2016-05-13T08:07:23-05:00 2015-06-30 990 2014-07-01 562276994 DAVIE COUNTY EMERGENCY HEALTH CORPORATION DAVI 3369981300 223 HOSPITAL STREET MOCKSVILLE NC 27028 DANNY SQUIRES VP/CFO 3369981300 2016-05-04 2014 2016-08-17 19:52:53Z WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITAL CHAD BROWN 223 HOSPITAL STREET MOCKSVILLE NC 27028 39864808 0 X WWW.WAKEHEALTH.EDU/DAVIE-HOSPITAL/ X 2001 NC PROVISION OF PATIENT-CENTERED HEALTHCARE SERVICES TO THE SURROUNDING AREA 14 13 268 49 0 0 0 0 24152242 39839894 1102 4093 7433 20821 24160777 39864808 32000 26400 0 0 8832066 9954379 0 0 0 19656108 20174959 28520174 30155738 -4359397 9709070 20496583 27517085 26861729 24173161 -6365146 3343924 X THE MEDICAL CENTER'S MISSION IS TO IMPROVE THE HEALTH OF OUR REGION BY: PROVIDING EXCELLENT CARE & AN EXCEPTIONAL EXPERIENCE; PROMOTING HEALTH & WELLNESS THROUGH COMMUNITY PARTNERSHIPS; & CONNECTING PEOPLE TO THE WORLD CLASS EXPERTISE OF WAKE FOREST BAPTIST MEDICAL CENTER. 0 0 27468233 26400 39857129 DAVIE HOSPITAL PROVIDED MEDICAL, EMERGENCY, AND OUTPATIENT CARE SERVICES TO THE RESIDENTS OF DAVIE COUNTY, NORTH CAROLINA, AND THE SURROUNDING AREAS. DURING THE FISCAL YEAR, THE HOSPITAL HAD 81 LICENSED INPATIENT BEDS, 5,554 PATIENT DAYS WITH 228 INPATIENT ADMISSIONS, 24,822 OUTPATIENT CLINICAL VISITS AND 12,294 EMERGENCY ROOM VISITS. THE HOSPITAL'S VISIONTO BE A MEDICAL CENTER OF CHOICE, PROMOTING HEALTH AND SERVING AS A DESTINATION FOR EXCELLENCE IN PATIENT CARE.THE HOSPITAL'S VALUES- COMPASSION: RESPONSIVE TO THE PHYSICAL, EMOTIONAL, SPIRITUAL, AND INTELLECTUAL NEEDS OF ALL;-SERVICE: CULTIVATE SELFLESS CONTRIBUTION FOR THE GREATER GOOD;-EXCELLENCE: DEMONSTRATE THE HIGHEST STANDARDS OF PATIENT-CENTERED CARE, EDUCATION, RESEARCH, AND OPERATIONAL EFFECTIVENESS; - INTEGRITY: DEMONSTRATE FAIRNESS, HONESTY, SINCERITY, AND ACCOUNTABILITY;- COLLEGIALITY: FOSTER MUTUAL RESPECT, FACILITATE PROFESSIONAL GROWTH AND MENTORSHIP, AND REWARD TEAMWORK AND COLLABORATION; - INNOVATION: PROMOTE CREATIVITY TO ENHANCE DISCOVERY AND THE APPLICATION OF KNOWLEDGE; AND- DIVERSITY: HONOR INDIVIDUALITY AND PROTECT THE DIGNITY OF ALL. 27468233 1 0 0 1 0 0 0 0 0 0 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 13 0 1 268 1 0 0 0 0 0 0 0 0 0 0 X 14 13 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X DANNY SQUIRES 3362384287 223 HOSPITAL STREET MOCKSVILLE NC 27028 K BARBARA CARBONE MD CHAIRMAN 8.00 X X 0 0 0 KEVIN P HIGH MD CHAIRMAN 4.00 X X 0 0 0 C DANIEL BARRETT VICE CHAIR 2.00 X X 0 0 0 TERRY BRALLEY BOARD MEMBER 2.00 X 0 0 0 BETH DIRKS BOARD MEMBER 2.00 X 0 0 0 CRAIG M GREVEN MD BOARD MEMBER 2.00 X 0 0 0 HEATHER L HAYES BOARD MEMBER 2.00 38.00 X 0 36555 3030 RUSSELL HOWERTON MD BOARD MEMBER 2.00 X 0 0 0 WILLIAM F JUNKER BOARD MEMBER 2.00 X 0 0 0 ANDREW L KOMAN MD BOARD MEMBER 2.00 X 0 0 0 DOUGLAS NELSON BOARD MEMBER 2.00 X 0 0 0 LYNN PITMAN BOARD MEMBER 2.00 38.00 X 0 197559 20817 KEN RETHMEIER BOARD MEMBER 2.00 X 0 0 0 MARY RITTLING PHD BOARD MEMBER 2.00 X 0 0 0 STEPHEN ROBERTSON BOARD MEMBER 2.00 6.00 X 0 0 0 RONALD SMALL BOARD MEMBER 2.00 X 0 0 0 STEVEN C SNELGROVE BOARD MEMBER 2.00 X 0 42245 3417 CHARLES TEGELER MD BOARD MEMBER 2.00 X 0 0 0 KENNON WHITE BOARD MEMBER 2.00 X 0 0 0 CHAD BROWN PRESIDENT 40.00 X 0 176830 27805 CHAD ECKES TREASURER 10.00 X 0 0 0 MIKE RUTHERFORD TREASURER 10.00 X 0 0 0 J MCLAIN WALLACE JR SECRETARY 2.00 38.00 X 0 458252 105752 DINA MARTY ASSISTANT SECRETARY 2.00 38.00 X 0 0 0 H GREGORY BRAY ASSISTANT TREASURER 2.00 38.00 X 0 221679 24425 DANNY SQUIRES VP - CFO 15.00 25.00 X 210375 0 24310 DONNY C LAMBETH FORMER OFFICER 0.00 X 0 272778 6504 BRET NICKS MD FORMER OFFICER 10.00 30.00 X 414106 0 27930 624481 1405898 243990 0 1 1 1 LINCARE INC 3900 WESTPOINT BLVD WINSTON SALEM NC 27103 RESPIRATORY SPECIALISTS 570800 NURSEFINDERS PO BOX 3749 BATON ROUGE LA 70821 STAFFING 556834 ALLIANCE HEALTHCARE SERVICES 100 BAYVIEW CIRCLE NEWPORT BEACH CA 92660 MEDICAL SERVICES 140528 BLAKLEY LANDSCAPING SERVICES INC 274 BAITY ROAD MOCKSVILLE NC 27028 LANDSCAPING 133794 LINDE RSS REMEO LLC 104B WEST COURT SQUARE LIVINGTON TN 38570 RESPIRATORY SOLUTIONS 124900 7 PATIENT SERVICE REVENUE 621400 39839894 39839894 39839894 4093 4093 3586 0 3586 3586 3586 OTHER REVENUE 900099 17235 17235 17235 39864808 39857129 0 7679 26400 26400 7952139 6896095 1056044 262730 227839 34891 1054171 914177 139994 685339 594326 91013 14332 14332 24380 24380 2074 2074 2940354 2560042 380312 290137 290137 20057 17393 2664 21400 18558 2842 4899529 4248872 650657 12571 12571 35870 30831 5039 1866517 1618643 247874 53383 46294 7089 MEDICAL SUPPLIES 8067775 8067775 BAD DEBT EXPENSE 1451144 1451144 PROVIDER ASSESSMENT TAX 246712 246712 MISCELLANEOUS EXPENSE 228724 198350 30374 30155738 27468233 2687505 0 3515396 12329826 5501895 4848879 907429 911583 50000 13365094 4148695 10534668 9216399 37195 160398 20496583 27517085 23990908 20874985 2870821 3298176 26861729 24173161 X -6366158 3342911 1012 1013 -6365146 3343924 20496583 27517085 9709070 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 2074 2074 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). A PORTION OF THE MEMBERSHIP DUES PAID ARE ALLOCATED TO LOBBYING EFFORTS BY THOSE ORGANIZATIONS ON BEHALF OF THEIR MEMBERSHIPS. THE CURRENT PORTION OF MEMBERSHIP DUES ALLOCATED TO LOBBYING IS $2,074. 329832 222647 107185 13035262 3926048 9109214 9216399 ESTIMATED 3RD PARTY PAYABLE 829442 DUE TO NCBH 2468734 3298176 X PART X, LINE 2: THE HOSPITAL IS A TAX-EXEMPT ORGANIZATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS GENERALLY EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES IS MADE IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. THE HOSPITAL HAS DETERMINED THAT THEY DO NOT HAVE UNCERTAIN INCOME TAX POSITIONS AS OF JUNE 30, 2015 AND JUNE 30, 2014. ALSO, THE HOSPITAL DOES NOT ANTICIPATE ANY INCREASE OR DECREASE IN UNRECOGNIZED TAX BENEFITS DURING THE NEXT TWELVE MONTHS THAT WOULD RESULT IN A MATERIAL CHANGE IN THEIR FINANCIAL PRESENTATION. 1 1 X 1 X 1 X 1 1 1 0 1 1 2172163 2172163 0.07570 3389123 3627232 -238109 0.00000 93957 120410 -26453 0.00000 5655243 3747642 1907601 0.07570 26400 26400 0.00090 26400 26400 0.00090 5681643 3747642 1934001 0.07660 1 369688 8557358 10945852 -2388494 X 1 1 1 1 WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA 223 HOSPITAL STREET MOCKSVILLE NC 27028 WWW.WAKEHEALTH.EDU/DAVIE-HOSPITAL H0171 X X X X WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X WWW.WAKEHEALTH.EDU/DAVIE-MEDICAL-CENTER/ABOUT/COMMUNITY-BENEFITS.HTM X 1 12 1 WWW.WAKEHEALTH.EDU/DAVIE-MEDICAL-CENTER/ABOUT/COMMUNITY-BENEFITS.HTM 0 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X WWW.WAKEHEALTH.EDU/DAVIE-MEDICAL-CENTER/ABOUT/COMMUNITY-BENEFITS.HTM X WWW.WAKEHEALTH.EDU/DAVIE-MEDICAL-CENTER/ABOUT/COMMUNITY-BENEFITS.HTM X WWW.WAKEHEALTH.EDU/FINANCIAL-ASSISTANCE.HTM X X X X 1 0 X X X X 1 X 0 0 WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA PART V, SECTION B, LINE 5: THE COMMUNITY'S PERSPECTIVE WAS OBTAINED THROUGH A THIRTY QUESTION COMMUNITY SURVEY DISTRIBUTED TO DAVIE COUNTY RESIDENTS VIA SURVEY MONKEY. OVER 500 RESPONSES WERE RECEIVED, INCLUDING THOSE FROM A STOREHOUSE FOR JESUS (SHFJ). SHFJ SERVES WORKING POOR FAMILIES, FAMILIES WITHOUT INCOME, SINGLE PARENT FAMILIES, FAMILES AFFECTED BY ILLNESS, ELDERLY, DOMESTIC VIOLENCE FAMILIES AND THE HOMELESS/TRANSIENT POPULATION OF DAVIE COUNTY. THE HOSPITAL ALSO WORKED WITH PUBLIC HEALTH EXPERTS FROM THE DAVIE COUNTY HEALTH DEPARTMENT TO CONDUCT THE CHNA. WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA PART V, SECTION B, LINE 11: THE HOSPITAL IS EDUCATING THE COMMUNITY ON THE PRINCIPALS OF PROPER NUTRITION AND PHYSICAL ACTIVITY BY WORKING IN COLLABORATION WITH SMART START OF DAVIE COUNTY AND THE DAVIE CHAMBER OF COMMERCE TO DISSEMINATE INFORMATION AND ACTIVITY KITS ABOUT HEALTHY EATING, EXERCISE AND HEALTHY LIFESTYLE TIPS. IN ADDITION, THE HOSPITAL SPONSORS BOOTHS TO PROMOTE HEALTHY LIFESTYLES AND PROVIDES HEALTHY EATING TIPS THROUGH VISITS WITH A REGISTERED DIETITIAN OR PHYSICIAN. FINALLY, THE HOSPITAL PROVIDES FREE BMI SCREENINGS ANNUALLY TO INCREASE THE PUBLIC AWARENESS OF OBESITY.THE HOSPITAL WORKS WITH VARIOUS PARTNERS, INCLUDING THE DAVIE FAMILY YMCA, DAVIE COUNTY SENIOR CENTER AND THE PUBLIC HEALTH DEPARTMENT TO PROVIDE INFORMATION AND FREE SCREENINGS TO LOWER THE RISK OF HEART DISEASE. THE HOSPITAL'S HEALTHY HEART PROGRAMS INCLUDE BLOOD PRESSURE SCREENINGS, FREE SELF-HELP SMOKING CESSATION INFORMATION AND OTHER PROGRAMS RELATED TO CHRONIC HEART DISEASE AND PREVENTION IN THE COMMUNITY. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA PART V, SECTION B, LINE 16A WEBSITE: WWW.WAKEHEALTH.EDU/DAVIE-MEDICAL-CENTER/ABOUT/COMMUNITY-BENEFITS.HTM WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA PART V, SECTION B, LINE 16B WEBSITE: WWW.WAKEHEALTH.EDU/DAVIE-MEDICAL-CENTER/ABOUT/COMMUNITY-BENEFITS.HTM WAKE FOREST BAPTIST HEALTH-DAVIE HOSPITA PART V, SECTION B, LINE 16C WEBSITE: WWW.WAKEHEALTH.EDU/FINANCIAL-ASSISTANCE.HTM 14 DMC BERMUDA RUN - PHYSICAL THERAPY 313 NC HWY 801 BERMUDA RUN NC 27006 PHYSICAL THERAPY DMC BERMUDA RUN - OCCUPATIONAL THERAPY 313 NC HWY 801N BERMUDA RUN NC 27006 OCCUPATIONAL THERAPY DMC BERMUDA RUN - CARDIOLOGY 313 NC HWY 801 BERMUDA RUN NC 27006 CARDIAC REHAB DMC BERMUDA RUN - LAB 313 NC HWY 801 BERMUDA RUN NC 27006 PHLEBOTOMY DMC BERMUDA RUN - ORTHOPAEDICS 313 NC HWY 801 BERMUDA RUN NC 27006 X-RAY & ORTHOPEDICS DMC BERMUDA RUN - PULMONARY 329 NC HWY 801 - PLAZA 2 BERMUDA RUN NC 27006 PULMONARY FUNCTION LAB DMC BERMUDA RUN - RADIOLOGY 329 NC HWY 801 - PLAZA 2 BERMUDA RUN NC 27006 RADIOLOGY DMC BERMUDA RUN - NEUROLOGY 329 NC HWY 801 - PLAZA 2 BERMUDA RUN NC 27006 EEG/EMG TESTING DMC BERMUDA RUN - NEUROLOGY 329 NC HWY 801 - PLAZA 2 BERMUDA RUN NC 27006 SLEEP LAB DMC BERMUDA RUN - LAB 329 NC HWY 801 - PLAZA 2 BERMUDA RUN NC 27006 PHLEBOTOMY DMC EMERGENCY SERVICES 329 NC HWY 801 BERMUDA RUN NC 27006 EMERGENCY ROOM DMC BERMUDA RUN - EYE CENTER 313 NC HWY 801N BERMUDA RUN NC 27006 OPTHALMOLOGY DMC BERMUDA RUN - NEUROLOGY 313 NC HWY 801N BERMUDA RUN NC 27006 NEUROLOGY DMC BERMUDA RUN - PODIATRY 313 NC HWY 801N BERMUDA RUN NC 27006 PODIATRY PART I, LINE 3C: THE ORGANIZATION ALSO EVALUATES CERTAIN CREDIT FILE DATA ELEMENTS TO INDENTIFY POTENTIAL SOURCES OF HIDDEN INCOME TO MORE ACCURATELY INFORM CHARITY CARE ELIGIBILITY ASSESSMENTS. PATIENTS WITH ESTIMATED HOUSEHOLD INCOME BELOW 200% OF FPG, WHO ARE IDENTIFIED AS HAVING COMMERICAL CREDIT ACCOUNTS THAT ARE BEING SERVICED IN A MANNER THAT SUGGESTS ADDITIONAL SOURCES OF INCOME, ARE NOT AUTOMATICALLY GRANTED PRESUMPTIVE CHARITY CARE. PART I, LINE 7: THE ORGANIZATION USED THE WORKSHEETS PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H TO COMPUTE ITS COST TO CHARGE RATIO FOR PURPOSES OF THE 2014 SCHEDULE H. PART I, LN 7 COL(F): THE ORGANIZATION'S PATIENT BAD DEBT EXPENSE PER THE AUDITED FINANCIALS STATEMENTS WAS $1,451,144. THIS AMOUNT WAS REMOVED FROM THE CALCULATION OF CHARITY CARE. PART I, LINE 7B - MEDICAID DIRECT OFF SETTING REVENUE THE HOSPITAL PARTICIPATES IN A PROVIDER ASSESSMENT PROGRAM ADMINISTERED BY THE NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES. UNDER THE PROGRAM, A FEE IS ASSESSED AGAINST NON-MEDICAID PATIENT SERVICE REVENUE OF PRIVATE HOSPITALS. THE FEDERAL GOVERNMENT MATCHES THE ASSESSMENT AT A RATE OF 2 TO 1 AND THESE AMOUNTS ARE ALLOCATED TO NORTH CAROLINA HOSPITALS QUARTERLY. ADDITIONALLY, THE HOSPITAL PARTICIPATES IN THE NORTH CAROLINA MEDICAID REIMBURSEMENT INITIATIVE (MRI). UNDER THE MRI, THE HOSPITAL RECEIVES ADDITIONAL REIMBURSEMENT BASED ON MEDICAID COST DEFICITS AND TREATMENT OF A DISPROPORTIONATE SHARE OF UNINSURED PATIENTS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A DISCRETE FOOTNOTE EXPLAINING BAD DEBT EXPENSE. BAD DEBT HAS NOT BEEN INCLUDED IN THE COMPUTATION OF COMMUNITY BENEFIT ON PART I, LINE 7. AMOUNTS USED TO COMPUTE CHARITY CARE AND BAD DEBT ON SCHEDULE H USE THE MOST CURRENT DATA AVAILABLE AT THE TIME OF FILING. THE ORGANIZATION USED WORKSHEET 2 OF THE 2014 SCHEDULE H INSTRUCTIONS TO COMPUTE A COST TO CHARGES RATIO USED TO CALCULATE BAD DEBT AT COST. PART III, LINE 8: THE HOSPITAL USES AN OVERALL COST TO CHARGE RATIO CALCULATION BASED ON AUDITED FINANCIAL STATEMENTS BUT REMOVES COSTS ASSOCIATED WITH BAD DEBT, GME, COMMUNITY BUILDING AND CHARITY CARE. PART III, LINE 9B: PATIENT FINANCIAL RESOURCES SERVICES WORKS WITH THE PATIENT FOR ANY PATIENT LIABILITY. OUR MAIN FOCUS IS PRIOR TO SERVICES AND/OR DISCHARGE; HOWEVER, WE DO WORK WITH PATIENTS AFTER SERVICES HAVE BEEN RECEIVED AND BILLED. PATIENT FINANCIAL RESOURCES SERVICES IS REALLY TWO AREAS IN ONE--THE RESOURCE RECOVERY SPECIALIST/RRS (FORMERLY FINANCIAL COUNSELING) AND THE MEDICAID ELIGIBILITY TEAM/MPS. THESE TWO AREAS WORK TOGETHER TO FIND A RESOLUTION TO PATIENT LIABILITY, SELF PAY OR INSURED. THE RRS WORKS TO NOTIFY THE PATIENT OF ANY PATIENT LIABILITY AND ASK FOR PAYMENT FOR THAT LIABILITY. IF THE PATIENT INDICATES THAT HE/SHE NEEDS ASSISTANCE, THEN THE RRS WILL COMPLETE A FINANCIAL STATEMENT ON THE PATIENT. WHILE TAKING THAT FINANCIAL STATEMENT THE RRS IS LOOKING FOR INFORMATION THAT COULD QUALIFY THE PATIENT FOR MEDICAID OR FOR OTHER AGENCY PROGRAMS THAT ARE AVAILABLE TO THE MEDICAL CENTER. WHEN THAT INFORMATION IS IDENTIFIED THE RRS WILL LET THE PATIENT KNOW THAT A REFERRAL WILL BE MADE FOR MEDICAID OR OTHER ASSISTANCE AND A MPS WILL BE IN TOUCH WITH HIM/HER. THE RRS ALSO EXPLAINS TO THE PATIENT OR FAMILY THAT CHARITY CARE IS A LAST RESORT AND THEY MUST COOPERATE WITH ANY OTHER ASSISTANCE PROGRAMS THAT WE HAVE IDENTIFIED AND BE FOUND INELIGIBLE BEFORE CHARITY CARE WILL BE APPROVED/APPLIED. IT IS ALSO COMMUNICATED WITH THE PATIENT OR FAMILY IS INFORMED IF ANY SUPPORTING DOCUMENTATION IS NEEDED FOR ANY ASSISTANCE, WHETHER THAT BE CHARITY, MEDICAID, OR OTHER PROGRAMS. PART VI, LINE 2: THE BOARD OF TRUSTEES APPROVED THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT ON MAY 7, 2013. A COMMUNITY WIDE TEAM COMPRISED OF THE DAVIE COUNTY HEALTH DEPARTMENT, THE HOSPITAL, UNITED WAY, STOREHOUSE FOR JESUS, THE YMCA AND OTHER COMMUNITY GROUPS, THE DAVIE COUNTY GOVERNMENT AND OTHERS CONVENED TO CONDUCT A COLLABORATIVE COMMUNITY HEALTH NEEDS ASSESSMENT WITH INPUT FROM COUNTY HEALTH EXPERTS, KEY COMMUNITY LEADERS AND THE PUBLIC (THROUGH SURVEYS). THE HOSPITAL ALSO PARTICIPATES IN A WIDE VARIETY OF LOCAL COALITIONS, INCLUDING SEVERAL SPONSORED BY THE DAVIE COUNTY HEALTH DEPARTMENT - CHRONIC DISEASE COMMITTEE AND THE COUNTY WELLNESS COMMITTEE, AS WELL AS PARTNERSHIPS AND SPONSORSHIPS WITH MANY COMMUNITY BASED ORGANIZATIONS. PART VI, LINE 3: THE ORGANIZATION USES A VARIETY OF MEANS TO EDUCATE AND INFORM PATIENTS OF THEIR CHARITY CARE OPTIONS, INCLUDING INFORMATION ON A WEBSITE, BILLING PAMPHLETS AVAILABLE IN CLINICAL OFFICES AND THE BUSINESS OFFICE, SIGNS IN CHECK-IN AREAS, INFORMATION ON PATIENT BILL STATEMENTS, AND FROM STAFF MEMBERS DURING CONVERSATIONS CONCERNING A PATIENT'S LIABILITY FOR SERVICES. THE HOSPITAL EMPLOYS A ROBUST PRE-SERVICE FINANCIAL CLEARANCE PROCESS THAT SCREENS PATIENTS PRIOR TO SERVICE DELIVERY FOR EXISTING OR AVAILABLE PAYER SOURCES AS A MEANS OF AVOIDING BAD DEBT AND INAPPROPRIATE BILLING TO PATIENTS WITHOUT THE MEANS TO PAY. IF A PAYER SOURCE IS IDENTIFIED, HOSPITAL STAFF ASSIST THE PATIENT WITH ENROLLMENT. PART VI, LINE 4: DAVIE HOSPITAL SERVES DAVIE COUNTY, NORTH CAROLINA AND THE SURROUNDING AREAS. THE POPULATION OF DAVIE COUNTY IS APPROXIMATELY 42,000 ACCORDING TO THE U.S. CENSUS BUREAU. 11.7 % OF THE POPULATION IS AT OR BELOW THE POVERTY LEVEL. 87.5% OF THE POPULATION IS WHITE, 6.3% IS AFRICAN AMERICAN, AND 6.2% IS OTHER DEMOGRAPHICS. THE UNEMPLOYMENT RATE IN MARCH 2011 WAS 9.7%. THE MEDIAN INCOME IS $59,503. THE GROWTH RATE OF THE COMMUNITY IS 1.9%. PART VI, LINE 5: HOSPITAL REPRESENTATIVES ATTEND NUMEROUS HEALTH FAIRS AND PERFORM CHOLESTROL SCREENING CHECKS. THE HOSPITAL ALSO INVITES THE COMMUNITY TO ATTEND ITS LADIES' NIGHT OUT EVENT TO PROMOTE BREAST HEALTH AND BREAST CANCER AWARENESS. THE HOSPITAL IS INVOLVED WITH THE LOCAL SENIOR CENTER AND PROVIDES HEALTH EDUCATION ON VARIOUS TOPICS THROUGH OUT THE YEAR. PART VI, LINE 6: THE MEMBER OF THE ORGANIZATION IS NORTH CAROLINA BAPTIST HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES NC 1 1 0 0 0 0 0 0 0 LYNN PITMAN BOARD MEMBER 0 189013 0 8057 0 489 0 5067 0 15750 0 218376 0 0 CHAD BROWN PRESIDENT 0 126408 0 30000 0 20422 0 15471 0 12334 0 204635 0 0 J MCLAIN WALLACE JR SECRETARY 0 398920 0 39900 0 19432 0 86901 0 18851 0 564004 0 0 H GREGORY BRAY ASSISTANT TREASURER 0 213217 0 7608 0 854 0 5711 0 18714 0 246104 0 0 DANNY SQUIRES VP - CFO 195375 0 15000 0 0 0 4597 0 19713 0 234685 0 0 0 DONNY C LAMBETH FORMER OFFICER 0 0 0 0 0 272778 0 0 0 6504 0 279282 0 0 BRET NICKS MD FORMER OFFICER 249181 0 164745 0 180 0 5693 0 22237 0 442036 0 0 0 PART I, LINES 4A-B CERTAIN EXECUTIVES PARTICIPATE IN OR RECEIVE PAYMENTS FROM SEVERANCE AND SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLANS PROVIDED BY A RELATED ORGANIZATION. THE DETERMINATION OF THE AMOUNT OF THE FOLLOWING SEVERANCE PAYMENTS FOLLOW THE RELATED ORGANIZATION'S COMPENSATION PROCEDURES AS OUTLINED IN PART VI, SECTION B, LINE 15 OF THEIR FORM 990. SEVERANCE - DONNY C. LAMBETH $272,778 - HEATHER HAYES $16,158 FORM 990, PART VII, LINE 5 COMPENSATION FROM UNRELATED ORGANIZATIONS LISTED IN PART VII AND SCHEDULE J, PART II -DANNY SQUIRE'S COMPENSATION WAS PROVIDED BY LEXINGTON MEDICAL CENTER, AN UNRELATED TAX-EXEMPT ORGANIZATION. -BRETT NICKS M.D.'S COMPENSATION WAS PROVIDED BY WAKE FOREST UNIVERSITY HEALTH SCIENCES, AN UNRELATED TAX-EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 3 AS ESTABLISHED IN THE ORGANIZATIONS BYLAWS, THE BOARD OF TRUSTEES MAY ESTABLISH AN EXECUTIVE COMMITTEE CONSISTING OF THREE OR MORE TRUSTEES, THE MAJORITY OF WHOM SHALL BE NORTH CAROLINA BAPTIST HOSPITAL (NCBH) TRUSTEES AND THE REMAINDER SHALL BE DAVIE HOSPITAL TRUSTEES. DURING THE INTERVALS BETWEEN MEETINGS OF THE BOARD OF TRUSTEES, THE EXECUTIVE COMMITTEE SHALL HAVE AND MAY EXERCISE THE POWERS OF THE BOARD OF TRUSTEES IN THE MANAGEMENT OF THE BUSINESS AND AFFAIRS OF THE CORPORATION; PROVIDED THAT THE EXECUTIVE COMMITTEE MAY NOT TAKE ANY ACTION THAT WOULD REQUIRE A SUPERMAJORITY VOTE OF THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS NORTH CAROLINA BAPTIST HOSPITAL, A NORTH CAROLINA NONPROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE THE RIGHT AT ALL TIMES, WITH RESPECT TO THE ORGANIZATION, TO ELECT AND REMOVE THE TRUSTEES, AS PROVIDED IN THE ORGANIZATION'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE THE RIGHT AT ALL TIMES, WITH RESPECT TO THE ORGANIZATION, TO APPROVE OF THE SALE, LEASE, OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION, AS PROVIDED IN THE ORGANIZATION'S BYLAWS. THE SOLE MEMBER MAY ACT WITHOUT A MEETING. FORM 990, PART VI, SECTION B, LINE 11 THE FILING ORGANIZATION'S BOARD OF DIRECTORS RECEIVES COPIES OF THE FORM 990 WITH SUFFICIENT TIME TO PERMIT REVIEW, COMMENT, AND QUESTIONS PRIOR TO ITS FILING. THE AUDIT AND COMPLIANCE COMMITTEES OF THE GOVERNING BOARDS OF WFUHS AND NCBH REVIEW IN ADDITIONAL DETAIL THE FILING ORGANIZATION'S FORM 990 WITH THE ORGANIZATION'S CHIEF FINANCIAL OFFICER OR HIS DESIGNEE, WHO ANSWERS QUESTIONS AND ADDRESSES CONCERNS RAISED BY SUCH COMMITTEE MEMBERS OR OTHER FILING ORGANIZATION DIRECTORS. IF MODIFICATIONS ARE REQUIRED FOLLOWING SUCH REVIEW AND COMMENT, THE REVISED FORM 990 IS REDISTRIBUTED TO ALL DIRECTORS PRIOR TO ITS FILING WITH THE IRS, ALONG WITH A REPORT NOTING THE MODIFICATIONS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ITS OFFICERS, DIRECTORS AND ANY KEY EMPLOYEES TO REVIEW THE CONFLICT OF INTEREST POLICY AND DISCLOSE ANY POTENTIAL CONFLICTS OF INTERESTS ANNUALLY AND AS THEY ARISE. ANY ITEMS DISCLOSED ARE REVIEWED AND MANAGED IN ACCORDANCE WITH THE ORGANIZATION'S POLICY ON CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION PAYS NO COMPENSATION TO OFFICERS, DIRECTORS OR KEY EMPLOYEES. ALL COMPENSATION PAID TO OFFICERS AND DIRECTORS AND FORMER OFFICERS AND DIRECTORS WAS PAID BY RELATED ORGANIZATIONS. COMPENSATION PAID TO THESE INDIVIDUALS ARE REVIEWED AND APPROVED IN ACCORDANCE WITH THE RELATED ORGANIZATION'S COMPENSATION POLICIES AND PROCEDURES WHICH INCLUDE INDEPENDENT COMPENSATION CONSULTANTS, COMPENSATION SURVEYS AND STUDIES TO DETERMINE THE APPROPRIATENESS OF EACH OFFICERS AND DIRECTORS' COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. NORTH CAROLINA BAPTIST HOSPITAL MEDICAL CENTER BLVD WINSTON SALEM NC 27157 560552787 HEALTHCARE NC 501(C)(3) LINE 3 N/A 0 NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION MEDICAL CENTER BLVD WINSTON SALEM NC 27157 561685120 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11A, I NORTH CAROLINA BAPTIST HOSPITAL 0 THE REHABILITATION & SKILLED NURSING FACILITY AT OAK SUMMIT MEDICAL CENTER BLVD WINSTON SALEM NC 27157 561826396 HEALTHCARE (INACTIVE) NC 501(C)(3) LINE 9 NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION 0 THE HAWTHORNE INN & CONFERENCE CENTER INC 420 HIGH STREET WINSTON SALEM NC 27101 561793617 LODGING/ CONFERENCE ACCOMMODATION NC 501(C)(3) LINE 11A, I NORTH CAROLINA BAPTIST HOSPITAL 0 CARENET INC 2000 WEST FIRST STREET SUITE 410 WINSTON SALEM NC 27104 561977341 HEALTHCARE NC 501(C)(3) LINE 11B, II NORTH CAROLINA BAPTIST HOSPITAL 0 FAITHHEALTH INNOVATIONS INC MEDICAL CENTER BLVD WINSTON SALEM NC 27157 237426944 HEALTHCARE NC 501(C)(3) LINE 9 NORTH CAROLINA BAPTIST HOSPITAL 0 DAVIE COUNTY HOSPITAL FOUNDATION 156 ROLAND RD MOCKSVILLE NC 27028 581477280 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11C, III-FI N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0