Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (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 | |||||
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Total |
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Calendar year
(or fiscal year beginning in)
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(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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. | ||||||
Calendar year
(or fiscal year beginning in)
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(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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 | ||||||
Calendar year (or fiscal
year beginning in) ![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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.) | ||||||
Calendar year
(or fiscal year beginning in)
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(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 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) |
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| 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): |
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| 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 | ||||
| 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 2023 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-2023 |
(iii) Distributable Amount for 2023 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2023 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2023 (reasonable cause required-- explain in Part VI).
See instructions. |
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| 3 Excess distributions carryover, if any, to 2023: | ||||
| a From 2018....... | ||||
| b From 2019....... | ||||
| c From 2020....... | ||||
| d From 2021....... | ||||
| e From 2022....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2023 distributable amount | ||||
|
i
Carryover from 2018 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2023 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2023 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2023, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2023. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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7 Excess distributions carryover to 2024. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2019..... | ||||
| b Excess from 2020..... | ||||
| c Excess from 2021..... | ||||
| d Excess from 2022..... | ||||
| e Excess from 2023..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
| Return Reference | Explanation |
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| Form 990, Part V, Line 1: | Form 1096 is filed by Baptist Health Deaconess Madisonville, Inc., FEIN XXX-XX-XXXX. |
| Form 990, Part VI, Section A, line 2 | Kim Ashby, Richard Carrico, Patrick Falvey, Gerald Coleman, Lynn C. Lingafelter, and Shawn McCoy have a business relationship. |
| Form 990, Part VI, Section A, line 3 | Alisa Coleman, President, is employed by Deaconess Health System, an unrelated organization. Compensation for the President is provided by Deaconess Health System through a management agreement for services to Baptist Health Deaconess Madisonville, Baptist Health Deaconess Medical Group, and Baptist Health Deaconess of Madisonville Foundation. All three are related entities. This position has the responsibility of supervising the management, administration and operation of the Medical Group, Baptist Health Deaconess Foundation, and Baptist Health Deaconess Madisonville. Below is the calendar year 2023 compensation for the President. Compensation $451,153 Retirement 22,914 Benefits 22,722 |
| Form 990, Part VI, Section A, line 6 | Baptist Health Deaconess, LLC is the sole member of the corporation. |
| Form 990, Part VI, Section A, line 7a | The Board of Directors of Baptist Health Deaconess Medical Group are the same individuals as those serving on the Baptist Health Deaconess, LLC, the sole member. Baptist Healthcare System, Inc. and Deaconess Health Kentucky, Inc. each appoint 50% of the governing board of Baptist Health Deaconess, LLC. The Directors may be removed at any time, with or without cause, by the System that appointed them. As such, Baptist Healthcare System, Inc and Deaconess Health Kentucky effectively appoint the board of this entity. |
| Form 990, Part VI, Section A, line 7b | Approval to take any of the following actions shall require the affirmative vote of a majority of the BHSI Directors and a majority of the DHKY Directors: (a) sell or agree to sell or otherwise dispose of all or a substantial part of the assets of the Corporation or any investment or interest in any business enterprise; (b) amend, repeal or alter the articles of incorporation or these bylaws of the Corporation; (c) merge or consolidate or agree to merge or consolidate the Corporation with or into any other organization; (d) liquidate, dissolve, reorganize, or recapitalize the Corporation, or take any actions relating to bankruptcy or receivership; (e) create or incur any indebtedness with BHSI or DHKY, or with any third party in an amount exceeding $500,000; (f) make any capital expenditure requiring the payment of more than $500,000; (g) authorize the execution of any contract, agreement, or similar instrument by which the Corporation may be obligated to pay more than $500,000 or as otherwise specified in a policy adopted by the board in accordance with the voting requirements of this Section 2.09; (h) acquire any stock of any corporation or invest in or acquire any interest in any business enterprise; (i) approve the annual operating budget and capital expenditures budget of the Corporation, as well as any capital expenditures over $500,000; (j) approve the mission, vision, and values of the Corporation and amendments thereto; (k) approve strategic plans of the Corporation; (l) establish appropriate reserves (consistent with operational needs and strategic initiatives for the community) and/or make any distributions or charitable donations; (m) make any material changes to the Corporation's core services; and n) take action on any issue identified at any time as a key decision for Member action by a Member representative on the Corporation's board. |
| Form 990, Part VI, Section A, line 8b | The Medical Group does not have committees with authority to act on behalf of the governing body. |
| Form 990, Part VI, Section B, line 11b | The Form 990 will be provided to each voting member of the Board of Directors prior to filing with the IRS. The CFO reviews the Form 990 before it is filed with the IRS. |
| Form 990, Part VI, Section B, line 12c | Annually, the Secretary of Baptist Health Deaconess LLC. (BHD) sends out a Conflict of Interest questionnaire to each of the officers and directors serving on the Board of Baptist Health Deaconess Medical Group, Inc. (BHDMG). After completion, they are returned to the Secretary and reviewed by the Board or the Governance Effectiveness Committee for any potential conflicts. A conflict of interest is any circumstance, relationship (financial or otherwise), activity or decision (made in the course of governance, management or professional responsibilities or otherwise) that adversely influences or appears to adversely influence the ability of a Covered Person to: 1) make objective decisions on behalf of BHDMG and/or 2) act in the best interests of BHDMG in a manner consistent with the tax exempt purposes of BHDMG. The Board or Committee will determine by a majority vote of disinterested directors whether the disclosed financial or special interest may result in a conflict of interest. |
| Form 990, Part VI, Section B, line 15 | Compensation for the President is provided by Deaconess Health System, an unrelated organization for services to the Medical Group and the related entities. Deaconess Health System, an unrelated organization, and Baptist Health Deaconess Madisonville, a related organization, have a management agreement in place for services provided. Deaconess Health System uses comparability data, an independent compensation committee, and substantiation to determine the compensation of the President. This is completed on an annual basis. Compensation for the VP of Finance is provided by Baptist Health Deaconess Madisonville, a related organization. Baptist health Deaconess Madisonville uses comparability data, independent persons, and substantiation to determine the compensation of the VP of Finance. This is completed on an annual basis. |
| Form 990, Part VI, Section C, line 19 | The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. |
| Form 990, Part IX, line 11g | Contract Services: Program service expenses 7,275,160. Management and general expenses 1,520,326. Fundraising expenses 0. Total expenses 8,795,486. Professional Fees: Program service expenses 915,232. Management and general expenses 11,000. Fundraising expenses 0. Total expenses 926,232. |
| Form 990, Part XI, line 9: | Net Assets received from Baptist Health Deaconess Madisonville, Inc. 1,821,790. |
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