2014-04-12T14:15:42-05:00 2013-09-30 020383073 WILLIAM STEELE & ASSOCIATES PC 40 STARK STREET MANCHESTER NH 03101 990 2012-10-01 020483054 SOUTHERN NEW HAMPSHIRE MEDICAL CENTER SOUT 6035772000 8 PROSPECT STREET PO BOX 2014 NASHUA NH 030612014 THOMAS E WILHELMSEN 6035772000 2014-04-04 1 WILLIAM G STEELE JR CPA P00233103 6036228881 2012 2015-11-30 17:44:51Z THOMAS E WILHELMSEN JR 8 PROSPECT STREET PO BOX 2014 NASHUA NH 030612014 209318019 0 X SNHHS.ORG X 1892 NH SOUTHERN NEW HAMPSHIRE MEDICAL CENTER IS COMMITTED TO IMPROVING, MAINTAINING, AND PRESERVING THE OVERALL HEALTH AND WELL BEING OF INDIVIDUALS LIVING IN THE GREATER NASHUA AREA BY PROVIDING INFORMATION, EDUCATION AND ACCESS TO EXCEPTIONAL HEALTH AND MEDICAL CARE SERVICES. 14 13 1755 332 357186 -3293 130522 130903 194694882 198523922 12276873 10221616 57038 441578 207159315 209318019 0 0 0 0 98610250 96542258 0 0 0 73818198 74401589 172428448 170943847 34730867 38374172 313156702 334813337 159975014 149580410 153181688 185232927 X SOUTHERN NEW HAMPSHIRE MEDICAL CENTER IS COMMITTED TO IMPROVING, MAINTAINING, AND PRESERVING THE OVERALL HEALTH AND WELL BEING OF INDIVIDUALS LIVING IN THE GREATER NASHUA AREA BY PROVIDING INFORMATION, EDUCATION AND ACCESS TO EXCEPTIONAL HEALTH AND MEDICAL CARE SERVICES. 0 0 126024836 198502248 PROVIDES ACUTE HEALTHCARE SERVICES TO A DIVERSE POPULATION BASE INCLUDING INDIGENT WITHIN SOUTHERN AND CENTRAL NEW HAMPSHIRE. SOUTHERN NEW HAMPSHIRE MEDICAL CENTER IS A NONPROFIT HOSPITAL, SERVING ALL WHO NEED CARE, REGARDLESS OF ABILITY TO PAY. MEDICAL SERVICES PROVIDED INCLUDED 8,830 INPATIENT ADMISSIONS, 225,127 OUTPATIENT REGISTRATIONS, 42,974 ER VISITS, 5,432 SURGICAL PROCEDURES AND 1,395 BIRTHS. 9991993 0 CHARITY CARE ($5,223,359) AND OTHER UNCOMPENSATED CARE ($4,768,634) AT COST. 2227613 106066 COMMUNITY HEALTH SERVICES AND HEALTH PROFESSIONAL EDUCATION. 138244442 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 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 1 245 0 1 1755 1 1 1 0 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X MICHAEL ROSE 6035772004 8 PROSPECT STREET NASHUA NH 030612014 X PRAVEN K SUCHDEV MD 2.00 X X 0 0 0 TIMOTHY C SULLIVAN ESQ 2.00 X X 0 0 0 THOMAS E WILHELMSEN JR 40.00 X X 655478 0 750630 J TERRANCE BUCHANNAN MD 2.00 X 0 0 0 ROBERT B EISENBERG 2.00 X 0 0 0 COLLEEN P GUIRY MD 2.00 X 0 0 0 HOLLY J HARMON-MORSE 2.00 X 0 0 0 CLIFFORD R KINGHORN JR JUDGE 2.00 X 0 0 0 LORI A LIBERTY 2.00 X 0 0 0 JOHN M MERCIER 2.00 X 0 0 0 MARTHA E O'NEIL ESQ 2.00 X 0 0 0 THOMAS A PURSCH 2.00 X 0 0 0 JAMES K STEINER 2.00 X 0 0 0 TIMOTHY J WHITAKER 2.00 X 0 0 0 MICHAEL S ROSE 40.00 X 333417 0 56276 SUSAN DESOCIO 40.00 X 288716 0 49466 RICHARD DUGUAY 40.00 X 217934 0 30475 COLETTE TILTON 40.00 X 229206 0 25153 STEPHANIE WOLF-ROSENBLUM 40.00 8.00 X 293772 68480 6694 ANDREW WATT 40.00 X 331904 0 29362 JOESPH M LEAHY 40.00 X 374634 0 38398 ELIZABETH A KARAGOSIAN 40.00 X 288030 0 25377 DANIEL WEIDNER 40.00 X 305235 0 40314 MARC DEBELL 40.00 X 310929 0 18725 NORMAN P KOSSAYDA 40.00 X 298709 0 33967 DAVID CAWLEY 40.00 X 385465 0 9126 4313429 68480 1113963 83 1 1 0 FULCRUM ASSOCIATES 5 TECH CIRCLE AMHERST NH 03031 CONSTRUCTION 10562625 SIEMENS MEDICAL SOLUTIONS DEPT AT 40065 ATLANTA GA 31192 SYSTEM SUPPORT 2863997 QUEST DIAGNOSTICS 5763 COLLECTION CTR DR CHICAGO IL 60693 LAB 1199092 SODEXO INC 9801 WASHINGTON BLVD GAITHERSBURG MD 20878 FOOD SERVICES 776982 GE HEALTHCARE PO BOX 640944 PITTSBURGH PA 152640944 DIAGNOSTIC IMAGING 402654 32 130903 130903 HOSPITAL SERVICES 621110 198523922 198523922 198523922 10216766 10216766 4850 0 4850 4850 4850 ANCILLARY SERVICES (NE REHAB FOOD 722210 283369 283369 OTHER REVENUE 900099 88312 84392 3920 ANCILLARY SERVICES (NE REHAB ENVI 811000 69897 69897 441578 209318019 198608314 357186 10221616 3298483 3298483 78568960 62855168 15713792 2324901 1859921 464980 6814704 6210208 604496 5535210 4428168 1107042 190826 190826 140400 140400 839265 839265 703049 703049 2001638 1601310 400328 4557284 3645827 911457 51617 41294 10323 291651 233321 58330 4618585 3694868 923717 2722106 2722106 11978759 9583007 2395752 296892 237514 59378 SUPPLIES 23400050 21335295 2064755 NEW HAMPSHIRE MEDICAID 7262691 7262691 PURCHASE SERVICES 5296164 4720377 575787 SERVICE CONTRACTS 3538363 2830690 707673 6512249 4982677 1529572 170943847 138244442 32699405 0 52106037 41643809 21136572 23174204 2614903 2809265 2765253 3099955 238734256 123276287 114140395 115457969 106523261 133895550 679454 630526 13190827 14102059 313156702 334813337 37291296 40394464 93490966 92400213 750094 430843 28442658 16354890 159975014 149580410 X 150775973 182817632 50202 59782 2355513 2355513 153181688 185232927 313156702 334813337 X 38374172 -6322933 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 12580 0 0 0 12580 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: 23.76% OF DUES TO AMERICAN HOSPITAL ASSOCIATION, 22.96% OF DUES TO NEW HAMPSHIRE HOSPITAL ASSOCIATION, ALONG WITH DIRECT PAYMENTS THROUGHT NEW HAMPSHIRE HOSPITAL ASSOCIATION WERE USED FOR LOBBYING ACTIVITES. 60583371 7455943 68039314 51079549 9503822 60583371 50596135 483414 51079549 46166746 4429389 50596135 46228437 -61691 46166746 0.96540 0.03460 0 0 10801630 10801630 145614182 64060177 81554005 2069933 1455125 614808 75821946 57760985 18060961 4426565 4426565 115457969 UNEARNED INCOME - MOB 150702 INSURANCE RESERVES 3431121 OTHER LIABILITIES SERP 2635345 ACCRUED PENSION EXPENSE - LT 8434031 457 (B) DEFERRED COMP PLAN 1703691 16354890 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USES OF THE ORGANIZATION'S ENDOWMENT FUNDS ARE TO FULFILL DONOR'S INTENTIONS ON THE PERMANENTLY RESTRICTED FUNDS AND FOR FUTURE PLANT REPLACEMENT AND TECHNOLOGY INVESTMENTS FROM BOARD DESIGNATED FUNDS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE SYSTEM, MEDICAL CENTER AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. MANAGEMENT EVALUATED THE SYSTEM'S TAX POSITIONS AND CONCLUDED THE SYSTEM HAS MAINTAINED ITS TAX-EXEMPT STATUS, DOES NOT HAVE ANY SIGNIFICANT UNRELATED BUSINESS INCOME AND HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE CONSOLIDATED FINANCIAL STATEMENTS. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATION BY THE U.S. FEDERAL OR STATE TAX AUTHORITIES FOR YEARS BEFORE 2010. 1 1 1 X 225.000000000000 0 1 1 1 0 1 1 5223359 5223359 0.03060 21723510 7805343 13918167 0.08140 26946869 7805343 19141526 0.11200 267295 106066 161229 0.00090 1610071 1610071 0.00940 1919032 1037037 881995 0.00520 24912 24912 0.00010 382921 382921 0.00220 4204231 1143103 3061128 0.01780 31151100 8948446 22202654 0.12980 1861 1861 0.00000 36416 36416 0.00020 708 708 0.00000 3991 3991 0.00000 5504 5504 0.00000 48480 48480 0.00020 1 6871885 4768634 43142077 47504347 -4362270 X 1 1 1 1 SOUTHERN NEW HAMPSHIRE MEDICAL CENTER

8 PROSPECT STREET PO BOX 2014 NASHUA NH 030612014

SNHHS.ORG X X X SOUTHERN NEW HAMPSHIRE MEDICAL CENTER 1 1 X X X X X X X X 12 1 1 1 X X X X X X X X X X 1 0 1 1 225.000000000000 0 0 1 1 X X X X 1 X X X 1 X X X X X X X 1 X 0 1 PART I, LINE 3C: THE MEDICAL CENTER OFFERS A DISCOUNT EQUAL TO THE AVERAGE OF THEIR THREE LARGEST PAYORS TO ALL SELF PAY PATIENTS. PART I, LINE 7: THE COSTING METHODOLGY USED WAS THE RATIO OF COST TO CHARGE AS OUTLINED IN WORKSHEET 2 OF THE INSTRUCTIONS. THE ONLY EXCEPTION TO THIS WAS FOR SUBSIDIZED SERVICE AREA WHERE THE COST STRUCTURE WAS SPECIFIC TO THAT SERVICE AREA. FOR THOSE AREAS, OUR COST ACCOUNTING SYSTEM WAS USED. PART II: SOUTHERN NEW HAMPSHIRE MEDICAL CENTER IS COMMITTED TO IMPROVING THE HEALTH AND WELL-BEING OF THE GREATER NASHUA AREA AND OUR COMMUNITY BUILDING ACTIVITIES HELP US ACHIEVE THIS GOAL. THROUGH OUR INVOLVEMENT IN THE ROTARY CLUB AND NASHUA CHAMBER OF COMMERCE, ALONG WITH OTHER COMMUNITY ORGANIZATIONS, WE ARE ABLE TO EXHANGE IDEAS WITH AREA LEADERS CONCERNING HEALTH CARE ISSUES AND MAKE INFORMATIVE DECISIONS THAT BEST ADDRESS THE HEALTH NEEDS OF OUR COMMUNITY. WE PROVIDE MEDICARE COUNSELING TO AREA SENIOR CITIZENS GIVING THEM THE GUIDANCE THEY NEED TO MAKE INFORMED DECISIONS ABOUT THIER HEALTHCARE COVERAGE. OUR SUPPORT OF THE UNITED WAY'S DAY OF CARING HAS RESULTED IN A GROWING NUMBER OF OUR EMPLOYEES GOING OUT INTO THE AREA AND HELPING MEMBERS OF THE COMMUNITY WITH HEALTHCARE AND OTHER NEEDS. WE ARE STONG IN OUR COMMITMENT TO THE GREATER NASHUA AREA AND PLAN TO CONTINUE TO SUPPORT AND GROW COMMUNITY BUILDING ACTIVITES THAT IMPROVE THE OVERALL HEALTH OF THE AREA.A MAJORITY OF THE ORGANIZATION'S BOARD OF TRUSTEES IS COMPRISED OF PERSONS WHO RESIDE IN THE PRIMARY SERVICE AREA (PSA) WHO OTHERWISE HAVE NO RELATIONSHIP WITH THE ORGANIZATION. MANY MEMBERS OF THE ORGANIZATION VOLUNTEER THEIR TIME TO OTHER COMMUNITY AGENCIES IN THE PSA. PART III, LINE 4: ON THE BASIS OF HISTORICAL EXPERIENCE, A SIGNIFICANT PORTION OF THE SYSTEM'S UNINSURED PATIENTS WILL BE UNABLE OR UNWILLING TO PAY FOR THE SERVICES PROVIDED. THUS, THE SYSTEM RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED. THE FASB ISSUED AN ACCOUNTING STANDARDS UPDATE THAT STATES THAT A HEALTH CARE ENTITY THAT RECOGNIZES SIGNIFICANT AMOUNTS OF PATIENT SERVICE REVENUE AT THE TIME SERVICES ARE RENDERED, EVEN THOUGH IT DOES NOT ASSESS THE PATIENT'S ABILITY TO PAY, MUST PRESENT BAD DEBTS AS A REDUCTION OF NET PATIENT REVENUE AND NOT AS A SEPARATE ITEM IN OPERATING EXPENSES. THE RATIO OF COST TO CHARGE METHODOLOGY WAS USED TO DETERMINE COST AS OUTLINED IN WORKSHEET 2 OF THE INSTRUCTIONS. CONSISTENT WITH THE ACCOUNTING TREATMENT MENTIONED ABOVE, SINCE THE SYSTEM DOES NOT ASSESS THE PATIENT'S ABILITY TO PAY,THE COST OF BAD DEBT FOR THOSE PATIENTS WITHOUT ANY FORM OF INSURANCE SHOULD BE CLASSIFIED AS COMMUNITY BENEFIT. PART III, LINE 8: THE RATIO OF COST TO CHARGE METHODOLOGY WAS USED TO DETERMINE COST AS OUTLINED IN WORKSHEET 2 OF THE INSTRUCTIONS. THERE ARE SERVICE AREAS WHERE GOVERNMENT PROGRAMS SUCH AS MEDICARE AND MEDICAID DO NOT REIMBURSE THE ORGANIZATION ADEQUATE AMOUNTS TO COVER THE COSTS TO PROVIDE THOSE SERVICES. THE HOSPITAL MUST PROVIDE THOSE SERVICES REGARDLESS OF THE FINANCIAL SHORTFALL. PART III, LINE 9B: SNHMC RECOGNIZES THAT NOT ALL PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE WILL FOLLOW THROUGH WITH AN APPLICATION FOR FINANCIAL ASSISTANCE. PRIOR TO PLACING ANY ACCOUNT WITH A COLLECTION AGENCY, THE MEDICAL CENTER USES A FINANCIAL ASSISTANCE QUALIFICATION SERVICE TO CATEGORIZE PATIENTS BASED PRIMARILY ON INCOME AND ASSETS ESTIMATED FROM CENSUS TRACT DATA. THOSE PATIENTS WHOSE ESTIMATED INCOME/ASSETS FALL WITHIN THE MEDICAL CENTER'S FINANCIAL ASSISTANCE GUIDELINES ARE AWARDED CHARITY OR FREE CARE ASSISTANCE FOR THEIR ENCOUNTER. SOUTHERN NEW HAMPSHIRE MEDICAL CENTER PART V, SECTION B, LINE 3: DURING THE PROCESS OF DEVELOPING THE COMMUNITY HEALTH NEEDS ASSESSMENT, NASHUA RESIDENTS, MEDICAL PROVIDERS AND KEY LEADERS IN THE COMMUNITY WERE ASKED TO RANK THE HEALTH OF THE COMMUNITY AND TO PRIORITIZE THE NEEDS. ASSESSMENT TEAMS APPROACHED 833 HOUSEHOLDS IN NASHUA AND COMPLETED 207 SURVEYS. RESPONDENTS TO THE NASHUA COMMUNITY HEALTH SURVEY IDENTIFIED ISSUES CONSIDERED TO BE MAJOR PROBLEMS IN THEIR COMMUNITY AND FOR FAMILIES. THERE WERE ALSO TWO FOCUS GROUPS WHOSE MEMBERS INCLUDED 16 KEY LEADERS AND 18 MEDICAL PARTNERS. KEY LEADERS: SANDERS BURNSTEIN, MD MEDICAL DIRECTOR DARTMOUTH-HITCHCOCK (NASHUA); DANIELLE FULLER DIRECTOR, HUMAN RESOURCES GATEWAYS; ROLF GOODWIN VICE CHAIR, BOARD OF DIRECTORS UNITED WAY OF GREATER NASHUA; TRACEY GOYETTE, RN BSN SCHOOL NURSE CITY OF NASHUA, NASHUA SCHOOL DISTRICT; DONNALEE LOZEAU MAYOR CITY OF NASHUA; MELINDA LUTHER, RN PROFESSOR, NURSING DEPARTMENT NASHUA COMMUNITY COLLEGE; ANN PETERS CEO LAMPREY HEALTH CARE NASHUA CENTER; DAVID ROSS PRESIDENT & CEO ST. JOSEPH HOSPITAL; MELISSA SEARS VICE PRESIDENT, STRATEGY/BUSINESS DEVELOPMENT ST. JOSEPH HOSPITAL; JASON SMITH EXECUTIVE DIRECTOR COURVILLE AT NASHUA; SUSAN STEARNS DIRECTOR, DEVELOPMENT GREATER NASHUA MENTAL HEALTH CENTER OF COMMUNITY COUNCIL; ANTHONY STORACE, DMD CHAIRMAN CITY OF NASHUA, BOARD OF HEALTH; DEDRA TWOMEY BUSINESS MANAGER GREATER NASHUA DENTAL CONNECTION; RONALD VAILLANCOURT DIRECTOR, FIELD OPERATIONS ROCKINGHAM REGIONAL AMBULANCE; SCOTT WESTOVER VICE PRESIDENT, PLANNING AND COMMUNICATION SOUTHERN NEW HAMPSHIRE MEDICAL CENTER; TOM WILHELMSEN PRESIDENT & CEO SOUTHERN NEW HAMPSHIRE MEDICAL CENTER FACILITATOR; KATHY HERSH, NASHUA COMMUNITY DEVELOPMENT DIVISION DIRECTOR FOCUS GROUP: ALBEE BUDNITZ, MD INTERNAL MEDICINE SOUTHERN NEW HAMPSHIRE MEDICAL CENTER; MARK CONWAY, MD OBSTETRICS & GYNECOLOGY ST. JOSEPH HOSPITAL; REBECCA COOPER PIELA, APRN INTERNAL MEDICINE SOUTHERN NEW HAMPSHIRE MEDICAL CENTER; LESLIE DIONNE, MD INTERNAL MEDICINE DARTMOUTH-HITCHCOCK; ROB DORF, MD FAMILY MEDICINE SOUTHERN NEW HAMPSHIRE MEDICAL CENTER; JACK FARACI, MD OBSTETRICS & GYNECOLOGY ST. JOSEPH HOSPITAL; LARRY LEARNER, MD PEDIATRICS MERRIMACK VALLEY PEDIATRICS; DONALD LEVI, MD PEDIATRICS ST. JOSEPH HOSPITAL; LOUISE MERMER, APRN PEDIATRICS ST. JOSEPH HOSPITAL; DANA O'SHEA, MD INTERNAL MEDICINE HARBOR CARE CLINIC; MARY PETERSON, PA INTERNAL MEDICINE ST. JOSEPH HOSPITAL; JOANNE POMERANZ, ARPN INTERNAL MEDICINE HARBOR CARE CLINIC; DONALD REAPE, MD INTERNAL MEDICINE ST. JOSEPH HOSPITAL; CHRIS RICCIO, MD INTERNAL MEDICINE/ PEDIATRICS SOUTHERN NEW HAMPSHIRE MEDICAL CENTER; AJAY SHARMA, MD FAMILY MEDICINE CITY OF NASHUA, BOARD OF HEALTH; EDWARD SCULLY, MD MEDICAL DIRECTOR LAMPREY HEALTH CARE NASHUA CENTER; JON THYNG, MD FAMILY MEDICINE DARTMOUTH-HITCHCOCK; BARBARA WATROUS, CNM OBSTETRICS & GYNECOLOGY ST. JOSEPH HOSPITAL FACILITATOR; DEBBIE DANIELS, MD, MPH, MEDICAL DIRECTOR FOR DPHCS SOUTHERN NEW HAMPSHIRE MEDICAL CENTER PART V, SECTION B, LINE 4: THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSEMENT WAS A COLLABORATION OF CITY OF NASHUA HEALTH DEPARTMENT AND OTHER STAKEHOLDERS, INCLUDING ST. JOSEPH HOSPITAL. THE MEDICAL CENTER PREPARED ITS OWN SEPARATE ASSESSMENT, BASED ON THAT INFORMATION. SOUTHERN NEW HAMPSHIRE MEDICAL CENTER PART V, SECTION B, LINE 11: THE STATE OF NEW HAMPSHIRE MANDATES A DISCOUNT FOR ALL UNINSURED PATIENTS. THIS DISCOUNT IS EQUAL TO THE AVERAGE DISCOUNT NEGOTIATED BY THE TOP (BY VOLUME) THREE COMMERCIAL INSURERS. THIS DISCOUNT FOR THE UNINSURED IS AUTOMATIC AND APPLIED TO ALL BALANCES PRIOR TO SENDING THE FIRST BILLING STATEMENT TO THE PATIENT. SOUTHERN NEW HAMPSHIRE MEDICAL CENTER PART V, SECTION B, LINE 18E: SEE RESPONSE FOR III.C.9B ABOVE. PRIOR TO PLACING ACCOUNTS WITH COLLECTION AGENCIES, SNHMC PULLS OUT PATIENTS WHO QUALIFY FOR CHARITY BASED ON CENSUS TRACT DATA AND DOES NOT PLACE THOSE ACCOUNTS WITH AN AGENCY BUT RATHER, AWARDS CHARITY OR FREE CARE ASSISTANCE FOR THEIR ENCOUNTER. SOUTHERN NEW HAMPSHIRE MEDICAL CENTER PART V, SECTION B, LINE 20D: THE STATE OF NEW HAMPSHIRE MANDATES A DISCOUNT FOR ALL UNINSURED PATIENTS. THIS DISCOUNT IS EQUAL TO THE AVERAGE DISCOUNT NEGOTIATED BY THE TOP (BY VOLUME) THREE COMMERCIAL INSURERS. THIS DISCOUNT FOR THE UNINSURED IS AUTOMATIC AND APPLIED TO ALL BALANCES PRIOR TO SENDING THE FIRST BILLING STATEMENT TO THE PATIENT. SOUTHERN NEW HAMPSHIRE MEDICAL CENTER PART V, SECTION B, LINE 22: SNHMC MAY CHARGE PATIENTS WHO ARE HAVING COSMETIC OR EXPERIMENTAL, NON-COVERED SERVICES GROSS CHARGES FOR THAT ENCOUNTER. PART VI, LINE 2: THE SOUTHERN NEW HAMPSHIRE HEALTH SYSTEMS 2013 COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY WAS A COLLABORATION WITH THE CITY OF NASHUA AND OTHER AREA HEALTH PARTNERS. THE 2011 CREATING A HEALTHIER COMMUNITY: CITY OF NASHUA HEALTH ASSESSMENT (THE ASSESSMENT) WAS PUBLISHED BY THE CITY OF NASHUA DIVISION OF PUBLIC HEALTH AND COMMUNITY SERVICES ON SEPTEMBER 9,2011. THE PROGRAM COORDINATORS OF THE ASSESSMENT WERE ASHLEY CONLEY, EPIDEMIOLOGIST, AND DEBBIE DANIELS, MEDICAL DIRECTOR FROM THE NASHUA DEPARTMENT OF PUBLIC HEALTH. THE ASSESSMENT RESULTS INCLUDE INFORMATION GATHERED FROM A DOOR-TO-DOOR SURVEY OF 833 HOUSEHOLDS IN NASHUA CONDUCTED IN OCTOBER AND NOVEMBER 2010. IN CONJUNCTION WITH THIS, IN MARCH 2011, DATA WERE GATHERED FROM TWO FOCUS GROUPS, ONE WITH AREA KEY LEADERS, THE OTHER CONSISTING OF MEDICAL PARTNERS FROM THE GREATER NASHUA AREA. PART VI, LINE 3: AT EACH REGISTRATION POINT, SNHMC HAS SIGNAGE AND BROCHURES EXPLAINING OUR VARIOUS FORMS OF FINANCIAL ASSISTANCE, INCLUDING CHARITY CARE. ADDITIONALLY, PATIENT REGISTRARS OFFER THE CHARITY BROCHURES TO SELF PAY PATIENTS. PATIENTS WHO CALL REGARDING BILLING CONCERNS ARE OFFERED CHARITY ASSISTANCE. ADDITIONALLY, VERBIAGE REGARDING CHARITY CARE IS PRINTED ON EACH BILLING STATEMENT THE PATIENT RECEIVES. ALSO, CHARITY CARE INFORMATION IS AVAILABLE ON OUR HOSPITAL WEBSITE. PART VI, LINE 4: SNHHS'S SERVICE AREA CONSISTS OF NINETEEN NEW HAMPSHIRE AND FOUR MASSACHUSETTS TOWNS. THE SERVICE AREA IS DIVIDED INTO A PRIMARY SERVICE AREA (PSA) OF TWELVE NEW HAMPSHIRE TOWNS (AMHERST, BROOKLINE, HOLLIS, HUDSON, LITCHFIELD, LYNDEBOROUGH, MERRIMACK, MILFORD, MONT VERNON, NASHUA, PELHAM AND WILTON), A SECONDARY SERVICE AREA (SSA) OF SEVEN NEW HAMPSHIRE TOWNS (DERRY, GREENVILLE, LONDONDERRY, NEW BOSTON, NEW IPSWICH, SALEM AND WINDHAM) AND A MASSACHUSETTS SERVICE AREA (MSA) OF FOUR NEIGHBORING MASSACHUSETTS TOWNS (DUNSTABLE, PEPPERELL, TOWNSEND AND TYNGSBORO). ACCORDING TO THE 2012 NEEDS ASSESSMENT, THE POPULATION OF THE GREATER NASHUA REGION IS GROWING ( 4.5% GROWTH FROM 2000 TO 2010), YOUNGER THAN THE NEW HAMPSHIRE STATE AVERAGE (53.5% UNDER 40 YEARS OF AGE COMPARED WITH 50.7% FOR THE STATE) , AND ALSO MORE CULTURALLY DIVERSE THAN THE REST OF THE STATE (85.7% IDENTIFIED AS WHITE VERSUS 94.8% FOR THE STATE) . PART VI, LINE 6: SOUTHERN NH HEALTH SYSTEM, INC. IS A NOT-FOR-PROFIT ENTITY ORGANIZED TO SUPPORT SOUTHERN NH MEDICAL CENTER AND FOUNDATION MEDICAL PARTNERS, INC. BOTH THE MEDICAL CENTER AND FOUNDATION ARE NOT-FOR-PROFIT ENTITIES, ESTABLISHED TO PROVIDE MEDICAL SERVICES TO THE PEOPLE OF THE GREATER NASHUA AREA. REPORTS FILED WITH STATES PART VI, LINE 7 NH X 1 1 X X X X 0 1 0 0 0 0 0 1 0 THOMAS E WILHELMSEN JR 486610 0 107049 0 61819 0 718802 0 31828 0 1406108 0 0 0 MICHAEL S ROSE 246369 0 45500 0 41548 0 22792 0 33484 0 389693 0 0 0 SUSAN DESOCIO 237309 0 33324 0 18083 0 11768 0 37698 0 338182 0 0 0 RICHARD DUGUAY 168833 0 23900 0 25201 0 0 0 30475 0 248409 0 0 0 COLETTE TILTON 167673 0 18189 0 43344 0 0 0 25153 0 254359 0 0 0 STEPHANIE WOLF-ROSENBLUM 224820 68480 26656 0 42296 0 0 0 6694 0 300466 68480 0 0 ANDREW WATT 296009 0 26114 0 9781 0 0 0 29362 0 361266 0 0 0 JOESPH M LEAHY 335135 0 21639 0 17860 0 0 0 38398 0 413032 0 0 0 ELIZABETH A KARAGOSIAN 264741 0 5749 0 17540 0 0 0 25377 0 313407 0 0 0 DANIEL WEIDNER 271952 0 5841 0 27442 0 0 0 40314 0 345549 0 0 0 MARC DEBELL 286947 0 5730 0 18252 0 0 0 18725 0 329654 0 0 0 NORMAN P KOSSAYDA 291483 0 5642 0 1584 0 0 0 33967 0 332676 0 0 0 DAVID CAWLEY 357106 0 0 0 28359 0 0 0 9126 0 394591 0 207882 0 PART I, LINE 1A SOUTHERN NEW HAMPSHIRE MEDICAL CENTER USES THE FACILITIES AT THE NASHUA COUNTRY CLUB FOR MEETINGS AND OTHER BUSINESS RELATED PURPOSES. THE CLUB DOES NOT HAVE A CORPORATE MEMBERSHIP, THEREFORE, AN INDIVIDUAL ASSOCIATED WITH THE MEDICAL CENTER MUST BE A MEMBER OF THE CLUB. THE MEMBERSHIP IS TITLED IN THE CEO'S NAME AND INVOICES ARE ADDRESSED TO THE CEO, NOT SNHMC. SNHMC PAYS THE ANNUAL DUES AND ALL RELATED EXPENSES INCURRED BY THE ORGANIZATION. THE FACILITIES ARE ONLY AVAILABLE TO CLUB MEMBERS. PART I, LINE 3 THE COMPENSATION OF THE CEO AND CFO IS EVALUATED BY AN OUTSIDE CONSULTANT. THE COMPENSATION OF THE CEO IS APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD AND THE BOARD OF TRUSTEES. A MARKET ANALYSIS IS PERFORMED FOR ALL KEY EMPLOYEES ON AN ANNUAL BASIS. ONCE THE CEO AND CFO APPROVED THE FINAL COMPENSATION FIGURES FOR KEY EMPLOYEES, THE CEO REPORTS THESE FIGURES TO THE CHAIRPERSON AND VICE CHAIRPERSON OF THE BOARD. PART I, LINE 4B FUNDING FOR SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN- SUSAN DESOCIO -$11,768.00, MICHAEL S. ROSE -$22,792.00,AND THOMAS E. WILHELMSEN, JR. -$718,802.00. IN 2010, AN ERROR WAS DISCOVERED IN THE FORMULA USED TO CALCULATE MR. WILHELMSEN'S SERP CONTRIBUTION. AS A RESULT, A ONE-TIME CATCH-UP CONTRIBUTION OF $629,109 WAS MADE IN 2013 THAT COVERS 2002 - 2013 AND IS INCLUDED IN MR. WILHELMSEN'S TOTAL. PART I, LINE 7 THERE IS AN ADDITIONAL COMPENSATION PLAN AVAILABLE TO MANAGERS, DIRECTORS AND SENIOR MANAGEMENT THAT IS PART OF THEIR ANNUAL PERFORMANCE PLAN. THE PLAN TAKES INTO CONSIDERATION QUALITY MEASURES, PATIENT SATISFACTION, INDIVIDUAL GOALS, BUDGET ADHERENCE AND OVERALL ORGANIZATIONAL PERFORMANCE. THE RANGE AND OVERALL POOL IS REVIEWED AND APPROVED BY THE BOARD OF TRUSTEES' EXECUTIVE COMPENSATION COMMITTEE. THE AMOUNT DESIGNATED FOR THE CEO AND CFO ARE CONSIDERED IN THE COMPENSATION CONSULTANT'S ANALYSIS OF EXECUTIVE COMPENSATION REPORTED ON THE 990 PART VI SECTION B LINE 15B. A NHHEF AUTHORITY 020279866 644614SWO 2007-08-30 89836797 REFUNDING AND NEW CONSTRUCTION 1 0 0 B NHHEF AUTHORITY 020279866 2010-12-15 5500000 EQUIPMENT PURCHASE 0 0 0 A 89836797 49731438 949525 39155834 1 1 1 1 B 5500000 25672 5474328 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 1 0 0 0 0 0 B 1 0 0 0 0 0 A 1 B 1 FORM 990, PART VI, SECTION A, LINE 6 SOUTHERN NEW HAMPSHIRE HEALTH SYSTEM, INC., IS THE SOLE CORPORATE MEMBER OF SOUTHERN NEW HAMPSHIRE MEDICAL CENTER (SNHMC) AND THE TWO (2) ORGANIZATIONS HAVE IDENTICAL BOARDS WITH THE EXCEPTION OF TWO (2) ADDITIONAL MEMBERS SERVING SOLELY ON THE SNHMC BOARD. THESE INCLUDE A PHYSICIAN MEMBER AND THE CURRENT SNHMC CHIEF OF STAFF WHO IS AN EX-OFFICIO MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE MEDICAL CENTER IS GOVERNED BY THE BOARD OF TRUSTEES, WHO ARE ELECTED BY THE TRUSTEES OF ITS SOLE MEMBER SOUTHERN NEW HAMPSHIRE HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7B THE MEDICAL CENTER IS GOVERNED BY THE BOARD OF TRUSTEES, WHO ARE ELECTED BY THE TRUSTEES OF ITS SOLE MEMBER SOUTHERN NEW HAMPSHIRE HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 WAS PRESENTED TO THE FULL BOARD AND APPROVED BY THE FINANCE COMMITTEE OF THE BOARD OF TRUSTEES PRIOR TO SUBMISSION FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ALL ITS PERSONNEL, INCLUDING LEADERS, TO FORMALLY ACKNOWLEDGE THAT THEY HAVE READ & WILL ABIDE BY OUR CODE OF CONDUCT, WHICH INCLUDES OUR CONFLICT OF INTEREST POLICY. SNHHS/SNMC MONITORS COMPLIANCE OF ITS CONFLICT OF INTEREST PROCESS, WHICH REQUIRES COMPLETION OF DISCLOSURE FORMS BY ALL LEADERS ON AN ANNUAL BASIS OR ON A REAPPOINTMENT BASIS (EVERY TWO YEARS) FOR MEDICAL/ALLIED STAFF, TO ENSURE FULL COMPLIANCE. INTERIM DISCLOSURES ARE ALSO REQUIRED AND REVIEWED SHOULD A SUBSEQUENT CONFLICT ARISE. ANY RELATED PARTY DISCLOSURES REQUIRE REVIEW AND APPROVAL BY A DESIGNATED COMMITTEE. AN ANNUAL COMPLIANCE REPORT IS PROVIDED TO SNHHS/SNHMC'S COMPLIANCE COMMITTEE AND BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE CEO AND CFO IS EVALUATED BY AN OUTSIDE CONSULTANT. THE COMPENSATION OF THE CEO IS APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD AND THE BOARD OF TRUSTEES. A MARKET ANALYSIS IS PERFORMED FOR ALL KEY EMPLOYEES ON AN ANNUAL BASIS. ONCE THE CEO AND CFO APPROVED THE FINAL COMPENSATION FIGURES FOR KEY EMPLOYEES, THE CEO REPORTS THESE FIGURES TO THE CHAIRPERSON AND VICE CHAIRPERSON OF THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS 990 AND 990T AVAILABLE FOR INSPECTION UPON REQUEST AND PROVIDES AN ANNUAL REPORT THAT IS AVAILABLE ON ITS WEBSITE. THE CODE OF CONDUCT IS ALSO AVAILABLE ON THE ORGANIZATION'S WEBSITE. THE CODE OF CONDUCT ADDRESSES CERTAIN CORPORATE POLICIES INCLUDING CONFIDENTIALITY, CONFLICT OF INTEREST, PATIENT RIGHTS AND OTHER GOVERNING DOCUMENTS. THE ORGANIZATION ALSO MAKES ALL RELEVANT DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. SECTION A COLUMN B THE AVERAGE HOURS PER WEEK DEVOTED TO THE FOUNDATION MEDICAL PARTNERS, A RELATED ORGANIZATION BY KEY EMPLOYEE STEPHANIE WOLF-ROSENBLUM, VP OF MEDICAL AFFAIRS, IS 8 HOURS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TRANSFERS TO AFFILIATES -17,083,130. PENSION ADJUSTMENT 10,735,197. NET ASSETS RELEASED FROM RESTRICTION 25,000. FOUNDATION MEDICAL PARTNERS INC 8 PROSPECT STREET NASHUA NH 03060 020456218 PHYSICIAN SERVICES NH 501(C)(3) 9 SNHHS 0 SOUTHERN NEW HAMPSHIRE HEALTH SYSTEM 8 PROSPECT STREET NASHUA NH 03060 020509221 MEDICAL SERVICES NH 501(C)(3) 11 N/A 0 ADVANTAGE NETWORK PHO 10 PROSPECT STREET NASHUA NH 03060 020482950 MEDICAL SERVICES NH C 22529 64135 0.50000 0 SOUTHERN NH HEALTH VENTURES INC 8 PROSPECT STREET NASHUA NH 03060 020499623 MEDICAL SERVICES NH C 1.00000 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 1 1 1 1 0 FOUNDATION MEDICAL PARTNERS INC D 600868 FAIR MARKET VALUE FOUNDATION MEDICAL PARTNERS INC J 2378353 FAIR MARKET VALUE FOUNDATION MEDICAL PARTNERS INC K 171105 FAIR MARKET VALUE FOUNDATION MEDICAL PARTNERS INC L 4857582 COST FOUNDATION MEDICAL PARTNERS INC M 849297 COST FOUNDATION MEDICAL PARTNERS INC O 110249 COST FOUNDATION MEDICAL PARTNERS INC P 21163933 COST FOUNDATION MEDICAL PARTNERS INC Q 2561120 COST FOUNDATION MEDICAL PARTNERS INC R 17083130 FAIR MARKET VALUE