2014-05-09T07:30:43-05:00 2013-06-30 010523282 Berry Dunn McNeil & Parker PO Box 1100 Portland ME 041041100 990 2012-07-01 020222156 Memorial Hospital MEMO 6033565461 3073 White Mountain Highway North Conway NH 038605001 Scott McKinnon 6033565461 2014-05-07 1 Barbara J McGuan CPA P00219457 2077752387 2014-05-07 2012 2015-11-30 17:44:51Z Scott McKinnon 3073 White Mountain Highway North Conway NH 038605001 65399558 0 X www.memorialhospitalnh.org X 1910 NH Critical Access Hospital 11 11 543 73 0 0 173102 555036 68927414 62396653 565551 233086 575987 -27966 70242054 63156809 0 0 0 0 27563896 35117259 0 0 819562 40504315 26505961 68068211 61623220 2173843 1533589 71845152 74062812 25192746 25061742 46652406 49001070 X Memorial Hospital provides healthcare services to the residents and visitors of the Mount Washington Valley area of New Hampshire. 1 0 52962851 62144813 Memorial Hospital provides healthcare services to the residents and visitors of the Mount Washington area of New Hampshire. Memorial Hospital is a 25 bed Critical Access Hospital and a 45 bed Intermediate Care Facility (Merriman House). The Hospital provides Med/Surg, ICU, ICF, Ovstetrics, Radiology/Imaging, Oncology/Infusion, Cardiac Rehab, Wound Care, Specialty Care, ED and Primary Care. The Hospital had 4,834 Acute Inpatients Days and 12,528 ED Outpatient Visits in Fiscal Year 2013. 52962851 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 1 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 98 0 1 543 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Scott McKinnon CEO 6033565461 3073 White Mountain Highway North Conway NH 038605001 Gene Bergoffen 1.00 X X 0 0 0 Phil Davies 1.00 X X 0 0 0 John Stratton 1.00 X X 0 0 0 Laura Jawitz 1.00 X X 0 0 0 Thaire Bryant 1.00 X X 0 0 0 Melissa Myers 1.00 X 0 0 0 Janice Crawford 1.00 X 0 0 0 Barbara Hopkins 1.00 X 0 0 0 Daphne Wall 1.00 X 0 0 0 Ken Cargill 1.00 X 0 0 0 Allan Stam 1.00 X 0 0 0 Roger Clapp 1.00 X X 0 0 0 George Epstein 1.00 X 0 0 0 Scott McKinnon 40.00 X 305967 0 36343 Vera Schumann 40.00 X 31724 0 0 John Newton 40.00 X 352508 0 17040 Steven Wyrsch 40.00 X 225490 0 4988 Raymond Rabideau 40.00 X 0 292200 30648 Marni Madnick 40.00 X 8083 290830 34943 Kimberly Goodwin 40.00 X 218697 0 26891 Douglas Taylor 40.00 X 1000 543354 34943 Morice Dennery 40.00 X 0 526693 34943 Victor Lazaron 40.00 X 1000 431852 34943 David Riss 40.00 X 1000 422878 27266 Robert Tilney 40.00 X 0 361414 27266 1145469 2869221 310214 35 0 1 0 MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 Physician Services 8400637 NORDX 301 US Route 1 Ste A Scarborough ME 04074 Reference Laboratory 332387 Diversified Clinical Services 45 Salisbury Rd 300 Jacksonville FL 32216 Wound Care Services 318326 Weatherby Locums Inc PO Box 972633 Dallas TX 75397 Locums Services 291675 Hinckley Allen & Snyder 11 South Main Street Concord NH 03301 Legal Services 252890 12 34141 520895 555036 Patient Service Revenue 621110 111170303 111170303 Other Patient Service Revenue 621110 427093 175253 251840 Provision for Bad Debt 621110 -7759210 -7759210 Contractual Allowances 621110 -41441533 -41441533 62396653 41330 41330 114357 142323 -27966 -27966 -27966 2090901 144482 1985440 58187 105461 86295 191756 191756 56799 34141 56799 0 63156809 62144813 0 456960 X 1227731 573379 654352 25841642 22525571 3122969 193102 395673 344899 47817 2957 6262872 5459203 756870 46799 1389341 1211057 167902 10382 317993 317993 95627 95627 44762 44762 8728192 8728192 8863 8863 2672481 2107388 565093 441507 441507 1571609 1509957 61652 46096 34467 10400 1229 972838 972838 3669579 3669579 Medical Supplies 4388257 4388257 Medicaid Enhancement Ta 2696039 2696039 Equipment Lease 852118 849413 2705 61623220 52962851 7840807 819562 11668040 6688420 9569980 15444451 7338200 8592470 1906329 2131649 23319 350006 65418212 36902390 28573535 28515822 8348027 9047979 366950 302088 273695 262308 3777077 2727619 71845152 74062812 4082435 4599974 19106647 18680037 542664 320731 1461000 1461000 25192746 25061742 X 45694398 47917756 344645 469951 613363 613363 46652406 49001070 71845152 74062812 X 1533589 879936 -64861 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 7984 7984 0 Explanation of Lobbying Activities: Part II-B, Line 1: The Hospital pays dues to various associations, a portion of which is attributable to lobbying expenses. 6740032 1132158 7872190 6639144 100888 6740032 3575593 2400000 663551 6639144 3311669 263924 3575593 3205137 640000 -533468 3311669 0.97750 0.01250 0.01000 0 0 598483 598483 41415304 21744588 19670716 20227937 13710070 6517867 3176488 1447732 1728756 28515822 Contingent Liabilities 1461000 1461000 1 Davenport & Barr Inc 19 Rock Pine Drive East Thetford VT 05043 Managing Philantropy Department 0 90940 56450 34490 90940 56450 34490 Annual Golf Tournament 58210 32695 25515 20639 4876 Gala 32730 1446 31284 12893 7961 2450 7980 90940 34141 56799 33532 7961 2450 12856 56799 0 1 1 X 1 X 250.000000000000 1 X 1 1 0 1 1 2538672 1387490 1151182 0.01870 8329332 9644979 -1315647 0.00000 10868004 11032469 -164465 0.01870 10868004 11032469 -164465 0.01870 1 4084723 0 18531339 18531339 X 1 1 1 1 Memorial Hospital

3073 White Mountain Highway North Conway NH 03860

X X X X Memorial Hospital 1 1 X X X X 10 1 0 1 X X X X X 1 0 1 1 250.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X 1 0 1 X 0 0 Part I, Line 7: A cost reporting system was used to calculate the amounts reported in the table. The cost accounting system addresses all patient segments. A cost-to-charge ratio was used. The ratio was derived from Worksheet 2. Part III, Line 4: Patient accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to provision for bad debts and a credit to a valuation allowance based on its assessment of individual accounts and historical adjustments. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable.In evaluating the collectibility of accounts receivable, the Hospital analyzes past results and identifies trends for each major payor source of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payor sources in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a provision for bad debts in the period of service based on past experience, which indicates that many patients are unable or unwilling to pay amounts for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated or eligible) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged against the allowance for doubtful accounts.During 2013, the Hospital increased its estimate from $3,025,000 to $3,783,299 in the allowance for doubtful accounts relating to self-pay patients. During 2013, self-pay write-offs increased from $6,166,466 to $7,001,207. Such increases resulted from trends experienced in the collection of amounts from self-pay patients. Part III, Line 8: The Organization used a cost report as the costing methodology to determine the amount of allowable Medicare costs. Part III, Line 9b: With the exception of insurance coverage the collection activity shall not be initiated or pursued for any amount approved under the Memorial Hospital Healthcare Assistance Program. Memorial Hospital Part V, Section B, Line 3: A community needs assessment survey was used to elicit community input and information. The needs assessment survey was distributed in June 9, 2010 edition of the Conway Daily Sun and reached over 16,000 people in New Hampshire and Maine. An additional 2,000 copies were made available to and distributed by the members of the MWV Community Collaborative. In addition, the Gibson Center for Senior Services and the Mount Washington Valley Chamber of Commerce circulated the survey to their members. The survey resulted in 592 responses. Memorial Hospital Part V, Section B, Line 12h: 1. Documentation in the case of a civil union to determine household size.2. Applicants that have Health Savings Accounts must provide proof that the HSA has been spent down prior to applying for Healthcare Assistance. Part VI, Line 2: See narrative provided for Schedule H, Part V, Section B, Line 3. Part VI, Line 3: The Hospital utilizes several methods for communicating and education patients regarding financial assistance with their hospital bills. At our registration and credit and collection offices it is visible to all with handouts. Our website includes information regarding the Healthcare Assistance Program. Hospital bills with a patient liability include information regarding the availability of financial assistance. Also the State Hospital Association website has links to various programs. Part VI, Line 4: The Hospital serves the northern part of Carroll County in New Hampshire and the western portion of Oxford County in Maine. The Mount Washington Valley is a four season destination resort area and serves the tourists that frequent the area. Reports Filed With States Part VI, Line 7 NH X X X X X 0 0 0 1 0 1 0 0 0 Scott McKinnon 242592 0 63375 0 0 0 7325 0 29018 0 342310 0 0 0 John Newton 233750 0 25500 0 93258 0 0 0 17040 0 369548 0 0 0 Steven Wyrsch 182215 0 43275 0 0 0 3804 0 1184 0 230478 0 0 0 Raymond Rabideau 0 292200 0 0 0 0 0 7226 0 23422 0 322848 0 0 Marni Madnick 8083 290830 0 0 0 0 0 7500 0 27443 8083 325773 0 0 Kimberly Goodwin 218697 0 0 0 0 0 6636 0 20255 0 245588 0 0 0 Douglas Taylor 1000 543354 0 0 0 0 0 7500 0 27443 1000 578297 0 0 Morice Dennery 0 526693 0 0 0 0 0 7500 0 27443 0 561636 0 0 Victor Lazaron 1000 431852 0 0 0 0 0 7500 0 27443 1000 466795 0 0 David Riss 1000 422878 0 0 0 0 0 7500 0 19766 1000 450144 0 0 Robert Tilney 0 361414 0 0 0 0 0 7500 0 19766 0 388680 0 0 Part I, Line 5 A portion of the CEO and CMO Compensation was based on achieving certain organization goals including financial goals related to meeting target operational margin. Part I, Line 6 A portion of the CEO and CMO Compensation was based on achieving certain organization goals including financial goals related to meeting target operational margin. A New Hampshire Health and Education Facilities Authority 020279866 644614QC6 2006-06-14 20955000 To construct & renovate Hospital facility and payoff existing debt 0 0 0 A 2274963 20955000 1725373 324775 20630225 2009 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 0 A 1 New Program Services Form 990, Part III, line 2 The Hospital opened a sleep lab during FY 2013 offering a new services to North Conway and surrounding area residents. Form 990, Part VI, Section A, line 6 The sole member of Memorial Hospital is the Memorial Development Foundation. Form 990, Part VI, Section A, line 7b The sole member of the Memorial Development Foundation ratifies the appointments to the Board of Trustees of Memorial Hospital Form 990, Part VI, Section B, line 11 Form 990 is provided to the Finance Committee and the full Board of Trustees. It is sent to the entire Finance Committee via electronic means and then forwarded to the full Board of Trustees for approval. Form 990, Part VI, Section B, line 12c Conflict of interest declaration forms are submitted annually in January by members of the Board of Trustees and are shared with the full board for information purposes and reviewd in depth by the Governance Committee. It is the members responsibility to notify the board should any conflicts arise in between signing and of all members of the board to immediately raise any conflicts that they become aware of and the board member with a conflict will recuse themselves from discussions and votes on the issue. Form 990, Part VI, Section B, line 15 The Compensation Committee of the Board conducts the CEO evaluation and compensation process. The CEO's performance is reviewed against targets set for the year and his semi-annual bonus determination. The CEO compensation is compared to the Sullivan Cotter and Associates information and periodically reviewed by our compensation consultant. No one with a conflict of interest relative to the Hospital is involved in these discussions and minutes are recorded by the Secretary of the Board. Determining compensation for other officers and key employees included reference to professional association compensation data for comparable organizations and position scope. Compensation was reviewed and approved by the CEO and/or the Executive Committee of the Board of Trustees acting as the Compensation Committee. Form 990, Part VI, Section C, line 19 Memorial Hospital will make copies of such documents available to the general public upon request. Other Fees Form 990, Part IX, line 11g Contract Services: Program service expenses 8,728,192. Management and general expenses 0. Fundraising expenses 0. Total expenses 8,728,192. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Equity Loss in Subsidiary -64,861. Memorial Development Foundation PO Box 5001 North Conway NH 03860 223160795 Coordinate healthcare NH 501(c)(3) Line 11a, I N/A 0 VN & HCS of Northern Carroll Cty PO Box 432 North Conway NH 03860 020311473 Visiting nurse & hospice services NH 501(c)(3) Line 9 N/A 0 White Mountain Community Health PO Box 2800 Conway NH 03818 020358715 Community health center NH 501(c)(3) Line 9 N/A 0 Carroll County Health & Home Care Services Inc PO Box 420 Chocorua NH 03817 237337000 Home Care Services NH 501(c)(3) Line 7 N/A 0 MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 020477066 Contract with healthcare professionals and retail NH Memorial Hospital C 8381165 1419838 1.00000 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 MWV Healthcare Assoc Inc P 8549748 Amounts Paid White Mountain Community Health J 59004 Amounts Paid White Mountain Community Health Q 62272 Amounts Paid White Mountain Community Health P 60800 Amounts Paid