2024-08-15T12:27:22-05:00 2023-09-30 381357951 PLANTE & MORAN PLLC 250 S HIGH ST SUITE 100 COLUMBUS OH 43215 990 2022-10-01 341048666 COMMUNITY HOSPITALS & WELLNESS CENTERS COMM 4196361131 433 W HIGH STREET BRYAN OH 43506 CHRISTA POMEROY CFO 4196361131 2024-08-14 1 0 AMY CIMINELLO P00796388 6148493000 2024-08-14 2022 2024-08-08 14:25:15Z CHAD D TINKEL 433 W HIGH STREET BRYAN OH 43506 118114175 0 X WWW.CHWCHOSPITALS.ORG X 1969 OH WE WILL PROVIDE COMPREHENSIVE, PATIENT CENTERED HEALTHCARE. WE WILL RESPECT THE DIGNITY AND UNIQUENESS OF ALL. WE WILL ENHANCE THE HEALTH, SAFETY, AND WELL BEING OF OUR COMMUNITY. 10 9 895 9 -4181 0 3496834 2495258 101277699 111982510 1157990 1225556 2037901 2122535 107970424 117825859 0 0 0 0 57944522 65719401 0 0 0 55089779 56657412 113034301 122376813 -5063877 -4550954 144492449 137389135 52418625 44756074 92073824 92633061 X WE WILL PROVIDE COMPREHENSIVE, PATIENT CENTERED HEALTHCARE. WE WILL RESPECT THE DIGNITY AND UNIQUENESS OF ALL. WE WILL ENHANCE THE HEALTH, SAFETY, AND WELL BEING OF OUR COMMUNITY. 0 0 12487564 0 16793844 INPATIENT CARE: BRYAN HOSPITAL MEDICAL & SURGICAL UNIT HAS 54 BEDS AND PROVIDE CARE FOR 662 PATIENTS AND 312 OBSERVATION PATIENTS; BRYAN HOSPITAL INTENSIVE CARE UNIT AND TELEMETRY UNIT HAS 16 BEDS AND PROVIDE CARE FOR 1,083 INPATIENTS AND 480 OBSERVATION PATIENTS; BRYAN HOSPITAL OBSTETRICS HAS 9 BEDS AND PROVIDED CARE FOR 462 INPATIENTS AND 547 OBSERVATION PATIENTS. MONTPELIER HOSPITAL HAS 25 BEDS AND PROVIDED CARE TO 211 INPATIENTS. 13025320 0 41862002 SURGERY CARE: BRYAN SURGERY HAS 6 OPERATING ROOMS THAT DID 687 GENERAL SURGERY CASES, 1,785 PAIN MANAGEMENT CASES, 729 ORTHOPEDIC CASES, 528 OPHTHALMOLOGY CASES, 389 ENT CASES, 97 GYNECOLOGY CASES, 146 UROLOGY CASES, 870 GASTROENTEROLOGY CASES AND 195 PODIATRY CASES, 82 COLORECTAL CASES. ARCHBOLD SURGERY HAS 4 OPERATING ROOMS THAT DID 17 GENERAL SURGERY CASES, 811 GASTROENTEROLOGY CASES AND 222 COLORECTAL CASES. 5918362 0 24841004 EMERGENCY ROOM CARE: BRYAN ED CARED FOR 16,283 PATIENTS WITH 1,406 BEING ADMITTED; MONTPELIER ED CARED FOR 4,121 PATIENTS WITH 0 BEING ADMITTED. 63498855 0 28521378 COMMUNITY HOSPITALS AND WELLNESS CENTERS PROVIDED SERVICES TO APPROXIMATELY 2,418 INPATIENTS, APPROXIMATELY 1,350 OBSERVATION PATIENTS, AND APPROXIMATELY 20,404 EMERGENCY DEPARTMENT PATIENTS DURING THIS FISCAL YEAR. THE HOSPITAL UTILIZES A BOARD APPROVED CHARITABLE CARE PROGRAM THAT MEASURES INDIVIDUAL AND FAMILY NEEDS BASED ON FEDERAL POVERTY GUIDELINES. THE PROGRAM IS APPLIED UNIFORMLY ACROSS ALL LEVELS OF HOSPITAL SERVICES. THE PROGRAM EXTENDS BEYOND THE FEDERAL POVERTY DEFINITIONS TO ALLOW THE HOSPITAL TO PROVIDE FREE AND/OR SUBSIDIZED CARE FOR PERSONS FALLING WITHIN AND BEYOND THE FEDERAL GUIDELINES. THIS PROGRAM PROVIDED ASSISTANCE TO APPROXIMATELY 4,575 ACCOUNTS DURING THIS FISCAL YEAR. 63498855 0 28521378 94930101 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 58 0 1 895 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 10 9 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 X CHRISTA POMEROY 4196333594 433 W HIGH STREET BRYAN OH 43506 STEVE BUMB MD DIRECTOR: CHIEF OF STAFF 49.50 0.50 X 306264 0 23674 CHRISTOPHER KANNEL CHAIR OF BOARD 0.10 0.10 X X 0 0 0 ELENA WEST VICE-CHAIR 0.10 0.10 X X 0 0 0 DR CAROLYN DORSTEN VICE CHIEF OF STAFF 0.10 0.10 X 0 0 0 KATRINA P HESTER DIRECTOR 0.10 0.10 X 0 0 0 CINDY REED DIRECTOR 0.10 0.10 X 0 0 0 RUSS DAVIES DIRECTOR 0.10 0.10 X 0 0 0 ALLYN LUCE DIRECTOR 0.10 0.10 X 0 0 0 LARS ELLAR DIRECTOR 0.10 0.10 X 0 0 0 JAMES WATKINS DIRECTOR 0.10 0.10 X 0 0 0 CHAD D TINKEL EX-OFFICIO DIR: PRESIDENT/CEO/SECRETARY 49.50 0.50 X 367685 0 43175 WADE PATRICK VP/CIO 50.00 0.00 X 228288 0 41222 CHRISTA POMEROY TREASURER: VP/CFO 49.50 0.50 X 187092 0 15373 JANICE DAVID VP PATIENT CARE: THRU 01.23 50.00 0.00 X 461149 0 27887 ELIZABETH GRIMES VP PATIENT CARE 50.00 0.00 X 175483 0 22674 DR KHALID MINHAS PHYSICIAN 50.00 0.00 X 785902 0 22674 DR DAVID COOLEY PHYSICIAN 50.00 0.00 X 700996 0 22079 DR JODI TINKEL PHYSICIAN 50.00 0.00 X 617880 0 0 DR WAINWRIGHT JAGGERNAUTH PHYSICIAN 50.00 0.00 X 570608 0 0 DR MICHAEL NOSANOV PHYSICIAN 50.00 0.00 X 555688 0 10294 4957035 0 229052 61 0 1 0 PARVIEW HEALTH BOX 5600 FT WAYNE IN 46895 PHYSICIAN SERVICES 1686397 FORT WAYNE RADIOLOGY 3707 NEW VISION DR FT WAYNE IN 46845 RADIOLOGOY 1630756 WILLIAMS EMERGENCY GROUP LLP PO BOX 677979 DALLAS TX 752677979 PHYSICIAN SERVICES 1434939 UT PHYSICIANS MAIL STOP 840 4510 DORR ST TOLEDO OH 43615 PHYSICIAN SERVICES 404198 VAN WERT HEALTH 1250 SOUTH WASHINGTON VAN WERT OH 45891 PHYSICIAN SERVICES 371300 5 2487717 7541 2495258 PATIENT REVENUE 621400 111982510 111982510 111982510 1137145 1137145 452632 222948 229684 229684 229684 153779 34243 31125 -34243 122654 88411 88411 INSURANCE FUNDS 621400 1857133 1857133 CAFETERIA/VENDING 621400 4181 4181 LOSS FROM VANTAGE HEALTHCARE 621400 -4181 -4181 35718 35718 1892851 117825859 112018228 -4181 3316554 3563331 1293177 2270154 44158311 37324633 6833678 1929889 1666849 263040 12711517 8859367 3852150 3356353 2625915 730438 15053925 11880913 3173012 500256 500256 370736 370736 154323 59011 95312 761322 545717 215605 1792141 92190 1699951 68482 48163 20319 145062 58938 86124 1891859 1891859 5917487 5221695 695792 833444 249179 584265 BILLABLE/NONBILLABLE SU 19508933 19166574 342359 BAD DEBT EXPENSE 4739312 4739312 FRANCHISE FEES & TAXES 2448518 96097 2352421 REPAIRS & MAINTENANCE 1910085 945724 964361 561527 56647 504880 122376813 94930101 27446712 0 1990425 6078501 4481315 0 18142004 17936683 2932812 1928686 444928 1092619 150437300 83066264 71563785 67371036 30582233 31767191 1315426 587358 13039521 10627061 144492449 137389135 14378692 8147919 25305979 24171619 12141128 11243690 592826 1192846 52418625 44756074 X 92073824 92633061 92073824 92633061 144492449 137389135 X -4550954 1610191 3500000 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2267 2267 0 PART II-B, LINE 1: PART OF OHA DUES ARE ATTRIBUTED TO LOBBYING, TOTAL DUES WERE $41,210 OF WHICH 5.5% WERE CONTRIBUTED TO LOBBYING. 830800 2572072 3402872 95094863 42891707 52203156 10928109 7521544 3406565 40617225 32445473 8171752 394231 207540 186691 67371036 OTHER RECEIVABLES 536535 ASSETS LIMITED TO USE 8594549 COST REPORT SETTLEMENT 1495977 10627061 SETTLEMENTS PAYABLE UNDER THIRD PARTY REIMBURSEMENT CONTRACTS 1192846 1192846 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND TO RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT, AS OF SEPTEMBER 30, 2023 AND 2022, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 2388717 299195 2089522 0.01770 15618192 9055590 6562602 0.05570 18006909 9354785 8652124 0.07340 176533 176533 0.00150 56078 56078 0.00050 232611 232611 0.00200 18239520 9354785 8884735 0.07540 1 4739312 473931 18259521 22699413 -4439892 X 1 1 2 1 BRYAN HOSPITAL 433 WEST HIGH STREET BRYAN OH 43506 X X X 2 MONTPELIER HOSPITAL 909 EAST SNYDER AVENUE MONTPELIER OH 43543 X X X SWING BEDS BRYAN HOSPITAL 1 0 0 1 X X X X X X X X X X 22 1 1 1 1 X HTTPS://WWW.CHWCHOSPITAL.ORG/COMMUNITY-HEALTH-ASSESSMENT/ HTTPS://WW.CHWCHOSPITAL.ORG/WP-CONTENT/UPLOADS/2022/09/2022-WILLIAMS-COUNTY X X 1 23 1 HTTPS://WWW.CHWCHOSPITAL.ORG/COMMUNITY-HEALTH-ASSESSMENT/ 0 1 X 200.000000000000 300.000000000000 X X X 1 1 X X X 1 X HTTPS://WWW.CHWCHOSPITAL.ORG/CHWC-FINANCIAL-ASSISTANCE/ X HTTPS://WWW.CHWCHOSPITAL.ORG/CHWC-FINANCIAL-ASSISTANCE/ X HTTPS://WWW.CHWCHOSPITAL.ORG/CHWC-FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X X X 1 X 0 0 MONTPELIER HOSPITAL 2 0 0 1 X X X X X X X X X X 22 1 1 1 1 X HTTPS://WWW.CHWCHOSPITAL.ORG/COMMUNITY-HEALTH-ASSESSMENT/ X HTTPS://WW.CHWCHOSPITAL.ORG/WP-CONTENT/UPLOADS/2022/09/2022-WILLIAMS-COUNTY X X 1 23 1 HTTPS://WWW.CHWCHOSPITAL.ORG/COMMUNITY-HEALTH-ASSESSMENT/ 0 1 X 200.000000000000 300.000000000000 X X X X X X X 1 1 X X X 1 X HTTPS://WWW.CHWCHOSPITAL.ORG/CHWC-FINANCIAL-ASSISTANCE/ X HTTPS://WWW.CHWCHOSPITAL.ORG/CHWC-FINANCIAL-ASSISTANCE/ X HTTPS://WWW.CHWCHOSPITAL.ORG/CHWC-FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X X X 1 X 0 0 BRYAN HOSPITAL PART V, SECTION B, LINE 3J: THE OVERALL GOAL OF THE NEEDS ASSESSMENT WAS TO PERFORM A COMMUNITY HEALTH ASSESSMENT THAT WILL LEAD TO IMPROVED QUALITY OF PUBLIC AND PRIVATE HEALTH SERVICES. IN ADDITION, THE HEALTH ASSESSMENT CAN BE USED FOR A VARIETY OF PURPOSES SUCH AS THE FOLLOWING:- TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS.- TO ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH.- TO MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS. - TO PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. THE STUDY CAN ASSIST STAKEHOLDERS WORKING COLLABORATIVELY IN THE COMMUNITY TO ADDRESS ISSUES THAT AFFECT HEALTH.THE COMMUNITY HEALTH ASSESSMENT WILL CONTINUE TO BE REPEATED EVERY THREE YEARS TO DETERMINE IF ACTIONS TAKEN BY COMMUNITIES ARE IMPACTING THE BEHAVIORS THAT LEAD TO POOR HEALTH. MONTPELIER HOSPITAL PART V, SECTION B, LINE 3J: THE OVERALL GOAL OF THE NEEDS ASSESSMENT WAS TO PERFORM A COMMUNITY HEALTH ASSESSMENT THAT WILL LEAD TO IMPROVED QUALITY OF PUBLIC AND PRIVATE HEALTH SERVICES. IN ADDITION, THE HEALTH ASSESSMENT CAN BE USED FOR A VARIETY OF PURPOSES SUCH AS THE FOLLOWING:- TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS.- TO ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH.- TO MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS. - TO PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. THE STUDY CAN ASSIST STAKEHOLDERS WORKING COLLABORATIVELY IN THE COMMUNITY TO ADDRESS ISSUES THAT AFFECT HEALTH.THE COMMUNITY HEALTH ASSESSMENT WILL CONTINUE TO BE REPEATED EVERY THREE YEARS TO DETERMINE IF ACTIONS TAKEN BY COMMUNITIES ARE IMPACTING THE BEHAVIORS THAT LEAD TO POOR HEALTH. BRYAN HOSPITAL PART V, SECTION B, LINE 5: THE WILLIAMS COUNTY HEALTH PARTNERS HAS BEEN CONDUCTING CHAS SINCE 2006 FOR THE PURPOSE OF MEASURING COMMUNITY HEALTH STATUS. THE MOST RECENT WILLIAMS COUNTY CHA WAS CROSS-SECTIONAL IN NATURE AND INCLUDED A WRITTEN SURVEY OF ADULTS AND AN ELECTRONIC SURVEY OF ADOLESCENTS WITHIN WILLIAMS COUNTY. THE QUESTIONS WERE MODELED AFTER THE SURVEY INSTRUMENTS USED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) FOR THEIR NATIONAL AND STATE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS) AND YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM (YRBSS). THIS HAS ALLOWED WILLIAMS COUNTY TO COMPARE THEIR CHA DATA TO NATIONAL, STATE, AND LOCAL HEALTH TRENDS. COMMUNITY STAKEHOLDERS WERE ACTIVELY ENGAGED IN THE EARLY PHASES OF CHA PLANNING AND HELPED DEFINE THE CONTENT, SCOPE, AND SEQUENCE OF THE PROJECT. THE WILLIAMS COUNTY COMBINED HEALTH DISTRICT CONTRACTED WITH THE HOSPITAL COUNCIL OF NORTHWEST OHIO (HCNO), A NEUTRAL, REGIONAL, NONPROFIT HOSPITAL ASSOCIATION, TO FACILITATE THE CHA AND CHIP. THE WILLIAMS COUNTY COMBINED HEALTH DISTRICT, ALONG WITH COMMUNITY HOSPITALS AND WELLNESS CENTERS (CHWC), THEN INVITED VARIOUS COMMUNITY STAKEHOLDERS TO PARTICIPATE IN THE COMMUNITY HEALTH IMPROVEMENT PROCESS. DATA FROM THE MOST RECENT CHA WERE CAREFULLY CONSIDERED AND CATEGORIZED INTO COMMUNITY PRIORITIES WITH ACCOMPANYING STRATEGIES. THIS WAS DONE USING THE NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS' (NACCHO) NATIONAL FRAMEWORK: MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP). OVER THE NEXT THREE YEARS, THESE PRIORITIES AND STRATEGIES WILL BE IMPLEMENTED AT THE COUNTY-LEVEL WITH THE HOPE TO IMPROVE POPULATION HEALTH AND CREATE LASTING, SUSTAINABLE CHANGE. IT IS THE HOPE OF THE WILLIAMS COUNTY PARTNERS HEALTH PARTNERS THAT EACH AGENCY IN THE COUNTY WILL TIE THEIR INTERNAL STRATEGIC PLAN TO AT LEAST ONE STRATEGY IN THE CHIP.THE CHIP WAS PLANNED BY VARIOUS AGENCIES AND SERVICE-PROVIDERS WITHIN WILLIAMS COUNTY. FROM OCTOBER 2022 TO JANUARY 2023, THE WILLIAMS COUNTY HEALTH PARTNERS REVIEWED MANY DATA SOURCES CONCERNING THE HEALTH AND SOCIAL CHALLENGES THAT WILLIAMS COUNTY RESIDENTS ARE FACING. THEY DETERMINED PRIORITY ISSUES WHICH, IF ADDRESSED, COULD IMPROVE FUTURE OUTCOMES; DETERMINED GAPS IN CURRENT PROGRAMMING AND POLICIES; EXAMINED BEST PRACTICES AND SOLUTIONS; AND DETERMINED SPECIFIC STRATEGIES TO ADDRESS IDENTIFIED PRIORITY ISSUES. WE WOULD LIKE TO RECOGNIZE THESE INDIVIDUALS AND THANK THEM FOR THEIR DEDICATION TO THIS PROCESS: WILLIAMS COUNTY HEALTH PARTNERS; ALICIA GRAHAM, SHALOM COUNSELING & MEDIATION CENTER; ALLYN LUCE, ALTENLOH, BRINCK & CO.; AMY KIRBY, UNITED WAY OF WILLIAMS COUNTY; ASHLEY EPLING, WILLIAMS COUNTY ECONOMIC; DEVELOPMENT CORPORATION (WEDCO); BECKY KIMBLE, THE ABILITY CENTER; BECKY MCGUIRE, OHIO STATE UNIVERSITY EXTENSION OFFICE; BETHANY COUTZ, EDUCATING COMMUNITIES ON HEALTHY OPPORTUNITIES (ECHO) COALITION; BETHANY SHIRKEY, FOUR COUNTY ALCOHOL, DRUG ADDICTION AND MENTAL HEALTH SERVICES (ADAMHS) BOARD; BOBBI CASE, COMMUNITY HOSPITALS AND WELLNESS CENTERS (CHWC); CHASITY YODER, UNITED WAY OF WILLIAMS COUNTY; CHRIS KANNEL, VILLAGE OF MONTPELIER; DEANNA CUSTAR, WILLIAMS COUNTY BOARD OF HEALTH; DONNA SPROW, WILLIAMS COUNTY DEPARTMENT OF AGING; GENE MCBRIDE, PIONEER AREA MINISTERIAL ASSOCIATION; JENNI MCKARNS, WILLIAMS COUNTY COMMUNITY GARDENING ASSOCIATION (WCCGA); JIM WATKINS, WILLIAMS COUNTY HEALTH DEPARTMENT (WCHD); JIM WYSE, MILLCREEK-WEST UNITY LOCAL SCHOOLS; KAREN VONDEYLEN, MAUMEE VALLEY GUIDANCE CENTER; KATIE BROWN, WCHD; KEIRA CHRISTMAN, WEDCO; KERMIT RIEHLE, EDGERTON SCHOOLS; KIM LAMMERS, MAUMEE VALLEY PLANNING ORGANIZATION; MELISSA EWERS, VILLAGE OF MONTPELIER; MICHELLE KANNEL, MONTPELIER SCHOOLS; NATHAN HOFFER, WCHD; RACHEL AESCHLIMAN, WCHD; RACHEL BLANTON, SARAH'S FRIENDS; RUTH PECK, RECOVERY SERVICES OF NORTHWEST OHIO; SALLY TAYLOR, PARKVIEW PHYSICIANS GROUP; SARAH VASHAW, BRYAN CITY SCHOOLS; SHEANA BEHRINGER, NOCAC; SUSAN SHEETS, WILLIAMS COUNTY JUVENILE COURTS; TAMMY RIEGSECKER, WCHD; TODD ROTH, WILLIAMS COUNTY ENGINEER'S OFFICE; AND VICTORIA SMITH, WCHDPROGRESS WILL BE MONITORED WITH MEASURABLE INDICATORS IDENTIFIED FOR EACH STRATEGY. MOST INDICATORS ALIGN DIRECTLY WITH THE SHIP. THE INDIVIDUALS OR AGENCIES THAT ARE WORKING ON STRATEGIES WILL MEET ON AN AS NEEDED BASIS. THE FULL COMMITTEE WILL MEET QUARTERLY OR AS NEEDED TO REPORT OUT PROGRESS. THE COMMITTEE WILL CREATE A PLAN TO DISSEMINATE THE CHIP TO THE COMMUNITY. STRATEGIES, RESPONSIBLE AGENCIES, AND TIMELINES WILL BE REVIEWED AT THE END OF EACH YEAR BY THE COMMITTEE. AS THIS CHIP IS A LIVING DOCUMENT, EDITS AND REVISIONS WILL BE MADE ACCORDINGLY.WILLIAMS COUNTY WILL CONTINUE FACILITATING CHA EVERY THREE YEARS TO COLLECT DATA AND DETERMINE TRENDS. PRIMARY DATA WILL BE COLLECTED FOR ADULTS AND YOUTH USING NATIONAL SETS OF QUESTIONS TO NOT ONLY COMPARE TRENDS IN WILLIAMS COUNTY, BUT ALSO BE ABLE TO COMPARE TO THE STATE AND NATION. THIS DATA WILL SERVE AS MEASURABLE OUTCOMES FOR EACH PRIORITY AREA. IN ADDITION TO OUTCOME EVALUATION, PROCESS EVALUATION WILL ALSO BE USED ON A CONTINUOUS BASIS TO FOCUS ON THE SUCCESS OF THE STRATEGIES. AREAS OF PROCESS EVALUATION THAT THE CHIP COMMITTEE WILL MONITOR INCLUDE THE FOLLOWING: NUMBER OF PARTICIPANTS, LOCATION(S) WHERE SERVICES ARE PROVIDED, NUMBER OF POLICIES IMPLEMENTED, ECONOMIC STATUS AND RACIAL/ETHNIC BACKGROUND OF THOSE RECEIVING SERVICES (WHEN APPLICABLE), AND INTERVENTION DELIVERY (QUANTITY AND FIDELITY).FURTHERMORE, ALL STRATEGIES HAVE BEEN INCORPORATED INTO A "PROGRESS REPORT" TEMPLATE THAT CAN BE COMPLETED AT ALL FUTURE MEETINGS, KEEPING THE COMMITTEE ON TASK AND ACCOUNTABLE. THIS PROGRESS REPORT MAY ALSO SERVE AS MEETING MINUTES. MONTPELIER HOSPITAL PART V, SECTION B, LINE 5: THE WILLIAMS COUNTY HEALTH PARTNERS HAS BEEN CONDUCTING CHAS SINCE 2006 FOR THE PURPOSE OF MEASURING COMMUNITY HEALTH STATUS. THE MOST RECENT WILLIAMS COUNTY CHA WAS CROSS-SECTIONAL IN NATURE AND INCLUDED A WRITTEN SURVEY OF ADULTS AND AN ELECTRONIC SURVEY OF ADOLESCENTS WITHIN WILLIAMS COUNTY. THE QUESTIONS WERE MODELED AFTER THE SURVEY INSTRUMENTS USED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) FOR THEIR NATIONAL AND STATE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS) AND YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM (YRBSS). THIS HAS ALLOWED WILLIAMS COUNTY TO COMPARE THEIR CHA DATA TO NATIONAL, STATE, AND LOCAL HEALTH TRENDS. COMMUNITY STAKEHOLDERS WERE ACTIVELY ENGAGED IN THE EARLY PHASES OF CHA PLANNING AND HELPED DEFINE THE CONTENT, SCOPE, AND SEQUENCE OF THE PROJECT. THE WILLIAMS COUNTY COMBINED HEALTH DISTRICT CONTRACTED WITH THE HOSPITAL COUNCIL OF NORTHWEST OHIO (HCNO), A NEUTRAL, REGIONAL, NONPROFIT HOSPITAL ASSOCIATION, TO FACILITATE THE CHA AND CHIP. THE WILLIAMS COUNTY COMBINED HEALTH DISTRICT, ALONG WITH COMMUNITY HOSPITALS AND WELLNESS CENTERS (CHWC), THEN INVITED VARIOUS COMMUNITY STAKEHOLDERS TO PARTICIPATE IN THE COMMUNITY HEALTH IMPROVEMENT PROCESS. DATA FROM THE MOST RECENT CHA WERE CAREFULLY CONSIDERED AND CATEGORIZED INTO COMMUNITY PRIORITIES WITH ACCOMPANYING STRATEGIES. THIS WAS DONE USING THE NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS' (NACCHO) NATIONAL FRAMEWORK: MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP). OVER THE NEXT THREE YEARS, THESE PRIORITIES AND STRATEGIES WILL BE IMPLEMENTED AT THE COUNTY-LEVEL WITH THE HOPE TO IMPROVE POPULATION HEALTH AND CREATE LASTING, SUSTAINABLE CHANGE. IT IS THE HOPE OF THE WILLIAMS COUNTY PARTNERS HEALTH PARTNERS THAT EACH AGENCY IN THE COUNTY WILL TIE THEIR INTERNAL STRATEGIC PLAN TO AT LEAST ONE STRATEGY IN THE CHIP.THE CHIP WAS PLANNED BY VARIOUS AGENCIES AND SERVICE-PROVIDERS WITHIN WILLIAMS COUNTY. FROM OCTOBER 2022 TO JANUARY 2023, THE WILLIAMS COUNTY HEALTH PARTNERS REVIEWED MANY DATA SOURCES CONCERNING THE HEALTH AND SOCIAL CHALLENGES THAT WILLIAMS COUNTY RESIDENTS ARE FACING. THEY DETERMINED PRIORITY ISSUES WHICH, IF ADDRESSED, COULD IMPROVE FUTURE OUTCOMES; DETERMINED GAPS IN CURRENT PROGRAMMING AND POLICIES; EXAMINED BEST PRACTICES AND SOLUTIONS; AND DETERMINED SPECIFIC STRATEGIES TO ADDRESS IDENTIFIED PRIORITY ISSUES. WE WOULD LIKE TO RECOGNIZE THESE INDIVIDUALS AND THANK THEM FOR THEIR DEDICATION TO THIS PROCESS: WILLIAMS COUNTY HEALTH PARTNERS; ALICIA GRAHAM, SHALOM COUNSELING & MEDIATION CENTER; ALLYN LUCE, ALTENLOH, BRINCK & CO.; AMY KIRBY, UNITED WAY OF WILLIAMS COUNTY; ASHLEY EPLING, WILLIAMS COUNTY ECONOMIC; DEVELOPMENT CORPORATION (WEDCO); BECKY KIMBLE, THE ABILITY CENTER; BECKY MCGUIRE, OHIO STATE UNIVERSITY EXTENSION OFFICE; BETHANY COUTZ, EDUCATING COMMUNITIES ON HEALTHY OPPORTUNITIES (ECHO) COALITION; BETHANY SHIRKEY, FOUR COUNTY ALCOHOL, DRUG ADDICTION AND MENTAL HEALTH SERVICES (ADAMHS) BOARD; BOBBI CASE, COMMUNITY HOSPITALS AND WELLNESS CENTERS (CHWC); CHASITY YODER, UNITED WAY OF WILLIAMS COUNTY; CHRIS KANNEL, VILLAGE OF MONTPELIER; DEANNA CUSTAR, WILLIAMS COUNTY BOARD OF HEALTH; DONNA SPROW, WILLIAMS COUNTY DEPARTMENT OF AGING; GENE MCBRIDE, PIONEER AREA MINISTERIAL ASSOCIATION; JENNI MCKARNS, WILLIAMS COUNTY COMMUNITY GARDENING ASSOCIATION (WCCGA); JIM WATKINS, WILLIAMS COUNTY HEALTH DEPARTMENT (WCHD); JIM WYSE, MILLCREEK-WEST UNITY LOCAL SCHOOLS; KAREN VONDEYLEN, MAUMEE VALLEY GUIDANCE CENTER; KATIE BROWN, WCHD; KEIRA CHRISTMAN, WEDCO; KERMIT RIEHLE, EDGERTON SCHOOLS; KIM LAMMERS, MAUMEE VALLEY PLANNING ORGANIZATION; MELISSA EWERS, VILLAGE OF MONTPELIER; MICHELLE KANNEL, MONTPELIER SCHOOLS; NATHAN HOFFER, WCHD; RACHEL AESCHLIMAN, WCHD; RACHEL BLANTON, SARAH'S FRIENDS; RUTH PECK, RECOVERY SERVICES OF NORTHWEST OHIO; SALLY TAYLOR, PARKVIEW PHYSICIANS GROUP; SARAH VASHAW, BRYAN CITY SCHOOLS; SHEANA BEHRINGER, NOCAC; SUSAN SHEETS, WILLIAMS COUNTY JUVENILE COURTS; TAMMY RIEGSECKER, WCHD; TODD ROTH, WILLIAMS COUNTY ENGINEER'S OFFICE; AND VICTORIA SMITH, WCHDPROGRESS WILL BE MONITORED WITH MEASURABLE INDICATORS IDENTIFIED FOR EACH STRATEGY. MOST INDICATORS ALIGN DIRECTLY WITH THE SHIP. THE INDIVIDUALS OR AGENCIES THAT ARE WORKING ON STRATEGIES WILL MEET ON AN AS NEEDED BASIS. THE FULL COMMITTEE WILL MEET QUARTERLY OR AS NEEDED TO REPORT OUT PROGRESS. THE COMMITTEE WILL CREATE A PLAN TO DISSEMINATE THE CHIP TO THE COMMUNITY. STRATEGIES, RESPONSIBLE AGENCIES, AND TIMELINES WILL BE REVIEWED AT THE END OF EACH YEAR BY THE COMMITTEE. AS THIS CHIP IS A LIVING DOCUMENT, EDITS AND REVISIONS WILL BE MADE ACCORDINGLY.WILLIAMS COUNTY WILL CONTINUE FACILITATING CHA EVERY THREE YEARS TO COLLECT DATA AND DETERMINE TRENDS. PRIMARY DATA WILL BE COLLECTED FOR ADULTS AND YOUTH USING NATIONAL SETS OF QUESTIONS TO NOT ONLY COMPARE TRENDS IN WILLIAMS COUNTY, BUT ALSO BE ABLE TO COMPARE TO THE STATE AND NATION. THIS DATA WILL SERVE AS MEASURABLE OUTCOMES FOR EACH PRIORITY AREA. IN ADDITION TO OUTCOME EVALUATION, PROCESS EVALUATION WILL ALSO BE USED ON A CONTINUOUS BASIS TO FOCUS ON THE SUCCESS OF THE STRATEGIES. AREAS OF PROCESS EVALUATION THAT THE CHIP COMMITTEE WILL MONITOR INCLUDE THE FOLLOWING: NUMBER OF PARTICIPANTS, LOCATION(S) WHERE SERVICES ARE PROVIDED, NUMBER OF POLICIES IMPLEMENTED, ECONOMIC STATUS AND RACIAL/ETHNIC BACKGROUND OF THOSE RECEIVING SERVICES (WHEN APPLICABLE), AND INTERVENTION DELIVERY (QUANTITY AND FIDELITY).FURTHERMORE, ALL STRATEGIES HAVE BEEN INCORPORATED INTO A "PROGRESS REPORT" TEMPLATE THAT CAN BE COMPLETED AT ALL FUTURE MEETINGS, KEEPING THE COMMITTEE ON TASK AND ACCOUNTABLE. THIS PROGRESS REPORT MAY ALSO SERVE AS MEETING MINUTES. BRYAN HOSPITAL PART V, SECTION B, LINE 6A: MONTPELIER HOSPITAL MONTPELIER HOSPITAL PART V, SECTION B, LINE 6A: BRYAN HOSPITAL BRYAN HOSPITAL PART V, SECTION B, LINE 6B: WILLIAMS COUNTY HEALTH DEPARTMENT MONTPELIER HOSPITAL PART V, SECTION B, LINE 6B: WILLIAMS COUNTY HEALTH DEPARTMENT BRYAN HOSPITAL PART V, SECTION B, LINE 7D: THE 2022 WILLIAMS COUNTY HEALTH ASSESSMENT IS AVAILABLE ON THE FOLLOWING WEBSITES:COMMUNITY HOSPITALS AND WELLNESS CENTERSHTTPS://WWW.CHWCHOSPITAL.ORG/COMMUNITY-HEALTH-ASSESMENT/WILLIAMS COUNTY COMBINED HEALTH DISTRICTHTTP://WWW.WILLIAMSCOUNTYHEALTH.ORG/HOSPITAL COUNCIL OF NORTHWEST OHIOHTTP://WWW.HCNO.ORG/COMMUNITY/REPORTS.HTML MONTPELIER HOSPITAL PART V, SECTION B, LINE 7D: THE 2019 WILLIAMS COUNTY HEALTH ASSESSMENT IS AVAILABLE ON THE FOLLOWING WEBSITES:COMMUNITY HOSPITALS AND WELLNESS CENTERSHTTPS://WWW.CHWCHOSPITAL.ORG/COMMUNITY-HEALTH-ASSESMENT/WILLIAMS COUNTY COMBINED HEALTH DISTRICTHTTP://WWW.WILLIAMSCOUNTYHEALTH.ORG/HOSPITAL COUNCIL OF NORTHWEST OHIOHTTP://WWW.HCNO.ORG/COMMUNITY/REPORTS.HTML BRYAN HOSPITAL PART V, SECTION B, LINE 11: THE STRATEGIC PLAN OF ACTION IS TO ADDRESS THREE PRIORITIES 1) ACCESS TO CARE, 2) HEALTH BEHAVIORS, 3) MENTAL HEALTH AND ADDICTION. ALL PRIORITIES HAVE SPECIFIC STRATEGIES AND ACTION STEPS OUTLINED ON PAGES 38-50 IN TEH WILLIAMS COUNTY CHIP PLAN.PROGRESS WILL BE MONITORED WITH MEASURABLE INDICATORS IDENTIFIED FOR EACH STRATEGY. MOST INDICATORS ALIGN DIRECTLY WITH THE SHIP. THE INDIVIDUALS OR AGENCIES THAT ARE WORKING ON STRATEGIES WILL MEET ON AN AS NEEDED BASIS. THE FULL COMMITTEE WILL MEET QUARTERLY OR AS NEEDED TO REPORT OUT PROGRESS. THE COMMITTEEWILL CREATE A PLAN TO DISSEMINATE THE CHIP TO THE COMMUNITY. STRATEGIES, RESPONSIBLE AGENCIES, AND TIMELINES WILL BE REVIEWED AT THE END OF EACH YEAR BY THE COMMITTEE. AS THIS CHIP IS A LIVING DOCUMENT, EDITS AND REVISIONS WILL BE MADE ACCORDINGLY.WILLIAMS COUNTY WILL CONTINUE FACILITATING CHA EVERY THREE YEARS TO COLLECT DATA AND DETERMINE TRENDS. PRIMARY DATA WILL BE COLLECTED FOR ADULTS AND YOUTH USING NATIONAL SETS OF QUESTIONS TO NOT ONLY COMPARE TRENDS IN WILLIAMS COUNTY, BUT ALSO BE ABLE TO COMPARE TO THE STATE AND NATION. THIS DATA WILL SERVE AS MEASURABLE OUTCOMES FOR EACH PRIORITY AREA. INDICATORS HAVE ALREADY BEEN DEFINED THROUGHOUT THIS REPORT AND ARE IDENTIFIED WITH THE ICON.IN ADDITION TO OUTCOME EVALUATION, PROCESS EVALUATION WILL ALSO BE USED ON A CONTINUOUS BASIS TO FOCUS ON THE SUCCESS OF THE STRATEGIES. AREAS OF PROCESS EVALUATION THAT THE CHIP COMMITTEE WILL MONITOR INCLUDE THE FOLLOWING: NUMBER OF PARTICIPANTS, LOCATION(S) WHERE SERVICES ARE PROVIDED, NUMBER OF POLICIES IMPLEMENTED, ECONOMIC STATUS AND RACIAL/ETHNIC BACKGROUND OF THOSE RECEIVING SERVICES (WHEN APPLICABLE), AND INTERVENTION DELIVERY (QUANTITY AND FIDELITY).FURTHERMORE, ALL STRATEGIES HAVE BEEN INCORPORATED INTO A "PROGRESS REPORT" TEMPLATE THAT CAN BE COMPLETED AT ALL FUTURE MEETINGS, KEEPING THE COMMITTEE ON TASK AND ACCOUNTABLE. THIS PROGRESS REPORT MAY ALSO SERVE AS MEETING MINUTES. MONTPELIER HOSPITAL PART V, SECTION B, LINE 11: THE STRATEGIC PLAN OF ACTION IS TO ADDRESS THREE PRIORITIES 1) ACCESS TO CARE, 2) HEALTH BEHAVIORS, 3) MENTAL HEALTH AND ADDICTION. ALL PRIORITIES HAVE SPECIFIC STRATEGIES AND ACTION STEPS OUTLINED ON PAGES 38-50 IN TEH WILLIAMS COUNTY CHIP PLAN.PROGRESS WILL BE MONITORED WITH MEASURABLE INDICATORS IDENTIFIED FOR EACH STRATEGY. MOST INDICATORS ALIGN DIRECTLY WITH THE SHIP. THE INDIVIDUALS OR AGENCIES THAT ARE WORKING ON STRATEGIES WILL MEET ON AN AS NEEDED BASIS. THE FULL COMMITTEE WILL MEET QUARTERLY OR AS NEEDED TO REPORT OUT PROGRESS. THE COMMITTEEWILL CREATE A PLAN TO DISSEMINATE THE CHIP TO THE COMMUNITY. STRATEGIES, RESPONSIBLE AGENCIES, AND TIMELINES WILL BE REVIEWED AT THE END OF EACH YEAR BY THE COMMITTEE. AS THIS CHIP IS A LIVING DOCUMENT, EDITS AND REVISIONS WILL BE MADE ACCORDINGLY.WILLIAMS COUNTY WILL CONTINUE FACILITATING CHA EVERY THREE YEARS TO COLLECT DATA AND DETERMINE TRENDS. PRIMARY DATA WILL BE COLLECTED FOR ADULTS AND YOUTH USING NATIONAL SETS OF QUESTIONS TO NOT ONLY COMPARE TRENDS IN WILLIAMS COUNTY, BUT ALSO BE ABLE TO COMPARE TO THE STATE AND NATION. THIS DATA WILL SERVE AS MEASURABLE OUTCOMES FOR EACH PRIORITY AREA. INDICATORS HAVE ALREADY BEEN DEFINED THROUGHOUT THIS REPORT AND ARE IDENTIFIED WITH THE ICON.IN ADDITION TO OUTCOME EVALUATION, PROCESS EVALUATION WILL ALSO BE USED ON A CONTINUOUS BASIS TO FOCUS ON THE SUCCESS OF THE STRATEGIES. AREAS OF PROCESS EVALUATION THAT THE CHIP COMMITTEE WILL MONITOR INCLUDE THE FOLLOWING: NUMBER OF PARTICIPANTS, LOCATION(S) WHERE SERVICES ARE PROVIDED, NUMBER OF POLICIES IMPLEMENTED, ECONOMIC STATUS AND RACIAL/ETHNIC BACKGROUND OF THOSE RECEIVING SERVICES (WHEN APPLICABLE), AND INTERVENTION DELIVERY (QUANTITY AND FIDELITY).FURTHERMORE, ALL STRATEGIES HAVE BEEN INCORPORATED INTO A "PROGRESS REPORT" TEMPLATE THAT CAN BE COMPLETED AT ALL FUTURE MEETINGS, KEEPING THE COMMITTEE ON TASK AND ACCOUNTABLE. THIS PROGRESS REPORT MAY ALSO SERVE AS MEETING MINUTES. BRYAN HOSPITAL PART V, SECTION B, LINE 13B: ALL PATIENTS REGISTERING FOR EMERGENCY OR MEDICALLY NECESSARY CARE WILL BE OFFERED A FINANCIAL APPLICATION AND "PLAIN LANGUAGE SUMMARY" AT THE TIME OF REGISTRATION. CHWC WILL ALSO FOLLOW UP WITH UNINSURED PATIENTS WITHIN 3 TO 4 WEEKS OF SERVICE, IF A FINANCIAL APPLICATION IS NOT RECEIVED OR MEDICAID APPLICATION IS NOT COMPLETED BY THAT DATE. FOLLOW UP CONSISTS OF A PHONE CALL TO OFFER THE PATIENT ASSISTANCE WITH THE MEDICAID APPLICATION AND DISCUSS FINANCIAL ASSISTANCE OPTIONS. PATIENT BILLING STATEMENTS INCLUDE ON THE BACK SIDE, INFORMATION ON THE HCAP AND HOSPITAL FINANCIAL ASSISTANCE PROGRAMS, INCLUDING CURRENT POVERTY LEVELS, AS REQUIRED BY HCAP POLICY. THE OPTIONS FOR REQUESTING A FINANCIAL APPLICATION ARE ALSO LISTED ON THE STATEMENT. REFERENCE TO THE FINANCIAL ASSISTANCE INFORMATION WILL BE CLEARLY NOTED ON THE FRONT SIDE OF THE STATEMENT. THE PLAIN LANGUAGE SUMMARY, FINANCIAL APPLICATION, BILLING AND COLLECTIONS POLICY, AND THIS FINANCIAL ASSISTANCE POLICY ARE DISPLAYED ON THE HOSPITAL WEBSITE. IN COMPLIANCE WITH THE 5-PERCENT/1000 PERSON THRESHOLD UNDER THE HHS GUIDANCE SAFE HARBOR AND 501R REGULATIONS, THE SPANISH VERSION OF THE FAP, FINANCIAL APPLICATION AND PLAIN LANGUAGE SUMMARY IS ALSO AVAILABLE AT ALL HOSPITAL LOCATIONS AND ON THE HOSPITAL WEBSITE. SIGNAGE IS POSTED AT ALL 3 HOSPITAL BUILDINGS IN CUSTOMER AREAS INCLUDING ADMISSIONS OFFICE, BILLING OFFICE, CASHIER AREA AND EMERGENCY DEPARTMENT. THE SIGNAGE WILL PROVIDE INFORMATION ON THE HOSPITAL FINANCIAL PROGRAM AND THE APPLICATION PROCESS.COPIES OF THE FINANCIAL APPLICATION AND PLAIN LANGUAGE SUMMARY ARE DISTRIBUTED TO THE COMPASSION CLINIC IN WILLIAMS COUNTY. THIS IS A 'FREE CLINIC AND PATIENTS ARE ENCOURAGED TO COMPLETE THE APPLICATION IF THEY NEED FOLLOW UP SERVICES AT THE HOSPITAL. CHWC WILL PERIODICALLY INCLUDE INFORMATION ON THE HOSPITAL FINANCIAL ASSISTANCE POLICIES, IN THE QUARTERLY NEWSLETTER THAT IS MAILED TO RESIDENTS IN THE 4 COUNTY AREA. MONTPELIER HOSPITAL PART V, SECTION B, LINE 13B: ALL PATIENTS REGISTERING FOR EMERGENCY OR MEDICALLY NECESSARY CARE WILL BE OFFERED A FINANCIAL APPLICATION AND "PLAIN LANGUAGE SUMMARY" AT THE TIME OF REGISTRATION. CHWC WILL ALSO FOLLOW UP WITH UNINSURED PATIENTS WITHIN 3 TO 4 WEEKS OF SERVICE, IF A FINANCIAL APPLICATION IS NOT RECEIVED OR MEDICAID APPLICATION IS NOT COMPLETED BY THAT DATE. FOLLOW UP CONSISTS OF A PHONE CALL TO OFFER THE PATIENT ASSISTANCE WITH THE MEDICAID APPLICATION AND DISCUSS FINANCIAL ASSISTANCE OPTIONS. PATIENT BILLING STATEMENTS INCLUDE ON THE BACK SIDE, INFORMATION ON THE HCAP AND HOSPITAL FINANCIAL ASSISTANCE PROGRAMS, INCLUDING CURRENT POVERTY LEVELS, AS REQUIRED BY HCAP POLICY. THE OPTIONS FOR REQUESTING A FINANCIAL APPLICATION ARE ALSO LISTED ON THE STATEMENT. REFERENCE TO THE FINANCIAL ASSISTANCE INFORMATION WILL BE CLEARLY NOTED ON THE FRONT SIDE OF THE STATEMENT. THE PLAIN LANGUAGE SUMMARY, FINANCIAL APPLICATION, BILLING AND COLLECTIONS POLICY, AND THIS FINANCIAL ASSISTANCE POLICY ARE DISPLAYED ON THE HOSPITAL WEBSITE. IN COMPLIANCE WITH THE 5-PERCENT/1000 PERSON THRESHOLD UNDER THE HHS GUIDANCE SAFE HARBOR AND 501R REGULATIONS, THE SPANISH VERSION OF THE FAP, FINANCIAL APPLICATION AND PLAIN LANGUAGE SUMMARY IS ALSO AVAILABLE AT ALL HOSPITAL LOCATIONS AND ON THE HOSPITAL WEBSITE. SIGNAGE IS POSTED AT ALL 3 HOSPITAL BUILDINGS IN CUSTOMER AREAS INCLUDING ADMISSIONS OFFICE, BILLING OFFICE, CASHIER AREA AND EMERGENCY DEPARTMENT. THE SIGNAGE WILL PROVIDE INFORMATION ON THE HOSPITAL FINANCIAL PROGRAM AND THE APPLICATION PROCESS.COPIES OF THE FINANCIAL APPLICATION AND PLAIN LANGUAGE SUMMARY ARE DISTRIBUTED TO THE COMPASSION CLINIC IN WILLIAMS COUNTY. THIS IS A 'FREE CLINIC AND PATIENTS ARE ENCOURAGED TO COMPLETE THE APPLICATION IF THEY NEED FOLLOW UP SERVICES AT THE HOSPITAL. CHWC WILL PERIODICALLY INCLUDE INFORMATION ON THE HOSPITAL FINANCIAL ASSISTANCE POLICIES, IN THE QUARTERLY NEWSLETTER THAT IS MAILED TO RESIDENTS IN THE 4 COUNTY AREA. BRYAN HOSPITAL PART V, SECTION B, LINE 20E: VISITS DETERMINED TO BE CHARITY ELIGIBLE THROUGH THE I-SOLUTIONS PROGRAM, WILL RECEIVE CHARITY DISCOUNTS ACCORDING TO THE 'SELF PAY/COLLECTION POLICY'. I-SOLUTIONS IS AN ELECTRONIC SCREENING PROCESS THAT PROVIDES A SCORE RELATING TO THE PATIENT'S ABILITY TO PAY.PRESUMPTIVE ELIGIBILITY IS DETERMINED IMMEDIATELY PRIOR TO SENDING AN ACCOUNT TO COLLECTIONS. PATIENTS RECEIVING A FINANCIAL DISCOUNT FROM THE I-SOLUTIONS PROCESS MAY ALSO COMPLETE A FINANCIAL APPLICATION TO DETERMINE ELIGIBILITY FOR A HIGHER DISCOUNT, AS LONG AS THE APPLICATION IS COMPLETED WITHIN 240 DAYS OF THE 1ST STATEMENT DATE. THE PATIENT DOES NOT RECEIVE NOTIFICATION OF THE CHARITY DISCOUNT APPLIED BASED ON PRESUMPTIVE ELIGIBILITY AS THE ACCOUNT HAS ALREADY MET THE HOSPITAL GUIDELINES FOR PLACEMENT WITH A COLLECTION AGENCY AND IS IMMEDIATELY FORWARDED TO THE AGENCY FOR COLLECTION OF THE REMAINING BALANCE. THE COLLECTION AGENCY WILL ENCOURAGE COMPLETION OF A FINANCIAL APPLICATION, IF THEY DETERMINE THE PATIENT IS LIKELY ELIGIBLE FOR FINANCIAL ASSISTANCE, REGARDLESS IF THE ACCOUNT HAS ALREADY RECEIVED A DISCOUNT BASED ON PRESUMPTIVE ELIGIBILITY. MONTPELIER HOSPITAL PART V, SECTION B, LINE 20E: VISITS DETERMINED TO BE CHARITY ELIGIBLE THROUGH THE I-SOLUTIONS PROGRAM, WILL RECEIVE CHARITY DISCOUNTS ACCORDING TO THE 'SELF PAY/COLLECTION POLICY'. I-SOLUTIONS IS AN ELECTRONIC SCREENING PROCESS THAT PROVIDES A SCORE RELATING TO THE PATIENT'S ABILITY TO PAY.PRESUMPTIVE ELIGIBILITY IS DETERMINED IMMEDIATELY PRIOR TO SENDING AN ACCOUNT TO COLLECTIONS. PATIENTS RECEIVING A FINANCIAL DISCOUNT FROM THE I-SOLUTIONS PROCESS MAY ALSO COMPLETE A FINANCIAL APPLICATION TO DETERMINE ELIGIBILITY FOR A HIGHER DISCOUNT, AS LONG AS THE APPLICATION IS COMPLETED WITHIN 240 DAYS OF THE 1ST STATEMENT DATE. THE PATIENT DOES NOT RECEIVE NOTIFICATION OF THE CHARITY DISCOUNT APPLIED BASED ON PRESUMPTIVE ELIGIBILITY AS THE ACCOUNT HAS ALREADY MET THE HOSPITAL GUIDELINES FOR PLACEMENT WITH A COLLECTION AGENCY AND IS IMMEDIATELY FORWARDED TO THE AGENCY FOR COLLECTION OF THE REMAINING BALANCE. THE COLLECTION AGENCY WILL ENCOURAGE COMPLETION OF A FINANCIAL APPLICATION, IF THEY DETERMINE THE PATIENT IS LIKELY ELIGIBLE FOR FINANCIAL ASSISTANCE, REGARDLESS IF THE ACCOUNT HAS ALREADY RECEIVED A DISCOUNT BASED ON PRESUMPTIVE ELIGIBILITY. 2 1 - ARCHBOLD MEDICAL CENTER 121 WESTFIELD DR ARCHBOLD OH 43502 OP SURGERY CENTER, OP RADIOLOGY, OP LAB, OP THERAPIES, AND MOB 2 - RADIATION ONCOLOGY CENTER 524 WEST HIGH ST BRYAN OH 43506 RADIATION ONCOLOGY PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO (51%) WHICH WAS DERIVED FROM WORKSHEET 2. PART I, LINE 7G: NOT APPLICABLE PART I, LN 7 COL(F): THE PERCENTAGE CALCULATED ON LINE 7F IS BASED ON TOTAL EXPENSES FROM FORM 990, PART IX, LESS BAD DEBTS IN THE AMOUNT OF $4,739,312. PART I, LINE 7E: AMOUNTS PRESENTED ARE BASED ON ACTUAL SPEND FOR THOSE SERVICES AND BENEFITS PROVIDED DEEMED TO IMPROVE THE HEALTH OF THE COMMUNITIES IN WHICH WE SERVE AND CONFORM WITH THE MISSION OF OUR EXEMPT PURPOSE. PART I, LINE 7I: IN KEEPING WITH OUR MISSION AND COMMITMENT TO THE COMMUNITIES IN WHICH WE SERVE, COMMUNITY HOSPITALS AND WELLNESS CENTERS CONTINUES ITS TRADITION OF CONTRIBUTING TO NUMEROUS ORGANIZATIONS ON BOTH AN AS-NEEDED BASIS AND NEGOTIATED BASIS. AMOUNTS PRESENTED REPRESENT ACTUAL SPEND TO ORGANIZATIONS THROUGHOUT OUR COMMUNITIES. PART II, COMMUNITY BUILDING ACTIVITIES: NOT APPLICABLE PART III, LINE 2: BAD DEBT WAS CALCULATED USING AUDITED FINANCIAL, IT IS NOT AN ESTIMATED AMOUNT. PART III, LINE 3: ESTIMATE OF 10% OF TOTAL BAD DEBT EXPENSE IN ORDER TO CALCULATE THE AMOUNT RECORDED AS BAD DEBT THAT WOULD BE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. NONE OF THE BAD DEBT EXPENSE IS TREATED AS A COMMUNITY BENEFIT. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY).FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDE BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: MEDICARE COSTS WERE CALCULATED USING A COST TO CHARGE RATIO BASED ON METHODOLOGY REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. THE SHORTFALL IS CONSIDERED COMMUNITY BENEFIT DUE TO THE ELDERLY POPULATION IN THE HOSPITAL'S SERVICE AREA. PART III, LINE 9B: THE FOLLOWING COLLECTION PRACTICES ARE CONSISTENANT WITH ALL PATIENTS:STATEMENT CYCLE:THE FIRST STATEMENT MAILED TO THE PATIENT/GUARANTOR IS A STATEMENT SUMMARIZING THE CHARGES AND INSURANCE PAYMENTS, IF APPLICABLE. THIS STATEMENT IS MAILED TO THE GUARANTOR THE DAY AFTER THE ACCOUNT IS FINAL BILLED IN THE HOSPITAL SYSTEM, OR THE DAY FOLLOWING RECEIPT AND SETTLEMENT OF INSURANCE PAYMENT, IF APPLICABLE. IF INSURANCE HAS PENDED PROCESSING OF A CLAIM, HOLDING FOR REQUESTED INFORMATION FROM THE POLICY HOLDER, THE BILLER CALLS THE GUARANTOR OF THE ACCOUNT, IF UNABLE TO REACH THEM A LETTER IS SENT TO THE PATIENT/GUARANTOR ASKING THEM TO PROVIDE THE INSURANCE WITH THE REQUESTED INFORMATION AND NOTIFY THE PATIENT ACCOUNTS OFFICE WHEN IT IS COMPLETED. IF THE PATIENT DOES NOT RESPOND TO THE LETTER BY THE DUE DATE, THE ACCOUNT WILL BE CHANGED TO SELF-PAY PRIOR TO INSURANCE PAYMENT, AND THE PATIENT WILL BEGIN RECEIVING STATEMENTS. FOLLOWING THE INITIAL SUMMARY STATEMENT, A GUARANTOR STATEMENT IS MAILED TO THE GUARANTOR THE FIRST WEEK OF EACH MONTH, UNTIL THE ACCOUNT IS SETTLED IN FULL, OR REFERRED TO AN OUTSIDE AGENCY FOR COLLECTIONS. THE GUARANTOR STATEMENT LISTS ALL ACCOUNTS WITH AN OUTSTANDING PATIENT BALANCE, EXCLUDING BAD DEBT ACCOUNTS THAT ARE PROCESSING WITH A COLLECTION AGENCY. ACCOUNTS PROCESSING WITH INSURANCE WILL NOT BE INCLUDED ON PATIENT/GUARANTOR STATEMENTS, UNTIL THERE IS A PATIENT BALANCE DUE ON THE ACCOUNT. PHONE CALLS:CHWC WILL ATTEMPT TO MAKE A PHONE CALL TO ALL PATIENTS WITH NO INSURANCE APPROXIMATELY 2 WEEKS AFTER THE DATE OF SERVICE, AT THAT TIME WE OFFER ASSISTANCE WITH MEDICAID ENROLLMENT, FINANCIAL ASSISTANCE INCLUDING HOSPITAL PROGRAM AND HCAP OR SETTING UP PAYMENT ARRANGEMENTS. THIS PHONE CALL WILL BE DOCUMENTED ON THE ACCOUNT NOTES. PAYMENT ARRANGEMENT GUIDELINES:THE PATIENT STATEMENT INCLUDES CONTACT INFORMATION FOR THE PATIENT ACCOUNTS BILLING OFFICE. PATIENT REPRESENTATIVES ARE AVAILABLE TO SET UP PAYMENT ARRANGEMENTS WITH THE GUARANTOR. WHEN A GUARANTOR CALLS TO SET UP PAYMENT ARRANGEMENTS, THE GUARANTOR IS ASKED TO PAY IN FULL, AND OFFERED THE OPTION OF A 15% PROMPT PAY DISCOUNT IF PAID IN FULL WITHIN 30 DAYS OF THE FIRST STATEMENT DATE. REQUESTS FOR DISCOUNTS EXCEEDING 15% ARE TO BE APPROVED BY THE PRESIDENT/CEO OR CFO. IF PAYMENT IN FULL IS NOT POSSIBLE, THE GUARANTOR IS ASKED TO MAKE MONTHLY PAYMENTS TO PAY THE ACCOUNT IN FULL WITHIN 18 MONTHS, AND WITH A MINIMUM PAYMENT OF $50.00 PER MONTH. EXCEPTIONS CAN BE MADE TO THESE PAYMENT GUIDELINES TO ALLOW A SMALLER PAYMENT OR EXTENDED TIME TO PAY OFF THE BILL, IF DETERMINATION IS MADE THAT THE GUARANTOR IS MAKING EVERY EFFORT TO PAY AND AGREES TO INCREASE PAYMENTS IN THE FUTURE, IF THE FINANCIAL CIRCUMSTANCES CHANGE. THE GUARANTOR MAY BE ASKED TO COMPLETE A FINANCIAL APPLICATION TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE, IF HE/SHE IS NOT ABLE TO MAKE ACCEPTABLE PAYMENT ARRANGEMENTS. (SEE FINANCIAL ASSISTANCE POLICY). FINAL NOTICE:IF NO PAYMENT IS RECEIVED OR PAYMENT ARRANGEMENT ESTABLISHED BY DAY 63 FROM THE INITIAL STATEMENT DATE, A "PAST DUE LETTER" IS SENT TO THE GUARANTOR OF PARAGON ACCOUNTS WITH A REQUEST TO PAY IN FULL OR CONTACT PATIENT ACCOUNTS WITHIN 30 DAYS. THE PAST DUE LETTER WILL INCLUDE THE 'PLAIN LANGUAGE SUMMARY". THE PAST DUE LETTER WILL INFORM THE PATIENT THAT THE ACCOUNT WILL BE CONSIDERED FOR COLLECTIONS IF THERE IS NO RESPONSE WITHIN 30 DAYS AND WILL ALSO LIST THE ECA'S (SEE ECA BELOW) THAT MAY BE INITIATED IF THE GUARANTOR DOES NOT RESPOND. IF THERE IS NO RESPONSE BY THE 38TH DAY FOLLOWING THE DATE OF THE 'PAST DUE LETTER OR ACCEPTABLE PAYMENTS HAVE NOT BEEN ESTABLISHED, THE ACCOUNT IS REVIEWED BY THE PATIENT REPRESENTATIVE TO DETERMINE ELIGIBILITY FOR BAD DEBT AND COLLECTION AGENCY PROCESSING. IF THE PATIENT HAD PREVIOUSLY ESTABLISHED A PAYMENT ARRANGEMENT BUT DID NOT FOLLOW THROUGH WITH TIMELY PAYMENTS, A PHONE CALL TO THE PATIENT WILL BE MADE TO RE-ESTABLISH THE PAYMENT ARRANGEMENT. IF THE PATIENT IS NOT ABLE TO BE REACHED AFTER A MINIMUM OF 2 ATTEMPTS, OR IS NOT COOPERATIVE, THE ACCOUNT WILL BE CONSIDERED FOR BAD DEBT/COLLECTIONS DURING THE NEXT TRANSFER OF ACCOUNTS. INVALID ADDRESS OR CONTACT INFORMATION:IF A PATIENT STATEMENT IS RETURNED FOR AN INVALID ADDRESS, THE PATIENT WILL BE CONTACTED BY PHONE TO OBTAIN CORRECT BILLING INFORMATION. IF THERE IS NO VALID PHONE CONTACT, OR THE PATIENT DOESN'T RESPOND TO A PHONE CALL, THE ACCOUNT MAY BE SENT TO THE COLLECTION AGENCY PRIOR TO SENDING A FINAL "PAST DUE LETTER". THE AGENCY WILL ATTEMPT TO LOCATE A VALID ADDRESS FOR THE GUARANTOR. THE AGENCY WILL NOTIFY THE HOSPITAL IF A VALID ADDRESS IS OBTAINED. IF THE PATIENT DOES NOT COOPERATE WITH THE COLLECTION AGENCY REGARDING PAYMENT OR COMPLETION OF A FINANCIAL APPLICATION, THE AGENCY WILL CONTACT THE HOSPITAL SO THAT A FINAL 'PAST DUE LETTER' CAN BE SENT. IF THERE IS NO RESPONSE TO THE PAST DUE LETTER, THE COLLECTION AGENCY MAY CONTINUE WITH APPROPRIATE ECA'S 240 DAYS FROM THE ORIGINAL STATEMENT DATE. THE HOSPITAL AND AGENCY WILL WORK TOGETHER TO ASSURE THE AGENCY HAS THE APPROPRIATE 1ST STATEMENT DATE SINCE THE ACCOUNTS MAY BE INITIALLY SENT TO THE AGENCY PRIOR TO THE NORMAL MINIMUM OF DAY 100. PRESUMPTIVE ELIGIBILITY:AFTER THE SECONDARY COLLECTION AGENCY HAS DETERMINED AN ACCOUNT TO BE UNCOLLECTIBLE, THE ACCOUNT IS SENT TO "I-SOLUTIONS" TO REVIEW AND DETERMINE CHARITY ELIGIBILITY. ANY ACCOUNTS THAT LIST ON THE I-SOLUTIONS REPORT AS "YES" UNDER THE CHARITY COLUMN WILL RECEIVE A CHARITY DISCOUNT EQUAL TO THE "W/O AMOUNT" LISTED ON THE REPORT. ACCOUNTS THAT CONTAIN A POSITIVE "W/O AMOUNT AND FALL IN THE "BD OR "LOW" PROPENSITY TO PAY CATEGORY, AND ACCOUNTS WITH NO LISTED PROPENSITY TO PAY BUT A POSITIVE "W/O AMOUNT" WILL ALSO RECEIVE A CHARITY DISCOUNT EQUAL TO THE "W/O AMOUNT" LISTED ON THE REPORT. VISITS WITH A PROPENSITY TO PAY "NMD" (NEED MORE DATA) DO NOT RECEIVE A CHARITY ADJUSTMENT.THE ADMISSION AUTHORIZATION FORM INCLUDES A STATEMENT AUTHORIZING THE HOSPITAL TO REVIEW THE GUARANTOR'S CREDIT INFORMATION. IF THIS IS NOT SIGNED BY THE PATIENT OR HIS/HER REPRESENTATIVE, THE VISIT WILL NOT BE SENT TO I-SOLUTIONS FOR REVIEW. ACCOUNTS RECEIVING A DISCOUNT BASED ON PRESUMPTIVE ELIGIBILITY ARE ELIGIBLE TO APPLY FOR AN ADDITIONAL DISCOUNT IF A FINANCIAL APPLICATION IS COMPLETED WITHIN 240 DAYS FROM THE 1ST STATEMENT DATE. PART VI, LINE 2: THE WILLIAMS COUNTY PARTNERS FOR HEALTH COMMITTEE PRESENTS THE 2022 WILLIAMS COUNTY COMMUNITY HEALTH ASSESSMENT. THE DATA CONTAINED IN THIS REPORT IS A SCIENTIFICALLY VALID SAMPLING CONDUCTED EVERY THREE YEARS IN THE COMMUNITY TO BETTER IDENTIFY AND UNDERSTAND HEALTH ISSUES FACING WILLIAMS COUNTY RESIDENTS. THROUGH A COMBINED EFFORT BY THE WILLIAMS COUNTY HEALTH DEPARTMENT, COMMUNITY HOSPITALS AND WELLNESS CENTERS BRYAN AND MONTPELIER, AND THE MANY ORGANIZATIONS LISTED IN THIS PUBLICATION, WE ARE ABLE TO PROVIDE VALUABLE INFORMATION BOTH TO INDIVIDUAL RESIDENTS AND ORGANIZATIONS IN THE COMMUNITY. IN THE PAST, THIS INFORMATION HAS HELPED TO EDUCATE CITIZENS ABOUT THEIR COMMUNITY AND WE HOPE YOU FIND THE NEW REPORT HELPFUL IN THAT REGARD. IN THE 2022 REPORT YOU WILL FIND THAT IN MANY WAYS THE HEALTH OF OUR COMMUNITY IS VERY GOOD AND RANKS HIGHER THAN BOTH THE NATION AND STATE AVERAGES. IN OTHER AREAS, YOU WILL FIND WE STILL HAVE CHALLENGES THAT NEED TO BE ADDRESSED FOR THE BETTERMENT OF OUR COMMUNITY. WHETHER YOU USE THIS INFORMATION TO APPLY FOR GRANTS OR JUST BECOME MORE INFORMED WE HOPE THAT YOU FIND THIS REPORT USEFUL FOR YOUR PURPOSES. PART VI, LINE 3: ALL PATIENTS REGISTERING FOR EMERGENCY OR MEDICALLY NECESSARY CARE WILL BE OFFERED A FINANCIAL APPLICATION AND "PLAIN LANGUAGE SUMMARY" AT THE TIME OF REGISTRATION. CHWC WILL ALSO FOLLOW UP WITH UNINSURED PATIENTS WITHIN 3 TO 4 WEEKS OF SERVICE, IF A FINANCIAL APPLICATION IS NOT RECEIVED OR MEDICAID APPLICATION IS NOT COMPLETED BY THAT DATE. FOLLOW UP CONSISTS OF A PHONE CALL TO OFFER THE PATIENT ASSISTANCE WITH THE MEDICAID APPLICATION AND DISCUSS FINANCIAL ASSISTANCE OPTIONS. PATIENT BILLING STATEMENTS INCLUDE ON THE BACK SIDE, INFORMATION ON THE HCAP AND HOSPITAL FINANCIAL ASSISTANCE PROGRAMS, INCLUDING CURRENT POVERTY LEVELS, AS REQUIRED BY HCAP POLICY. THE OPTIONS FOR REQUESTING A FINANCIAL APPLICATION ARE ALSO LISTED ON THE STATEMENT. REFERENCE TO THE FINANCIAL ASSISTANCE INFORMATION WILL BE CLEARLY NOTED ON THE FRONT SIDE OF THE STATEMENT. THE PLAIN LANGUAGE SUMMARY, FINANCIAL APPLICATION, BILLING AND COLLECTIONS POLICY, AND THIS FINANCIAL ASSISTANCE POLICY ARE DISPLAYED ON THE HOSPITAL WEBSITE. IN COMPLIANCE WITH THE 5-PERCENT/1000 PERSON THRESHOLD UNDER THE HHS GUIDANCE SAFE HARBOR AND 501R REGULATIONS, THE SPANISH VERSION OF THE FAP, FINANCIAL APPLICATION AND PLAIN LANGUAGE SUMMARY IS ALSO AVAILABLE AT ALL HOSPITAL LOCATIONS AND ON THE HOSPITAL WEBSITE. SIGNAGE IS POSTED AT ALL 3 HOSPITAL BUILDINGS IN CUSTOMER AREAS INCLUDING ADMISSIONS OFFICE, BILLING OFFICE, CASHIER AREA AND EMERGENCY DEPARTMENT. THE SIGNAGE WILL PROVIDE INFORMATION ON THE HOSPITAL FINANCIAL PROGRAM AND THE APPLICATION PROCESS.COPIES OF THE FINANCIAL APPLICATION AND PLAIN LANGUAGE SUMMARY ARE DISTRIBUTED TO THE COMPASSION CLINIC IN WILLIAMS COUNTY. THIS IS A 'FREE CLINIC AND PATIENTS ARE ENCOURAGED TO COMPLETE THE APPLICATION IF THEY NEED FOLLOW UP SERVICES AT THE HOSPITAL. CHWC WILL PERIODICALLY INCLUDE INFORMATION ON THE HOSPITAL FINANCIAL ASSISTANCE POLICIES, IN THE QUARTERLY NEWSLETTER THAT IS MAILED TO RESIDENTS IN THE 4 COUNTY AREA. PART VI, LINE 4: HOSPITALS ARE LOCATED IN BRYAN AND MONTPELIER, OHIO, IN ADDITION TO A MEDICAL CENTER LOCATED IN ARCHBOLD. CHWC SERVICES THE FOLLOWING THREE COUNTIES: WILLIAMS, DEFIANCE AND FULTON. APPROXIMATELY 17.9% OF THE POPULATION IS 65 YEARS OR OLDER, 19.5% IS BELOW POVERTY LEVEL, AND 10.8% ARE WITHOUT HEALTH INSURANCE UNDER AGE 65. PART VI, LINE 5: THE ORGANIZATION'S TEN BOARD MEMBERS RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA, WITH ONLY ONE BEING AN EMPLOYEE. NINE OF THE TEN BOARD MEMBERS ARE VOLUNTEER POSITIONS WITH NO PAY. THE HOSPITAL PROVIDES THE HIGHEST QUALITY OF CARE IN THE MOST EFFICIENT MANNER POSSIBLE. WE TAKE INTO CONSIDERATION THE COMMUNITIES FEEDBACK ON SERVICES THEY WOULD LIKE PROVIDED LOCALLY AND ASSESS IF WE CAN PROVIDE THEM WITH THE UPMOST QUALITY AND EFFICIENCY. PART VI, LINE 6: NOT APPLICABLE X X X X X 0 1 0 0 0 0 0 0 0 DR KHALID MINHAS PHYSICIAN 785902 0 0 0 0 0 0 0 22674 0 808576 0 0 0 DR DAVID COOLEY PHYSICIAN 700996 0 0 0 0 0 0 0 22079 0 723075 0 0 0 DR JODI TINKEL PHYSICIAN 617880 0 0 0 0 0 0 0 0 0 617880 0 0 0 DR WAINWRIGHT JAGGERNAUTH PHYSICIAN 570608 0 0 0 0 0 0 0 0 0 570608 0 0 0 DR MICHAEL NOSANOV PHYSICIAN 555688 0 0 0 0 0 0 0 10294 0 565982 0 0 0 JANICE DAVID VP PATIENT CARE: THRU 01.23 218908 0 0 0 242241 0 17500 0 10387 0 489036 0 0 0 CHAD D TINKEL EX-OFFICIO DIR: PRESIDENT/CEO/SECRET 367685 0 0 0 0 0 20500 0 22675 0 410860 0 0 0 STEVE BUMB MD DIRECTOR: CHIEF OF STAFF 306264 0 0 0 0 0 0 0 23674 0 329938 0 0 0 WADE PATRICK VP/CIO 228288 0 0 0 0 0 17500 0 23722 0 269510 0 0 0 CHRISTA POMEROY TREASURER: VP/CFO 187092 0 0 0 0 0 0 0 15373 0 202465 0 0 0 ELIZABETH GRIMES VP PATIENT CARE 175483 0 0 0 0 0 0 0 22674 0 198157 0 0 0 PART I, LINE 3 THE FOLLOWING INDVIDUALS PARTICIPATED IN A 457(B) RETIREMENT PLAN: JANICE DAVID, WADE PATRICK AND CHAD D. TINKEL. A $20,500 CONTRIBUTION WAS MADE TO 457(B) PLAN TO TINKEL. A $17,500 CONTRIBUTION WAS MADE TO 457(B) TO PATRICK & DAVID. THESE AMOUNTS HAVE BEEN PROPERLY INCLUDED IN OFFICERS' COMPENSATION ON SCHEDULE J, PART II, COLUMN B(III). THE HOSPITAL HAS A SUPPLEMENTAL EXECUTIVE RETENTION PLAN FOR THESE EXECUTIVES UNDER IRC SECTION 457(B). THE AMOUNTS DEFERRED UNDER THIS PLAN WILL BE TAXABLE TO THE EXECUTIVE WHEN VESTED AND THERE IS NO LONGER A SUBSTANTIAL RISK OF FORFEITURE. IN ORDER TO HAVE THE RIGHT TO FUTURE PAYMENT OF ANY EMPLOYER DEFERRAL, THE EXECUTIVE WILL HAVE TO REMAIN IN SERVICE UNTIL THE ACCOUNT BECOMES VESTED AS PROVIDED IN THE PLAN DOCUMENT. A CITY OF BRYAN OH 346400228 2008-07-01 10000000 SEE PART VI 0 0 0 B VILLAGE OF ARCHBOLD OH 346400063 2008-08-20 10000000 SEE PART VI 0 0 0 C CITY OF BRYAN OH 346400228 2016-06-15 10000000 SEE PART VI 0 0 0 D COUNTY OF WILLIAMS OH 346401595 2016-06-30 10000000 SEE PART VI 0 0 0 A 10208153 10208153 2011 0 0 1 1 B 10208153 10208153 2011 0 0 1 1 C 10000000 10000000 1 0 1 1 D 10000000 1000000 2011 1 0 1 1 A 0 0 1 1 0 0.01240 0.01240 0 0 1 B 0 0 1 1 0 0 0 1 C 0 1 1 1 0 0.31000 0.31000 0 0 1 D 0 1 1 1 0 0.01240 0.01240 0 0 1 A 0 0 1 1 1 0 0 0 1 B 0 0 1 1 1 0 0 0 1 C 0 1 1 0 1 1 FIFTH THIRD BANK 1.400000000000 0 0 0 0 1 D 0 1 1 0 1 1 FIFTH THIRD BANK 1.400000000000 0 0 0 0 1 A 1 B 1 C 1 D 1 FORM 990, SCHEDULE K, PART II PART II, LINE 3, COLUMN A: TOTAL PROCEEDS OF ISSUE ARE $10,208,153, WHICH ARE SALE PROCEEDS OF $10,000,000 PLUS INVESTMENT EARNINGS OF $208,153. PART II, LINE 3, COLUMN B: TOTAL PROCEEDS OF ISSUE ARE $10,208,153 WHICH ARE SALE PROCEEDS OF $10,000,000 PLUS INVESTMENT EARNINGS OF $208,153. PART III, LINE 4, COLUMN D: PRIVATE BUSINESS USE OF 1.24% IS A RESULT OF A DISCRETE PAIN MANAGEMENT AREA WITHIN THE BOND-FINANCED PROJECT. PART IV, LINE 2C, COLUMN A: REBATE COMPUTATION WAS PERFORMED ON 02/04/2013. PART IV, LINE 2C, COLUMN B: REBATE COMPUTATION WAS PERFORMED ON 02/04/2013. JODI TINKEL SEE SCH L, PART V 617880 JODI TINKEL IS THE SPOUSE OF CHAD TINKEL, PRESIDENT/CEO. 0 FORM 990, PART VI, SECTION A, LINE 2 DR. DORSTEN HAS A BUSINESS RELATIONSHIP WITH THE PHYSICIAN GROUP MCHA/PPG-OH. FORM 990, PART VI, SECTION A, LINE 3 DR. DORSTEN PROVIDED SERVICES AS CHIEF OVER THE MEDICAL STAFF, THROUGH HER OUTSIDE EMPLOYER. THE AMOUNT WAS ($500X12/MO) $6,000. FORM 990, PART VI, SECTION B, LINE 11B PRIOR TO FILING, FORM 990 IS PROVIDED TO THE BOARD, AND A SUMMARY OF THE DISCLOSURES AND CHANGES TO THE FORM IS PRESENTED BY THE PREPARERS OF THE TAX RETURN (PLANTE & MORAN) AT A MONTHLY BOARD MEETING. ALL BOARD MEMBERS WILL RECEIVE A COPY OF FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS AND VOTING MEMBERS OF THE BOARD ARE COVERED BY THE CONFLICT OF INTEREST POLICY, WHICH THEY SIGN ON AN ANNUAL BASIS. CONFLICTS OF INTEREST ARE REVIEWED ON A CASE BY CASE BASIS. IF A TRANSACTION ARISES THAT WOULD RESULT IN A CONFLICT, THE INTERESTED INDIVIDUAL SIGNS A CONFLICT OF INTEREST STATEMENT NOTING THAT THEY ARE NOT INDEPENDENT WITH RESPECT TO THE TRANSACTION, AND THEY ABSTAIN FROM VOTING ON THAT MATTER. THE POLICY IS MONITORED BY ALL BOARD MEMBERS AND OFFICERS. THE POLICY IS REVIEWED WITH ANY NEW BOARD MEMBERS OR OFFICERS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS REVIEWED ANNUALLY AND APPROVED BY THE COMPENSATION COMMITTEE. THE VICE AND ASSISTANT VICE PRESIDENTS' COMPENSATIONS ARE REVIEWED ANNUALLY AND APPROVED BY THE COMPENSATION COMMITTEE. THE DECISIONS REGARDING COMPENSATION ARE DOCUMENTED IN THE MINUTES FROM THE COMPENSATION COMMITTEE MEETINGS. OHA SURVEY DATA IS USED FOR COMPARABILITY PURPOSES. SIMILAR HOSPITALS' 990'S ARE REVIEWED FOR COMPARABILITY PURPOSES. THE PROCESS WAS LAST UNDERTAKEN FOR THE PRESIDENT, VICE AND ASSSISTANT PRESIDENTS IN DECEMBER 2023. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, LINE 16: CHWC DID NOT ENTER INTO ANY NEW JOINT VENTURES DURING THE YEAR. WHEN THE PAIN MANAGEMENT JOINT VENTURE WAS ESTABLISHED CHWC HAD OUTSIDE LEGAL COUNCIL REVIEW AND APPROVE THE DOCUMENTS. FORM 990, PART XI, LINE 9: TRANSFER FROM SHARE FOUNDATION 3,500,000. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS AN AUDIT COMMITTEE THAT OVERSEES THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SHARE FOUNDATION 433 WEST HIGH STREET BRYAN OH 43506 341596175 ASSIST COMMUNITY HOSPITALS AND WELLNESS CENTERS WITH FUNDRAISING OH 501(C)(3) 11A COMMUNITY HOSPITALS AND WELLNESS CENTERS 1 COMMUNITY HOSPITALS & WELLNESS CENTERS PAIN MANAGEMENT LLC 433 WEST HIGH STREET BRYAN OH 43506 461084537 MEDICAL SERVICES OH COMMUNITY HOSPITALS & WELLNESS CENTERS RELATED 842424 1222518 0 1 0.51000 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 1 CHWC PAIN MANAGEMENT LLC Q 2084958 ACTUAL EXPENSES CHWC PAIN MANAGEMENT LLC O 514967 ACTUAL EXPENSES CHWC PAIN MANAGEMENT LLC K 73811 ACTUAL EXPENSES SHARE FOUNDATION S 3500000 CASH TRANSACTIONS