2013-01-30T07:34:37-06:00 2011-12-31 BDO USA LLP 100 PARK AVENUE NEW YORK NY 10017 990 2011-01-01 111667765 SOUTHAMPTON HOSPITAL ASSOCIATION % CHRISTOPHER SCHULTHEIS SOUT 6317268301 240 MEETING HOUSE LANE SOUTHAMPTON NY 11968 CHRISTOPHER J SCHULTHEIS 2013-01-29 true Paul Hammerschmidt 2128858000 2011 2016-02-25 16:41:14Z ROBERT S CHALONER 240 MEETING HOUSE LANE SOUTHAMPTON NY 11968 110069928 false X www.southamptonhospital.org X 1909 NY To provide and ensure the highest quality of healthcare services for its entire community. 25 24 1107 6 1487379 4082097 4889480 106304350 101425895 385561 424256 37093 -428517 110809101 106311114 0 0 0 0 62678644 66468243 0 0 0 47309251 38025175 109987895 104493418 821206 1817696 87206773 87464223 79512614 82870381 7694159 4593842 X The Vision of Southampton Hospital Association is to meet the evolving healthcare needs of its Eastern Long Island community by providing access to a continuum of high quality clinical services. To achieve this, the organization will focus resources on continuously improving clinical outcomes, patient safety, service excellence and promoting educational outreach and professional development of its staff. The organization is a member of the East End Health Alliance, the Article 28 parent of Eastern Long Island Hospital, Peconic Bay Medical Center and Southampton Hospital. Consistent with the Mission of Southampton Hospital, the goals of the Alliance are as follows: 1) To collaboratively develop high quality, comprehensive and accessible health care services to meet the needs of the community served; 2) To rationalize health care services across the system; and 3) To realize management efficiencies. The organization is also affiliated with Stony Brook Medicine, along with the other two E false false 89376688 101425895 Southampton Hospital Association offers a full continuum of ambulatory and inpatient services ranging from primary medical care to specialized surgical procedures, and is staffed by more than 230 physicians, dentists and allied health professionals representing 44 medical specialties. The organization has developed numerous services and outreach, detailed below, to respond to the needs of their patients, including recruiting additional primary care physicians and implementing a graduate medical education program that will hopefully attract these young physicians to stay and practice in the community. Since The organization's service area extends from Westhampton Beach to Montauk, The organization has a number of satellite care offices to provide convenient, specialized care to the community. These include: A) Meeting House Lane Medical Practice - providing primary care at seven locations in East Hampton, Hampton Bays, Montauk, Sag Harbor, Southampton, Wainscott, and Water Mill. B) Westhampton Primary Care Center - providing care in the Westhampton, Westhampton Beach, Quogue, and Remsenburg communities. C) Laboratory and Imaging Services - providing services in East Hampton, Hampton Bays and Southampton. D) Center for Physical Therapy and Rehabilitation - providing care in the Westhampton, Westhampton Beach, East Quogue, Quogue, and Remsenburg communities. E) THE SHINNECOCK INDIAN HEALTH CLINIC - SINCE APRIL OF 1995, SOUTHAMPTON HOSPITAL HAS WORKED WITH THE NATION TO PROVIDE SERVICES AT THE SHINNECOCK INDIAN HEALTH CLINIC THROUGH A CONTRACT WITH THE NEW YORK STATE DEPARTMENT OF HEALTH. ON AN ANNUAL BASIS, THE CLINIC PROVIDES APPROXIMATELY 2,000 MEDICAL, 800 DENTAL AND 400 DENTAL HYGIENE VISITS FOR ELIGIBLE MEMBERS OF THE SHINNECOCK NATION. DENTAL SERVICES, INCLUDING COMMUNITY EDUCATION, SCREENING, RADIOLOGICAL EXAMS, DENTAL HYGIENE AND RESTORATIVE CARE (CROWNS, FILLINGS AND BRIDGES) ARE PROVIDED THROUGH A SUBCONTRACT WITH STONY BROOK SCHOOL OF DENTAL MEDICINE. CURRENTLY, DENTAL SERVICES ARE AVAILABLE EIGHT DAYS PER MONTH FOR ADULTS AND TWO DAYS PER MONTH FOR CHILDREN. IN ADDITION TO PRIMARY CARE, DENTAL SERVICES, NUTRITIONAL COUNSELING, PRENATAL CARE AND ENDOCRINE SERVICES, THE CLINIC PROVIDES SOCIAL WORK, MENTAL HEALTH AND SUBSTANCE ABUSE COUNSELING. MAMMOGRAPHY SCREENING DAY IS ALSO HELD ANNUALLY IN COLLABORATION WITH THE HOSPITAL'S ELLEN HERMANSON BREAST CENTER. F) The David E. Rogers Center for HIV/AIDS Care - Another important collaboration between Southampton Hospital, Stony Brook University Medical Center and town and community organizations of the East End of Long Island. Major funding is provided through Ryan White Part A federal funds. The david e. rogers center provides medical and mental health services to individuals who are HIV positive, as well as, support services and prevention education to partners and family members affected by HIV/AIDS. The Center is a member of the Peconic Community Council, a not-for-profit coalition of organizations and individuals dedicated to the promotion and preservation of health and human services for the entire East End community. G) Center for Prenatal Care - THE CENTER FOR PRENATAL CARE AT GREENPORT PROVIDES COMPREHENSIVE PRENATAL, GYNECOLOGIC AND FAMILY PLANNING SERVICES FOR WOMEN AND IS AN IMPORTANT OUTREACH ACTIVITY THAT PERMITS THE HOSPITAL TO TAILOR ITS PROGRAMS TO COMMUNITY NEEDS. THE CENTER REACHES OUT TO THE COMMUNITY THROUGH COLLABORATIVE EFFORTS WITH A NUMBER OF LOCAL ORGANIZATIONS, INCLUDING CAST, A LOCAL SOUTHOLD SOCIAL SERVICE AGENCY, THE PERINATAL COALITION, EASTERN LONG ISLAND HOSPITAL, SUFFOLK COUNTY DEPARTMENT OF HEALTH AND LOCAL CHURCHES. THE CENTER HAS SUCCESSFULLY WORKED WITH THE LOCAL TOWN GOVERNMENT TO OBTAIN THE AGREEMENT OF LOCAL GROCERS TO ACCEPT WIC VOUCHERS. STAFF ALSO UTILIZES FLYERS, BROCHURES, AND POSTERS TO INCREASE AWARENESS OF HOSPITAL SERVICES AND OFFERS TRANSLATION SERVICES TO THE SIGNIFICANT NUMBER OF HISPANIC WOMEN SEEKING CARE AT THE CENTER. The Center provides prenatal care to approximately 50 mothers annually in an underserved and geographically remote area. A majority of these babies are born at Southampton Hospital's Kathleen D. Allen Maternity Center. The organization is proud of the exceptional specialty services it provides to the community. These include: 1) The Ellen Hermanson Breast Center offers a wide spectrum of breast health services, including education, early detection screenings, surgery, breast cancer treatment and support. The Center utilizes state-of-the-art diagnostic techniques, including computer-assisted mammography, ultrasound and breast biopsy. 2) The Ed & Phyllis Davis Wellness Institute offers the only hospital-based integrative medicine on Long Island's East End. A satellite site in Hampton Bays was opened in late 2011 and wellness programs are now offered in Montauk. Integrative medicine combines modern science, psychology, nutrition, and exercise to enhance the natural healing capacity of the body. Special programs are available for patients suffering from chronic illness. Classes in yoga, tai chi, pilates, zumba, are available. Programs in stress management, nutritional and weight loss counseling, smoking cessation, massage therapy, and acupuncture are also available. 3) The Jenny and John Paulson Department of Emergency Medicine serves more than 25,000 emergency patients annually and is the only hospital-based emergency care on the South Fork of Long Island. Staffed 24/7 by Board-certified emergency physicians and specialty-trained nurses and staff, it has the most sophisticated, non-invasive cardiac diagnostic and monitoring technology available and, as a New York State-designated Stroke Center, it is the destination of ambulances when a heart attack or stroke is suspected. 89376688 true true false true false false false false true true true false false true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true true true false false true 223 0 true 1107 true true true false false false false false false false false false X 25 24 false false false false true true true true true false false true true true true true true true true true false NY X X CHRISTOPHER SCHULTHEIS 6317268301 240 MEETING HOUSE LANE SOUTHAMPTON NY 11968 X PETER M LARSEN 1.25 X X 0 0 0 RICHARD J HIEGEL ESQ 1.25 X X 0 0 0 KENNETH B WRIGHT 1.25 X X 0 0 0 STANLEY D FRIEDMAN 1.25 X X 0 0 0 LAWRENCE A WILLIS 1.25 X X 0 0 0 PATRICIA STEWART 1.25 X X 0 0 0 GEORGE F BIONDO ESQ 1.25 X 0 0 0 RICHARD BRUCE 1.25 X 0 0 0 JEAN LITTLE FITZSIMMONS 1.25 X 0 0 0 JAMES FORBES 1.25 X 0 0 0 STEVEN R GOLDFARB MD 1.25 X 5350 0 0 JOHN E GRIM III 1.25 X 0 0 0 CHARLES HOLMES THRU 5132011 1.25 X 0 0 0 MICHAEL ISRAEL MD 1.25 X 201449 0 19309 GEORGE P KAZDIN 1.25 X 0 0 0 LISA KOMBRINK 1.25 X 0 0 0 JAY K LEVIN 1.25 X 0 0 0 DOROTHY LEWIS 1.25 X 0 0 0 R TIMOTHY MARAN 1.25 X 0 0 0 JOHN MCGOWAN 1.25 X 0 0 0 PHILIP A PIRO JR MD 1.25 X 0 0 FLORENCE ROLSTON MD 1.25 X 0 0 0 STEPHEN H SHAPOFF 1.25 X 0 0 MICHAEL F SMITH 1.25 X 0 0 0 MARTIN L STONE MD 1.25 X 0 0 JOHN WAMBOLD 1.25 X 0 0 ROBERT S CHALONER 38.8 X 615254 0 35982 CHIRSTOPHER J SCHULTHEIS 37.5 X 192145 0 32857 FREDERIC I WEINBAUM 37.5 X 421765 0 37559 PATRICIA A DARCEY 37.5 X 191959 0 34434 PAUL R DARVIN 37.5 X 190764 0 32596 STEVEN M BERNSTEIN 9.5 X 81543 244632 35982 GEORGE KECKEISEN 37.5 X 344315 0 22859 EDNA KAPENHAS 37.5 X 324339 0 35983 DANIEL M VANARSDALE 37.5 X 288402 0 34379 CHARLES ARCOLEO 37.5 X 278875 0 34369 SHAWN CANNON 37.5 X 249026 0 10320 3385186 244632 366629 11 false true false MORRISON MANAGEMENT SPECIALIST 4721 MORRISON DRIVE SUITE 300 MOBILE AL 36609 FOOD SRVC & SUPPLIES 899186 HAMPTONS GYNECOLOGY OB 595 HAMPTONS ROAD SOUTHAMPTON NY 11968 MEDICAL 817860 LONG ISLAND PATHOLOGY PC PO BOX 2098 SOUTHAMPTON NY 11969 PATHOLOGY 431520 WINHAVEN REALTY LLC 98 CUTTER MILL ROAD SUITE 350S GREAT NECK NY 11021 REAL ESTATE 303349 BOROWSKY BUILDING CONTRACTING PO BOX 297 EAST HAMPTON NY 11937 CONTRACTING 278063 18 117585 3575913 1059952 136030 4889480 INPATIENT SERVICES 624200 55438803 55438803 OUTPATIENT SERVICES 624200 47419391 47419391 LABORATORY EXTENDED SERVICES 621500 1487379 1487379 LESS: PROVISION FOR UNCOLLECTIBLES, NET 624200 -4000000 -4000000 LABORATORY REVENUE 621500 647416 647416 432906 432906 101425895 153300 153300 0 0 574687 1164333 -589646 -589646 -589646 2858177 7260 2594481 263696 7260 270956 270956 0 0 0 TELEVISION REVENUE 900099 12838 12838 VENDOR REBATES 900099 9370 9370 FILM COPIES 900099 3763 3763 135158 135158 161129 106311114 99938516 1487379 -4261 0 0 0 0 1876358 1876358 0 47644876 41995509 5649367 3520656 3101411 419245 9822202 8643747 1178455 3604151 3171653 432498 771612 679019 92593 211325 211325 295447 295447 21157 18618 2539 0 49215 49215 3550655 3124576 426079 26159 23020 3139 13255232 11664604 1590628 855436 752784 102652 0 2052881 1806535 246346 223166 223166 0 7303 7303 2782239 2448370 333869 0 4805514 4228852 576662 1169330 1029010 140320 OTHER PURCHASE SERVICES 5623881 4949015 674866 OTHER DIRECT EXPENSES 1520140 1337723 182417 MISCELLANEOUS 804483 402242 402241 104493418 89376688 15116730 0 1064887 9392332 8276962 1533510 0 0 11221858 12735489 0 0 0 0 0 0 1426697 1587149 224215 246167 130603550 96311952 34912202 34291598 0 0 26969470 26702806 0 0 0 0 3110482 975172 87206773 87464223 16191326 17777052 0 0 0 0 35558409 34744808 0 0 0 0 8916102 8433046 0 0 18846777 21915475 79512614 82870381 X -374818 -3483874 5234960 5243699 2834017 2834017 7694159 4593842 87206773 87464223 X 1817696 -4918013 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 21157 false false false 21157 false false PART II-B, LINE 1F: Southampton Hospital Association pays membership dues to the below mentioned organizations. A percentage of these dues are then used to reimburse the organization for the cost of lobbying activities performed on behalf of the Hospital. The funds are used for lobbying purposes in connection with New York State and Federal policy issues. Membership dues paid to other organizations and used for lobbying purposes: Healthcare Association of New York State........$13,378 Nassau Suffolk Hospital Council..................$1,047 Greater NY Hospital Association..................$6,732 Total...........................................$21,157 4213766 -98387 4115379 3943577 371238 95021 6028 4213766 4031782 73511 23873 137843 3943577 4235635 -146059 30806 26988 4031782 0.31136 0.68864 false false 1366275 1366275 44392358 18509175 25883183 83433466 76866993 6566473 1411451 935784 475667 34291598 SHORT TERM INVESTMENTS 1538056 F RESTRICTIONS 8077716 F INVESTMENTS IN SHA PROPERTIES 6300000 C DEBT SERVICE FUND 5739790 F MALPRACTICE SELF INSURANCE-FUN 4942000 F OTHER INVESTMENTS 105244 F 26702806 0 ACCRUED PENSION LIABILITY 11416649 DUE TO THIRD-PARTY PAYORS, NET 5556826 MALPRACTICE SELF-INSURANCE LIAB. 4942000 21915475 106311114 104493418 1817696 -757107 -4160906 -4918013 -3100317 102660147 -757107 -2844645 -3601752 106261899 49215 49215 106311114 105760464 1316261 1316261 104444203 49215 49215 104493418 PART V, LINE 4: Southampton Hospital Association currently reports Endowment Funds within its December 31, 2011 financial statements. The governing body intends to use these funds to offset the cost of indigent care, emergency services and nursing education. PART X, LINE 2: Southampton Hospital Association has not taken an unsubstantiated tax position that would require provision of a liability under ASC 740. Under ASC 740, an organization must recognize the tax benefit associated with tax positions taken for tax return purposes when it is more-likely-than-not that the position will not be sustained. The organization does not believe there are any material uncertain tax positions and, accordingly, have not recognized any liability for unrecognized tax benefits. The organization has filed IRS Form 990 tax returns, as required, and all other applicable returns in jurisdictions when it is required. For the year ended December 31, 2011, there was no interest or penalties recorded or included in the consolidated financial statements. PART XI, LINE 8: SHA PROPERTIES INCOME.............................313,666 SHA PROPERTIES EXPENSES..........................(151,928) PENSION OBLIGATION.............................(4,322,644) UNREALIZED LOSS ON INVESTMENTS...................(757,107) TOTAL..........................................(4,918,013) PART XII, LINE 2D: SHA PROPERTIES INCOME.............................313,666 PENSION OBLIGATION.............................(4,322,644) RENTAL EXPENSES.................................1,164,333 TOTAL..........................................(2,844,645) PART XIII, LINE 2D: SHA PROPERTIES EXPENSES...........................151,928 RENTAL EXPENSES.................................1,164,333 TOTAL...........................................1,316,261 true true X true X 400. true X false true true false true true 2 5573 3240793 -2078464 1162329 0.01100 10440563 7043012 3397550 0.03220 2 5573 13681356 4964548 4559879 0.04320 5499090 2003026 3496064 0.03310 2 659 610859 855400 -244541 0.00230 2 659 6109949 2858426 3251523 0.03080 4 6232 19791305 7822974 7811402 0.07400 220915 220915 0.00200 220915 220915 0.00200 true 4000000 0 145092981 105318198 39774783 X true true HAMPTONS IMAGING RADIOLOGY SERVICES 0.50000 MEETINGHOUSE LN PRAC PRIMARY/SPECIALTY 1.00000 14 1 SOUTHAMPTON HOSPITAL

240 MEETING HOUSE LANE SOUTHAMPTON NY 11968

X 2 DIALYSIS CENTER

184 W MONTAUK HIGHWAY HAMPTON BAYS NY 11946

X DIALYSIS TREATMENT FACILITY 3 GREENPORT PRENATAL

300 ATLANTIC AVENUE GREENPORT NY 11944

X PRENATAL/WOMEN'S SERVICES 4 LAB EAST

200 PANTIGO PLACE EAST HAMPTON NY 11937

X LABORATORY SERVICES 5 IMAGING - EH

200 PANTIGO PLACE EAST HAMPTON NY 11937

X RADIOLOGY SERVICES 6 WESTHAMPTON PRIMARY CARE

80 OLD RIVERHEAD ROAD WESTHAMPTON BEACH NY 11978

X PRIMARY CARE PRACTICE 7 WESTHAMPTON SPORTS REHAB

74 OLD RIVERHEAD ROAD WESTHAMPTON NY 11978

X SPORTS REHAB/ PHYSICAL THERAPY SERVICES 8 LAB SOUTH

325 MEETING HOUSE LANE SOUTHAMPTON NY 11968

X LABORATORY SERVICES 9 ATRIUM LAB

182 W MONTAUK HIGHWAY HAMPTONS BAYS NY 11946

X LABORATORY SERVICES 10 DAVID ROGERS CENTER

335 D MEETINGHOUSE LANE SOUTHAMPTON NY 11968

X HIV/AIDS CARE 11 SHINNECOCK HEALTH

CHURCH STREET SOUTHAMPTON NY 11968

X PRIMARY CARE/DENTAL SERVICES 12 SOUTHAMPTON CARE CENTER

240 MEETINGHOUSE LANE SOUTHAMPTON NY 11968

X NURSING HOME (FACILITY CLOSED) 13 HAMPTONS IMAGING

182 W MONTAUK HIGHWAY HAMPTONS BAYS NY 11946

X RADIOLOGY SERVICES 14 MEETINGHOUSE LANE PRACTICE

PO BOX 2340 SOUTHAMPTON NY 11968

X PRIMARY/SPECIALTY PHYSICIAN PATIENT CARE SOUTHAMPTON HOSPITAL 1 true true 400. true 400. true X X X true true X X X X X X true false true X false false DIALYSIS CENTER 2 true true 400. true 400. true X X X true true X X X X X X true false true X false false GREENPORT PRENATAL 3 true true 400. true 400. true X X X true true X X X X X X true false true X false false LAB EAST 4 true true 400. true 400. true X X X true true X X X X X X true false true X false false IMAGING - EH 5 true true 400. true 400. true X X X true true X X X X X X true false true X false false WESTHAMPTON PRIMARY CARE 6 true true 400. true 400. true X X X true true X X X X X X true false true X false false WESTHAMPTON SPORTS REHAB 7 true true 400. true 400. true X X X true true X X X X X X true false true X false false LAB SOUTH 8 true true 400. true 400. true X X X true true X X X X X X true false true X false false ATRIUM LAB 9 true true 400. true 400. true X X X true true X X X X X X true false true X false false DAVID ROGERS CENTER 10 true true 400. true 400. true X X X true true X X X X X X true false true X false false SHINNECOCK HEALTH 11 true true 400. true 400. true X X X true true X X X X X X true false true X false false SOUTHAMPTON CARE CENTER 12 true true 400. true 400. true X X X true true X X X X X X true false true X false false HAMPTONS IMAGING 13 true true 400. true 400. true X X X true true X X X X X X true false true X false false MEETINGHOUSE LANE PRACTICE 14 true true 400. true 400. true X X X true true X X X X X X true false true X false false PART I, LINE 3C: THERE ARE TWO LEVELS OF CHARITY CARE COVERAGE: PRIMARY SERVICE AREA AND NON-PRIMARY SERVICE AREA. A PRIMARY SERVICE AREA PATIENT IS A PATIENT WHO RESIDED IN NEW YORK STATE WITHIN THE COUNTIES OF SUFFOLK OR NASSAU AT THE TIME OF SERVICE. A NON-PRIMARY SERVICE AREA PATIENT IS A PATIENT WHO RESIDED IN NEW YORK STATE BUT NOT IN THE COUNTIES OF SUFFOLK OR NASSAU AT THE TIME OF SERVICE. ELIGIBLE SERVICES FOR A PRIMARY SERVICE AREA PATIENT: A PRIMARY SERVICE AREA PATIENT WHO MEETS THE FINANCIAL REQUIREMENTS IS ELIGIBLE FOR THE FOLLOWING MEDICALLY NECESSARY SERVICES: INPATIENT, AMBULATORY, EMERGENCY ROOM, EMERGENCY TRANSFERS UNDER THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA), OUTPATIENT, AND DIAGNOSTIC CARE. UNDERINSURED PRIMARY SERVICE AREA PATIENTS ARE ELIGIBLE FOR FINANCIAL ASSISTANCE ON MEDICARE AND COMMERCIAL INSURANCE CARRIER CO-INSURANCES FORALL ABOVE LISTED SERVICES. ELIGIBLE SERVICES FOR A NON-PRIMARY SERVICE AREA PATIENT: A NON-PRIMARY SERVICE AREA PATIENT WHO MEETS THE FINANCIAL REQUIREMENTS IS ELIGIBLE FOR THE FOLLOWING MEDICALLY NECESSARY SERVICES: EMERGENCY ROOM, EMERGENT ADMISSIONS, AND EMERGENCY TRANSFERS UNDER THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA). UNDERINSURED NON-PRIMARY SERVICE AREAPATIENTS ARE ELIGIBLE FOR FINANCIAL ASSISTANCE ON MEDICARE AND COMMERCIAL INSURANCE CARRIER CO-INSURANCES FOR ALL ABOVE LISTED SERVICES. INELIGIBLE SERVICES: THE FOLLOWING SERVICES AND/OR ITEMS ARE NOT COVERED BY CHARITY CARE FOR ANY PATIENT: NOT MEDICALLY NECESSARY SERVICES AS DETERMINED BY MEDICARE(E.G. COSMETIC SURGERY, BARIATRIC SURGERY), INSURANCE CO-PAYMENTS, INSURANCE DEDUCTIBLES, NON-COVERED SERVICES AS DETERMINED BY THE PATIENT'S INSURANCE CARRIER, PRIVATE ROOM RATES, AND PRIVATE PHYSICIAN FEES WHICH ARE NOT BILLED BY SOUTHAMPTON HOSPITAL (E.G. RADIOLOGY, PATHOLOGY, ANESTHESIOLOGY, EMERGENCY). FAMILY INFORMATION REQUIREMENTS: A PATIENT MUST PROVIDE ON THEIR CHARITY CARE APPLICATION A LIST OF THE FAMILY/HOUSEHOLD MEMBERS AND OR DEPENDENTS WITH WHOM THE PATIENT RESIDES. IF THE PATIENT IS AN ADULT, THE PATIENT MUST LIST THEIR SPOUSE OR DOMESTIC PARTNER, CHILDREN UNDER THE AGE OF 21, AND ANY CLAIMED DEPENDENTS OR OTHER HOUSEHOLD MEMBERS THAT LIVE WITH THE PATIENT. IF THE PATIENT IS A CHILD UNDER THE AGE OF 21, THE APPLICANT MAY LIST THE PATIENT'S PARENTS, SIBLINGS UNDER THE AGE OF 21, AND ANY CLAIMED DEPENDENTS OR OTHER HOUSEHOLD MEMBERS THAT LIVE WITH THE PATIENT. A CLAIMED DEPENDENT IS DEFINED AS A PERSON WHO IS LISTED OR WOULD BE LISTED AS A DEPENDENT FOR THE PURPOSES OF AN INCOME TAX SUBMISSION TO THE IRS. FINANCIAL REQUIREMENTS: TO BE FINANCIALLY ELIGIBLE TO RECEIVE CHARITY CARE, A PATIENT MUST HAVE A GROSS FAMILY/HOUSEHOLD INCOME LESS THAN OR EQUAL TO 400% OF THE FEDERAL POVERTY LEVEL GUIDELINE (FPG). ELIGIBLE INCOME: THE FOLLOWING INCOME ITEMS WILL BE USED TO DETERMINE A PATIENT'S INCOME: EARNINGS FROM EMPLOYMENT, UNEMPLOYMENT COMPENSATION, WORKERS COMPENSATION, DISABILITY, SOCIAL SECURITY, ANNUITIZED PENSION PLAN, CHILD SUPPORT, ALIMONY, DIVIDENDS, INTEREST, RENTALS, ESTATES, TRUSTS, SALE OF ASSETS, AND OTHER MISCELLANEOUS INCOME. SOLE PROPRIETORSHIP, PARTNERSHIP, AND S CORPORATION INCOME WILL BE CALCULATED BY ITS GROSS PROFIT OR TOTAL INCOME PRIOR TO EXPENSES AND DEDUCTIONS; HOWEVER, COST OF GOODS SOLD MAY BE DEDUCTED FROM GROSS SALES. SALE OF ASSETS, SUCH AS REPORTED ON A SCHEDULE D OR ITS EQUIVALENT, WILL BE CALCULATED BY THEIR SALE PRICE AND NOT BY THEIR GAIN OR LOSS. FINANCIAL DOCUMENTATION REQUIREMENTS: A PATIENT MUST PROVIDE FINANCIAL DOCUMENTATION TO SUPPORT THEIR CURRENT STATED INCOME. THE FOLLOWING DOCUMENTS ARE ACCEPTABLE AS PROOF: COPIES OF RECENT PAY STUBS (SEVERAL CONSECUTIVE ARE PREFERRED WHEN AVAILABLE), A RECENT UNEMPLOYMENT OR DISABILITY STATEMENT, A LETTER FROM AN EMPLOYER, OR A SELF-ATTESTATION LETTER. A PATIENT MAY BE REQUIRED TO SUBMIT ADDITIONAL DOCUMENTATION AT SOUTHAMPTON HOSPITAL'S REQUEST IN ORDER TO SUBSTANTIATE THEIR STATED INCOME. IF A PATIENT IS CLAIMING ZERO INCOME, THE PATIENT WILL BE REQUIRED TO SUBMIT A VERIFICATION OF NON-FILING LETTER FROM THE IRS. THIS LETTER IS OBTAINED THROUGH IRS FORM 4506-T WHICH WILL BE MADE AVAILABLE TO THE PATIENT UPON REQUEST. THE PATIENT MUST ALSO SUBMIT A LETTER DESCRIBING THE MEANS BY WHICH THEY ARE SUPPORTED. IF THE PATIENT IS UNABLE TO FILE IRS FORM 4506-T DUE TO NOT HAVING A SOCIAL SECURITY NUMBER, THE PATIENT MUST SUBMIT THE ABOVE-MENTIONED LETTER. APPLICABLE RATES: THE APPLICABLE RATE FOR AN INPATIENT VISIT IS THE MEDICARE DIAGNOSIS RELATED GROUP (DRG) RATE FOR THAT VISIT. THE APPLICABLE RATE FOR AN AMBULATORY, EMERGENCY ROOM, OUTPATIENT, OR DIAGNOSTIC CARE VISIT IS THE MEDICARE HCPCS/CPT PAYMENT PLUS MINIMUM UNADJUSTED CO-PAYMENT FOR THAT VISIT. THE APPLICABLE RATE FOR LAB TESTS ON OUTPATIENT AND EMERGENCY ROOM VISITS WILL BE 10% OF THE CHARGE PER TEST. CO-INSURANCE: PATIENTS WHO ARE ELIGIBLE FOR A DISCOUNT ON MEDICARE OR COMMERCIAL INSURANCE CARRIER CO-INSURANCES WILL HAVE THOSE BALANCES REDUCED ACCORDING TO THE FOLLOWING SCALE. PERCENTAGE OF FPG: PERCENT OF CO-INSURANCE RESPONSIBLY: 0% TO 100%........0% >100% TO 125%....10% >125% TO 150%....20% >150% TO 175%....28% >175% TO 200%....36% >200% TO 225%....44% >225% TO 250%....52% >250% TO 275%....60% >275% TO 300%....68% >300% TO 325%....76% >325% TO 350%....84% >350% TO 375%....92% >375% TO 400%...100% SELF-PAY DISCOUNT: SOUTHAMPTON HOSPITAL OFFERS A SELF-PAY DISCOUNT TO UNINSURED PATIENTS FOR SERVICES AND PROCEDURES PROVIDED AND BILLED BY SOUTHAMPTON HOSPITAL. A) ELIGIBLE SERVICES - THE FOLLOWING SERVICES PERFORMED BY SOUTHAMPTON HOSPITAL ARE ELIGIBLE FOR A SELF-PAY DISCOUNT: INPATIENT, AMBULATORY, EMERGENCY ROOM, EMERGENCY TRANSFERS UNDER THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA), OUTPATIENT, AND DIAGNOSTIC CARE. B) INELIGIBLE SERVICES - THE FOLLOWING SERVICES AND ITEMS ARE NOT ELIGIBLE FOR A SELF-PAY DISCOUNT: OUTPATIENT CARDIAC REHABILITATION, OUTPATIENT NUTRITIONAL COUNSELING, WELLNESS CENTER SERVICES/PROGRAMS, OUTPATIENT PHYSICAL THERAPY, PRIVATE PHYSICIAN FEES NOT BILLED BY SOUTHAMPTON HOSPITAL (E.G. RADIOLOGY, PATHOLOGY, ANESTHESIOLOGY, EMERGENCY). C) DISCOUNT - SELF-PAY ACCOUNTS ARE DISCOUNTED AT A RATE OF 70% OFF TOTAL CHARGES. A. AUTOMATIC DISCOUNTING - THE SELF-PAY DISCOUNT WILL BE CALCULATED AND APPLIED TO THE PATIENTS' ACCOUNT AUTOMATICALLY BY THE HOSPITAL INFORMATION SYSTEM (HIS). B. MANUAL DISCOUNTING - THE SELF-PAY DISCOUNT MAY NEED TO BE MANUALLY CALCULATED AND APPLIED IN CERTAIN CIRCUMSTANCES (E.G. LATE CHARGES) AND WILL BE HANDLED BY PATIENT FINANCIAL SERVICES. D) ADDITIONAL FINANCIAL ASSISTANCE - PATIENTS WHO ARE UNABLE TO PAY FOR A SELF-PAY DISCOUNTED BILL MAY STILL APPLY FOR OTHER TYPES OF FINANCIAL ASSISTANCE SUCH AS CHARITY CARE. APPLYING FOR ANOTHER TYPE OF FINANCIAL ASSISTANCE WILL NOT RESULT IN THE LOSS OF THE OFFERED SELF-PAY DISCOUNT, HOWEVER, IF ACCEPTED INTO ANOTHER FINANCIAL ASSISTANCE PROGRAM, THAT PROGRAMS CALCULATION METHODOLOGY WILL BE DONE INDEPENDENTLY OF THE SELF-PAY DISCOUNTED AMOUNT (I.E. FINANCIAL ASSISTANCE PROGRAMS ARE MUTUALLY EXCLUSIVE). PART I, LINE 7G: HEALTHCARE INFORMATION: SOUTHAMPTON HOSPITAL PROVIDES FREE HEALTH EDUCATION/ INFORMATION PROGRAMS THROUGH ITS WELL-ATTENDED "HEALTH INSIGHTS" PROGRAM. THE DAVID E. ROGERS CENTER FOR HIV/AIDS CARE (DRC): THE DRC IS ANOTHER IMPORTANT COLLABORATIVE EFFORT BETWEEN SOUTHAMPTON HOSPITAL, STONY BROOK UNIVERSITY MEDICAL CENTER AND TOWN AND COMMUNITY ORGANIZATIONS OF THE EASTEND OF LONG ISLAND. MAJOR FUNDING FOR THE DRC IS PROVIDED THROUGH RYAN WHITE PART A FEDERAL FUNDS THE DRC PROVIDES MEDICAL AND MENTAL HEALTH SERVICES TO INDIVIDUALS WHO ARE HIV POSITIVE, AS WELL AS, SUPPORT SERVICES AND PREVENTION EDUCATION TO PARTNERS AND FAMILY MEMBERS AFFECTED BY HIV/AIDS. THE DRC IS A MEMBER OF THE PECONIC COMMUNITY COUNCIL, A NOT-FOR-PROFIT COALITION OF ORGANIZATIONS AND INDIVIDUALS DEDICATED TO THE PROMOTION AND PRESERVATION OF HEALTH AND HUMAN SERVICES FOR THE ENTIRE EAST END COMMUNITY. THE SHINNECOCK INDIAN HEALTH CLINIC: IN ADDITION, THE HOSPITAL'S SERVICE AREA IS HOME TO THE SHINNECOCK NATION. SINCE APRIL OF 1995, SOUTHAMPTON HOSPITAL HAS WORKED WITH THE NATION TO PROVIDE SERVICES AT THE SHINNECOCK INDIAN HEALTH CLINIC THROUGH A CONTRACT WITH THE NEW YORK STATE DEPARTMENT OF HEALTH. ON AN ANNUAL BASIS, THE CLINIC PROVIDES APPROXIMATELY 2,000 MEDICAL, 800 DENTAL AND 400 DENTAL HYGIENE VISITS FOR ELIGIBLE MEMBERS OF THE SHINNECOCK NATION. DENTAL SERVICES, INCLUDING COMMUNITY EDUCATION, SCREENING, RADIOLOGICAL EXAMS, DENTAL HYGIENE AND RESTORATIVE CARE (CROWNS, FILLINGS AND BRIDGES) ARE PROVIDED THROUGH A SUBCONTRACT WITH STONY BROOK SCHOOL OF DENTAL MEDICINE. CURRENTLY, DENTAL SERVICES ARE AVAILABLE EIGHT DAYS PER MONTH FOR ADULTS AND TWO DAYS PER MONTH FOR CHILDREN. IN ADDITION TO PRIMARY CARE, DENTAL SERVICES, NUTRITIONAL COUNSELING, PRENATAL CARE AND ENDOCRINE SERVICES, THE CLINIC PROVIDES SOCIAL WORK, MENTAL HEALTH AND SUBSTANCE ABUSE COUNSELING. MAMMOGRAPHY SCREENING DAY IS ALSO HELD ANNUALLY IN COLLABORATION WITH THE HOSPITAL'S ELLEN HERMANSON BREAST CENTER. PART III, LINE 4: THE ORGANIZATION DETERMINE EXPECTED BAD DEBT WRITE-OFFS BASED ON ACTUAL ACCOUNTS, NET OF AN EXPECTED RATE OF RECOVERY. IT'S NOT BASED ON A PERCENTAGE OF REVENUE. PART III, LINE 8: SOUTHAMPTON HOSPITAL UTILIZED PAYMENTS RECEIVED FROM MEDICARE ($145,092,981) TO CALCULATE THE TOTAL REVENUE RECEIVED FROM MEDICARE. MEDICARE ALLOWABLE COSTS WERE CALCULATED USING MEDICARE GROSS CHARGES (WHICH ARE 300% OF THE MEDICARE FEE SCHEDULE) MULTIPLIED BY A COST TO CHARGE RATIO OF 30%. (TOTAL MEDICARE GROSS CHARGES OF $145,092,981 MULTIPLIED BY 30% TO ARRIVE AT $43,527,894 OF MEDICARE ALLOWABLE COSTS FOR THE CALENDAR YEAR OF 2011.) THEREFORE, THE SHORTFALL OF $3,753,111 MAY BEDEEMED A COMMUNITY BENEFIT. PART III, LINE 9B: ACCOUNTS WITH UNCOLLECTABLE BALANCES ARE ACCOUNTS FOR A PATIENT (GUARANTOR) WHO HAS NOT RESPONDED TO REQUESTS FOR PAYMENT OR WHO HAS DEMONSTRATED AN EXEMPTION FROM PAYMENT. THE REQUEST FOR PAYMENT &/OR THE EXEMPTION MUST MEET THE FOLLOWING CRITERIA: 1. AT LEAST FOUR (4) CONSECUTIVE 120-DAY BILLS MUST HAVE BEEN GENERATED (OR NO LESS THAN 120 DAYS FROM FIRST BILL) AND SENT WITHOUT RESPONSE FROM THE PATIENT (GUARANTOR) BEFORE BEING SENT TO A COLLECTION AGENCY; OR 2. THE PATIENT (GUARANTOR) HAS DECLARED BANKRUPTCY (DISCHARGE OF DEBT OR MUST HAVE BEEN RECEIVED); OR 3. THE ESTATE OF THE PATIENT (GUARANTOR) HAS BEEN SETTLED AND THERE WERE NO FUNDS FOR PAYMENT LEFT IN THE ESTATE; OR 4. MAIL HAS BEEN RETURNED AND OTHER METHODS OF CONTACTING THE PATIENT (GUARANTOR) HAVE FAILED. THE ACCOUNT IS THEN CONSIDERED AND HANDLED AS A BAD DEBT ACCOUNT. PATIENT FINANCIAL SERVICES MAY ELECT TO SEND THE ACCOUNT TO AN OUTSIDE AGENCY, UP TO AND INCLUDING LEGAL ACTION. BAD DEBT ACCOUNTS ARE PURE SELF PAY ACCOUNTS FOR A PATIENT (GUARANTOR) WHO HAS NOT RESPONDED TO REQUESTS FOR PAYMENT. THE REQUEST FOR PAYMENT MUST MEET THE FOLLOWING CRITERIA: AT LEAST FOUR (4) CONSECUTIVE 30-DAY BILLS MUST HAVE BEEN GENERATED AND SENT WITHOUT RESPONSE FROM THE PATIENT (GUARANTOR); OR MAIL HAS BEEN RETURNED AND ALL OTHER METHODS OF CONTACTING THE PATIENT(GUARANTOR) HAVE FAILED. ONCE IT IS DETERMINED AN ACCOUNT BALANCE CANNOT BE COLLECTED BY PATIENT FINANCIAL SERVICES, THE ACCOUNT MAY BE TURNED OVER FOR COLLECTION BY AN OUTSIDE AGENCY, UP TO AND INCLUDING LEGAL ACTION. THE OUTSIDE COLLECTION AGENCY, AFTER DUE DILIGENCE, MAY DETERMINE THE BALANCE ON AN ACCOUNT CANNOT BE COLLECTED, THE ACCOUNT BALANCE MAY BE WRITTEN OFF USING THE APPROPRIATE CODE FOR THE ACCOUNT. PART VI, LINE 2: NEEDS ASSESSMENT/PROMOTION OF COMMUNITY HEALTH: SOUTHAMPTON HOSPITAL HAS AN EXTENSIVE PROGRAM OF COMMUNITY OUTREACH, COMPLEMENTED BY THE EAST END HEALTH ALLIANCE, THE HOSPITAL'S ACTIVE PARENT. COMMUNITY SERVICE PLAN INPUT IS RECEIVED FROM BOTH INTERNAL AND EXTERNAL SOURCES. NEEDS ARE ASSESSED ANNUALLY BY THE BOARD OF TRUSTEES, HOSPITAL MANAGEMENT AND STAFF, VOLUNTEERS, AND LEADERS OF LOCAL NOT-FOR-PROFIT ORGANIZATIONS AND GOVERNMENTAL AGENCIES. THE HOSPITAL HAS SIGNIFICANT REPRESENTATION ON A WIDE-RANGE OF COMMUNITY ORGANIZATIONS THAT FACILITATE INPUT FROM RESIDENTS, CORPORATE AND COMMUNITY LEADERS, PATIENTS AND ALLIED HEALTH PROFESSIONS. THESE COMMUNITY PARTNERSHIPS ARE LISTED BELOW. THE HOSPITAL PRESIDENT AND CHIEF EXECUTIVE OFFICER AND OTHER SENIOR STAFF REGULARLY MEET WITH COMMUNITY GROUPS FROM THE EAST END REGION OF LONG ISLAND TO KEEP AREA RESIDENTS INFORMED ABOUT HOSPITAL PROGRAMS AND TO RECEIVE FEEDBACK AND FIELD QUESTIONS FROM THE COMMUNITY. SOUTHAMPTON'S COMMUNITY PARTNERS INCLUDE THE FOLLOWING: A) EMERGENCY MEDICAL SQUADS (EAST HAMPTON AND SOUTHAMPTON TOWNS; INCORPORATED VILLAGES ON FOUTH FORK) B) LONG ISLAND BLOOD SERVICES C) CHAMBERS OF COMMERCE (EAST HAMPTON, SOUTHAMPTON, SAG HARBOR, WESTHAMPTON BEACH) D) LOCAL SCHOOL DISTRICTS IN THE TOWNS OF EAST HAMPTON AND SOUTHAMPTON E) LOCAL SERVICES ORGANIZATIONS (EAST HAMPTON, SOUTHAMPTON, HAMPTON BAYS ROTARY CLUBS; EAST HAMPTON AND SOUTHAMPTON LIONS CLUBS) F) AMERICAN HEART ASSOCIATION G) NASSAU SUFFOLK HOSPITAL COUNCIL H) NEW YORK ORGAN DONOR NETWORK I) SOUTH FORK BREAST HEALTH COALITION J) FIGHTING CHANCE K) SUFFOLK COUNTY DEPARTMENT OF HEALTH L) SUFFOLK COUNTY OFFICE FOR THE AGING M) UNITE WAY OF LONG ISLAND THE HOSPITAL ALSO RECEIVES INPUT FROM THE COMMUNITY THROUGH HOSPITAL STAFF AND HOSPITAL TRUSTEE PARTICIPATION ON COMMUNITY SERVICE ORGANIZATIONS AND OPEN DIALOGUE WITH RESPECTED COMMUNITY LEADERS. PARTICIPATION INCLUDES: Long Island Blood Services, LI 2-Day Walk, American Cancer Society, American Heart Association, American Lung Association, American Diabetes Association, Nassau-Suffolk Care Network, Catholic Charities, Dominican Sisters Family Health Services, South Fork Community Health Initiative, East End Hospice, New York Organ Donor Network, East Hampton Healthcare Foundation, Ellen's Run, Ellen's Well, Suffolk County Department of Health Services, Suffolk County Community College, Suffolk County Office for the Aging, Family Service League, Fighting Chance, Town of East Hampton, Town of Southampton, Emergency Medical Corps, Women's Health Partnership of Long Island, Alzheimer's Foundation of Suffolk County, Rogers Memorial Library, Southampton Hampton Bays Library, Southampton Rotary, East Hampton Lions and Coalition for Women's Cancers at Southampton Hospital. IN COLLABORATION WITH THE EAST END HEALTH ALLIANCE, THE HOSPITALS HAVE ALSO USED A NUMBER OF RESOURCES TO ASSESS COMMUNITY NEED AND PROVIDED THIS INFORMATION THROUGH A NUMBER OF ORGANIZED ADVISORY BOARDS WITH PARTICIPATION FROM PHYSICIAN GROUPS THAT INCLUDE A STRATEGIC PLANNING COMMITTEE WITH REPRESENTATIVES FROM COMMUNITY TRUSTEES, LEADERSHIP FROM THE HOSPITALS' MEDICAL STAFF, PHYSICIAN TRUSTEES AND CHIEF MEDICAL OFFICERS. THE ALLIANCE ALSO HAS A CANCER ADVISORY COMMITTEE AND A CARDIAC ADVISORY COMMITTEE TO ASSESS COMMUNITY NEEDS AND RECOMMEND STRATEGIES TO ADDRESS THESE HEALTH CARE NEEDS. THE HOSPITALS HAVE PROVIDED THESE GROUPS WITH INFORMATION RELATED TO THE INCIDENCE AND PREVALENCE OF DISEASE IN THE SERVICE AREA, PREVENTABLE QUALITY INDICATORS, PATTERNS OF ACCESSING HEALTH CARE SERVICES AND USE RATES. THE HOSPITAL'S SATELLITE CARE CENTERS, INCLUDING THE SHINNECOCK INDIAN HEALTH CLINIC, THE DAVID E. ROGERS CENTER FOR HIV/AIDS CARE, THE EAST HAMPTON HEALTHCARE CENTER, AND HOSPITAL REGIONAL DIALYSIS CENTER CLOSELY COLLABORATE WITH COMMUNITY ADVISORY COMMITTEES THAT HELP WITH PLANNING AND DECISION MAKING RELATED TO THE SERVICES OFFERED. STRATEGIC PLANNING COMMITTEE: THE STRATEGIC PLANNING COMMITTEE HAS BEEN MEETING SINCE THE BEGINNING OF THE FORMATION OF THE EAST END HEALTH ALLIANCE AND ADOPTED A STRATEGIC PLAN THAT FOCUSED ON NEAR AND MID-TERM OPPORTUNITIES FOR IMPROVING MANAGEMENT EFFICIENCIES AND STRATEGIES FOR WORKING MORE CLOSELY WITH OUR RESPECTIVE PHYSICIAN COMMUNITIES. THE STRATEGIES IDENTIFIED IN THE FIRST STRATEGIC PLAN ARE WELL ON THEIR WAY TO COMPLETION. THE HOSPITAL'S STRATEGIC PLANNING COMMITTEE CONTINUES TO ROUTINELY ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY SERVED BY THE HOSPITAL AND ITS AFFILIATED MEDICAL STAFFS BASED ON PUBLICALLY AVAILABLE INFORMATION, INCLUDING THE ANALYSIS OF THE FOLLOWING INFORMATION: A) SPARCS DATA B) PREVENTION QUALITY INDICATORS C) REPORT EVALUATIONS - LOCAL, STATE AND FEDERAL AGENCIES D) PATIENT SATISFACTION SURVEYS E) INDUSTRY JOURNALS AND NEWSLETTERS F) TRENDS IN HEALTHCARE JOURNALS AND PERIODICALS THE HOSPITAL'S EXTENSIVE OUTREACH ALSO INCLUDES PARTICIPATION IN VARIOUS PROGRAMS SPONSORED BY COMMUNITY ORGANIZATIONS INCLUDING SCHOOL HEALTH FAIRS, SENIOR CITIZEN CENTERS, SERVICE ORGANIZATIONS (ROTARY, KIWANIS, LIONS, ELKS), NEW YORK ORGAN DONOR NETWORK, LECTURES AT LOCAL LIBRARIES, AND FUNDRAISING EVENTS. RECENT EXAMPLES INCLUDE: LI2-DAY WALK (IN SUPPORT OF BREAST CANCER), ELLEN'S RUN (IN SUPPORT BREAST CANCER), DIABETES LECTURE AT EAST HAMPTON NUTRITION CENTER, FLU IMMUNIZATION, AND BLOOD DONATION DRIVES. VARIOUS WELLNESS PROGRAMS THROUGH THE HOSPITAL'S ED & PHYLLIS DAVIS WELLNESS INSTITUTE IN SOUTHAMPTON, HAMPTON BAYS, AND MONTAUK INCLUDE SMOKING CESSATION, NUTRITIONAL AND WEIGHT LOSS COUNSELING, DIABETES MANAGEMENT, MIND-BODY, CANCER AND CARDIAC WELLNESS, FUNCTIONAL FITNESS FOR SENIORS, SUPPORT SERVICES FOR HIV/AIDS, STRESS MANAGEMENT, MASSAGE THERAPY AND VARIOUS EXERCISE CLASSES. THE HOSPITAL'S "IMPORTANT MEDICAL INFORMATION" (VIAL OF LIFE) PROGRAM HAS REACH THOUSANDS OF COMMUNITY MEMBERS WITH MEDICAL CONCERNS THROUGH LOCAL EMERGENCY MEDICAL SERVICE ORGANIZATIONS, PHYSICIAN OFFICES, AND HOSPITAL DISTRIBUTION. ASSESSMENT OF PUBLIC HEALTH PRIORITIES: ADDITIONALLY, SOUTHAMPTON HOSPITAL WAS AN ACTIVE PARTICIPANT IN THE COLLABORATIVE PLANNING PROCESS WITH THE SUFFOLK COUNTY DEPARTMENT OF HEALTH AND COMMUNITY PARTNERS TO ASSESS COMMUNITY HEALTH NEEDS, TO IDENTIFY HEALTH PRIORITIES, AND TO DEVELOP PUBLIC HEALTH PROGRAMS TO MEET THE IDENTIFIED NEEDS. THIS COLLABORATIVE GROUP MET FROM THE FALL OF 2008 THROUGH AUGUST OF 2009, AND SELECTED TOBACCO USE AND UNINTENTIONAL INJURY AS THE TWO HEALTH PRIORITIES IDENTIFIED IN THE NEW YORK STATE PREVENTION AGENDA TOWARD THE HEALTHIEST STATE. 2011 SMOKING CESSATION UPDATE: A) THE HOSPITAL'S SMOKE FREE CAMPUS PROGRAM WENT INTO EFFECT ON NOVEMBER 18, 2010; B) THE HOSPITAL PROVIDES TAILORED SMOKING CESSATION COUNSELING FOR PATIENTS THROUGH THE HOSPITAL'S RESPIRATORY THERAPY DEPARTMENT AND ITS ED AND PHYLLIS DAVIS WELLNESS INSTITUTE; C) THE HOSPITAL PROVIDES NICOTINE WITHDRAWAL TO PATIENTS WHO SMOKE; D) THE HOSPITAL RUNS A SMOKING CESSATION PROGRAM FOR BOTH HOSPITAL EMPLOYEES AND THE PUBLIC AT LARGE; AND E) THE HOSPITAL ALSO HAS A SIGNIFICANT OUTREACH PROGRAM AIMED AT SMOKING CESSATION, PROVIDING INFORMATION THROUGH DISSEMINATION OF POSTERS, SIGNAGE, AND PUBLIC INFORMATION THROUGH PRESS RELEASES, PUBLIC SERIVCE ANNOUNCEMENTS, AND THE HOSPITAL'S WEBSITE. 2010 SMOKING CESSATION UPDATE: WE OFFER TOBACCO CESSATION PROGRAMS TO THE COMMUNITY AND EMPLOYEES THREE TIMES PER YEAR. THE PROGRAM IS BASED ON THE FORMAT USED BY THE SUFFOLK COUNTY DEPARTMENT OF HEALTH. IT IS A SIX-WEEK PROGRAM THAT INCLUDES CONSULTATION WITH A NURSE PRACTITIONER AND MAKES TOBACCO REPLACEMENT THERAPIES (NICOTINE GUM, LOZENGES, AND PATCHES) AND PRESCRIPTIONS AVAILABLE TO PARTICIPANTS. THE PROGRAMS ARE FREE FOR EMPLOYEES. BY ENCOURAGING OUR EMPLOYEES AND COMMUNITY MEMBERS TO BECOME TOBACCO-FREE AND BY SUPPORTING THEM IN THEIR EFFORTS TO BECOME TOBACCO-FREE, WE FEEL THAT WE ARE CONTRIBUTING TO AN IMPROVEMENT IN COMMUNITY HEALTH BY REDUCING THE RISK ASSOCIATED WITH SMOKING AND EXPOSURE TO SECOND-HAND SMOKE. 2011 FALL PREVENTION UPDATE: A) IN OCTOBER 2009, SOUTHAMPTON HOSPITAL WAS RECOGNIZED BY NASSAU SUFFOLK HOSPITAL COUNCIL WITH AN AWARD FOR OUR PROGRAM "ORGANIZATIONAL APPROACH TO FALL PREVENTION;" B) IN 2010, SOUTHAMPTON WAS ASKED BY THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI) TO BE A MENTOR TO OTHER HOSPITALS IN THE AREA OF FALLS PREVENTION; AND, C) OUTCOME: IN 2009, WE FURTHER DECREASED (IN LEVEL 2 OR ABOVE) INJURIES BY 50% (ONLY ONE FALL RESULTED IN AN INJURY OF LEVEL 2 OR ABOVE); PLUS AN ADDITIONAL DECREASE IN THE NUMBER OF FALLS, BRINGING THE TOAL DECREASE OF 58% IN FALLS SINCE 2006. 2010 FALL PREVENTION UPDATE: SOUTHAMPTON HOSPITAL TREATS A NUMBER OF OUR SENIOR PATIENTS AT HIGH RISK FOR FALLS BOTH WITHIN THE COMMUNITY AND AS INPATIENTS AT THE HOSPITAL. ALL PATIENTS ADMITTED TO SOUTHAMPTON HOSPITAL ARE ASSESSED FOR FALL RISK AND AS NEEDED RECEIVE FALL PREVENTION INFORMATION, PHYSICAL THERAPY AND A DISCHARGE PLAN AIMED AT MEETING THEIR NEEDS. WITHIN THE H PART VI, LINE 3: FINANCIAL AID PROGRAM: SOUTHAMPTON HOSPITAL'S COMMITMENT AND DETERMINATION TO PROVIDE QUALITY HEALTHCARE AT AFFORDABLE RATES HAS LEAD US TO DESIGN A CHARITY CARE PROGRAM THAT GOES "ABOVE AND BEYOND" THE EXPECTATIONS AND MINIMUM REQUIREMENTS SET FORTH BY NEW YORK STATE LAW. IT IS THE HOSPITAL'S "ABOVE AND BEYOND" ATTITUDE THAT IS OUR PROGRAMS GREATEST STRENGTH AND CAN BEST BE SEEN IN OUR POLICY TO PROVIDE CHARITY CARE DISCOUNTED RATES TO PATIENTS MAKING UP TO 400% OF THE FEDERAL POVERTY LEVEL GUIDELINE (FPG) RATHER THAN THE MINIMUM REQUIREMENT OF 300% FPG. IN ADDITION, THE HOSPITAL INCLUDES A FORM TO APPLY FOR CHARITY CARE IN EVERY SELF-PAY BILL TO BE RETURNED TO PATIENT FINANCIAL SERVICES. SELF-PAY PATIENTS ARE GIVEN A 70% DISCOUNT OF CHARGES, AS WELL. SOUTHAMPTON HOSPITAL CONTINUES TO FACE FINANCIAL CHALLENGES INCLUDING REDUCTIONS IN NEW YORK STATE AND FEDERAL REIMBURSEMENT RATES AT THE SAME TIME THAT HOSPITAL FACES THE INCREASING COST OF PROVIDING CARE, INCLUDING DOUBLE DIGIT EXPENSES INCREASES IN SOME CATEGORIES. WHILE THE HOSPITAL WAITS TO UNDERSTAND THE IMPACT ON ITS CHARITY POLICIES THAT MAY RESULT FROM EXPANDING RESIDENT ACCESS TO HEALTH CARE INSURANCE THAT IS PART OF HEALTH CARE REFORM, THE HOSPITAL REMAINS CONCERNED THAT A SIGNIFICANT PART OF THE INDIGENT CARE THE HOSPITAL PROVIDES TO UNDOCUMENTED WORKERS WILL NOT BE COVERED. PART VI, LINE 4: SOUTHAMPTON'S SERVICE AREA EXTENDS FROM MONTAUK TO THE EAST TO WESTHAMPTON BEACH TO THE WEST AND THE SOUTHERN AREA OF RIVERHEAD IN THE CENTER OF THE EAST END OF LONG ISLAND. THE SERVICE AREA ACCOUNTS FOR APPROXIMATELY EIGHT-FIVE (85) PERCENT OF TOTAL ADMISSIONS TO THE HOSPITAL AND INCLUDES THE FOLLOWING ZIP CODES: EAST HAMPTON (11937); BRIDGEHAMPTON (11932); SOUTHAMPTON (11968); HAMPTON BAYS (11946); SAG HARBOR (11963); SAGAPONACK (11962); MONTAUK (11954); RIVERHEAD (11901); EAST QUOGUE (11942); QUOGUE (11959); REMSENBURG (11960); WATER MILL (11976); WESTHAMPTON BEACH (11978); AND WESTHAMPTON(11977). AS THE TABLE BELOW INDICATES, THIS SERVICE AREA HAS A YEAR ROUND POPULATION OF APPROXIMATELY 85,000 RESIDENTS. THE AREA IS PROJECTED TO SEE A SIGNIFICANT INCREASE IN POPULATION, MORE THAN 4 PERCENT OVER THE NEXT FIVE YEARS. DEMOGRAPHIC CHARACTERISTICS SELECTED AREA USA 2000 TOTAL POPULATION............97,063............281,421,906 2011 TOTAL POPULATION............84,845............310,650,750 2016 TOTAL POPULATION............90,080............323,031,618 % CHANGE 2011 - 2016...............6.2%...................4.0% AVERAGE HOUSEHOLD INCOME........$97,980................$67,259 THE POPULATION ON THE HOSPITAL'S SERVICE AREA, A RESORT DESTINATION, MORE THAN DOUBLES DURING THE SUMMER SEASON WHEN TOURISTS FROM ALL OVER THE WORLD VISIT THE SOUTH FORK OF LONG ISLAND. AS A RESULT, DEMAND FOR SOUTHAMPTON HOSPITAL SERVICES INCREASES SIGNIFICANTLY DURING THE SUMMER, IN PARTICULAR DEMAND FOR THE HOSPITAL'S EMERGENCY SERVICES. THE HOSPITAL HAS RESPONDED TO THIS NEED BY MAKING A CAPITAL INVESTMENT IN EXPANDING AND RENOVATING THE EMERGENCY DEPARTMENT AND IMPLEMENTING A STATE-OF-THE-ART EMERGENCY DEPARTMENT INFORMATION SYSTEMS THAT PERMITS THE HOSPITAL TO TRACK PATIENTS, AND READ AND INTERPRET LABORATORY AND RADIOLOGICAL RESULTS. AS THE TABLE BELOW INDICATES, THE SERVICE AREA HAS A SIGNIFICANT PERCENTAGE OF THEIR POPULATION AGED FIFTY-FIVE (55) AND OVER, A POPULATION THAT HAS GREATER NEED FOR HEALTH CARE SERVICES. AGE DISTRIBUTIONAGE: GROUP 2010 % OF TOTAL 2016 % OF TOTAL USA 2011 % OF TOTAL 0-14 13,033 15.4% 13,192 14.6% 20.2% 15-17 3,255 3.8% 3,303 3.7% 4.2% 18-24 6,800 8.0% 7,519 8.3% 9.7% 25-34 8,161 9.6% 9,259 10.3% 13.3% 35-54 24,395 28.8% 22,668 25.2% 27.6% 55-64 12,702 15.0% 14,838 16.5% 11.7% 65+ 16,499 19.4% 19,301 21.4% 13.3% TOTAL 84,845 100.0% 90,080 100.0% 100.0% THERE ARE NO FIRM ESTIMATES OF THE NUMBER OF MIGRANT AGRICULTURAL WORKERS THAT COME INTO THIS AREA. AGRICULTURE IS ONE OF SUFFOLK COUNTY'S LEADING INDUSTRIES. ITS SUCCESS RELIES ON WORKERS WHO MOVE THROUGH THE EASTERN UNITED STATES IN RESPONSE TO THE AVAILABILITY OF SEASONAL WORK. SOUTHAMPTON HOSPITAL RECOGNIZES THAT THIS POPULATION PRESENTS SERIOUS HEALTH PROBLEMS AND IS COMMITTED TO PROVIDING CARE FOR ITS CULTURALLY DIVERSE PATIENT POPULATION. MANY OF THESE INDIVIDUALS ARE UNINSURED AND UNABLE TO SPEAK ENGLISH. THEY RELY ON THE HOSPITAL'S EMERGENCY DEPARTMENT, AS WELL AS THE SUFFOLK COUNTY HEALTH CLINIC, LOCATED ON THE HOSPITAL'S CAMPUS, FOR HEALTH CARE. AS ARESULT, THE HOSPITAL'S OFFICE OF CULTURAL DIVERSITY PROVIDES TRANSLATION AND INTERPRETATION SERVICES, AS WELL AS COUNSELING ON MEDICAL INSURANCE AND BILLING FOR THOSE INDIVIDUALS WHO DO NOT SPEAK ENGLISH. THE HOSPITAL PROVIDES BI-LINGUAL PUBLICATIONS AND SIGNAGE AND ACTIVELY ASSISTS THE CULTURALLY DIVERSE COMMUNITIES IT CARES FOR. RACE/ETHNICITY: RACE/ETHNICITY DISTRIBUTION RACE/ETHNICITY 2011 POP % OF TOTAL USA % OF TOTAL WHITE NON-HISPANIC 64,412 75.9% 64.2% BLACK NON-HISPANIC 2,239 2.6% 12.1% HISPANIC 14,828 17.5% 16.1% ASIAN & PACIFIC IS. 1,137 1.3% 4.6% ALL OTHERS 2,229 2.6% 3.0% TOTAL 84,845 100.0% 100.0% PART VI, LINE 5: SOUTHAMPTON HOSPITAL SPONSORS "FOCUS ON SOUTHAMPTON HOSPITAL" ON SEA-TV, A MONTHLY PUBLIC ACCESS INTERVIEW PROGRAM FOR THE TOWNS OF EAST HAMPTON AND SOUTHAMPTON THAT COVERS HEALTH-RELATED INFORMATION OF INTEREST TO THE COMMUNITY AND PROVIDES INFORMATION ON HEALTHCARE SERVICES AVAILABLE AT SOUTHAMPTON HOSPITAL. THE HOSPITAL HAS DEVELOPED NUMEROUS SERVICES AND OUTREACH TO RESPOND TO THE NEEDS OF THESE PATIENTS, INCLUDING RECRUITING ADDITIONAL PRIMARY CARE PHYSICIANS AND IMPLEMENTING A GRADUATE MEDICAL EDUCATION PROGRAM THAT WILL HOPEFULLY ATTRACT THESE YOUNG PHYSICIANS TO STAY AND PRACTICE IN THE COMMUNITY. THE HOSPITAL'S WEBSITE, WWW.SOUTHAMPTONHOSPITAL.ORG, PROVIDES INFORMATION ON HOSPITAL SERVICES, SPECIAL PROGRAMS AND EVENTS. THE SITE ENABLES PATIENTS TO FIND PHYSICIANS IN DIFFERENT SPECIALTIES, ALLOWS ON-LINE INQUIRIES THAT ARE ANSWERED DAILY, AND PROVIDES ACCESS TO AVAILABLE EMPLOYMENT OPPORTUNITY AND JOB APPLICATIONS. SERVICES FOR SHORT-TERM AND LONG-TERM CARE FOR CHRONIC AND ACUTE ILLNESS ARE CONTINUALLY EVALUATED THROUGH STATISTICAL DATA THAT INCLUDE QUALITY INDICATORS AND PATIENT OUTCOMES. THIS DATA IS COMPARED NATIONALLY WITH OTHER HEALTH FACILITIES AND INFORMS THE HOSPITAL'S STRATEGIC PLAN AND COMMUNITY SERVICE PLAN. THE HOSPITAL'S STRATEGIC PLANNING COMMITTEE INCLUDES COMMUNITY MEMBERS, HOSPITAL STAFF AND HOSPITAL AND FOUNDATION BOARD MEMBERS WHO WORK COLLABORATIVELY TO ASSESS COMMUNITY NEEDS AND DEVELOP STRATEGIES TO MEET THESE NEEDS. THE HOSPITAL'S PUBLIC AFFAIRS COMMITTEE IS RESPONSIVE TO COMMUNITY INTERESTS AND CONCERNS. MEMBERSHIP IS A CROSS-SECTION OF PHYSICIANS, HOSPITAL MANAGEMENT, BOARD MEMBERS AND HOSPITAL EMPLOYEES. BASED ON THE HOSPITAL'S ASSESSMENT OF INTEREST IN THE COMMUNITY, A NUMBER OF HEALTH LECTURES AND PROGRAMS ARE PROVIDED THROUGHOUT THE YEAR. THESE PROGRAMS ARE SOMETIMES SPONSORED THROUGH OUR PARTNERSHIPS WITH LOCAL ORGANIZATIONS INCLUDING FIGHTING CHANCE, NEW YORK ORGAN DONOR NETWORK, COMMUNITY LIBRARIES, AND SERVICE CLUBS (LIONS, KIWANIS, ELKS). THE 2011 SCHEDULE INCLUDED THE FOLLOWING: HEALTH FAIR, FITNESS PROGRAM (JUNE), HEALTH FAIR, "LOOK GOOD, FEEL BETTER" PROGRAM (APRIL), GENETIC COUNSELING LECTURE (IN CONJUNCTION WITH ROGERS MEMORIAL LIBRARY), WELLNESS PROGRAM, SPANISH OUTREACH (MARCH), HEALTH FAIR, CELEBRATING SURVIVORSHIP, "LOOK GOOD, FEEL BETTER" (FEBRUARY), HEALTH FAIR, WELLNESS PROGRAM, PINK TUESDAY (JANUARY), THE PROGRAM SCHEDULE FOR 2010 INCLUDED LECTURES ON MIDWIFERY, TICK-BORNE ILLNESSES, KIDNEY HEALTH, STROKE, GENETICS, SLEEP DISORDERS, OSTEOPOROSIS, AND THE AFFECT OF LIGHT ON OUR HEALTH. PUBLIC INFORMATION: SOUTHAMPTON HOSPITAL UNDERSTANDS THE IMPORTANCE OF LETTING THE COMMUNITY KNOW WHAT COMMUNITY SERVICES ARE AVAILABLE. AS A RESULT, THE HOSPITAL DISTRIBUTES COMMUNITY SERVICE BROCHURES THROUGHOUT ITS COMMUNITY AT EVERY OPPORTUNITY - HEALTH FAIRS, SPEACKERS BUREAU, CLUBS AND ORGANIZATIONS, INFORMATION BOOTHS, ETC. IN ADDITION, THIS INFORMATION, ALONG WITH THE 2009-2011 HOSPITALS COMMUNITY SERVICE PLAN IS AVAILABLE ON THE HOSPITAL'S WEB SITE WWW.SOUTHAMPTONHOSPITAL.ORG AND THROUGH A LINK ON THE ALLIANCE'S WEB SITE WWW.HEALLI.ORG. GENERAL INFORMATION: PATIENT SATISFACTION SURVEYS: IN ADDITION, SOUTHAMPTON HOSPITAL CONTINUALLY SOLICITS PATIENT INPUT THROUGH ITS PATIENT SATISFACTION SURVEY PROCESS, WHICH INCLUDES EVERY INPATIENT, AMBULATORY SURGERY PATIENT AND EMERGENCY ROOM PATIENT. THE DATA COLLECTED FROM THESE COMPREHENSIVE SURVEYS PROVIDES VALUABLE INFORMATION ON A WIDE RANGE OF QUALITY INDICATORS AND AREAS OF INTEREST TO THE HOSPITAL'S PATIENTS. RESULTS FROM THESE SURVEYS ARE REGULARLY DISTRIBUTED TO HOSPITAL AND MEDICAL STAFFS AND THE BOARD OF DIRECTORS. THE QUALITY MANAGEMENT AND PUBLIC AFFAIRS DEPARTMENTS, AS WELL AS THE OFFICE OF THE PRESIDENT, CAREFULLY REVIEW CORRESPONDENCE FROM PATIENTS ANDTHE COMMUNITY AT LARGE. A MEMBER OF THE HOSPITAL STAFF PERSONALLY ANSWERS ALL CORRESPONDENCE. X true true X X X false false false false false false false false false ROBERT S CHALONER 422550 0 140000 0 52704 0 14700 0 21282 0 651236 0 CHIRSTOPHER J SCHULTHEIS 191973 0 0 0 172 0 11575 0 21282 0 225002 0 FREDERIC I WEINBAUM 332631 0 50128 0 39006 0 14700 0 22859 0 459324 0 PATRICIA A DARCEY 191221 0 0 0 738 0 11575 0 22859 0 226393 0 PAUL R DARVIN 186446 0 0 0 4318 0 11314 0 21282 0 223360 0 STEVEN M BERNSTEIN 65762 197288 13000 39000 2781 8344 3675 11025 5320 15962 90538 271619 MICHAEL ISRAEL MD 174184 0 0 0 27265 0 10673 0 8636 0 220758 0 GEORGE KECKEISEN 286815 0 50000 0 7500 0 0 0 22859 0 367174 0 EDNA KAPENHAS 324050 0 0 0 289 0 14700 0 21283 0 360322 0 DANIEL M VANARSDALE 288298 0 0 0 104 0 11520 0 22859 0 322781 0 CHARLES ARCOLEO 256375 0 20000 0 2500 0 11510 0 22859 0 313244 0 SHAWN CANNON 193847 0 55000 0 179 0 10320 0 0 0 259346 0 PART I, LINE 1A: The Southampton Hospital Association provides the following special allowances/perquisites to the President & CEO, as well as to certain key executives. These allowances for housing and automobile are stipulated in the executives Employment Agreement/terms at time of hire. All payments of these perquisites are made on a bi-weekly basis with the employees regular paycheck and they are made in accordance with the guidelines of a non-accountable expense plan. Annual allowances are as listed below: 1) Robert Chaloner, President & CEO: Housing Allowance......$38,000 Automobile Allowance....$8,400 2) Fredric Weinbaum ,MD,COO and CMO: Housing allowance......$30,000 Automobile Allowance....$7,000 3) Paul Davin, VP, Human Resources: Automobile Allowance....$3,600 PART II, COLUMN (B)(II): The President/CEO, and the Executive Vice President/Chief Medical Officer of Southampton Hospital were both eligible for a performance bonus in 2011 which was based upon criteria that the Executive Committee of the Board established. The President/CEO's bonus is an annual bonus set forth in his employment agreement and is determined after a review of how well he performed in the prior year against goals and objectives established by the Executive Committee. The Executive Vice President/CMO was awarded a performance bonus based upon the recommendation of the President/CEO as well as a review of his performance against goals and objectives established by the President and the Executive Committee. During 2011, the Hospital President/CEO awarded bonuses to Management/Department Heads who were assigned to an Operational Improvement Teams and who satisfactorily completed their projects. The focus and goals of these projects are defined by the President and are overseen and monitored by an "executive sponsor". The Executive Vice President/Chief Medical Officer met periodically with each Team to ensure that the project scope and objectives were clearly defined. The progress of the teams is monitored and at the end of the projects, the teams accomplishments are reviewed and validated by the Executive Vice President/CMO as well as the Chief Financial Officer. Bonus payments of between $1,000 and $2,000 were awarded to individual Team members based upon the Team's overall results. FORM 990, PART I, LINE 9 AND PART VIII, LINE 2: In July 2011, the FASB issued ASU 2011-07, "Presentation and Disclosure of Patient Service Revenue, Provision for Bad Debts, and the Allowance for Doubtful Accounts for Certain Health Care Entities". ASU 2011-07 requires certain health care entities that recognize significant amounts of patient service revenue at the time the services are rendered without assessing the patient's ability to pay to present the provision for bad debts related to patient service revenue as a deduction from patient service revenue in the statement of operations rather than as an operating expense. Additional disclosures relating to sources of patient service revenue and the allowance for uncollectible accounts will also be required. This new guidance is effective for fiscal years and interim periods within those fiscal years beginning after December 15, 2011, with early adoption permitted. The Hospital's management has adopted the provisions of ASU 2011-07 and retrospectively applied the presentation requirements on the attached audited financial statements. FORM 990, PART VI, SECTION A, LINES 6, 7A AND 7B: THE ORGANIZATION'S SOLE MEMBER IS EAST END HEALTH ALLIANCE, A NOT-FOR-PROFIT CORPORATION THAT CAN ELECT ONE OR MORE MEMBERS OF THE HOSPITAL'S GOVERNING BODY. THE EAST END HEALTH ALLIANCE, THE ARTICLE 28 PARENT OF EASTERN LONG ISLAND HOSPITAL, PECONIC BAY MEDICAL CENTER AND SOUTHAMPTON HOSPITAL, WAS CREATED IN RESPONSE TO THE RECOMMENDATIONS OF THE COMMISSION ON HEALTH CARE IN THE 21ST CENTURY. CONSISTENT WITH THE MISSION OF SOUTHAMPTON HOSPITAL, THE GOALS OF THE ALLIANCE ARE AS FOLLOWS: A) TO COLLABORATIVELY DEVELOP HIGH QUALITY, COMPREHENSIVE AND ACCESSIBLE HEALTH CARE SERVICES TO MEET THE NEEDS OF THE COMMUNITY SERVED; B) TO RATIONALIZE HEALTH CARE SERVICES ACROSS THE SYSTEM; AND C) TO REALIZE MANAGEMENT EFFICIENCIES. THE FOLLOWING DECISIONS MADE BY THE GOVERNING BODY OF SOUTHAMPTON HOSPITAL REQUIRE EAST END HEALTH ALLIANCE APPROVAL: ADOPTION OF OPERATING BUDGETS, APPLICATION FOR NEW CERTIFICATES OF NEED, AND CERTAIN BORROWING TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 11B: Southampton Hospital Association has its Form 990 prepared by an outside accounting firm and has established the following review process to ensure that the information reported is complete and accurate. Upon completion, the Form 990 is reviewed by management and is then forwarded electronically to the members of the Board of Trustees for their review. Any questions or issues are then addressed by the appropriate parties prior to the filing of the return. FORM 990, PART VI, SECTION B, LINE 12C: Southampton Hospital currently has a conflict of interest policy and a procedure for annual disclosure by key employees, Physician Leaders, and senior management. When new/potential conflicts/relationships are identified, they are investigated by the Corporate Compliance Officer and any recommendations and/or corrective actions are presented to the President and CEO. As appropriate, these potential conflicts/disclosures are also reviewed with the CFO and Medical Director/COO. When a potential conflict is identified, the staff member is prohibited from taking part in any Hospital decisions that may relate to the interest or relationship, until the review is completed and a determination is made that there is no conflict. Similarly, on an annual basis, all members of the Board of Directors are required to complete a Conflict of Interest Form. All potential conflicts of interest that may exist must be disclosed. If a potential or actual conflict of interest exists, the affected member will be notified and the Executive Committee of the Board will investigate and make the determination as to what, if any recusal or other corrective action may be required to avoid any potential conflict. The results of the investigation will then be reported to the governing body. If an actual conflict of interest exists, the affected member will be notified of this determination and their participation in related matters and/or voting rights, pertaining to the area of conflict, will be relinquished. FORM 990, PART VI, SECTION B, LINES 15A AND 15B: Southampton Hospital has established an Executive Compensation Policy which sets forth the terms and criteria for the review of the compensation of the President & CEO, the Chief Medical Officer/COO and the Vice President of Finance/CFO as well as other executive leaders. The policy outlines the procedures and criteria the Executive Committee will follow in evaluating the CEO's and the CMO/COO's performance against established goals. It also outlines the Executive Committees' role and responsibility in determining all aspects of the CEO's and the Chief Medical Officer/COO's compensation including any incentive or bonus compensation. The Committee reviews contract terms which cover compensation and benefits including, but not limited to, housing allowances, automobile allowances, severance or change of control payments. On a periodic basis, the Executive Committee meets to review the terms of compensation and reviews external compensation data and studies to ensure that compensation decisions are reasonable and consistent with fair market value. The Committee documents the full terms of compensation approved and includes date of the decision, details of the comparability data obtained and relied upon, and how the data was obtained. Members of the Executive Committee must be free from any conflict of interest that may relate to the arrangement. All members of the Committee who were present during the discussion of the arrangement will be documented in the Meeting minutes along with their votes. The compensation review process for the Pres. & CEO, Chief Medical Officer and top management officials was last undertaken May 9, 2011. FORM 990, PART VI, SECTION C, LINE 19: Southampton Hospitals Form 990, as well as its financial statements and conflict of interest policy, are available for public inspection upon request, as required under Section 6104 of the Internal Revenue Code. Interested parties may request the documents at 240 Meetinghouse Lane, Southampton, NY 11968 or by calling the organization directly at (631)726-8301. FORM 990, PART VII, SECTION A, LINE 32 AND SCHEDULE J: STEVEN M. BERNSTEIN, FOUNDATION PRESIDENT, IS COMPENSATED EXCLUSIVELY BY SOUTHAMPTON HOSPITAL ASSOCIATION WHERE HE DEDICATES 25% OF HIS TIME. THE REMAINDER 75% OF HIS TIME IS CHARGED TO THE SOUTHAMPTON HOSPITAL FOUNDATION, INC. (A RELATED 501(C)(3) ORGANIZATION). PART XI, LINE 5: SHA PROPERTIES INCOME.............................313,666 SHA PROPERTIES EXPENSES..........................(151,928) PENSION OBLIGATION.............................(4,322,644) UNREALIZED LOSS ON INVESTMENTS...................(757,107) TOTAL..........................................(4,918,013) HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JOHN E. GRIM III TITLE:TRUSTEE HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL ISRAEL, MD TITLE:PHYSICIAN/TRUSTEE HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ROBERT S. CHALONER TITLE:PRESIDENT & CEO HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CHIRSTOPHER J. SCHULTHEIS TITLE:CHIEF FINANCIAL OFFICER HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:STEVEN M. 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