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OHIOHEALTH CORPORATION: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
OHIOHEALTH CORPORATION (EIN 31-4446959)
Tax period
2012-07-01 to 2013-06-30
Filed
2014-05-14
IRS object ID
201431349349306148
Schema version
2012v2.1
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2014-05-14T16:15:07-05:00Timestamp
Tax Period End Date2013-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN381357951EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1PLANTE & MORAN PLLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line165 EAST STATE ST STE 600AddressLine1
CityCOLUMBUSCity
StateOHState
ZIP Code43215ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN314446959EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1SHELTERING ARMS HOSPITAL FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlSHELNameControl
Phone7405935551Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line155 HOSPITAL DRIVEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameKEN DICKENName
TitleCFOTitle
Phone7405935551Phone
Date Signed2014-05-14DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameBERNIE OSTROWSKIName
PTINP00366367PTIN
Phone6148493000Phone
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2015-11-30 17:44:51ZBuildTS

Form 990 IRS990

Doing Business As DoingBusinessAs

FieldValueIRS element (for citing)
Business Name Line1O'BLENESS MEMORIAL HOSPITALBusinessNameLine1
FieldValueIRS element (for citing)
Name Of Principal Officer PersonGREG LONGNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line155 HOSPITAL DRIVEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode
FieldValueIRS element (for citing)
Gross Receipts114786472GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.OBLENESS.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1948YearFormation
State Legal DomicileOHStateLegalDomicile
Activity Or Mission DescriptionTO PROVIDE SUPERIOR HEALTHCARE AT A COST THAT REPRESENTS VALUE TO THE COMMUNITY.ActivityOrMissionDescription
Nbr Voting Members Governing Body11NbrVotingMembersGoverningBody
Nbr Independent Voting Members9NbrIndependentVotingMembers
Total Nbr Employees585TotalNbrEmployees
Total Nbr Volunteers204TotalNbrVolunteers
Total Gross UBI161136TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year123132ContributionsGrantsPriorYear
Contributions Grants Current Year209045ContributionsGrantsCurrentYear
Program Service Revenue Prior Year80159827ProgramServiceRevenuePriorYear
Program Service Revenue CY88593096ProgramServiceRevenueCY
Investment Income Prior Year584777InvestmentIncomePriorYear
Investment Income Current Year1287890InvestmentIncomeCurrentYear
Other Revenue Prior Year1462087OtherRevenuePriorYear
Other Revenue Current Year3660884OtherRevenueCurrentYear
Total Revenue Prior Year82329823TotalRevenuePriorYear
Total Revenue Current Year93750915TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year36462389SalariesEtcPriorYear
Salaries Etc Current Year40557519SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year43594333OtherExpensePriorYear
Other Expenses Current Year47903839OtherExpensesCurrentYear
Total Expenses Prior Year80056722TotalExpensesPriorYear
Total Expenses Current Year88461358TotalExpensesCurrentYear
Revenues Less Expenses Prior Year2273101RevenuesLessExpensesPriorYear
Revenues Less Expenses CY5289557RevenuesLessExpensesCY
Total Assets BOY74008787TotalAssetsBOY
Total Assets EOY80344106TotalAssetsEOY
Total Liabilities BOY41235556TotalLiabilitiesBOY
Total Liabilities EOY43182827TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY32773231NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY37161279NetAssetsOrFundBalancesEOY
Mission DescriptionTO PROVIDE SUPERIOR HEALTHCARE AT A COST THAT REPRESENTS VALUE TO THE COMMUNITY.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense79719851Expense
Grants0Grants
Revenue90602718Revenue
DescriptionMEDICAL SERVICES: PATIENT CARE PROVIDED INCLUDED 7,769 INPATIENT DAYS OF CARE TO 2,820 ACUTE PATIENTS; 27,030 EMERGENCY ROOM VISITS; 78,651 OTHER OUTPATIENT VISITS; 3,360 INPATIENT AND OUTPATIENT SURGERIES; AND 580 BIRTHS. PROCEDURES AND TESTS PERFORMED INCLUDED 918,105 LAB TESTS; 24,838 X-RAY'S; 3,002 MAMMOGRAPHIES; 2,370 ULTRASOUNDS; 1,032 NUCLEAR MEDICINE SCANS; 7,384 CT SCANS; 148 CARDIOVASCULAR CATHETERIZATIONS; 20,961 PHYSICAL THERAPY MODALITIES; 45,034 CARDIOPULMONARY PROCEDURES; 2,281 MRI'S; AND 10,751 EKG'S. CHARITY CARE: THE HOSPITAL WILL OFFER AND PROVIDE FREE OR DISCOUNTED CARE TO ANY PATIENT WHO MEETS THE ELIGIBILITY REQUIREMENTS FOR FREE OR DISCOUNTED CARE UNDER THE OCAP OR HCAP FINANCIAL ASSISTANCE POLICIES. CHARGES FOREGONE FOR CHARITY AMOUNTED TO $10,533,880.Description

Activity2 Activity2

FieldValueIRS element (for citing)
Expense1654345Expense
Grants0Grants
Revenue1127388Revenue
DescriptionMEDICAL EDUCATION: THE HOSPITAL IS A TEACHING HOSPITAL THAT PROVIDES MEDICAL TRAINING TO 22 INTERNS AND RESIDENTS IN THE SPECIALTY AREAS OF FAMILY MEDICINE, DERMATOLOGY, AND OB/GYN.Description
FieldValueIRS element (for citing)
Total Program Service Expense81374196TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments1TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets1ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Financial Stmt Attached1FinancialStmtAttached
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds1TaxExemptBonds
Invest Tax Exempt Bonds0InvestTaxExemptBonds
Escrow Account0EscrowAccount
On Behalf Of Issuer0OnBehalfOfIssuer
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP1LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity1RelatedOrgControlledEntity
Transaction Related Entity1TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109691NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees585NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income1UnrelatedBusinessIncome
Form990-T Filed1Form990-TFiled
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members11NbrVotingGoverningBodyMembers
Number Independent Voting Members9NumberIndependentVotingMembers
Family Or Business Relationship1FamilyOrBusinessRelationship
Delegation Of Management Duties1DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters1LocalChapters
Policies Reference Chapters1PoliciesReferenceChapters
Form990 Provided To Governing Body0Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other0CompensationProcessOther
Investment In Joint Venture1InvestmentInJointVenture
Written Policy Or Procedure1WrittenPolicyOrProcedure
States Where Copy Of Return Is FiledOHStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1KEN DICKENBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number7405929298TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line155 HOSPITAL DRIVEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (18 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekAverage Hours Per Week RelatedAverageHoursPerWeekRelatedIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationKey EmployeeKeyEmployeeHighest Compensated EmployeeHighestCompensatedEmployee
GREG LONG
CEO/PRESIDENT40.000.00XX000
DOUGLAS BOLON PHD
VICE-CHAIR2.000.00XX000
DON COOLEY
TREASURER2.000.00XX000
MICHAEL BERNSTEIN
DIRECTOR2.000.00X000
SUSAN QUINN OD
CHAIR2.000.00XX000
JACQUELINE LEGG
SECRETARY2.000.00XX000
CANDY KEMMERER
DIRECTOR2.000.00X000
GERALD A MOLLICA
DIRECTOR2.000.00X000
BRENDA NOFTZ
DIRECTOR2.000.00X000
DAWN SAMMONS
DIRECTOR2.000.00X962200
BOB NORRIS
DIRECTOR2.000.00X000
KEN DICKEN
CFO40.000.00X000
MARK ROTHSTEIN
PHYSICIAN40.000.00381820018528X
KATHLEEN BERTUNA
PHYSICIAN40.000.0037728207581X
NEAL NESBITT
PHYSICIAN40.000.00419184013973X
DERRICK REEDUS
PHYSICIAN40.000.00549121024128X
JASON REED
PHYSICIAN40.000.001308611026910X
STENNETH ADAMS
PHYSICIAN40.000.00369894021281X
FieldValueIRS element (for citing)
Total Reportable Comp From Org3415534TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation112401TotalOtherCompensation
Number Individuals GT100 K31NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
OHIOHEALTH HOSPITAL MANAGEMENT SERVICES
3535 OLENTANGY RIVER ROADCOLUMBUSOH43214MANAGEMENT1319051
BRICKER & ECKLER LLP
100 SOUTH THIRD STREETCOLUMBUSOH432154291LEGAL SERVICES543828
OLOGIE LLC
447 EAST MAIN STREETCOLUMBUSOH43215MARKETING286096
ACCESS HEALTH ATHENS LLC
7450 HUNTINGTON PARK DRIVE SUITE 1COLUMBUSOH43235HEALTHCARE273654
DAWSON HEALTHCARE
3650 OLENTANGY RIVER ROAD SUITE 45COLUMBUSOH43214HEALTHCARE STAFFING SOLUTION158735
FieldValueIRS element (for citing)
Number Of Contractors GT100 K5NumberOfContractorsGT100K
All Other Contributions209045AllOtherContributions
Total Contributions209045TotalContributions

Program Service Revenue ProgramServiceRevenue (2 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
PATIENT SERVICES6221108852589688525896
RENT FROM AFFILIATE6311106720067200
FieldValueIRS element (for citing)
Total Program Service Revenue88593096TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column381247TotalRevenueColumn
Exclusion$381,247ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real1645091Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real1282353Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real362738Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column362738TotalRevenueColumn
Exclusion$362,738ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Securities20659847Securities

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities19772761Securities
Other-19557Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities887086Securities
Other19557Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column906643TotalRevenueColumn
Exclusion$906,643ExclusionAmount

Other Revenue Misc OtherRevenueMisc (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncomeUnrelated Business RevenueUnrelatedBusinessRevenue
AMA CONTRACTED SVCS90009910373951037395
CAFETERIA722210458116458116
PASS-THROUGH INVESTMENTS621500284299123163161136

Miscellaneous Revenue MiscellaneousRevenue

FieldValueIRS element (for citing)
Total Revenue Column1518336TotalRevenueColumn
Related Or Exempt Function Income1518336RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Other Revenue3298146TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column93750915TotalRevenueColumn
Related Or Exempt Function Income91730106RelatedOrExemptFunctionIncome
Unrelated Business Revenue161136UnrelatedBusinessRevenue
Exclusion$1,650,628ExclusionAmount
FieldValueIRS element (for citing)
Info In Schedule O Part IXXInfoInScheduleOPartIX

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total30630343Total
Program Services27444787ProgramServices
Management And General3185556ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total1154839Total
Program Services1034735ProgramServices
Management And General120104ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total6633836Total
Program Services5943917ProgramServices
Management And General689919ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total2138501Total
Program Services1916097ProgramServices
Management And General222404ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total657757Total
Management And General657757ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total65322Total
Management And General65322ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total16043498Total
Program Services15124498ProgramServices
Management And General919000ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total567858Total
Program Services508802ProgramServices
Management And General59056ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total4078883Total
Program Services3654679ProgramServices
Management And General424204ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total22286Total
Program Services19968ProgramServices
Management And General2318ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total718208Total
Program Services643514ProgramServices
Management And General74694ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total169176Total
Program Services151582ProgramServices
Management And General17594ManagementAndGeneral

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total61032Total
Program Services54685ProgramServices
Management And General6347ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total2082814Total
Program Services1866201ProgramServices
Management And General216613ManagementAndGeneral

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total2390010Total
Program Services2141448ProgramServices
Management And General248562ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total1708766Total
Program Services1531054ProgramServices
Management And General177712ManagementAndGeneral

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServices
MEDICAL SUPPLIES1218845712188457
BAD DEBTS EXPENSE69169546916954
MEMBERSHIP DUES129718129718
COMMUNITY BENEFIT2302323023

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total80077Total
Program Services80077ProgramServices

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total88461358Total
Program Services81374196ProgramServices
Management And General7087162ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY11293554BOY
EOY13030307EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY8720400BOY
EOY10087641EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY8098990BOY
EOY9069965EOY

Receivables From Officers Etc ReceivablesFromOfficersEtc

FieldValueIRS element (for citing)
BOY291885BOY
EOY102819EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY799178BOY
EOY1700248EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY2422067BOY
EOY1892944EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis83773339LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec48231110LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY31464155BOY
EOY35542229EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY1166120BOY
EOY-185650EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY9752438BOY
EOY9103603EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY74008787BOY
EOY80344106EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY3196277BOY
EOY4300976EOY

Tax Exempt Bond Liabilities TaxExemptBondLiabilities

FieldValueIRS element (for citing)
BOY27407500BOY
EOY26847083EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY848555BOY
EOY985317EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY9783224BOY
EOY11049451EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY41235556BOY
EOY43182827EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY32110934BOY
EOY36525620EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY52429BOY
EOY25791EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY609868BOY
EOY609868EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY32773231BOY
EOY37161279EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY74008787BOY
EOY80344106EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses5289557ReconcilationRevenueExpenses
Reconciliation Unrealized Invest-63813ReconciliationUnrealizedInvest
Reconcilation Other Changes-837696ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement ConsolidatedXFinancialStatementConsolidated
FieldValueIRS element (for citing)
Audit Committee1AuditCommittee
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members0MailingsMembers
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations0GrantsOtherOrganizations
Direct Contact Legislators0DirectContactLegislators
Rallies Demonstrations0RalliesDemonstrations
Other Activities1OtherActivities
Other Activities$1,444OtherActivitiesAmount
Total Lobbying Expenditures IIB1444TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierEXPLANATION OF LOBBYING ACTIVITIES:Identifier
Return ReferencePART II-B, LINE 1:ReturnReference
ExplanationLOBBYING EXPENSES RELATE TO THE PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION WHICH IS USED FOR LOBBYING.Explanation

Schedule D IRS990ScheduleD

Current Year CurrentYear

FieldValueIRS element (for citing)
Beginning Of Year Balance662294BeginningOfYearBalance
Investment Earnings Or Losses-26635InvestmentEarningsOrLosses
End Of Year Balance635659EndOfYearBalance

Current Year Minus1 Year CurrentYearMinus1Year

FieldValueIRS element (for citing)
Beginning Of Year Balance770777BeginningOfYearBalance
Investment Earnings Or Losses-108483InvestmentEarningsOrLosses
End Of Year Balance662294EndOfYearBalance

Current Year Minus2 Years CurrentYearMinus2Years

FieldValueIRS element (for citing)
Beginning Of Year Balance786504BeginningOfYearBalance
Investment Earnings Or Losses-15727InvestmentEarningsOrLosses
End Of Year Balance770777EndOfYearBalance

Current Year Minus3 Years CurrentYearMinus3Years

FieldValueIRS element (for citing)
Beginning Of Year Balance801779BeginningOfYearBalance
Investment Earnings Or Losses-15275InvestmentEarningsOrLosses
End Of Year Balance786504EndOfYearBalance
FieldValueIRS element (for citing)
Board Designated EOY Balance0.04060BoardDesignatedEOYBalance
Permanent Endowment EOY Balance0.95940PermanentEndowmentEOYBalance
Endowments Held By Unrelated Orgs0EndowmentsHeldByUnrelatedOrgs
Endowments Held By Related Orgs0EndowmentsHeldByRelatedOrgs

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis2389777OtherCostOrOtherBasis
Book Value2389777BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis33257951OtherCostOrOtherBasis
Depreciation17102063Depreciation
Book Value16155888BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis38998188OtherCostOrOtherBasis
Depreciation29027798Depreciation
Book Value9970390BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis9127423OtherCostOrOtherBasis
Depreciation2101249Depreciation
Book Value7026174BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings35542229TotalOfBookValueLandBuildings

Other Assets OtherAssets (3 entries)

DescriptionDescriptionBook ValueBookValue
LONG TERM ASSETS LIMITED AS TO USE7756217
BOND ISSUE COSTS784469
CURRENT ASSETS LIMITED AS TO USE562917
FieldValueIRS element (for citing)
Total Book Value Other Assets9103603TotalBookValueOtherAssets

Other Liabilities OtherLiabilities (4 entries)

DescriptionDescriptionAmountAmount
ACCRUED WAGES$3,511,292
OTHER ACCRUED LIABILITIES$2,995,679
OTHER LONG TERM LIABILITIES$916,185
LEASED PROPERTY DEPOSITS$3,626,295
FieldValueIRS element (for citing)
Total Of Amounts11049451TotalOfAmounts
Footnote In Part XIIIXFootnoteInPartXIII

Form990 Schedule D Part XIII Form990ScheduleDPartXIII (2 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS:PART V, LINE 4:THE ENDOWMENTS ARE INTENDED FOR THE SUPPORT OF THE ORGANIZATION'S HEALTHCARE ACTIVITIES.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X, LINE 2:O'BLENESS MEMORIAL HOSPITAL AND THE APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES, INC. ARE EXEMPT FROM FEDERAL TAXES UNDER SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ATHENS MEDICAL LABORATORY ASSOCIATES, INC., ATHENS SURGERY CENTER, LTD., ATHENS MEDICAL ASSOCIATES, LLC, AND O'BLENESS MEMORIAL PAIN MANAGEMENT CLINIC, LLC ARE FOR-PROFIT SUBSIDIARIES SUBJECT TO FEDERAL INCOME TAXES. FEDERAL INCOME TAX EXPENSE IS NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF JUNE 30, 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO JUNE 30, 2009.

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
Policy Applied To All HospitalsXPolicyAppliedToAllHospitals
FPG Reference Free Care1FPGReferenceFreeCare
Pcent150XPcent150
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent200 DXPcent200D
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget1ExpensesExceededBudget
Unable To Provide Care0UnableToProvideCare
Annual Community Benefit Report0AnnualCommunityBenefitReport

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense6108766TotalCommunityBenefitExpense
Direct Offsetting Revenue2075605DirectOffsettingRevenue
Net Community Benefit Expense4033161NetCommunityBenefitExpense
Percent Of Total Expense0.04870PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense15576325TotalCommunityBenefitExpense
Direct Offsetting Revenue9253233DirectOffsettingRevenue
Net Community Benefit Expense6323092NetCommunityBenefitExpense
Percent Of Total Expense0.07630PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense21685091TotalCommunityBenefitExpense
Direct Offsetting Revenue11328838DirectOffsettingRevenue
Net Community Benefit Expense10356253NetCommunityBenefitExpense
Percent Of Total Expense0.12500PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Total Community Benefit Expense6660TotalCommunityBenefitExpense
Direct Offsetting Revenue600DirectOffsettingRevenue
Net Community Benefit Expense6060NetCommunityBenefitExpense
Percent Of Total Expense0.00010PercentOfTotalExpense

Health Professions Education HealthProfessionsEducation

FieldValueIRS element (for citing)
Total Community Benefit Expense980342TotalCommunityBenefitExpense
Direct Offsetting Revenue808774DirectOffsettingRevenue
Net Community Benefit Expense171568NetCommunityBenefitExpense
Percent Of Total Expense0.00210PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense987002TotalCommunityBenefitExpense
Direct Offsetting Revenue809374DirectOffsettingRevenue
Net Community Benefit Expense177628NetCommunityBenefitExpense
Percent Of Total Expense0.00220PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense22672093TotalCommunityBenefitExpense
Direct Offsetting Revenue12138212DirectOffsettingRevenue
Net Community Benefit Expense10533881NetCommunityBenefitExpense
Percent Of Total Expense0.12720PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported1BadDebtExpenseReported
Bad Debt Expense$6,888,418BadDebtExpenseAmount
Amount Attributable To206653AmountAttributableTo
Amount Reimbursed By Medicare16835512AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare15887945CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall947567MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
Cost To Charge RatioXCostToChargeRatio
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare

Form990 Schedule H Part IV Form990ScheduleHPartIV (2 entries)

Description Ent Primary ActivityDescriptionEntPrimaryActivityOrganization Profit Or OwnershipOrganizationProfitOrOwnershipOfficers Etc Profit Or OwnershipOfficersEtcProfitOrOwnershipPhysicans Profit Or OwnershipPhysicansProfitOrOwnership
1 ATHENS SURGERY CENTER LTD
OUTPATIENT SURGERY0.597900.041200.36090
2 O'BLENESS MEMORIAL PAIN MANAGEMENT LLC
PAIN MANAGEMENT0.510000.000000.49000
FieldValueIRS element (for citing)
Number Of Hospital Facilities1NumberOfHospitalFacilities

Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA

FieldValueIRS element (for citing)
Facility Number1FacilityNumber

Name Name

FieldValueIRS element (for citing)
Business Name Line1O'BLENESS MEMORIAL HOSPITALBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line155 HOSPITAL DRIVEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Teaching HospitalXTeachingHospital
Er24 HoursXEr24Hours

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1O'BLENESS MEMORIAL HOSPITALBusinessNameLine1
FieldValueIRS element (for citing)
Hospital Facility Number1HospitalFacilityNumber
CHNA Conducted1CHNAConducted
Community DefinitionXCommunityDefinition
Community DemographicsXCommunityDemographics
Existing ResourcesXExistingResources
How Data ObtainedXHowDataObtained
Community Health NeedsXCommunityHealthNeeds
Other Health IssuesXOtherHealthIssues
Identifying ProcessXIdentifyingProcess
Consulting ProcessXConsultingProcess
Information GapsXInformationGaps
Needs Assessment Conducted12NeedsAssessmentConducted
Take Into Account1TakeIntoAccount
Other Facilities0OtherFacilities
CHNA Widely Available1CHNAWidelyAvailable
Own WebsiteXOwnWebsite
On RequestXOnRequest
Prioritize Health NeedsXPrioritizeHealthNeeds
All Needs Addressed1AllNeedsAddressed
Organization Incur Excise Tax0OrganizationIncurExciseTax
Eligibility Criteria Explained1EligibilityCriteriaExplained
Uses FPG Free1UsesFPGFree
FPG Free Percent150.000000000000FPGFreePercent
Uses FPG Discounted1UsesFPGDiscounted
FPG Discount Percent200.000000000000FPGDiscountPercent
Explains Basis1ExplainsBasis
Income LevelXIncomeLevel
Insurance StatusXInsuranceStatus
Medicaid MedicareXMedicaidMedicare
State RegulationXStateRegulation
Explains Application Method0ExplainsApplicationMethod
Includes Publicity Measures0IncludesPublicityMeasures
Actions On Nonpayment1ActionsOnNonpayment
Collection Activities0CollectionActivities
Nondiscrim Emergency Care Policy1NondiscrimEmergencyCarePolicy
Used Other MethodXUsedOtherMethod
Amounts Generally Billed0AmountsGenerallyBilled
Gross Charges0GrossCharges

Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC

FieldValueIRS element (for citing)
Number Of Other Facilities1NumberOfOtherFacilities

Other Facilities OtherFacilities

Name Name

FieldValueIRS element (for citing)
Business Name Line1ATHENS MEDICAL ASSOCIATES LLCBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line155 HOSPITAL DRIVEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode
FieldValueIRS element (for citing)
Facility TypePHYSICIAN SERVICESFacilityType

Form990 Schedule H Part VI Form990ScheduleHPartVI (14 entries)

ExplanationExplanationIdentifierIdentifierReturn ReferenceReturnReference
PART I, LINE 3C: THE HOSPITAL HAS MORE THAN ONE POLICY CONCERNING FREE OR DISCOUNTED CARE. O'BLENESS MEMORIAL HOSPITAL WILL OFFER AND PROVIDE FREE CARE TO ANY PATIENT WHO MEETS THE ELIGIBILITY REQUIREMENT FOR FREE CARE UNDER THE OCAP OR HCAP FINANCIAL ASSISTANCE POLICIES. THE FOLLOWING STEPS WILL BE USED TO DETERMINE ELIGIBILITY FOR FREE CARE UNDER OCAP (O'BLENESS CARE ASSURANCE PROGRAM): 1. A RECIPIENT OF THE OHIO MEDICAID PROGRAM IS NOT ELIGIBLE. (OAC RULE 5 10 1 :3-2-07.17) 2. IF THE PATIENT IS COVERED UNDER A THIRD-PARTY INSURER OR A GOVERNMENTAL PROGRAM, THE THIRD PARTY WILL BE BILLED AND ANY PAYMENT RECEIVED WILL BE APPLIED TO THE ACCOUNT FIRST. ANY BALANCE ON THE ACCOUNT WILL BE CONSIDERED FOR THE OCAP WRITE-OFF. 3. OCAP ASSISTANCE WILL BE APPROVED ONLY WHEN SERVICES ARE PROVIDED BY O'BLENESS MEMORIAL HOSPITAL. THESE SERVICES ALSO INCLUDE PHYSICIAN INTERPRETATION FEES FOR CARDIOPULMONARY SERVICES AND SERVICE PROVIDED IN THE O'BLENESS FAMILY PRACTICE CLINIC.4. FAMILY INCOME IS BETWEEN 100 TO 150% OF THE FEDERAL POVERTY GUIDELINES. FAMILY: FAMILY SHALL BE DEFINED AS THE PATIENT, THE PATIENT'S SPOUSE, AND ALL OF THE PATIENT'S CHILDREN, NATURAL AND ADOPTIVE UNDER THE AGE OF EIGHTEEN WHO LIVE AT HOME. IF THE PATIENT IS UNDER THE AGE OF EIGHTEEN THE FAMILY SHALL INCLUDE THE PATIENT, THE PATIENT'S NATURAL OR ADOPTIVE PARENT(S) AND THE PARENT(S) CHILDREN, NATURAL OR ADOPTIVE UNDER THE AGE OF EIGHTEEN WHO LIVE IN THE HOME. IF THE PATIENT IS A CHILD OF A MINOR PARENT WHO STILL RESIDES IN THE HOME OF THE PATIENT'S GRANDPARENTS, THE FAMILY SHALL INCLUDE ONLY THE PARENT(S) OF ANY OF THE PARENT(S) NATURAL OR ADOPTIVE CHILDREN WHO RESIDE IN THE HOME. INCOME: INCOME SHALL BE DEFINED AS THE TOTAL SALARIES, WAGES AND CASH RECEIPTS BEFORE TAXES: RECEIPTS THAT REFLECT REASONABLE DEDUCTION FOR BUSINESS EXPENSES SHALL BE COUNTED FOR BOTH FARM AND NON-FARM SELF-EMPLOYMENT. THE FOLLOWING STEPS WILL BE USED TO DETERMINE ELIGIBILITY FOR FREE CARE UNDER HCAP (HOSPITAL CARE ASSURANCE PROGRAM): 1. A COMPLETED APPLICATION WILL BE OBTAINED FROM ALL PATIENTS SEEKING FREE CARE UNDER HCAP. 2. A PATIENT MUST BE A RESIDENT OF THE STATE OF OHIO TO BE ELIGIBLE FOR HCAP. 3. O'BLENESS MEMORIAL HOSPITAL WILL DEFINE INCOME REQUIREMENTS USING THE FEDERAL POVERTY GUIDELINES AS INDICATED YEARLY. 4. O'BLENESS MEMORIAL HOSPITAL WILL DEFINE A FAMILY AS INDICATED IN BALDWIN'S OHIO ADMINISTRATIVE CODE CHAPTER 5101:3-2-0717. 5. THE INCOME PROVIDED BY THE APPLICANT WILL BE VERIFIED VIA SWORN SIGNATURE. 6. A RECIPIENT OF THE OHIO MEDICAID PROGRAM IS NOT ELIGIBLE (OAC RULE: 5101:3-2-0717) IF A PATIENT HAS INSURANCE COVERAGE, O'BLENESS MEMORIAL HOSPITAL WILL FIRST BILL THE INSURANCE AND RECEIVE A PAYMENT OF A DENIAL BEFORE THE HCAP APPLICATION IS PROCESSED.
PART I, LINE 7: THE COST OF CHARITY CARE, UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS WAS ESTIMATED USING A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. COSTING METHODOLOGY USED TO DETERMINE THE COST OF COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS: THE HOSPITAL USES THE COMPUTER SOFTWARE CBISA TO TRACK OUR PROGRAMS THAT HAPPEN IN THE COMMUNITY OR AT THE HOSPITAL FOR THE COMMUNITY. THE COMPUTER TRACKS DIRECT EXPENSES ASSOCIATED WITH THE PROGRAMS AS WELL AS ANY OFFSETTING REVENUE THAT WILL DECREASE THE COMMUNITY BENEFIT. THE SYSTEM ACCOUNTS FOR UTILITIES USED IF THE ACTIVITY OCCURS AT THE FACILITY (HOSPITAL). THE SYSTEM ALSO ACCOUNTS FOR ANY SUPPLIES USED AND WAGES OF ANY EMPLOYEE THAT IS PRESENT AT THE ACTIVITY. A HOSPITAL WIDE WAGE AVERAGE IS USED IN DETERMINING THE AMOUNT OF SALARY TO USE IN THE DIRECT EXPENSES.
PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 6888418.
PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLES ARE CARRIED AT THE ORIGINAL CHARGE LESS AN ESTIMATE MADE FOR DOUBTFUL OR UNCOLLECTIBLE ACCOUNTS. THE ALLOWANCE IS BASED UPON A REVIEW OF THE OUTSTANDING BALANCES AGED BY FINANCIAL CLASS. MANAGEMENT USES COLLECTION PERCENTAGES BASED UPON HISTORICAL COLLECTION EXPERIENCE TO DETERMINE COLLECTABILITY. MANAGEMENT ALSO REVIEWS TROUBLED, AGED ACCOUNTS TO DETERMINE COLLECTION POTENTIAL. PATIENT ACCOUNTS RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO BAD DEBT EXPENSE WHEN RECEIVED. INTEREST IS NOT CHARGED ON PATIENT ACCOUNTS RECEIVABLE.FINANCIAL STATEMENT FOOTNOTE: ACCOUNTS RECEIVABLE ARE STATED NET OF CONTRACTUAL ALLOWANCES AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS DETERMINED UTILIZING A NUMBER OF FACTORS INCLUDING ACCOUNT AGING AND FINANCIAL CLASS INFORMATION AS WELL AS RECENT AND HISTORICAL COLLECTION ACTIVITY.THE BAD DEBT WAS DETERMINED BASED ON FORM 990, PART IX. THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS ESTIMATED AT 3% OF BAD DEBT.
PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING METHODOLOGY REQUIRED FOR THE MEDICARE COST REPORT (COST TO CHARGE RATIO).
PART III, LINE 9B: PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE ASKED TO FILL OUT THE PAPERWORK ASSOCIATED WITH THE PROGRAMS WE HAVE AVAILABLE TO PATIENTS WITH LOW INCOME. WE DO NOT HAVE A COLLECTIONS PROCESS FOR CHARITY CARE PATIENTS AND THE FULL AMOUNT IS WRITTEN OFF TO THE ASSOCIATED PROGRAM. THIS DOES NOT APPLY TO PATIENTS THAT DO NOT QUALIFY FOR EITHER OF THE PROGRAMS. IF IT IS DETERMINED THAT THE PATIENT IS CAPABLE OF PAYING FOR THEIR MEDICAL CARE, THEN AT THAT POINT THEY ARE BILLED AT A DISCOUNTED RATE FOR THE SERVICES PROVIDED. IF THEY FAIL TO PAY AT THE DISCOUNTED RATE THEN COLLECTION PRACTICES ENSUE.
PART V, SECTION B, LINE 3: THE HOSPITAL SOUGHT INPUT FROM SEVERAL STRATEGIC MEMBERS OF THE COMMUNITY WHEN CONDUCTING THE CHNA. AFTER INPUT WAS OBTAINE, THESE INDIVIDUALS ALONG WITH KEY MEMBERS FROM THE HOSPITAL CAME TOGETHER TO DEVELOP THE REPORT AND STRATEGY. THE COMMUNITY MEMBERS INCLUDED: DR. GASKELL, MEDICAL DIRECTOR OF THE HEALTH DEPARTMENT/HEALTH COMMISSIONER; DR. SHUBROOK, DIABETES RESEARCH, TREATMENT, AND EDUCATION; KATHY TRACE, DIRECTOR OF AREA HEALTH EDUCATION CENTER AND COMMUNITY HEALTH SERVICES AT THE OHIO UNIVERSITY HERITAGE COLLEGE OF OSTEOPATHIC MEDICINE; DR. CLARK, VICE PRESIDENT OF MEDICAL AFFAIRS AT O'BLENESS MEMORIAL HOSPITAL; ADAM KLESS, CHIEF NURSING OFFICER AT O'BLENESS MEMORIAL HOSPITAL; AND DR. BASTA, ASSOCIATE PROFESSOR/DIRECTOR OF SOCIAL AND PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES AND PROFESSIONS.O'BLENESS MEMORIAL HOSPITAL
PART V, SECTION B, LINE 20D: THE MAXIMUM AMOUNTS CHARGED TO FINANCIAL ASSISTANCE POLICY ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY IS $0 FOR PATIENTS WHO FALL WITHIN 150% OF THE FPG AND 50% OF CHARGEMASTER RATES FOR PATIENTS WHO FALL WITHIN 200% OF THE FPG.O'BLENESS MEMORIAL HOSPITAL
HTTP://WWW.OBLENESS.ORG/ABOUT/COMMUNITY-NEEDS-ASSESSMENT-REPORT-2013/SCHEDULE H, PART V, SECTION B, LINE 5A
PART VI, LINE 2: THE HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT TO BEST SERVE THE NEEDS OF THE PATIENTS AND BE IN COMPLIANCE WITH FUTURE HEALTHCARE LEGISLATION.
PART VI, LINE 3: THE HOSPITAL INFORMS PATIENTS OF THEIR ELIGIBILITY FOR ASSISTANCE IN DIFFERENT WAYS. THERE IS A SIGN IN THE ADMITTING AREA THAT DIRECTS THEIR ATTENTION TO THE FACT THAT THERE IS AVAILABLE CARE AT A REDUCED FEE OR FREE OF CHARGE. ON EACH DATA MAILER THAT IS SENT OUT TO PATIENTS, THERE IS A SECTION THAT INFORMS THEM OF THE AVAILABILITY OF THIS CARE. ANY PATIENT THAT COMES IN WITHOUT INSURANCE OR PROOF OF INSURANCE IS SUPPLIED A SELF-PAY PACKET. IN THIS PACKET IS AN OUTLINE ON HOW TO OBTAIN FREE OR DISCOUNTED CARE; THE PACKET ALSO DETAILS THE PARAMETERS OF EACH PROGRAM. IF ANY OF OUR EMPLOYEES ARE ASKED IN ADMISSIONS OR DURING THEIR CARE IF THERE ARE ANY OPTIONS AVAILABLE FOR PAYMENT OF THEIR CARE, THE EMPLOYEES WILL DESCRIBE TO THE PATIENTS THE PROGRAMS AVAILABLE OR PROVIDE THEM WITH MATERIALS ON HOW TO APPLY AND BE ACCEPTED INTO THE FREE OR DISCOUNTED CARE PROGRAMS.
PART VI, LINE 4: O'BLENESS MEMORIAL HOSPITAL IS A COMMUNITY HOSPITAL IN A RURAL AREA OF APPALACHIA. OUR PRIMARY SERVICE AREA INCLUDES THE COMMUNITIES WITHIN ATHENS COUNTY, OHIO, WHICH HAS BEEN IDENTIFIED BY THE APPALACHIAN REGIONAL COMMISSION AS AN ARC-DESIGNATED DISTRESSED COUNTY. ACCORDING TO THE UNITED STATES CENSUS BUREAU, THE POPULATION OF ATHENS COUNTY IN 2013 WAS 64,681. THE MEDIAN INCOME OF $33,836 IS NOT TRULY REPRESENTATIVE OF THE POPULATION, AS THE COMMUNITY INCLUDES A MAJOR UNIVERSITY. ATHENS COUNTY HAS THE HIGHEST POVERTY LEVEL OF ANY COUNTY IN OHIO, AS 32.2% OF THE COMMUNITY RESIDENTS HAVE INCOMES AT OR BELOW THE FEDERAL POVERTY GUIDELINE. UNINSURED INDIVIDUALS IN ATHENS COUNTY REPRESENT 21% OF THE POPULATION. THE HOSPITAL'S PATIENT POPULATION INCLUDES 8.8% WHO ARE UNINSURED AND 23.18% WHO ARE MEDICAID RECIPIENTS. LOCATED WITHIN O'BLENESS' PRIMARY SERVICE AREA OF ATHENS COUNTY IS ONE ADDITIONAL HOSPITAL, DOCTORS HOSPITAL OF NELSONVILLE AFFILIATED WITH OHIOHEALTH BASED IN COLUMBUS, OHIO. PORTIONS OF THE PATIENT POPULATION ARE ALSO SERVED BY EIGHT OTHER HOSPITALS IN WASHINGTON, GALLIA, JACKSON, HOCKING, FAIRFIELD AND ROSS COUNTIES IN OHIO AND WOOD COUNTY IN WEST VIRGINIA, AS WELL AS THREE MAJOR HEALTH SYSTEMS WITH MULTIPLE FACILITIES IN FRANKLIN COUNTY, OHIO. TWO TOWNSHIPS IN ATHENS COUNTY HAVE BEEN DESIGNATED AS MEDICALLY UNDERSERVED AREAS/POPULATIONS BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: LODI AND TRIMBLE.
PART VI, LINE 5: AT O'BLENESS MEMORIAL HOSPITAL IT IS OUR GOAL TO GIVE ACCESS TO ANY PERSON IN OUR COMMUNITY TO MODERN DAY HEALTHCARE AT A COST EFFECTIVE PRICE. AS THE ONLY HOSPITAL IN ATHENS, WE STRIVE TO GIVE HELP WHERE HELP IS NEEDED. TO FURTHER OUR COMMITMENT TO THE COMMUNITY AND OUR EXEMPT PURPOSE WE ENGAGE IN MANY ACTIVITIES. OUR BOARD IS COMPILED OF PEOPLE WHO RESIDE IN OUR COMMUNITY WITHOUT A CONFLICT OF INTEREST WITH THE HOSPITAL. WE BELIEVE THE MORE DIVERSE THE BOARD THE BETTER THEY WILL BE ABLE TO IDENTIFY THE NEEDS OF THE COMMUNITY. THE MAJORITY OF THE BOARD HAS NO CONNECTION TO THE ORGANIZATION NOR ARE CONTRACTED WITH THE HOSPITAL. THEY PROVIDE THEIR CONSULT AND GUIDANCE OUT OF THE PURE DESIRE TO SEE THEIR COMMUNITY BE AFFORDED THE SAME QUALITY OF CARE AS BIGGER MARKETS. WE EXTEND MEDICAL PRIVILEGES TO QUALIFIED PHYSICIANS THAT HAVE A DESIRE TO PRACTICE WITHIN OUR FACILITIES. WE CONTINUE TO SEARCH FOR PROGRAMS AND ACTIVITIES THAT WILL BE NEW TO THE COMMUNITY IN ORDER TO GIVE THE POPULATION VARIETY AND HEALTH ORIENTED ALTERNATIVES. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT THAT IS VITAL IN KEEPING UP WITH AN EVER EVOLVING MEDICAL WORLD. IT IS ALSO USED TO FUND ACTIVITIES INSIDE AND OUTSIDE OF THE HOSPITAL THAT INVOLVES THE COMMUNITY ON VARIOUS LEVELS WHETHER IT BE A HEALTH FAIR OR AN INTERACTIVE EXERCISE PROGRAM. WE HAVE MANY VOLUNTEERS FROM THE COMMUNITY THAT ARE INSTRUMENTAL IN CARRYING OUT VARIOUS ACTIVITIES.
PART VI, LINE 6: THE O'BLENESS HEALTH SYSTEM IS DESIGNED TO OFFER THE MOST COMPREHENSIVE MEDICAL ATTENTION TO A MAINLY CENTRALIZED LOCATION TO THE COMMUNITY IN WHICH WE LIVE. THE AFFILIATES OF THE SYSTEM WORK TOGETHER IN A COLLABORATIVE EFFORT TO INCREASE THE EFFICIENCY AND COST OF HEALTHCARE TO THE PATIENT. THE O'BLENESS MEMORIAL HOSPITAL IS THE MAIN COMPONENT OF THE HEALTH SYSTEM. AT THE HOSPITAL WE OFFER A VARIETY OF INPATIENT AND OUTPATIENT SERVICES. THE EMERGENCY DEPARTMENT IS OPERATIONAL 24 HOURS A DAY 7 DAYS A WEEK. WE OFFER CARE TO ANYONE REGARDLESS OF ABILITY TO PAY. WE ARE THE ONLY FULLY FUNCTIONAL HOSPITAL IN THE COMMUNITY. IT IS OUR GOAL NOT TO EXCLUDE ANYONE FROM OUR COMMUNITY THAT IS IN NEED OF CARE. THE ATHENS MEDICAL LAB (AML) IS AN AFFILIATE OF THE SYSTEM THAT IS A MEDICAL REFERENCE LAB THAT OFFERS CONVENIENCE AND COST EFFICIENCY FOR THE PATIENT. THIS ALLOWS US TO KEEP PATIENTS CLOSE TO HOME AND SPEED UP RESULT TIME. THE ATHENS MEDICAL ASSOCIATES (AMA) IS A MULTI-PHYSICIAN PRACTICE THAT OFFERS A VARIETY OF SERVICES TO PATIENTS. AMA IS COMPRISED OF A MULTIFACETED OB/GYN PRACTICE, AN ORTHOPEDIC SURGEON, AND A FAMILY PRACTICE CLINIC THAT SERVICE NUMEROUS MEMBERS OF THE COMMUNITY. THERE IS ALSO APPALACHIAN COMMUNITY VISITING NURSES ASSOCIATION, HOSPICE AND HEALTH SERVICES (ACVNAHHS). THIS AFFILIATE PROVIDES HOSPICE SERVICES TO NOT ONLY ATHENS COUNTY BUT SURROUNDING COUNTIES. THEY ARE ALSO PROVIDERS OF VISITING NURSES THAT SERVE OUR CLIENTS OUT OF THE COMFORT OF THEIR OWN HOME.

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (6 entries)

TitleTitleBase Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
MARK ROTHSTEIN
PHYSICIAN33230400049516075000110280400348000
KATHLEEN BERTUNA
PHYSICIAN2800000963820900075000810384863000
NEAL NESBITT
PHYSICIAN3900000002918407500064730433157000
DERRICK REEDUS
PHYSICIAN430000000119121075000166280573249000
JASON REED
PHYSICIAN65000006478930107180750001941001335521000
STENNETH ADAMS
PHYSICIAN3698940000075000137810391175000

Form990 Schedule J Part III Form990ScheduleJPartIII

FieldValueIRS element (for citing)
Return ReferencePART I, LINE 3ReturnReference
ExplanationTHE CEO IS COMPENSATED THROUGH AN UNRELATED MANAGEMENT COMPANY, OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC. THE CONTRACT WITH THE MANAGEMENT COMPANY IS REVIEWED AND APPROVED BY THE BOARD. THE COMPENSATION FOR THE CEO IS REVIEWED AND APPROVED BY THE MANAGEMENT COMPANY.Explanation

Schedule K IRS990ScheduleK

Form990 Schedule K Part I Form990ScheduleKPartI

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd

Issuer Name IssuerName

FieldValueIRS element (for citing)
Business Name Line1COUNTY OF ATHENS OHIOBusinessNameLine1
FieldValueIRS element (for citing)
Issuer EIN316400063IssuerEIN
CUSIP Number047075BA3CUSIPNumber
Date Issued2003-08-21DateIssued
Issue Price31263724IssuePrice
Description Of PurposeBOND REFUNDING, HOSPITAL CONSTRUCTION & RENOVATIONDescriptionOfPurpose
Defeased0Defeased
On Behalf Of Issuer0OnBehalfOfIssuer
Pool Financing0PoolFinancing

Form990 Schedule K Part II Form990ScheduleKPartII

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Total Proceeds31263724TotalProceeds
Amount In Reserve Fund2493855AmountInReserveFund
Issuance Costs From Proceeds625274IssuanceCostsFromProceeds
Year Of Subst Completion2005YearOfSubstCompletion
Current Refunding0CurrentRefunding
Advance Refunding0AdvanceRefunding
Final Allocation Made1FinalAllocationMade
Adequate Books And Recds Maintaind1AdequateBooksAndRecdsMaintaind

Form990 Schedule K Part III Form990ScheduleKPartIII

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Owning Bond Financed Property0OwningBondFinancedProperty
Any Lease Arrangements0AnyLeaseArrangements
Mngment Cntrct Bond Financd Prprty0MngmentCntrctBondFinancdPrprty
Any Research Agreements0AnyResearchAgreements
Prcntge Prvt Business Use By Others0.00000PrcntgePrvtBusinessUseByOthers
Percentage Of Prvt Business Re UBI0.00000PercentageOfPrvtBusinessReUBI
Total Private Business Use0.00000TotalPrivateBusinessUse
Bond Iss Meet Prvt Security Pay Test0BondIssMeetPrvtSecurityPayTest
Change In Use Bond Financed Prop0ChangeInUseBondFinancedProp
Non Qualified Bond Remed Procdrs0NonQualifiedBondRemedProcdrs

Form990 Schedule K Part IV Form990ScheduleKPartIV

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Form8038 T Filed0Form8038TFiled
Rebate Not Due Yet0RebateNotDueYet
Exception To Rebate0ExceptionToRebate
No Rebate Due0NoRebateDue
Variable Rate Issue0VariableRateIssue
Hedge Identified In Books And Recds0HedgeIdentifiedInBooksAndRecds
Gross Proceeds Invested In GIC0GrossProceedsInvestedInGIC
Gross Proceeds Invested0GrossProceedsInvested
Written Proc To Monitor Reqs0WrittenProcToMonitorReqs

Form990 Schedule K Part V Form990ScheduleKPartV

FieldValueIRS element (for citing)
Bond ReferenceABondReferenceCd
Proc To Undertk Corrective Action0ProcToUndertkCorrectiveAction

Schedule L IRS990ScheduleL

Loan Table LoanTable (3 entries)

Relationship With OrganizationRelationshipWithOrganizationPurpose Of LoanPurposeOfLoanLoan From OrganizationLoanFromOrganizationOriginal PrincipalOriginalPrincipalAmountBalance DueBalanceDueDefaultDefaultApproved By BoardApprovedByBoardWritten AgreementWrittenAgreement
DAWN SAMMONS
DIRECTOR/PHYSICIANPHYSICIAN EDUCATION LOANX$250,0006000011
MARK ROTHSTEIN
PHYSICIANPHYSICIAN EDUCATION LOANX$50,00016667011
DERRICK REEDUS
PHYSICIANPHYSICIAN EDUCATION LOANX$178,62480152011
FieldValueIRS element (for citing)
Total Balance Due102819TotalBalanceDue

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (10 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 2BUSINESS RELATIONSHIP BETWEEN MICHAEL BERNSTEIN (BOARD MEMBER) AND GREG LONG (OFFICER AND BOARD MEMBER). CANDY KEMMERER (BOARD MEMBER) IS AN EMPLOYEE OF HOCKING VALLEY BANK WITH WHOM THERE ARE ACCOUNTS.
FORM 990, PART VI, SECTION A, LINE 3THE ORGANIZATION ENTERED INTO A MANAGEMENT AGREEMENT WITH OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC, AN OHIO NONPROFIT LIMITED LIABILITY COMPANY, EFFECTIVE AUGUST 1, 2010 FOR A FIVE YEAR TERM. OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC IS A WHOLLY OWNED SUBSIDIARY OF OHIOHEALTH CORPORATION, AN OHIO NONPROFIT CORPORATION THAT IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE IRS.
FORM 990, PART VI, SECTION B, LINE 11THE CHIEF FINANCIAL OFFICER REVIEWS THE FORM 990 THROUGHOUT THE PREPARATION PROCESS. THE FORM 990 IS REVIEWED BY THE MANAGEMENT COMPANY.
FORM 990, PART VI, SECTION B, LINE 12CALL OFFICERS AND DIRECTORS ANNUALLY DISCLOSE INTERESTS THAT COULD GIVE RISE TO CONFLICT THROUGH AN ANNUAL QUESTIONNAIRE. ADDITIONALLY, CONFLICTS THAT ARISE THROUGHOUT THE YEAR ARE TO BE DISCLOSED AS SOON AS POSSIBLE. CONFLICTS ARE ADDRESSED BY IMPOSING RESTRICTIONS SUCH AS PROHIBITIONS AGAINST PARTICIPATING IN GOVERNING BODY'S DELIBERATIONS, AND MAKING DECISIONS RELATIVE TO TRANSACTIONS RELATED TO THE CONFLICT, ANY TIME THE CONFLICT ITSELF CANNOT BE REVERSED.
FORM 990, PART VI, SECTION B, LINE 15ACOMPENSATION OF THE EXECUTIVE DIRECTOR IS DETERMINED BASED ON COMPARABILITY DATA, CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION AND BY A COMPENSATION COMMITTEE WITH THE FULL BOARD'S APPROVAL. THE EXECUTIVE IS PAID THROUGH OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC. THE LAST COMPENSATION REVIEW WAS COMPLETED IN 2013.
FORM 990, PART VI, SECTION C, LINE 18FORM 1023, 990 AND 990-T ARE AVAILABLE IN HARD COPY UPON REQUEST.
FORM 990, PART VI, SECTION C, LINE 19THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART IX, LINE 11GPHYSICIAN RECRUITMENT FEES: PROGRAM SERVICE EXPENSES 164,660. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 164,660. CONSULTING FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 295,111. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 295,111. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 2,389,758. MANAGEMENT AND GENERAL EXPENSES 265,529. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,655,287. BANKING AND COLLECTIONS SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 350,606. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 350,606. TRANSCRIPTION SERVICES: PROGRAM SERVICE EXPENSES 115,420. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 115,420. LAUNDRY SERVICES: PROGRAM SERVICE EXPENSES 279,755. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 279,755. PRINTING SERVICES: PROGRAM SERVICE EXPENSES 69,789. MANAGEMENT AND GENERAL EXPENSES 7,754. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 77,543. PHYSICIAN/HEALTHCARE CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 12,100,668. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,100,668. PATIENT TRANSPORTATION: PROGRAM SERVICE EXPENSES 4,448. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,448.OTHER FEES
FORM 990, PART XI, LINE 9:REDUCTION IN PLEDGE RECEIVABLE VALUE -26,638. CAPITAL CONTRIBUTIONS TO/FROM AFFILIATE -526,759. S-CORPORATION INCOME TAXABLE ON RETURN NOT ON BOOKS -161,136. PAIN MANAGEMENT INCOME ON RETURN NOT ON BOOKS -123,163.CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XII, LINE 2CTHE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR.

Schedule R IRS990ScheduleR

Form990 Schedule R Part I Form990ScheduleRPartI

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1ATHENS MEDICAL ASSOCIATES LLCBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line175 HOSPITAL DRIVEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode
FieldValueIRS element (for citing)
EIN020734615EIN
Primary ActivitiesPHYSICIAN SERVICESPrimaryActivities
Legal Domicile StateOHLegalDomicileState
Total Income9789773TotalIncome
EOY Assets1792027EOYAssets

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1SHELTERING ARMS HOSPITAL FOUNDATIONBusinessNameLine1

Form990 Schedule R Part II Form990ScheduleRPartII

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATIONBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line130 HERROLD AVENUEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode
FieldValueIRS element (for citing)
EIN311045101EIN
Primary ActivitiesHOSPICE AND HEALTH SERVICESPrimaryActivities
Legal Domicile StateOHLegalDomicileState
Exempt Code Section501(C)(3)ExemptCodeSection
Public Charity StatusLINE 3PublicCharityStatus

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1SHELTERING ARMS HOSPITAL FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Controlled Org1ControlledOrg

Form990 Schedule R Part III Form990ScheduleRPartIII (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivityPrimaryActivityLegal Domicile StateLegalDomicileStateDirect Controlling Entity NADirectControllingEntityNAPredominant Income TypePredominantIncomeTypeShare Of Total IncomeShareOfTotalIncomeShare Of EOY AssetsShareOfEOYAssetsDisproportionate AllocationsDisproportionateAllocationsGeneral Or Managing PartnerGeneralOrManagingPartnerPercentage OwnershipPercentageOwnership
ATHENS SURGERY CENTER LTD
75 HOSPITAL DRIVEATHENSOH45701550840856OUTPATIENT SURGERYOHN/ARELATED138350340328010.59790
O'BLENESS MEMORIAL PAIN MANAGEMENT CLINIC LLC
55 HOSPITAL DRIVEATHENSOH45701454587317PAIN MANAGEMENTOHN/ARELATED123163171255010.51000

Form990 Schedule R Part IV Form990ScheduleRPartIV

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1ATHENS MEDICAL LABORATORY ASSOCIATES INCBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1265 WEST UNION STREET SUITEAddressLine1
CityATHENSCity
StateOHState
ZIP Code45701ZIPCode
FieldValueIRS element (for citing)
EIN311381808EIN
Primary ActivityMEDICAL LABORATORYPrimaryActivity
Legal Domicile StateOHLegalDomicileState

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1SHELTERING ARMS HOSPITAL FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Type Of EntitySTypeOfEntity
Share Of Total Income1456554ShareOfTotalIncome
Share Of EOY Assets819805ShareOfEOYAssets
Percentage Ownership1.00000PercentageOwnership
Controlled Org1ControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties1ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org1LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Dividends Related Organization1DividendsRelatedOrganization
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets1ExchangeOfAssets
Rental Of Facilities To Other Orgs1RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org1ReimbursementPaidByOtherOrg
Other Transfer To Other Org1OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (6 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolvedMethod Of Amt DeterminationMethodOfAmtDetermination
ATHENS SURGERY CENTER LTD
P51941ALLOCATION OF COSTS
APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION
A67200LEASE AGREEMENT
ATHENS SURGERY CENTER LTD
A412208LEASE AGREEMENT
APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION
D235000LOAN AGREEMENT
ATHENS SURGERY CENTER LTD
R186557DISTRIBUTIONS
ATHENS MEDICAL LABORATORY ASSOCIATES INC
R564000DISTRIBUTIONS