2016-02-09T12:05:48-06:00 2015-09-30 020476956 TYLER SIMMS & ST SAUVEUR CPA PC 19 MORGAN DRIVE LEBANON NH 03766 990 2014-10-01 020276210 UPPER CONNECTICUT VALLEY HOSPITAL UPPE 6032374971 CORLISS LANE COLEBROOK NH 03576 JAMES TIBBETTS TREASURER 6032374971 2016-02-09 1 JAMES N GODFREY CPA P00913422 6036530044 2016-02-09 2014 2016-04-25 22:37:26Z GREG PLACY CORLISS LANE COLEBROOK NH 03576 18075887 0 X WWW.UCVH.ORG X 1969 NH TO PROVIDE HEALTH CARE SERVICES. 13 11 152 16 0 0 97385 160264 15055633 15616811 630220 358185 42991 44750 15826229 16180010 50000 12500 0 0 7943323 8181244 0 0 978 6652023 7442599 14645346 15636343 1180883 543667 21230154 23313655 6232373 8151482 14997781 15162173 UPPER CONNECTICUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 0 0 12881498 12500 15616811 UPPER CONNECTICUT VALLEY HOSPITAL PROVIDED HOSPITAL CARE AND INPATIENT AND OUTPATIENT SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2015 WAS $435,543. 12881498 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 27 0 152 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 11 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X THE ORGANIZATION 6032374971 UCVH CORLISS LANE COLEBROOK NH 03576 X E HARLAN CONNARY SECRETARY 1.00 X X 0 0 0 BRUCE BEAN DIRECTOR 1.00 X 0 0 0 ODETTE CRAWFORD VICE CHAIR 1.00 X X 0 0 0 JAMES TIBBETTS TREASURER 1.00 X X 0 0 0 GREG PLACY CHAIRMAN 1.00 X X 0 0 0 PALMER LEWIS DIRECTOR 1.00 X 0 0 0 PETER MORAN MD DIRECTOR 1.00 X 0 0 0 ERIC STOHL DIRECTOR 1.00 X 0 0 0 SALLY WENTZELL DIRECTOR 1.00 X 0 0 0 EDWARD LAVERTY PA-C CHIEF OF STAFF 56.00 X 199666 0 32333 FREDERICK D BROCK DIRECTOR 1.00 X 0 0 0 PETER L GOSLINE CHIEF ADMINISTRATIVE OFFICER 24.00 X X 0 94500 0 ROBERT ROSE MD PHYSICIAN, CHIEF MEDICAL OFFICER 44.00 X X 352371 0 0 CELESTE PITTS CHIEF FINANCIAL OFFICER 16.00 X 140237 0 15334 KIMBERLEE DALEY PATIENT EXPERIENCE OFFICER 40.00 X 122140 0 14243 THOMAS COCHRAN PHYSICIAN 16.00 X 182991 0 0 JOHN EPPOLIOTO PHYSICIAN 63.00 X 365590 0 22258 CHARANJIT VEDI PHYSICIAN 34.00 X 323604 0 25062 JOSEPH KIERNAN PHYSICIAN 31.00 X 263220 0 5963 ROBERT GOOCH PHARMACIST 41.00 X 173576 0 7164 NICOLE PAIER-MULLEN PHYSICIAN, CHIEF MEDICAL OFFICER 32.00 X 270183 0 21303 2393578 94500 143660 10 1 1 1 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 REHAB SERVICES 956852 NORTHERN NH HEALTHCARE MANAGEMENT LLC 59 PAGE HILL ROAD BERLIN NH 03570 MANAGEMENT SERVICES 345171 DARTMOUTH HITCHCOCK CLINIC 1 MEDICAL CENTER DRIVE LEBANON NH 03756 PATHOLOGIST & RADIOLOGIST STAFFING 195251 3 63995 96269 160264 PATIENT SERVICE REVENU 621400 29443704 29443704 MISCELLANOUS REVENUE 624100 216266 216266 SCHOOL NURSING 624100 211290 211290 MEANINGFUL USE REVENUE 621400 193316 193316 MEDICAL RECORD TRANSMI 624100 -75 -75 -14447690 -14447690 15616811 192420 192420 2061642 1795131 100746 266511 -100746 165765 165765 CAFETERIA 900099 44750 44750 44750 16180010 15616811 0 402935 12500 12500 581926 388426 193500 6069807 5125848 943959 59144 50447 8697 1070720 907625 163095 399647 340883 58764 151671 151671 46193 46193 52948 52948 21672 18894 2778 1536215 1487641 48574 276819 195420 81399 548312 426845 121467 129103 86572 42531 333 333 617939 617939 130689 130689 PURCHASED SERVICES 2455161 1823664 631497 MEDICAID ENHANCEMENT TA 760722 760722 RECRUITMENT 234343 234068 275 REPAIRS AND MAINTENANCE 216228 212725 3503 264251 191279 71994 978 15636343 12881498 2753867 978 303517 189100 3498816 2790585 2137100 2546607 267879 296832 210553 268316 11843231 7609450 4449915 4233781 8293695 10834794 271581 473161 1797098 1680479 21230154 23313655 2274599 2485739 417675 356417 977598 750405 2562501 4558921 6232373 8151482 X 14542320 14791324 362391 197779 93070 173070 14997781 15162173 21230154 23313655 543667 -379274 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3787 3787 0 PART II-B, LINE 1: UPPER CONNECTICUT VALLEY HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THIS ORGANIZATION IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF UCVH AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITIES. 0 191998 80000 3175 11651 263522 170203 20000 14929 13134 191998 161056 18320 9173 170203 129746 31310 161056 127616 2130 129746 0.65680 0.34320 0 0 9700 9700 3982468 2296400 1686068 237084 129376 107708 7613743 5183674 2430069 236 236 4233781 OTHER RECEIVABLES 1469497 DEPOSITS & OTHER 97149 RECEIVABLE FROM NORTHERN NH HEALTHCARE COLLABORATIVE 109951 RECEIVABLE FROM NORTHERN NH HEALTHCARE MANAGEMENT 3882 1680479 DUE TO THIRD PARTY PAYERS 4558921 4558921 15799758 -379274 -978 -380252 16180010 0 16180010 15635366 0 15635366 978 978 15636344 PART V, LINE 4: THE INVESTMENTS ARE TO BE HELD IN PERPETUITY. THE INCOME FROM THE INVESTMENTS IS EXPENDABLE TO SUPPORT THE HOSPITAL'S HEALTH CARE SERVICES. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES -978. PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSE 978. 1 1 1 X 1 X 1 1 0 1 1 461344 115184 346160 0.02210 2367549 1781536 586013 0.03750 2828893 1896720 932173 0.05960 3680153 2567448 1112705 0.07120 50079 50079 0.00320 864275 319491 544784 0.03480 13046 13046 0.00080 4607553 2886939 1720614 0.11000 7436446 4783659 2652787 0.16960 54929 54929 0.00350 2181 2181 0.00010 57110 57110 0.00360 1 505793 16185 8349722 8434062 -84340 X 1 1 1 NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC LLC OF 3 COOS COUNTY HOSPITALS 1 1 UPPER CONNECTICUT VALLEY HOSPITAL 181 CORLISS LANE COLEBROOK NH 03576 X X X X UPPER CONNECTICUT VALLEY HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 0 1 1 X WWW.UCVH.ORG 1 13 1 WWW.UCVH.ORG 0 0 1 X 125.000000000000 300.000000000000 X X X X X X 1 1 X X X X 1 X WWW.UCVH.ORG X 1 X 0 X X X 1 X 0 0 UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 5: UPPER CONNECTICUT VALLEY HOSPITAL USED INFORMATION GATHERED FROM A NUMBER OF SOURCES INTERNAL AND EXTERNAL TO COMPLETE ITS CHNA. THESE SOURCES INCLUDE INDIAN STREAM HEALTH CENTER (FQHC) IN COLEBROOK, NH; UNITED STATES CENSUS BUREAU; CENTERS FOR MEDICARE AND MEDICAID SERVICES; STATE OF NEW HAMPSHIRE, DEPARTMENT OF HEALTH AND HUMAN SERVICES, DIVISION OF PUBLIC HEALTH SERVICES; NATIONAL ADVISORY COUNCIL; NATIONAL RESEARCH CORPORATION; AND THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY.INPUT FROM THE COMMUNITY WAS GATHERED USING TWO METHODS INCLUDING AN INTERNET/PAPER SURVEY AND FOCUS GROUP INTERVIEWS IN COLLABORATION WITH INDIAN STREAM HEALTH. UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 11: CHRONIC DISEASE MANAGEMENT: A HIGH PERCENT OF THE POPULATION IN THE UPPER CONNECTICUT VALLEY HOSPITAL SERVICE AREA HAS A HIGHER USE OF HEALTH CARE SERVICES FOR CHRONIC AMBULATORY CARE SENSITIVE CONDITIONS (960.8 VS. 605.4 FOR NH) WHICH INDICATES THAT THERE IS AN OPPORTUNITY TO REDUCE ADMISSIONS THROUGH STRENGTHENED PRIMARY CARE AND PREVENTATIVE SERVICES. THROUGH COLLABORATION BETWEEN UPPER CONNECTICUT VALLEY HOSPITAL AND INDIAN STREAM HEALTH CENTER, THE ORGANIZATIONS WILL FORM A TEAM THAT IS CHARGED WITH DEVELOPMENT OF A ROBUST CARE MANAGEMENT SYSTEM THAT BUILDS STRATEGIES TO IMPROVE TRANSITIONS OF CARE. UCVH WILL CONTINUE TO REVIEW AND IMPLEMENT STRATEGIES AIMED AT IMPROVING AND SUSTAINING CMS CORE MEASURE PERFORMANCE. THESE MEASURES ARE REPORTED TO THE BOARD ON AN ANNUAL BASIS VIA THE QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI) PLAN ANNUAL REPORT, WHICH MUST BE APPROVED BY THE BOARD.UCVH COLLABORATES WITH ISHC TO PROVIDE NUTRITION AND DIABETIC EDUCATION SERVICES TO THE PATIENTS OF OUR PRIMARY SERVICE AREA. SERVICES ARE PROVIDED TO PATIENTS REGARDLESS OF THE ABILITY TO PAY. IN ADDITION, UCVH HAS COMMITTED RESOURCES TO TRAIN AN ADDITIONAL STAFF MEMBER TO BE A CERTIFIED DIABETIC EDUCATOR TO STRENGTHEN DIABETIC EDUCATION IN BOTH THE OUTPATIENT AND INPATIENT SETTINGS.AVAILABILITY OF PHYSICIANS: SURVEY AND FOCUS GROUP PARTICIPANTS INDICATED RECRUITMENT AND RETENTION OF PHYSICIANS IN THE AREA AS THERE SECOND PRIORITY TO ASSURE ACCESS TO QUALITY CARE. RESPONDENTS ALSO WERE NOT CLEAR ABOUT THE AVAILABILITY OF SPECIALTY SERVICES THAT EXIST WITHIN THE COMMUNITY. UCVH IN COLLABORATION WITH ANDROSCOGGIN VALLEY HOSPITAL WILL CONTINUE TO DEVELOP STRATEGIES TO EDUCATE THE COMMUNITY IN REGARD TO AVAILABILITY OF SPECIALTY SERVICES WITHIN THE PRIMARY SERVICE AREA. UCVH WILL CONTINUE TO PARTICIPATE IN OUTREACH ACTIVITIES AT COMMUNITY EVENTS AND OFFER FINANCIAL ASSISTANCE TO PATIENTS WHO REQUIRE SPECIALTY SERVICES AND HAVE AN INABILITY TO PAY.UCVH AND ISHC UNDERTOOK PHYSICIAN AND PROVIDER RECRUITMENT ACTIVITIES COLLABORATIVELY TO RECRUIT MEDICAL PROFESSIONALS INTO THE AREA. UCVH HAS BEEN DESIGNATED AS A NATIONAL HEALTH SERVICES CORP SITE AND WILL CONTINUE CERTIFICATION ACTIVITIES AS REQUIRED. TO DATE, ISHC IS FULLY STAFFED WITH PROVIDERS AND ABLE TO MEET THE NEEDS OF THE COMMUNITIES SERVED.AVAILABILITY OF EMERGENCY CARE: UPPER CONNECTICUT VALLEY HOSPITAL IS LOCATED IN A RURAL ISOLATED MOUNTAINOUS AREA AND HAS THE LARGEST GEOGRAPHIC SERVICE AREA OF ANY HOSPITAL LOCATED IN NEW HAMPSHIRE. THE EMERGENCY DEPARTMENT SERVES AS A SAFETY NET FOR THE MOST DISADVANTAGED AND MEDICALLY UNDERSERVED CITIZENS OF NEW HAMPSHIRE. RESIDENTS AND VISITORS WOULD HAVE TO TRAVEL AT LEAST AN HOUR TO THE NEXT CLOSEST FACILITY FOR ACCESS TO EMERGENCY CARE SERVICES.SURVEY AND FOCUS GROUP PARTICIPANTS IDENTIFIED THE PROVISION OF EMERGENCY CARE AS THEIR THIRD PRIORITY AS A COMMUNITY NEED.UCVH CURRENTLY MAINTAINS AN EMERGENCY DEPARTMENT THAT PROVIDES ACCESS TO EMERGENCY CARE SERVICES WITHOUT REGARD TO THE ABILITY TO PAY FOR SUCH SERVICES. UCVH IS THE MEDICAL RESOURCE HOSPITAL TO LOCAL EMERGENCY MANAGEMENT SERVICES (AMBULANCE SERVICES). EMERGENCY MEDICAL SERVICES IS A SUBSIDIZED SERVICE THAT IS DEPENDENT ON APPROPRIATE FUNDING STREAMS. UCVH WILL CONTINUE TO STRIVE TO DEVELOP STRATEGIES TO IMPROVE AND MAINTAIN FINANCIAL PERFORMANCE THAT SUSTAINS EMERGENCY MEDICAL SERVICES IN THE REGION. TO THIS END, UCVH IS IN THE PROCESS OF AFFILIATING WITH OTHER HOSPITALS IN NORTHERN NH TO DEVELOP OF PLATFORM FOR SHARED SAVINGS AND REGIONAL NON-EMERGENCY SERVICES. THE GOAL OF THE AFFILIATION WILL BE TO MAINTAIN THE NECESSARY LEVELS OF PRIMARY CARE AND EMERGENCY CARE IN EVERY COMMUNITY.THERE WERE NO NEEDS SPECIFIED BY THE PUBLIC THAT UCVH, IN COLLABORATION WITH ISHC, WAS NOT ABLE TO MEET. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: WWW.UCVH.ORG PART I, LINE 7: PART I, LINES 7A-C; THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES.PART I, LINES 7E-I; THE HOSPITAL DETERMINES COST BY COMBINING DIRECT EXPENSES IDENTIFIED BY ITS ACCOUNTING SYSTEM WITH AN ESTIMATED OVERHEAD ALLOCATION. PART I, LINE 7G: SPECIALTY CARE PROVIDERS, LET NO WOMAN BE OVERLOOKED PART I, LN 7 COL(F): PART III, LINE 2-3; THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. THE CCR WAS THEN APPLIED TO BAD DEBT EXPENSE AT CHARGE VALUE IN ORDER TO ARRIVE AT THE ESTIMATED EXPENSE REPORTED. THE HOSPITAL ESTIMATED THAT APPROXIMATELY 3.2% OF THIS VALUE CAN BE ATTRIBUTED TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FAP. THIS ESTIMATE WAS SOLELY DERIVED FROM A SURVEY REPORTING THE AVERAGE % REPORTED FOR SIMILAR SIZED HOSPITALS. PART II, COMMUNITY BUILDING ACTIVITIES: THE COMMUNITY BUILDING ACTIVITIES UNDERTAKEN BY UCVH CONSIST OF SUPPORTING LOCAL GOVERNMENT AND OTHER HEALTH CARE PROVIDERS, COORDINATION OF DISASTER DRILLS, EMERGENCY PREPAREDNESS, AND SUPPORT OF OTHER LOCAL ORGANIZATIONS WITHIN THE COMMUNITY. IN ADDITION, IN AN EFFORT TO PROVIDE THE NECESSARY HEALTH CARE SERVICES FOR THE POPULATION WITHIN A REASONABLE DRIVING DISTANCE, UCVH HAS ENTERED INTO A COLLABORATION WITH THE OTHER TWO COOS COUNTY HOSPITALS TO PROVIDE NECESSARY SPECIALTY SERVICES FOR THE UCVH SERVICE AREA. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICE PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, INCLUDING BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND CO-PAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR ONLY PART OF THE BILL, THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL HAS ESTIMATED ITS COST OF BAD DEBT USING COST-TO-CHARGE METHODOLOGY IN ACCORDANCE WITH WORKSHEET 2 OF THE FORM 990 SCHEDULE H INSTRUCTIONS. PART III, LINE 8: ALLOWABLE COSTS COME FROM THE FILED COST REPORT. AS UCVH OPERATES AT A LOSS FROM MEDICARE, THE SHORTFALL COULD BE TREATED AS COMMUNITY BENEFIT AS THERE ARE NO OTHER FUNDS AVAILABLE TO SUBSIDIZE THE LOSS. UCVH USES CCR TO DETERMINE COST. REVENUE RECEIVED IS NET PATIENT REVENUE. PART III, LINE 9B: IF KNOWN TO QUALIFY FOR CHARITY OR FINANCIAL ASSISTANCE, PATIENTS ARE GIVEN THE ASSISTANCE NEEDED. PART VI, LINE 2: UCVH, WITH COLLABORATION FROM INDIAN STREAM HEALTH CENTER (A FEDERALLY QUALIFIED HEALTH CENTER), COMPLETED ITS LAST COMMUNITY HEALTH NEEDS ASSESSMENT IN 2013. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS CONDUCTED USING FOCUS GROUPS TO SOLICIT FEEDBACK FROM KEY STAKEHOLDERS, AND TO ANALYZE TRENDS IN REGARD TO POPULATION, HEALTH AND RISK FACTORS FOR THE COOS COUNTY. THE INFORMATION GATHERED IS THEN USED AS PART UCVH'S STRATEGIC PLANNING PROCESS. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS AVAILABLE ON THE ORGANIZATION'S WEBSITE. PART VI, LINE 3: UCVH HAS A FULL TIME PATIENT FINANCIAL COUNSELOR WHO IS RESPONSIBLE FOR WORKING WITH PATIENTS AND ANY WHO MAY BE BILLED FOR THEIR CARE TO DETERMINE THEIR ELIGIBILITY, ON A CASE BY CASE BASIS, FOR ANY GOVERNMENT PROGRAMS, SUCH AS MEDICAID OR THE UCVH FINANCIAL ASSISTANCE PROGRAM. ALL STAFF AT UCVH, PARTICULARLY REGISTRATION STAFF WHO WILL BE THE FIRST ONES TO NOTICE IF A PATIENT DOES NOT HAVE INSURANCE, ARE TRAINED TO REFER THE PATIENT TO THE FINANCIAL COUNSELOR. IN ADDITION, BROCHURES ARE AVAILABLE, AS IS CONTACT INFORMATION ON THE WEBSITE. PART VI, LINE 4: UCVH IS THE SMALLEST CRITICAL ACCESS HOSPITAL IN NEW HAMPSHIRE THAT SERVES THE LARGEST GEOGRAPHIC SERVICE AREA (OVER 850 SQUARE MILES) INCLUDING COMMUNITIES IN THE STATES OF NEW HAMPSHIRE, VERMONT, AND MAINE. ACCORDING TO THE NEW HAMPSHIRE STATE HEALTH PROFILE, OUR RESIDENTS ARE THE MOST FRAGILE OF ALL CITIZENS IN NEW HAMPSHIRE AS IT RELATES TO HEALTH OUTCOMES AND ECONOMIC CONDITIONS. UCVH IS DEPENDENT OF PUBLIC FUNDING AND DISPROPORTIONATE SHARE FUNDING TO SUBSIDIZE THE CARE PROVIDED TO THE PATIENTS WE SERVE. PART VI, LINE 7, REPORTS FILED WITH STATES NH 0 INDIAN STREAM HEALTH CENTER INC 2 CORLISS LN RR2 BOX 25 COLEBROOK NH 03576 200999212 501(C)3 12500 FMV MEDICAL SERVICESMEDICAL SERVICES X X X 0 0 0 0 0 0 0 0 0 EDWARD LAVERTY PA-C CHIEF OF STAFF 199666 0 0 0 0 0 3403 0 28930 0 231999 0 0 0 ROBERT ROSE MD PHYSICIAN, CHIEF MEDICAL OFFICER 352371 0 0 0 0 0 0 0 0 0 352371 0 0 0 CELESTE PITTS CHIEF FINANCIAL OFFICER 140237 0 0 0 0 0 4336 0 10998 0 155571 0 0 0 THOMAS COCHRAN PHYSICIAN 182991 0 0 0 0 0 0 0 0 0 182991 0 0 0 JOHN EPPOLIOTO PHYSICIAN 365590 0 0 0 0 0 1021 0 21237 0 387848 0 0 0 CHARANJIT VEDI PHYSICIAN 323604 0 0 0 0 0 5009 0 20053 0 348666 0 0 0 JOSEPH KIERNAN PHYSICIAN 263220 0 0 0 0 0 5104 0 859 0 269183 0 0 0 ROBERT GOOCH PHARMACIST 173576 0 0 0 0 0 3365 0 3799 0 180740 0 0 0 NICOLE PAIER-MULLEN PHYSICIAN, CHIEF MEDICAL OFFICER 270183 0 0 0 0 0 0 0 21303 0 291486 0 0 0 FORM 990, PART VII, SECTION A, LINE 5 AN UNRELATED ORGANIZATION, WEEKS MEDICAL CENTER EIN: 02-0222242, PROVIDES COMPENSATION TO CELESTE PITTS, INCLUDING REPORTABLE COMPENSATION AS REPORTED PER FORM W-2 BOX 5 OF $140,237 AND NONTAXABLE BENEFITS TOTALING $15,334, AS REPORTED IN FORM 990 PART VII, SECTION A. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT PROVIDE COMPENSATION DIRECTLY TO CELESTE PITTS FOR HER SERVICES PERFORMED AS THE CHIEF FINANCIAL OFFICER OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 3 NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT, LLC PROVIDES MANAGEMENT SERVICES TO THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PROVIDED TO THE FINANCE COMMITTEE FOR REVIEW AND APPROVAL BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS, AMD KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST DOCUMENT. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL CAO'S COMPENSATION AND BENEFIT PACKAGE IS REVIEWED PERIODICALLY BY COMMUNITY BOARD MEMBERS WHO GOVERN THE NON-PROFIT ORGANZATION AS UNPAID, INDEPENDENT VOLUNTEERS. THE PERIODIC REVIEW INCLUDES COMPARABILITY DATA, AND THE DELIBERATION AND DECISION-MAKING IS SUBSTANTIATED BY WRITTEN MINUTES. FORM 990, PART VI, SECTION C, LINE 18 UVCH MAKES ITS 990 AVAILABLE UPON REQUEST AND ON THE GUIDESTAR WEBSITE FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST FORM 990, PART VII CELESTE PITTS IS THE CFO FOR UCVH AND FOR WEEKS MEDICAL CENTER, TWO FIFTHS OF HER TIME IS SPENT AT UCVH. SHE RECEIVES A FORM W-2 FROM WEEKS MEDICAL CENTER. WEEKS MEDICAL CENTER IS PAID FOR HER TIME BY NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC, WHICH IS PAID BY UCVH. AN ALLOCATION OF HER CALENDAR-YEAR WAGES AND BENEFITS ARE INCLUDED ON PART VII. HER FISCAL-YEAR WAGES AND BENEFITS ARE NOT SHOWN SEPARATELY ON PART IX, LINE 5, BUT ARE INCLUDED IN THE PAYMENT TO NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC. NORTHERN NEW HAMPSHIRE HEALTHCARE COLLABORATIVE INC 462459559 HEALTHCARE NH 501(C)(3) LINE 9 0 NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC 455617105 MANAGEMENT SERVICES NH RELATED 0 1 0.33330 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 NORTHERN NH HEALTHCARE MANAGEMENT LLC M 345171