2015-02-04T12:02:49-06:00 2014-06-30 010242373 MACPAGE LLC 30 LONG CREEK DRIVE SOUTH PORTLAND ME 04106 990 2013-07-01 010284446 REDINGTON-FAIRVIEW GENERAL HOSPITAL REDI 2074745121 PO BOX 468 SKOWHEGAN ME 049760468 ELMER DOUCETTE CFO 2074745121 2015-02-02 1 GEORGE RAFUSE P00340697 2077745701 2015-02-02 2013 2016-03-07 17:11:31Z PO BOX 468 SKOWHEGAN ME 049760468 81089005 0 X WWW.RFGH.NET X 1969 ME SEE SCHEDULE O 9 6 744 35 0 0 2323659 1981712 75333058 77566822 1054884 1272066 251757 268405 78963358 81089005 0 0 0 0 44421042 45468399 0 0 0 35327969 36835768 79749011 82304167 -785653 -1215162 95979301 101992529 35479448 36796290 60499853 65196239 X SEE SCHEDULE O 0 0 40613763 52061485 RFGH PROVIDES 24 HOUR SEVEN DAY A WEEK EMERGENCY SERVICES. THESE SERVICES INCLUDE AN EMERGENCY DEPARTMENT STAFFED WITH PHYSICIANS 24 HOURS A DAY AS WELL AS AN AMBULANCE SERVICE WHICH OPERATES 24 HOURS A DAY. DURING FISCAL 2014, RFGH HAD 22,905 EMERGENCY DEPARTMENT VISITS AND 3,720 AMBULANCE RUNS. IN ADDITION TO EMERGENCY SERVICES, THE HOSPITAL PROVIDES A FULL RANGE OF SERVICES, RADIOLOGY, C.T., ULTRASOUND, NUCLEAR MEDICINE, BLOOD BANK, PATHOLOGY, CARDIOLOGY AND LABORATORY SERVICES. IN TOTAL, THESE SERVICES TREATED APPROXIMATELY 44,659 PATIENTS. 16432312 7124614 RFGH OPERATES A NUMBER OF PHYSICIAN OFFICES IN ORDER TO BETTER SERVE THE RESIDENTS OF SOMERSET COUNTY. DURING FISCAL 2014, THESE PHYSICIAN SPECIALTIES INCLUDED INTERNAL MEDICINE,ENDOCRINOLOGY,GENERAL SURGERY, ORTHOPEDICS, PEDIATRICS,FAMILY MEDICINE,OBSTETRICS GASTROENTEROLOGY AND NEUROLOGY. DURING FISCAL 2014, THESE PHYSICIAN SPECIALTIES SERVED 13,545 PATIENTS WHO TOTALLED 56,219 VISITS AT THESE OFFICES. 12564527 18649129 RFGH IS LICENSED AS A CRITICAL ACCESS HOSPITAL OPERATING 25 BEDS. RFGH EMPLOYS HOSPITALISTS WHO ARE PHYSICIANS DEDICATED TO THE TREATMENT OF INPATIENTS. INPATIENT SERVICES INCLUDE MEDICAL AND SURGICAL, SPECIAL CARE, OBSTETRICS AND PEDIATRICS. DURING FISCAL 2014, RFGH PROVIDED INPATIENT SERVICES TO 1,546 PATIENTS WHO STAYED 5,100 PATIENT DAYS. MEDICARE AND MEDICAID PATIENTS REPRESENTED 77% OF RFGH'S INPATIENTS. 1613294 1529633 REDINGTON-FAIRVIEW GENERAL HOSPITAL OPERATES SOMERSET PUBLIC HEALTH, A PROGRAM WHOSE PURPOSE IS TO PROTECT AND IMPROVE THE QUALITY OF LIFE AND HEALTH OF ALL GREATER SOMERSET COUNTY RESIDENTS. 1613294 1529633 71223896 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 91 0 1 744 1 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X RICHARD D WILLETT 2078582315 46 FAIRVIEW AVE SKOWHEGAN ME 049760468 CHRISTOPHER PERKINS PRESIDENT 2.00 X X 0 0 0 L JOSEPH CLARK VICE PRESIDENT 2.00 X X 0 0 0 JEFFREY LLOYD DIRECTOR 2.00 X 0 0 0 DONNA FINLEY DIRECTOR 2.00 X 0 0 0 MICHAEL CURRAN MD DIRECTOR 50.00 X 431301 0 0 WILLIAM LANEY TREASURER 2.00 X X 0 0 0 MICHAEL LAMBKE MD DIRECTOR 50.00 X 239417 0 0 JOHN WITHERSPOON DIRECTOR 2.00 X 0 0 0 GINA GOMEZ MD DIRECTOR 50.00 X 268714 0 0 RICHARD D WILLETT CEO/SECRETARY 50.00 X 364897 0 0 DANA C KEMPTON CFO 50.00 X 260209 0 0 TIRUNELLAI R SHANKAR SURGEON 50.00 X 323657 0 0 AMIR BAIG MD ANESTHESIOLOGIST 50.00 X 333916 0 0 JOHN COMIS MD ER PHYSICIAN 50.00 X 342581 0 0 MANJUNATH BANNUR MD ER PHYSICIAN 50.00 X 284593 0 0 WINOAH HENRY MD GASTROENTEROLOGIST 50.00 X 365621 0 0 3214906 0 0 38 0 1 0 VISTA STAFFING SOLUTIONS 275 EAST 200 SOUTH SALT LAKE CITY UT 84111 CLINICAL STAFFING 1394916 QUEST DIAGNOSTIC INC 5763 COLLECTION CENTER DR CHICAGO IL 60693 LAB TESTING 495338 DAHL-CHASE DIAGNOSTIC SERVICES 417 STATE STREET BANGOR ME 04401 LAB TESTING 492984 COMPHEALTH PO BOX 972651 DALLAS TX 75297 CLINICAL STAFFING 457255 MAINEGENERAL HEALTH 33 STONE STREET AUGUSTA ME 04330 LAB TEST & CLINICAL STAFFING 394562 14 824156 1157556 1981712 NET PATIENT REVENUE 622110 77566822 77566822 77566822 1272066 1272066 CAFETERIA 622110 254411 254411 OTHER MISCELLANEOUS 622110 13994 13994 268405 81089005 77580816 0 1526477 1564538 939432 625106 33862564 29973760 3888804 1513198 1271086 242112 6151615 5167357 984258 2376484 1996247 380237 55261 55261 109005 24833 84172 10270 10270 243578 12604 230974 4461964 4353151 108813 293359 293359 7455361 6973958 481403 2787569 608801 2178768 1303214 1149693 153521 104440 103110 1330 238777 203622 35155 1089617 937070 152547 3440680 2827985 612695 742651 605538 137113 BAD DEBT EXPENSE 7322462 7322462 EQUIPMENT & MAINTENANCE 3122390 2865136 257254 MEDICAID PROVIDER TAX 1574203 1574203 PHARMACEUTICALS 1260210 1260210 1220757 1053638 167119 82304167 71223896 11080271 0 3009011 1474138 5094548 9541144 10512090 10717369 496491 486469 1392696 1508274 96401 131158 71818972 44731494 26306934 27087478 39835391 50310530 9235739 735969 95979301 101992529 7083803 8165135 23135190 22350718 5260455 6280437 35479448 36796290 X 59687418 64116694 812435 1079545 60499853 65196239 95979301 101992529 X -1215162 4141369 1770179 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 10270 10270 10270 10270 82293897 82293897 82304167 82304167 1000000 1000000 250000 250000 0 0 0 0 1000000 1000000 1000000 1000000 4000000 6000000 8973 9178 9617 10270 38038 250000 250000 250000 250000 1000000 1500000 340981 340981 41219031 20393977 20825054 30258960 24337517 5921443 27087478 LIABILITY FOR PENSION BENEFITS 3095584 ESTIMATED THIRD PARTY SETTLEMENTS 3184853 6280437 X 77907912 4141369 4141369 73766543 7322462 7322462 81089005 74981705 0 74981705 7322462 7322462 82304167 PART X, LINE 2: SCHEDULE D - PART X: THE HOSPITAL IS EXEMPT FROM TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. MANAGEMENT EVALUATED THE HOSPITAL'S TAX POSITIONS AND CONCLUDED THAT THE HOSPITAL HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRED ADJUSTMENT TO THE FINANCIAL STATEMENTS. THE HOSPITAL HAS PROCESSES PRESENTLY IN PLACE TO ENSURE THE MAINTENANCE OF ITS TAX-EXEMPT STATUS; TO IDENTIFY AND REPORT UNRELATED INCOME AS NECESSARY; DETERMINE ITS FILING AND TAX OBLIGATIONS IN JURISDICTIONS FOR WHICH IT HAS NEXUS; AND TO REVIEW OTHER MATTERS THAT MAY BE CONSIDERED TAX POSITIONS. THE HOSPITAL IS SUBJECT TO U.S. FEDERAL AND STATE EXAMINATIONS BY TAX AUTHORITIES FOR YEARS ENDING JUNE 30, 2011 THROUGH 2014. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 7,322,462. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 7,322,462. 1 1 1 X 1 X 1 1 0 0 1383318 1383318 0.01680 1383318 1383318 0.01680 1677655 1677655 0.02040 16432312 7124614 9307698 0.11310 18109967 7124614 10985353 0.13350 19493285 7124614 12368671 0.15030 1 3773561 27496233 27787338 -291105 X 1 1 1 1 REDINGTON-FAIRVIEW GENERAL HOSPITAL 46 FAIRVIEW AVENUE PO BOX 468 SKOWHEGAN ME 04976 WWW.RFGH.NET 38095 X REDINGTON-FAIRVIEW GENERAL HOSPITAL 1 1 X X X X X X 12 1 1 1 X HTTPS://WWW.RFGH.NET/PORTALS/0/PDFS/COMMU X SEE COMPLETE URL IN PART VI X X X X X X X 1 0 1 1 150.000000000000 1 225.000000000000 1 X 1 1 X X X X X 0 0 X X X X 1 X 0 0 REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 3: HOW THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY AND IDENTIFY THE PERSONS THE HOSPITAL CONSULTED:THE ORIGINAL SOURCE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT IS THE SOMERSET COUNTY HEALTH COLLABORATIVE WHICH IS COMPOSED OF MANY COMMUNITY ORGANIZATIONS SUCH AS THE POLICE DEPARTMENT, SMALL BUSINESSES, RELIGIOUS GROUPS, BEHAVIORAL HEALTH GROUPS, SCHOOL SYSTEMS, AND OTHER RESOURCE GROUPS. AT THE REGIONAL LEVEL, SOMERSET PUBLIC HEALTH HAS TWO REPRESENTATIVES THAT PARTICIPATE ON THE CENTRAL DISTRICT GROUP WHERE COLLABORATION WITH OTHER HEALTH SYSTEMS OCCURS. REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 4: OTHER HOSPITALS INCLUDED IN CONDUCTING COMMUNITY HEALTH NEEDS ASSESSMENT:THE 2012 COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN COLLABORATION WITH: MAINEGENERAL HEALTH, EASTERN MAINE MEDICAL CENTER, AND MAINE MEDICAL CENTER. REDINGTON-FAIRVIEW GENERAL HOSPITAL PART V, SECTION B, LINE 20D: HOW HOSPITAL DETERMINED THE MAXIMUM AMOUNTS THAT CAN BE CHARGED FAP-ELIGIBLE INDIVIDUALS:ALL ACCOUNT GUARANTORS WHO EXPRESS AN INABILITY TO PAY FOR SERVICES ARE SCREENED FOR ELIGIBILITY FOR FINANCIAL ASSISTANCE USING AN APPLICATION AND GUIDELINES ESTABLISHED BY THE HOSPITAL. UNDER THESE GUIDELINES, ELIGIBLE APPLICANTS MAY QUALIFY FOR 100% CHARITY CARE OR DISCOUNTED CHARGES RANGING FROM 25% TO 100%. PART I, LINE 7: METHODOLOGY USED TO ESTIMATE FINANCIAL ASSISTANCE AT COST:CHARITY CARE WRITE-OFFS ARE RECORDED AT GROSS CHARGES. IN ORDER TO COMPUTE THE COST OF THESE SERVICES, THE HOSPITAL ADJUSTED BOTH GROSS CHARGES AND EXPENSES BY EXCLUDING THE GROSS CHARGES AND EXPENSES ASSOCIATED WITH SUBSIDIZED HEALTH SERVICES REPORTED IN SCHEDULE H PART I LINE 7G AND CALCULATED A RATIO OF COST-TO-CHARGES. THE RESULTING RATIO OF 51.53% WAS APPLIED TO THE GROSS CHARGES PERTAINING TO CHARITY CARE WRITE-OFFS.METHODOLOGY USED TO ESTIMATE COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS:THESE COMMUNITY BENEFIT EXPENSES REPRESENT THE ACTUAL EXPENDITURES OF OPERATING THE SOMERSET PUBLIC HEALTH COLLABORATIVE WHICH SERVES MOST OF MAINE'S SOMERSET COUNTY. PART I, LINE 7G: METHODOLOGY USED TO ESTIMATE SUBSIDIZED HEALTH SERVICES:THESE COMMUNITY BENEFIT EXPENSES REPRESENT THE DIRECT AND INDIRECT COSTS OF OPERATING PHYSICIAN PRACTICES WHICH OPERATE WITH REVENUES THAT ARE INSUFFICIENT TO COVER THE OVERALL COSTS. INDIRECT COSTS ARE CALCULATED USING AN ALLOCATION METHOD SIMILAR TO MEDICARE COST REPORT METHODS OF ALLOCATING OVERHEAD COSTS. PART III, LINE 2: BAD DEBT WRITE-OFFS ARE RECORDED AT GROSS CHARGES. IN ORDER TO COMPUTE THE COST OF THESE SERVICES, THE HOSPITAL ADJUSTED BOTH GROSS CHARGES AND EXPENSES BY EXCLUDING THE GROSS CHARGES AND EXPENSES ASSOCIATED WITH SUBSIDIZED HEALTH SERVICES REPORTED IN SCHEDULE H PART I LINE 7G AND CALCULATED A RATIO OF COST-TO-CHARGES. THE RESULTING RATIO OF 51.53% WAS APPLIED TO THE GROSS CHARGES PERTAINING TO BAD DEBT WRITE-OFFS. PART III, LINE 4: FOOTNOTE DESCRIBING BAD DEBTSNOTE 2 - CONCENTRATION OF CREDIT RISKIN FULFILLING ITS CHARITABLE MISSION, THE HOSPITAL GRANTS CREDIT WITHOUT COLLATERAL TO THEIR PATIENTS, MANY OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. AT JUNE 30, 2014 AND 2013, NET ACCOUNTS RECEIVABLE RELATING TO PATIENTS WITHOUT INSURANCE WAS 24.0% AND 13.1%, RESPECTIVELY.ACCOUNTS RECEIVABLE ARE STATED AT THE AMOUNT THAT MANAGEMENT EXPECTS TO COLLECT. MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS THROUGH A CHARGE TO THE CONSOLIDATED STATEMENT OF OPERATIONS AND A CREDIT TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON ITS ASSESSMENT OF THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE ACCOUNT AND A CREDIT TO ACCOUNTS RECEIVABLE.IN ADOPTING ACCOUNTING STANDARD UPDATE 2011-07 - PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES (ASU 2011-07), THE HOSPITAL RECLASSIFIED $7,322,462 AND $6,554,465 IN FISCAL 2014 AND 2013, RESPECTIVELY, FROM OPERATING EXPENSES TO DEDUCTION FROM REVENUES.ACCOUNTS RECEIVABLE AT JUNE 30, 2014 AND 2013 ARE COMPRISED OF THE FOLLOWING:_______________________________________2014__________________2013 PATIENT ACCOUNTS___________________$19,107,740______________$20,320,105ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS(3,640,921)____________(4,254,500)ALLOWANCE FOR CONTRACTUAL ALLOWANCES(4,749,449)____________(5,553,514)ACCOUNT RECEIVABLE - NET__________$ 10,717,370_____________$10,512,091 PART III, LINE 8: MEDICARE SHORTFALL METHOD OF CALCULATING:MEDICARE COSTS WERE OBTAINED FROM THE FILED MEDICARE COST REPORT. THE COSTS ARE BASED ON MEDICARE ALLOWABLE COSTS AS REPORTED ON WORKSHEET B. INPATIENT MEDICARE COSTS ARE CALCULATED BASED UPON A COMBINATION OF ALLOWABLE COST PER DAY MULTIPLIED BY MEDICARE DAYS FOR ROUTINE SERVICES PLUS A COST-TO-CHARGE RATIO MULTIPLIED BY MEDICARE CHARGES BY ANCILLARY DEPARTMENT. OUTPATIENT COST IS CALCULATED BASED ON A COST-TO-CHARGE RATIO MULTIPLIED BY MEDICARE CHARGES BY ANCILLARY DEPARTMENT. PART III, LINE 9B: THE HOSPITAL'S COLLECTION POLICY CONTAINS THE GUIDELINES FOR FINANCIAL ASSISTANCE, AND CONTAINS PROVISIONS FOR HOSPITAL STAFF TO EXTEND TO QUALIFIED PATIENTS WHO WOULD LIKELY MEET SLIDING SCALE FEE CRITERIA THE OPPORTUNITY TO APPLY FOR DISCOUNTED CARE. HOSPITAL RESOURCES ARE MADE AVAILABLE TO PATIENTS REQUIRING ASSISTANCE IN COMPLETING APPLICATIONS. PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY ARE PROVIDED DISCOUNTS RANGING FROM 25% TO 100% OF CHARGES. ONCE QUALIFIED PATIENTS MAY BE EXTENDED REDUCED FEE FOR HEALTH CARE SERVICES RECEIVED IN THE FUTURE. ALL PATIENTS ARE ASKED TO REAPPLY ANNUALLY TO THE SLIDING FEE PROGRAM. OUTSIDE COLLECTION AGENCIES CONTRACTED WITH THE HOSPITAL MUST SPECIFY THEIR STANDARDS AND SCOPE OF PRACTICES, ALL OF WHICH MUST BE IN COMPLIANCE WITH THE COLLECTION POLICY. SCHEDULE H, PART V B, LINE 5A HTTPS://WWW.RFGH.NET/PORTALS/0/PDFS/COMMUNITY%20HEALTH%20NEEDS%20ASSESSMENT%202012.PDF PART VI, LINE 2: NEEDS ASSESSMENT: DESCRIBE HOW THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES, IN ADDITION TO ANY CHNAS REPORTED.REDINGTON-FAIRVIEW GENERAL HOSPITAL OPERATES SOMERSET PUBLIC HEALTH (SPH), A PROGRAM WHOSE PURPOSE IS TO PROTECT AND IMPROVE THE QUALITY OF LIFE AND HEALTH OF ALL GREATER SOMERSET COUNTY RESIDENTS. SPH PROVIDES PLANNING AND EVALUATION OF BOTH LONG AND SHORT RANGE STRATEGIES FOR ESSENTIAL PUBLIC HEALTH SERVICES. SPH INVOLVES CITIZENS IN DEVELOPING AND CARRYING OUT CHRONIC DISEASE PREVENTION THROUGH VARIOUS INITIATIVES. SPH MOBILIZES BOTH PUBLIC AND PRIVATE RESOURCES IN SUPPORT OF THESE INITIATIVES AND COORDINATES EFFORTS THROUGHOUT THE COMMUNITY. BY WORKING WITH CITIZENS, SPH SERVES AS ADVOCATES ON MATTERS OF POLICIES THAT AFFECT HEALTH STATUS, WHILE PROMOTING INSTITUTIONAL IMPROVEMENT AND DESIRABLE CHANGES IN SOCIAL POLICY AND ENVIRONMENTAL CHANGE. SPH IMPLEMENTS PROGRAMS FINANCED THROUGH GRANTS, OR DELEGATES IMPLEMENTATION TO OTHER AGENCIES. SPH ALSO IDENTIFIES AND PURSUES OTHER AVAILABLE FUNDS DEEMED IMPORTANT FOR THE HEALTH OF CITIZENS. IN ITS WORK TO IMPROVE AND PROTECT PUBLIC HEALTH AND REDUCE CHRONIC DISEASE, SPH FOCUSES ITS EFFORTS AND FUNDING ON SUBSTANCE ABUSE AND TOBACCO PREVENTION, PHYSICAL ACTIVITY AND NUTRITION PROMOTION, AND WORKSITE WELLNESS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:REDINGTON-FAIRVIEW GENERAL HOSPITAL PROVIDES THE FOLLOWING INFORMATION IN THE FIRST BILL THAT EACH PATIENT RECEIVES:REDINGTON-FAIRVIEW GENERAL HOSPITAL46 FAIRVIEW AVENUEPO BOX 468SKOWHEGAN, ME 04976207-474-5121CATEGORY A & B SLIDING FEE SCALEREDINGTON-FAIRVIEW GENERAL HOSPITAL (RFGH) FOLLOWS MAINE STATE LAW AND PROVIDES FREE HOSPITAL SERVICE TO THOSE INDIVIDUALS WHO CANNOT AFFORD TO PAY UNDER CATEGORY A FREE CARE. RFGH HAS A SLIDING FEE SCALE (CATEGORY B) AND OTHER PROGRAMS AVAILABLE WHICH MAY PROVIDE HOSPITAL SERVICES AT A REDUCED AMOUNT TO THOSE INDIVIDUALS WHO CANNOT AFFORD TO PAY. IF YOU BELIEVE YOU QUALIFY FOR ASSISTANCE, YOU MAY COMPLETE AN APPLICATION AT THE PATIENT ACCOUNTS OFFICE, LOCATED AT 22 JONES STREET-THE WHITE BUILDING IN THE BACK PARKING LOT OF THE HOSPITAL. THE PATIENT ACCOUNTS OFFICE IS OPEN FROM 7:30AM TO 3:00 PM MONDAY THROUGH FRIDAY. IF YOU WOULD LIKE TO SPEAK TO A REPRESENTATIVE REGARDING THE APPLICATION PROCESS AND/OR WOULD LIKE TO MAKE AN APPOINTMENT TO COMPLETE THE APPLICATION PROCESS, PLEASE CALL 858 - 8367 TO COMPLETE THE APPLICATION PROCESS YOU (OR YOUR DESIGNEE) WILL NEED TO PRESENT AND PROVIDE PROOF OF INCOME TO DETERMINE YOUR ELIGIBILITY FOR ASSISTANCE, INCLUDING THE FOLLOWING: YOUR MOST RECENT FEDERAL INCOME TAX RETURN, IF YOU DO NOT FILE TAXES YOU WILL HAVE TO SIGN A DOCUMENT STATING YOU DO NOT FILE INCOME TAXES. YOUR LAST THREE MONTHS WAGE STUBS OR A SIGNED STATEMENT FROM YOUR EMPLOYER VERIFYING YOUR GROSS EARNINGS FOR THE LAST THREE MONTHS. A LIST OF ALL INCOME FROM STOCKS, BONDS, INTEREST INCOME ON SAVINGS ACCOUNTS, ANNUITIES, AND RENTAL INCOME.YOU WILL ALSO BE ASKED TO OBTAIN A DENIAL LETTER FROM THE STATE OF MAINE IF YOU ARE NOT ELIGIBLE FOR MAINECARE ASSISTANCE. {NOTE: THIS DENIAL LETTER IS ONLY GOOD FOR THIRTY (30) DAYS.}TO BE ELIGIBLE FOR FREE CARE (CATEGORY A) OR THE RFGH SLIDING FEE (CATEGORY B), YOUR FAMILY INCOME MUST BE BELOW THE FOLLOWING LEVELS. THE HOSPITAL WILL CONSIDER THE HIGHEST INCOME LEVEL AVAILABLE BASED ON THE NUMBER OF DEPENDENTS THAT YOU HAVE (SEE THE TABLES BELOW). IF YOU DO NOT QUALIFY FOR FREE CARE (CATEGORY A), YOU ARE ALLOWED TO ASK FOR A FAIR HEARING. THE STATE DEPARTMENT OF HUMAN SERVICES WILL TELL YOU HOW TO APPLY FOR A FAIR HEARING. IN ADDITION, RFGH WILL PROVIDE YOU WITH A FINAL DETERMINATION OF YOUR ELIGIBILITY FOR ASSISTANCE WITHIN FIVE (5) WORKING DAYS OF YOUR REQUEST. IF YOU DO NOT QUALIFY FOR A FULL 100% RFGH DISCOUNT (CATEGORY B), A MONTHLY PAYMENT PLAN WILL BE CALCULATED BY THE PATIENT ACCOUNTS REPRESENTATIVE. DURING THE DETERMINATION OF YOUR PAYMENT PLAN YOU WILL ALSO NEED TO HAVE INFORMATION ABOUT YOUR HOUSEHOLD EXPENSES AVAILABLE. YOU WILL NEED TO SIGN A PAYMENT AGREEMENT CONTRACT AND FAITHFULLY COMPLETE YOUR PAYMENT PORTION IN ORDER TO RECEIVE THE NEGOTIATED DISCOUNT. **SERVICES THAT ARE NOT MEDICALLY NECESSARY ARE NOT ELIGIBLE FOR FREE OR DISCOUNTED CARE AND YOU WILL BE REQUIRED TO PAY FOR THEM BEFORE SERVICES ARE RENDERED.**CATEGORY AFREE CARE @ 100%FAMILY SIZE ANNUAL INCOME1_______17,5052_______23,5953_______29,6854_______35,7755_______41,8656_______47,9557_______54,0458_______60,135FOR EACH ADDITIONAL PERSON, ADD $4,060 ANNUALLY.CATEGORY B RFGH SLIDING FEE SCALEDISCOUNT 100% 75% 50% 25% INCOME INCOME INCOME INCOME FAMILY SIZE TO TO TO TO1_____________28,008________31,742_______35,477_______39,2112_____________33,692________37,426_______41,161_______44,8953_____________39,376________43,110_______46,845_______50,5794_____________45,060________48,794_______52,529_______56,2635_____________50,744________54,478_______55,213_______61,9476_____________56,428________60,162_______63,897_______67,6317_____________62,112________65,846_______69,581_______73,3158_____________67,796________71,530_______75,265_______78,999 FOR EACH ADDITIONAL PERSON, ADD $5,684 ANNUALLY PART VI, LINE 4: COMMUNITY INFORMATION:REDINGTON-FAIRVIEW GENERAL HOSPITAL IS AN INDEPENDENT 25-BED CRITICAL ACCESS HOSPITAL LOCATED IN SKOWHEGAN, MAINE. THE HOSPITAL PROVIDES HEALTH CARE TO MORE THAN 30,000 RESIDENTS LIVING IN SOMERSET COUNTY, MAINE. ITS PRIMARY SERVICE AREA EXTENDS FROM SKOWHEGAN TO THE CANADIAN BORDER. A STATE OF THE ART MEDICAL OFFICE BUILDING ADJACENT TO THE HOSPITAL PROVIDES EASY ACCESS TO PRIMARY AND SPECIALTY CARE. A MEDICAL STAFF OF MORE THAN 40 PHYSICIANS SKILLED IN A VARIETY OF FIELDS, AND APPROXIMATELY 650 FULL AND PART-TIME PROFESSIONAL AND TECHNICAL EMPLOYEES ENSURE THE DELIVERY OF PROGRESSIVE HEALTH AND MEDICAL SERVICES. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH:THE HOSPITAL IS LOCATED IN A MEDICALLY UNDERSERVED AREA. CONSEQUENTLY, THE HOSPITAL MAINTAINS AN OPEN MEDICAL STAFF. IN ADDITION TO THE PROGRAMS OUTLINED IN OTHER AREAS OF THE FORM 990, THE HOSPITAL OPERATES A FITNESS FACILITY WHICH OPERATES AT A LOSS. THE FITNESS FACILITY OPERATES MANY PROGRAMS WHICH PROMOTES WELLNESS. OTHER WELLNESS PROGRAMS ARE ALSO PROVIDED THROUGH THE INDOOR POOL THAT THE HOSPITAL OPERATES AT A LOSS. THE POOL PROMOTES WELLNESS AMONG INDIVIDUALS WHO WOULD NOT BE ABLE TO OTHERWISE EXERCISE (DISABLED INDIVIDUALS WITH CHRONIC PAIN, MS AND OTHER DEBILITATING DISEASES). THE HOSPITAL ALSO OPERATES SOMERSET PUBLIC HEALTH, A PROGRAM WHOSE PURPOSE IS TO PROTECT AND IMPROVE THE QUALITY OF LIFE AND HEALTH OF ALL GREATER SOMERSET COUNTY RESIDENTS. X X X X 0 0 0 1 0 0 0 0 0 MICHAEL CURRAN MD DIRECTOR 347284 0 68538 0 15479 0 0 0 0 0 431301 0 0 0 MICHAEL LAMBKE MD DIRECTOR 177199 0 49622 0 12596 0 0 0 0 0 239417 0 0 0 GINA GOMEZ MD DIRECTOR 239996 0 9232 0 19486 0 0 0 0 0 268714 0 0 0 RICHARD D WILLETT CEO/SECRETARY 341816 0 0 0 23081 0 0 0 0 0 364897 0 0 0 DANA C KEMPTON CFO 239479 0 0 0 20730 0 0 0 0 0 260209 0 0 0 TIRUNELLAI R SHANKAR SURGEON 246342 0 60705 0 16610 0 0 0 0 0 323657 0 0 0 AMIR BAIG MD ANESTHESIOLOGIST 315202 0 0 0 18714 0 0 0 0 0 333916 0 0 0 JOHN COMIS MD ER PHYSICIAN 325780 0 0 0 16801 0 0 0 0 0 342581 0 0 0 MANJUNATH BANNUR MD ER PHYSICIAN 270003 0 0 0 14590 0 0 0 0 0 284593 0 0 0 WINOAH HENRY MD GASTROENTEROLOGIST 351229 0 0 0 14392 0 0 0 0 0 365621 0 0 0 PART I, LINE 5 PHYSICIANS EMPLOYED BY THE HOSPITAL PARTICIPATE IN AN INCENTIVE BASED COMPENSATION PROGRAM. THE PROGRAM IS BASED UPON A REVENUE TARGET WHICH WILL PRODUCE A TARGET COMPENSATION LEVEL, WHICH IS BASED ON BOTH LOCAL AND NATIONAL BENCHMARK INFORMATION. IN ORDER TO ALIGN THE PHYSICIAN WITH THE CHARITABLE MISSION OF THE HOSPITAL THE PROGRAM IS BASED ON THE HOSPITAL'S ACTUAL CHARGES, SO THAT THE PHYSICIAN WILL HAVE AN INCENTIVE TO TAKE ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE SUM OF ALL CHARGES FOR SERVICES PERFORMED BY THE PHYSICIAN IS TABULATED ON A QUARTERLY BASIS. THAT TABULATION IS THEN DIVIDED BY THE REVENUE TARGET, WHICH IS MULTIPLIED TIMES THE TARGET COMPENSATION LEVEL. IF A PHYSICIAN'S ACTUAL COMPENATION IS LESS THAN THE CALULATED SALARY, THE PHYSICIAN WILL RECIEVE A BONUS PAYMENT THAT RECOGNIZES THE PHYSICIAN'S CONTIRBUTION TO THE HOSPITAL'S ACHIEVEMENT OF IT'S CHARITABLE MISSION TO PROVIDE HEALTH SERVICES FOR THE BENEFIT OF THE COMMUNITY. A MAINE HEALTH & HIGHER EDUCATION FACILITY AUTHORITY 010314384 560425V80 2007-11-01 72040461 REPLACEMENT OF TWO BOILERS, PURCHASE OF A BACK-UP GENERATOR 0 0 1 B MAINE HEALTH & HIGHER EDUCATION FACILITY AUTHORITY 010314384 560427JA5 2010-06-24 108030000 BOND REFINANCING 1 0 1 A 23882032 1513579 304303 23577729 0 0 1 1 B 4202585 390171 4439445 47690 0 1 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 FORM 990, PART I, LINE 1 MISSION STATEMENT: REDINGTON-FAIRVIEW GENERAL HOSPITAL'S MISSION IS TO DEVELOP, PROVIDE, AND FACILITATE QUALITY, SAFE, COMPREHENSIVE, COST-EFFECTIVE HEALTH SERVICES FOR THE PEOPLE WE SERVE. WE AFFIRM A COMMITMENT TO MAINTAIN OUR UNIQUE COMMUNITY HOSPITAL IDENTITY, OFFERING PERSONALIZED SERVICES. FORM 990, PART III, LINE 1 REDINGTON-FAIRVIEW GENERAL HOSPITAL'S MISSION IS TO DEVELOP, PROVIDE, AND FACILITATE QUALITY, SAFE, COMPREHENSIVE, COST-EFFECTIVE HEALTH SERVICES FOR THE PEOPLE WE SERVE. WE AFFIRM A COMMITMENT TO MAINTAIN OUR UNIQUE COMMUNITY HOSPITAL IDENTITY, OFFERING PERSONALIZED SERVICES. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING THE FORM 990, THE HOSPITAL'S CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER REVIEWED THE FILING IN DETAIL WITH THE HOSPITAL BOARD. THE BOARD FOUND THE REPORT TO BE COMPREHENSIVE AND COMPLETE AND SUPPORTED ITS FILING AS REVIEWED. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY THE CONFLICT OF INTERESTS DISCLOSURE IS REVIEWED WITH THE MEMBERS OF THE BOARD AND DIRECTORS, WHO THEN SIGN THE DISCLOSURE FORM 990, PART VI, SECTION B, LINE 15A SEE SCHEDULE J FORM 990, PART VI, SECTION C, LINE 19 REDINGTON FAIRVIEW GENERAL MAKE ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST FORM 990, PART XI, LINE 9: INCREASE IN TEMPORARILY RESTRICTED ASSETS 267,110. EFFECT OF ASC 715 1,503,069. SOMERSET FITNESS CENTER INC PO BOX 3158 SKOWHEGAN ME 04976 010524417 FITNESS ACTIVITIES FOR MEMBERS ME 296195 106768 REDINGTON FAIRVIEW GENERAL HOSPITAL REDINGTON MEMORIAL HOSPITAL ASSN PO BOX 468 SKOWHEGAN ME 04976 010211154 SOLE SUPPORTING ORGANIZATION OF RFGH ME 501 C (3) 11 (D) N/A 0 FAIRVIEW HOSPITAL INC PO BOX 468 SKOWHEGAN ME 04976 010222130 SOLE SUPPORTING ORGANIZATION OF RFGH ME 501 C (3) 11 (D) N/A 0 SOMERSET SPORTS & FITNESS CENTER 6 COMMERCE DRIVE SKOWHEGAN ME 04976 010524417 FITNESS CENTER ME RFGH 1.00000 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FAIRVIEW HOSPITAL INC C 30211 CASH RECEIVED