2025-11-07T13:19:17-06:00 2024-12-31 161226221 FUSTCHARLES LLP 220 S WARREN STREET SYRACUSE NY 13202 990 2024-01-01 150548010 COMMUNITY MEMORIAL HOSPITAL INC COMM 3158246550 150 BROAD STREET HAMILTON NY 13346 TRACY FRANK CFO 3158246550 2025-11-05 1 1 THOMAS J GIUFRE P00841958 3154463600 2025-11-05 2024 2025-03-06 01:10:19Z TRACY FRANK 150 BROAD STREET HAMILTON NY 13346 67627567 0 X COMMUNITYMEMORIAL.ORG X 1949 NY COMMUNITY MEMORIAL HOSPITAL'S MISSION-TO PROVIDE THE HIGHEST QUALITY, COMPASSIONATE CARE FOR ALL. 17 14 644 30 0 0 3171973 544569 57612419 66686587 149686 179233 655554 194165 61589632 67604554 0 0 0 0 33090367 39672252 0 0 0 29634705 29022766 62725072 68695018 -1135440 -1090464 35595283 44137714 15531104 28845183 20064179 15292531 X COMMUNITY MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE THE HIGHEST QUALITY, COMPASSIONATE CARE FOR ALL. 0 0 17456305 12317526 OPERATION OF A CRITICAL ACCESS HOSPITALBEDS 25PATIENT DAYS OF CARE 7,751ADMISSIONS 1,550COMMUNITY MEMORIAL HOSPITAL HAS RECEIVED MANY AWARDS FOR OUTSTANDING CARE TO INCLUDE: 1) RATED AS AN OUTSTANDING LEADER IN PATIENT CARE AND PATIENT SAFETY BY BOTH STATE AND FEDERAL SURVEYORS. IT IS A 4 TO 5 STAR RATED HOSPITAL FOR CMS PATIENT SATISFACTION RATING, WHICH VARIES BY QUARTER.2) HEALTHGRADES MULTI-YEAR 5 STAR RATING IN ORTHOPEDIC SURGERY FOR KNEE REPLACEMENTS. 3) EXCELLUS AWARD FOR COMBINED CLINICAL PROCESS AND SURGICAL CARE IMPROVEMENT.4) JOINT COMMISSION RECOGNITION AS TOP PERFORMER IN QUALITY MEASURES.COMMUNITY MEMORIAL HOSPITAL STRIVES TO IMPROVE THE HEALTH OF THE COMMUNITY BY:1) PARTICIPATING IN LOCAL HEALTH FAIRS.2) IMPROVING ACCESS TO PRIMARY CARE.3) IMPROVING THE CARE OF CHRONIC ILLNESSES SUCH AS DIABETES.4) IMPROVING MENTAL HEALTH SERVICES THROUGH THE INTEGRATION OF BEHAVIORAL HEALTH SERVICES IN THE CLINICS.5) INCREASING ACCESS TO SPECIALTY SERVICES SUCH AS WOMEN'S HEALTH, ORTHOPEDICS, CARDIOLOGY AND PULMONOLOGY.6) COUNSELING ON THERAPEUTIC DIETS AND WEIGHT RELATED ISSUES.7) OFFERING A PRE-DIABETIC COACHING COURSE ON DIET, EXERCISE AND OTHER WAYS TO REDUCE RISK OF PATIENTS BECOMING TYPE II DIABETIC.8) PROMOTING HEALTH SCREENING SERVICES SUCH AS COLONOSCOPY'S FOR MEN'S HEALTH AND MAMMOGRAPHY IMAGING FOR WOMEN'S HEALTH MONTH.9) CMH PROMOTES BACK TO SCHOOL AND SPORTS SCREENINGS TO THE COMMUNITY THROUGH EDUCATIONAL MAILINGS AND SOCIAL MEDIA REMINDERS FOR PARENTS.COMMUNITY MEMORIAL HOSPITAL HAS A CHARITY CARE PROGRAM FOR PATIENTS WHO CANNOT AFFORD TO PAY HOSPITAL BILLS AND FALL WITHIN THE NATIONAL POVERTY GUIDELINES, UP TO 400% OF THE POVERTY GUIDELINES. IN 2024 COMMUNITY MEMORIAL HOSPITAL PROVIDED CHARITY CARE IN THE AMOUNT OF $247,185 TO APPROXIMATELY 221 PATIENTS.) 15879885 26150617 OPERATION OF EMERGENCY SERVICES AND OUTPATIENT REFERRED AMBULATORY TESTINGEMERGENCY ROOM VISITS 12,461REFERRED AMBULATORY VISITS 41,981 15488205 13095692 OPERATION OF PRIMARY CARE CLINICSTOTAL VISITS 68,585 11892240 15122752 OPERATION OF AN AMBULATORY SURGERY UNITTOTAL VISITS 2,947 11892240 15122752 60716635 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 44 0 1 644 1 0 0 0 0 0 0 0 0 0 0 0 0 X 17 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NY X COMMUNITY MEMORIAL HOSPITAL 3158246550 150 BROAD STREET HAMILTON NY 13346 RICHARD RUSSELL TREASURER 1.00 X X 0 0 0 MARY BRUNDAGE TRUSTEE 1.00 X 0 0 0 RICHARD COHEN MD TRUSTEE 1.00 X 0 0 0 HAZEL L JACK SECRETARY 1.00 X X 0 0 0 ROBERT TYBURSKI VICE CHAIRPERSON 1.00 X X 0 0 0 SUNNY NELSON MD TRUSTEE 40.00 X 0 0 0 RAYMOND MEEKS MD TRUSTEE 1.00 X 0 0 0 ANNE CLAUSS TRUSTEE 1.00 X 0 0 0 ELLEN P KRALY CHAIRPERSON 1.00 X X 0 0 0 BRADFORD WHELER TRUSTEE 1.00 X 0 0 0 MICHAEL LATREILLE TRUSTEE 1.00 X 0 0 0 EVE ANN SCHWARTZ TRUSTEE 1.00 X 0 0 0 SAMANTHI MARTINEZ TRUSTEE 1.00 X 0 0 0 AVNEET SINGH MD VP, MEDICAL STAFF 40.00 X X 620046 0 20051 JOANN BORFITZ TRUSTEE 1.00 X 0 0 0 ELLEN LARSON TRUSTEE 1.00 X 0 0 0 ROBERT TENNEY TRUSTEE 1.00 X 0 0 0 JEFFERY COAKLEY PRESIDENT 40.00 X X 459090 0 48620 LEIGH BALDWIN TRUSTEE 1.00 X 0 0 0 SUSAN BARRETT TRUSTEE 1.00 X 0 0 0 WILLIAM GETMAN TRUSTEE 1.00 X 0 0 0 SETH KRONENBERG MD TRUSTEE 1.00 X 0 0 0 RUTH ANN LOVELESS TRUSTEE 1.00 X 0 0 0 DAVID ROGERS TRUSTEE 1.00 X 0 0 0 JEFF RUBENSTEIN TRUSTEE 1.00 X 0 0 0 JENNIFER MEYERS MD PRESIDENT, MEDICAL STAFF 40.00 X X 221933 0 11823 TRACY FRANK CFO 40.00 X 195581 0 933 MICHAEL WALSH PHYSICIAN 40.00 X 339757 0 15738 DAVE REBUCK MD PHYSICIAN 40.00 X 546949 0 44092 RICHELLE TAKEMOTO MD PHYSICIAN 40.00 X 797086 0 32408 GREGORY RIPICH MD PHYSICIAN 40.00 X 528721 0 36217 KAMALJEET BANGA PHYSICIAN 40.00 X 729627 0 31968 4438790 0 241850 88 0 1 0 THE HAYNER HOYT CORPORATION 625 ERIE BLVD WEST SYRACUSE NY 13204 CONSTRUCTION SERVICES 2868668 CROUSE HEALTH HOSPITAL INC 736 IRVING AVE SYRACUSE NY 13210 MGMT, CLINICAL, & IT 1318081 LABCORP PO BOX 12140 BURLINGTON NC 27216 LABORATORY SERVICES 1154228 RICH & GARDNER CONSTRUCTION 206 PLUM STREET SYRACUSE NY 13204 CONSTRUCTION SERVICES 869500 HEALTHCARE WORKFORCE LOGISTICS PO BOX 860573 MINNEAPOLIS MN 55486 STAFFING RESOURCES 808776 22 472038 72531 544569 REFERRED AMBULATORY 621990 26150617 26150617 AMBULATORY SURGERY 621990 15122752 15122752 INPATIENT 621110 12317526 12317526 CLINIC 621110 11010955 11010955 340B REVENUE 900099 2084737 2084737 66686587 182669 182669 37638 8308 29330 29330 29330 2078 9191 0 14705 2078 -5514 -3436 -3436 CAFETERIA SALES 900099 102219 102219 62616 62616 164835 67604554 66686587 0 373398 X 1578077 873852 704225 30128911 27365982 2762929 778684 697458 81226 4987254 4530508 456746 2199326 1964487 234839 222960 222960 208607 208607 10525 10525 8213 8213 11071774 10114432 957342 453450 100824 352626 640707 100645 540062 1737485 742315 995170 669011 650223 18788 76249 27938 48311 75729 75729 2719411 2586542 132869 835672 835672 MEDICAL SUPPLIES 9133837 9133837 0 PROVISION FOR BAD DEBTS 612122 612122 0 NYS ASSESSMENT 212663 212663 0 334351 91406 242945 68695018 60716635 7978383 0 7952364 9286837 5060716 8294188 574994 885892 1552086 1551050 60543353 37544127 19481825 22999226 973298 1120521 35595283 44137714 9498594 13353150 1100543 8588812 4931967 6903221 15531104 28845183 X 19314179 15292531 750000 0 20064179 15292531 35595283 44137714 X -1090464 -25505 -3655679 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 10525 0 0 1 0 0 10525 0 PART 11-B, LINE 1, LOBBYING ACTIVITIES: COMMUNITY MEMORIAL HOSPITAL HAS LIMITED LOBBYING ACTIVITIES. SEVERAL ACTIVITIES ARE CONDUCTED ON BEHALF OF THE ORGANIZATION THROUGH MEMBERSHIP IN THE IROQUOIS HEALTHCARE ALLIANCE AND HEALTHCARE ASSOCIATION OF NYS. THESE ACTIVITIES INCLUDE ADVETISEMENTS AND CONTACT WITH LEGISLATORS ON VARIOUS HEALTHCARE ISSUES. IROQUOIS HEALTHCARE ALLIANCE - MEMBERHSIP DUES OF $11,448 OF WHICH $5,724 WAS FOR LOBBYING. HEALTHCARE ASSOCIATION OF NYS - MEMBERSHIP DUES OF $26,379 OF WHICH $2,659 WAS FOR LOBBYING. AHA-MEMBERHSIP DUES OF $21,251 OF WHICH $2,142 WAS FOR LOBBYING. 3855233 629034 270631 4386 835167 3915345 3166252 444441 328177 23220 60417 3855233 3063566 479697 -310239 725 66047 3166252 1380696 1534889 178761 593 30187 3063566 654422 739279 100604 65769 47840 1380696 0.14700 0.85300 0 1 1 62115 62115 37603132 20211864 17391268 39694 31917 7777 20670531 16015804 4654727 2167881 1284542 883339 22999226 ACCRUED RETIREMENT OBLIGATIONS, NET 2431223 OTHER LONG-TERM LIABILITIES 352736 ESTIMATED 3RD PARTY PAYABLE, NET 4119262 6903221 X PART V, LINE 4: ENDOWMENT FUNDS ARE USED TO FURTHUR THE HOSPITAL'S TAX EXEMPT PURPOSE, SUCH AS FOR THE PURCHASE OF CAPITAL ASSETS. PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2024 AND 2023, THE HOSPITAL DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2021 THROUGH 2024. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 1 X 1 X 0 1 0 0 367449 75985 291464 0.00420 9437496 5316328 4121168 0.06000 9804945 5392313 4412632 0.06420 118332 78449 39883 0.00060 118332 78449 39883 0.00060 9923277 5470762 4452515 0.06480 1 612121 575641 8637885 11298519 -2660634 X 1 1 1 1 COMMUNITY MEMORIAL HOSPITAL INC 150 BROAD ST HAMILTON NY 13346 WWW.COMMUNITYMEMORIAL.ORG X X X X COMMUNITY MEMORIAL HOSPITAL INC 1 0 0 1 X X X X X X X X 22 1 1 1 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X 1 22 1 SEE PART V, PAGE 8 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X HTTPS://COMMUNITYMEMORIAL.ORG/PATIENT-VISITOR-INFO/FINANCIAL-ASSISTANCE/ X HTTPS://COMMUNITYMEMORIAL.ORG/PATIENT-VISITOR-INFO/FINANCIAL-ASSISTANCE/ X HTTPS://COMMUNITYMEMORIAL.ORG/PATIENT-VISITOR-INFO/FINANCIAL-ASSISTANCE/ X X X X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 5: COMMUNITY MEMORIAL HOSPITAL PARTNERED WITH MADISON COUNTY DEPARTMENT OF HEALTH (MCDOH), ONEIDA HEALTH, AND THE MADISON COUNTY RURAL HEALTH COUNCIL, INC. TO COMPLETE THE COMMUNITY HEALTH ASSESSMENT AND IMPROVEMENT PLAN PROCESS. REPRESENTATIVES FROM THE FOUR AGENCIES COMPRISED THE 2022-2024 STEERING COMMITTEE. THE COMMUNITY HEALTH ASSESSMENT AND IMPROVEMENT PLAN OUTLINES THE CURRENT HEALTH STATUS OF RESIDENTS AND IDENTIFIES A COMPREHENSIVE PLAN FOR ADDRESSING HEALTH CHALLENGES. THE PROCESS WAS UNDERTAKEN IN ALIGNMENT WITH THE 2019-2024 NEW YORK STATE PREVENTION AGENDA1, WHICH IDENTIFIES FIVE PRIORITY AREAS FOR HEALTH IMPROVEMENT: PREVENT CHRONIC DISEASES PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS PROMOTE A HEALTHY AND SAFE ENVIRONMENT PROMOTE HEALTHY WOMEN, INFANTS, AND CHILDREN PREVENT COMMUNICABLE DISEASES COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 6A: THE OTHER HOSPITAL THAT PARTICIPATED WAS ONEIDA HEALTHCARE. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 6B: PLEASE SEE LINE 5 EXPLANATION. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 11: THE 2022 CHA INTEGRATED RESULTS FROM THE PREVIOUS ASSESSMENTS WITH AN UPDATED COMMUNITY HEALTH STATUS ASSESSMENT. RESULTS OF THE REVISED CHA WERE PRESENTED TO THE STEERING COMMITTEE MEMBERS IN APRIL 2022 FOR THE SELECTION OF PRIORITY AREAS. A FACILITATED DISCUSSION LED TO THE DECISION TO FOCUS ON THE FOLLOWING PRIORITY AREAS: 1. PREVENT CHRONIC DISEASES 2. PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS TO PROMOTE ACTIVE COLLABORATION WITH COMMUNITY ORGANIZATIONS, THE STEERING COMMITTEE CONVENED PRIORITY AREA WORKGROUPS WITH REPRESENTATIVES FROM LOCAL ORGANIZATIONS. WORKGROUPS SELECTED GOALS, OBJECTIVES, AND EVIDENCE-BASED STRATEGIES TO ADDRESS PRIORITY AREAS. COMMUNITY MEMORIAL HOSPITAL WORKED CLOSELY WITH THE MADISON COUNTY PUBLIC HEALTH DEPARTMENT, AND ONEIDA HEALTHCARE. WE SELECTED PRIORITIES THAT COULD REACH THE MOST PEOPLE AND COULD HAVE THE MOST IMPACT, IDENTIFYING TWO PRIORITIES: PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS AND PREVENTION OF CHRONIC DISEASETHE IDENTIFIED GOALS RELATED TO SUBSTANCE ABUSE INCLUDE 1) ESTABLISH COLLABORATIVE CARE MODEL IN PRIMARY CARE SETTINGS COMMUNITY MEMORIAL HOSPITAL IS DEVELOPING AND IMPLEMENTING A NETWORK OF LOCAL HEALTHCARE PROVIDERS, PUBLIC HEALTH ENTITIES, AND COMMUNITY NONPROFIT ORGANIZATIONS TO ENHANCE AND SUSTAIN THE DELIVERY OF COMMUNITY-BASED, BEHAVIORAL HEALTH CARE SERVICES TO RURAL AND UNDERSERVED POPULATIONS IN CENTRAL NEW YORK. PARTNER AGENCIES: MADISON COUNTY MENTAL HEALTH DEPARTMENT, FAMILY COUNSELING SERVICES OF CORTLAND COUNTY AND THE MADISON COUNTY COUNCIL ON ALCOHOLISM AND SUBSTANCE ABUSE, INC. (BRIDGES). 2) EXPAND COMMUNITY ACCESS TO NALOXONE COMMUNITY MEMORIAL HOSPITAL IS PARTNERING WITH BRIDGES TO ENSURE THAT WE HAVE NALOXONE TO PROVIDE TO PATIENTS PRESCRIBED NARCOTICS IN PRIMARY CARE, THOSE DISCHARGED FROM THE HOSPITAL, AND THOSE PATIENTS WHO VISIT THE EMERGENCY DEPARTMENT. IDENTIFIED GOALS RELATED TO PREVENTION OF CHRONIC DISEASE INCLUDE 1) IMPROVING ACCESS TO CARE COMMUNITY MEMORIAL HOSPITAL IS ACTIVELY RECRUITING FAMILY PRACTICE PROVIDERS TO INCREASE ACCESS TO CARE. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 16J: A MESSAGE IS PRINTED ON PATIENTS' BILLS THAT STATES "COMMUNITY MEMORIAL HOSPITAL OFFERS A FINANCIAL ASSISTANCE PROGRAM. FOR MORE INFO PLEASE CALL 315-824-6552 OR 315-824-6553 OR GO TO WWW.COMMUNITYMEMORIAL.ORG" COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 20E: PATIENTS THAT ARE SELFPAY ON ADMISSION ARE SEEN BY THE FINANCIAL COUNSELING DEPARTMENT AND THE FINANCIAL ASSISTANCE PROGRAM IS DISCUSSED AND AN APPLICATION IS GIVEN. SELF PAY PATIENTS RECEIVING OUTPATIENT SERVICES ARE CALLED TO ADVISE THEM OF OUR POLICY BEFORE SERVICE IS SCHEDULED OR AFTER SERVICE IS RENDERED. PART V, SECTION B, LINE 7A: HOSPITAL FACILITY'S WEBSITE:HTTPS://COMMUNITYMEMORIAL.ORG/ABOUT/COMMUNITY-SERVICE-PLAN/ PART V, SECTION B, LINE 7B: OTHER WEBSITE:HTTPS://WWW.MADISONCOUNTY.NY.GOV/2482/COMMUNITY-HEALTH-ASSESSMENT-IMPROVEMENT PART V, SECTION B, LINE 10A: IMPLEMENTATION STRATEGY WEBSITE:HTTPS://COMMUNITYMEMORIAL.ORG/ABOUT/COMMUNITY-SERVICE-PLAN/ 5 1 - COMMUNITY MEMORIAL HOSPITAL FHC 164 BROAD ST HAMILTON NY 13346 PRIMARY AND SPECIALTY CARE 2 - COMMUNITY MEMORIAL HOSPITAL FHC 3460 SOUTH ST MORRISVILLE NY 13408 PRIMARY CARE PHYSICIAN OFFICE 3 - COMMUNITY MEMORIAL HOSPITAL FHC 117 WEST MAIN ST WATERVILLE NY 13480 PRIMARY CARE PHYSICIAN OFFICE 4 - COMMUNITY MEMORIAL HOSPITAL FHC 5180 SOUTH MAIN ST MUNNSVILLE NY 13409 PRIMARY CARE PHYSICIAN OFFICE 5 - COMMUNITY MEMORIAL HOSPITAL FHC 3045 JOHN TRUSH BLVD CAZENOVIA NY 13035 PRIMARY CARE PHYSICIAN OFFICE PART I, LINE 7: LINE 7A - A COST-TO-CHARGE RATIO WAS USED, DERIVED FROM WORKSHEET 2LINE 7B - A COST-TO-CHARGE RATIO WAS USED, DERIVED FROM WORKSHEET 2.LINE 7E - WE USED OUR ACTUAL EXPENSES AND ACTUAL REVENUE FROM OUR WELLNESS CENTER AND HEALTHY LIVING PROGRAM, EXPENSES ASSOCIATED WITH NURSING TIME SPENT FOR CERTAIN PROGRAMS, AND EXPENSES FOR DIETARY COUNSELING. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $612,121 WAS SUBTRACTED FROM FORM 990, PART IX, LINE 25, COLUMN A. PART III, LINE 2: LINE 2 METHODOLOGY- THE HOSPITAL ESTIMATES BAD DEBT EXPENSE BASED ON HISTORICAL EXPERIENCE EXPRESSED AS A PERCENTAGE OF CURRENT YEAR GROSS REVENUE. PART III, LINE 3: LINE 3 METHODOLOGY- THE APPROVAL PERCENTAGE OF 94.04% ON ALL PATIENTS WHO APPLIED FOR CHARITY CARE IN 2024 WAS MULTIPLIED BY THE AMOUNT ON LINE 2. THE RATIONAL BEING THAT THAT % WOULD HOLD ACROSS ALL OF OUR BAD DEBTS EXPENSE IF THOSE PATIENTS HAD APPLIED FOR CHARITY CARE. WE DID NOT INCLUDE BAD DEBT AMOUNTS IN COMMUNITY BENEFITS. BAD DEBTS EXPENSE IS NET OF DISCOUNTS AND PAYMENTS. PART III, LINE 4: SEE PAGE 14 OF ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: FOR LINE 6 - THE HOSPITAL DETERMINED MEDICARE ALLOWABLE COSTS BY MULTIPLYING THE RATIO OF PATIENT CARE COST TO CHARGES DERIVED FROM WORKSHEET 2 BY THE TOTAL MEDICARE CHARGES REPORTED IN THE 2024 MEDICARE COST REPORT.THE SHORTFALL OF $2,660,634 ON LINE 7 REPRESENTS UNRECOGNIZED COMMUNITY BENEFIT INHERENT IN PROVIDING MEDICAL CARE TO THE COMMUNITY. OUR UNREIMBURSED COSTS FROM MEDICARE ARE INCURRED BY PROVIDING SERVICES TO OUR RURAL COMMUNITIES THAT HAVE A HIGHER THAN AVERAGE MEDICARE POPULATION, MANY OF WHOM ARE INDIGENT. PART III, LINE 9B: LINE 9B -IN THE COLLECTION POLICY FOR COMMUNITY MEMORIAL HOSPITAL IT STATES THAT APPROVED APPLICATIONS WILL BE HONORED FOR A PERIOD OF TIME IF THE PATIENT RETURNS NEEDING MEDICAL SERVICES AND THE PATIENTS FINANCIAL STATUS HAS NOT CHANGED. PATIENTS WITHOUT INSURANCE ARE APPROVED FOR 3 MONTH COVERAGE PERIOD (MAY REAPPLY FOR COVERAGE IF ADDITIONAL MEDICAL SERVICES) AND PATIENTS WITH INSURANCE ARE APPROVED FOR ONE YEAR. PATIENTS WITH AN APPROVED APPLICATION ON FILE WILL BE IDENTIFIED UPON ADMISSION OR REGISTRATION IN THE HOSPITAL'S PATIENT ACCOUNTING SYSTEM BY PATIENT ACCESS STAFF. PATIENTS MAY ALSO CONTACT FINANCIAL COUNSELING TO NOTIFY THEM THAT AN APPROVED APPLICATION IS ON FILE IF THE APPROPRIATE DISCOUNT IS NOT TAKEN. ADDITIONAL DOCUMENTATION MAY BE REQUIRED TO DETERMINE IF INCOME LEVELS HAVE CHANGED. A NEW APPLICATION WILL BE REQUIRED AT THE END OF EACH COVERED PERIOD. PART VI, LINE 2: COMMUNITY MEMORIAL WAS AN ACTIVE PARTNER WITH THE MADISON COUNTY HEALTH DEPARTMENT, OTHER HEALTH AND HUMAN SERVICE AGENCIES, AND AREA COMMUNITY AND INDUSTRY LEADERS IN PERFORMING AN EXTENSIVE ASSESSMENT OF THE HEALTH NEEDS OF OUR AREA. THE SHARED INFORMATION COLLECTED HAS BEEN USEFUL IN OUR EFFORTS TO PLAN FOR THE CHANGING NEEDS AND DEMOGRAPHICS OF OUR SERVICE AREA POPULATIONS. INFORMATION USED IN OUR PLANNING AND ASSESSMENT IS DERIVED FROM THE FOLLOWING SOURCES: 1) PRIMARY - PATIENT SATISFACTION SURVEYS, BOARD OF DIRECTORS, AUXILIARY MEMBERSHIP, MEDICAL STAFF, AND EMPLOYEES 2)PRIMARY - MADISON COUNTY DEPARTMENT OF HEALTH AND COMMUNITY NEEDS ASSESSMENT PLAN, SECONDARY - CHENANGO COUNTY COMMUNITY NEEDS ASSESSMENT, SPARCS, NYSDOH REPORTS AND DATA SOURCES, PHYSICIAN AND HEALTH SERVICES USAGE DATA BASES, MARKET SHARE AND DEMOGRAPHICS DATA BASES, HEALTHCARE ASSOCIATION OF NYS, AMERICAN HOSPITAL ASSOCIATION, IROQUOIS HEALTH ASSOCIATION, AND VOLUNTARY HOSPITALS OF AMERICA STATISTICAL REPORTS. PART VI, LINE 3: LINE 3 - SIGNS ARE POSTED IN OUR ADMITTING/REGISTRATION AREAS REGARDING OUR POLICY OF PROVIDING SERVICES AT A REDUCED CHARGE OR NO CHARGE TO PATIENTS WHO HAVE FAMILY INCOME BELOW CERTAIN FEDERAL STANDARDS, INCLUDING A PHONE NUMBER TO CALL IN OUR FINANCIAL COUNSELING DEPARTMENT. A SUMMARY OF OUR FINANCIAL ASSISTANCE PROGRAM IS AVAILABLE FOR THEM TO TAKE. PATIENTS THAT ARE SELF PAY ON ADMISSION ARE SEEN BY THE FINANCIAL COUNSELING DEPARTMENT PERSONNEL AND THE FINANCIAL ASSISTANCE PROGRAM IS DISCUSSED AND AN APPLICATION IS GIVEN. PATIENTS THAT RECEIVE OUTPATIENT SERVICES ARE CALLED TO ADVISE THEM OF OUR POLICY BEFORE SERVICE IS SCHEDULED, OR AFTER SERVICE IS RENDERED. A MESSAGE IS AUTOMATICALLY PRINTED ON ALL PATIENT STATEMENTS THAT FINANCIAL ASSISTANCE IS AVAILABLE FOR THOSE WHO QUALIFY, WITH THE PHONE NUMBER TO CALL. OUR FINANCIAL ASSISTANCE PROGRAM POLICY, SUMMARY AND APPLICATION ARE AVAILABLE ON OUR HOSPITAL WEBSITE. PATIENTS ARE MADE AWARE THAT THEY MAY APPLY TO THE COUNTY IN WHICH THEY RESIDE FOR MEDICAID ASSISTANCE. PART VI, LINE 4: COMMUNITY MEMORIAL HOSPITAL IN HAMILTON, NY, SERVES 45,000 PEOPLE IN 27 CENTRAL NEW YORK COMMUNITIES. THE REGION IS NOTED FOR ITS RICH AGRICULTURAL HISTORY AND A STRONG TRADITION OF HIGHER EDUCATION. COLGATE UNIVERSITY, MORRISVILLE STATE COLLEGE, AND CAZENOVIA COLLEGE OFFER CURRICULUMS THAT ARE RENOWNED NATIONWIDE. THE COMMUNITIES WE SERVE ALSO HAVE A SIGNIFICANT NUMBER OF FRAIL AND POOR ELDERLY, MEDICAID OF ALL AGES AND WORKING POOR. COMMUNITY MEMORIAL HOSPITAL PROVIDES CARE TO ALL OF THESE GROUPS REGARDLESS OF ABILITY TO PAY. THIS APPLIES TO ALL HOSPITAL AND OUTPATIENT SERVICES. COMMUNITY MEMORIAL HOSPITAL HAS A FINANCIAL ASSISTANCE PROGRAM FOR THOSE WHO CANNOT AFFORD TO PAY FOR THEIR MEDICAL BILLS. PART VI, LINE 5: A MAJORITY OF COMMUNITY MEMORIAL HOSPITAL'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL, NOR FAMILY MEMBERS. COMMUNITY MEMORIAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. THE HOSPITAL USES SURPLUS FUNDS TO BUY STATE-OF-THE-ART CAPITAL EQUIPMENT, I.E. CARDIAC MONITOR FOR SPECIAL CARE UNIT, PHARMACY COMPUTER SYSTEM, SURGICAL EQUIPMENT, AND ADDITIONAL COMPUTERS/SERVERS.IN 1989, COMMUNITY MEMORIAL HOSPITAL EXPANDED ITS MISSION TO PROVIDE PRIMARY CARE IN THE RURAL COMMUNITIES OF ITS SERVICE AREA. SEVERAL PHYSICIANS HAD RETIRED OR WERE ABOUT TO CLOSE THEIR PRACTICES AND MANY SMALL TOWNS AND VILLAGES WERE LEFT WITHOUT ANY COVERAGE. THE HOSPITAL HAS A NETWORK OF SIX FAMILY HEALTH CENTERS (IN HAMILTON, CAZENOVIA, MORRISVILLE, MUNNSVILLE, SHERRILL AND WATERVILLE). THE HOSPITAL EMPLOYS FIVE FAMILY PRACTICE PHYSICIANS, ONE PEDIATRICIAN, ONE CARDIOLOGIST, ONE GENERAL SURGEON, TWO ORTHOPEDIC SURGEONS AND NURSE PRACTITIONERS/PHYSICIAN ASSISTANTS. WE CONTINUE TO ACTIVELY RECRUIT PRIMARY CARE PROVIDERS AND APPROPRIATE SPECIALISTS TO MEET THE NEEDS OF THE COMMUNITY. ALL PATIENTS WHO COME TO THE FAMILY HEALTH CENTERS ARE SERVED WITHOUT REGARD TO THEIR ABILITY TO PAY. THE HOSPITAL HAS DEVELOPED A SAFETY NET FOR LOW INCOME, UNINSURED AND/OR UNDERINSURED PATIENTS WHILE ENSURING PRIMARY CARE WILL REMAIN AVAILABLE IN RURAL CENTRAL NEW YORK.THE HOSPITAL PROMOTED CAREERS IN THE HEALTH CARE FIELD BY ATTENDING REGIONAL CAREER DAYS AT LOCAL HIGH SCHOOLS, COLLEGES AND LOCAL VENUES. THE HOSPITAL OFFERS A PRE-DIABETIC COACHING COURSE ON DIET, EXERCISE AND OTHER WAYS TO REDUCE THE LIKELIHOOD OF PATIENTS BECOMING DIABETIC. IN ADDITION, THE HOSPITAL DIETITIAN PROVIDES FREE COUNSELING TO THE COMMUNITY ON THERAPEUTIC DIETS AND WEIGHT RELATED ISSUES. PART VI, LINE 6: COMMUNITY MEMORIAL HOSPITAL IS AN INDEPENDENT, CRITICAL ACCESS HOSPITAL (CAH). CMH HAS CLINICAL AFFILIATIONS WITH REGIONAL HOSPITALS, INCLUDING CROUSE HOSPITAL TO ENSURE CONTINUITY OF CARDIOLOGY SERVICES. CROUSE AND CMH ALSO MAINTAIN AN OPERATIONAL AFFILIATION WITH INFORMATION TECHNOLOGY SYSTEMS, INCLUDING EMR AND OTHER IT SYSTEMS. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X X 0 0 0 0 0 0 0 0 0 RICHELLE TAKEMOTO MD PHYSICIAN 797028 0 0 0 58 0 4261 0 28147 0 829494 0 0 0 KAMALJEET BANGA PHYSICIAN 729538 0 0 0 89 0 250 0 31718 0 761595 0 0 0 AVNEET SINGH MD VP, MEDICAL STAFF 534616 0 85396 0 34 0 13454 0 6597 0 640097 0 0 0 DAVE REBUCK MD PHYSICIAN 521852 0 25000 0 97 0 10092 0 34000 0 591041 0 0 0 GREGORY RIPICH MD PHYSICIAN 528465 0 0 0 256 0 1832 0 34385 0 564938 0 0 0 JEFFERY COAKLEY PRESIDENT 428852 0 30000 0 238 0 15197 0 33423 0 507710 0 0 0 MICHAEL WALSH PHYSICIAN 317644 0 21875 0 238 0 9141 0 6597 0 355495 0 0 0 JENNIFER MEYERS MD PRESIDENT, MEDICAL STAFF 200000 0 21875 0 58 0 5226 0 6597 0 233756 0 0 0 TRACY FRANK CFO 185215 0 10000 0 366 0 0 0 933 0 196514 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CEO AND THE PRESIDENT OF THE BOARD OF DIRECTORS REVIEW THE CONFLICT OF INTEREST POLICIES ANNUALLY WITH THE FULL BOARD. ANY POSSIBLE CONFLICTS ARE REVIEWED AND APPROPRIATE ACTION TAKEN. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE CEO AND THE VP OF FINANCE IS DETERMINED BY THE BOARD OF DIRECTORS. THE BOARD REVIEWS COMPARATIVE DATA PROVIDED BY HOSPITAL TRADE ORGANIZATIONS SUCH AS HANYS. THE BOARD USES SALARY SURVEYS COMPLETED BY INDEPENDENT CONSULTANTS YAFFE & COMPANY. THE BOARD ALSO REVIEWS SALARIES FOR SIMILAR POSITIONS AT OTHER COMPARABLE HOSPITALS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE FILED WITH THE CHARITIES BUREAU AND ARE PART OF THE PUBLIC RECORD. IN ADDITION, THE ORGANIZATION PROVIDES ALL DOCUMENTS REQUIRED BY THE INTERNAL REVENUE CODE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,943,564. MANAGEMENT AND GENERAL EXPENSES 111,259. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,054,823. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 7,170,868. MANAGEMENT AND GENERAL EXPENSES 846,083. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,016,951. FORM 990, PART XI, LINE 9: RETIREMENT PLAN OBLIGATION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS 694,089. PAYMENT ON BEHALF OF RELATED ORGANIZATION -167,530. OTHER COMPONENTS OF NET PERIODIC BENEFIT COST -77,337. ALLOWANCE FOR HMS RECEIVABLE -4,104,901. FORM 990, PART XII, LINE 2C THERE WERE NO CHANGES TO THE OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE CURRENT YEAR. COMMUNITY MEMORIAL HOSPITAL FOUNDATION 150 BROAD ST HAMILTON NY 13346 161603283 FUNDRAISING NY 501 C 3 11- TYPE I N/A 0 HAMILTON MEDICAL SERVICES PLLC 150 BROAD STREET HAMILTON NY 13346 463823973 PHYSICIAN SERVICES NY COMMUNITY MEMORIAL HOSPITAL INC C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0