2021-08-12T11:07:07-05:00 2020-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2019-10-01 581519911 HAMILTON MEDICAL CENTER INC HAMI 7062782105 PO BOX 1168 DALTON GA 307221168 JULIE A SOEKORO VP/CFO/ASST. TREASURER 7062782105 2021-08-11 1 AMY BIBBY P00445891 8282542254 2021-08-11 2019 2022-09-23 18:48:47Z JEFFREY D MYERS PO BOX 1168 DALTON GA 307221168 750674171 0 X HAMILTONHEALTH.COM X 1983 GA HAMILTON MEDICAL CENTER, INC. OPERATES A 282-BED, ACUTE CARE HOSPITAL, INCLUDING A 24-HOUR EMERGENCY ROOM IN DALTON, GA. DURING THE FISCAL YEAR ENDED 09/30/2018, THE MEDICAL CENTER HAD 46,313 PATIENT DAYS AND 233,322 OUTPATIENT VISITS. HAMILTON SERVES THE NEEDS OF AREA RESIDENTS WITHOUT DISCRIMINATION AND REGARDLESS OF ABILITY TO PAY. 9 8 1926 0 39215 -153383 3500000 18909461 280815332 280773621 13536251 20403354 7341508 7532906 305193091 327619342 0 0 0 0 135645251 140343982 0 0 0 127867468 140061395 263512719 280405377 41680372 47213965 712815461 787563678 245376761 269654665 467438700 517909013 AS AN AFFILIATE OF HAMILTON HEALTH CARE SYSTEM, HAMILTON MEDICAL CENTER, INC. SUPPORTS THE SYSTEM MISSION OF PROVIDING LEADERSHIP, PARTNERSHIPS AND SEAMLESS RESOURCE COORDINATION TO MEET HEALTH CARE NEEDS THAT ADVANCE THE QUALITY AND DIGNITY OF LIFE. 0 0 228170201 280773621 HAMILTON MEDICAL CENTER, INC. OPERATES A 255-BED, ACUTE CARE HOSPITAL, INCLUDING A 24-HOUR EMERGENCY ROOM, WHICH SERVES THE NEEDS OF RESIDENTS OF THE CITY OF DALTON, WHITFIELD COUNTY AND SURROUNDING AREAS OF NORTHWEST GEORGIA. DURING THE FISCAL YEAR ENDED 09/30/2020, THE MEDICAL CENTER HAD 45,193 PATIENT DAYS AND 216,874 OUTPATIENT VISITS. HAMILTON SERVES THE NEEDS OF AREA RESIDENTS WITHOUT DISCRIMINATION AND REGARDLESS OF ABILITY TO PAY. ACCORDINGLY, THE HOSPITAL PROVIDED $52,933,117 IN CHARITY CARE AT ESTABLISHED RATES TO PATIENTS UNABLE TO PAY FOR THEIR HEALTH CARE SERVICES THIS FISCAL YEAR. IN ADDITION, CAHRGES OF $580,009,926 WERE NOT COLLECTED DUE TO SHORTFALLS FROM MEDICARE AND MEDICAID. 228170201 1 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 224 0 1 1926 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 GA X JULIE A SOEKORO 7062782105 1200 MEMORIAL DRIVE DALTON GA 30720 ROBERT M CHANDLER CHAIRMAN 1.00 X X 0 0 0 ROBERT H BROOKER VICE CHAIRMAN 1.00 X X 0 0 0 ROBERT B HUBBS SECRETARY/TREASURER 1.00 X X 0 0 0 J DAVID GREGG TRUSTEE 1.00 X 0 0 0 AYMAN RIFAI MD TRUSTEE 1.00 X 0 0 0 W SCOTT SELLERS TRUSTEE 1.00 X 0 0 0 S CRAIG TIDWELL MD TRUSTEE 1.00 X 0 0 0 WALLACE R WEEKS MD TRUSTEE 1.00 X 0 0 0 JEFFREY D MYERS PRESIDENT/CEO 1.00 40.00 X X 0 1378962 119775 RANDALL F FOSTER ASSISTANT TREASURER 40.00 X 121690 156172 35270 JULIE A SOEKORO VP/CFO/ASST. TREASURER 1.00 40.00 X 0 61103 6500 ANDREW BLAND MD VP & CMO 40.00 1.00 X 525627 0 14904 CHRISTOPHER DELASHMITT MD VP & CMO 40.00 X 224366 0 11291 SANDRA D MCKENZIE VICE PRESIDENT 40.00 X 0 601763 62414 ALFRED D WRIGHT VICE PRESIDENT 40.00 X 293533 0 47586 CATHY L FERGUSON VICE PRESIDENT 40.00 X 404955 0 80251 STEPHEN G ROHN MD VP/PHYSICIAN 40.00 X 143330 617208 78408 ERNALDO ELEMENTO VICE PRESIDENT 40.00 X 321656 0 73922 MICHAEL HARTLEY MD PHYSICIAN 40.00 X 755340 0 53878 HECTOR DOURRON MD PHYSICIAN 40.00 X 632288 0 35690 LISA DUHAIME MD PHYSICIAN 40.00 X 562502 0 23690 JEFFREY GLASS MD PHYSICIAN 40.00 X 543388 0 10893 PAYMAN SABETGHADAM MD PHYSICIAN 40.00 X 491841 0 8043 JOSEPH L MCGUIRE FORMER VP/CFO/ASST. TREASURER 0.00 0.00 X 0 327168 33533 5020516 3142376 696048 12 1 1 0 BRASFIELD & GORRIE LLC PO BOX 11407 BIRMINGHAM AL 35246 GENERAL CONTRACTOR 10906482 TU PARKS CONSTRUCTION CO 711 E MAIN ST CHATTANOOGA TN 37408 GENERAL CONTRACTOR 6363381 CERNER HEALTH SERVICES INC PO BOX 40065 ATLANTA GA 31192 I.S. SOFTWARE, CONSULTING AND SUPPORT 6096136 DALTON ANESTHESIA ASSOCIATES PC PO BOX 789 DALTON GA 30722 PROFESSIONAL SERVICES 2325416 HEALTHCARE IT LEADERS LLC PO BOX 930816 ATLANTA GA 31193 I.S. CONSULTING AND SUPPORT 2288978 102 10867053 8042408 18909461 NET PATIENT SERVICE RE 900099 278246669 278246669 WELLNESS CENTER 713940 1431003 1431003 MANAGEMENT FEES 561000 1095949 1095949 280773621 6049569 6049569 3356720 0 3356720 3356720 3356720 437388611 20003 423054829 0 14333782 20003 14353785 14353785 VENDOR REBATES 900099 1450834 1450834 GIFT SHOP 453220 313327 313327 EDUCATION 611710 32203 32203 2379822 39215 2340607 4176186 327619342 280773621 39215 27897045 X 2035157 2035157 103348073 97751230 5596843 3180213 2949898 230315 25278527 23447821 1830706 6502012 6031127 470885 2978223 2978223 1202481 1202481 61930 61930 1432856 1432856 31596405 30421605 1174800 186087 186087 22095052 3506352 18588700 8501300 8501300 7562294 7562294 185710 185710 219863 219863 6090303 6090303 17816134 17816134 2573733 2573733 MEDICAL SUPPLIES 32250988 32250988 PROVIDER TAX 3171055 3171055 MISCELLANEOUS 2136981 2136981 280405377 228170201 52235176 0 10971747 42562598 3462199 9381334 28338922 26056891 16597633 16266608 4900864 7095330 10024561 9068870 521711928 252380051 242373116 269331877 331587777 331318241 16226150 15984171 48332492 60497758 712815461 787563678 38789806 68605960 205200737 199690884 1386218 1357821 245376761 269654665 X 467438700 517909013 467438700 517909013 712815461 787563678 X 47213965 17709357 -14453009 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 31785240 31785240 248362253 90960395 157401858 213858518 158668535 55189983 27705917 2751121 24954796 269331877 PROGRAM RELATED INVESTMENTS 60497758 C 60497758 ASSET RETIREMENT OBLIGATION 1357821 1357821 X PART X, LINE 2: THE ORGANIZATION HAS ADOPTED PROCEDURES FOR DETERMINING THE EXISTENCE OF UNCERTAIN TAX POSITIONS, AND THE RELATED TIMING AND AMOUNT OF THEIR IMPACT ON THE FINANCIAL STATEMENTS, AND DETERMINED THAT THERE ARE NO UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2020. 1 1 X 1 X 125.000000000000 1 X 1 1 1 0 1 1 12306950 2337971 9968979 0.03560 35685696 24234465 11451231 0.04080 47992646 26572436 21420210 0.07640 1059033 149 1058884 0.00380 9337806 7685224 1652582 0.00590 270525 270525 0.00100 10667364 7685373 2981991 0.01070 58660010 34257809 24402201 0.08710 1 17777612 4444403 63022222 78131775 -15109553 X 1 1 1 1 HAMILTON MEDICAL CENTER 1200 MEMORIAL DRIVE DALTON GA 30720 X X X HAMILTON MEDICAL CENTER 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X HTTPS://WWW.HAMILTONHEALTH.COM/ABOUT/CHNA-IMPLEMENTATION-STRATEGY/ X 1 18 1 HTTPS://WWW.HAMILTONHEALTH.COM/ABOUT/CHNA-IMPLEMENTATION-STRATEGY/ 0 1 X 125.000000000000 250.000000000000 X X X 1 1 X X X X 1 X HTTPS://WWW.HAMILTONHEALTH.COM/PATIENTS-VISITORS/PATIENT-RESOURCES/BILL-PAY X HTTPS://WWW.HAMILTONHEALTH.COM/PATIENTS-VISITORS/PATIENT-RESOURCES/BILL-PAY X HTTPS://WWW.HAMILTONHEALTH.COM/PATIENTS-VISITORS/PATIENT-RESOURCES/BILL-PAY X X X X X X 1 X 0 X X X X 1 X 0 0 HAMILTON MEDICAL CENTER PART V, SECTION B, LINE 11: HAMILTON MEDICAL CENTER, INC. IDENTIFIED THE TOP SIX AREAS TO FOCUS ON OUT OF ALL NEEDS IDENTIFIED BY THE ASSESSMENT. THESE SIX ARE CONSIDERED THE MOST SIGNIFICANT HEALTH NEEDS IN THE COMMUNITY AND WILL BE COVERED BY THE IMPACT INITIATIVES. OTHER HEALTH NEEDS IDENTIFIED IN THE ASSESSMENT BUT NOT DEEMED SIGNIFICANT MAY BE INDIRECTLY IMPACTED BY THE INITIATIVES, BUT RESOURSE CONSTRAINTS PREVENT THE NEEDS FROM BEING ADDRESSED DIRECTLY. HAMILTON MEDICAL CENTER PART V, SECTION B, LINE 16J: UPON CONSULTATION WITH THE FINANCIAL COUNSELORS, THE FINANCIAL ASSISTANCE POLICY IS PRESENTED AND EXPLAINED. ASSISTANCE IS ALSO OFFERED FOR COMPLETION OF THE APPLICATION FOR FINANCIAL ASSISTANCE. 9 1 - HAMILTON DIAGNOSTIC CENTER 1407 NORTH THORNTON AVENUE DALTON GA 30720 DIAGNOSTIC IMAGING, SLEEP DISORDERS 2 - HAMILTON SPECIALTY IMAGING 1436 BROADRICK DRIVE DALTON GA 30720 DIAGNOSTIC IMAGING 3 - HAMILTON WOUND CARE 1109 BURLEYSON ROAD DALTON GA 30720 WOUND CARE 4 - ENDOVASCULAR SURGERY PRACTICE 1109 BURLEYSON ROAD DALTON GA 30720 ENDOVASCULAR SERVICES 5 - HAMILTON CONVENIENT CARE 1012 BURLEYSON ROAD DALTON GA 30720 URGENT CARE CLINIC, FAMILY PRACTICE 6 - HAMILTON SPINE CENTER 1107 MEMORIAL DRIVE DALTON GA 30720 SPINE CARE CLINIC 7 - BRADLEY WELLNESS CENTER 1250 BROADRICK DRIVE DALTON GA 30720 FITNESS, CARIAC REHAB, PHYS./OCC. THERAPY 8 - NEPHROLOGY PRACTICE 1506 BROADRICK DRIVE DALTON GA 30720 NEPHROLOGY SERVICES 9 - DIABETES TREATMENT CENTER 1109 BURLEYSON ROAD DALTON GA 30720 DIABETES TREATMENT CENTER PART I, LINE 6A: HAMILTON MEDICAL CENTER ANNUAL COMMUNITY BENEFIT INFORMATION IS INCLUDED IN A SPECIAL SECTION OF HAMILTONHEALTH, A MAGAZINE PUBLISHED QUARTERLY BY HAMILTON HEALTH CARE SYSTEM (HHCS). HAMILTONHEALTH IS MADE AVAILABLE BY DIRECT MAIL TO HOUSEHOLDS IN THE PRIMARY SERVICE AREA; WAITING AREAS AROUND THE CAMPUS; IN WAITING AREAS OF PHYSICIAN OFFICES IN THE PRIMARY SERVICE AREA; AND ON THE HHCS WEBSITE, WWW.HAMILTONHEALTH.COM. PART I, LINE 7: COSTS FOR THE PURPOSE OF PART I, LINE 7 ARE COMPUTED USING A COST-TO-CHARGES RATIO. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES PRESENTED ON PART I, LINE 7 INCLUDE THE FOLLOWING DEPARTMENTS AND SERVICES: - HOME HEALTH SERVICES 1,164,918 - HOSPICE CARE 487,664 TOTAL TO PART I, LINE 7G, COL (E): $ 1,652,582 PART III, LINE 2: THE ORGANIZATION UTILIZES A COST TO CHARGE RATIO PART III, LINE 3: THE ORGANIZATION ESTIMATES THAT 25% OF THOSE REPORTED AS BAD DEBT WOULD QUALIFY FOR FINANCIAL ASSISTANCE IF THE INDIVIDUAL APPLIED FOR ASSISTANCE. PART III, LINE 4: HAMILTON MEDICAL CENTER PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THIRD-PARTY PAYORS ARE BILLED DIRECTLY AND THE PATIENT'S PORTION IS DETERMINED AND BILLED SUBSEQUENTLY. ACCOUNTS NOT MEETING CHARITY ASSISTANCE GUIDELINES AND UNPAID AFTER CERTAIN COLLECTION EFFORTS ARE CONSIDERED DELINQUENT AND WRITTEN OFF AS BAD DEBTS. THE COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT REPORTED ON LINES 2 AND 3 IS COST TO CHARGE RATIO. THE AUDITED FINANCIAL STATEMENT FOR HAMILTON HEALTH CARE SYSTEM, INC, WHICH INCLUDES HAMILTON MEDICAL CENTER, REPORTS THE PROVISION FOR DOUBTFUL ACCOUNTS AT ESTABLISHED RATES AND CONTAINS THE FOLLOWING FOOTNOTE: "IMPLICIT PRICE CONCESSIONS FOR UNINSURED AND UNDERINSURED PATIENTS THAT DO NOT QUALIFY FOR FINANCIAL ASSISTANCE ARE ESTIMATED BASED ON HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS USING A PORTFOLIO APPROACH AS A PRACTICAL EXPEDIENT. FOR UNINSURED AND UNDERINSURED PATIENTS THAT DO NOT QUALIFY FOR FINANCIAL ASSISTANCE, THE SYSTEM RECOGNIZES REVENUE ON THE BASIS OF ESTABLISHED RATES, DISCOUNTED ACCORDING TO POLICY FOR SERVICES RENDERED. HISTORICAL EXPERIENCE HAS SHOWN A SIGNIFICANT PROPORTION OF THE SYSTEM'S UNINSURED PATIENTS, IN ADDITION TO A GROWING PROPORTION OF THE SYSTEM'S INSURED PATIENTS, WILL BE UNABLE OR UNWILLING TO PAY FOR THEIR RESPONSIBLE AMOUNTS FOR THE SERVICES PROVIDED. IN ORDER TO ESTIMATE THE NET REALIZABLE VALUE OF THE REVENUES AND ACCOUNTS RECEIVABLE ASSOCIATED WITH THIRD-PARTY PAYORS AND UNINSURED PATIENTS, MANAGEMENT REGULARLY ASSESSES THEIR VALUATION BASED UPON BUSINESS AND ECONOMIC CONSIDERATIONS, TRENDS IN HEALTHCARE COVERAGE, HISTORICAL WRITE-OFF EXPERIENCE AND OTHER COLLECTION TRENDS."SINCE HAMILTON MEDICAL CENTER PROVIDES CARE REGARDLESS OF ABILITY TO PAY, A PORTION OF THE PROVISION FOR DOUBTFUL ACCOUNTS SHOULD BE INCLUDED IN COMMUNITY BENEFIT. PART III, LINE 8: HAMILTON MEDICAL CENTER BELIEVES THAT THE ENTIRE AMOUNT OF MEDICARE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT. IT IS LIKELY THAT MANY OF THE INDIVIDUALS WOULD QUALIFY FOR CHARITY CARE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS AND THE BURDENS OF GOVERNMENT ARE RELIEVED UPON ACCEPTANCE OF PAYMENT LESS THAN COST. THE AMOUNT REPORTED WAS DERIVED FROM A COST ACCOUNTING SYSTEM THAT INCLUDES ALL SERVICE LINES AND PAYORS. PART III, LINE 9B: HAMILTON MEDICAL CENTER'S COLLECTIONS POLICY CONTAINS PROVISIONS RELATED TO THE MEDICALLY INDIGENT. PATIENTS WHO STATE THAT THEY HAVE LIMITED RESOURCES OR AN INABILITY TO PAY ARE SCREENED FOR ELIGIBILITY FOR CHARITY ASSISTANCE UNDER THE MEDICAL CENTER'S POLICY. QUALIFYING PATIENTS' ACCOUNTS ARE PARTIALLY OR FULLY WRITTEN-OFF UNDER POLICY PROVISIONS. UPON DETERMINATION OF PATIENT RESPONSIBILITY, BALANCES NOT QUALIFYING FOR ASSISTANCE ARE SUBJECTED TO A COLLECTION CYCLE WITH REGULAR NOTICES AND STATEMENTS. IF PAYMENT ARRANGEMENTS HAVE NOT BEEN MADE UPON COMPLETION OF THE COLLECTION CYCLE, THE ACCOUNT IS WRITTEN-OFF AND REFERRED FOR EXTERNAL COLLECTION FOLLOW-UP. PART VI, LINE 2: HAMILTON MEDICAL CENTER, IN CONJUNCTION WITH HAMILTON HEALTH CARE SYSTEM AND OTHER AFFILIATES, WORKS CLOSELY WITH LOCAL GOVERNMENT AND NOT-FOR-PROFIT AGENCIES TO ASSESS AND MEET THE COMMUNITY NEEDS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE LATEST CHNA WAS COMPLETED BY HAMILTON MEDICAL CENTER IN 2018. IN ORDER TO ASSESS THE UNMET PHYSICIAN NEEDS OF WHITFIELD AND MURRAY COUNTIES, PHYSICIAN NEEDS ASSESSMENTS ARE PERIODICALLY CONDUCTED, MOST RECENTLY IN 2018. PART VI, LINE 3: HAMILTON MEDICAL CENTER PROVIDES CARE REGARDLESS OF ABILITY TO PAY. HMC EMPLOYS TWO FULL TIME FINANCIAL COUNSELORS WHO ARE RESPONSIBLE FOR EDUCATING PATIENTS AND RESPONSIBLE PARTIES OF POTENTIAL PAYMENT OPTIONS AS WELL AS THE ORGANIZATION'S FINANCIAL ASSISTANCE PROGRAM. THE FINANCIAL COUNSELORS ASSIST PATIENTS WITH THE COMPLETION OF THE FINANCIAL ASSISTANCE APPLICATION AND PROCESS THE APPLICATION FOR APPROVAL. HMC ALSO EMPLOYS THE SERVICES OF A MEDICAID ELIGIBILITY SERVICE TO ASSIST ELIGIBLE PATIENTS WITH OBTAINING MEDICAID COVERAGE. PART VI, LINE 4: HAMILTON MEDICAL CENTER'S PRIMARY SERVICE AREA CONSISTS OF WHITFIELD AND MURRAY COUNTIES IN NORTHWEST GEORGIA AND REPRESENTS 89% OF THE FACILITY'S VOLUME. THE SERVICE AREA HAS A POPULATION OF 142,212 CONSISTING OF 102,945 AND 39,267 IN WHITFIELD AND MURRAY COUNTIES, RESPECTIVELY. MINORITY POPULATIONS IN WHITFIELD COUNTY CONSIST OF HISPANIC (33%) AND AFRICAN AMERICAN (4%). APPROXIMATELY 19% OF THE POPULATION LIVE BELOW THE POVERTY LEVEL. MINORITY POPULATIONS IN MURRAY COUNTY CONSIST OF HISPANIC (14%) AND AFRICAN AMERICAN (1%). APPROXIMATELY 20% OF THE POPULATION LIVE BELOW THE POVERTY LEVEL. PART VI, LINE 5: HAMILTON MEDICAL CENTER (HMC), INCLUDING ITS RELATED AFFILIATES, IS ORGANIZED AND OPERATED FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. HMC SUPPORTS THIS MISSION WITH A COMMUNITY BOARD, OPEN MEDICAL STAFF AND AN EMERGENCY ROOM AVAILABLE TO PATIENTS REGARDLESS OF ABILITY TO PAY. THE BOARD IS COMPOSED OF CIVIC LEADERS AND PHYSICIANS WHO RESIDE IN THE HOSPITAL'S SERVICE AREA. THE BOARD SETS POLICY AND STRATEGIC DIRECTION AND DETERMINES THE USE OF SURPLUS FUNDS IN FURTHERANCE OF THE HOSPITAL'S CHARITABLE PURPOSE. PART VI, LINE 6: HAMILTON MEDICAL CENTER, INC. (HMC) IS A CONTROLLED AFFILIATE OF HAMILTON HEALTH CARE SYSTEM, INC. (SYSTEM), WHEREBY THE TRUSTEES AND OFFICERS ARE ELECTED AND APPOINTED BY THE BOARD OF TRUSTEES OF SYSTEM. OTHER CONTROLLED AFFILIATES INCLUDE: DALTON SENIOR HOUSING, INC. AND WHITFIELD PLACE, INC., PROVIDERS OF HOUSING TO LOW INCOME SENIORS AND HANDICAPPED INDIVIDUALS; HAMILTON EMERGENCY MEDICAL SERVICES, INC., WHICH OPERATES WHITFIELD EMERGENCY MEDICAL SERVICES; HLTC, INC., A LONG-TERM CARE SERVICES PROVIDER; MURRAY MEDICAL CENTER, INC.; ROYAL OAK COMMUNITY, LTD., A RETIREMENT COMMUNITY; AND WHITFIELD HEALTHCARE FOUNDATION, INC., A PHILANTHROPIC ORGANIZATION. HAMILTON AMBULATORY SURGERY CENTER, INC., A MULTI-SPECIALTY SURGERY CENTER, AND HAMILTON PHYSICIAN GROUP, INC., A MULTI-SPECIALTY ORGANIZATION OF PHYSICIAN PRACTICES, AND HAMILTON CHILDREN'S INSTITUTE ARE CONTROLLED AFFILIATES OF HMC. X X 1 1 X X X 0 1 0 0 0 0 0 0 0 JEFFREY D MYERS PRESIDENT/CEO 0 901149 0 308775 0 169038 0 52987 0 66788 0 1498737 0 38987 RANDALL F FOSTER ASSISTANT TREASURER 97447 113852 1000 18048 23243 24272 5782 5948 14079 9461 141551 171581 0 0 ANDREW BLAND MD VP & CMO 234402 0 60000 0 231225 0 0 0 14904 0 540531 0 0 0 CHRISTOPHER DELASHMITT MD VP & CMO 182022 0 31250 0 11094 0 0 0 11291 0 235657 0 0 0 SANDRA D MCKENZIE VICE PRESIDENT 0 364688 0 103179 0 133896 0 23884 0 38530 0 664177 0 9884 ALFRED D WRIGHT VICE PRESIDENT 176463 0 54813 0 62257 0 10409 0 37177 0 341119 0 0 0 CATHY L FERGUSON VICE PRESIDENT 248613 0 92558 0 63784 0 14605 0 65646 0 485206 0 1977 0 STEPHEN G ROHN MD VP/PHYSICIAN 143330 467334 0 106339 0 43535 16666 26069 11333 24340 171329 667617 16666 12069 ERNALDO ELEMENTO VICE PRESIDENT 184160 0 69741 0 67755 0 13660 0 60262 0 395578 0 0 0 MICHAEL HARTLEY MD PHYSICIAN 503777 0 231036 0 20527 0 27188 0 26690 0 809218 0 15154 0 HECTOR DOURRON MD PHYSICIAN 513646 0 91453 0 27189 0 14000 0 21690 0 667978 0 0 0 LISA DUHAIME MD PHYSICIAN 491485 0 752 0 70265 0 0 0 23690 0 586192 0 0 0 JEFFREY GLASS MD PHYSICIAN 496128 0 0 0 47260 0 0 0 10893 0 554281 0 0 0 PAYMAN SABETGHADAM MD PHYSICIAN 439922 0 32292 0 19627 0 0 0 8043 0 499884 0 0 0 JOSEPH L MCGUIRE FORMER VP/CFO/ASST. TREASURER 0 193982 0 0 0 133186 0 10073 0 23460 0 360701 0 101684 PART I, LINE 1A THE PERSONAL USE PORTION OF BOTH SPOUSAL TRAVEL AND SOCIAL CLUB DUES ARE INCLUDED IN THE RECIPIENTS TAXABLE WAGES. PART I, LINE 4B THE FOLLOWING PERSONS RECEIVED CURRENT YEAR DEFERRED COMPENSATION ACCRUALS FROM NON-QUALIFIED PLANS: - JEFFREY D. MYERS - $ 38,987 - SANDRA D. MCKENZIE - $ 9,884 - MICHAEL HARTLEY, MD - $ 15,154 - STEPHEN ROHN, MD - $ 28,735 - CATHY FERGUSON - $ 1,977 A DEVELOPMENT AUTHORITY OF THE CITY OF DALTON 581519911 235550FGO 2012-12-05 55334800 REFUND BONDS ISSUED 12/18/96, 04/01/98 & 09/04/03 0 0 0 B DEVELOPMENT AUTHORITY OF THE CITY OF DALTON 581519911 NONEAVAIL 2012-12-05 60200000 REFUND BONDS ISSUED 11/18/92 & 09/04/03, IMPROVEMENTS TO MEDICAL CENTER 0 0 0 C DALTON-WHITFIELD COUNTY JOINT DEVELOPMENT AUTHORITY 581519911 235641AM9 2017-12-21 90000000 ACQUIRE, CONSTRUCT, RENOVATE AND EQUIP HEALTHCARE FACILITIES 0 0 0 A 55334834 734527 54600306 2012 1 0 1 1 B 60203454 200700 20057259 34044631 2016 1 0 1 1 C 96823965 1260588 69534068 26029309 0 0 0 1 A 0 0 0 0 0.01500 0.01500 0 0 0 B 0 0 0 0 0.00610 0.00610 0 0 0 C 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 1 B 0 1 0 0 1 0 0 0 1 C 0 1 0 0 0 0 0 0 1 A 0 B 0 C 0 FORM 990, PART VI, SECTION A, LINE 7A THE REGULAR TRUSTEES OF THE ORGANIZATION ARE APPOINTED BY THE BOARD OF TRUSTEES OF HAMILTON HEALTH CARE SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7B CERTAIN CAPITAL EXPENDITURE AND CONTRACTUAL COMMITMENT DECISIONS MUST BE SUBSEQUENTLY APPROVED BY THE HAMILTON HEALTH CARE SYSTEM BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11B FOLLOWING MANAGEMENT PREPARATION AND REVIEW, THE FORM 990 IS REVIEWED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM. SUBSEQUENTLY, A DRAFT OF THE UNFILED FORM 990 IS POSTED TO A SECURE PAGE ON THE HAMILTON HEALTH CARE SYSTEM WEBSITE FOR REVIEW AND COMMENT BY ALL MEMBERS OF THE BOARD OF TRUSTEES PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CLEAR AND DETAILED CONFLICT OF INTEREST POLICY WHICH ESTABLISHES A PROCEDURE FOR IDENTIFYING, REVIEWING AND ADDRESSING CONFLICTS OF INTEREST. THIS POLICY ALSO REQUIRED EACH TRUSTEE AND OFFICER OF THE ORGANIZATION TO ANNUALLY SIGN A STATEMENT ACKNOWLEDGING RECEIPT OF THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 UNDER A BOARD RESOLUTION, THE ORGANIZATION'S COMPENSATION COMMITTEE HAS THE AUTHORITY TO TAKE ACTION ON BEHALF OF THE BOARD WITH RESPECT TO THE COMPENSATION OF OFFICERS AND KEY EMPLOYEES. THE COMPENSATION COMMITTEE MAINTAINS MINUTES OF ITS PROCEDURES. ON AN ANNUAL BASIS THE COMPENSATION COMMITTEE WILL MEET TO SET THE ANNUAL COMPENSATION OF THE PRESIDENT/CEO. THIS ACTION IS BASED ON CONSULTATION WITH A THRID PARTY CONSULTING FIRM TO REVIEW THE TOTAL COMPENSATION OF THE CEO AND KEY EMPLOYEES SUCH THAT TOTAL COMPENSATION PACKAGES ARE CONSIDERED FAIR MARKET AND NOT EXCESSIVE. 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 OTHER: PROGRAM SERVICE EXPENSES 30,421,605. MANAGEMENT AND GENERAL EXPENSES 1,174,800. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 31,596,405. FORM 990, PART XI, LINE 9: CHANGE IN LIABILITY CLAIMS ACCRUAL 1,027,515. TRANSFER OF INVESTMENT FROM LIABILITY CLAIMS TRUST -877,201. DISTRIBUTION TO RELATED ENTITY (HPG) -14,603,323. HAMILTON HEALTH CARE SYSTEM INC PO BOX 1168 DALTON GA 30722 581519913 SUPPORT RELATED ENTITIES GA 501(C)(3) LINE 12B, II N/A 0 DALTON SENIOR HOUSING INC 519 WEST HAWTHORNE STREET DALTON GA 30720 581518011 LOW-INCOME HOUSING GA 501(C)(3) LINE 10 HAMILTON HEALTH CARE SYSTEM INC 0 HAMILTON AMBULATORY SURGERY CENTER INC PO BOX 1168 DALTON GA 30722 582654791 SURGICAL SERVICES GA 501(C)(3) LINE 3 HAMILTON MEDICAL CENTER INC 1 HAMILTON EMERGENCY MEDICAL SERVICES INC PO BOX 1168 DALTON GA 30722 581651002 EMERGENCY MEDICAL GA 501(C)(3) LINE 10 HAMILTON HEALTH CARE SYSTEM INC 0 HAMILTON PHYSICIAN GROUP INC PO BOX 1168 DALTON GA 30722 271198701 PHYSICIAN PRACTICE GA 501(C)(3) LINE 3 HAMILTON MEDICAL CENTER INC 1 HLTC INC PO BOX 1168 DALTON GA 30722 582341574 LONG TERM ELDERLY CARE GA 501(C)(3) LINE 10 HAMILTON HEALTH CARE SYSTEM INC 0 MURRAY MEDICAL CENTER INC PO BOX 1406 CHATSWORTH GA 30705 582373427 HOSPITAL CARE / SERVICES GA 501(C)(3) LINE 3 HAMILTON HEALTH CARE SYSTEM INC 0 ROYAL OAK COMMUNITY LTD PO BOX 1900 DALTON GA 30722 581970228 SENIOR LIVING SERVICES GA 501(C)(3) LINE 10 HAMILTON HEALTH CARE SYSTEM INC 0 WHITFIELD PLACE INC PO BOX 1168 DALTON GA 30722 582103085 LOW-INCOME HOUSING GA 501(C)(3) LINE 10 HAMILTON HEALTH CARE SYSTEM INC 0 DALTON-WHITFIELD COUNTY HOSPITAL LIABILITY TRUST PO BOX 1168 DALTON GA 30722 581331514 LIABILITY CLAIMS COVERAGE GA 501(C)(3) LINE 12C, III-FI HAMILTON HEALTH CARE SYSTEM INC 0 DALTON-WHITFIELD ADDITIONAL TRUST PO BOX 1168 DALTON GA 30722 586345013 FUNDS FOR INDIGENT CARE GA 501(C)(3) LINE 12C, III-FI N/A 0 DALTON-WHITFIELD INDIGENT CARE TRUST PO BOX 1168 DALTON GA 30722 586345011 FUNDS FOR INDIGENT CARE GA 501(C)(3) LINE 12C, III-FI N/A 0 WHITFIELD HEALTHCARE FOUNDATION INC PO BOX 1900 DALTON GA 30722 510175056 FUNDS FOR HEALTHCARE GA 501(C)(3) LINE 12B, II HAMILTON HEALTH CARE SYSTEM INC 0 HAMILTON CHILDREN'S INSTITUTE INC PO BOX 1168 DALTON GA 30722 823312912 PEDIATRIC DEVELOPMENTAL/BEHAVIORAL TREATMENT GA 501(C)(3) LINE 10 HAMILTON HEALTH CARE SYSTEM INC 0 HAMILTON HEALTH FIRST INC PO BOX 1168 DALTON GA 30722 581694713 PREFERRED PROVIDER GA N/A C 0 1 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 1 HAMILTON AMBULATORY SURGERY CENTER INC A 686496 FMV HAMILTON AMBULATORY SURGERY CENTER INC O 2176971 FMV HAMILTON AMBULATORY SURGERY CENTER INC P 239490 FMV HAMILTON AMBULATORY SURGERY CENTER INC Q 946604 FMV HAMILTON PHYSICIAN GROUP INC D 11638808 INCR. 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