2013-11-22T08:21:56-06:00 2012-12-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2012-01-01 344429514 VAN WERT COUNTY HOSPITAL ASSOCIATION VANW 4192388609 1250 SOUTH WASHINGTON STREET VAN WERT OH 45891 MICHAEL T HOLLIDAY 4192388609 2013-11-21 1 NANCY KIRCHNER P00386751 6148852583 2013-11-21 2012 2016-02-25 16:41:14Z X MICHAEL T HOLLIDAY 1250 SOUTH WASHINGTON STREET VAN WERT OH 45891 47656191 0 X WWW.VANWERTHOSPITAL.ORG X 1905 OH PROVIDE A CONTINUUM OF HEALTH CARE SERVICES IN INPATIENT AND AMBULATORY SETTINGS AND MAINTAIN OR EXTEND ALL NECESSARY ELEMENTS OF CARE TO ADDRESS THE NEEDS OF EVERY PATIENT IN A COMPASSIONATE MANNER. 14 12 365 13 0 0 387834 453985 46366564 43609288 1760772 1672422 699481 1240608 49214651 46976303 0 0 0 0 20506342 18651151 0 0 1934 25082666 24588481 45589008 43239632 3625643 3736671 73153577 79593368 13511844 12397760 59641733 67195608 X VAN WERT COUNTY HOSPITAL WILL MEET THE COMMUNITY HEALTH CARE NEEDS BY CONTINUALLY ENDEAVORING TO IMPROVE THE QUALITY OF PATIENT CARE WE PROVIDE WITHIN OUR RESOURCE CAPABILITIES. PROGRAMS AND SERVICES SPONSORED BY THE VAN WERT COUNTY HOSPITAL WILL SERVE AS AN ACCESS POINT TO HEALTH CARE WITHIN OUR COMMUNITY. WE ACCEPT RESPONSIBILITY FOR PROVIDING COMMUNITY LEADERSHIP. VAN WERT COUNTY HOSPITAL ASSURES THAT HEALTH CARE SERVICES PROVIDED ARE AVAILABLE TO ALL MEMBERS OF THE COMMUNITIES WE SERVE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, OR ABILITY TO PAY, WHILE AT THE SAME TIME RESPECTING BOTH THE RIGHTS AND RESPONSIBILITIES OF OUR PATIENTS. 0 0 7348947 10492912 INPATIENT CARE SERVICES 22036695 26122120 OUTPATIENT CARE SERVICES 4300635 7358756 EMERGENCY PATIENT CARE SERVICES 33686277 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 75 0 1 365 1 0 0 0 0 0 0 0 0 0 0 X 14 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X MICHAEL HOLLIDAY 4192388609 1250 SOUTH WASHINGTON STREET VAN WERT OH 45891 JON BAGLEY 2.00 X X 0 0 0 BARB KOHNEN 2.00 X X 0 0 0 GEORGE BROOKS 2.00 X 0 0 0 ANDY CZAJKOWSKI 2.00 X 0 0 0 DR ERIC JELINGER 2.00 X 0 0 0 DR JOEL KNERR 2.00 X 0 0 0 GARY ADAMS 2.00 X 0 0 0 AARON MECHLING 2.00 X 0 0 0 JON RHOADES 2.00 X 0 0 0 GARY CLAY 2.00 X X 0 0 0 DR BASHAR HAMDI 2.00 X 0 0 0 TIM JURCZYK 2.00 X 0 0 0 MARK MINICK 40.00 X X 555531 0 225473 THOMAS CONTE MD 40.00 X 342069 0 20332 MICHAEL HOLLIDAY 40.00 X 198534 0 8155 PATRICK BRUNO MD 40.00 X 155503 0 19878 THOMAS LAUTZENHEISER MD 40.00 X 162369 0 9153 JOCELYN WRAY MD 40.00 X 177469 0 22101 SCOTT JARVIS MD 40.00 X 239102 0 22306 DOUGLAS MOORE MD 40.00 X 213584 0 22302 PAM BAKER 40.00 X 209843 0 6803 2254004 0 356503 17 0 1 0 THERAPY SOLUTIONS 120 W MAIN STREET VAN WERT OH 45891 PHYSICAL THERAPY SERVICES 1416102 NEW VISION MEDICAL LABORATORY 750 WEST HIGH STREET LIMA OH 45801 LABORATORY SERVICES 1320000 CLINICAL COLLEAGUES 613 TATEM AVE COLLINGSWOOD NJ 08108 ANESTHESIA PROFESSIONAL SERVICES 1028032 PHOENIX PHYSICIANS 3114 CROADSDAILE DRIVE SUITE 200 DURHAM NC 27705 ER PHYSICIAN SERVICES 702224 SIEMENS MEDICAL SOLUTIONS USA 51 VALLEY STREAM PARKWAY MALVERN PA 19355 INFORMATION SYSTEMS 645256 18 50 100000 353935 453985 PATIENT SERVICE REVENUE 900099 43609288 43609288 43609288 2049577 2049577 902391 289838 612553 612553 612553 377155 -377155 -377155 -377155 25594 12895 12699 12699 MISCELLANEOUS INCOME 900099 239659 239659 CAFETERIA/VENDING 900099 195186 195186 WELLNESS INCOME 900099 133841 133841 46670 46670 615356 46976303 43982788 0 2539530 X 2617857 2617857 11472385 8719013 2753372 452336 343775 108561 3122842 2373360 749482 985731 749156 236575 704672 704672 44579 6687 37892 76601 76601 7633772 6604039 1029567 166 295201 259777 35424 739230 561815 177415 739157 502627 236530 2095974 1718699 377275 176796 53039 121989 1768 301319 256121 45198 2392181 1818058 574123 677303 636665 40638 MEDICAL SUPPLIES 4655004 4655004 BAD DEBT EXPENSE 2258391 2258391 MISCELLANEOUS 1130629 859278 271351 COLLECTIONS 411126 411126 256546 194975 61571 43239632 33686277 9551421 1934 876695 1688 336694 806884 585949 286336 5269409 4478829 695007 655861 555395 509920 58537366 39707538 19958500 18829828 40423669 49701593 4452259 4322429 73153577 79593368 4503758 4697927 6269804 5494995 1740020 1347699 998262 857139 13511844 12397760 X 55510039 63303702 817424 491251 3314270 3400655 59641733 67195608 73153577 79593368 X 3736671 3804309 12895 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3006 3006 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION IS USED FOR POLITICAL PURPOSES. 6717856 86376 1031004 172628 33806 7628802 6894036 690 55154 205252 26772 6717856 6496893 29533 612733 217775 27348 6894036 5715171 2535 1004939 202203 23549 6496893 5998772 63420 -111884 207220 27917 5715171 0.55000 0.45000 0 0 943059 943059 28474778 16735086 11739692 29054262 22972452 6081810 65267 65267 18829828 DEBT ISSUANCE COST, NET 26950 INVESTMENT IN JOINT VENTURES 419913 OTHER ASSETS 269996 ASSETS WHOSE USE IS LIMITED 3605570 4322429 THIRD PARTY SETTLEMENTS 679136 INTEREST RATE SWAP 123998 ESTIMATED LIABILITY CLAIMS 54005 857139 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INVESTMENT INCOME GENERATED BY THE ENDOWMENT FUNDS DISTRIBUTED TO THE HOSPITAL IS ABLE TO BE USED FOR GENERAL OPERATING AND CAPITAL EQUIPMENT NEEDS. SCHEDULE D, PART X, LINE 2 - ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THESE ENTITIES AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2012 AND 2011, THERE ARE NO UNCERTAIN TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. VAN WERT COMMUNITY HOSPITAL GOLF OU 25594 25594 2096 4091 6708 25594 25594 2096 4091 6708 12895 12699 1 1 1 X 1 X 1 1 0 1 1 852612 852612 0.02080 5069677 2389770 2679907 0.06540 5922289 2389770 3532519 0.08620 214656 6194 208462 0.00510 9019 9019 0.00020 537 537 0.00000 16019 16019 0.00040 240231 6194 234037 0.00570 6162520 2395964 3766556 0.09190 0 1374394 27488 8902460 9832500 -930040 X 1 1 1 VAN WERT MEDICAL SERVICES MEDICAL PROFESSIONAL SERVICES 1.00000 2 SARAH JANE LIVING CENTER LONG TERM ALZHEIMER'S CARE 0.50000 3 HOME HEALTH CARE SOLUTIONS HOME HEALTHCARE SERVICES 0.50000 4 THERAPY SOLUTIONS PHYSICAL THERAPY SOLUTIONS 0.50000 5 COMMUNITY CARE SYSTEMS MANAGED CARE CONTRACTING 0.50000 0.50000 6 DELPHOS REAL ESTATE LLC REAL ESTATE 0.50000 7 CONVOY HEALTH FACILITIES LLC HEALTH FACILITY 0.50000 8 WEST CENTRAL OHIO HOSPITAL CONSORTIUM LTD HEALTHCARE FACILITIES 0.33330 9 NEW VISION MEDICAL LABORATORIES LLC MEDICAL LABORATORIES 0.20000 1 1 VAN WERT COUNTY HOSPITAL

1250 WASHINGTON STREET VAN WERT OH 45891

X X X THE VAN WERT COUNTY HOSPITAL ASSOCIATION 1 1 1 100.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 2 SARAH JANE LIVING CENTER

328 W 2ND ST DELPHOS OH 45833

LONG TERM ALZHEIMERS CARE VANCREST OF CONVOY

510 TULLY DR CONVOY OH 45832

LONG TERM NURSING CARE PART I, LINE 3C: THE ORGANIZATION USED THE FPG TO DETERMINE ELIGIBILITY FOR FREE AND DISCOUNTED CARE. PART I, LINE 7: THE ORGANIZATION REPORTS BAD DEBTS AS AN OPERATING EXPENSE. THE COSTING METHODOLOGY USED IN REPORTING BAD DEBT DATA IS A COST TO CHARGE RATIO METHODOLOGY. THE ORGANIZATION DOES NOT CLAIM BAD DEBT EXPENSE AS A COMMUNITY BENEFIT. PART I, L7 COL(F): THE ASSOCIATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE ASSOCIATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY, SUCH AMOUNTS ARE NOT REPORTED AS REVENUE. BAD DEBTS ARE SHOWN AS AN EXPENSE VALUED AS REVENUE NOT RECEIVED AND WRITTEN OFF AS REVENUE. MANAGEMENT ESTIMATES AN ALLOWANCE FOR DOUTFUL ACCOUNTS BASED UPON FACTORS UNIQUE TO THE ASSOCIATION'S OPERATIONS. PART II: THE HOSPITAL ENGAGES IN A NUMBER OF HEALTH COALITION INITIATIVES TO IMPROVE HEALTH STATUS OF OUR POPULATION. THE HOSPITAL PROVIDED A STARTUP GRANT & ONGOING SUPPORT FOR THE FAMILY HEALTH CARE OF NORTHWEST OHIO, A FQHC CURRENTLY WITH LOOK-ALIKE STATUS. FAMILY HEALTH CARE OF NORTHWEST OHIO IS CURRENTLY SERVING RESIDENTS OF VAN WERT, PAULDING & MERCER COUNTIES. THROUGH THE HOSPITAL'S HELP OF PROVIDING PRIMARY CARE PHYSICIANS AND FUNDING, THIS CLINIC SERVES AS A SAFETY NET PROVIDER TO CITIZENS THAT CURRENTLY HAD NO PRIMARY CARE PHYSICIAN OR ACCESS TO PRIMARY CARE SERVICES. IN 2009, THE HOSPITAL UNDERTOOK AN EXPANSION OF OUR EMERGENCY SERVICES DEPARTMENT, BECAUSE OF INCREASING VISITS DUE TO ECONOMIC, BEHAVIORAL, AND AGING POPULATION THE HOSPITAL EXPERIENCED INCREASING VOLUMES. IN PARTNERSHIP WITH OUR COMMUNITY THROUGH A CAPITAL RAISING CAMPAIGN CONSTRUCTION IS UNDERWAY. THIS STATE-OF THE-ART FACILITY WILL BETTER SERVE OUR POPULATION WITH EXPANDED TREATMENT AREAS (12,000 SQ. FT.) AND NEW TECHNOLOGY. THIS EXPANSION HAS ALSO PROVIDED ENHANCED OUR DISASTER RESPONSE CAPABILITIES. THE SIZE OF THE PROJECT ALSO INCLUDES MANY ECONOMIC BENEFITS FOR OUR COMMUNITY BEYOND THE CONSTRUCTION PHASE. THE HOSPITAL ALSO PARTICIPATES IN INITIATIVES WITH OTHER PROVIDERS AND AFFILIATES IN PROVISION OF SERVICES AND/OR DONATIONS. THE PROVISIONS OF LOW COST HEALTH SCREENING SERVICES IN COLLABORATION WITH OTHER ORGANIZATIONS HELP US IDENTIFY CONDITIONS ON A PROACTIVE BASIS TO BETTER IMPROVE OUR CITIZEN'S HEALTH OR MANAGEMENT OF CHRONIC DISEASES. THE CO-ORDINATION OF CARE THROUGH OUR HOME HEALTH REHABILITATIVE AND LONG TERM CARE PROVIDERS SERVE TO BETTER MEET THE NEEDS OF OUR PATIENTS AND POPULATION. OUR REGIONAL LABORATORY INITIATIVE HAS SHORTENED TURNAROUND TIME FOR TESTS AND HAS LOWERED COST TO OUR PATIENTS. THE HOSPITAL ALSO PARTICIPATES IN ECONOMIC DEVELOPMENT EFFORTS THROUGH ITS MEMBERSHIP IN THE CHAMBER OF COMMERCE AND OTHER ORGANIZATIONS. PART III, LINE 4: THE ORGANIZATION REPORTS BAD DEBTS AS AN OPERATING EXPENSE. THE COSTING METHODOLOGY USED IN REPORTING BAD DEBT DATA IS A COST TO CHARGE RATIO METHODOLOGY. THE ORGANIZATION DOES NOT CLIAM BAD DEBT EXPENSE AS A COMMUNITY BENEFIT. PART III, LINE 8: THE ORGANIZATION DOES NOT CONSIDER THE MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. PART III, LINE 9B: FOLLOWING THE GUIDELINES AND PROCESSES AS INDICATED IN QUESTION 3, PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE, THE ORGANIZATION APPROPRIATELY IDENTIFIES ACCOUNTS AS TO THE TYPE OF ASSISTANCE QUALIFIED FOR. THE AMOUNTS ELIGIBLE FOR ASSISTANCE ARE WRITTEN OFF TO THE APPROPRIATE PROGRAM AND COLLECTION ACTIVITY CEASES IN REGARD TO THOSE AMOUNTS. THE GOAL OF THE ORGANIZATION'S POLICIES IS TO INDENTIY ACCOUNTS ELIGIBLE FOR ASSISTANCE AND BRING THE ACCOUNT TO AN APPROPRIATE CONCLUSION AS EARLY IN THE BILLING CYCLE AS POSSIBLE. PART VI, LINE 2: THE ORGANIZATION USES A VARIETY OF METHODS TO ASSESS HEALTH CARE NEEDS. DATA PROVIDED BY THE STATE OF OHIO IS USED TO DETERMINE EPIDEMIOLOGIES RELATED TO CHRONIC CONDITIONS AND CANCER REGISTRIES PROVIDING PREVALENCE. INTERNAL DATA IS ALSO USED AS WELL AS INPUT FROM OTHER PROVIDERS. THE HOSPITAL ALSO USES PATIENT ORIGIN DATA PROVIDED BY THE OHIO HOSPITAL ASSOCIATION TO DETERMINE CURRENT TREATMENT PATTERNS AND DIAGNOSIS FOR CURRENT RESIDENTS BEING TREATED IN VAN WERT COUNTY HOSPITAL AND OTHER SURROUNDING PROVIDERS. THE HOSPITAL ALSO SPONSORS A NUMBER OF HEALTH FAIRS/ASSESSMENTS TO BOTH ADULT AND PEDIATRIC POPULATIONS OF VAN WERT THAT IS ALSO EXAMINED FOR FREQUENCY AND NEEDS. A NUMBER OF STAFF AS WELL AS BOARD OF TRUSTEES MEMBERS ALSO SERVED ON COMMUNITY HEALTH PROVIDER BOARDS AND PROVIDE INPUT TO THE PLANNING PROCESS.THE HOSPITAL IS ALSO SUBSCRIBED TO A NUMBER OF BENCHMARKING ORGANIZATIONS THAT PROVIDE BEST OF INDUSTRY APPLICATIONS TO ASSESS METHODOLOGIES FOR TREATING OUR RESIDENTS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE BEGINS AT THE PATIENT ACCESS TO CARE AREAS. INFORMATIONAL SIGNAGE IS POSTED IN ALL PATIENT ACCESS AREAS IDENTIFYING FINANCIAL ASSISTANCE PROGRAMS AND INSTRUCTIONS OF HOW TO SEEK OUT THESE PROGRAMS. SIMILAR INFORMATION IS ALSO FOUND IN PATIENT INFORMATIONAL BROCHURES PROVIDED TO PATIENTS PRIOR TO THE RENDERING OF CARE BASED UPON THE TYPE OF CARE BEING PROVIDED. ALSO, AVAILABLE AT ALL PATIENT ACCESS POINTS ARE THE PATIENT FINANCIAL ASSISTANCE BROCHURE.PATIENT REGISTRATION STAFF AT ALL PATIENT ACCESS POINTS ARE TRAINED IN THE PATIENT FINANCIAL ASSISTANCE PROGRAMS AVAILABLE AT THE HOSPITAL. THEY BECOME A VALUABLE RESOURCE TO PATIENTS DIRECTING THEM TO THE PROGRAMS THEY MAY QUALIFY FOR AND THE PROCESS WITH WHICH TO SEEK THE APPROPRIATE ASSISTANCE.THE HOSPITAL UTILIZES THE HOSPITAL WEBSITE AS AN ON-LINE AND TECHNOLOGICALLY CURRENT SOURCE OF FINANCIAL ASSISTANCE INFORMATION FOR PATIENTS THAT PREFER FINDING EDUCATIONAL INFORMATION IN THIS FORMAT. FINANCIAL ASSISTANCE PROGRAMS, POLICIES, ELIGIBILITY CRITERIA, AND ON-LINE APPLICATIONS FOR THE VARIOUS PROGRAMS ARE AVAILABLE.PATIENT BILLING STATEMENTS PROVIDE ANOTHER AVENUE FOR EDUCATING PATIENTS AS TO FINANCIAL ASSISTANCE PROGRAMS AVAILABLE AND HOW TO CONTACT THE HOSPITAL TO DETERMINE ELIGIBILITY. THIS INFORMATION IS LOCATED ON THE BACK OF EACH BILLING STATEMENT RECEIVED BY THE PATIENT.THE EXISTENCE OF A FINANCIAL COUNSELOR IN THE PATIENT ACCOUNTING FUNCTION IS ANOTHER MECHANISM UTILIZED IN EDUCATING PATIENTS REGARDING FINANCIAL ASSISTANCE AVAILABLE FOR HOSPITAL SERVICES. ALL UNINSURED OR SELF-PAY POTENTIAL ACCOUNTS ARE IDENTIFIED TO THE FINANCIAL COUNSELOR UPON PATIENT REGISTRATION. PATIENTS MAY BE CONTACTED UPON COMPLETION OF SERVICES. ALL PATIENTS THAT WERE NOT CONTACTED UPON COMPLETION OF SERVICES RECEIVE A FINANCIAL ASSISTANCE APPLICATION THROUGH THE MAIL THAT INCLUDES INFORMATION REGARDING ALL FINANCIAL ASSISTANCE PROGRAMS. THE COUNSELOR PROVIDES FOLLOW-UP AND ASSISTANCE TO IDENTIFY THE PATIENT WITH THE APPROPRIATE FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: VAN WERT COUNTY HOSPITAL IS LOCATED IN THE RURAL COUNTY OF VAN WERT, OHIO THAT BOARDERS THE INDIANA STATE LINE ALONG ALLEN COUNTY INDIANA. OUR PRIMARY SERVICE AREA COMPRISES VAN WERT AND SOME PORTIONS OF PAULDING, PUTNAM AND MERCER COUNTIES. OHIO NUMERICALLY THIS BREAKS DOWN TO APPROXIMATELY 50,000 RESIDENTS IN OUR PRIMARY MARKET AREA. THE HOSPITAL IS LOCATED WITHIN THE CITY OF VAN WERT, WHICH POSSESSES A POPULATION OF 10,700. OUR POPULATION IS PREDOMINANTLY WHITE (97.1%) WITH HISPANIC (1.9%) A MIX OF MINORITIES COMPRISE THE REMAINDER. VAN WERT IS RURAL IN NATURE WITH EMPLOYMENT NOT ONLY IN AGRICULTURAL SERVICES BUT ALSO IN THE MANUFACTURING AND SERVICE SECTOR. OUR COUNTY HAS SEEN INCREASED UNEMPLOYMENT DUE TO THE LOSS OF MANUFACTURING JOBS RELATED TO THE AUTO SECTOR. THE UNEMPLOYMENT RATE IN 2009 WAS IN EXCESS OF 13%. THIS SITUATION HAS ALSO INCREASED THE NUMBER OF CITIZENS COVERED UNDER THE MEDICAID PROGRAM AND QUALIFYING FOR THE HOSPITAL'S CHARITY CARE PROGRAM AS WELL AS INCREASING BAD DEBT (IN 2000 4.2% OF THE POPULATION WAS BELOW FPG). LIKE MANY MIDWEST COMMUNITIES THE REGION IS EXPERIENCING AGING POPULATIONS OF 18.3% OVER 65 AND 27.2% 45-64 ACCORDING TO THE 2000 CENSUS. THE HOSPITAL ALSO HAS FACILITIES IN THE COMMUNITIES OF CONVOY AND DELPHOS PROVIDING LONG TERM CARE TO THESE GROUPS. BEHAVIORAL RISK FACTORS INCLUDE (2002 OHIO BEHAVIORAL RISK SURVEY) SMOKING (19.3%), ALCOHOL ABUSE (14%) AND OBESITY AT (34.1%) THESE BEHAVIORAL RISK FACTORS INFLUENCE THE INCIDENCE OF CHRONIC DISEASES WE TREAT. PART VI, LINE 5: THE VAN WERT COUNTY HOSPITAL ASSOCIATION BOARD OF TRUSTEES IS COMPRISED OF VOLUNTEERS FROM OUR COMMUNITY. THE MAJORITY OF THESE MEMBERS LIVE AND WORK WITHIN THE COMMUNITY AND ARE INVOLVED WITH OTHER NON-PROFIT AGENCIES. SENIOR LEADERSHIP ALSO LIVES IN THE PRIMARY SERVICE AREA. THIS "SPIRIT" OF COMMUNITY BASED HEALTHCARE RESIDES IN OUR BOARD OF TRUSTEES AND IS FURTHER EVIDENCED BY OUR OPEN MEDICAL STAFF. THE ACCOMMODATION OF SPECIALTY SERVICES NOT CURRENTLY PRESENT IN OUR AREA BEING PROVIDED THROUGH A SPECIALTY CLINIC OF THE HOSPITAL WHICH INCLUDE NEUROLOGY, NEUROSURGERY, IMMUNOLOGY, AND ENT SERVICES. THE HOSPITAL ASSOCIATED PERSONNEL ALSO SIT ON OTHER COMMUNITY BASED GOVERNANCE BOARDS (UNITED WAY, AMERICAN RED CROSS, CHAMBER OF COMMERCE, WRIGHT STATE UNIVERSITY REGIONAL CAMPUS, PUBLIC ACCESS TELEVISION, AMERICAN CANCER SOCIETY & VAN WERT ECONOMIC DEVELOPMENT TO NAME A FEW). THROUGH PHYSICIAN RECRUITMENT WE HAVE BROUGHT IN A NUMBER OF NEW SPECIALTIES INCLUDING OBSTETRICS AND ADDITIONAL LAPAROSCOPIC SURGICAL PROCEDURES. WE ALSO PROVIDE A LOAN FORGIVENESS PROGRAM FOR RESIDENTS INTERESTED IN BECOMING PHYSICIANS AND RETURNING TO OUR AREA. OUR WELLNESS CENTER PROVIDES HEALTH, EDUCATION, AND SOCIAL PROGRAMS FOR TARGETED POPULATIONS. WE HAVE JOINED A REGIONAL STROKE NETWORK AS WELL AS PARTICIPATING IN A NUMBER OF PATIENT AND EDUCATIONAL SUPPORT GROUPS (BETTER BREATHERS, STROKE SUPPORT GROUP, BETTER PARENTING). THE HOSPITAL ALSO PARTICIPATES IN HEALTH PROFESSIONS EDUCATIONAL PROGRAMS. A NUMBER OF OUR PHYSICIANS PROVIDE TRAINING FOR SENIOR MEDICAL STUDENTS THROUGH THE LIMA AREA HEALTH EDUCATION COMMITTEE. A NUMBER OF NURSING EDUCATIONAL PROGRAM USE OUR HOSPITAL TO DO THEIR CLINICAL ROTATIONS. THE HOSPITAL ON AVERAGE SPENDS IN EXCESS OF 1 MILLION DOLLARS IN NEW DIAGNOSTIC TECHNOLOGIES AND OTHER HEALTH RELATED EQUIPMENT TO BETTER DIAGNOSE AND TREAT OUR CLIENTS. X 1 1 X X X X X X 1 1 0 0 0 0 0 0 0 MARK MINICK 420450 0 133870 0 1211 0 216817 0 8656 0 781004 0 0 0 THOMAS CONTE MD 238533 0 102849 0 687 0 15000 0 5332 0 362401 0 0 0 MICHAEL HOLLIDAY 159207 0 38869 0 458 0 4755 0 3400 0 206689 0 0 0 PATRICK BRUNO MD 154500 0 781 0 222 0 15000 0 4878 0 175381 0 0 0 THOMAS LAUTZENHEISER MD 161903 0 0 0 466 0 5739 0 3414 0 171522 0 0 0 JOCELYN WRAY MD 132320 0 44768 0 381 0 15000 0 7101 0 199570 0 0 0 SCOTT JARVIS MD 170384 0 68227 0 491 0 15000 0 7306 0 261408 0 0 0 DOUGLAS MOORE MD 169635 0 43461 0 488 0 15000 0 7302 0 235886 0 0 0 PAM BAKER 194476 0 14807 0 560 0 3213 0 3590 0 216646 0 0 0 PART I, LINE 1A CLUB DUES ARE PROVIDED FOR MARK MINICK AND MIKE HOLLIDAY IN THE AMOUNT OF $1,364 EACH AND IS TAXABLE TO THE INDIVIDUALS. PART I, LINES 4A-B MARK MINICK - SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN - ACTUARIAL DETERMINED CATCH UP ANNUAL FUNDING FOR PLAN BENEFIT UNDER TERMS OF INCENTIVE AGREEMENT PAM BAKER - SEVERANCE PAYMENT OF $63,360 SUPPLEMENTAL INFORMATION PART III SERP - MARK J MINICK PARTICIPATES IN THE VAN WERT COUNTY HOSPITAL ASSOCIATION'S DEFERRED COMPENSATION PLAN. THE AMOUNT OF $216,817 REPORTED ON SCHEDULE J OF THE FORM 990 REPRESENTS THE ANNUAL INCREASE OR DECREASE IN ACTUARIAL VALUE OF THE BENEFIT PLAN AND A PORTION OF THIS AMOUNT AUGMENTS AMOUNTS PREVIOUSLY UNDERFUNDED. A COUNTY OF VAN WERT OHIO 346401507 2009-10-29 10755255 FINANCE ACQUISITION, CONSTRUCTION, & EQUIPPING OF HOSPITAL FACILITIES 0 0 0 A 10755255 57604 10697651 2010 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON, AGE 18 OR OLDER AND RESIDING IN VAN WERT COUNTY HOSPITAL'S GEOGRAPHIC SERVICE AREA, WHO SHALL HAVE CONTRIBUTED THE SUM OF ONE DOLLAR OR MORE TO THE ASSOCIATION DURING THE CALENDAR YEAR, SHALL BE A MEMBER. A CONTRBUTION OF TWENTY-FIVE DOLLARS AT ANY TIME SHALL CONSTITUTE A LIFE MEMBERSHIP. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF TRUSTEES SHALL BE ELECTED BY THE MEMBERS OF THE ASSOCIATION AT THE REGULAR ANNUAL MEETING. ONE SHALL BE APPOINTED BY THE VAN WERT COUNTY BOARD OF COMMISSIONERS. FORM 990, PART VI, SECTION A, LINE 7B SUBJECT TO THE ARTICLES OF INCORPORATION AND THIS CODE OF REGULATIONS, EACH MEMBER OF THE ASSOCIATION IN GOOD STANDING SHALL BE QUALIFIED TO VOTE ON ANY ISSUES THAT MAY PROPERLY COME BEFORE ANY MEETING OF THE MEMBERS OF THE ASSOCIATION. FORM 990, PART VI, SECTION B, LINE 11 THE PROCESS OF REVIEWING THE FORM 990 ENTAILS A DETAILED REVIEW BY THE ORGANIZATION'S ACCOUNTING DEPARTMENT. THE AUDIT COMMITTEE REVIEWS AND APPROVES THE 990. IT IS THEN PRESENTED TO THE FULL BOARD DURING A REGULARLY SCHEDULED BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED BY THE CHAIRPERSON OF THE BOARD OF TRUSTEES AND THE PRESIDENT & CEO. THE SCOPE OF THIS POLICY INCLUDES ALL STAFF AND BOARD OF TRUSTEES MEMBERS. A CONFLICT OF INTEREST QUESTIONNAIRE IS COMPLETED ON AN ANNUAL BASIS AND REVIEWED BY THE EXECUTIVE COMMITTEE. ANY ISSUES THAT ARISE ARE ADDRESSED WITH THE INDIVIDUAL AT THAT POINT. ANY ISSUES THAT ARISE THOUGHOUT THE YEAR ARE DEALT WITH AS NECESSARY. THIS MAY INVOLVE DECLARING THE CONFLICT OF INTEREST AND ABSTAINING FROM DISCUSSION OR A VOTE ON SPECIFIC TOPICS. THIS COULD ALSO TAKE THE FORM OF RECUSING ONESELF FROM PART OR A WHOLE MEETING AS NECESSARY AND REQUIRED DEPENDING UPON THE TOPIC FOR DISCUSION AND/OR ACTION. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE CONTRACTS WITH AN OUTSIDE, INDEPENDENT FIRM TO PROVIDE A COMPENSATION STUDY AND EVALUATION. THE COMMITTEE THEN USES THE RESULTS OF THE STUDY IN CONSULTATION WITH THE COMPENSATION FIRM AND THEN COMPENSATION PHILOSOPHY POLICY TO MAKE COMPENSATION DECISIONS. THE LAST COMPENSATION REVIEW WAS PERFORMED IN JULY, 2012. FORM 990, PART VI, SECTION C, LINE 19 THERE IS AN ANNUAL REPORT PREPARED THAT INCLUDES A STATEMENT OF OPERATIONS. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED HEALTH CARE SERVICES: PROGRAM SERVICE EXPENSES 3,260,326. MANAGEMENT AND GENERAL EXPENSES 1,029,567. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,289,893. OTHER: PROGRAM SERVICE EXPENSES 3,343,713. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 166. TOTAL EXPENSES 3,343,879. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN RESTRICTED NET ASSETS 12,895. 990T IN THE PAST THE ORGANIZATION HAS FILED A 990-T, HOWEVER, THIS ORGANIZATION IS NO LONGER REQUIRED TO FILE THAT FORM AS IT HAS NO UNRELATED BUSINESS INCOME TO REPORT. AMENDED RETURN THE RETURN HAS BEEN AMENDED IN THE FOLLOWING AREAS: 1. CHANGE IN BOARD OF DIRECTORS INFORMATION-DR. JOEL KNERR IS NO LONGER AN OFFICER IN 2012 2. SCHEDULE H PART VI, LINE 5 - WORDING CHANGES 3. SCHEDULE O PART VI, SECTION A, LINE 7A - WORDING CHANGES VAN WERT MEDICAL SERVICES 140 FOX RD VAN WERT OH 45891 202812541 MEDICAL PROFESSIONAL SERVICES OH -1103918 555973 VAN WERT COUNTY HOSPITAL ASSOCIATION SARAH JANE LIVING CENTER 1250 S WASHINGTON ST VAN WERT OH 45891 311684009 LONG TERM ALZHEIMERS CARE OH N/A RELATED -230805 529994 0 0 0.50000 HOME HEALTH CARE SOLUTIONS 1250 S WASHINGTON ST VAN WERT OH 45891 200330544 HOME HEALTH CARE SOLUTIONS OH N/A RELATED 50991 133426 0 0 0.50000 THERAPY SOLUTIONS 1250 S WASHINGTON ST VAN WERT OH 45891 201417403 PHYSICAL THERAPY SERVICES OH N/A RELATED -1560 261277 0 0 0.50000 COMMUNITY CARE SYSTEMS INC 1250 S WASHINGTON ST VAN WERT OH 45891 341783212 HEALTHCARE MANAGEMENT SERVICES OH N/A C -6781 6766 0.50000 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 SARAH JANE LIVING CENTER B 100000 CASH VAN WERT MEDICAL SERVICES P 1001022 CASH