2013-02-13T07:58:07-06:00 2012-09-30 020476956 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2011-10-01 020276210 UPPER CONNECTICUT VALLEY HOSPITAL UPPE 6032374971 CORLISS LANE COLEBROOK NH 03576 JAMES TIBBETTS 6032374971 2013-02-04 1 W JAY SIMMS P00435321 6036530044 2013-02-04 2011 2016-02-25 16:41:14Z WINSTON YOUNG CORLISS LANE COLEBROOK NH 03576 14880454 0 X WWW.DARTMOUTH-HITCHCOCK.ORG/UCVH X 1969 NH TO PROVIDE HEALTH CARE SERVICES. 9 9 169 10 0 0 94567 54407 15281183 14031660 388046 344058 408329 421752 16172125 14851877 0 85000 0 0 7449464 7918126 0 0 612 8184968 7271882 15634432 15275008 537693 -423131 16103171 17882185 4352765 4758783 11750406 13123402 UPPER CONNECTIBUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURUAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 0 0 12213419 85000 14418065 UPPER CONNECTICUT VALLEY HOSPTIAL PROVIDED HOSPITAL CARE AND INPATIENTS AND OUTPATIENTS SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2012 WAS $701,937. 12213419 1 0 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 38 0 1 169 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X THE ORGANIZATION 6032374971 UCVH CORLISS LANE COLEBROOK NH 03576 E HARLAN CONNARY 1.00 X 0 0 0 SHIRLEY POWELL 1.00 X 0 0 0 GREG E PLACY 1.00 X 0 0 0 JAMES TIBBETTS 1.00 X 0 0 0 WINSTON YOUNG 1.00 X 0 0 0 THE REV CRAIG CHENEY 1.00 X 0 0 0 PALMER LEWIS 1.00 X 0 0 0 BRUCE BEAN 1.00 X 0 0 0 ODETTE CRAWFORD 1.00 X 0 0 0 CHARLES WHITE 40.00 X 110098 0 18036 ROBERT GOOCH 40.00 X 142593 0 3493 FERIAL LADAK MD 29.00 X 185760 0 5585 ROBERT SOUCY MD 47.00 X 201986 0 23945 JOSEPH KIERNAN MD 31.00 X 180335 0 25069 EDWARD LAVERTY 53.00 X 165661 0 23941 986433 0 100069 12 0 1 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 REHAB PERSONNEL & SERVICES 522794 VISTA STAFFING SOLUTIONS FILE 50834 LOS ANGELES CA 50834 PROVIDES LOCUMS PHYSICIANS FOR HOSPITALI 423758 HELMS & COMPANY INC 1 PILLSBURY STREET CONCORD NH 03301 TEMPORARY CEO AND INSURANCE CONTRACT MAN 178344 3 46535 7872 54407 NET PATIENT REVENUE 621990 14031660 14031660 14031660 45713 45713 326922 0 28577 326922 -28577 298345 298345 OTHER INCOME 900099 194577 194577 SCHOOL NURSE PROGRAM 900099 158560 158560 CAFETERIA 900099 35347 35347 33268 33268 421752 14851877 14418065 0 379405 85000 85000 148004 148004 6259717 5412927 846790 37343 31635 5708 1090728 939260 151468 382334 323888 58446 75240 75240 69000 69000 32027 27287 4740 1173550 1110852 62698 204931 141395 63536 639244 549595 89649 115605 73082 42523 11166 11166 649083 649083 85835 85835 PURCHASED SERVICES 1736989 1082205 654784 PROVISION FOR BAD DEBT 1126703 1126703 MEDICAID ENHANCEMENT TA 593177 593177 REPAIRS AND MAINTENANCE 227929 220550 7379 531403 439957 90834 612 15275008 12213419 3060977 612 565903 652544 1713405 3077268 1517504 1455924 279493 288789 204376 121176 10403082 6303636 4522692 4099446 5916947 7021043 808417 704068 574434 461927 16103171 17882185 1303529 1213582 24790 15476 1767718 1561549 1256728 1968176 4352765 4758783 X 10595930 12521395 1085291 532822 69185 69185 11750406 13123402 16103171 17882185 X -423131 1796127 X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 3525 3525 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: UPPER CONNECTICUT VALLEY HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF UCVH AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT DIRECLTY PERFORM ANY LOBBYING ACTIVITIES. 129746 31310 161056 127616 2130 129746 112258 15358 127616 111704 554 112258 0.45370 0.54630 0 0 9700 9700 4168991 1996649 2172342 231555 79643 151912 5980886 4227344 1753542 11950 11950 4099446 DUE TO THIRD PARTY PAYERS 1946914 CAPITAL LEASE 21262 1968176 14851877 15275008 -423131 669424 1126703 1796127 1372996 14950660 669424 669424 14281236 570641 570641 14851877 14147693 0 14147693 1127315 1127315 15275008 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INVESTMENTS ARE TO BE HELD IN PERPETUITY. THE INCOME FROM THE INVESTMENTS IS EXPENDABLE TO SUPPORT THE HOSPITAL'S HEALTH CARE SERVICES. PART XI, LINE 8 - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT 1,126,703. PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 612. NET ASSETS RELEASED FOR CAP EXPENDITURES 570,029. PART XIII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 612. PROVISION FOR BAD DEBTS 1,126,703. 1 1 1 X 1 X 1 1 0 1 1 680390 227882 452508 0.03200 1872399 1758848 113551 0.00800 2552789 1986730 566059 0.04000 492279 158559 333720 0.02360 136896 136896 0.00970 4315556 2735788 1579768 0.11170 85343 85343 0.00600 5030074 2894347 2135727 0.15100 7582863 4881077 2701786 0.19100 1880 1880 0.00010 2748 2748 0.00020 3063 3063 0.00020 62742 62742 0.00440 6556 6556 0.00050 7242 7242 0.00050 84231 84231 0.00590 1 620641 19861 7776384 7699390 76994 X 1 1 1 1 UPPER CONNECTICUT VALLEY HOSPITAL

181 CORLISS LANE COLEBROOK NH 03576

X X X X UPPER CONNECTICUT VALLEY HOSPITAL 1 1 X X X X X X X X X 10 1 0 1 X X X X X X X 1 1 1 150.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X 1 0 1 X 0 0 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 $ 1126703. PART II: THE COMMUNITY BUILDING ACTIVITIES UNDERTAKEN BY UCVH CONSIST OF SUPPORTING LOCAL GOVERNMENT AND OTHER HEALTH CARE PROVIDERS, COORDINATION OF DISASTER DRILLS, EMERGENCY PREPAREDNESS AND ALSO SUPPORT OF OTHER LOCAL ORGANIZATIONS WITHIN THE COMMUNITY. IN ADDITION, IN AN EFFORT TO PROVIDE THE NECESSARY HEALTH CARE SERVICES FOR THE POPULATION WITHIN A REASONABLE DRIVING DISTANCE, UCVH HAS ENTERED INTO A COLLABORATION WITH THE OTHER TWO COOS COUNTY HOSPITALS TO PROVIDE NECESSARY SPECIALTY SERVICES FOR THE UCVH SERVICE AREA. PART III, LINE 4: COST TO CHARGE RATIO - OVERALL EXPENSES, NOT INCLUDING BAD DEBT, DIVIDED BY GROSS PATIENT REVENUE. PART III, LINE 8: ALLOWABLE COSTS COME FROM THE FILED COST REPORT. UCVH USES CCR TO DETERMINE COST, REVENUE RECEIVED IS NET PATIENT REVENUE, DSH FUNDS ARE INCLUDED AS PAYMENTS. PART III, LINE 9B: IF KNOWN TO QUALIFY FOR CHARITY OR FINANCIAL ASSISTANCE, THEY ARE GIVEN THE ASSISTANCE NEEDED. PART VI, LINE 2: UCVH COMPLETES A COMMUNITY NEEDS ASSESMENT ON A PERIODIC BASIS. THE 2010 COMMUNITY NEEDS ASSESMENT CONDUCTED FOCUS GROUPS TO SOLICIT FEEDBACK FROM KEY STAKEHOLDERS AND ANALYZED TRENDS IN REGARD TO POPULATION HEALTH AND RISK FACTORS FOR COOS COUNTY. THE INFORMATION IS USED AS PART OF THE UCVH STRATEGIC PLANNING PROCESS. IN 2013, UCVH WILL BE COLLABORATING WITH INDIAN STREAM HEALTH CENTER (A FEDERALLY QUALIFIED HEALTH CENTER) TO PERFORM A COMMUNITY NEEDS ASSESMENT. PART VI, LINE 3: UCVH HAS A FULL TIME PATIENT FINANCIAL COUNSELOR WHO IS RESPONSIBLE FOR WORKING WITH PATIENTS AND ANY WHO MAY BE BILLED FOR THEIR CARE TO DETERMINE THEIR ELIGIBILITY, ON A CASE BY CASE BASIS, FOR ANY GOVERNMENT PROGRAMS, SUCH AS MEDICAID OR THE UCVH FINANCIAL ASSISTANCE PROGRAM. ALL STAFF AT UCVH, PARTICULARLY REGISTRATION STAFF WHO WILL BE THE FIRST ONES TO NOTICE IF A PATIENT DOES NOT HAVE INSURANCE, ARE TRAINED TO REFER THE PATIENT TO THE FINANCIAL COUNSELOR. IN ADDITION, BROCHURES ARE AVAILABLE, AS IS CONTACT INFORMATION ON THE WEBSITE. PART VI, LINE 4: UCVH IS THE SMALLEST CRITICAL ACCESS HOSPITAL IN NEW HAMPSHIRE THAT SERVES THE LARGEST GEOGRAPHIC SERVICE AREA (OVER 850 SQUARE MILES) INCLUDING COMMUNITIES IN THE STATES OF NEW HAMPSHIRE, VERMONT, AND MAINE. ACCORDING TO THE NEW HAMPSHIRE STATE HEALTH PROFILE, OUR RESIDENTS ARE THE MOST FRAGILE OF ALL CITIZENS IN NEW HAMPSHIRE AS IT RELATES TO HEALTH OUTCOMES AND ECONOMIC CONDITIONS. UCVH IS DEPENDENT OF PUBLIC FUNDING AND DISPROPORTIONATE SHARE FUNDING TO SUBSIDIZE THE CARE PROVIDED TO THE PATIENTS WE SERVE. REPORTS FILED WITH STATES PART VI, LINE 7 NH 0 45TH PARALLEL EMS 46 RAMSEY ROAD COLEBROOK NH 03576 262005001 501(C)3 35000 FMV AMBULANCE SERVICES INDIAN STREAM HEALTH CENTER INC 2 CORLISS LN RR2 BOX 14 COLEBROOK NH 03576 200999212 501(C)3 50000 FMV MEDICAL SERVICES X X X 0 0 0 0 0 0 0 0 0 FERIAL LADAK MD 185760 0 0 0 0 0 183 0 5402 0 191345 0 0 0 ROBERT SOUCY MD 201986 0 0 0 0 0 4032 0 19913 0 225931 0 0 0 JOSEPH KIERNAN MD 180335 0 0 0 0 0 2800 0 22269 0 205404 0 0 0 EDWARD LAVERTY 165661 0 0 0 0 0 2853 0 21088 0 189602 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PROVIDED TO THE FINANCE COMMITTEE FOR REVIEW AND APPROVAL BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS, AMD KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST DOCUMENT. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL CAO'S COMPENSATION AND BENEFIT PACKAGE IS REVIEWED PERIODICALLY BY COMMUNITY BOARD MEMBERS WHO GOVERN THE NON-PROFIT ORGANZATION AS UNPAID, INDEPENDENT VOLUNTEERS. THE PERIODIC REVIEW INCLUDES COMPARABILITY DATA, AND THE DELIBERATION AND DECISION-MAKING IS SUBSTANTIATED BY WRITTEN MINUTES. HIS COMPENSATION PACKAGE IS REVIEWED BY THE UCVH BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 18 UVCH MAKES ITS 990 AVAILABLE UPON REQUEST AND ON THE GUIDESTAR WEBSITE FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 669,424. PROVISION FOR BAD DEBT 1,126,703. TOTAL TO FORM 990, PART XI, LINE 5: 1,796,127. WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 020222242 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 020280367 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 NORTHERN NH HEALTHCARE COLLABORATIVE LLC 455617105 HEALTHCARE COLLABORATIVE NH RELATED 0 1 0.33330 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 ANDROSCOGGIN VALLEY HOSPITAL L 605611 FMV WEEKS MEDICAL CENTER L 72713 FMV