2017-11-15T13:40:48-06:00 2016-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2016-01-01 464249555 GOUVERNEUR HOSPITAL GOUV 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 DAVID BENDER CEO 3152871000 2017-11-13 1 THOMAS J GIUFRE P00841958 3154463600 2017-11-13 24.39.85.114 2017-11-13 17:06:00 ES P 517AEBE328CBAAA90E396C2FD1060AA56161F780 375090CD680BE658025353FD36A4C812740AAA32 2016 2021-01-29 14:40:06Z DAVID BENDER 77 WEST BARNEY STREET GOUVERNEUR NY 13642 19182104 0 X WWW.GVNRHOSPITAL.ORG X 2013 NY OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. 8 8 223 15 0 0 498099 599921 16358200 18076448 38556 16665 690611 489070 17585466 19182104 0 0 0 0 10089626 10508920 0 0 0 8355398 8217418 18445024 18726338 -859558 455766 9880241 11697963 8662398 9267108 1217843 2430855 OUR MISSION IS TO PROVIDE SKILLED, COMPASSIONATE, COST-EFFECTIVE CARE THAT PROMOTES WELLNESS AND MEETS THE COMMUNITY'S HEALTHCARE NEEDS. 0 0 14294162 18345859 ACUTE DIRECT PATIENT CARE - INPATIENT, REFERRED AMBULATORY, EMERGENCY CARE AND CLINICS. IN 2016 GOUVERNEUR HOSPITAL SERVED 479 INPATIENTS, HAD 9,404 EMERGENCY ROOM VISITS, AND PATIENT PROCEDURES TOTALED 18,163 INPATIENT AND 109,556 FOR OUTPATIENTS. 14294162 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 37 0 1 223 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X ERIC BURCH 3152871000 77 WEST BARNEY STREET GOUVERNEUR NY 13642 MICHAEL BURGESS CHAIRPERSON 1.00 X X 0 0 0 MARK BRACKETT SECRETARY/TREASURER 1.00 X X 0 0 0 ANDREW WILLIAMS MD TRUSTEE 1.00 X 0 0 0 LAUREN FRENCH TRUSTEE 1.00 X 0 0 0 ANDREW LEONARD CO-CHAIR PERSON 1.00 X X 0 0 0 ROGER COOK DVM TRUSTEE 1.00 X 0 0 0 CAROLYN PISTOLESI TRUSTEE 1.00 X 0 0 0 MEGAN WHITTON TRUSTEE 1.00 X 0 0 0 MARY JANE GOTHAM QUALITY ASSURANCE DIRECTOR 40.00 X 113360 0 10025 RICHARD T LANG CHIEF FINANCIAL OFFICER 40.00 X 138573 0 9154 MARLINDA LAVALLEY CHIEF EXECUTIVE OFFICER 40.00 X 168646 0 22076 ALICE LOVING ANESTHESIOLOGIST 40.00 X 300596 0 31149 NABEEL AL-HUSSEIN PHYSICIAN 40.00 X 200604 0 13827 RICHARD CORCORAN PHYSICIAN ASSISTANT 40.00 X 153106 0 22643 GERALD L CALABRESE PHYSICIAN 40.00 X 130748 0 19938 NICOLE L WEBER PHYSICIAN 40.00 X 106429 0 954 1312062 0 129766 8 0 1 0 0 349127 250794 599921 623000 17203948 17203948 VAP FUNDS 623000 872500 872500 18076448 16665 16665 219659 0 219659 219659 219659 CAFETERIA SALES 900099 30086 30086 239325 239325 269411 19182104 18345859 0 236324 461834 346376 115458 7350857 5513143 1837714 316825 237619 79206 1770558 1327919 442639 608846 456635 152211 20813 15610 5203 100602 75452 25150 18721 18721 1652483 1253403 399080 182473 136855 45618 419469 314602 104867 28753 21565 7188 162698 122024 40674 718352 538764 179588 252131 192099 60032 PROFESSIONAL FEES 3620826 2715620 905206 BAD DEBT PROVISION 985611 985611 NYS ASSESSMENT FEE 54486 40865 13621 18726338 14294162 4432176 0 489614 745371 439632 769119 1911237 2307040 448089 416268 129193 208901 6823758 1404420 4976274 5419338 543118 729953 943084 1101973 9880241 11697963 1573387 1537946 7089011 7729162 8662398 9267108 X -419712 18076 239671 976651 1397884 1436128 1217843 2430855 9880241 11697963 X 455766 5439 751807 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 18721 18721 0 PART II-B, LINE 1: GOUVERNEUR HOSPITAL, THROUGH ITS MEMBERSHIP OR FEES PAID TO THE FOLLOWING ORGANIZATIONS, INCURRED $18,721 IN LOBBYING EXPENSE IN 2016: $4,548: IROQUOIS HEALTHCARE ALLIANCE $5,478: HANYS ANNUAL MEMBERSHIP DUES $8,695: AMERICAN HOSPITAL ASSOCIATION ANNUAL MEMBERSHIP DUES 0 1637555 1806389 38244 1069409 2412779 1672801 61715 -35323 61638 1637555 54334 1878461 217009 42985 1672801 54334 54334 0.59520 0.40480 0 0 230000 230000 2624783 271159 2353624 3657553 1133261 2524292 311422 311422 5419338 SHORT TERM INVESTMENTS 40756 C LONG TERM INVESTMENTS 689197 C 729953 FUNDS HELD IN TRUST BY OTHERS 981328 DUE FROM ST. LAWRENCE HEALTH SYSTEMS, INC. 120645 1101973 DUE TO AFFILIATE 2954349 DUE TO ST. LAWRENCE HEALTH SYSTEM 4456760 DUE TO IBM 17620 THIRD PARTY SETTLEMENTS 220433 ASSET RETIREMENT OBLIGATION 80000 7729162 X 19182104 0 19182104 0 19182104 18726338 0 18726338 0 18726338 PART V, LINE 4: THE ORGANIZATION USES THE INCOME FROM THE ENDOWMENT FUNDS FOR GENERAL OPERATING PURPOSES, AND LAWFUL PURPOSES AT THE DISCRETION OF THE BOARD OF DIRECTORS. PART X, LINE 2: THE HOSPITAL 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 PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM NEW YORK STATE INCOME TAXES. AS OF DECEMBER 31, 2016, 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 NEW YORK STATE TAXING AUTHORITIES ARE 2013 THROUGH 2016. 1 1 X 1 X 201.000000000000 1 X 449.000000000000 1 1 0 1 1 437527 35222 402305 0.02270 4773600 2136672 2636928 0.14860 5211127 2171894 3039233 0.17130 82827 82827 0.00470 82827 82827 0.00470 5293954 2171894 3122060 0.17600 1 985611 5471093 5416924 54169 X 1 1 1 1 GOUVERNEUR HOSPITAL 77 WEST BARNEY STREET GOUVERNEUR NY 13642 4423701C X X X X GOUVERNEUR HOSPITAL 1 0 0 1 X X X X X X X X X X 14 1 1 1 1 X WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL/ 1 14 1 WWW.GVNRHOSPITAL.ORG/ABOUT-OUR-HOSPITAL/ 0 1 X 201.000000000000 449.000000000000 1 1 X X X 1 X WWW.GVNRHOSPITAL.ORG X WWW.GVNRHOSPITAL.ORG X WWW.GVNRHOSPITAL.ORG X X X X 1 X 0 X X 1 X 0 0 GOUVERNEUR HOSPITAL PART V, SECTION B, LINE 5: GOUVERNEUR HOSPITAL'S (GH) MOST RECENT CHNA WAS CONDUCTED BY ITS NEW YORK STATE DSRIP PPS, ADIRONDACK HEALTH INSTITUTE, AS WELL AS ITS LOCAL PARTNERS, THE ST. LAWRENCE COUNTY PUBLIC HEALTH DEPARTMENT AND THE ST. LAWRENCE HEALTH INSTITUTE. GH PARTICIPATES AT THE BOARD LEVEL ON THE ST. LAWRENCE HEALTH INITIATIVE, A NOT-FOR-PROFIT ORGANIZATION COORDINATING HEALTH ASSESSMENT AMONG ALL AREA HEALTH FACILITIES. THIS ORGANIZATION AND OUR DSRIP PPS PROVIDE FORMAL ONGOING COORDINATION OF NEEDS ASSESSMENT AND PROGRAMMING. THE CHNA WAS COMPLETED IN 2014, UPDATED IN 2016, AND TAKES INTO ACCOUNT INPUT FROM PERSONS REPRESENTING THE COMMUNITY PRIMARILY THROUGH A TELEPHONE AND WEB SURVEY CONDUCTED IN THE SUMMER OF 2016 WITH 679 RESPONDENT RESIDENTS OF THE THREE-COUNTY REGION OF ST. LAWRENCE, LEWIS, AND JEFFERSON. GH ALSO SEEKS INPUT FORMALLY THROUGH AN ANNUAL FORUM WITH COMMUNITY LEADERS FROM ALL ACROSS OUR PRIMARY AND SECONDARY SERVICE AREAS, FREQUENT MEETINGS WITH PUBLIC HEALTH OFFICIALS, LOCAL COLLEGE PRESIDENTS, THE LEADERS OF OTHER AREA HEALTH FACILITIES, AND LOCAL GOVERNMENT OFFICIALS. ADDITIONAL INPUT WAS GATHERED FROM HOSPITAL AND HOSPITAL SYSTEM BOARD MEMBERS REPRESENTING PUBLIC HEALTH, DENTISTRY, HOSPICE AND PALLIATIVE CARE, VETERINARY HEALTH, AREA COLLEGES, AND AREA BUSINESSES. IN 2014, GH BECAME AFFILIATED WITH THE ST. LAWRENCE HEALTH SYSTEM PARTNERING WITH CANTON-POTSDAM HOSPITAL. THE COMMUNITY SERVICE INITIATIVES ARE COLLABORATED WITHIN AND TOGETHER UNDER THIS UMBRELLA SYSTEM. GOUVERNEUR HOSPITAL PART V, SECTION B, LINE 6A: PLEASE SEE LINE 5 EXPLANATION ABOVE. GOUVERNEUR HOSPITAL IS AFFILIATED WITH CANTON-POTSDAM HOSPITAL, AND COMPLETED THE CHNA WITH THE ENTITIES NOTED ABOVE. GOUVERNEUR HOSPITAL PART V, SECTION B, LINE 6B: PLEASE SEE LINE 5 EXPLANATION ABOVE. GOUVERNEUR HOSPITAL IS AFFILIATED WITH CANTON-POTSDAM HOSPITAL, AND COMPLETED THE CHNA WITH THE ENTITIES NOTED ABOVE. GOUVERNEUR HOSPITAL PART V, SECTION B, LINE 2: EFFECTIVE JANUARY 1, 2014, GOUVERNEUR HOSPITAL BEGAN OPERATIONS AS A TAX-EXEMPT HOSPITAL REPLACING THE FORMER HOSPITAL, EDWARD JOHN NOBLE HOSPITAL, WHICH CEASED OPERATIONS. GOUVERNEUR HOSPITAL PART V, SECTION B, LINE 11: GOUVERNEUR HOSPITAL'S CHNA IDENTIFIED CHRONIC DISEASE PREVENTION AND MANAGEMENT AND MENTAL, EMOTIONAL, AND BEHAVIORAL (MEB) HEALTH AS THE TWO HIGHEST PRIORITY AREAS NEEDING TO BE ADDRESSED. WITHIN THESE AREAS, CHILD AND ADOLESCENT OBESITY, HEART FAILURE, DIABETES, AND COPD WERE IDENTIFIED AS THE MOST PRESSING NEEDS IN CHRONIC DISEASE MANAGEMENT; SUBSTANCE ABUSE AND SUICIDE PREVENTION WERE IDENTIFIED AS TOP NEEDS IN THE MEB HEALTH CATEGORY. THESE PRIORITY AREAS DOVETAIL WITH THE HOSPITAL'S STRATEGIC PLAN, THE PRIORITIES OF THE NEW YORK STATE DSRIP PPS PARTNERS IN A NINE-COUNTY NORTHERN NEW YORK REGION THAT ENCOMPASSES ST. LAWRENCE COUNTY, THE PRIORITIES OF THE NEW YORK STATE HEALTHCARE REDESIGN COMMISSION, THE PRIORITIES OF THE NEW YORK STATE PREVENTION AGENDA, AND THE GOALS OF THE AFFORDABLE CARE ACT TO INCREASE ACCESS, REDUCE COSTS, AND IMPROVE QUALITY. SPECIFIC GOALS AND METRICS HAVE BEEN IDENTIFIED AND THE HOSPITAL'S OUTREACH PROGRAMS ARE DESIGNED TO ADDRESS THESE. AMONG THESE PROGRAMS IS AN EXTENSIVE EDUCATION SERIES FOR THE COMMUNITY ON VARIOUS HEALTH ISSUES; EDUCATION TARGETED TO THOSE WITH SPECIFIC DIAGNOSES; SUPPORT FOR OTHER COMMUNITY ORGANIZATIONS, SUCH AS THE GOUVERNEUR AREA CHILDREN'S COALITION, WHICH INCLUDES THE GOUVERNEUR EMS, THE SCHOOL SYSTEM, ALONG WITH GH, FOR INTEGRATING HEALTHY FOOD CHOICES IN CHILDHOOD AND ADOLESCENT ACTIVITIES. PART I, LINE 7: THE COSTING METHODOLOGY USED IN PART I IS THE COST-TO-CHARGE RATIO METHOD. THE RATIO WAS DERIVED FROM EXHIBIT 40 OF THE 2016 ICR. PART I, LN 7 COL(F): THE AMOUNT REPORTED ON LINE 2 FOR BAD DEBT EXPENSE IS DETERMINED BY COST, AND AGREES TO THE BAD DEBT EXPENSE REPORTED ON THE FINANCIAL STATEMENTS. PART III, LINE 4: FOOTNOTE FOR ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS: THE HOSPITAL FOOTNOTE DESCRIBING PATIENT ACCOUNTS RECEIVABLE IS IN THE ATTACHED FINANCIAL STATEMENT FOOTNOTE 1(K) ON PAGES 7-9. PART III, LINE 9B: THE ORGANIZATION APPLIES THE SAME COLLECTION PRINCIPLES TO AMOUNTS DUE FROM PATIENTS WHO HAVE QUALIFIED FOR PERCENTAGE DISCOUNTS BUT STILL HAVE A RESPONSIBILITY FOR A PORTION OF THEIR BILL BASED UPON THE SLIDING FEE SCHEDULE. NO SEPARATE DISTINCTION IS MADE FOR THE APPLICATION OF OUR COLLECTION PROCESSES IN THOSE CASES. PART VI, LINE 2: PLEASE REFERENCE THE ABOVE REQUIRED DESCRIPTIONS, PART V SECTION B, LINES 5 AND 11. PART VI, LINE 3: THE ORGANIZATION CONSPICUOUSLY POSTS ITS FINANCIAL ASSISTANCE POLICY IN EACH REGISTRATION/RECEPTION AREA. PATIENTS ARE ENCOURAGED TO APPLY FOR ASSISTANCE AND GIVEN CONTACT INFORMATION AT THESE AREAS. IN ADDITION, ANY PATIENT THAT IS UNINSURED AND ADMITTED TO THE HOSPITAL FOR CARE IS PHYSICALLY VISITED BY A FINANCIAL COUNSELOR, AND AN EXPLANATION OF OUR PROGRAM IS MADE ALONG WITH AN APPLICATION. PATIENTS REQUESTING ASSISTANCE IN THE COMPLETION OF THE APPLICATION ARE GIVEN SUCH. ANY INFORMATION REQUIRED FOR APPLICATION FOR THE NYS MEDICAID APPLICATION PROCESS IS COLLECTED BY OUR FINANCIAL CASE MANAGERS AND COMMUNICATED TO THE APPROPRIATE CASE MANAGERS AT OUR COUNTY DEPARTMENT OF SOCIAL SERVICES FOR DETERMINATION OF MEDICAID ELIGIBILITY. PART VI, LINE 4: GOUVERNEUR HOSPITAL IS LOCATED IN ST. LAWRENCE COUNTY IN UPSTATE NEW YORK. ST. LAWRENCE COUNTY, THE LARGEST COUNTY IN NEW YORK, IS LOCATED IN THE NORTHERNMOST REACHES OF THE STATE BORDERING ON THE ST. LAWRENCE RIVER AND CANADA. IT IS A RURAL ENVIRONMENT CONSISTING OF 2,685 SQUARE MILES WITH A POPULATION OF APPROXIMATELY 112,000 RESIDENTS.GOUVERNEUR HOSPITAL'S PRIMARY SERVICE AREA INCLUDES APPROXIMATELY 58,000 PEOPLE LIVING IN THE COMMUNITIES OF CANTON, HERMON, RICHVILLE, DEKALB JCT., ANTWERP AND SECONDARY SERVICE DEFINED BY THE TOWNS OF EDWARDS, HARRISVILLE AND INDIAN RIVER. THE SECONDARY SERVICE AREA FOR THE HOSPITAL IS PREDOMINANTLY THE REMAINING COMMUNITIES WITHIN ST. LAWRENCE COUNTY WITH SOME RESIDENTS OF THE WESTERN JEFFERSON COUNTY AREA BEING SERVED. PART VI, LINE 5: GOUVERNEUR HOSPITAL HELD MANY COMMUNITY ACTIVITIES TO HELP PROMOTE THE HEALTH OF THE COMMUNITY. SOME OF THESE ACTIVITIES INCLUDE BLOOD DRIVES, SCHOOL EDUCATION ACTIVITIES, BREAST CANCER WALKS, AND LUNCH & LEARNS. THE COMMUNITY LUNCH & LEARNS HELD BY GOUVERNEUR HOSPITAL HAD APPROXIMATELY 168 PEOPLE IN ATTENDANCE AND SPOKE TO VARIOUS HEALTH RELATED RISKS AND HOW TO MANAGE THEM. GOUVERNEUR HOSPITAL HAD 63 STUDENTS FROM MULTIPLE COLLEGES AND BOCES PROGRAMS SHADOW EMPLOYEES. GOUVERNEUR HOSPITAL HELD A "LET'S NOT MEET BY ACCIDENT" PROGRAM FOR 182 STUDENTS TO EDUCATE YOUNG DRIVERS ON THE DANGERS OF DWI AND TEXTING WHILE DRIVING. THE HOSPITAL ALSO WORKS WITH THE LOCAL POLICE DEPARTMENT EACH YEAR AND DOES A PROGRAM CALLED OPERATION SAFE CHILD WHERE YOUNG CHILDREN CAN ATTEND AND HAVE A PHOTO ID PLACED ON RECORD. PART VI, LINE 6: ST. LAWRENCE HEALTH SYSTEM, FORMED DECEMBER 5, 2013, IS OPERATED EXCLUSIVELY FOR THE SOLE CHARITABLE PURPOSE OF BENEFITING AND SUPPORTING GOUVERNEUR HOSPITAL, CANTON-POTSDAM HOSPITAL AND OTHER CORPORATIONS. AMONG OTHER BENEFITS, THE HEALTH SYSTEM MAY PROVIDE ADVICE AND ASSISTANCE CONCERNING LONG AND SHORT-RANGE PLANNING FOR, AND MONITOR AND PROVIDE ADVICE AND ASSISTANCE TO HELP COORDINATE THE ACTIVITIES OF THE SUPPORTED ORGANIZATION IN ELIMINATING DUPLICATIVE FUNCTIONS; PROVIDE MANAGEMENT CONSULTING ASSISTANCE TO THE SUPPORTED ORGANIZATION TO FURTHER IMPROVE AND ADVANCE HEALTH SERVICES TO THE RESIDENTS OF NEW YORK STATE AND COOPERATE WITH THE SUPPORTING ORGANIZATIONS IN CARRYING OUT THEIR CHARITABLE PURPOSES. PART VI, LINE 7, REPORTS FILED WITH STATES NY X 0 0 0 0 0 0 0 0 0 MARLINDA LAVALLEY CHIEF EXECUTIVE OFFICER 168646 0 0 0 0 0 0 0 22076 0 190722 0 0 0 ALICE LOVING ANESTHESIOLOGIST 300596 0 0 0 0 0 0 0 31149 0 331745 0 0 0 NABEEL AL-HUSSEIN PHYSICIAN 200604 0 0 0 0 0 0 0 13827 0 214431 0 0 0 RICHARD CORCORAN PHYSICIAN ASSISTANT 153106 0 0 0 0 0 0 0 22643 0 175749 0 0 0 GERALD L CALABRESE PHYSICIAN 130748 0 0 0 0 0 0 0 19938 0 150686 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ST. LAWRENCE HEALTH SYSTEM, INC. IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A ST. LAWRENCE HEALTH SYSTEM, INC., AS THE SOLE MEMBER, HAS THE ABILITY TO APPOINT MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER SHALL HAVE THE FOLLOWING POWERS WITH REGARD TO THE CORPORATION: -APPOINT THE MEMBERS OF THE BOARD OF DIRECTORS; -APPOINT AND REMOVE THE CHIEF EXECUTIVE OFFICER; -APPROVE THE ADOPTION AND AMENDMENT OF BYLAWS; -APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS; -APPROVE STRATEGIC PLANS; -APPROVE AND INITIATE THE FILING OF CERTIFICATE OF NEED APPLICATIONS; -REVIEW AND APPROVE THE ANNUAL AUDIT OF THE CORPORATION AND ANY SUBSIDIARY CORPORATIONS; -APPROVE THE DISSOLUTION OF THE CORPORATION; -APPROVE THE SALE, LEASE, MORTGAGE OR ENCUMBRANCE OF ANY ASSET OTHER THAN ANY SALE, LEASE OR MORTGAGE WHICH IS PART OF AN APPROVED BUDGET; -APPROVE THE SALE OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; -APPROVE ANY MERGER, BUSINESS CONSOLIDATION, ACQUISITION OR JOINT VENTURE; -APPROVE THE PURCHASE OR SALE OF PHYSICIAN PRACTICES OTHER THAN ANY PURCHASE OR SALE WHICH IS PART OF AN APPROVED BUDGET; -APPROVE AND MAY INITIATE THE COMMENCEMENT AND SETTLEMENT OF LITIGATION; -APPROVE ANY FILING OF A BANKRUPTCY PETITION; -APPROVE THE INCURRENCE OF ANY DEBT OTHER THAN DEBT WHICH IS INCURRED IN THE ORDINARY COURSE OF BUSINESS AND WHICH IS NOT INCONSISTENT WITH AN APPROVED BUDGET; -APPROVE NEW CLINICAL PROGRAMS OR THE TERMINATION OF EXISTING CLINICAL PROGRAMS OTHER THAN ANY ACTION WHICH IS PART OF AN APPROVED BUDGET; -APPROVE ANY OF THE FOLLOWING AGREEMENTS: (I) MANAGEMENT SERVICES AGREEMENT OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET; (II) CONTRACTS WITH A PHYSICIAN OR A PHYSICIAN GROUP; (III) AGREEMENTS FOR THE OUTSOURCING OF A GOUVERNEUR HOSPITAL SERVICE OR FUNCTION; (IV) COLLECTIVE BARGAINING AGREEMENTS; AND (V) ANY AGREEMENTS TO PARTICIPATE IN A RISK BEARING ARRANGEMENT SUCH AS AN ACCOUNTABLE CARE ORGANIZATION OR A BUNDLED PAYMENT ARRANGEMENT; -INITIATE, NEGOTIATE AND APPROVE MANAGED CARE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS AND OTHER PAYORS OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET; -DEVELOP INTEGRATED SERVICES AND MANDATE PARTICIPATION IN SUCH SERVICES (E.G., FINANCIAL MANAGEMENT, STRATEGIC PLANNING, HUMAN RESOURCES, INFORMATION TECHNOLOGY, LEGAL, QUALITY ASSURANCE, RISK MANAGEMENT, CONTRACTING AND RECRUITMENT); AND -REQUIRE THE GUARANTEE OF LOANS THROUGH AN OBLIGATED GROUP STRUCTURE THAT WILL SUPPORT ACCESS TO CAPITAL AND MAY INCLUDE DEBT SERVICES. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS EMAILED TO THE BOARD OF DIRECTORS PRIOR TO THE FILING OF THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, OFFICERS, DIRECTORS, AND KEY EMPLOYEES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST STATEMENT. COMPLIANCE WITH THIS REQUIREMENT IS MONITORED BY HOSPITAL ADMINISTRATION. FORM 990, PART VI, SECTION B, LINE 15 THE CHIEF EXECUTIVE OFFICER IS EVALUATED BY THE ST. LAWRENCE HEALTH SYSTEM CEO. HOSPITAL SENIOR LEADERSHIP IS EVALUATED BY THE HOSPITAL'S CEO. YAFFE AND COMPANY PROVIDES EXECUTIVE COMPENSATION DATA FOR CRITICAL ACCESS HOSPITALS WHICH IS UTILIZED BY THE ST. LAWRENCE HEALTH SYSTEM CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL CEO. THE SAME DATA IS UTILIZED BY THE HOSPITAL CEO TO DETERMINE APPROPRIATE COMPENSATION FOR THE HOSPITAL'S SENIOR LEADERSHIP. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: TRANSFER FROM SLHS 713,563. CHANGE IN FAIR VALUE OF PERMANENTLY RESTRICTED FUNDS 38,244. FORM 990, PART XII, LINE 2C: THE ST. LAWRENCE HEALTH SYSTEM'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT AND OVERSIGHT OF THE ANNUAL AUDIT. CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM NY 13676 161012691 HOSPITAL NY 501(C)(3) LINE 3 ST LAWRENCE HEALTH SYSTEM INC 0 ST LAWRENCE HEALTH SYSTEM INC 50 LEROY STREET POTSDAM NY 13676 464259168 PROVIDES SUPPORT TO CANTON-POTSDAM HOSPITAL & AFFILIATES NY 501(C)(3) LINE 12B, II N/A 0 CANTON-POTSDAM MEDICAL PRACTICE PLLC 77 WEST BARNEY STREET GOUVERNEUR NY 13642 460714367 PHYSICIAN SERVICES NY 501(C)(3) LINE 10 ST LAWRENCE HEALTH SYSTEM INC 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 1 1 1 0 1