2013-08-13T13:36:56-05:00 2012-09-30 061533253 SASLOW LUFKIN & BUGGY LLP TEN TOWER LANE AVON CT 06001 990 2011-10-01 060646559 BRISTOL HOSPITAL INC BRIS 8605853000 BREWSTER RD BRISTOL CT 06011 GEORGE W EIGHMY 8605853000 2013-08-13 1 BETH THURZ P00346435 8606789200 2011 2016-02-24 21:20:13Z KURT BARWIS BREWSTER RD BRISTOL CT 06011 148061522 0 X WWW.BRISTOLHOSPITAL.ORG X 1920 CT TO PROVIDE QUALITY HEALTHCARE SERVICES TO THE COMMUNITY. 17 13 1399 300 981636 -576333 1812490 1338407 126737955 131079119 516585 477499 5445575 3914160 134512605 136809185 0 0 0 0 64766097 69542815 0 0 0 67128430 64943488 131894527 134486303 2618078 2322882 103125741 112654038 95110053 102022703 8015688 10631335 X BRISTOL HOSPITAL IS COMMITTED TO PROVIDING THE BEST PATIENT EXPERIENCE IN THE REGION. OUR 134-BED, FULL-SERVICE HEALTH CARE INSTITUTION PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT CARE FOR THE GREATER BRISTOL, CONNECTICUT AREA. 0 0 111143719 133059206 AS A SHORT-TERM ACUTE CARE COMMUNITY HOSPITAL, BRISTOL HOSPITAL PROVIDES A BROAD SPECTRUM OF HEALTHCARE SERVICES TO ANY INDIVIDUAL REGARDLESS OF THE INDIVIDUAL'S ABILITY TO PAY. THE HOSPITAL PROVIDED $3,781,958 IN CHARITY CARE DURING THE OPERATING YEAR. THE HOSPITAL ALSO PROVIDES EDUCATION AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE ACTIVITIES TYPICALLY REACH ABOUT 1,600 INDIVIDUALS PER QUARTER. THESE ACTIVITIES INCLUDE: WELLNESS CENTER - SPECIAL CENTER FOR EDUCATIONAL OUTREACH PROGRAMMING SERVING HUNDREDS OF INDIVIDUALS PER MONTH. - COMMUNITY HEALTH SCREENINGS - ONGOING FREE AND REDUCED PRICE SCREENINGS FOR MAMMOGRAMS, BLOOD PRESSURE, CHOLESTEROL, PROSTATE CANCER, SKIN CANCER AND A FLU CLINIC PROVIDING FREE FLU SHOTS IN THE FALL. - SPEAKERS BUREAU - A COMMUNITY SERVICE WHERE THE HOSPITAL PROVIDES SPEAKERS ON A VARIETY OF TOPICS TO SERVE THE COMMUNITY'S EDUCATIONAL NEEDS. - PERIODIC COMMUNITY SERVICE PROJECTS - THE HOSPITAL HAS SPONSORED TWO MAJOR OUTREACH EFFORTS, ONE TO PROMOTE EARLY DETECTION OF BREAST CANCER AND ONE TARGETED TO PREVENT COLON CANCER. BOTH PROGRAMS HAVE INCREASED THE COMMUNITY'S COMPLIANCE WITH THE RECOMMENDED CANCER SCREENINGS AND HAVE BEEN RECOGNIZED WITH STATE, REGIONAL AND NATIONAL AWARDS. 111143719 1 1 0 1 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 0 0 0 1 91 0 1 1399 1 1 1 0 0 0 0 0 0 0 0 0 X 17 13 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 1 1 X GEORGE EIGHMY 8605853000 BREWSTER ROAD BRISTOL CT 06011 KENNETH BENOIT MD 2.00 X 0 0 0 MARK BLUM 2.00 X X 0 0 0 BALA SHANMUGAM MD 2.00 X 7313 260077 4900 JOHN J LEONE JR 2.00 X X 0 0 0 GLENN HEISER 2.00 X 0 0 0 KURT BARWIS 60.00 X X 807328 0 121318 JOHN LODOVICO JR 2.00 X 0 0 0 MARIE O'BRIEN 2.00 X X 0 0 0 KENNETH RHEE MD 40.00 X 83068 0 0 RICK ABBOTT 2.00 X 0 0 0 DOUGLAS DEVNEW 2.00 X 0 0 0 KAREN GUADAGNINI MD 2.00 X 16269 106410 3280 MARY ANN CORDEAU PHD RN 2.00 X 0 0 0 FAWAD KAZI MD 2.00 X 0 0 0 THOMAS MONAHAN 2.00 X 0 0 0 ELLEN SOLEK 2.00 X 0 0 0 VALERIE VITALE MD 2.00 X 0 0 0 GEORGE EIGHMY 40.00 X 68138 0 2543 LEONARD BANCO MD 40.00 X 348660 0 25975 JEANINE RECKDENWALD 40.00 X 188090 0 22996 DAVE RACKLIFF 40.00 X 160838 0 24658 SHEILA KEMPF PHD 40.00 X 251331 0 28149 KATHLEEN BUCKLEY 40.00 X 199327 0 6440 JOSEPH HART 40.00 X 177641 0 16882 PAUL SMITH 40.00 X 156000 0 0 RUSSELL TUVERSON MD 40.00 X 155226 0 7775 BARBARA NAWROCKI 40.00 X 153000 0 0 2772229 366487 264916 58 0 1 0 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 55480 LAB SERVICES 911521 CROSS COUNTRY STAFFING PO BOX 404674 ATLANTA GA 30384 TEMP LABOR SERVICES 637806 TOTAL LAUNDRY COLLABORATIVE LLC 114 WOODLAND STREET HARTFORD CT 06105 LAUNDRY SERVICES 278919 KFORCE INC PO BOX 277997 ATLANTA GA 30384 TEMP LABOR SERVICES 203243 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 603966485 PET/CT SCANS 193250 19 219460 1118947 21556 1338407 PATIENT SERVICE REVENU 900099 130360493 129429200 931293 OCCUPATIONAL HEALTH RE 621990 718626 718626 131079119 355214 355214 337948 0 337948 337948 337948 11374622 11252337 122285 122285 122285 MISC. PROGRAM AND HEAL 621990 2186068 2186068 JOINT VENTURES 900099 775655 725312 50343 CAFETERIA 722210 406124 406124 208365 208365 3576212 136809185 133059206 981636 1429936 2377048 2377048 52251262 44793228 7458034 3885661 3108529 777132 7028996 5623197 1405799 3999848 3199878 799970 599068 26500 572568 145261 145261 73891 73891 1681180 208263 1472917 1046774 126646 920128 12783150 12309762 473388 2487846 212330 2275516 2546189 2164261 381928 241525 190230 51295 1681654 1681654 6287299 5658569 628730 1410661 1128529 282132 MEDICAL SERVICES FEES 12289846 12215585 74261 DRUGS 7350714 7350714 BAD DEBT 6470292 6470292 REPAIR & MAINTENENCE 1792084 1111496 680588 6056054 3564056 2491998 134486303 111143719 23342584 0 4272881 9376449 96343 96452 20427829 16562143 1696559 1592222 2119071 2242612 143218358 105453829 40030258 37764529 11618379 13893883 12513653 13377950 5034092 7642154 5316676 10105644 103125741 112654038 29472454 29017801 1186812 630235 24658242 24261420 305407 297961 2351228 1957753 37135910 45857533 95110053 102022703 X 427122 -376115 1021495 4079847 6567071 6927603 8015688 10631335 103125741 112654038 X 2322882 292765 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 884 0 1 73007 73891 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE CONNECTICUT HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. $19,007 REPRESENTS THE PORTION OF THE DUES PAID TO THESE ASSOCIATIONS WHICH WERE USED FOR LOBBYING PURPOSES. THE HOSPITAL ENGAGED CAMILLIERE, CLOUD & KENNEDY, A CONNECTICUT LOBBYING AND BUSINESS DEVELOPMENT FIRM, FOR CONSULTING SERVICES IN THE AMOUNT OF $54,000. 12736479 2000000 4558973 1625979 17669473 12881077 40613 185211 12736479 12016137 1587194 722254 12881077 13256619 570728 -523731 1287479 12016137 0.37700 0.39210 0.23090 0 0 1506976 1506976 57966190 38330377 19635813 1006331 696644 309687 78595185 64298581 14296604 4143676 2128227 2015449 37764529 FUNDS HELD FOR MALPRACTICE SELF-INSURANCE 6914759 F ASSETS HELD IN TRUST BY OTHERS 3103647 F FUNDS HELD UNDER BOND INDENTURE 2506470 F DONOR RESTRICTED INVESTMENTS 394142 F DEBT SERVICE FUND 458932 C 13377950 INVESTMENTS IN JOINT VENTURES 933589 C INTEREST IN NET ASSETS OF FOUNDATION 6708565 F 7642154 OTHER RECEIVABLES 4999472 DUE FROM AFFILIATES 3142097 ESTIMATED SETTLEMENTS WITH THIRD-PARTY PAYERS 1964075 10105644 ACCRUED POSTRETIREMENT BENEFIT LIABILITY 7151257 LINE OF CREDIT 3375000 ASSET RETIREMENT OBLIGATIONS 2116281 ACCRUED PENSION LIABILITY 30446134 OTHER LIABILITIES 2768861 45857533 136809185 134486303 2322882 2626853 -2334088 292765 2615647 136787629 0 136787629 21556 21556 136809185 134486303 0 134486303 0 134486303 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF MULTIPLE FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES, SUCH AS CAPITAL EXPENDITURES, OPERATING EXPENSES, AND OTHER SPECIFIED DONOR AND BOARD RESTRICTED USES. 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 SEPTEMBER 30, 2012 AND 2011. IT IS THE HOSPITAL'S POLICY TO RECORD PENALTIES AND INTEREST ASSOCIATED WITH UNCERTAIN TAX PROVISIONS AS A COMPONENT OF OPERATING EXPENSES. 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 BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: INCREASE IN PERMANENTLY RESTRICTED NET ASSETS 360,532. TRANSFER TO BRISTOL HOSPITAL MULTISPECIALTY GROUP -576,633. PENSION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS -6,181,908. CHANGES IN POSTRETIREMENT HEALTH & WELFARE BENEFITS -1,390,669. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 2,376,146. NONCASH VACCINE CONTRIBUTIONS -21,556. TRANSFER FROM BRISTOL HOSPITAL AND HEALTH CARE GROUP 1,100,000. TEMPORARILY RESTRICTED CONTRIBUTIONS 2,000,000. TOTAL TO SCHEDULE D, PART XI, LINE 8: -2,334,088. PART XII, LINE 4B - OTHER ADJUSTMENTS: NONCASH VACCINE CONTRIBUTIONS 21,556. 1 1 1 X 250.000000000000 0 1 1 1 0 0 4132987 2719308 1413679 0.01050 24401608 16662718 7738890 0.05750 28534595 19382026 9152569 0.06800 147790 0 147790 0.00110 147790 147790 0.00110 28682385 19382026 9300359 0.06910 1 2042723 510681 49410291 54068747 -4658456 X 1 1 1 BRISTOL MSO LLC RADIOLOGY SERVICES 0.50000 0.00000 0.00000 2 MEDWORKS LLC REHAB & OCCUPATIONAL HEALTH 0.50000 0.00000 0.00000 3 CT OCCUPATIONAL MEDICAL PARTNERS OCCUPATIONAL HEALTH 0.33000 0.00000 0.00000 4 MEDCONN COLLECTION AGENCY COLLECTION SERVICES 0.25000 0.00000 0.00000 5 TOTAL LAUNDRY COLLABORATIVE LLC LAUNDRY SERVICES 0.14110 0.00000 0.00000 6 CENTRAL CT ENDOSCOPY CENTER MEDICAL SERVICES 0.06500 0.00000 0.00000 7 HEALTH CT LLC MEDICAL SERVICES 0.05400 0.00000 0.00000 1 1 BRISTOL HOSPITAL INC

BREWSTER ROAD BRISTOL CT 06010

X X X X BRISTOL HOSPITAL INC 1 1 1 250.000000000000 0 1 X X X 1 1 X X X X X 1 X X X 1 X X X X X X X 1 X 0 0 11 BRISTOL BEHAVIORAL HEALTH SERVICES

10 N MAIN STREET SUITE 210 BRISTOL CT 06010

BEHAVIORAL HEALTH BRISTOL HOSPITAL CENTER FOR DIABETES

102 NORTH STREET BRISTOL CT 06010

DIABETES MEDICAL CARE AND EDUCATION BRISTOL HOSPITAL COUNSELING CENTER

440-C NORTH MAIN STREET BRISTOL CT 06010

THERAPY AND COUNSELING BRISTOL HOSPITAL WELLNESS CENTER

842 CLARK AVENUE BRISTOL CT 06010

MEDICAL AND FITNESS SERVICES BRISTOL RADIOLOGY CENTER

25 COLLINS ROAD BRISTOL CT 06010

MAMMOGRAPHY AND MRI MED HELP

539 FARMINGTON AVENUE BRISTOL CT 06010

URGENT CARE MEDWORKS LLC

375 CEDAR STREET NEWINGTON CT 06111

OCCUPATIONAL HEALTH SERVICES PARENT & CHILD CENTER - BRISTOL HOSPITA

9 PROSPECT STREET BRISTOL CT 06010

CHILDREN AND FAMILY SERVICES REHAB DYNAMICS

975 FARMINGTON AVENUE BRISTOL CT 06010

PHYSICAL THERAPY AND SPORTS MEDICINE BRISTOL HOSPITAL LABORATORY

641 FARMINGTON AVENUE BRISTOL CT 06010

LABORATORY SERVICES BRISTOL HOSPITAL LABORATORY

27 MAIN STREET TERRYVILLE CT 06786

LABORATORY SERVICES PART I, LINE 3C: THERE IS AN APPROVED SLIDING SCALE FOR DISCOUNTS BASED ON INCOME LEVELS AND FAMILY SIZE. PART III, LINE 4: USE OF ESTIMATES - THE PREPARATION OF FINANCIAL STATEMENTS IN CONFORMITY WITH GAAP REQUIRES MANAGEMENT TO MAKE ESTIMATES AND ASSUMPTIONS THAT IMPACT THE REPORTED AMOUNTS OF ASSETS AND LIABILITIES AND DISCLOSURE OF CONTINGENT ASSETS AND LIABILITIES AT THE DATE OF THE FINANCIAL STATEMENTS. ESTIMATES ALSO IMPACT THE REPORTED AMOUNTS OF REVENUES AND EXPENSES DURING THE REPORTING PERIOD. ACTUAL RESULTS COULD DIFFER FROM THOSE ESTIMATES. THE HOSPITAL'S SIGNIFICANT ESTIMATES RELATE TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ALLOWANCES ON PATIENT ACCOUNTS RECEIVABLE, VALUATION OF INVESTMENTS, ESTIMATED SETTLEMENTS DUE TO THIRD-PARTY PAYERS, RESERVES FOR SELF-INSURANCE LIABILITIES AND THE PENSION AND OTHER POSTRETIREMENT EMPLOYEE BENEFIT PLAN LIABILITY ASSUMPTIONS.THE METHODOLOGY USED IN DETERMINING THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY ASSUMES, BASED ON PAST EXPERIENCE AND PATIENT DEMOGRAPHICS, THAT 25% OF BAD DEBT ACCOUNTS ARE FROM INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR FINANCIAL ASSISTANCE OR MEDICAID, HAD THEY FOLLOWED THROUGH PROPERLY WITH THE APPLICATION PROCESS. THIS AMOUNT SHOULD BE INCLUDED AS COMMUNITY BENEFIT. PART III, LINE 8: THE CALCULATED MEDICARE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE IT REPRESENTS UNREIMBURSED COSTS FOR PATIENT SERVICES. THESE UNREIMBURSED COSTS ARE BRISTOL HOSPITAL EXPENSES THAT ULTIMATELY BENEFIT THE COMMUNITY BRISTOL HOSPITAL SERVICES. PART III, LINE 9B: IT IS THE POLICY OF BRISTOL HOSPITAL TO PROVIDE EVERY PATIENT FROM THE COMMUNITY WE SERVE WITH MEDICALLY NECESSARY HEALTH SERVICES REGARDLESS OF THEIR ABILITY TO PAY. THE POLICY SETS SPECIFIC GUIDLINES FOR THE COLLECTION OF PATIENT PAYMENTS AND ESTABLISHES A HIERARCHY FOR PAYMENT METHODS THAT ARE BOTH FRIENDLY TO THE PATIENT AND BENEFICIAL TO THE HOSPITAL. PATIENTS WHO ARE UNABLE TO PAY THEIR LIABILITY ARE REFERRED TO A FINANCIAL COUNSELOR WHO WILL ASSESS THE PATIENT'S ELIGIBILITY FOR CHARITY CARE OR ALTERNATIVE FUNDING SOURCES. FUNDING SOURCES INCLUDE CHARITY CARE, OUTSIDE FINANCING, HOSPITAL PAYMENT PLANS, FEDERAL, STATE AND LOCAL PROGRAMS AND THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. BRISTOL HOSPITAL, INC. PART V, SECTION B, LINE 10: THERE IS AN APPROVED SLIDING SCALE FOR DISCOUNTS BASED ON INCOME LEVELS AND FAMILY SIZE AS FURTHER DETAILED IN PART V QUESTION 11H. BRISTOL HOSPITAL, INC. PART V, SECTION B, LINE 11H: BRISTOL HOSPITAL RECOGNIZES THAT THE BURDEN OF HEALTH CARE COSTS ON INDIVIDUALS IS A NATIONAL CRISIS. DECADES OF HOSPITAL PRICING, DISTORTED BY THE UNIQUE BILLING REQUIREMENTS IMPOSED BY PRIVATE AND GOVERNMENTAL PAYERS AND REGULATIONS, HAS RESULTED IN A CHARGE STRUCTURE WHICH UNFAIRLY BURDENS THE INDIVIDUALS AND FAMILIES WITHOUT OR WITH LIMITED INSURANCE. BRISTOL HOSPITAL WISHES TO CORRECT THIS UNFAIRNESS BY ENSURING THAT ALL UNINSURED PATIENTS' CHARGES ARE LIMITED AND CAPPED AT MEDICARE PAYMENT LEVELS. THIS DISCOUNTED LEVEL IS DEFINED AS THE RATIO OF MEDICARE CHARGE TO PAYMENTS AND IS LISTED ON THE MOST RECENT OHCA FILING. THE MOST CURRENT DISCOUNT IS 71%. WHEN A PATIENT HAS NO INSURANCE, THEIR BILL WILL BE IMMEDIATELY REDUCED BY THAT PERCENTAGE DISCOUNT, USING THE CHARITY CARE UNINSURED ALLOWANCE CODE. PATIENTS WHO HAVE BALANCES DUE AFTER INSURANCE AND REQUIRE FINANCIAL ASSISTANCE IN PAYING THOSE BILLS, WILL BE ENTITLED TO A CHARITY CARE PATIENT ASSISTANCE DISCOUNT BASED ON THEIR INCOME AND FAMILY SIZE, USING THE APPROVED SLIDING FINANCIAL ASSISTANCE SCALE. THE STATE OF CONNECTICUT HAS SET RECOMMENDED LEVELS OF CHARITY CARE DISCOUNTS WHICH STIPULATES THAT FOR FAMILIES AT OR BELOW 200% OF FEDERAL POVERTY LEVELS SHOULD BE DISCOUNTED TO COST, AND THAT FOR FAMILIES BETWEEN 200 AND 400% SHOULD BE DISCOUNTED TO THE COMMERCIAL AND/OR MEDICARE RATE. THE BRISTOL HOSPITAL SLIDING SCALE HAS GREATER DISCOUNTS APPLIED AT LOWER LEVELS OF THE FEDERAL POVERTY INCOME LEVELS. PART VI, LINE 2: HOSPITAL ASSESSMENT OF THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES IS A DYNAMIC PROCESS THAT INVOLVES ALL LEVELS OF HOSPITAL ADMINISTRATION, STAFF, THE BOARD OF DIRECTORS (BOD), AND MEDICAL STAFF. VARIOUS COMMITTEES AND GROUPS AT THE HOSPITAL MEET PERIODICALLY TO DISCUSS THE NEEDS OF THE COMMUNITY WE SERVE AS WELL AS THE RESOURCES AND SERVICES AVAILABLE AT THE HOSPITAL AND OTHER AGENCIES IN THE AREA. THE HOSPITAL IS REPRESENTED AT COMMUNITY LEVEL ORGANIZATIONS AND GROUPS THAT ARE ALSO INVOLVED WITH ASSESSMENT OF THE COMMUNITY NEEDS. HOSPITAL RESOURCES ARE FREQUENTLY CALLED UPON TO PARTICIPATE IN PROGRAMS AND PROJECTS PUT TOGETHER TO ADDRESS THOSE NEEDS. PART VI, LINE 3: AT BRISTOL HOSPITAL, PATIENTS ARE NOTIFIED OF THEIR ABILITY TO DISCUSS FINANCIAL ASSISTANCE OPTIONS INCLUDING CHARITY CARE IN ALL OF THEIR BILLING STATEMENTS. THE HOSPITAL ENCOURAGES PATIENTS TO FIND OUT THEIR ELIGIBILITY FOR ASSISTANCE AND PROVIDES FINANCIAL COUNSELORS TO ASSIST PATIENTS IN APPLYING FOR CHARITY CARE.PATIENTS CAN CONTACT THE FINANCIAL ASSISTANCE DEPARTMENT WITHIN THE HOSPITAL AT 860-585-3878. THIS SUPPORT ALSO INCLUDES A REPRESENTATIVE THROUGH THE STATE OF CONNECTICUT (REPRESENTATIVE PAID BY BRISTOL HOSPITAL) SO WE ENSURE THAT ALL ASPECTS OF ASSISTANCE ARE PROVIDED FOR EACH PATIENT.THE FINANCIAL ASSISTANCE DEPARTMENT ALSO DISCUSSES GOVERNMENT BENEFITS WITH PATIENTS THAT THEY MAY BE ELIGIBLE FOR.CONTACT INFORMATION FOR OUR FINANCIAL COUNSELOR IS ALSO INCLUDED ON THE HOSPITAL WEBSITE FOR PATIENTS TO REFERENCE. THE HOSPITAL ALSO OFFERS MANY FREE PROGRAMS FOR THE UNINSURED INCLUDING FREE BLOOD PRESSURE CLINICS, SKIN CANCER SCREENING CLINICS AND SEMINARS TO PROVIDE PATIENTS ACCESS TO AS MUCH FREE HEALTH INFORMATION AS POSSIBLE. PART VI, LINE 4: BRISTOL HOSPITAL IS COMMITTED TO PROVIDING THE BEST PATIENT EXPERIENCE IN THE REGION. OUR 134-BED, FULL-SERVICE HEALTH CARE INSTITUTION PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT CARE FOR THE GREATER BRISTOL, CONNECTICUT AREA.BRISTOL IS A SUBURBAN CITY LOCATED IN HARTFORD COUNTY, CONNECTICUT, UNITED STATES 20 MILES SOUTHWEST OF HARTFORD. BRISTOL HAS A TOTAL AREA OF 26.8 SQUARE MILES AND A POPULATION OF APPROX 62K. IN BRISTOL, 84.2% OF THE PEOPLE SPEAK ENGLISH AND 4.8% OF PEOPLE SPEAK SPANISH. IN BRISTOL, 54.6% OF PEOPLE ARE MARRIED AND 92.2% OF RESIDENTS WERE BORN IN THE US.COMMUNITY INFORMATION:THE PRIMARY SERVICE AREA (PSA) FOR OUR HOSPITAL INCLUDES:BRISTOL (ZIP CODE 06010,06011)- 2011 CENSUS 62,078BURLINGTON (ZIP CODE 06013)- 2011 CENSUS- 10,011PLAINVILLE (ZIP CODE 06062)- 2011 CENSUS 17,767PLYMOUTH (ZIP CODE 06781,06782,06786)- 2011 CENSUS 12,605THE TOTAL POPULATION FROM THE 2011 CENSUS FOR OUR PSA IS- 102,461IN 2010, THE LATEST DATE DATA BECAME AVAILABLE AND THE FOLLOWING DATA POINTS WERE PROVIDED FOR THE FOLLOWING COMMUNITIES: BRISTOL:MEDIAN HOUSEHOLD INCOME: $57,781FAMILIES BELOW POVERTY LEVEL- 5.6%INDIVIDUALS BELOW POVERTY LEVEL- 7.7%RACE: WHITE- 87.6%, BLACK OR AFRICAN AMERICAN- 3.6%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 1.8%, OTHER RACE- 3.9%BURLINGTON: MEDIAN HOUSEHOLD INCOME: $116,419 FAMILIES BELOW POVERTY LEVEL- 1.2% INDIVIDUALS BELOW POVERTY LEVEL- 1.9% RACE: WHITE- 98%, BLACK OR AFRICAN AMERICAN- 0.2%,AMERICAN INDIAN OR ALASKA NATIVE- 0.1%, ASIAN- 1.2%PLAINVILLE: MEDIAN HOUSEHOLD INCOME: $62,440 FAMILIES BELOW POVERTY LEVEL- 4.1% INDIVIDUALS BELOW POVERTY LEVEL- 5.0% RACE: WHITE- 93.1%, BLACK OR AFRICAN AMERICAN- 2.5%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 1.3%, OTHER RACE- 0.6% PLYMOUTH: MEDIAN HOUSEHOLD INCOME: $70,132 FAMILIES BELOW POVERTY LEVEL- 2.9% INDIVIDUALS BELOW POVERTY LEVEL- 5.6% RACE: WHITE- 96.7%, BLACK OR AFRICAN AMERICAN- 0.5%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 0.6%, OTHER RACE- 0.7% THE SECONDARY SERVICE AREA (SSA) FOR OUR HOSPITAL INCLUDES:FARMINGTON (ZIP CODE 06085,06087)- 2011 CENSUS 6,058SOUTHINGTON (ZIP CODE 06489)- 2011 CENSUS 33,560WOLCOTT (ZIP CODE 06716)- 2011 CENSUS 17,458THOMASTON (ZIP CODE 06787)- 2011 CENSUS 8,512HARWINTON (ZIP CODE 06791)- 2011 CENSUS 5,938THE TOTAL POPULATION FROM THE 2011 CENSUS FOR OUR SSA IS- 71,526BOTH THE PSA (PRIMARY SERVICE AREA) AND SSA (SECONDARY SERVICE AREA) ARE PRIMARILY SUBURBAN AND RURAL AREAS BUT ALSO INCLUDE SOME URBAN AREAS AS WELL. SOME OF THE MAJOR HEALTH PROBLEMS PREVALENT IN OUR PSA ARE ASSOCIATED WITH BEHAVIORAL HEALTH, CHEMICAL DEPENDENCY, OBESITY, AND PULMONARY DISEASE. PART VI, LINE 5: BRISTOL HOSPITAL TAKES GREAT PRIDE IN SERVING THE COMMUNITY. AS PART OF ITS MISSION, BRISTOL HOSPITAL INCORPORATES A BROAD ARRAY OF COMMUNITY OUTREACH AND WELLNESS ACTIVITIES, DELIVERING EDUCATIONAL MATERIAL AND COUNSELING, OFFERING FREE OR LOW COST HEALTH SCREENINGS AND HOSTING PATIENT AND FAMILY SUPPORT GROUPS. WE UNDERSTAND THE IMPORTANCE AND VALUE OF EMPHASIZING GOOD HEALTH, FITNESS, SAFETY AND THE PROMOTION OF EARLY DETECTION OF ILLNESS OR DISEASE. THEREFORE, ALL OF OUR OUTREACH EFFORTS REFLECT OUR STRONG DESIRE TO IMPROVE THE QUALITY OF LIFE FOR ALL WHO LIVE AND WORK IN THE COMMUNITIES WE SERVE. BRISTOL HOSPITAL PROVIDES FINANCIAL SUPPORT AND ACCESS TO APPROPRIATE CLINICAL CARE FOR SEVERAL LIFE-SAVING INITIATIVES, INCLUDING THE BRISTOL COMMUNITY BREAST HEALTH PROJECT AND THE COLON CANCER AWARENESS PROJECT OF GREATER BRISTOL, WHICH ALLOW US TO OFFER FREE BREAST, AND COLORECTAL CANCER SCREENINGS TO THOSE WHO, DUE TO INSURANCE OR INCOME FACTORS, MIGHT NOT OTHERWISE HAVE ACCESS TO THESE VALUABLE DIAGNOSTIC SCREENING SERVICES. THE EYE CARE PROJECT OF GREATER BRISTOL PROVIDES VITAL ACCESS TO SERVICES FOR THOSE SUFFERING FROM VISION IMPAIRMENT.AT BRISTOL HOSPITAL WE UNDERSTAND THE IMPORTANCE OF OUR ROLE AS AN EXEMPT HEALTHCARE PROVIDER TO THE COMMUNITY WE SERVICE. OUR LEADERSHIP TEAM IS COMMITTED TO PROVIDING OUTSTANDING PATIENT CARE AND PROMOTING THE HEALTH OF THE COMMUNITY. BRISTOL HOSPITAL ATTEMPTS TO PROMOTE OUR FREE AND NON-REVENUE GENERATING PROGRAMS IN A VARIETY OF WAYS. THREE TIMES A YEAR, THE HOSPITAL MAILS A "PATHWAYS TO YOUR HEALTH" CATALOG. THE CATALOG CONTAINS A LISTING OF PROGRAMS AVAILABLE TO THE GREATER BRISTOL COMMUNITY. THIS CATALOG IS MAILED TO OVER 60,000 RESIDENTS AND PROVIDES INFORMATION ON FREE HEALTH SCREENINGS, SUPPORT GROUPS, HEALTH EDUCATION, WELLNESS PROGRAMS, ETC. THE CATALOG IS ALSO INCLUDED ON OUR HOSPITAL WEBSITE TO PROVIDE INCREASED ACCESS TO PATIENTS. THE PATHWAYS CATALOG IS DELIVERED AND DISPLAYED IN EACH DEPARTMENT WITHIN THE HOSPITAL AND IS FREE FOR ALL PATIENTS TO TAKE. PROGRAMS ARE ALSO LISTED ON OUR WEBSITE UNDER AN "EVENTS" SECTION WHERE PATIENTS CAN REGISTER FOR FREE, DIRECTLY ONLINE. WE ALSO PROMOTE OUR PROGRAMS MONTHLY IN THE BRISTOL PRESS, BRISTOL OBSERVER, HARTFORD COURANT AND PLYMOUTH CONNECTION. WE SUBSCRIBE TO AN "ON-HOLD" SYSTEM FOR OUR PHONES WHICH ALLOWS US TO RECORD MESSAGES FOR PATIENTS WHEN THEY CALL THE HOSPITAL. MANY OF THESE MESSAGES ARE ABOUT FREE PROGRAMS AND SERVICES, HEALTH EDUCATION FACTS AND SERVICES TO THE COMMUNITY. PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 CT X 1 0 X X X X X 0 1 0 0 0 1 0 0 0 BALA SHANMUGAM MD 0 260077 0 0 7313 0 0 4900 0 0 7313 264977 0 0 KURT BARWIS 441529 0 93469 0 272330 0 104419 0 16899 0 928646 0 271758 0 LEONARD BANCO MD 308318 0 40342 0 0 0 12250 0 13725 0 374635 0 0 0 JEANINE RECKDENWALD 163163 0 24927 0 0 0 6097 0 16899 0 211086 0 0 0 DAVE RACKLIFF 144341 0 16497 0 0 0 7431 0 17227 0 185496 0 0 0 SHEILA KEMPF PHD 219055 0 32276 0 0 0 11250 0 16899 0 279480 0 0 0 KATHLEEN BUCKLEY 199327 0 0 0 0 0 0 0 6440 0 205767 0 0 0 JOSEPH HART 164083 0 13558 0 0 0 8367 0 8515 0 194523 0 0 0 PAUL SMITH 156000 0 0 0 0 0 0 0 0 0 156000 0 0 0 RUSSELL TUVERSON MD 155226 0 0 0 0 0 7775 0 0 0 163001 0 0 0 BARBARA NAWROCKI 153000 0 0 0 0 0 0 0 0 0 153000 0 0 0 PART I, LINE 1A THE HOSPITAL PAID $6,305 IN GOLF CLUB MEMBERSHIP FEES FOR ITS PRESIDENT DURING THE CALENDAR YEAR 2011. PART I, LINE 4B KURT BARWIS, PRESIDENT, PARTICIPATES IN THE HOSPITAL'S 457(F) DEFINED CONTRIBUTION PLAN. PART I, LINE 6 THE COMPENSATION OF THE HOSPITAL'S PRESIDENT, KURT BARWIS, IS BASED IN PART ON THE NET EARNINGS OF THE HOSPITAL. MORRIS LAVIERO PURCHASE BUILDING X 350000 297961 0 1 1 297961 X 1 21556 REPORT FROM DHHS 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 A COMPLETED 990 IS PROVIDED TO EACH BOARD MEMBER. THIS PROVIDES AN OPPORTUNITY FOR MEMBERS TO ASK QUESTIONS AND FOLLOW UP WITH THE FINANCE TEAM REGARDING ANY ISSUES OR CONCERNS. THE 990 IS ALSO REVIEWED INTERNALLY BY MEMBERS OF THE FINANCE AND MANAGEMENT TEAMS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL APPLICABLE PARTIES ARE REQUIRED TO RECEIVE AND SIGN A STATEMENT ACKNOWLEDGING THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO COMPLY WITH THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMPENSATION COMMITTEE IS AUTHORIZED UNDER THE BRISTOL HOSPITAL AND HEALTH CARE GROUP BYLAWS AND IS RESPONSIBLE FOR (1) DETERMINING THE OVERALL TOTAL COMPENSATION STRATEGY FOR ALL CORPORATE OFFICERS, (2) APPROVING ALL COMPENSATION AND BENEFITS DECISIONS FOR CORPORATE OFFICERS, AND (3) REPORTING SUCH ACTIONS TO THE FULL BRISTOL HOSPITAL AND HEALTH CARE GROUP BOARD ON AN ANNUAL BASIS. IN ADDITION, THE EXECUTIVE COMPENSATION COMMITTEE EXPRESSLY DETERMINES THE REASONABLENESS OF TOTAL COMPENSATION AND BENEFITS FOR ALL CORPORATE OFFICERS AND ASSURES THAT ALL OFFICER COMPENSATION DECISIONS ARE MADE AFTER THOROUGH CONSIDERATION OF AND COMPARISON TO THE MARKET PRACTICES OF OTHER SIMILARLY SITUATED NOT-FOR-PROFIT HEALTHCARE EXECUTIVES IN COMPARABLE ORGANIZATIONS. THE EXECUTIVE COMPENSATION COMMITTEE CONSISTS OF BOARD MEMBERS WHO DO NOT HAVE MATERIAL FINANCIAL INTERESTS THAT COULD BE AFFECTED BY THE OFFICER COMPENSATION DECISIONS MADE BY THE COMMITTEE. THE COMPARABILITY DATA USED TO ASSIST THE EXECUTIVE COMPENSATION COMMITTEE IN ITS COMPENSATION DELIBERATIONS ARE COMPILED BY AN INDEPENDENT, NATIONAL COMPENSATION CONSULTING FIRM THAT IS RETAINED BY AND REPORTS DIRECTLY TO THE EXECUTIVE COMPENSATION COMMITTEE. THE DATA COLLECTED BY THE CONSULTANT CONSISTS OF MARKET INFORMATION FOR EXECUTIVES IN FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS. THE DELIBERATIONS AND DECISIONS OF THE EXECUTIVE COMPENSATION COMMITTEE ARE CONTEMPORANEOUSLY DOCUMENTED, REVIEWED AND APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE AND PROVIDED TO THE BOARD ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 2,626,853. INCREASE IN PERMANENTLY RESTRICTED NET ASSETS 360,532. TRANSFER TO BRISTOL HOSPITAL MULTISPECIALTY GROUP -576,633. PENSION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS -6,181,908. CHANGES IN POSTRETIREMENT HEALTH & WELFARE BENEFITS -1,390,669. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 2,376,146. NONCASH VACCINE CONTRIBUTIONS -21,556. TRANSFER FROM BRISTOL HOSPITAL AND HEALTH CARE GROUP 1,100,000. TEMPORARILY RESTRICTED CONTRIBUTIONS 2,000,000. TOTAL TO FORM 990, PART XI, LINE 5: 292,765. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESSES OF OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. 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