2013-08-12T09:03:45-05:00 2012-09-30 061533253 SASLOW LUFKIN & BUGGY LLP TEN TOWER LANE AVON CT 06001 990 2011-10-01 060646678 THE CHARLOTTE HUNGERFORD HOSPITAL CHAR 8604966728 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 SUSAN M SCHAPP 8604966728 2013-08-08 1 BETH THURZ P00346435 8606789200 2011 2016-02-25 16:41:14Z SUSAN M SCHAPP 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 127718537 0 X WWW.CHARLOTTESWEB.HUNGERFORD.ORG X 1917 CT TO PROVIDE QUALITY, COMPASSIONATE AND COST EFFECTIVE HEALTHCARE TO THE COMMUNITY OF NORTHWESTERN CONNECTICUT. 17 17 1152 170 1753630 0 3090679 2991772 111675220 118802100 1535589 2267570 481119 620288 116782607 124681730 12000 12000 0 0 69100340 72583360 0 0 420740 44844632 49361413 113956972 121956773 2825635 2724957 118964048 126686772 52846422 64748035 66117626 61938737 X THE CHARLOTTE HUNGERFORD HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION. IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR AN INDIVIDUAL'S INABILITY TO PAY COEXIST. THESE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SPECIAL PROGAMS FOR THE ELDERLY, HANDICAPPED, THE MEDICALLY UNDERSERVED AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. 0 0 109126980 12000 117413302 DURING FY 2012 THE HOSPITAL CONTRIBUTED OVER 18,000 HOURS TOWARD THE COMMON PURPOSE OF SERVICING THE HEALTHCARE NEEDS OF THE COMMUNITY. THE VALUE OF THIS CONTRIBUTION IS APPROXIMATELY $145,000, WHICH IS GIVEN BACK TO THE COMMUNITY THROUGH LOWER COSTS IN BOTH PATIENT SERVICES AND OTHER "WELLNESS" PROGRAMS. IN ADDITION THE HOSPITAL GRANTED CHARITY CARE IN THE AMOUNT OF $1,791,880 DURING FISCAL YEAR 2012. THE CHARLOTTE HUNGERFORD HOSPITAL RENDERED THE FOLLOWING SERVICES DURING FY 2012:INPATIENT SERVICES:DISCHARGES 6,338PATIENT DAYS 25,249 SPECIAL SERVICES: OPERATING ROOM CASES 4,060 AMBULATORY SURGERY CASES 3,335 ENDOSCOPY CASES 894 AMBULATORY MEDICAL CASES 2,854WOUND CARE CASES 3,331 POST ANESTHESIA CARE UNIT CASES 2,438 DELIVERY ROOM DELIVERIES 376RESPIRATORY THERAPY TREATMENTS 38,826 PULMONARY REHAB TESTS 5,313PULMONARY FUNCTION LAB TESTS 1,710 CARDIO DIAGNOSTIC EXAMS 13,840EEG EXAMS 2,308PHYSICAL THERAPY TREATMENTS 27,475 CARDIAC REHAB TREATMENTS 3,077 SPEECH THERAPY TREATMENTS 773 OCCUPATIONAL THERAPY TREATMENTS 3,198 SLEEP STUDY TESTS 631 DIAGNOSTIC RADIOLOGY EXAMS 27,761 MAMMOGRAPHY EXAMS 9,446 NUCLEAR MEDICINE EXAMS 1,222 ULTRASOUND EXAMS 9,170C.A.T. SCAN EXAMS 13,030 P.E.T. SCAN EXAMS 126 M.R.I. EXAMS 1,066SPECIAL PROCEDURES (RADIOLOGY) EXAMS 1,262 RADIATION THERAPY TREATMENTS 7,940LABORATORY TESTS 653,635 PSYCHIATRIC CLINIC VISITS 35,780 PHP-ADULT/ADOLESCENT VISITS 4,783 RENAL DIALYSIS VISITS 256 EMERGENCY DEPARTMENT VISITS 34,275 EMERGENCY DEPARTMENT PHYSICIAN VISITS 8,993 OUTPATIENT DIABETES PROGRAM VISITS 1,666 WALK IN CENTER BLOOD DRAWING VISITS 207 WALK IN CENTER VISITS 11,109 PROFESSIONAL SERVICE CONSULTS 112,280HUNGERFORD EMERGENCY MEDICAL CENTER: CARDIAC REHAB TREATMENTS 1,431 DIAGNOSTIC RADIOLOGY EXAMS 3,955 LABORATORY TESTS 21,688 EMERGENCY DEPARTMENT VISITS 6,603 EMERGENCY DEPARTMENT PHYSICIAN VISITS 1,765 PULMONARY REHAB TESTS 2,209 109126980 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 207 0 1 1152 1 1 1 0 0 0 0 0 0 0 0 0 X 17 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X SUSAN M SCHAPP 8604966728 540 LITCHFIELD STREET TORRINGTON CT 06790 EDWARD ARUM 2.50 X 0 0 0 RICHARD DUTTON MD 1.00 X 0 0 0 GLADYS CERRUTO 1.00 X 0 0 0 DAVID J FRAUENHOFER 1.00 X X 0 0 0 JAMIE GREG 1.00 X 0 0 0 KENDRICK HOM MD 1.00 X 0 0 0 JOHN JANCO 2.50 X X 0 0 0 NANCY SULLIVAN HODKOSKI 1.00 X 0 0 0 JOHN LAVIERI 2.50 X X 0 0 0 DIANE LIBBY CPA 1.00 X 0 0 0 JAMES O'LEARY 1.00 X 0 0 0 CHARLES W RORABACK 1.00 X 0 0 0 EDWIN G BOOTH JR 1.00 X 0 0 0 FRANK BUONOCORE JR 1.00 X 0 0 0 STEPHANIE FOWLER MD 1.00 X 0 0 0 MICHAEL PATTERSON 1.00 X 0 0 0 ANDREW SZCZEPANSKI MD 1.00 X 0 0 0 DANIEL J MCINTYRE 60.00 X 386373 0 95051 SUSAN M SCHAPP 60.00 X 213092 0 54870 JOHN J CAPOBIANCO 60.00 X 208875 0 44178 MARK PRETE MD 60.00 X 265799 0 64583 RAYMOND J ELLIOTT 60.00 X 163480 0 54363 BRIAN MATTIELLO 60.00 X 124160 0 19797 STEVEN SINGER MD 60.00 X 281162 0 68738 ELZBIETA LACH-PASKO MD 60.00 X 395369 0 57171 ROBERTA MELTZER MD 60.00 X 184573 0 64301 ASHOK DUBEY MD 60.00 X 261431 0 26241 MUSTAFA UGURLU MD 60.00 X 354447 0 41538 TIMOTHY GOSTKOWSKI MD 60.00 X 478491 0 70448 RAHUL MAGAVI MD 60.00 X 217318 0 24802 WILLIAM MCGEEHIN MD 60.00 X 402406 0 58002 3936976 0 744083 72 0 1 0 ADULT & PEDIATRIC UROLOGY OF NW CONNECTI 538 LITCHFIELD STREET SUITE 102 TORRINGTON CT 06790 MEDICAL 1455650 BUILDING ONE FACILITY SERVICES 57 OZICK DRIVE SUITE A DURHAM CT 06422 CLEANING SERVICES 1370633 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINEAPOLIS MN 554809146 LABORATORY TESTS 1306027 NWCT EMERGENCY SERVICES 80 S MAIN STREET WEST HARTFORD CT 06107 MEDICAL 870492 NEW MILFORD LAUNDRY 40 COMMONS COURT WATERBURY CT 06704 LAUNDRY/LINEN SERVICES 460644 35 41662 2223916 726194 2991772 NET PATIENT REVENUE 900099 103849081 103849081 LABORATORY SERVICES 621500 12464751 10791599 1673152 OTHER HOSPITAL SERVICE 900099 2488268 2488268 118802100 1516030 1516030 659985 375631 284354 284354 284354 3294904 2540289 3075 754615 -3075 751540 751540 122045 41662 42059 79986 79986 132343 75753 56590 56590 GAIN FROM EQUITY METHO 900001 118880 118880 MEDCONN 561499 80478 80478 199358 124681730 117413302 1753630 2523026 12000 12000 2622135 1966601 655534 53414790 48244285 4966288 204217 6814679 6106171 683673 24835 6019934 5394054 603941 21939 3711822 3325912 372383 13527 2709845 2428108 271861 9876 257120 230388 25795 937 131256 117610 13168 478 10641852 9535442 1067628 38782 546039 489268 54781 1990 365297 327318 36648 1331 1408257 1261844 141281 5132 2146786 1923589 215373 7824 49976 44780 5014 182 264154 236690 26501 963 6060455 5430363 608006 22086 2018607 1808737 202514 7356 SUPPLIES 16267850 14576517 1632048 59285 PHYSICIAN FEES 3306463 2479847 826616 PROVISION FOR BAD DEBT 3125364 3125364 HOSPITAL AUXILIARY EXPE 62092 62092 121956773 109126980 12409053 420740 35278 60839 8542940 9947626 169438 88492 11144539 13441100 2009008 2047381 1051648 979386 144551188 106698401 39976419 37852787 51701434 59313706 4333344 2955455 118964048 126686772 8948843 9069553 128582 147665 2355000 1200000 3610528 3421466 37803469 50909351 52846422 64748035 X 47173941 41061265 2830655 3256943 16113030 17620529 66117626 61938737 118964048 126686772 X 2724957 -6903846 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 0 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL PAID DUES TO THE CONNECTICUT HOSPITAL ASSOCIATION. SOME PORTION OF THESE DUES MAY HAVE BEEN USED FOR LOBBYING EXPENSES ON BEHALF OF ITS' MEMBERS. 46929816 239485 6103897 108153 53165045 49273746 186977 -2264127 266780 46929816 45533758 690138 3824302 774452 49273746 47240328 1043719 -1532480 1217809 45533758 0.60770 0.33140 0.06090 0 0 155467 155467 78733907 51002643 27731264 59841496 51429908 8411588 5820318 4265850 1554468 37852787 INVESTMENTS HELD IN TRUST FOR ESTIMATED SELF-INSURANCE LIABILITIES 4248076 F UNDER BOND INDENTURE AGREEMENT-HELD BY OTHERS 400278 F BENEFICIAL INTEREST IN ASSETS HELD IN TRUST BY OTHERS 13868151 F LONG-TERM INVESTMENTS 33807880 F DONOR RESTRICTED ASSETS 6989321 F 59313706 ESTIMATED AMOUNTS DUE TO THIRD PARTY REIMBURSEMENT AGENCIES 1917192 MISCELLANEOUS CURRENT LIABILITIES 168679 ESTIMATED SELF-INSURANCE LIABILITIES 3125672 ACCRUED PENSION LIABILITY 38287989 PENSION CONTRIBUTION - CURRENT PORTION 7409819 50909351 124681730 121956773 2724957 6020484 -12924330 -6903846 -4178889 124298305 0 124298305 383425 383425 124681730 121882681 0 121882681 74092 74092 121956773 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS WILL BE USED PRIMARILY FOR CAPITAL PURCHASES, INDIGENT CARE AND OTHER USES AS APPROVED BY THE BOARD IN ACCORDANCE WITH DONOR RESTRICTIONS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740, "INCOME TAXES" WHICH PROVIDES A FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS IN THEIR FINANCIAL STATEMENTS. THE HOSPITAL MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2012 AND 2011. AS OF SEPTEMBER 30, 2012 AND 2011, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL'S PRIOR THREE TAX YEARS ARE OPEN AND SUBJECT TO EXAMINATION. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COSTS -12,816,177. NET ASSETS RELEASED FROM RESTRICTIONS -108,153. TOTAL TO SCHEDULE D, PART XI, LINE 8: -12,924,330. PART XII, LINE 4B - OTHER ADJUSTMENTS: TEMPORARY RESTRICTED ACTIVITY 294,050. AUXILIARY REVENUE 89,375. PART XIII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 74,092. GOLF TOURNAMENT 84950 84950 4810 26969 457 DINNER DANCE 37095 37095 9823 11 41662 41662 163707 41662 122045 4810 36792 457 42059 79986 1 1 1 X 1 X 1 1 0 1 1 1708 1115685 139542 976143 0.00800 42017 26430956 21887963 4542993 0.03730 1427 606352 428461 177891 0.00150 45152 28152993 22455966 5697027 0.04680 9 4449 47329 0 47329 0.00040 184 1320 0 1320 0.00000 19038842 17049990 1988852 0.01630 9 4633 19087491 17049990 2037501 0.01670 9 49785 47240484 39505956 7734528 0.06350 1 3125364 39829908 38655708 1174200 X 1 1 1 ADVANCED MEDICAL IMAGING OF NORTHWEST CT LLC IMAGING CENTER 0.50000 0.00000 0.50000 2 MEDCONN COLLECTION AGENCY LLC PATIENT COLLECTION AGENCY 0.25000 0.00000 0.00000 3 UROLOGY CENTER OF NW CT UROLOGY CENTER 0.62500 0.00000 0.37500 4 LITCHFIELD COUNTY HEALTHCARE SERVICE CORP PHYSICIANS PRACTICE 1.00000 0.00000 0.00000 2 1 CHARLOTTE HUNGERFORD HOSPITAL

540 LITCHFIELD STRRET TORRINGTON CT 06790

X X X X 2 HUNGERFORD EMERGENCY MEDICAL CENTER

115 SPENCER STREET WINSTED CT 06098

X CHARLOTTE HUNGERFORD HOSPITAL 1 1 X X X X X X X X 10 1 0 1 X X X X X X X X X 0 1 1 200.000000000000 1 250.000000000000 1 X X 1 1 X X X X X 1 X X 1 X X X X X 1 X 0 0 HUNGERFORD EMERGENCY MEDICAL CENTER 2 1 X X X X X X X X 10 1 0 1 X X X X X X X X X X 0 1 1 200.000000000000 1 250.000000000000 1 X X 1 1 X X X X X 1 X X 1 X X X X X 1 X 0 0 13 NORTHWEST CONNECTICUT MEDICAL WALK IN

1598 EAST MAIN STREET TORRINGTON CT 06790

WALK IN MEDICAL CLINIC THE HUNGERFORD CENTER

780 LITCHFIELD STREET TORRINGTON CT 06790

CARDIAC AND PULMONARY REHAB SERVICES THE CENTER FOR CANCER CARE

200 KENNEDY DRIVE TORRINGTON CT 06790

CANCER TREATMENT CENTER HUNGERFORD DIAGNOSTIC CENTER

220 KENNEDY DRIVE TORRINGTON CT 06790

RADIOLOGY SERVICES THE CENTER FOR YOUTH AND FAMILIES

1061 EAST MAIN STREET TORRINGTON CT 06790

PSYCH SERVICES FOR CHILDREN AND FAMILIES BRIDGES EXTENDED DAY PROGRAM

28 SAINT JOHN PLACE TORRINGTON CT 06790

CHILD GUIDANCE CLINIC WINSTED BEHAVIORAL HEALTH CENTER

294 MAIN STREET WINSTED CT 06098

PSYCH SERVICES SURGICAL ASSOCIATES OF CHH

538 LITCHFIELD STREET TORRINGTON CT 06790

SURGICAL PHYSICIANS PRACTICE NEUROLOGY PBC

780 LITCHFIELD STREET TORRINGTON CT 06790

NEUROLOGY PHYSICIANS PRACTICE CHH PRIMARY CARE

780 LITCHFIELD STREET TORRINGTON CT 06790

PRIMARY CARE PHYSICIANS PRACTICE CHH CARDIOVASCULAR MEDICINE SERVICE

1215 NEW LITCHFIELD STREET TORRINGTON CT 06790

CARDIOVASCULAR PHYSICIANS PRACTICE CHH WOUND CARE AND HYPERBARIC MEDICINE

7 FELICITY LANE TORRINGTON CT 06790

WOUND CARE PHYSICIANS PRACTICE CHH UROLOGY MEDICINE

538 LITCHFIELD STREET TORRINGTON CT 06790

ADULT AND PEDIATRIC UROLOGY PHYSICIANS PRACTICE PART I, LINE 3C: CARE WILL BE PROVIDED FREE FOR THOSE UNINSURED WHO QUALIFY AS UNINSURED AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS LESS THAN 200% OF THE FEDERAL INCOME POVERTY LEVEL. CARE WILL BE PROVIDED AT HOSPITAL COST, AS ESTABLISHED BY THE OFFICE OF HEALTH CARE ACCESS (OCHA), FOR THOSE UNINSURED PATIENTS WHO REQUEST ASSISTANCE AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS BETWEEN 200% AND 250% OF THE FPL. CARE WILL BE DISCOUNTED BY 30% FOR THOSE UNISURED PATIENTS WHO REQUEST ASSISTANCE AND VERIFICATION HAS DETERMINED THAT THEIR ANNUAL INCOME IS BETWEEN 250% AND 400% OF THE FPL. THE HOSPITAL WILL ALSO CONSIDER THE TOTAL MEDICAL EXPENSES FACED BY THE FAMILY AND THE FAMILY'S ABILITY TO PAY FOR THOSE EXPENSES, AND WILL CONSIDER OFFERING GREATER ASSISTANCE WHEN POSSIBLE TO THOSE FAMILIES FACING CATASTROPHIC MEDICAL EXPENSES. PART I, LINE 7: A COST TO CHARGE RATIO BASED ON CHARITY CARE CHARGES AND EXPENSES. PART III, LINE 4: THE RATIONALE FOR REPORTING BAD DEBT EXPENSE DIRECTLY FROM THE TRIAL BALANCE IS THAT ACCOUNTS HAVE ALREADY BEEN DISCOUNTED PRIOR TO BEING CLASSIFIED AS A BAD DEBT EXPENSE. PART III, LINE 8: THE REPORTED AMOUNTS FOR MEDICARE REVENUE RECEIVED AND MEDICARE COSTS ARE DERIVED DIRECTLY FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL ATTEMPTS TO HAVE INDIVIDUALS FILL OUT ALL PAPER WORK REQUIRED FOR CHARITY CARE. IF THE PERSON IS NOT CAPABLE OF DOING THIS OR IS KNOWN TO BE UNABLE TO DO THIS (SUCH AS A KNOWN HOMELESS PERSON), THEN THE FINANCIAL ASSISTANCE COMMITTEE WILL ADJUST THE ACCOUNT TO CHARITY CARE AND IT WILL NOT BE REPORTED AS BAD DEBT. IF THE ACCOUNT HAS BEEN REPORTED AS BAD DEBT AND INFORMATION COMES FORTH INDICATING AN INABILITY TO PAY, THEN THE ACCOUNT WOULD BE REMOVED FROM BAD DEBT AND MOVED TO CHARITY CARE. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 3: A CONSULTANT WAS ENGAGED TO CONDUCT A COMMUNITY PERCEPTION SURVEY. IN ADDITION TO THIS THE MEDICAL STAFF, BOARD OF DIRECTORS, AND EMPLOYEES WERE SURVEYED FOR THEIR INPUT INTO THE PROCESS. HUNGERFORD EMERGENCY MEDICAL CENTER PART V, SECTION B, LINE 3: THE HOSPITAL ALONG WITH OTHER AGENCIES/ENTITIES FUNDED A COMMUNITY HEALTH ASSESSMENT. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 7: NOT ALL NEEDS HAVE BEEN ADDRESSED SINCE THE ASSESSMENT WAS IN YEAR TWO OF A FIVE YEAR PLAN WITH A CONTINUED EFFORT TO REFINE ASSESSMENTS. HUNGERFORD EMERGENCY MEDICAL CENTER PART V, SECTION B, LINE 7: NOT ALL NEEDS HAVE BEEN ADDRESSED SINCE THE ASSESSMENT WAS IN YEAR TWO OF A FIVE YEAR PLAN WITH A CONTINUED EFFORT TO REFINE ASSESSMENTS. CHARLOTTE HUNGERFORD HOSPITAL PART V, SECTION B, LINE 19D: CONNECTICUT STATE LAW (LOONEY BILL) REQUIRES THE HOSPITAL TO ADJUST THE PATIENT'S BALANCE EQUAL TO THE COST OF PROVIDING THE CARE. HUNGERFORD EMERGENCY MEDICAL CENTER PART V, SECTION B, LINE 19D: CONNECTICUT STATE LAW (LOONEY BILL) REQUIRES THE HOSPITAL TO ADJUST THE PATIENT'S BALANCE EQUAL TO THE COST OF PROVIDING THE CARE. PART VI, LINE 2: THE HOSPITAL OFFERS FREE HEALTH SCREENINGS, FREE HEALTH EDUCATION AND LECTURES AT VARIOUS COMMUNITY EVENTS INCLUDING FAIRS, EXPOS, PRIVATE COMPANIES, PUBLIC MUNICIPALITIES, AND PUBLIC GATHERINGS. THIS HELPS THE COMMUNITY ASSESS THEIR MEDICAL NEEDS. IN ADDITION TO THE ABOVE ITEMS, THE HOSPITAL DISTRIBUTES FREE MEDICAL SUMMARY CARDS WHICH ALLOW PATIENTS TO TRACK THEIR MEDICATIONS. PART VI, LINE 3: THE HOSPITAL COUNSELS ALL SELF PAY PATIENTS EITHER BY MEETING WITH A FINANCIAL COUNSELOR OR IF HE OR SHE IS AN INPATIENT, MEETING WITH A SOCIAL WORKER. ALL STATEMENTS RECEIVED BY PATIENTS INCLUDE FINANCIAL COUNSELING INFORMATION. SIGNS ARE POSTED THROUGHOUT THE HOSPITAL INCLUDING IN THE EMERGENCY ROOM WHICH STATE THE CHARITY CARE POLICIES AND FINANCIAL ASSISTANCE INFORMATION. PART VI, LINE 4: THE CHARLOTTE HUNGERFORD HOSPITAL IS A 109 BED, GENERAL ACUTE CARE HOSPITAL LOCATED IN TORRINGTON, CONNECTICUT, THAT SERVES AS A REGIONAL HEALTH CARE RESOURCE FOR 100,000 RESIDENTS OF LITCHFIELD COUNTY AND NORTHWEST CONNECTICUT. CHH OFFERS PERSONALIZED ATTENTION FROM AN EXPERT TEAM OF CAREGIVERS AND PHYSICIANS THAT UTILIZE ADVANCED TECHNOLOGY AND CLINICAL PARTNERSHIPS IN A CONVENIENT, SAFE AND COMFORTABLE PATIENT ENVIRONMENT. RECENT ASSESSMENTS FROM THE AREA THAT THE HOSPITAL SERVES HAS FOUND THE FOLLOWING: - THE COUNTY HAS BECOME MORE RACIALLY AND ETHNICALLY DIVERSE. - THE COUNTY HAS THE HIGHEST PROPORTION OF RESIDENTS AGES 50+ IN THE STATE. - AREA RATES OF OBESITY AND CURRENT SMOKING EXCEED THE STATE AVERAGE. - STUDENTS IN NEARLY HALF OF THE AREA'S SCHOOL DISTRICTS SCORED BELOW THE STATE AVERAGE IN STANDARDIZED PHYSICAL FITNESS TESTS. - NEARLY ONE IN FOUR COUNTY RESIDENTS HAS HYPERTENSION. - NEARLY 40% HAVE BEEN TOLD BY THEIR HEALTH PROFESSIONAL THAT THEY HAVE HIGH CHOLESTEROL. - THE COUNTY HAS A RATIO OF ONE PRIMARY CARE PHYSICIAN TO EVERY 1,123 RESIDENTS. THIS WELL BELOW BOTH STATE AND NATIONAL BENCHMARKS. PART VI, LINE 5: ALL BOARD OF DIRECTORS MEMBERS RESIDE IN THE COMMUNITY SERVED BY THE CHARLOTTE HUNGERFORD HOSPITAL AND ARE NOT EMPLOYEES OF THE HOSPITAL NOR ARE THEY INDEPENDENT CONTRACTORS DOING BUSINESS WITH THE HOSPITAL. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS WHO APPLY FOR SUCH PRIVILEGES. THE HOSPITAL ESTABLISHES AN ANNUAL CAPITAL BUDGET TO ADD OR REPLACE PATIENT CARE EQUIPMENT AND FACILITIES. MEDICAL EDUCATION IS PROVIDED TO PHYSICIANS THROUGH CONFERENCES ON A MONTHLY BASIS. REPORTS FILED WITH STATES PART VI, LINE 7 CT 1 HEALTHCARE SCHOLARSHIPS 12 12000 THE CHARLOTTE HUNGERFORD HOSPITAL AUXILIARY AWARDS SCHOLARSHIPS IN THE AMOUNT OF $1,000 EACH TO STUDENTS PURSUING HEALTHCARE EDUCATIONS. THE STUDENTS MUST LIVE IN THE AREA SERVED BY THE HOSPITAL. THEY MUST ALSO PROVIDE EVIDENCE OF HAVING BEEN ACCEPTED INTO A COLLEGE PROGRAM OR THEIR CURRENT GRADES IN COLLEGE. RECIPIENTS OF THE SCHOLARSHIPS MUST SUBMIT LETTERS OF RECOMMENDATION FROM THEIR TEACHERS AND ALSO FROM NON-FAMILY PERSONS. X X X 0 0 0 0 0 0 0 0 0 DANIEL J MCINTYRE 386373 0 0 0 0 0 56269 0 38782 0 481424 0 0 0 SUSAN M SCHAPP 213092 0 0 0 0 0 33481 0 21389 0 267962 0 0 0 JOHN J CAPOBIANCO 208875 0 0 0 0 0 23213 0 20965 0 253053 0 0 0 MARK PRETE MD 265799 0 0 0 0 0 37904 0 26679 0 330382 0 0 0 RAYMOND J ELLIOTT 163480 0 0 0 0 0 37954 0 16409 0 217843 0 0 0 STEVEN SINGER MD 281162 0 0 0 0 0 40517 0 28221 0 349900 0 0 0 ELZBIETA LACH-PASKO MD 395369 0 0 0 0 0 17486 0 39685 0 452540 0 0 0 ROBERTA MELTZER MD 184573 0 0 0 0 0 45775 0 18526 0 248874 0 0 0 ASHOK DUBEY MD 261431 0 0 0 0 0 0 0 26241 0 287672 0 0 0 MUSTAFA UGURLU MD 354447 0 0 0 0 0 5961 0 35577 0 395985 0 0 0 TIMOTHY GOSTKOWSKI MD 478491 0 0 0 0 0 22420 0 48028 0 548939 0 0 0 RAHUL MAGAVI MD 217318 0 0 0 0 0 2989 0 21813 0 242120 0 0 0 WILLIAM MCGEEHIN MD 402406 0 0 0 0 0 17611 0 40391 0 460408 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS BEFORE IT IS FILED WITH THE IRS. THIS ENABLES THE BOARD TO ASK QUESTIONS, AND TO APPROVE THE DISCLOSURES MADE IN THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY TO ITS BOARD OF DIRECTORS, ALL MANAGEMENT PERSONNEL, AND PURCHASING AGENTS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR SENIOR STAFF IS DETERMINED USING THE FOLLOWING STEPS: - A MARKET SURVEY BASED ON CT HOSPITAL ASSOCIATION IS USED AS A STARTING POINT. - ADJUSTMENTS ARE THEN MADE BASED ON THE CANDIDATE'S CURRENT SALARY AND PRIOR EXPERIENCE. - THE COMPENSATION FIGURE IS THEN PRESENTED TO THE BOARD OF DIRECTORS FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING POLICIES AVAILABLE TO THE PUBLIC UPON REQUEST. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO THE BOARD OF DIRECTORS, ALL MANAGEMENT PERSONNEL, AND THE PURCHASING AGENTS FOR THE HOSPITAL. AN ANNUAL REPORT OF THE OPERATIONS OF THE HOSPITAL INCLUDING FINANCIAL INFORMATION IS PUBLISHED EACH YEAR AND IS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 6,020,484. PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COSTS -12,816,177. NET ASSETS RELEASED FROM RESTRICTIONS -108,153. TOTAL TO FORM 990, PART XI, LINE 5: -6,903,846. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THESE FUNCTIONS AND PROCESSES HAVE NOT CHANGED FROM THE PRIOR YEAR. ADVANCED MEDICAL IMAGING OF NW CT LLC 57 COMMERCIAL BLVD TORRINGTON CT 06790 061594854 MAGNETIC RESONANCE IMAGING CT N/A RELATED 458786 262853 0 0 0.50000 UROLOGY CENTER OF NW CT LLC 538 LITCHFIELD STREET TORRINGTON CT 06790 582674029 EQUIPMENT RENTAL CT N/A RELATED 33221 38679 0 0 0.62500 LITCHFIELD COUNTY HEALTHCARE SERVICE CORPORATION 540 LITCHFIELD STREET TORRINGTON CT 06790 061227655 MANAGEMENT SERVICES CT THE CHARLOTTE HUNGERFORD HOSPTIAL C 505 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ADVANCED MEDICAL IMAGING OF NW CT LLC R 470000 ACTUAL