF HEALTHCARE INCLUDE LABORATORY SERVICES, PATIENT FINANCIAL SERVICES, COST OF FACILITIES, MALPRACTICE INSURANCE, AND OTHER SUPPORT SERVICES.
Form 990, Part VI, Line 1a PART VI, LINE 1A THE BOARD OF DIRECTORS SHALL APPOINT ANNUALLY FROM ITS MEMBERSHIP AN EXECUTIVE COMMITTEE OF NOT LESS THAN FIVE (5) NOR MORE THAN NINE (9) MEMBERS, OF WHICH THREE (3) MEMBERS SHALL BE THE CHAIRMAN, THE VICE CHAIRMAN, AND THE SECRETARY/TREASURER OF THE HOSPITAL. THE EXECUTIVE COMMITTEE SHALL HAVE AND EXERCISE ALL OF THE POWERS OF THE BOARD OF DIRECTORS NOT PROHIBITED BY STATUTE OR SECTION 1 OF THE HOSPITAL'S BYLAWS BETWEEN MEETINGS THEREOF.
Form 990, Part VI, Line 6 Classes of members or stockholders PURSUANT TO THE ORGANIZATION'S GOVERNING DOCUMENTS, THE SOLE VOTING MEMBER OF THE ORGANIZATION IS UCM COMMUNITY HEALTH & HOSPITAL DIVISION, INC., A RELATED TAX-EXEMPT ORGANIZATION. AS THE ORGANIZATION'S SOLE CORPORATE MEMBER, IT HAS THE RIGHT TO PARTICIPATE IN THE ORGANIZATION'S GOVERNANCE.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body DIRECTORS, OTHER THAN THE DIRECTORS EX OFFICIO, SHALL BE ELECTED ANNUALLY BY UCM COMMUNITY HEALTH & HOSPITAL DIVISION, INC., OR AT SUCH OTHER TIMES AS MAY BE DETERMINED BY THE SOLE MEMBER OF THE CORPORATION.
Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders UCM COMMUNITY HEALTH & HOSPITAL DIVISION, INC. SHALL RETAIN THE RIGHT TO REMOVE ANY DIRECTOR, OTHER THAN DIRECTORS EX OFFICIO, WITH OR WITHOUT CAUSE, AT ANY TIME. UCM COMMUNITY HEALTH & HOSPITAL DIVISION, INC. MUST APPROVE ANY MODIFICATION OR AMENDMENT TO ANY MISSION STATEMENT, STATEMENT OF GOALS OR VALUES, THE ARTICLES OF INCORPORATION OR THE BYLAWS OF THE CORPORATION; THE SALE, LEASE, EXCHANGE OR DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; AND THE MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION.
Form 990, Part VI, Line 11b Review of form 990 by governing body THE FORM 990 IS PREPARED INTERNALLY AND REVIEWED IN DETAIL BY AN INDEPENDENT ACCOUNTING FIRM WITH INFORMATION PROVIDED BY MANAGEMENT. THE FULL FORM 990, INCLUDING SUPPLEMENTAL SCHEDULES, WAS PRESENTED BY THE CHIEF FINANCIAL OFFICER TO THE FINANCE COMMITTEE AT A COMMITTEE MEETING. THE FULL BOARD HAS GRANTED TO THE FINANCE COMMITTEE AUTHORITY TO APPROVE THE FORM 990. THE FULL BOARD WILL RECEIVE A REPORT FROM THE FINANCE COMMITTEE DESCRIBING THE FINANCE COMMITTEE'S REVIEW PERFORMED. PRIOR TO FILING WITH THE IRS, THE FORM 990 WILL BE AVAILABLE AT THE ORGANIZATION'S BOARD MEETING FOR EACH MEMBER'S REVIEW.
Form 990, Part VI, Line 12c Conflict of interest policy PURSUANT TO THE ORGANIZATION'S CONFLICT OF INTEREST POLICY, ALL OFFICERS, DIRECTORS, BOARD MEMBERS, AND KEY EMPLOYEES MUST AVOID SITUATIONS IN WHICH THEIR PERSONAL INTERESTS MAY CONFLICT, OR APPEAR TO CONFLICT, WITH THE INTEREST OF INGALLS, AND INGALLS REVIEWS ITS OWN RELATIONSHIPS WITH OTHER CARE PROVIDERS, EDUCATIONAL INSTITUTIONS, AND PAYERS TO DETERMINE IF POTENTIAL CONFLICTS EXISTS. BOARD MEMBERS AND EMPLOYEES SHALL HAVE THE CONTINUING AFFIRMATIVE DUTY TO REPORT TO THE PRESIDENT AND CHIEF EXECUTIVE OFFICER (CEO) OF INGALLS ANY PERSONAL OWNERSHIP OF INTEREST OR OTHER RELATIONSHIP THAT MIGHT AFFECT THEIR ABILITY TO EXERCISE IMPARTIAL, ETHICAL BUSINESS JUDGMENTS IN THE AREA OF THEIR RESPONSIBILITIES. PER THE ORGANIZATION'S CONFLICT OF INTEREST POLICY, BOARD MEMBERS AND EMPLOYEES AT MANAGEMENT LEVEL WILL BE REQUIRED TO COMPLETE A CERTIFICATION AND DISCLOSURE FORM, ON A SCHEDULE DETERMINED BY THE CORPORATE COMPLIANCE OFFICER. COMPLETION OF THIS FORM IS A REQUIREMENT FOR ALL BOARD MEMBERS AND MANAGERIAL EMPLOYEES, AND MAY BE REQUIRED OF NON MANAGEMENT EMPLOYEES AS DETERMINED BY THE PRESIDENT AND CEO AND CORPORATE COMPLIANCE OFFICER. EMPLOYEES ALSO HAVE A DUTY TO REPORT CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST OF WHICH THEY MAY BE AWARE OF INVOLVING OTHER EMPLOYEES. EACH SITUATION REPORTED SHALL BE REVIEWED BY THE PRESIDENT AND CEO, AND INGALL'S CORPORATE COMPLIANCE OFFICER, AND A DETERMINATION SHALL BE MADE AS TO WHETHER A CONFLICT OF INTEREST EXISTS OF MAY ARISE FROM SUCH SITUATION. THE DECISION OF THE PRESIDENT AND CEO AND CORPORATE COMPLIANCE OFFICER REGARDING WHETHER A CONFLICT EXISTS SHALL BE FINAL. PERSONS WITH A CONFLICT ARE PROHIBITED FROM PARTICIPATING IN THE GOVERNING BODY'S RESOLUTION OF SUCH CONFLICT. THE ORGANIZATION FURTHER PROMOTES KNOWLEDGE AND UNDERSTANDING OF THE CONFLICT OF INTEREST POLICY IN THE EMPLOYEE HANDBOOK. EACH EMPLOYEE IS REQUIRED TO SIGN AN ACKNOWLEDGEMENT OF THE HANDBOOK UPON EMPLOYMENT.
Form 990, Part VI, Line 15a Process to establish compensation of top management official THE UNIVERSITY OF CHICAGO MEDICAL CENTER (UCMC) IS RESPONSIBLE FOR DETERMINING AND ADMINISTERING COMPENSATION FOR ALL OFFICERS OF EACH RESPECTIVE ENTITY WITHIN THE UCMC CORPORATE STRUCTURE. ALL COMPENSATION AND BENEFIT APPROVALS ARE MADE (BY THE UCM CHHD COMPENSATION COMMITTEE, AS EXPLAINED BELOW) AS RECOMMENDATIONS TO THE UCMC COMPENSATION COMMITTEE AND ARE SUBJECT TO FURTHER REVIEW AND APPROVAL BY THE UCMC COMPENSATION COMMITTEE. BELOW IS THE PROCESS USED TO ESTABLISH COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL AND SENIOR EXECUTIVES. THE UCM COMMUNITY HEALTH AND HOSPITAL DIVISION, INC (UCM CHHD) COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES (THE COMMITTEE) IS RESPONSIBLE FOR THE OVERSIGHT OF THE INGALLS MEMORIAL HOSPITAL EXECUTIVE COMPENSATION DECISION-MAKING PROCESS. ITS REVIEW PROCESS IS DESIGNED TO SATISFY THE PROCEDURAL CRITERIA NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS (UNDER INTERMEDIATE SANCTIONS REGULATIONS) WITH RESPECT TO THE TOTAL COMPENSATION AND BENEFITS PROVIDED. THE COMMITTEE IS COMPRISED OF INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS, ALL OF WHOM ARE "DISINTERESTED" WITHIN THE MEANING OF THE INTERMEDIATE SANCTIONS REGULATIONS. IT REVIEWS AND APPROVES COMPENSATION AND EMPLOYEE BENEFITS PROVIDED TO THE ORGANIZATION'S PRESIDENT AND KEY EXECUTIVES BY FOLLOWING ITS WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY STATEMENT AND WRITTEN COMPENSATION REVIEW PROCESS, WHICH INCLUDES SEEKING COUNSEL FROM OUTSIDE PROFESSIONAL ADVISORS AND RELYING IN ADVANCE ON APPROPRIATE COMPARABILITY DATA (FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED HEALTHCARE ORGANIZATIONS) PROVIDED BY AN INDEPENDENT THIRD-PARTY CONSULTANT. THE COMMITTEE REVIEWS AND APPROVES ALL NEW COMPENSATION RANGES, AS WELL AS CURRENT PACKAGES FOR NEWLY HIRED EXECUTIVES, AS NEEDED, BUT AT LEAST ANNUALLY. IT PREPARES A TIMELY AND THOROUGH WRITTEN RECORD OF ITS DELIBERATIONS AND CONCLUSIONS.
Form 990, Part VI, Line 15b Process to establish compensation of other employees AN INDEPENDENT COMPENSATION CONSULTANT REVIEWS THE REASONABLENESS OF PROPOSED TOTAL DIRECT COMPENSATION FOR EACH EXECUTIVE BY PERFORMING A MARKET COMPARISON FOR EACH EXECUTIVE. THE MARKET COMPARISON INVOLVES COLLECTING SURVEY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILAR HEALTHCARE ORGANIZATIONS. PERFORMANCE GOALS ARE NORMALLY ESTABLISHED BASED ON THE BUDGET/BUSINESS PLAN APPROVED BY THE BOARD FOR THE FISCAL YEAR. THE OUTSIDE CONSULTANT OPINES WHETHER OR NOT PERFORMANCE GOALS HAVE BEEN REACHED BEFORE A FISCAL YEAR END. PAYMENTS ARE PRESENTED TO THE COMPENSATION COMMITTEE FOR REVIEW AND APPROVAL. THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES PREPARES A TIMELY AND THOROUGH WRITTEN RECORD OF ITS DELIBERATIONS AND CONCLUSIONS.
Form 990, Part VI, Line 19 Required documents available to the public IMH'S BYLAWS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
Form 990, Part VIII, Line 2f Other Program Service Revenue CLIENT SERVICE REVENUE - Total Revenue: 143741, Related or Exempt Function Revenue: 143741, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ;
Form 990, Part VIII, Line 11d Other Miscellaneous Revenue MISCELLANEOUS REVENUE - Total Revenue: 685432, Related or Exempt Function Revenue: 685432, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; MOBILE INTENSIVE CARE FEE - Total Revenue: 101207, Related or Exempt Function Revenue: 101207, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; PROGRAM REVENUE - Total Revenue: 100530, Related or Exempt Function Revenue: 100530, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; MED RECORD & TRANS FEES - Total Revenue: 17047, Related or Exempt Function Revenue: 17047, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; RETINAL FASC - OTHER - Total Revenue: 9069, Related or Exempt Function Revenue: 9069, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; PAS/PAGER RENTAL - Total Revenue: 4888, Related or Exempt Function Revenue: 4888, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; DISCOUNT EARNINGS - Total Revenue: 561, Related or Exempt Function Revenue: 561, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ;
Form 990, Part IX, Line 11g Other Fees PATIENT CARE SERVICES - Total Expense: 26150725, Program Service Expense: 25418468, Management and General Expenses: 732257, Fundraising Expenses: ; LABORATORY SERVICES - Total Expense: 355771, Program Service Expense: 178809, Management and General Expenses: 176962, Fundraising Expenses: ; FOOD SERVICES - Total Expense: 5868381, Program Service Expense: 4401286, Management and General Expenses: 1467095, Fundraising Expenses: ; ENVIRONMENTAL/HOSPITALITY SVCS - Total Expense: 6131905, Program Service Expense: 5600823, Management and General Expenses: 531082, Fundraising Expenses: ; PATIENT TRANSPORTATION - Total Expense: 1616267, Program Service Expense: 1616267, Management and General Expenses: , Fundraising Expenses: ; PATIENT FINANCIAL SERVICES - Total Expense: 1592383, Program Service Expense: , Management and General Expenses: 1592383, Fundraising Expenses: ; FAMILY CARE CENTERS - Total Expense: 2719654, Program Service Expense: 2533270, Management and General Expenses: 186384, Fundraising Expenses: ; OTHER - Total Expense: 5389687, Program Service Expense: 2472797, Management and General Expenses: 2916890, Fundraising Expenses: ; RENTAL EXPENSE RECLASS - Total Expense: -6836, Program Service Expense: , Management and General Expenses: -6836, Fundraising Expenses: ;
Form 990, Part XI, Line 9 Other changes in net assets or fund balances FAIR VALUE OF DERIVATIVE INSTRUMENTS - 4228851; CHANGE IN INTEREST OF FOUNDATION - 50440; TRANSFERS FROM AFFILIATES - 6405400;
Form 990, Part XII, Line 3a Single Audit Act and OMB Circular A-133 The organization is subject to a single audit requirement for its fiscal year ending June 30, 2022. The organization began the process to undergo the required audit during its fiscal year ending June 30, 2023 and will file a single audit in conjunction with the University of Chicago by 3/31/2023.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
The Ingalls Memorial Hospital
 
Employer identification number

36-2170866
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?
Yes No
(1)ARCH DEVELOPMENT CORPORATION
5555 S WOODLAWN AVENUE

CHICAGO,IL60637
36-3485244 		TECH TRANSFER IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(2)ASIAN HEALTH COALITION
180 W WASHINGTON ST SUITE 1

CHICAGO,IL60602
31-1607193 		HLTH ACCESS IL 501(c)(3) 10 UNIV CHICAGO
 
 
No
(3)CHAPIN HALL CENTER FOR CHILDREN
1313 E 60TH STREET

CHICAGO,IL60637
36-2167012 		POL RES CTR IL 501(c)(3) 7 NA
 
 
No
(4)CHICAGO HOME FOR THE INCURABLES
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-2169138 		SUPP RESEARCH IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(5)CHICAGO TUMOR INSTITUTE
5801 S ELLIS AVENUE

CHICAGO,IL60637
23-7136019 		SUPP RESEARCH IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(6)COURT THEATRE FUND
5535 S ELLIS AVENUE

CHICAGO,IL60637
36-3203660 		SUPP THE ARTS IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(7)FERMI RESEARCH ALLIANCE LLC
PO BOX 500

BATAVIA,IL60510
57-1239010 		MANAGE LAB IL 501(c)(3) 7 NA
 
 
No
(8)HYMEN MILGROM SUPPORTING ORGANIZATION
33 N LASALLE ST STE 2131

CHICAGO,IL60602
46-6789522 		SUPP EDU RES VA 501(c)(3) Type III-O NA
 
 
No
(9)INGALLS DEVELOPMENT FOUNDATION
ONE INGALLS DRIVE

HARVEY,IL60426
36-3189150 		SUPPORT IL 501(c)(3) 7 UCHHD
 
 
No
(10)INGALLS HEALTH VENTURES
ONE INGALLS DRIVE

HARVEY,IL60426
36-3239703 		AMBULATORY IL 501(c)(3) Type I UCHHD
 
 
No
(11)INGALLS HOME CARE
ONE INGALLS DRIVE

HARVEY,IL60426
36-3367939 		HEALTHCARE IL 501(c)(3) 10 IMH
 
Yes
 
(12)LAKE PARK ASSOCIATES
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-6111317 		PROP HOLDG IL 501(c)(2)   UNIV CHICAGO
 
 
No
(13)NATIONAL OPINION RESEARCH CENTER (NORC)
55 E MONROE AVENUE

CHICAGO,IL60603
36-2167808 		SO SCI SRVYS IL 501(c)(3) 7 NA
 
 
No
(14)PRIMARY HEALTHCARE ASSOCIATES SC
71 W 156TH STREET

HARVEY,IL60426
36-4132865 		HEALTHCARE IL 501(c)(3) 10 UCHHD
 
 
No
(15)THE JOHN CRERAR FOUNDATION
5730 S ELLIS AVENUE

CHICAGO,IL60637
36-3155157 		SUPP LIBRARY IL 501(c)(3) Type III-O UNIV CHICAGO
 
 
No
(16)THE MARINE BIOLOGICAL LABORATORY
7 MBL STREET

WOODS HOLE,MA02543
04-2104690 		RES & EDU MA 501(c)(3) 7 UNIV CHICAGO
 
 
No
(17)THE QUADRANGLE CLUB
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-1655190 		SOCIAL CLUB IL 501(c)(7)   UNIV CHICAGO
 
 
No
(18)THE UNIV OF CHICAGO FDN IN THE HONG KONG LTD
 
 
FUNDRAISING HK     UNIV CHICAGO
 
 
No
(19)THE UNIVERSITY OF CHICAGO CLOISTERS CLUB
1212 E 59TH STREET

CHICAGO,IL60637
 SOCIAL CLUB IL     UNIV CHICAGO
 
 
No
(20)UCHICAGO RESEARCH BANGLADESH LTD
 
 
RESEARCH BG     UCH RS INTL
 
 
No
(21)UCHICAGO RESEARCH INTERNATIONAL LIMITED
5801 S ELLIS AVENUE

CHICAGO,IL60637
26-2741573 		RESEARCH IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(22)UCM CARE NETWORK MEDICAL GROUP INC
5841 S MARYLAND AVE MC 1086

CHICAGO,IL60637
47-4221241 		HEALTH SERVICE IL 501(c)(3) 10 UCMC
 
 
No
(23)UCM COMMUNITY HEALTH & HOSPITAL DIVISION
ONE INGALLS DRIVE

HARVEY,IL60426
36-3181170 		MANAGEMENT IL 501(c)(3) Type I UCMC
 
 
No
(24)UCMC TITLE HOLDING CORPORATION
5841 S MARYLAND AVE MC 1086

CHICAGO,IL60637
81-2126789 		TITLE HOLD IL 501(c)(3) Type I UCMC
 
 
No
(25)UCMC TITLE HOLDING CORPORATION II NFP
5841 S MARYLAND AVE MC 1086

CHICAGO,IL60637
82-1736040 		TITLE HOLD IL 501(c)(3) Type I UCMC
 
 
No
(26)UNIV OF CHI BOOTH SCH OF BUS (SINGAPORE)
 
 
EDUCATION SN     UNIV CHICAGO
 
 
No
(27)UNIV OF CHI BOOTH SCH OF BUS (UK)
 
 
EDUCATION UK     UNIV CHICAGO
 
 
No
(28)UNIV OF CHICAGO CANCER RESEARCH FD
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-6056201 		SUPP RESEARCH IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(29)UNIV OF CHICAGO CENTER IN PARIS (FRANCE)
 
 
EDUCATION FR     UNIV CHICAGO
 
 
No
(30)UNIV OF CHICAGO CHARTER SCHOOL CORP
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-4225812 		EDUCATION IL 501(c)(3) 2 UNIV CHICAGO
 
 
No
(31)UNIV OF CHICAGO PROPERTY HOLDING CO
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-6108743 		PROP HOLDG IL 501(c)(2)   UNIV CHICAGO
 
 
No
(32)UNIV OF CHICAGO RETIREE MEDICAL TRUST
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-3999692 		MEDICAL TRUST IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(33)UNIV OF CHICAGO SELF INSURANCE TRUST
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-3020034 		MALPRAC TR IL 501(c)(3) Type I UNIV CHICAGO
 
 
No
(34)UNIVERSITY OF CHICAGO
5801 S ELLIS AVENUE

CHICAGO,IL60637
36-2177139 		EDUCATION IL 501(c)(3) 2 NA
 
 
No
(35)UNIVERSITY OF CHICAGO MEDICAL CENTER
5841 S MARYLAND AVENUE

CHICAGO,IL60637
36-3188183 		HOSPITAL IL 501(c)(3) 3 UNIV CHICAGO
 
 
No
(36)UNIVERSITY OF CHICAGO TRUST (INDIA)
L-9 East Wing Raheja Towers MG R
BANGALORE,Karnataka560001
IN
FUNDRAISING IN     UNIV CHICAGO
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) INGALLS SAME DAY SURGERY CTR

6701 W 159TH ST
TINLEY PARK,IL60477
36-3368549 		SURGERY CENTER IL NA
  		N/A       No     No  
(2) UCMC-SOLIS ON-CAMPUS MAMMOGRAPHY LLC

15601 DALLAS PARKWAY
SUITE 500
ADDISON,TX75001
35-2641914 		MAMMOGRAPHY DE NA
  		N/A       No     No  
(3) UCMC-SOLIS OFF-CAMPUS MAMMOGRAPHY SERVICES LLC

15601 DALLAS PARKWAY
SUITE 300
ADDISON,TX75001
38-4108853 		MAMMOGRAPHY DE NA
  		N/A       No     No  
(4) PABHS-UCM MSO JV LLC

2845 N SHERIDAN RD
SUITE 6400
CHICAGO,IL60657
87-4074642 		RADIOLOGY ONCOLOGY IL NA
  		N/A       No     No  
(5) PABHS-UCM RADONC JV

2845 N SHERIDAN RD
SUITE 6400
CHICAGO,IL60657
87-4057862 		RADIOLOGY ONCOLOGY IL NA
  		N/A       No     No  




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
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) CHARITABLE LEAD TRUST (0)

5801 S ELLIS AVENUE
CHICAGO,IL60637
 CHAR LEAD TRUST IL NA
  		Trust         No
(2) CHARITABLE REMAINDER TRUSTS (75)

5801 S ELLIS AVENUE
CHICAGO,IL60637
 CHAR RMDR TRUST IL NA
  		Trust         No
(3) INGALLS CASUALTY INSURANCE LTD

ONE INGALLS DRIVE
HARVEY,IL60426
98-0485714 		LIAB INSURANCE CJ NA
  		C Corporation         No
(4) INGALLS HEALTH COUNCIL

ONE INGALLS DRIVE
HARVEY,IL60426
27-3226539 		PURCHASING GROUP IL NA
  		C Corporation         No
(5) INGALLS PROVIDER GROUP

ONE INGALLS DRIVE
HARVEY,IL60426
36-3485578 		INSURANCE SERVICE IL IMH
  		C Corporation 14,841,124 1,652,064 100 % Yes  
(6) MEDCENTRIX INC

ONE INGALLS DRIVE
HARVEY,IL60426
36-3374228 		BILLING & MGMT IL NA
  		C Corporation         No
(7) PHOENIX OVERLAY FUND LTD

401 N MICHIGAN AVE
C/O INVST OFFICE
CHICAGO,IL60611
 INVESTMENT CJ NA
  		          No
(8) POOLED INCOME FUND (1)

5801 S ELLIS AVENUE
CHICAGO,IL60637
 POOLED INCO FUND IL NA
  		C Corporation         No
(9) SC CURRICULUM INC

70 WEST MADISON ST
CHICAGO,IL60602
 SCNC CURRICULUM IL NA
  		C Corporation         No
(10) UCHICAGO (BEIJING) CONSULTING CO LTD

 
 
CONSULTING CH NA
  		          No
(11) UCHICAGO CENTER IN INDIA PRIVATE LIMITED

 
 
CONSULTING IN NA
  		C Corporation         No
(12) TRULEN INSURANCE SPC LIMITED

 
 
98-1571288 		LIAB INSURANCE CJ UCHHD
  		          No
(13) EMPLOYED PHYSICIANS SP A SEGREGATED PORTFOLIO OF TRULEN INSURANCE SPC LTD

 
 
98-1571310 		LIAB INSURANCE CJ UCHHD
  		          No
(14) HPL-GL SP A SEGREGATED PORTFOLIO OF TRULEN INSURANCE SPC LTD

 
 
98-1571446 		LIAB INSURANCE CJ UCHHD
  		          No
(15) NON-EMPLOYED PHYSICIANS SP A SEGREGATED PORTFOLIO OF TRULEN INSURANCE SPC L
TD
 
 
98-1571387 		LIAB INSURANCE CJ UCHHD
  		          No
(16) UCHICAGO MEDICINE NORTHWEST INDIANA INC

5841 S MARYLAND AVE
CHICAGO,IL60637
92-2355855 		HEALTHCARE IN UCMC
  		C Corporation         No
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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
No
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 .....................
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) ............................
1b
 
No
c Gift, grant, or capital contribution from related organization(s) ............................
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) ............................
1d
 
No
e Loans or loan guarantees by related organization(s) ............................
1e
 
No
f Dividends from related organization(s) ............................
1f
 
No
g Sale of assets to related organization(s) ............................
1g
 
No
h Purchase of assets from related organization(s) ............................
1h
 
No
i Exchange of assets with related organization(s) ............................
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) .......................
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) ......................
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) .....................
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) .................
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................
1n
Yes
 
o Sharing of paid employees with related organization(s) ............................
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses ............................
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses ............................
1q
Yes
 
r Other transfer of cash or property to related organization(s) ............................
1r
Yes
 
s Other transfer of cash or property from related organization(s) ............................
1s
Yes
 
2
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) INGALLS HOME CARE - A(iv)

 A 84,000 FMV
(2) INGALLS PROVIDER GROUP

 P 1,109,313 FMV
(3) INGALLS PROVIDER GROUP

 Q 1,823,596 FMV



Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(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? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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) 2021

Additional Data


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Software Version: 2021v4.2