2021-05-05T10:37:02-05:00 2020-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2019-07-01 560619359 GASTON MEMORIAL HOSPITAL INC GAST 7048342000 2525 COURT DRIVE GASTONIA NC 28054 DAVID O'CONNOR EVP, CFO 7048342000 2021-05-05 1 AMY BIBBY P00445891 8282542254 2019 2022-09-23 18:48:47Z CAROMONT REGIONAL MEDICAL CTR DAVID O'CONNOR 2525 COURT DRIVE GASTONIA NC 28054 583581267 0 X WWW.CAROMONT.ORG X 1945 NC TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 13 8 3912 177 117355 79825 294834 642684 544024173 569291318 -369974 109185 3058549 13455701 547007582 583498888 1366506 1172657 0 0 225013059 226010355 0 0 0 269560015 299315037 495939580 526498049 51068002 57000839 440718400 442215147 306850039 337638253 133868361 104576894 TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 0 0 489491875 1172657 569335799 CAROMONT HEALTH'S PHILOSOPHY OF CARE IS FOUNDED IN THREE DISTINCT WAYS.IT IS A HEALTH SYSTEM THAT INVESTS IN THE FUTURE OF HEALTHCARE FROM RESEARCH TO EDUCATION.IT IS AN ACTIVE COMMUNITY PARTNER, SUPPORTING AND DRIVING PROGRAMS THAT ENCOURAGE HEALTHIER LIFESTYLES. IT IS ALSO A DYNAMIC ORGANIZATION FOCUSED ON CONTINUOUS DAILY IMPROVEMENT, ADVANCED MEDICINE AND THE DELIVERY OF COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. THE FISCAL YEAR ENDING JUNE 30, 2020 SAW CAROMONT HEALTH LIVING ITS VISION TO BE OUR COMMUNITY'S MOST TRUSTED HEALTHCARE PARTNER. THE COMPLETE 2020 COMMUNITY BENEFIT REPORT CAN BE FOUND ATWWW.CAROMONTHEALTH.ORG. 489491875 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 255 0 1 3912 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 13 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X THE ORGANIZATION 7048342000 2525 COURT DRIVE GASTONIA NC 28054 MR DONNIE LOFTIS CHAIR (THRU MAY 2020) 1.00 2.00 X X 0 0 0 MR DAVID PAYSEUR VICE CHAIR/CHAIR(BEG. 05/20) 1.00 1.00 X X 0 0 0 DR ANDREW LIGHT SECRETARY 1.00 2.00 X X 0 0 0 MR BARRY M POMEROY TREASURER 1.00 1.00 X X 0 0 0 MR JOSEPH B DAVIS JR DIRECTOR 1.00 1.00 X 0 0 0 MR TIMOTHY E GAUSE DIRECTOR (THRU DEC 2019) 1.00 2.00 X 0 0 0 MR WILLIAM ANTHONY DIRECTOR 1.00 2.00 X 0 0 0 DR CHARLES MEAKIN III DIRECTOR 1.00 3.00 X 0 0 0 MS PEARL BURRIS FLOYD DIRECTOR 1.00 1.00 X 0 0 0 MS ANNETTE CARTER DIRECTOR 1.00 1.00 X 0 0 0 MR JEFFREY CASH DIRECTOR 1.00 1.00 X 0 0 0 DR TIMOTHY D CONNER DIRECTOR 1.00 1.00 X 0 0 0 FRANK STEWART DIRECTOR 1.00 2.00 X 0 0 0 MR BOB HOVIS (COMMISSIONER LIASON) 1.00 2.00 X 0 18699 0 DR PATRICK RUSSO PAST-CHIEF-OF-STAFF (NON-VOTING) 2.00 40.00 X 0 654411 40208 DR ERIC T EMERSON IMMEDIATE PAST-CHIEF-OF-STAFF (NON-VOTING) 1.00 1.00 X 30000 0 0 DR MICHEAL GASLIN CHIEF-OF-STAFF 1.00 1.00 X 26632 0 0 DR JAY HENDLER CHIEF-OF-STAFF ELECT (NON-VOTING) 1.00 1.00 X 0 464199 29613 K CHRISTOPHER PEEK CEO 45.00 10.00 X 858440 0 194798 DAVID M O'CONNOR EVP/ASST. TREASURER 45.00 10.00 X 643022 0 127057 LEIGH K HICKMAN CLO/ASST. SEC. 45.00 10.00 X 268134 0 26264 KATHLEEN K BESSON EVP/COO 45.00 10.00 X 611712 0 150413 TODD R DAVIS EVP CHIEF MEDICAL OFFICER 45.00 10.00 X 619368 0 121597 GEORGE E ADCOCK III VP 40.00 10.00 X 472617 0 83287 SHADI HIJJAWI CHIEF MEDICAL INFO OFFICER 40.00 10.00 X 0 339513 36106 RICHARD C BLACKBURN VP SUPPORT SERVICES 40.00 10.00 X 346117 0 71281 SCOTT E WELLS VP PATIENT CARE SERVICES 40.00 10.00 X 369784 0 68211 ROBIN L LANG VP INFORMATION SERVICES 40.00 10.00 X 337991 0 74739 4583817 1476822 1023574 200 0 1 0 EPIC SYSTEMS CORPORATION PO BOX 88314 MILWAUKEE WI 532880314 SOFTWARE SYSTEMS 3224631 BEAM CONSTRUCTION COMPANY INC PO BOX 129 CHERRYVILLE NC 28021 CONSTRUCTION MANAGEMENT 2952069 FEREBEE LANE CO 3 N LARENS STREET GREENVILLE SC 29601 ADVERTISING/AGENCY FEES 2512154 DPR HARDIN CONSTRUCTION 3301 WINDY RIDGE PKWY 400 ATLANTA GA 303395618 CONSTRUCTION MANAGEMENT 1923824 MICROSOFT LICENSING 1950 N STEMMONS FWY STE 5010 DALLAS TX 75207 MICROSOFT 365 LICENSES 1285318 65 642684 642684 PATIENT SERVICE REVENUE 621500 566983371 566983371 ANCILLARY REVENUE 621500 2307947 2190592 117355 569291318 48383 48383 60802 0 60802 60802 60802 137602 82379 55223 55223 ECONOMIC IMPACT STIMULUS PAYMENT 900099 10192890 10192890 CAFETERIA & VENDING INCOME 722210 1761672 1761672 MISCELLANEOUS REVENUE 900099 1324598 1324598 121318 121318 13400478 583498888 569173963 117355 13564886 X 1104011 1104011 68646 68646 3952476 26632 3925844 170407151 153038824 17368327 6352345 5576547 775798 33330218 29259669 4070549 11968165 10506518 1461647 796836 796836 163000 163000 1970 1970 20 20 56590412 51617890 4972522 1434833 74991 1359842 4220191 2790622 1429569 2229819 2229819 10584760 10584760 156744 115521 41223 386463 188156 198307 6527097 6527097 39528628 39528628 2218827 2218827 MEDICAL SUPPLIES 100247072 100247072 UBI TAX 41218 41218 BAD DEBT 63547583 63547583 MEDICAID ASSESSMENT FEE 5018579 5018579 5620985 5221483 399502 526498049 489491875 37006174 0 110927 101676 61425767 52785755 9580547 9919291 8166096 9162934 610687112 369163835 250345983 241523277 67066 71979 8599275 7313661 102422739 121336574 440718400 442215147 45898050 63226340 165247253 157789480 95704736 116622433 306850039 337638253 X 111594819 49902739 22273542 54674155 133868361 104576894 440718400 442215147 X 57000839 -107 -86292199 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 0 0 0 1 63684 0 1 44906 108590 0 PART II-B, LINE 1: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, OF WHICH $44,906 WAS DETERMINED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. THE ORGANIZATION HAD AN ADDITIONAL $45,666 IN LOBBYING COSTS FOR FISCAL YEAR 2020. LOBBYING REGISTRATION IS IN THE NAME OF CAROMONT HEALTH, INC. LOBBYING EXPENDITURES ARE REPORTED ON THE GASTON MEMORIAL HOSPITAL, INC FORM 990. 10310 228 348 10190 10049 655 394 10310 9841 703 495 10049 9521 1013 693 9841 10002 -278 203 9521 1.00000 0 0 8736410 8736410 326966593 184697708 142268885 9746642 8370790 1375852 244301811 171557897 72743914 20935656 4537440 16398216 241523277 NET PENSION ASSET/DEFERRAL 55859083 DEFERRED FINANCING COSTS 1081272 OTHER RECEIVABLES 4232799 457B PLAN ASSETS 14620472 DEFERRED CHARGE-INTEREST RATE SWAP 28638074 457F PLAN ASSETS 2259874 PREPAID COUNTY LEASE 14645000 121336574 457B PLAN LIABILITY 14620472 ESTIMATED 3RD PARTY SETTLEMENTS 62997194 INTEREST RATE SWAP LIABILITY 28638074 457F PLAN LIABILITY 2259874 PENSION DEFERRED INFLOW 8106819 116622433 X 433605366 -107 -107 433605473 20 149893395 149893415 583498888 462882148 0 462882148 20 63615881 63615901 526498049 PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR ONCOLOGY MEDICATIONS FOR INDIGENT PATIENTS. PART X, LINE 2: THE SYSTEM IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM HAS DETERMINED THAT IT DOES NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF JUNE 30, 2020 AND 2019. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 63,547,583. INTERCOMPANY TRANSFER FROM AFFILIATE 86,290,589. CHANGE IN VALUE OF INTEREST RATE SWAP AUXILIARY REVENUES 55,223. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 63,547,583. AUXILIARY SCHOLARSHIPS 68,298. 1 1 1 X 1 X 1 1 0 1 1 13542967 13542967 0.02930 74551861 67409263 7142598 0.01540 88094828 67409263 20685565 0.04470 1501563 2026 1499537 0.00320 2185812 210412 1975400 0.00430 405247 139797 265450 0.00060 1168283 1168283 0.00250 5260905 352235 4908670 0.01060 93355733 67761498 25594235 0.05530 1414236 1414236 0.00310 1414236 1414236 0.00310 63547583 15845682 103864631 117420451 -13555820 X 1 1 1 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 X X X 3 DIAGNOSTIC IMAGING CENTERS AND 6 OP SERIVCE CENTER CAROMONT REGIONAL MEDICAL CENTER 1 0 0 1 X X X X X X X X 18 1 0 1 1 X WWW.CAROMONTHEALTH.ORG X WWW.GASTONGOV.COM/DEPARTMENTS/HEALTH-AND-HUMAN-SERVICES X X 1 18 1 HTTP://WWW.CAROMONTHEALTH.ORG/DOCUMENTS/FOR-HEALTHCARE-PROFESSIONALS/GASTON 0 1 X 200.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X SEE DISCLOSURE X SEE DISCLOSURE X SEE DISCLOSURE X X X X X X X 1 X 0 X X X X 1 X 0 0 CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5: GASTON COUNTY COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED BY THE FOLLOWING PARTNERS: THE GASTON COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES, GASTON TOGETHER, UNITED WAY OF GASTON COUNTY, CAROMONT HEALTH, AND STAKEHOLDER ORGANIZATIONS. THE ASSESSMENT INCLUDES THE COLLECTION AND ANALYSIS OF EXISTING STATISTICAL DATA, QUALITY OF LIFE SURVEY DATA COLLECTED DIRECTLY FROM RESIDENTS AND INPUT FROM COMMUNITY FOCUS GROUPS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6B: THE HOSPITAL CONDUCTED THEIR CHNA WITH THE FOLLOWING ORGANIZATIONS: GASTON COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES, CAROMONT HEALTH, GASTON TOGETHER, THE UNITED WAY OF GASTON COUNTY AND REPRESENTATIVES OF OTHER STAKEHOLDER ORGANIZATIONS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 7D: PARTNERING AGENCIES PRESENTED THE CHNA AT WORKSHOPS, MEETINGS AND ON AGENCY WEBSITES TO ENCOURAGE COMMUNITY STAKEHOLDERS TO USE THEM TO ENHANCE THE WELLBEING OF GASTON COUNTY AND ITS RESIDENTS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 11: CAROMONT HEALTH PRIORITIES (2019-2021) ARE TO PROACTIVELY MANAGE MENTAL HEALTH ISSUES IN PRIMARY CARE OFFICES THROUGH THE HIRE OF MORE LCSWS, ENHANCE OPIOID AND PRESCRIPTION DRUG ABUSE INTERVENTION AND MANAGEMENT PROTOCOLS AND TO IMPROVE ACCESS TO AFFORDABLE HEALTH FOOD IN LOW INCOME COMMUNITIES THROUGH WORK WITH LOCAL STAKEHOLDERS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 13B: REGARDLESS OF INCOME, ASSETS ARE ALSO USED TO DETERMINE IF A PATIENT QUALIFIES FOR CHARITY. BELOW IS THE VERBIAGE FROM THIS POLICY: EXEMPT ASSETSTHE PRIMARY RESIDENCE ON UP TO ONE ACRE OF LAND, ONE AUTOMOBILE FOR EACH WORKING AGED ADULT, AND OTHER ASSETS, INCLUDING BUT NOT LIMITED TO, RETIREMENT FUNDS, INVESTMENTS AND OTHER FINANCIAL ASSETS, CASH VALUE OF LIFE INSURANCE POLICIES, AND EQUITY IN PROPERTY OR REAL ASSETS, TOTALING UP TO $25,000 ARE ALSO EXEMPT FROM CONSIDERATION AS ASSETS IN DETERMINING CHARITY CARE ELIGIBILITY. ANNUAL INCOME FROM PROPERTY OF REAL ASSETS WILL BE DEDUCTED FROM THE AMOUNT OF EQUITY IN THE ASSET WHEN CALCULATING THE EXEMPTION. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 15E: CAROMONT HEALTH HAS A TEAM DEDICATED TO EDUCATING AND/OR ASSISTING PATIENTS WITH OTHER STATE OR GOVERNMENT AGENCIES THAT MAY BE A SOURCE OF ASSISTANCE. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 16J: PLAIN LANGUAGE BROCHURES AT REGISTRATION SITES. PROACTIVELY COMMUNICATING VERBALLY OR IN WRITING TO SCHEDULED PATIENTS PRIOR TO SERVICE. COMMUNICATING IN-HOUSE, DURING SERVICE, OR AFTER SERVICE TO THOSE MOST LIKELY TO REQUIRE FINANCIAL ASSISTANCE. VERBIAGE IS ALSO ON THE PATIENT BILLING STATEMENTS. SPANISH INSTRUCTIONS ON WEBSITE FOR CHARITY CARE AND IN PERSON INTERPRETER STAFF AVAILABLE TO ASSIST. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 18E: COLLECTION ACTIONS ARE TAKEN AFTER REASONABLE EFFORTS HAVE BEEN MADE TO DETERMINE PATIENT'S ELIGIBILITY FOR ASSISTANCE. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 20E: PLAIN LANGUAGE BROCHURES AT REGISTRATION SITES. PROACTIVELY COMMUNICATING VERBIALLY AND/OR IN WRITING TO SCHEDULED PATIENTS PRIOR TO SERVICE. COMMUNICATING IN-HOUSE, DURING SERVICE, OR AFTER SERVICE TO THOSE MOST LIKELY TO QUALIFY FOR ASSISTANCE. PART V, SECTION B, LINE 16A THE PLAIN LANGUAGE SUMMARY AND CHARITY CARE APPLICATION CAN BE FOUND USING THE LINKS BELOW:PLAIN LANGUAGE SUMMARY: HTTP://WWW.CAROMONTHEALTH.ORG/DOCUMENTS/REGISTRATION_CHARITYCAREPOLICYCHARITY CARE APPLICATION: HTTP://WWW.CAROMONTHEALTH.ORG/DOCUMENTS/CHARITY-CARE-APPLICATION-ENGLISH PART I, LINE 3C: FREE CARE IS PROVIDED TO PATIENTS WITH A FPG OF 200% OR LESS. ALL OTHER PATIENTS RECEIVE AN INSURANCE DISCOUNT BASED ON THEIR INDIVIDUAL INSURANCE PLAN AGREEMENT OR AN UNINSURED DISCOUNT FOR SELF PAY PATIENTS. UNINSURED DISCOUNTS ARE COMPARABLE TO OUR INSURANCE DISCOUNTS.REGARDLESS OF INCOME, ASSETS ARE ALSO USED TO DETERMINE IF A PATIENT QUALIFIES FOR CHARITY. BELOW IS THE VERBIAGE FROM THIS POLICY:EXEMPT ASSETSTHE PRIMARY RESIDENCE ON UP TO ONE ACRE OF LAND, ONE AUTOMOBILE FOR EACH WORKING AGED ADULT, AND OTHER ASSETS UP TO $25,000 INCLUDING BUT NOT LIMITED TO, RETIREMENT FUNDS, INVESTMENTS AND OTHER FINANCIAL ASSETS, CASH VALUE OF LIFE INSURANCE POLICIES, AND EQUITY IN PROPERTY OR REAL ASSETS ARE ALSO EXEMPT FROM CONSIDERATION AS ASSETS IN DETERMINING CHARITY CARE ELIGIBILITY. ANNUAL INCOME FROM PROPERTY OF REAL ASSETS WILL BE DEDUCTED FROM THE AMOUNT OF EQUITY IN THE ASSET WHEN CALCULATING THE EXEMPTION.PART 1, LINE 6A:COMMUNITY BENEFIT REPORT: THE ORGANIZATION'S COMMUNITY BENEFIT REPORT MADE AVAILABLE TO THE PUBLIC CONTAINS COMMUNITY BENEFITS FOR ALL RELATED ORGANIZATIONS TO THE HOSPITAL. PART I, LINE 7: THE COSTING METHODOLOGY USED IS A COST ACCOUNTING SYSTEM. ALL PATIENT SEGMENTS ARE INCLUDED. THIS SYSTEM ASSIGNS DIRECT COSTS TO SUPPLIES, PROCEDURES, ROUTINE AND SPECIALTY ROOM RATES BASED ON THE DEPARTMENT OF ORIGINATION. FIXED COSTS ARE ALLOCATED BASED ON STATISTICAL BASIS. THESE COSTS ARE THEN AGGREGATED AT THE PATIENT LEVEL AND TABULATED BY PAYOR TYPE. NO COST TO CHARGE RATIOS WERE USED IN THE CALCULATIONS. PART I, LN 7 COL(F): 63,547,583 BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES PRIOR TO CALCULATING PERCENT OF TOTAL EXPENSE. PART I, LINE 7H: CAROMONT HEALTH IS INVOLVED IN APPROXIMATELY 40 RESEARCH STUDIES, APPROXIMATELY 55% OF WHICH ARE CLINICAL TRIALS COOPERATIVE GROUP PROGRAM STUDIES SPONSORED BY THE NATIONAL CANCER INSTITUTE (NCI). CAROMONT HEALTH ALSO PARTICIPATES IN DRUG AND DEVICE STUDIES SPONSORED BY VARIOUS PHARMACEUTICAL, BIOTECHNOLOGY, AND DEVICE COMPANIES, AS WELL AS UNFUNDED ONCOLOGY, NURSING AND PHARMACY RESEARCH STUDIES. PART II, COMMUNITY BUILDING ACTIVITIES: WORKFORCE DEVELOPMENT - CAROMONT HEALTH'S RECRUITMENT OF PHYSICIANS AND ADVANCED CARE PRACTITIONERS INTO THE FIVE COUNTIES THE SYSTEM SERVES IS DRIVEN BY THE CHANGING POPULATION OF THE REGION AND THE SPECIFIC HEALTH NEEDS OF PATIENTS. THE SYSTEM RECRUITS BASED ON A MEDICAL STAFF DEVELOPMENT PLAN THAT IDENTIFIES COMMUNITY HEALTH CARE NEEDS FOR THE NEXT FIVE YEARS. THE SYSTEM'S GOAL IS TO BE PRO-ACTIVE AND ANTICIPATORY SO THAT THE HEALTH CARE NEEDS OF THE COMMUNITY ARE MET IN A QUALITY-DRIVEN AND CONVENIENT MANNER. ADDITIONALLY, CAROMONT HEALTH OFFERS A FULL PROGRAM FOCUSED ON JOB COMPETENCY TRAINING AND PROFESSIONAL DEVELOPMENT OPPORTUNITIES FOR EMPLOYEES AT ALL LEVELS OF THE ORGANIZATION. PART III, LINE 2: CHARGES FOR SERVICES PROVIDED IN THE EMERGENCY DEPARTMENT ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING. CHARGES FOR SERVICES PROVIDED ELSEWHERE IN THE HOSPITAL ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING AND/OR APPLICATIONS FILED BY THE PATIENTS. IF NO MEANS TESTING IS DONE AND NO APPLICATION IS FILED, THE UNPAID AMOUNT IS WRITTEN-OFF TO BAD DEBT. THE % OF PATIENTS QUALIFYING FOR CHARITY IN THE EMERGENCY DEPARTMENT WAS APPLIED TO THE REMAINDER OF THE HOSPITAL TO DETERMINE THE % OF BAD DEBT PATIENTS WHO COULD HAVE BEEN CHARITY. PART III, LINE 2: CHARGES WRITTEN OFF TO BAD DEBT WERE TABULATED AT THE PATIENT LEVEL AND ARE REPORTED AT THE AMOUNT CHARGED TO PATIENTS. ACCOUNTS ARE RESERVED AS BAD DEBT BASED ON AN ACCOUNTS RECEIVABLE AGING METHODOLOGY. WHEN ACCOUNTS ARE SENT TO A COLLECTION AGENCY, THEY ARE WRITTEN OFF THE ACCOUNTS RECEIVABLE SYSTEM. ANY SUBSEQUENT COLLECTIONS ON THE ACCOUNTS ARE POSTED AS RECOVERIES AND REDUCE THE EXPENSE. ALL UNINSURED PATIENTS RECEIVE A DISCOUNT ON THEIR BILL, WHICH IS RECORDED AS A CONTRACTUAL ADJUSTMENT. THE AMOUNT OF THE UNINSURED DISCOUNTS ARE EXCLUDED FROM BAD DEBT EXPENSE. PART III, LINE 3: CHARGES FOR SERVICES PROVIDED IN THE EMERGENCY DEPARTMENT ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING. CHARGES FOR SERVICES PROVIDED ELSEWHERE IN THE HOSPITAL ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING AND/OR APPLICATIONS FILED BY THE PATIENTS. IF NO MEANS TESTING IS DONE AND NO APPLICATION IS FILED, THE UNPAID AMOUNT IS WRITTEN-OFF TO BAD DEBT. THE % OF PATIENTS QUALIFYING FOR CHARITY IN THE EMERGENCY DEPARTMENT WAS APPLIED TO THE REMAINDER OF THE HOSPITAL TO DETERMINE THE % OF BAD DEBT PATIENTS WHO COULD HAVE BEEN CHARITY. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE ON BAD DEBT EXPENSE. BAD DEBT EXPENSE IS REPORTED AS A DEDUCTION FROM PATIENT REVENUE. PART III, LINE 1: THE ORGANIZATION COMPLIES WITH THE REPORTING REQUIREMENTS OF GASB. STATEMENT NO. 15 IS NOT APPLICABLE. PART III, LINE 8: THE MEDICARE COST REPORT STANDARD COSTING METHODOLOGY WAS FOLLOWED WHEN FILING THE COST REPORT. THIS IS A STEP DOWN METHODOLOGY THAT APPLIES THE AVERAGE PATIENT COST TO MEDICARE PATIENTS. THE COST REPORT DOES NOT ALLOW HOSPITALS TO REPORT ALL OPERATING COSTS. BECAUSE OF THESE TWO ISSUES, THE MEDICARE COST REPORT METHODOLOGY UNDERSTATES THE TRUE COST OF TREATING MEDICARE PATIENTS. PART III, LINE 9B: THE POLICY CONTAINS PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. BELOW IS VERBIAGE FROM THE CHARITY POLICY:CAROMONT REGIONAL MEDICAL CENTER OFFERS MEDICAL SERVICES FREE OF CHARGE THROUGH THE CHARITY CARE PROGRAM. DETERMINATION OF CHARITY CARE WILL BE BASED ON THE PATIENT'S INCOME, FAMILY SIZE, AND ASSETS. POTENTIAL ELIGIBILITY EXISTS ONLY AFTER THE REIMBURSEMENT EFFORTS FROM ALL OTHER THIRD PARTY RESOURCES, FEDERAL, STATE, AND LOCAL ASSISTANCE PROGRAMS HAVE BEEN EXHAUSTED. PART VI, LINE 2: CAROMONT HEALTH ESTABLISHES COMMUNITY PRIORITIES THROUGH A NUMBER OF MECHANISMS:1. LEADERSHIP OPINIONS ARE SOUGHT TO HELP IDENTIFY NEEDED SERVICES IN THE COMMUNITY VIA PARTNERSHIPS WITH THE GASTON COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES, LOCAL NON-PROFIT ORGANIZATIONS FOCUSED ON HEALTH IMPROVEMENT IN OUR COMMUNITIES AND OTHER HEALTH-FOCUSED ENTITIES. CAROMONT HEALTH ALSO WORKS WITH COMMUNITY AGENCIES TO CONDUCT COMMUNITY NEEDS ASSESSMENTS AND QUALITY OF LIFE SURVEYS EVERY TWO TO THREE YEARS. 2. PATIENT SATISFACTION DATA IS ANALYZED TO DETERMINE WHERE AND/OR HOW SERVICES NEED TO BE IMPROVED.3. SERVICE AREA DATA (VITAL STATISTICS, DEMOGRAPHICS AND UTILIZATION) ARE ANALYZED FOR TRENDS. THIS INFORMATION IS COORDINATED WITH PUBLIC HEALTH DATA TO DETERMINE VOIDS AND SERVICE AREA HEALTH PROBLEMS.4. FINDINGS FROM COMMUNITY SURVEYS/REPORTS PUBLISHED BY OTHER ORGANIZATIONS (UNITED WAY, CHAMBER OF COMMERCE, PARTNERSHIP FOR CHILDREN, GASTON COUNTY GOVERNMENT, ETC.) ARE GATHERED AND REVIEWED FOR PERTINENCE TO COMMUNITY HEALTH PROBLEMS.5. BOARD MEMBERS, SENIOR LEADERS AND DEPARTMENT DIRECTORS ARE INVOLVED IN NUMEROUS ORGANIZATIONS IN THE COMMUNITY. THROUGH THIS NETWORK OF RELATIONSHIPS, INFORMATION ABOUT THE COMMUNITY AND THE NEEDS OF AREA RESIDENTS AND ORGANIZATIONS IS USED IN THE DEVELOPMENT OF PROGRAMS AND SERVICES AVAILABLE THOUGH CAROMONT HEALTH. PART VI, LINE 3: THE ORGANIZATION INFORMS AND EDUCATES THE PATIENTS ABOUT THEIR ELIGIBILITY FOR ASSISTANCE IN SEVERAL WAYS. A CHARITY AND FINANCIAL SUMMARY IS ON OUR WEBSITE, AND BROCHURES ARE DISTRIBUTED IN THE EMERGENCY ROOM AND ALL OTHER REGISTRATION SITES. SPECIFICALLY TRAINED STAFF (FINANCIAL COUNSELORS AND BENEFIT ELIGIBILITY SPECIALISTS) PROACTIVELY MAKE CONTACT WITH PATIENTS PRIOR TO, AT TIME OF SERVICE, AND/OR AFTER DISCHARGE TO DISCUSS ELIGIBILITY FOR MEDICAID AND OTHER INSURANCE BENEFITS AND OFFER ASSISTANCE WITH THE APPLICATIONS. THE COMMUNICATION IS ATTEMPTED AS SOON AS POSSIBLE. WRITTEN COMMUNICATION IS MADE PRIOR TO COLLECTION AGENCY PLACEMENT. PART VI, LINE 4: GASTON COUNTY, COVERING 355.9 SQUARE MILES IN THE SOUTHERN PORTION OF THE PIEDMONT REGION OF NORTH CAROLINA, IS THE ORGANIZATION'S PRIMARY MARKET. LINCOLN, CLEVELAND AND YORK COUNTY, AS WELL AS PARTS OF WESTERN MECKLENBURG COUNTY, MAKE UP THE HEALTH SYSTEM'S SECONDARY MARKET. ACCORDING TO THE U.S. CENSUS BUREAU, GASTON COUNTY HAD AN ESTIMATED POPULATION OF 224,529, A MEDIAN HOUSEHOLD INCOME OF $49,384 AND 14.2% OF PERSONS IN POVERTY. RACE AND ETHNIC DEMOGRAPHICS STATE THAT 77.6% OF THE POPULATION IDENTIFY THEMSELVES AS WHITE, 17.9% AS BLACK OR AFRICAN AMERICAN, 7.6% AS HISPANIC, 2.2% AS TWO OR MORE RACES AND 1.6% AS ASIAN. PART VI, LINE 5: COMMUNITY HEALTHCOMMUNITY HEALTH INITIATIVES ARE FOCUSED PRIMARILY ON DISEASE PREVENTION AND BETTER MANAGEMENT OF CHRONIC ILLNESSES. THAT INCLUDES WORKING WITH LOCAL EMPLOYERS ON INNOVATIVE PROGRAMS AND COLLABORATING WITH OUR HEALTH CARE NEIGHBORS, MANAGING ILLNESS WITHIN THE HEALTH SYSTEM'S WORKFORCE AND INTENSE FOCUS ON SUCCESSFUL CARE COORDINATION FOR PATIENTS WITH CHRONIC DISEASE. ADDITIONALLY, CAROMONT PROVIDES NEARLY $1 MILLION ANNUALLY IN SPONSORSHIP AND GRANT SUPPORT FOR LOCAL NON-PROFITS, COMMUNITY PROGRAMS AND SERVICES, AND OTHER COMMUNITY INITIATIVES AIMED AT IMPROVING THE HEALTH OF OUR COMMUNITY. THROUGH INNOVATION AND A FOCUS ON COMMUNITY WELLNESS, CAROMONT HEALTH IS DETERMINED TO MAKE POSITIVE IMPACT ON HEALTH AND WELLNESS OF THE POPULATIONS WE SERVE. PART VI, LINE 6: ESTABLISHED IN 1946, CAROMONT REGIONAL MEDICAL CENTER IS A 435-BED, NOT-FOR-PROFIT ACUTE CARE FACILITY OFFERING COMPREHENSIVE INPATIENT HOSPITAL SERVICES. CAROMONT REGIONAL MEDICAL CENTER IS THE ANCHOR OF CAROMONT HEALTH, A HEALTH CARE SYSTEM WITH FIVE AFFILIATE COMPANIES INCLUDING A NETWORK OF 55 PRIMARY AND SPECIALTY PHYSICIAN OFFICES.CAROMONT REGIONAL MEDICAL CENTER HAS 3 DIAGNOSTIC IMAGING CENTERS, A SAME-DAY SURGERY CENTER, AND 1 OFF-SITE EMERGENCY DEPARTMENT. CAROMONT HEALTH ALSO HAS A FREE-STANDING ENDOSCOPY CENTER, 1 AMBULATORY SURGERY CENTER, AND 1 OCCUPATIONAL MEDICINE CLINIC. PART VI, LINE 7, REPORTS FILED WITH STATES NC 1 GASTON COUNTY LEASE 128 WEST MAIN AVE GASTONIA NC 28052 566000300 GOVERNMENTAL 472987 COMMUNITY ASSISTANCE KINTEGRA HEALTH 991 WEST HUDSON BLVD GASTONIA NC 28052 581958398 501(C)(3) 262524 COMMUNITY ASSISTANCE GASTON COUNTY FAMILY YMCA 201 SOUTH CLAY STREET GASTONIA NC 28052 560655420 501(C)(3) 107500 COMMUNITY ASSISTANCE GASTON COUNTY SCHOOLS PO BOX 1397 GASTONIA NC 280531397 566001032 GOVERNMENTAL 75000 COMMUNITY ASSISTANCE GASTON REGIONAL CHAMBER 601 W FRANKLIN BLVD GASTONIA NC 28053 560232990 501(C)(6) 33000 COMMUNITY ASSISTANCE GASTON TOGETHER P O BOX 817 GASTONIA NC 28053 562048064 501(C)(3) 22000 COMMUNITY ASSISTANCE CITY OF MT HOLLY MUNICIPAL COMPLEX 400 EAST CENTRAL AVE MT HOLLY NC 28120 566001295 501(C)(3) 16000 COMMUNITY ASSISTANCE DOWNTOWN BELMONT DEVELOPMENT ASSOCIATION PO BOX 431 BELMONT NC 28012 474333734 501(C)(3) 15000 COMMUNITY ASSISTANCE MONTCROSS AREA CHAMBER OF COMMERCE PO BOX 368 BELMONT NC 28012 560710166 501(C)(3) 13000 COMMUNITY ASSISTANCE THE CATHERINE PHARR CARSTARPHEN PO BOX 1939 MCADENVILLE NC 28101 560623961 501(C)(3) 12500 COMMUNITY ASSISTANCE HEART SOCIETY OF GASTON COUNTY 1201 EAST GARRISON BLVD GASTONIA NC 28054 561330921 501(C)(3) 12000 COMMUNITY ASSISTANCE HOLY ANGELS INC 660 WILKINSON BLVD BELMONT NC 28012 561762654 501(C)(3) 10000 COMMUNITY ASSISTANCE UNITED WAY OF GASTON COUNTY 200 EAST FRANKLIN BLVD GASTONIA NC 28052 560653356 501(C)(3) 10000 COMMUNITY ASSISTANCE BOYS AND GIRLS CLUB OF GREATER GASTON PO BOX 23 GASTONIA NC 28053 561419498 501(C)(3) 8000 COMMUNITY ASSISTANCE GIRLS ON THE RUN OF GASTON COUNTY 190 S OAKLAND STREET GASTONIA NC 28052 474179257 501(C)(3) 7500 COMMUNITY ASSISTANCE CITY OF BESSEMER CITY 125 EAST VIRGINA AVE BESSEMER CITY NC 28016 566001177 GOVERNMENTAL 7000 COMMUNITY ASSISTANCE CANCER SERVICES OF GASTON COUNTY 306 SOUTH COLUMBIA ST GASTONIA NC 28054 561164253 501(C)(3) 5000 COMMUNITY ASSISTANCE CITY OF GASTONIA PO BOX 1748 GASTONIA NC 28053 566000227 GOVERNMENTAL 5000 COMMUNITY ASSISTANCE CITY OF LOWELL 101 WEST FIRST ST LOWELL NC 28098 GOVERNMENTAL 5000 COMMUNITY ASSISTANCE GASTON COUNTY EDUCATION FOUNDATION PO BOX 1397 GASTONIA NC 28053 561764830 501(C)(3) 5000 COMMUNITY ASSISTANCE 19 1 ONCOLOGY PHARMACY FUND 7 348 SCHOLARSHIPS 38 68298 PART I, LINE 2: OTHER ORGANIZATIONS THAT RECEIVE GRANT FUNDS MAY BE REQUIRED TO SUBMIT MONTHLY REPORTS THAT ARE MONITORED BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. ALL GRANTS DECISIONS ARE DOCUMENTED. SCHEDULE I, PART III THE PURPOSE OF THE GERTRUDE CLINTON HEALTH CAREERS SCHOLARSHIP IS TO ENCOURAGE MEDICAL AND HEALTH-RELATED PROFESSIONALS IN THE FIELD OF HUMAN SERVICES TO PRACTICE THEIR SPECIALTIES AT CAROMONT REGIONAL MEDICAL CENTER OR IN GASTON COUNTY. X X 1 0 X X X X X 0 1 0 0 0 1 1 0 0 DR PATRICK RUSSO PAST-CHIEF-OF-STAFF (NON-VOTING) 0 550856 0 102260 0 1295 0 19600 0 20608 0 694619 0 0 DR JAY HENDLER CHIEF-OF-STAFF ELECT (NON-VOTING) 0 426012 0 34238 0 3949 0 9800 0 19813 0 493812 0 0 K CHRISTOPHER PEEK CEO 657863 0 192930 0 7647 0 174008 0 20790 0 1053238 0 0 0 DAVID M O'CONNOR EVP/ASST. TREASURER 449942 0 101741 0 91339 0 106289 0 20768 0 770079 0 75414 0 LEIGH K HICKMAN CLO/ASST. SEC. 238796 0 28618 0 720 0 12366 0 13898 0 294398 0 0 0 KATHLEEN K BESSON EVP/COO 437101 0 99423 0 75188 0 129650 0 20763 0 762125 0 67556 0 TODD R DAVIS EVP CHIEF MEDICAL OFFICER 431578 0 98673 0 89117 0 100835 0 20762 0 740965 0 66915 0 GEORGE E ADCOCK III VP 299767 0 170087 0 2763 0 62603 0 20684 0 555904 0 0 0 SHADI HIJJAWI CHIEF MEDICAL INFO OFFICER 0 317855 0 21433 0 225 0 16536 0 19570 0 375619 0 0 RICHARD C BLACKBURN VP SUPPORT SERVICES 251660 0 54709 0 39748 0 50603 0 20678 0 417398 0 32783 0 SCOTT E WELLS VP PATIENT CARE SERVICES 267343 0 57961 0 44480 0 55370 0 12841 0 437995 0 36086 0 ROBIN L LANG VP INFORMATION SERVICES 275435 0 61931 0 625 0 64497 0 10242 0 412730 0 0 0 PART I, LINE 1A THE ORGANIZATION HAS A POLICY TO ADDRESS WHEN SPOUSAL TRAVEL IS PERMITTED AND PAYS CLUB DUES FOR THE PRESIDENT/CEO FOR BUSINESS PURPOSES AS PART OF THE EMPLOYMENT CONTRACT. PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS FROM THE FILING ORGANIZATION FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 86,689 KATHLEEN K. BESSON - 84,713 TODD DAVIS, MD - 84,067 K. CHRISTOPHER PEEK - 158,940 DR. G.E. WARD ADCOCK III- 46,463 SCOTT E. WELLS- 41,182 ROBIN LANG- 41,655 PART I, LINE 6 EXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES WHICH INCLUDE A FINANCIAL GOAL ATTRIBUTABLE TO OPERATING MARGIN. MANAGER INCENTIVE PLAN BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS. CERTAIN CAROMONT MEDICAL GROUP, INC. PHYSICIAN'S COMPENSATION PACKAGES ARE BASED ON THE INDIVIDUAL PHYSICIANS NET RESULTS FROM OPERATIONS AS CALCULATED BASED SOLELY ON HIS/HER NET CHARGES LESS HIS/HER ALLOCABLE SHARE OF CLINIC OVERHEAD COSTS. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2003-01-23 120000000 SEE PART VI 0 0 0 B NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2019-11-19 41460000 SEE PART VI 0 0 0 A 1700000 123594002 5150936 1256069 3386000 91583288 22217709 2005 0 1 1 1 B 5000 41460000 0 1 1 1 A 0 0 1 1 1 1 0.00150 0.00150 0 1 0.00110 0 1 B 0 0 0 0 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 MERRILL LYNCH CAPITAL SERVICES 31.600000000000 1 0 0 0 1 B 0 0 0 0 1 0 0 0 1 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: NORTH CAROLINA MEDICAL CARE COMMISSION DATE THE REBATE COMPUTATION WAS PERFORMED: 12/05/2017 SCHEDULE K SUPPLENTAL INFORMATION THREE 501(C)(3) ORGANIZATIONS WITHIN THE PARENT-SUBSIDIARY CONTROLLED GROUP BENEFIT FROM THE BONDS AS FOLLOWS: GASTON MEMORIAL HOSPITAL, INC. (56-0619359) CAROMONT HEALTH, INC. (58-1636959) CAROMONT HEALTH SERVICES, INC. (56-1455630) CAROMONT REGIONAL MEDICAL CENTER HOLDS THE LIABILITY FOR THE BONDS, PER AUDITED FINANCIAL STATEMENTS. SCHEDULE K, PART I, COLUMN (F); DESCRIPTION OF PURPOSE: ISSUE A - THE SYSTEM USED THE PROCEEDS FROM THESE BONDS FOR VARIOUS CAPITAL IMPROVEMENTS, INCLUDING, BUT NOT LIMITED TO, A NEW WOMEN'S CENTER AND PARKING DECK, RENOVATIONS TO EXISTING FACILITIES, AND EQUIPMENT. IN ADDITION, PROCEEDS WERE USED TO REFUND IN ADVANCE OF THEIR MATURITIES $17,000,000 IN PRINCIPAL AMOUNT OF THE SERIES 1998 HOSPITAL REVENUE BONDS. ISSUE B - ON NOVEMBER 19, 2019 THE BANK EXCHANGED THE 2018 TAXABLE BONDS FOR FIXED RATE TAX-EXEMPT BONDS (THE "2019 TAX-EXEMPT BONDS") ISSUED BY THE NCMCC. THIS EXCHANGE OF THE SERIES 2018 BONDS FOR THE SERIES 2019 TAX-EXEMPT BONDS CONSTITUTES A CURRENT REFUNDING OF THE SERIES 2018 BONDS AND PROVIDES CAROMONT WITH INCREMENTAL INTEREST COST SAVINGS. SCHEDULE K, PART II, LINE 3 COLUMN (A): LINE 3 COLUMN (A) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 3,594,002. SCHEDULE K, PART II, LINE 11; OTHER SPENT PROCEEDS: OTHER SPENT PROCEEDS INCLUDE DEPOSITS MADE INTO A REFUNDING ESCROW ACCOUNT ALONG WITH INTEREST EARNED ON THE ACCOUNT, BOTH OF WHICH WERE SUBSEQUENTLY USED TO PAY PRINCIPLE AND INTEREST ON THE REFUNDED BONDS. SEE THE RESPONSE FOR PART I, COLUMN (F) FOR DETAILS. GENA POMEROY FAMILY RELATIONSHIP WITH BOARD MEMBER 49410 COMPENSATION FOR EMPLOYEE SERVICES 0 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS CAROMONT HEALTH, INC., A NORTH CAROLINA NOT-FOR-PROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS CONSISTS OF FOURTEEN (14) MEMBERS, ALL OF WHOM ARE THE MEMBERS OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH, INC., AND ALL OF WHOM ARE APPOINTED BY THE BOARD OF DIRECTORS OF CAROMONT HEALTH. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING POWERS OF THE CORPORATION SHALL BE RESERVED TO CAROMONT HEALTH, INC., THE PARENT CORPORATION AND HOLDING COMPANY OF THE CORPORATION: (A) FINANCIAL POWERS, INCLUDING THE POWER TO APPROVE AN OPERATING BUDGET FOR THE CORPORATION, POWER TO APPROVE COMPENSATION PLANS, AND POWER TO ASSUME DEBT ON BEHALF OF THE CORPORATION; (B) GOVERNING POWERS, INCLUDING THE POWER TO APPROVE ALL CHANGES TO THE GOVERNING DOCUMENTS OF THE CORPORATION AND POWER TO APPROVE THE MISSION, VISION AND VALUES OF THE CORPORATION; AND (C) STRATEGIC POWERS, INCLUDING THE POWER TO APPROVE ALL CERTIFICATE OF NEED APPLICATIONS WHICH THE CORPORATION MAY FILE IN ANY STATE, AND THE POWER TO APPROVE ALL SALE OR LEASE TRANSACTIONS OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S FORM 990 WAS REVIEWED BY THE AUDIT FINANCE INVESTMENT COMMITTEE OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH PRIOR TO PRESENTATION TO THE FULL BOARD BEFORE THE FORM WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS OF THE BOARD OF DIRECTORS, MEMBERS OF SENIOR LEADERSHIP, ANY PHYSICIAN HOLDING A LEADERSHIP OR ADMINISTRATIVE POSITION WITHIN THE ORGANIZATION, DIRECTORS, RESEARCH STUDY PERSONNEL, MANAGERS AND ALL STAFF MEMBERS OF THE PURCHASING AND MARKETING DEPARTMENTS AND ANY OTHER DEPARTMENT DEEMED TO HAVE MATERIAL DECISION MAKING RESPONSIBILITIES ON BEHALF OF CAROMONT HEALTH SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE INDIVIDUAL'S OBLIGATION TO IMMEDIATELY MAKE THE CORPORATE RESPONSIBILITY OFFICER AWARE IN WRITING OF ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AS THEY MAY ARISE AND CONTAIN SAID INDIVIDUAL'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES ARE REVIEWED ANNUALLY BY THE CHIEF LEGAL OFFICER AND THE CORPORATE RESPONSIBILITY OFFICER. QUESTIONNAIRES SUBMITTED BY DIRECTORS ARE REVIEWED ANNUALLY BY THE NOMINATING COMMITTEE OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO, COO, CMO AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY CAROMONT REGIONAL MEDICAL CENTER, A SUBSIDIARY OF CAROMONT HEALTH, INC. THE COMPENSATION OF ALL CAROMONT EXECUTIVES FOR EACH YEAR IS ESTABLISHED BY THE COMPENSATION COMMITTEE OF THE CAROMONT HEALTH BOARD OF DIRECTORS, BASED ON GUIDANCE AND OPINIONS PROVIDED BY AN INDEPENDENT, THIRD-PARTY COMPENSATION CONSULTANT. PURSUANT TO THE COMMITTEE CHARTER FOR THE COMPENSATION COMMITTEE OF THE BOARD, THE BOARD OF DIRECTORS APPROVES THE EXECUTIVE COMPENSATION PHILOSOPHY, WHICH ESTABLISHES THE PARAMETERS FOR ALL EXECUTIVE COMPENSATION DECISIONS. THE BOARD OF DIRECTORS DELEGATES ALL COMPENSATION DECISIONS FOR ALL EXECUTIVES TO THE COMPENSATION COMMITTEE, PROVIDED SUCH DECISIONS ARE CONSISTENT WITH THE COMPENSATION PHILOSOPHY. BOARD APPROVAL MUST BE OBTAINED WHEN COMPENSATION DECISIONS DEVIATE FROM THE COMPENSATION PHILOSOPHY. A MAJORITY OF BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE ARE INDEPENDENT AND ALL ARE FREE FROM ANY CONFLICT OF INTEREST. ANY COMPENSATION COMMITTEE MEMBER WHO DEVELOPS A CONFLICT OF INTEREST DURING HIS/HER TERM WITH RESPECT TO THE DISCUSSION OF ANY EXECUTIVE'S COMPENSATION DOES NOT PARTICIPATE IN THE DISCUSSION OR DECISION-MAKING BY THE REMAINING MEMBERS OF THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE RETAINS JURISDICTION OVER THE TOTAL COMPENSATION PACKAGE FOR EXECUTIVES AND REVIEWS EXECUTIVE BENEFITS AND PERQUISITES AS WELL AS TOTAL CASH COMPENSATION. COMPENSATION FOR THE CEO IS ESTABLISHED THROUGH A PROCESS OF PERFORMANCE EVALUATION, COMPARISON WITH COMPARABLE MARKET DATA AND DETERMINATION BY THE COMPENSATION COMMITTEE OF ACCEPTABLE SALARY RANGE AND PERCENTILE RANKING. ALL COMPENSATION DECISIONS FOR THE CEO ARE APPROVED BY THE COMPENSATION COMMITTEE, AS LONG AS THE COMPENSATION DECISIONS ARE CONSISTENT WITH THE EXECUTIVE COMPENSATION PHILOSOPHY. THE PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVE MANAGEMENT UTILIZES COMPENSATION SURVEYS AND STUDIES. FULL COLLECTED COMPENSATION INFORMATION AND ANY COMPENSATION OPINIONS PROVIDED DURING THESE PROCESSES WILL BE KEPT WITH THE COMPENSATION COMMITTEE OR BOARD MINUTES, AS APPLICABLE. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 AT THIS TIME, THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE ENTIRE ORGANIZATION'S COMBINED FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G HOSPITALIST FEES: PROGRAM SERVICE EXPENSES 8,335,038. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,335,038. PHYSICIAN LEADERSHIP FEES: PROGRAM SERVICE EXPENSES 269,449. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 269,449. INTEGRATION & PERFORMANCE IMPROVEMENT FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 583,225. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 583,225. CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 28,041,906. MANAGEMENT AND GENERAL EXPENSES 2,139,613. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 30,181,519. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 7,742,020. MANAGEMENT AND GENERAL EXPENSES 514,612. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,256,632. PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 5,737,270. MANAGEMENT AND GENERAL EXPENSES 60,758. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,798,028. CTS BIOMED: PROGRAM SERVICE EXPENSES 1,276,826. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,276,826. CONSULTING FEES: PROGRAM SERVICE EXPENSES 139,172. MANAGEMENT AND GENERAL EXPENSES 1,382,362. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,521,534. LICENSE FEES: PROGRAM SERVICE EXPENSES 76,209. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 76,209. TAX EXEMPT BOND FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 291,952. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 291,952. FORM 990, PART XI, LINE 9: INTERCOMPANY TRANSFER FROM AFFILIATE -86,290,589. AUXILIARY NET ASSET ADJUSTMENT -1,610. PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM LAST YEAR. FORM 990, PART V AND PART VII COMMON PAYMASTER: THE FILING ORGANIZATION USES A RELATED ORGANIZATION FOR ITS PAYROLL FUNCTION. ALL W-2S ARE FILED BY THE COMMON PAYMASTER. HOWEVER, AMOUNTS PAID BY THE COMMON PAYMASTER ARE TREATED AS IF PAID DIRECTLY BY THE ORGANIZATION FOR WHICH SERVICES ARE PERFORMED. CAROMONT HEALTH INC 2525 COURT DRIVE GASTONIA NC 28054 581636959 MEDICAL SERVICES NC 501(C)(3) LINE 12C, III-FI N/A 0 CAROMONT HEALTH SERVICES INC 2526 COURT DRIVE GASTONIA NC 28054 561455630 OUTPATIENT SERVICES NC 501(C)(3) LINE 3 CAROMONT HEALTH INC 0 GASTON MEMORIAL HOSPITAL FOUNDATION INC 2527 COURT DRIVE GASTONIA NC 28054 561479699 FOUNDATION NC 501(C)(3) LINE 11 CAROMONT HEALTH INC 0 CAROMONT MEDICAL GROUP INC 2528 COURT DRIVE GASTONIA NC 28054 561479712 MEDICAL GROUP NC 501(C)(3) LINE 11 CAROMONT HEALTH INC 0 HOSPICE OF GASTON COUNTY INC 2529 COURT DRIVE GASTONIA NC 28054 581341530 HOSPICE CARE NC 501(C)(3) LINE 7 CAROMONT HEALTH INC 0 GASTON COUNTY PO BOX 1578 GASTONIA NC 280531578 566000300 GOVERNMENT ADMINISTRATION NC N/A 0 0 0 1 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1