2013-08-15T09:07:46-05:00 2012-09-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2011-10-01 560603900 ASHE MEMORIAL HOSPITAL INC ASHE 3368467101 200 HOSPITAL AVENUE JEFFERSON NC 28640 LAURA LAMBETH 3368467101 2013-08-14 1 JOHN NORMAN P01506766 7049985200 2011 2016-02-25 16:41:14Z LAURA LAMBETH 200 HOSPITAL AVE JEFFERSON NC 28640 30304389 0 X WWW.ASHEMEMORIAL.ORG X 1939 NC ACUTE HOSPITAL CARE SERVICES PROVIDED TO THE RESIDENTS OF ASHE COUNTY, NC AND SURROUNDING AREAS. 18 16 430 63 0 0 976258 728508 31277161 28925590 19446 175658 212723 438907 32485588 30268663 0 16093 0 0 16889710 16921317 0 0 297927 16232833 13924067 33122543 30861477 -636955 -592814 18588566 17668240 10342629 10185242 8245937 7482998 X THE HOSPITAL'S MISSION STATEMENT IS ICARE, WHICH STANDS FOR INVESTMENT IN THE DEVELOPMENT OF PEOPLE, COMMITMENT TO CONTINUOUS IMPROVEMENT, ACCOUNTABILITY TO THOSE WE SERVE, RESPONSIVENESS TO THE HEALTH CARE NEEDS OF THE COMMUNITY, AND EXCELLENCE IN PRIMARY HEALTHCARE. 0 0 27658115 16093 28925590 ASHE MEMORIAL HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF ASHE COUNTY AND THE SURROUNDING AREAS. RECENT PROJECTS COMPLETED THAT IMPROVED THE FACILITY AND THE SERVICES OFFERED TO THE COMMUNITY INCLUDED: (1) A NEW BUILDING COMPLETED ON THE CAMPUS OF ASHE MEMORIAL HOSPITAL, INC TO HOUSE MOUNTAIN FAMILY CARE CENTER, OUR HOSPITAL-BASED RURAL HEALTH CLINIC, (2)ENHANCEMENTS AND ADDITIONS OF SOFTWARE TO ACHIEVE "MEANINGFUL USE" IN THE ELECTRONIC HEALTH RECORD PROJECT, (3) RENOVATION OF OFFICE SPACE THAT IS OCCUPIED BY MOUNT JEFFERSON FAMILY MEDICINE IN THE HOSPITAL-OWNED PHYSICIAN BUILDING, (4) NEW HOSPITAL-OWNED OB/GYN PRACTICE OPENED IN AN AREA WITHIN 3 MILES OF THE HOSPITAL, (5) NEW MEDICAL EQUIPMENT IN THE OPERATING ROOM AND FITNESS EQUIPMENT AT MOUNTAIN HEARTS, (6) NEW FURNITURE IN THE OUTPATIENT/EMERGENCY DEPARTMENT AREA, (7) ENHANCEMENT OF THE PHONE AND COMMUNICATIONS SYSTEM, AND (8) A FACELIFT TO THE CHAPEL LOCATED WITHIN THE HOSPITAL. THE HOSPITAL PROVIDED A SIGNIFICANT AMOUNT OF COMMUNITY BENEFIT AND OUTREACH TO THE COUNTY AND SURROUNDING AREAS. BENEFIT AND OUTREACH PROGRAMS ARE PROVIDED IN CONJUNCTION WITH THE ASHE COUNTY HEALTH COUNCIL AND INDEPENDENTLY THROUGH VARIOUS DEPARTMENTS AND SERVICES. OUR SIXTH COMMUNITY HEALTH FAIR WAS HELD DURING THE SUMMER. THIS PROJECT CONTINUES TO RECEIVE THE HIGHEST EVALUATION SCORES OF ANY SECTION OF THE BLUE RIDGE ELECTRIC ANNUAL MEETING. 27658115 1 1 0 1 0 0 0 0 0 0 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 54 0 1 430 1 0 0 0 0 0 0 0 0 0 0 X 18 16 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X JOY R MCCLURE CFO 3368467101 200 HOSPITAL AVENUE JEFFERSON NC 28640 X HOBART DAVIS 1.00 X 0 0 0 DR CHARLES JONES 1.00 X 0 0 0 TIM VANNOY 1.00 X 0 0 0 BRADLEY MCNEILL 1.00 X 0 0 0 BRETT T SUMMEY DDS 1.00 X 0 0 0 EDWARD J MILLER MD 1.00 X 0 0 0 STEPHEN SHOEMAKER 1.00 X 0 0 0 JANE LONON 1.00 X 0 0 0 MICHAEL MINCEY 1.00 X 0 0 0 SUE HAMPTON 1.00 X 0 0 0 NANCY KAUTZ 1.00 X 0 0 0 WALTER E DAVIS MD 1.00 X 0 0 0 JAMES G GAMBILL JR 1.00 X 0 0 0 DICK MILLER 1.00 X 0 0 0 TOM EFFORD 1.00 X 0 0 0 JAN CADDELL 1.00 X 0 0 0 MARYANNE MOORE 1.00 X 0 0 0 JAMES MICHAEL A TAN 44.40 X 277065 0 26682 WILLIAM BLACKERBY 41.40 X 263987 0 18693 CHARLES B JONES JR 47.80 X 217962 0 18504 MARK T SCOTT 47.10 X 212884 0 16223 TERRY L WILLIAMS JR 40.00 X 175200 0 9032 1147098 0 89134 10 0 1 0 RESTORE RESPIRATORY CARE 200 GALLERIA PARKWAY SUITE 1800 ATLANTA GA 30339 RESPIRATORY THERAPY 701423 QUORUM HEALTH RESOURCES LLC 105 CONTINENTAL PLACE BRENTWOOD TN 370271018 MANAGEMENT FEES/CEO 329726 HERMITAGE ANESTHESIA PO BOX 1153 JEFFERSON NC 28640 ANESTHESIA 225996 DEBORAH L SIDERS CRNA 257 NEW BEGINNINGS WEST JEFFERSON NC 28694 ANESTHESIA 216000 CRNA PLUS PA 411 HWY 16 SOUTH JEFFERSON NC 28640 ANESTHESIA 216000 8 373283 211159 144066 728508 PATIENT SERVICE REVENU 623000 26366629 26366629 OTHER OPERATING REVENU 623000 2078025 2078025 PHARMACY 446110 348958 348958 FITNESS CENTER 713940 101210 101210 LIFELINE RENTALS 900099 30768 30768 28925590 20816 20816 142101 0 142101 142101 142101 190568 35726 154842 154842 154842 CAFETERIA & VENDING 722210 167412 167412 INSURANCE REFUNDS/SETT 900099 128531 128531 PURCHASE DISCOUNTS 900099 863 863 296806 30268663 28925590 0 614565 16093 16093 1237949 1237949 12472181 12216480 255701 2294598 2103609 173601 17388 916589 840298 69346 6945 114146 114146 15293 15293 61350 61350 1261309 1166934 94375 32168 6400 25446 322 4788493 4478350 289402 20741 301285 34533 266752 1038021 1038021 70932 58202 12730 210286 210286 1575135 1575135 319274 319274 BAD DEBT EXPENSE 3153747 3153747 MISCELLANEOUS 898198 440753 204914 252531 RECRUITMENT 84430 84430 30861477 27658115 2905435 297927 1475185 1254600 318633 518467 2806350 2144079 21269 609786 608861 126083 120079 30764844 19135857 10693024 11628987 520187 0 1290365 1006578 748953 365320 18588566 17668240 6070650 4717438 385335 377669 3833259 4680617 53385 409518 10342629 10185242 X 8001227 7335573 244710 147425 8245937 7482998 18588566 17668240 X -592814 -170125 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4682 4682 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING EXPENDITURES ON BEHALF OF ITS MEMBERSHIP BODY. THE AMOUNT OF DUES ALLOCATED TO LOBBYING EXPENDITURES WAS ******** 277913 277913 15505148 8365813 7139335 1208575 747585 460990 13752783 10022459 3730324 20425 20425 11628987 INVESTMENT IN HOME HEALTH PROJECT 972833 C OTHER 33745 C 1006578 MEDICARE/MEDICAID DUE 409518 409518 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE ORGANIZATION HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012 AND 2011. FISCAL YEARS ENDING ON AND AFTER SEPTEMBER 30, 2009, REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 1 X 1 1 0 1 1 660905 660905 0.02390 3941151 4654291 -713140 0.00000 132366 88520 43846 0.00160 4734422 4742811 -8389 0.02550 4734422 4742811 -8389 0.02550 16779 16779 0.00060 16779 16779 0.00060 1 1542182 616873 3582826 5030840 -1448014 X 1 0 1 1 ASHE MEMORIAL HOSPITAL

200 HOSPITAL AVENUE JEFFERSON NC 28640

X X X X CRITICAL ACCESS HOSPITAL ASHE MEMORIAL HOSPITAL INC 1 1 1 25000.000000000000 1 25000.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X X X 0 1 X 0 0 3 AMH SEGRAVES CARE CENTER

200 HOSPITAL AVENUE JEFFERSON NC 28640

SKILLED NURSING MOUNTAIN FAMILY CARE CENTER

200 HOSPITAL AVENUE JEFFERSON NC 28640

RURAL HEALTH CLINIC AMH ASHE WOMEN'S CENTER

420 E 2ND STREET WEST JEFFERSON NC 28694

PHYSICIANS OFFICES PART I, LINE 6A: NCHA PART 1, LINE 6A THE COMMUNITY BENEFIT REPORT WAS PREPARED ON THE ORGANIZATION'S BEHALF WITH ASSISTANCE FROM THE NORTH CAROLINA HOSPITAL ASSOCIATION, AND THE FINAL REPORT WAS MADE AVAILABLE TO THE PUBLIC ON THE NCHA'S WEBSITE. PART 1, LINE 7 THE ORGANIZATION USED AN INTERNALLY-DERIVED RATIO OF COSTS TO CHARGES OF 48.67% TO CALCULATE CHARITY CARE AND UNREIMBURSED MEDICAID TREATMENTS AT COST. PART 1, LINE 7 COL(F) THE AMOUNT ON FORM 990, PART IX, LINE 25 CONTAINS A BAD DEBT EXPENSE OF $3,153,747 THAT HAS BEEN OMITTED FOR PURPOSES OF CALCULATING THE AMOUNT ON PART 1, LINE 7, COL (F). 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 $ 3153747. COMMUNITY BUILDING ACTIVITIES -- COALITION BUILDING PART II, LINE 6 ASHE MEMORIAL HOSPITAL, INC HAS EMPLOYED AN OUTREACH COORDINATOR FOR SEVERAL YEARS WHO HAS WORKED WITH OTHER ORGANIZATIONS OF THE COUNTY TO PROMOTE SUCCESSFUL OUTCOMES IN HEALTH AND WELLNESS. THE HOSPITAL HAD BEEN THE LEAD MEMBER IN FORMING MANY COALITIONS AND ORGANIZATIONS THAT COULD MEET COMMUNITY NEEDS. DUE TO LACK OF FUNDS WITHIN THE HOSPITAL, THIS DEPARTMENT WAS ELIMINATED IN NOVEMBER 2011 AFTER THE RETIREMENT OF THE COORDINATOR, AND SHORTLY THEREAFTER, THE ASHE HEALTH ALLIANCE WAS FORMED TO RESUME THE NEEDED WORK. THE HOSPITAL STILL MAINTAINS A MEMBERSHIP OF THIS ALLIANCE, AND CONTINUES TO WORK THRU THE SHARED SERVICES OF ALL THE AGENCIES. AT THE TIME OF THE ELIMINATION OF THE COMMUNITY OUTREACH DEPARTMENT IN NOV 2011, THE EXPENSES TOTALED $ 16,779 WHICH INCLUDED SALARIES AND WAGES, OUTSIDE FEES, RENTALS, OFFICE SUPPLIES, AND OTHER MISCELLANEOUS EXPENSES. PART III, LINE 4 THE ORGANIZATION DID NOT HAVE A FOOTNOTE IN THE CURRENT AUDITED FINANCIALS THAT DESCRIBES BAD DEBT EXPENSE. THE ORGANIZATION USED AN INTERNALLY-DERIVED RATIO OF COSTS TO CHARGES OF 48.89 % TO CALCULATE BAD DEBT AT COST. THE ORGANIZATION ESTIMATES THAT APPROXIMATELY 40% OF BAD DEBTS AT COST COULD BE ATTRIBUTABLE TO PATIENTS THAT COULD BE ELIGIBLE FOR FINANCIAL ASSISTANCE. THIS ESTIMATE IS BASED ON EXPERIENCE AND HISTORICAL DATA IN THE COMMUNITY WE SERVE. A NUMBER OF OLDER PATIENTS THAT FAIL TO QUALIFY FOR MEDICAID OR MEDICARE BENEFITS DECLINE TO PROVIDE THE FINANCIAL INFORMATION REQUIRED TO QUALIFY A PATIENT FOR OUR ASSISTANCE POLICY. IN ADDITION, THERE IS A GROWING DIFFICULTY IN OBTAINING THE INFORMATION FROM YOUNGER PATIENTS, DESPITE THE HOSPITAL'S BEST ATTEMPTS AT OBTAINING THIS INFORMATION. AS A RESULT, MANY UNPAID MEDICAL CHARGES ULTIMATELY END UP BEING CHARGED TO BAD DEBT DUE TO UNAVAILABLE INFORMATION IN THE CURRENT YEAR. PART III, LINE 8 AMOUNTS REPORTED ON PART III, LINES 5 AND 6 ARE DERIVED FROM THE ORGANIZATION'S MEDICARE COST REPORT. PART III, LINE 9B: THE POLICY DOES NOT SPECIFICALLY ADDRESS THIS ISSUE BUT WE NORMALLY PROVIDE THE CHARITY CARE DISCOUNT PRIOR TO SENDING TO BAD DEBT IF THE PATIENT QUALIFIES FOR CHARITY IN PART BUT FAILS TO PAY THEIR PORTION DUE. PART III, LINE 9B WHEN A PATIENT HAS QUALIFIED FOR FINANCIAL ASSISTANCE BASED ON FINANCIAL STATUS, AND THERE IS A CO-PAY AMOUNT DUE AND PAYABLE BY THE PATIENT, THE AMOUNT DUE FROM THE PATIENT IS THE ONLY AMOUNT THAT MAY BE SENT OUT FOR COLLECTION. THE HOSPITAL UTILIZES A THIRD-PARTY SERVICE FOR THE MAJORITY OF ITS COLLECTIONS. THE REMAINDER OF THE BILL IS WRITTEN OFF TO CHARITY CARE. PART VI, LINE 2 THE HOSPITAL WORKS WITH THE APPALACHIAN DISTRICT HEALTH DEPARTMENT TO ASSESS COMMUNITY NEEDS, USING PRIMARY AND SECONDARY DATA EVERY THREE YEARS. IN ADDITION, THE ASHE HEALTHY CAROLINIANS ASSESSES COMMUNITY NEEDS INFORMALLY ON AN ONGOING BASIS USING OPINION SURVEYS AND SECONDARY DATA. IT PRESENTS THIS DATA ON A REGULAR BASIS TO THE COMMUNITY FOR PLANNING OF SERVICES BY LOCAL GOVERNMENT AND NON-PROFITS. PART VI, LINE 3 THE HOSPITAL PRINTS INFORMATIONAL PACKETS AND SUPPORTS THE COMMUNITY OUTREACH DEPARTMENT TO EDUCATE THE PUBLIC ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS POSTED ON A PUBLIC WEBSITE MAINTAINED BY THE NORTH CAROLINA HOSPTIAL ASSOCIATION. ASHE MEMORIAL PROVIDES FISCAL AND SUPERVISORY MANAGEMENT FOR SEVERAL FEDERAL AND STATE PROGRAMS, INCLUDING THE ASHE/ALLEGHANY FARMWORKERS HEALTH PROGRAM, AND THE ASHE MEDICATION ASSISTANCE PROGRAM. IN ADDITION, IT PROVIDES OVERSIGHT AND FISCAL MANAGEMENT FOR AN ENDOWMENT FUND TO PROVIDE ASSISTANCE TO THOSE AFFECTED BY CANCER IN THE COMMUNITY. UNINSURED PATIENTS ARE INFORMED OF FINANCIAL ASSISTANCE AT REGISTRATION, DURING THE VISIT, AND UPON DISCHARGE BOTH UNINSURED AND UNDERINSURED PATIENTS RECEIVE INFORMATION ON THE BACK OF BILLING STATEMENTS OF FINANCIAL ASSISTANCE ROUTES THAT PATIENTS MAY TAKE IF THEY CANNOT PAY PART OR ALL OF THEIR BILL STATEMENTS. THERE ARE ALSO SIGNS AND PLACARDS IN THE REGISTRATION AREA INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE. PART VI, LINE 4 THE HOSPITAL SERVES ASHE COUNTY, NORTH CAROLINA, AN ISOLATED, ECONOMICALLY DEPRESSED, RURAL COUNTY IN THE NORTHWEST MOUNTAINS OF NORTH CAROLINA. HAVING A POPULATION OF 27,143 AND AN UNEMPLOYMENT RATE OF 12.2% IN 2011, IT CONTINUES TO EXPAND THE NUMBER OF PERSONS BELOW THE POVERTY RATE, WHICH IN 2012 WAS 20% OF THE POPULATION OF ASHE COUNTY, COMPARED TO THE STATE AVERAGE OF 17.4%. THE PER CAPITA PERSONAL INCOME IS $31,965, WELL BELOW THE STATE AVERAGE OF $43,417. ASHE MEMORIAL IS THE ONLY HOSPITAL IN ASHE COUNTY. PART VI, LINE 5 THE ORGANIZATION EXTENDS PRIVILEGES TO LOCAL PHYSICIANS AND MEDICALSTAFF IN MOST DEPARTMENTS OF THE HOSPITAL. THE ORGANIZATION'S GOVERNING BODY CONSISTS PRIMARILY OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE HOSPITAL. ASHE MEMORIAL HOSPITAL IS ORGANIZED AS A 501(C)(3)ORGANIZATION. THE INCOME GENERATED BY THE PROVISION OF SERVICES IS USED TO SUPPORT THE ONGOING OPERATIONS OF THE ORGANIZATION. ANY SURPLUS FUNDS GENERATED FROM OPERATIONS ARE UTILIZED TO FUND IMPROVEMENTS TO THE PHYSICAL PLANT AND TO SUPPORT THE PROVISION OF SERVICES TO INVIDIVUALS WHO AREUNABLE TO PAY FOR THEIR CARE. ASHE MEMORIAL HOSPITAL PROVIDES A MONTHLY OPPORTUNITY FOR THE PUBLIC TO HAVE THEIR BLOOD SUGAR AND CHOLESTEROL LEVELS CHECKED WITH A FASTING BLOOD DRAW. THE HOSPITAL CHARGES $20 FOR THIS SERVICE. THE SERVICE REQUIRES THE FOLLOWING FROM HOSPITAL STAFF: (1) MOUNTAIN HEARTS RECEPTIONIST - SETS APPOINTMENTS (2) LAB PHLEBOTOMIST - BLOOD DRAW (3) REGISTRATION CLERK - REGISTERS PATIENT IN THE HOSPITAL PATIENT SYSTEM (4) LAB TECH - RUNS THE TESTS (5) LAB TECH - PRINTS RESULTS AND MAILS TO PATIENT. THE RESULTING COST TO THE HOSPITAL IS $2000 PER SCREENING. THE PROGRAM WAS DESIGNED TO BREAK EVEN IN ORDER TO PROVIDE THIS VALUABLE SERVICE AT AN AFFORDABLE COST. THE HOSPITAL ALSO SUPPORTS THE ASHE HEALTHY CAROLINIANS TASK FORCE WHICH HAS BEEN INSTRUMENTAL IN THE ASSESSMENT AND PLANNING TO MEET COMMUNITY NEEDS FOR THE LAST 18 YEARS. SOME OF THE PROJECTS HAVE INCLUDED THE IMPLEMENTATION OF A SCHOOL BASED HEALTH CENTER IN OUR ONLY MIDDLE SCHOOL IN THE COUNTY, PROVIDING ACCESS TO CARE BY SUPPORT OF THE ASHE COUNTY FREE MEDICAL CLINIC, AND THE PRESENT DEVELOPMENT 0F NETWORKS TO ASSURE ACCESS TO CARE FOR THE UNINSURED AND UNDERINSURED IN THE COUNTY. PART VI, LINE 7 NC X 0 0 X X X 0 0 0 0 0 0 0 0 0 JAMES MICHAEL A TAN 277065 0 0 0 0 0 11823 0 14859 0 303747 0 0 0 WILLIAM BLACKERBY 263987 0 0 0 0 0 11431 0 7262 0 282680 0 0 0 CHARLES B JONES JR 217962 0 0 0 0 0 12290 0 6214 0 236466 0 0 0 MARK T SCOTT 212884 0 0 0 0 0 11935 0 4288 0 229107 0 0 0 TERRY L WILLIAMS JR 175200 0 0 0 0 0 0 0 9032 0 184232 0 0 0 PART I, LINE 1A THE HOSPITAL PAYS FOR MEMBERSHIP DUES TO THE JEFFERSON ROTARY CLUB FOR CERTAIN KEY OFFICERS. THE PURPOSE OF THE ROTARY CLUB IS TO BRING TOGETHER BUSINESS AND PROFESSIONAL LEADERS TO PROVIDE HUMANITARIAN SERVICE, ENCOURAGE HIGH ETHICAL STANDARDS IN ALL VOCATIONS, AND HELP BUILD GOODWILL AND PEACE IN THE WORLD. AMOUNTS ARE BILLED DIRECTLY TO THE ORGANIZATION. THE HOSPITAL ALSO PAYS DUES TO JEFFERSON LANDING GOLF CLUB FOR CERTAIN KEY OFFICERS. ALL INVOICES ARE PAID DIRECTLY BY THE ORGANIZATION. PART I, LINE 3 COMPENSATION FROM AN UNRELATED ORGANIZATION (SEE FORM 990, PART VII, LINE 5). RAYMOND D WILLIAMS IS COMPENSATED THROUGH QUORUM HEALTH RESOURCES, LLC, AN UNRELATED ORGANIZATION, FOR HIS SERVICES AS CEO OF THE HOSPITAL. PLEASE SEE THE RESPONSE TO FORM 990, PART VI, LINE 15A FOR MORE DETAILS. SUPPLEMENTAL INFORMATION PART III ASHE MEMORIAL HOSPITAL DOES NOT COMPENSATE MEMBERS FOR THEIR SERVICE AS DIRECTORS OF THE BOARD. ALL COMPENSATION LISTED ON PART VII, LINE 1, COLUMN (D) FOR BOARD MEMBERS WAS PAID FOR VARIOUS MEDICAL SERVICES RENDERED TO THE ORGANIZATION. SARA HOUSER ACCUMULATED STUDENT LOAN, TO BE PAID BACK THROUGH EMPLOYMENT X 8017 21269 0 1 1 21269 DRAGO PROPERTIES LLC OWNED BY OFFICER JOE THORE 29108 RENTAL PAYMENTS FOR STORAGE SPACE 0 JMG ENERGY SOLUTIONS INC OWNED AND OPERATED BY FAMILY MEMBERS OF BOARD MEMBER JAMES GAMBILL 12984 PURCHASE OF FUEL, OIL, AND ENERGY SERVICES 0 FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS RICHARD MILLER AND JOE THORE HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE CEO OF THE HOSPITAL IS CONTRACTED FOR HIS SERVICE THROUGH QUORUM HEALTH RESOURCES, LLC (QHC) BY THE BOARD OF TRUSTEES. SEE THE RESPONSE TO PART VI, LINE 15A FOR FURTHER DETAILS. FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL IS ORGANIZED AS A STOCK CORPORATION, AND SHARES OF STOCK ARE SOLD TO MEMBERS OF THE COMMUNITY AND ARE FREELY TRANSFERABLE, BUT HAVE NO CAPITAL VALUE. SHAREHOLDERS DO NOT RECEIVE DIVIDENDS. FORM 990, PART VI, SECTION A, LINE 7A TRUSTEES SHALL BE ELECTED BY THE SHAREHOLDERS OF THE CORPORATION AT THE ANNUAL MEETING OF THE MEMBERSHIP. EACH SELECTED TRUSTEE SHALL HOLD OFFICE FOR A TERM OF THREE YERAS AND UNTIL HIS SUCCESSOR IS ELECTED AND QUALIFIED. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION CANNOT SELL REAL PROPERTY WITHOUT APPROVAL BY THE SHAREHOLDERS. PLEASE SEE THE RESPONSE TO LINE 6 ABOVE. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH THE ASSISTANCE AND OVERSIGHT OF MANAGEMENT. PRIOR TO SUBMISSION TO THE IRS, THE BOARD PLANNING AND FINANCE COMMITTEE REVIEWED THE RETURN AND MADE RECOMMENDATIONS FOR APPROVAL TO THE FULL BOARD. THE FULL BOARD OF TRUSTEES AUTHORIZED THE RETURN FOR SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ALL VOTING MEMBERS ARE REQUIRED TO REVIEW AND SIGN A CONFLICT OF INTEREST SURVEY AND RETURN TO THE BOARD CHAIRMAN. THE SURVEY INCLUDES A DISCLOSURE STATEMENT AND A REVIEW OF THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL CEO IS AN EMPLOYEE THROUGH CONTRACT MANAGEMENT SERVICE QUORUM HEALTH RESOURCES, LLC (QHR), AN UNRELATED CORPORATION. QHR PROVIDES COMPARATIVE SALARY RANGES FROM UP TO THREE SOURCES OF HOSPITALS OF SIMILAR NET REVENUES AND RECOMMENDS TO THE BOARD OF TRUSTEES ANY SALARY ADJUSTMENT FOR THE CEO. APPROVAL BY THE BOARD IS REQUIRED. FOR OTHER KEY EMPLOYEES, THERE IS A REVIEW PROCESS ANNUALLY BY THE CHIEF HUMAN RESOURCES OFFICER USING THE NORTH CAROLINA HEALTHCARE HUMAN RESOURCES ASSOCIATION COMPENSATION AND BENEFITS SURVEY. BASE RATES ARE COMPARED TO THE SURVEY RESULTS, INCORPORATED INTO THE BUDGET BY THE CEO, CFO, AND CHRO, AND SUBMITIED FOR BOARD APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, THE HOSPITAL WIDELY DISTRIBUTES AN ANNUAL REPORT TO THE COMMUNITY. PLEASE CONTACT THE ADMINISTRATIVE OFFICE FOR FURTHER DETAILS. SEE FORM 990, PART VI, LINE 20. PART VII, LINE 1 BOARD MEMBER AND OFFICER JOE THORE WORKED AN AVERAGE OF 5 HOURS PER WEEK FOR ASHE MEMORIAL FOUNDATION, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -170,125. FORM 990, PART XII, LINE 2C: NO CHANGES FOR APPROVING AUDITED FINANCIAL STATEMENTS OR SELECTION OF INDEPENDENT ACCOUNTANTS HAVE OCCURRED FROM THE PRIOR YEAR. AMH ASHE WOMEN'S CENTER LLC 200 HOSPITAL AVENUE JEFFERSON NC 28640 451482188 PHYSICIANS PRACTICE NC 244803 142476 ASHE MEMORIAL HOSPITAL ASHE MEMORIAL HOSPITAL FOUNDATION INC 200 HOSPITAL AVE JEFFERSON NC 28640 582078244 FUNDRAISING NC 501(C)(3) 11A ASHE MEMORIAL HOSPITAL 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 ASHE MEMORIAL HOSPITAL FOUNDATION C 373283 INVOICES