2019-08-12T13:22:09-05:00 2018-09-30 010494526 Baker Newman & Noyes PO Box 507 Portland ME 04112 990 2017-10-01 020222131 Frisbie Memorial Hospital FRIS 6033325211 11 Whitehall Rd Rochester NH 03867 James Hutchinson Interim CFO 6033325211 2019-08-09 1 Nicholas E Porto P01310283 2078792100 2019-08-09 208.105.168.164 2019-08-09 10:33:33 ED P 3452BD8595D9AC820B41F271E29CE8BF50AD3EDC 86AD5A998A217BD7885303F5109AB5202568ED7D 2017 2019-02-21 02:37:17Z Jocelyn Caple MD 11 Whitehall Rd Rochester NH 03867 158901589 0 X www.frisbiehospital.com X 1941 NH To excel at caring for the community. 12 11 1231 134 638629 88566 187397 478413 147306971 152557888 2167515 2470869 -666763 1287648 148995120 156794818 219240 198967 0 0 87123256 87276240 0 0 143218 82870094 85378683 170212590 172853890 -21217470 -16059072 131957524 114107159 68412836 67651648 63544688 46455511 X To excel at caring for the community by providing safe, effective, equitable, timely healthcare services. We will ally ourselves with other community healthcare providers to enhance our mutual ability to improve the health of our community, and the quality of life for the people we serve. 0 0 135756862 198967 151919259 Frisbie Memorial Hospital is a nonprofit community hospital that continuously evaluates and addresses the comprehensive healthcare needs of Rochester, NH and the surrounding communities. In response to these healthcare needs, the hospital coordinates, develops, and provides high-quality, affordable, preventative, educational, acute, and chronic care services. In fiscal year ending September 30, 2018, 27,103 patients were treated in our emergency department, 14,660 ambulance calls were made, 3,126 inpatients were cared for, and surgeries on 7,303 patients were performed. Additionally, 314 newborns were welcomed into the world, 25,762 radiology procedures/tests provided, 65,976 rehabilitative treatments were provided, 421,288 laboratory tests were performed, and 4,131 oncology patients were treated. 6763668 Frisbie Memorial Hospital provided uncompensated care for those in need. Frisbie ranks among the top in New Hampshire for the money value of charity care provided to patients. 549619 Frisbie Memorial Hospital presented or sponsored numerous community programs which assisted with the special needs of our most vulnerable at risk population groups. These programs improved education and health awareness in the community, and provided greater access to health services. 143070149 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 54 0 1 1231 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 1 0 NH X James Hutchinson 6033325211 11 Whitehall Rd Rochester NH 03867 X John Britton MD Trustee 2.00 0.00 X 0 0 0 Mark Farrell Trustee 2.00 0.00 X 0 0 0 John Hall Trustee 2.00 0.00 X 0 0 0 Frank Jones Trustee 2.00 0.00 X 0 0 0 Ron Poulin Trustee 3.00 2.00 X 0 0 0 Julie Reynolds Trustee 2.00 0.00 X 0 0 0 Lisa Stanley Trustee 2.00 2.00 X 0 0 0 Brian Szymanski MD Trustee 2.00 0.00 X 0 0 0 Brian Hughes Chairman, Trustee 3.00 3.00 X X 0 0 0 James Jalbert Vice Chairman, Trustee 3.00 3.00 X X 0 0 0 TJ Jean Vice Chairman, Trustee (part year) 3.00 2.00 X X 0 0 0 William Cormier Secretary, Trustee 3.00 3.00 X X 0 0 0 Jeanette Poulin Treasurer, Trustee 3.00 0.00 X X 0 0 0 John Marzinsik President & CEO (end 2/18) 40.00 5.00 X 438984 0 30489 Jocelyn Caple MD President & CEO (start 2/18) 40.00 5.00 X 257954 0 26401 Robert Cochrane VP Finance, CFO 40.00 5.00 X 250529 0 17461 Christi Green VP Human Resources 40.00 0.00 X 187748 0 11088 Paula Mahoney VP Physician Practices 40.00 0.00 X 232032 0 47039 Joseph Shields Senior VP 40.00 0.00 X 235977 0 29997 Trevor Eide MD Physician 40.00 0.00 X 574915 0 18302 John Freese MD Physician 40.00 0.00 X 521659 0 23190 Mathurin Malby MD Physician 40.00 0.00 X 436810 0 35937 Michael Metzger MD Physician 40.00 0.00 X 397625 0 34930 Michael Southworth MD Physician 40.00 0.00 X 456005 0 27211 3990238 0 302045 119 0 1 1 HealthNET Systems Consulting 20 Burlington Mall Road Burlington MA 01803 IT Consulting 3179022 Crothall Healthcare 13028 Collections Center Drive Chicago IL 60693 Facilities Management 3139263 Unidine Corporation PO Box 360639 Pittsburgh PA 152516639 Dietary Services 1891623 Surgical Associates of Rochester 21 Whitehall Road Suite 3 Rochester NH 03867 Physician Practice 1683465 Navin Haffty & Associates LLC 1900 West Park Drive Suite 180 Westborough MA 01581 IT Consulting 852818 17 478413 478413 Net Patient Service Revenue 621110 142204189 142204189 Disproportionate Share Funding 621110 5601861 5601861 Miscellaneous Revenue 621110 4162223 3523594 638629 Cafeteria 561000 589615 589615 152557888 594370 594370 3983270 2106771 1876499 1876499 1876499 Equity Earnings in Benevera, LLC 523000 939661 939661 Equity Earnings in Affiliates 523000 347987 347987 1287648 156794818 151919259 638629 3758517 X 164973 164973 33994 33994 2654023 419072 2234951 65713619 53734008 11877147 102464 1171181 928070 241354 1757 13407886 10619829 2767964 20093 4329531 3434510 888527 6494 366359 366359 118121 118121 79204 79204 20569848 13785305 6773391 11152 160282 160282 1940312 1103559 835498 1255 7393019 5555918 1837101 73884 72181 1700 3 1293571 1293571 7755163 7755163 1890381 929680 960701 Supplies 22684742 22222802 461940 Bad Debt Expense 11099338 11099338 NH Medicaid Enhancement 6870549 6870549 UBIT Expense 4434 4434 3079476 3043193 36283 172853890 143070149 29640523 143218 1209842 732064 1991593 1813338 24784938 16624306 4040135 3449405 1326575 797321 160258369 98995350 67617399 61263019 11243311 8584835 12843120 13122247 6900611 7720624 131957524 114107159 19385785 21131279 21587470 21616486 12048933 9859128 4995000 3915000 10395648 11129755 68412836 67651648 X 61024294 43498277 603702 1040542 1916692 1916692 63544688 46455511 131957524 114107159 -16059072 -1030105 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 21841 21841 0 Part II-B, Line 1: The Hospital pays dues to various professional and healthcare associations, a portion of which is attributable to lobbying expenses. The below detail provides additional disclosures and information regarding the Hospital's dues and associated lobbying costs. Organization: American Hospital Association Total Dues Paid: $25,530 Portion Expended for Lobbying Purposes: $5,803 Organization: New Hampshire Hospital Association Total Dues Paid: $85,792 Portion Expended for Lobbying Purposes: $16,038 17792984 206456 1327943 4600638 79205 14647540 31526165 100889 2877676 16587188 124558 17792984 29464678 2195487 134000 31526165 34288142 -4823464 29464678 31227443 3323272 262573 34288142 0.80540 0.19460 0.00000 1 0 181776 181776 88595109 49880174 38714935 1498988 1119962 379026 68077890 46586521 21491369 1904606 1408693 495913 61263019 Corporate Bonds 5181545 F Assets Held in Employee Benefit Plans 7940702 F 13122247 DSH Revenue Receivable 1400465 Malpractice Claims Receivable 2011090 Other Assets 517327 Investment in Yankee Alliance, LLC 5000 Investment in Benevera Health, LLC 433383 Cash Surrender Value, Life Insurance 438201 Investment in Strafford Health Alliance 2915158 7720624 Estimated Third Party Payor Settlements 34671 Due to Affiliates 417865 Malpractice Liability Claims Payable 2361090 Accrued Pension 8316129 11129755 X 155681077 -1030103 -1030103 156711180 79204 4434 83638 156794818 172770252 0 172770252 79204 4434 83638 172853890 Part V, Line 4: The Hospital's endowment funds are to be used in furtherance of the Hospital's charitable mission. Part X, Line 2: The Hospital and the Foundation are not-for-profit organizations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Hospital and Foundation's tax positions and concluded the Hospital and Foundation have maintained their tax-exempt status, do not have any significant unrelated business income and have taken no uncertain tax positions that require adjustment to the consolidated financial statements. Part XI, Line 4b - Other Adjustments: Unrelated Business Income Tax 4,434. Part XII, Line 4b - Other Adjustments: Unrelated Business Income Tax 4,434. 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 1086250 1086250 0.00670 26168479 20763751 5404728 0.03340 27254729 20763751 6490978 0.04010 1904261 70789 1833472 0.01130 51421585 24654569 26767016 0.16550 53325846 24725358 28600488 0.17680 80580575 45489109 35091466 0.21690 129445 129445 0.00080 129445 129445 0.00080 1 4495218 0 24827306 41109196 -16281890 X 1 1 1 1 Frisbie Memorial Hospital 11 Whitehall Road Rochester NH 03867 www.frisbiehospital.com 00028 X X X Geropsychiatric Unit Frisbie Memorial Hospital 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X Please see Part V, Section C X 1 16 1 Please see Part V, Section C 1 0 1 X 300.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X Please see Part V, Section C X Please see Part V, Section C X Please see Part V, Section C X X X X X X 1 X 0 X X X X X 1 X 0 0 Frisbie Memorial Hospital Part V, Section B, Line 5: Members of the committee were chosen based on their knowledge of local healthcare. Crescendo Consulting Group, LLC was also brought in to assist in the completion of the CHNA. Please see page 6 of the Hospital's 2015 CHNA for a detailed list of community members.Released after the fiscal year covered by this tax return, the Hospital issued a new CHNA in January of 2019. Information related to the new CHNA will be more thoroughly detailed in the Hospital's tax filing for fiscal year ending September 30, 2019 (its 2018 Form 990 and Schedule H filing). Frisbie Memorial Hospital Part V, Section B, Line 11: Please see the attached Community Health Needs Assessment and Action Plan for how Frisbie Memorial Hospital is addressing the significant needs identified in its most recently conducted CHNA. Frisbie Memorial Hospital Part V, Section B, Line 20e: Frisbie Memorial Hospital notified individuals of the financial assistance policy during the admissions process, prior to and during the patient discharge process, and in communications with the individuals when discussing the individuals' medical bills. Frisbie Memorial Hospital also documented its determination of whether individuals were eligible for financial assistance under the hospital's financial assistance policy. Schedule H, Part V, Section B, Line 7a & 10a: The CHNA is available at the Hospital facility's website:https://mk0frisbiec1qb6hmg3m.kinstacdn.com/wp-content/uploads/2018/06/Financial-Assistance-Application-6_18.pdfAdditionally, the Hospital's new CHNA, released in January of 2019 for the 2018 tax year is available on the Hospital's website at:https://mk0frisbiec1qb6hmg3m.kinstacdn.com/wp-content/uploads/2019/05/Community-Assessment-Report-Frisbie-Memorial-Hospital-FINAL.pdfImplementation Strategy:https://mk0frisbiec1qb6hmg3m.kinstacdn.com/wp-content/uploads/2018/04/CHNA-Implementation-Plan.pdf Schedule H, Part V, Section B, Line 16a-c: The Hospital's Financial Assistance Policy, Application, and Plain Language Summary can be found online at:Financial Assistance Policy:https://mk0frisbiec1qb6hmg3m.kinstacdn.com/wp-content/uploads/2019/04/Frisbie-Memorial-Hospital-FAP-eff-4119.pdf Financial Assistance Application: https://mk0frisbiec1qb6hmg3m.kinstacdn.com/wp-content/uploads/2018/06/Financial-Assistance-Application-6_18.pdf Plain Language Summary:https://mk0frisbiec1qb6hmg3m.kinstacdn.com/wp-content/uploads/2018/08/Plain-Language-Summary.pdf 20 1 - Rochester Obstetrics & Gynecology 21 Whitehall Road Rochester NH 03867 Outpatient obstetrical and gynecological services 2 - Rochester Hill Family Practice 245 Rochester Hill Road Rochester NH 03867 Preventative Health Services 3 - Skyhaven Internal Medicine 6 Healthcare Drive Rochester NH 03867 Outpatient Primary Healthcare Services 4 - White Mountain Med Ctr Primary Care 2531 White MTN Highway Sanbornville NH 03872 Outpatient primary care services 5 - Rochester Pediatric Associates 245 Rochester Hill Road Rochester NH 03867 Outpatient and Inpatient pediatric medical care 6 - Family Care of Farmington 316 NH Route 11 Farmington NH 03835 Preventative Healthcare Services 7 - Strafford Cardiology 21 Whitehall Road Rochester NH 03867 Outpatient and Inpattient Cardiology services 8 - Barrington Family Practice 426 Calef Highway Barrington NH 03825 Physician Family Practice 9 - Rochester Vascular Surgery 6 Healthcare Drive Rochester NH 03867 Outpatient vascular disease services 10 - Family Care of Somersworth 245 Rochester Hill Road Rochester NH 03867 Preventative Health Services 11 - Rochester Pulmonary Medicine 21 Whitehall Road Rochester NH 03867 Outpatient and inpatient respiratory illness care 12 - Diabetes and Endocrine Center 245 Rochester Hill Road Rochester NH 03867 Outpatient Diabetes Treatment Center 13 - Sanford Medical Associates 272 Cottage Street Sanford ME 04073 Outpatient and inpatient general surgery 14 - Barrington Walk-In-Care 426 Calef Highway Barrington NH 03825 Walk-In Clinic 15 - Rochester Rheumatology 21 Whitehall Road Rochester NH 03867 Outpatient treatment of rhematic and autoimmune diseases 16 - Rochester Infectious Disease 21 Whitehall Road Rochester NH 03867 Outpatient care for patients with infectious disease 17 - Seacoast Business & Health Clinic 11 Whitehall Road Rochester NH 03867 Occupational Health 18 - Skyhaven Surgery Center LLC 11 Whitehall Road Rochester NH 03867 Ambulatory Surgery 19 - Granite State Lab LLC 11 Whitehall Road Rochester NH 03867 Laboratory Services 20 - Granite State Express LLC 11 Whitehall Road Rochester NH 03867 Express Care Part I, Line 7: The instructions for Form 990, Schedule H, contain a template (titled "Worksheet 2") that may be used to determine an overall Cost to Charge Ratio. This ratio may be applied to the charges listed throughout the Schedule H in order to calculate their associated costs. Where applicable, the Hospital has utilized Worksheet 2 for various calculations. The Hospital utilized Worksheet 2 for all calculations on Part 1, Line 7, except for the following specific instances:Schedule H, Worksheet 6 - Subsidized Health Services (the supporting worksheet for Part I, Line 7g). The Hospital did not utilize Worksheet 2 to determine the profit or loss for each of the hospital clinical services or hospital-owned physician practices. Instead, when compiling the subsidized hospital clinical services and hospital-own physician practices listed in 1c below, the Hospital utilized the actual estimated costs on the modified Medicare cost report. Part I, Line 7g: Frisbie Hospital has several hospital clinical services and hospital-owned physician practices. Per the instructions for IRS Form 990, Schedule H, Worksheet 6, organizations may include any applicable physician practice that the Hospital subsidizes or operates at a loss, including service areas such as the Hospital's inpatient psychiatric unit, in completing Schedule H. Therefore, the Hospital has included the following hospital clinical services and hospital-owned physician practices that subsidizes or operates at a loss, and the associated costs of these practices:a. Inpatient Psychiatric unitb. Outpatient Psychiatric Servicesc. Oncologyd. Family Care of Somersworthe. Barrington Family Practicef. Rochester Pulmonary Medicineg. Internal Medicineh. Rheumatologyi. Rochester Infectous Diseasej. Rochester Vascular Surgeryk. Diabetes Servicesl. Strafford Cardiologym. Rochester Pediatricsn. Barrington Walk-In Clinico. OB/GYN Servicesp. White Mountain Medical q. Wound Care Clinicr. Emergency Room Servicess. Sanford Medical Servicest. Ambulance ServicesThe above listed hospital clinical services and hospital-owned physician practices have a community benefit, otherwise categorized as an aggregate loss or subsidy from the Hospital, of approximately $26.77 million. The community benefit figure does not take into account bad debts, charity care, or contractual adjustments. Thus, this community benefit of approximately $26.77 million is a conservative figure that reconciles to the community benefit reported on IRS Form 990, Schedule H, Part I, Line 7g, Column e. Part I, Ln 7 Col(f): The Bad Debt expense is included on Form 990, Part IX, Line 25(A). The $11,099,338 that is included on Form 990, Part IX, Line 25(A) is also subtracted for purposes of calculating the percentage in this column (please see the attached financial statements, page 28). Part II, Community Building Activities: Please see narrative for Part VI, Line 5. Part III, Line 2: The Hospital utilized Worksheet 2 from the IRS Schedule H instructions and guidance to determine the ratio of patient care to cost to charge (40.50% for fiscal year 2018), and multiplied this ratio by the Hospital's total bad debt expense of $11,099,338 to determine the Part II, Line 2 bad debt expense of $4,495,218. Part III, Line 3: Frisbie Memorial Hospital estimates this percentage based upon historical data. This amount is reported at cost, and is not reported as a community benefit within Part 1, Line 7. Part III, Line 4: Please see Footnote 2, "Accounts Receivable and the Allowance for Doubtful Accounts" on page 10 of the attached audited financial statements. Part III, Line 8: Form 990, Schedule H instructions and guidance contain a template (Worksheet 2) that may be used to determine the overall cost to charge ratio that could be applied throughout Schedule H in order to convert charges to cost. Where applicable, the Hospital has utilized Worksheet 2 for various calculations. The only areas where Worksheet 2 was not utilized for Part III, Line 8 was Schedule H, Worksheet B, Line 2 & 6, Medicare Allowable Costs and Payments Related to Subsidized Health Services. The Hospital utilized the Medicare cost report for estimated cost and payment for these services.The Hospital believes that its hospital clinical services, hospital-owned physician practices, emergency room and inpatient psychiatric units listed above should all be considered community benefits. These services, facilities, and programs provide a benefit to community members, and are both offered and subsidized by the Hospital.Medicare shortfall is reported to the State of New Hampshire in the Community Benefits Report, under Section 4, Unreimbursed Costs, Government-Sponsored Health Care.In prior years, the State of New Hampshire used MET dollars to service the general fund of the State. However, recently the State has used these dollars to directly fund medical and other related budgetary goals. As a result of this change in the State's appropriation of these funds, the net MET/DSH impact is considered a healthcare-related expenditure by the Hospital. Part III, Line 9b: Collection policy provides for accounts known to qualify for free care be removed from transfer to an outside agency for further collection activity. Part VI, Line 2: Frisbie Memorial Hospital (FMH) conducts a Community Needs Assessment every three years, the most recent completed in 2015. FMH worked with Health Strategies Plus to bring together health care and public services stakeholders.The Frisbie Memorial Hospital CHNA methodology includes a combination of quantitative and qualitative research methods designed to evaluate perspectives and opinions of area stakeholders and healthcare consumers - including those from underserved populations. The methodology used helps prioritize the needs and establish a basis for continued community engagement.The major sections of the methodology include the following: - Strategic secondary research - Qualitative discussion groups with Leadership Team members - Community surveys - Needs prioritization using a modified Delphi processReleased after the fiscal year covered by this tax return, the Hospital issued a new CHNA in January of 2019. In conducting its new CHNA, the Hospital expanded upon many of the methodologies used in its previous efforts. Information related to the new CHNA will be more thoroughly detailed in the Hospital's tax filing for fiscal year ending September 30, 2019 (its 2018 Form 990 and Schedule H filing). Part VI, Line 3: Frisbie Memorial Hospital is committed to providing quality health care that is affordable and accessible to all, regardless of ability to pay. The Hospital offers financial assistance to eligible patients and help patients apply for other programs that they may be eligible. Patients can learn more about these programs by visiting the Hospital's website or contacting the Hospital's Patient Accounts department. Beginning with the registration process and through the billing, patients can obtain an application for financial assistance or speak with a financial counselor. Part VI, Line 4: Frisbie Memorial Hospital's patient service area is urban, consisting of Northern Strafford, NH and Western York, ME counties. Population served for our Strafford County (upon which Frisbie is located in) is over 128,000 with a median income of $50,759 and 11.7% of community residents living below the federal poverty guidelines. Part VI, Line 5: Frisbie's Community Education & Conference Center is utilized by a multitude of community-based social and civic organizations as a convenient location for holding professional trainings and seminars, conferences, meetings, maternal classes, caregiver trainings and wellness events. The Conference Center is available at no charge to community nonprofit organizations for health promotion, disease prevention, and educational purposes. In light of the facts and circumstances surrounding the Community Center's varied purposes, the Hospital has claimed 50% of the expenses for this area as a benefit to the community. Part VI, Line 6: Through its affiliations, Frisbie Memorial Hospital and its partners work together to improve access to preventative health care services as well as those services put in place to address the following prioritized needs identified in 2015 Community Health Needs Assessment: Affordable medical care; mental health services; Substance abuse treatment services.- Granite State Lab: Offers lower cost laboratory services- Seacoast RediCare: Provides convenient access to health care services, which help to fill the gap between family physician and emergency room visits.- Women's Life Imaging: Provides convenient access to preventative mammography services.- Rochester Community Counseling: A joint effort between Community Partners and Frisbie Memorial Hospital to improve access to much behavioral health services in Rochester. Part VI, Line 7, Reports Filed With States NH,ME 1 Foundation for Healthy Communities 125 Airport Road Concord NH 03301 020275078 501(c)(3) 158659 Financial support for the recipient organization's mission. Veterans Count (aka Easter Seals Maine Inc) 125 Presumpscot Street Portland ME 04103 861073632 501(c)(3) 6000 Financial support for the recipient organization's mission. 2 0 Scholarships to Pursue Professional Education 25 33994 Part I, Line 2: All donations are tracked internally and follow up calls are placed to ensure funds have been used for the purposes of which they were intended. X X X 1 1 0 0 0 0 0 1 0 John Marzinsik President & CEO (end 2/18) 429753 0 9231 0 0 0 10800 0 19689 0 469473 0 0 0 Jocelyn Caple MD President & CEO (start 2/18) 238754 0 19200 0 0 0 0 0 26401 0 284355 0 0 0 Robert Cochrane VP Finance, CFO 235529 0 15000 0 0 0 0 0 17461 0 267990 0 0 0 Christi Green VP Human Resources 172748 0 15000 0 0 0 1040 0 10048 0 198836 0 0 0 Paula Mahoney VP Physician Practices 200532 0 15000 0 16500 0 24886 0 22153 0 279071 0 0 0 Joseph Shields Senior VP 216797 0 19180 0 0 0 8665 0 21332 0 265974 0 0 0 Trevor Eide MD Physician 279542 0 295373 0 0 0 8839 0 9463 0 593217 0 0 0 John Freese MD Physician 266427 0 255232 0 0 0 9165 0 14025 0 544849 0 0 0 Mathurin Malby MD Physician 246188 0 190622 0 0 0 9536 0 26401 0 472747 0 0 0 Michael Metzger MD Physician 397625 0 0 0 0 0 10800 0 24130 0 432555 0 0 0 Michael Southworth MD Physician 456005 0 0 0 0 0 6769 0 20442 0 483216 0 0 0 Part I, Lines 4a-b Line 4a: The following individuals listed in Form 990, Part VII received a severance payment from the Hospital during the year. -John Marzinisik received $259,878 -Joseph Shields received $257,360 -Paula Mahoney received $141,953 The severance payments were paid to the above individuals during the fiscal year covered by this tax return but after December 31, 2017. In accordance with IRS instructions, these amounts will be reflected on the Organization's 2018 Form 990 filing in Schedule J, Part II, Column B(iii) as part of the recipients' Box 5 Form W-2 taxable wages. Line 4b: The Hospital has a 457(f) deferred compensation plan which covers highly compensated employees. The Organization incurred liabilities related to salary continuation agreements with highly compensated employees. Under the terms of the agreements they are entitled to receive a lump sum of their account balance, including earnings, within 30 days after the date elected by the employee. Payments received by employees under the 457(f) plan for the calendar year ending 12/31/17 and were included in Schedule J, Part II, Column C were as follows: Paula Mahoney - $38,484 There were no distributions from anyone's plan during 2017. Part I, Line 7 The bonus compensation listed for the Organization's physicians is based on a Relative Value Unit-Based compensation system. Schedule J, Part VII, Line 5: Steve Guimond served as interim CFO of the Hospital from August 2016 to March 2017 when a permanent CFO was hired. Mr. Guimond was a contracted professional who was leased through a management company, Leaders for Today, an unrelated organization. The Hospital paid $71,416 to Leaders for Today for Mr. Guimond's services to the organization. This amount represents compensation for Mr. Guimond's services as interim CFO for a term that was completed prior to the fiscal year covered by this return. In accordance with IRS instructions, Mr. Guimond has not been listed in Form 990, Part VII as the reportable compensation paid to him in 2017 was below the filing threshold to be classified as a "former" officer. In the interest of transparency, the Hospital is disclosing this residual amount of compensation. A NHHEFA 020279866 644614QD4 2014-08-01 22475000 Refunding Series 2006 Bonds 0 0 0 A 22475000 22475000 2014 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 John Britton MD Board Member 1101369 Dr. Britton is a 33.33% owner of Surgical Associates of Rochester. The general surgeons at Surgical Associates of Rochester provide a wide range of services to patients of the Hospital, from minor office procedures to major surgery, done with both laparoscopic and open techniques, for adult and pediatric patients. During 2017, Frisbie Memorial Hospital paid $1,683,465 to Surgical Associates of Rochester for services rendered to the Hospital. All transactions were at arm's length. 0 Form 990, Part VI, Section A, line 2 Trustees Ronald Poulin and Jeanette Poulin have a family relationship. Form 990, Part VI, Section B, line 11b The Form 990 is prepared with the assistance of the Hospital's independent public accounting firm and is thoroughly reviewed by key financial staff. The CFO then reviews the 990 and a copy is then made available to the board for review. After any questions are answered, the return is filed with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c In accordance with the written conflict of interest policy, the office of the President annually secures a signed copy of the Trustee/Officer Conflict of Interest Statement and maintains them on file. Form 990, Part VI, Section B, line 15 Each year, the executive compensation committee comprised of four members of the FMH Board reviews the Hospital CEO performance and compensation. The VP of Human Resources presents the compensation committee with comparative salary and benefit data. Senior management compensation is also reviewed by the committee, but their compensation is determined by the CEO. Form 990, Part VI, Section C, line 19 The Hospital will provide its governing documents, financial statements, and conflict of interest policy upon request. Form 990, Part VII: Steve Guimond served as interim CFO of the Hospital from August 2016 to March 2017 when a permanent CFO was hired. Mr. Guimond was a contracted professional who was leased through a management company, Leaders for Today, an unrelated organization. The Hospital paid $71,416 to Leaders for Today for Mr. Guimond's services to the organization. This amount represents compensation for Mr. Guimond's services as interim CFO for a term that was completed prior to the fiscal year covered by this return. In accordance with IRS instructions, Mr. Guimond has not been listed in Form 990, Part VII as the reportable compensation paid to him in 2017 was below the filing threshold to be classified as a "former" officer. In the interest of transparency, the Hospital is disclosing this residual amount of compensation. Form 990, Part IX, line 11g Purchased Medical Services: Program service expenses 13,785,305. Management and general expenses 6,773,391. Fundraising expenses 11,152. Total expenses 20,569,848. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. Form 990, Part VI, Line 16b: The Hospital does not have a formal joint venture policy in written format. However, any joint venture agreement the Hospital may consider is thoroughly vetted by the board or subcommittee to ensure that the joint venture significantly improves and furthers the Hospital's exempt charitable mission. On-going monitoring is also conducted to safeguard the Hospital's invested assets from private benefit or other misappropriation. Granite State Lab LLC 11 Whitehall Road Manchester NH 03867 464121424 Laboratory Services NH -293375 183872 Frisbie Memorial Hospital Granite State Express LLC 11 Whitehall Road Manchester NH 03867 464115911 Express Care NH 0 0 Frisbie Memorial Hospital Frisbie Foundation 11 Whitehall Road Rochester NH 03867 020465942 Coordinate Funds Raised for Hospital NH 501(c)(3) Line 12b, II Frisbie Memorial Hospital 1 Skyhaven Surgery Center LLC 11 Whitehall Road Rochester NH 03867 463885261 Ambulatory Surgery NH Frisbie Memorial Hospital Related -3612674 90714 0 1 0.90000 Seacoast Business & Health Clinic Seacoast Redicare 396 High Street Somersworth NH 03878 020375898 Occupational Health NH Frisbie Memorial Hospital C 106763 1283890 1.00000 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 0 1 0 0 Skyhaven Surgery Center LLC B 233069 Actual per Books Granite State Lab LLC L 343765 Actual per Books Skyhaven Surgery Center LLC L 293922 Actual per Books Form 990, Schedule R, Part III Skyhaven Surgery Center, LLC is a multi-member limiited liability company formed in August 2013 to own and operate an ambulatory surgery center in the city of Rochester. The Frisbie Foundation is the majority owner of the Surgery Center and its operating agreement provides that individual physician members or entitites will own no greater than 10% individually or 30% in aggregate of the membership rights in the Surgery Center. On December 7, 2017, the Board of Trustees voted to discontinue the operations of the Surgery Center. The operating results and activity of the Surgery Center for 2018 and 2017 are reported as discontinued operations in the Hospital's audited consolidated statements of operations.