2013-11-14T15:49:14-06:00 2012-12-31 752570395 DURBIN & COMPANY LLP 2950 50TH STREET LUBBOCK TX 79413 990 2012-01-01 274005511 BELLVILLE GENERAL HOSPITAL BELL 9794137400 44 NORTH CUMMINGS BELLVILLE TX 77418 JEFFERY BARNHART 9794137400 2013-11-14 1 JONATHAN PHILLIPS P01605460 8067911591 2013-11-14 2012 2016-02-25 16:41:14Z JEFFERY BARNHART 44 NORTH CUMMINGS BELLVILLE TX 77418 10470814 0 X WWW.BELLVILLEHOSPITAL.COM X 2010 TX THE HOSPITAL IS ORGANIZED FOR THE EXCLUSIVE PURPOSES OF OPERATING A COMMUNITY HOSPITAL AND PROVIDING NON-ELECTIVE HEALTHCARE TO THE GENERAL PUBLIC REGARDLESS OF THE ABILITY OF PATIENTS TO PAY FOR THESE SERVICES. 5 5 109 0 0 0 78637 243105 11922333 9660979 1609 1465 289975 388305 12292554 10293854 0 0 0 0 4581954 5029701 0 0 0 6658378 6782814 11240332 11812515 1052222 -1518661 2251510 3663998 1199288 4130437 1052222 -466439 THE PRIMARY PURPOSE OF THE HOSPITAL IS TO SUPPORT ITS COMMUNITY IN PROVIDING FOR THE HEALTHCARE NEEDS OF ITS COMMUNITY. 0 0 10295126 10049284 HOSPITAL SERVICES THAT INCLUDE BUT ARE NOT LIMITED TO: 1,689 TOTAL PATIENT DAYS, 4,733 EMERGENCY ROOM VISITS, 48,639 LABORATORY PROCEDURES AND 7,559 RADIOLOGY PROCEDURES. THE HOSPITAL ALSO PROVIDED $334,813 IN CHARITY CARE. 10295126 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 42 0 1 109 1 0 0 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 1 1 0 0 TX X BELLVILLE GENERAL HOSPITAL 9794137400 44 NORTH CUMMINGS BELLVILLE TX 77418 JOHN GRUBE 1.00 X 0 0 0 JOHN HARLE 1.00 X 0 0 0 STEVE LACKEY 1.00 X 0 0 0 KARA GALLE 1.00 X 0 0 0 MIKE ALDREDGE 1.00 X 0 0 0 MICHAEL MORRIS 40.00 X 151365 0 22033 JAN WALKER 40.00 X 71042 0 0 SHARON GLENTZER 40.00 X 93414 0 0 315821 0 22033 1 0 1 0 CONCORD MEDICAL GROUP PO BOX 489 MULESHOE TX 79347 PHYSICIAN SERVICES 445142 OUTSOURCED RECEIVABLES MANAGEMENT PO BOX 8621 CORPUS CHRISTI TX 78468 A/R BILLING AND COLLECTION SERVICES 198791 HUNTER PHARMACY SERVICES PO BOX 30573 AUSTIN TX 78755 PHARMACY MANAGEMENT 164994 WILLFORD V MORRIS JR DO PA 3433 HWY 36 SOUTH SEALY TX 77474 CLINIC PHYSICIAN 128000 DMS IMAGING INC 415 LOCKHAVEN DR HOUSTON TX 77073 MRI SERVICES 117699 5 243105 243105 PATIENT REVENUES, NET 621990 7199426 7199426 INDIGENT CARE SUPPORT 621990 2461553 2461553 9660979 1465 1465 249179 176960 72219 72219 72219 MISCELLANEOUS INCOME 900099 278582 278582 CAFETERIA SALES 900099 16114 16114 REBATES 900099 14549 14549 6841 6841 316086 10293854 10049284 0 1465 X 3961967 3386859 575108 28886 28886 1038848 726667 312181 14390 14390 66547 66547 1548723 1281888 266835 26803 427 26376 407929 347376 60553 23152 23152 1901249 1867142 34107 55848 13084 42764 20143 12667 7476 182 182 54118 54118 BAD DEBT 1562712 1562712 MEDICAL SUPPLIES 1028951 1017990 10961 DUES & SUBSCRIPTIONS 27642 10509 17133 LICENSE & FEES 20142 13935 6207 24283 1832 22451 11812515 10295126 1517389 0 868052 179352 749552 759389 237492 249855 44033 51583 2274977 107319 272171 2167658 80210 256161 2251510 3663998 999288 2274112 200000 1856325 1199288 4130437 X 1052222 -466439 1052222 -466439 2251510 3663998 -1518661 0 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3897 3897 16516 16516 2254564 107319 2147245 2167658 RENT RECEIVABLE 900 MEDICARE & MEDICAID COST REPORT RECEIVABLE 39789 UNCOMPENSATED CARE RECEIVABLE 215472 256161 X 8908102 176960 176960 8731142 1562712 1562712 10293854 10426763 176960 176960 10249803 1562712 1562712 11812515 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT ORGANIZATION THAT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL EVALUATES AND ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES (FORMERLY FASB INTERPRETATION 48 (FIN 48) ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THIS STANDARD REQUIRES CERTAIN DISCLOSURES ABOUT UNCERTAIN INCOME TAX POSITIONS. THE HOSPITAL EVALUATES ANY UNCERTAIN TAX POSITIONS USING THE PROVISIONS OF ASC 450, CONTINGENCIES. AS A RESULT, MANAGEMENT DOES NOT BELIEVE THAT ANY UNCERTAIN TAX POSITIONS CURRENTLY EXIST AND NO LOSS CONTINGENCY HAS BEEN RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS FILED ALL APPLICABLE TAX RETURNS. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 176,960. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,562,712. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 176,960. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,562,712. 1 1 X 1 X 1 X 500.000000000000 1 1 0 1 1 391805 266599 125206 0.01220 2224605 2110901 113704 0.01110 112605 106812 5793 0.00060 2729015 2484312 244703 0.02390 2729015 2484312 244703 0.02390 1 773731 541128 2085476 658982 1426494 X 1 1 1 1 BELLVILLE GENERAL HOSPITAL

44 N CUMMINGS BELLVILLE TX 77418

X X X HOSPITAL BELLVILLE GENERAL HOSPITAL 1 0 1 1 200.000000000000 1 500.000000000000 1 X X X X 1 1 X X X X X 0 0 0 X 0 0 1 MEDICAL CLINIC OF BELLVILLE

235 W PALM SUITE 108 BELLVILLE TX 77418

RURAL HEALTH CLINIC 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 $ 1562712. PART III, LINE 4: THE ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE PATIENT ACCOUNTS RECEIVABLE IS MAINTAINED AT A LEVEL WHICH, IN MANAGEMENT'S JUDGMENT, IS ADEQUATE TO ABSORB PATIENT ACCOUNT BALANCE WRITE-OFFS INHERENT IN THE BILLING PROCESS. THE AMOUNT OF THE ALLOWANCE IS BASED ON MANAGEMENT EVALUATION OF THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, INCLUDING THE NATURE OF THE ACCOUNTS, CREDIT CONCENTRATIONS, HISTORICAL WRITE-OFF TRENDS, SPECIFIC IMPAIRED ACCOUNTS, AND ECONOMIC CONDITIONS. ALLOWANCES FOR UNCOLLECTIBLE AND CONTRACTUALS ARE GENERALLY DETERMINED BY APPLYING HISTORICAL PERCENTAGES TO FINANCIAL CLASSES WITHIN ACCOUNTS RECEIVABLE. THE ALLOWANCES ARE INCREASED BY A PROVISION FOR BAD DEBT EXPENSES AND CONTRACTUAL ADJUSTEMENTS, AND REDUCED BY WRITE-OFFS, NET OF RECOVERIES. PART III, LINE 8: LINE 6 IS ARRIVED BY USING THE COST TO CHARGE RATIOS BASED ON THE MEDICARE COST REPORT.LINE 7 SHOULD BE TREATED AS A COMMUNITY BENEFIT IN THAT THE HOSPITAL TREATS PATIENTS REGARDLESS OF THE REIMBURSEMENT BY MEDICARE. PART III, LINE 9B: THE DEBT COLLECTION POLICY PROVIDES A PROVISION THAT EXCLUDES THOSE WHO QUALIFY FOR CHARITY FROM EVER BEING A PART OF THE BAD DEBT. BELLVILLE GENERAL HOSPITAL PART V, SECTION B, LINE 10: A FINANCIALLY INDIGENT PATIENT IS A PERSON WHO IS UNINSURED OR UNDERINSURED AND IS ACCEPTED FOR CARE WITH NO OBLIGATION OR A DISCOUNTED OBLIGATION TO PAY FOR SERVICES RENDERED BASED ON THE HOSPITAL'S ELIGIBILITY CRITERIA. TO BE ELIGIBLE FOR CHARITY CARE AS A FINANCIALLY INDIGENT PATIENT, A PERSON'S GROSS ANNUAL INCOME SHALL BE AT OR BELOW 200 PERCENT OF THE FEDERAL POVERTY GUIDELINES AND HAVE NO ALTERNATIVE RESOURCES AVAILABLE. HOSPITAL MAY CONSIDER OTHER FINANCIAL ASSETS AND LIABILITIES OF THE PERSON WHEN DETERMINING ELIGIBILITY. BELLVILLE GENERAL HOSPITAL PART V, SECTION B, LINE 11: A MEDICALLY INDIGENT PATIENT IS A PERSON WHO'S MEDICAL OR HOSPITAL BILLS AFTER PAYMENT BY THIRD-PARTY PAYERS EXCEED A SPECIFIC PERCENTAGE OF THE PERSON'S ANNUAL GROSS INCOME AND WHO IS UNABLE TO PAY THE REMAINING BILL. THE HOSPITAL MAY CONSIDER OTHER ASSETS AND LIABILITIES OF THE PERSON WHEN DETERMINING ABILITY TO PAY. TO BE ELIGIBLE FOR CHARITY CARE AS A MEDICALLY INDIGENT PATIENT, THE PATIENT'S GROSS ANNUAL INCOME MUST BE GREATER THAN 200 PERCENT BUT LESS THAN OR EQUAL TO 500 PERCENT OF THE FEDERAL POVERTY LEVEL AND THE AMOUNT OWED BY THE PATIENT ON THE HOSPITAL BILL AFTER PAYMENT BY THIRD PARTY PAYERS MUST EXCEED 10 PERCENT OF THE PATIENT'S GROSS ANNUAL INCOME. IN THESE INSTANCES, THE HOSPITAL MAY DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE GRANTED TO THESE PATIENTS AS SET FORTH IN THE HOSPITAL'S FINANCIAL ASSISTANCE ELIGIBILITY DISCOUNT GUIDELINES. TO QUALIFY AS CATASTROPHIC MEDICAL INDIGENCE, THE PATIENT'S REMAINING BILL MUST BE NO GREATER THAN 50 PERCENT OF THE PATIENT'S GROSS ANNUAL INCOME AND THE PATIENT'S INCOME MUST BE GREATER THAN 500 PERCENT OF THE FEDERAL POVERTY GUIDELINES. IN THESE INSTANCES, THE HOSPITAL MAY DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE GRANTED TO THESE PATIENTS IN ACCORDANCE WITH THE HOSPITAL'S FINANCIAL ASSISTANCE ELIGIBILITY DISCOUNT GUIDELINES. A DETERMINATION OF A PATIENT'S ABILITY TO PAY THE REMAINDER OF THE BILL WILL BE BASED ON WHETHER THE PATIENT CAN REASONABLY BE EXPECTED TO PAY THE ACCOUNT IN FULL OVER A TWO-YEAR PERIOD. IF A DETERMINATION IS MADE THAT A PATIENT HAS THE ABILITY TO PAY THE REMAINDER OF THE BILL, SUCH A DETERMINATION DOES NOT PREVENT A RE-ASSESSMENT OF THE PATIENT'S ABILITY TO PAY AT A LATER DATE. BELLVILLE GENERAL HOSPITAL PART V, SECTION B, LINE 12H: THE HOSPITAL IS A NOT FOR PROFIT CORPORATION OFFERING A CHARITY CARE PROGRAM. THE HOSPITAL WILL NOT DISCRIMINATE ON THE BASIS OF RACE, ANCESTRY, RELIGION, NATIONAL ORIGIN, CITIZENSHIP STATUS, AGE, DISABILITY, OR GENDER IN ITS CONSIDERATION OF A PATIENT'S QUALIFICATION FOR CHARITY CARE. THE CLASSIFICATION OF A PATIENT AS BEING ELIGIBLE FOR CHARITY CARE SHALL OCCUR AT THE TIME SUFFICIENT INFORMATION HAS BEEN OBTAINED TO VERIFY THE PATIENT'S INABILITY TO PAY FOR NEEDED MEDICAL SERVICES, AND AS SOON AS POSSIBLE AFTER THE PATIENT FIRST PRESENTS FOR SERVICES OR INDICATES AN INABILITY TO PAY FOR SERVICES. THIS PATIENT'S IDENTIFICATION PROCESS INCLUDES PATIENTS WITH THIRD PARTY COVERAGE (I.E., INSURANCE, MEDICARE, ETC.) WHERE THE PATIENT HAS A RESPONSIBILITY FOR PAYMENT AND HAS AN INABILITY TO PAY.THE HOSPITAL PERSONNEL SHALL ATTEMPT TO IDENTIFY ALL CASES THAT QUALIFY AS CHARITY PATIENTS AT THE TIME OF PRE-REGISTRATION OR ADMISSION. PATIENTS IDENTIFIED AS POSSIBLE CHARITY CARE PATIENTS WILL BE GIVEN AN APPLICATION AND POLICY GUIDELINES TOGETHER WITH DIRECTIONS ON COMPLETING THE PAPER WORK AND ANY ADDITIONAL DOCUMENTATION NEEDED TO CONSIDER THE APPLICATION. THE PATIENT WILL ALSO BE GIVEN CONTACT INFORMATION FOR THE APPROPRIATE PERSONNEL TO WHOM THEY SHOULD RETURN THE APPLICATION.APPLICANTS MUST FULLY COOPERATE AND COMPLY WITH ELIGIBILITY REQUIREMENTS FOR ANY OTHER HEALTHCARE PROGRAM(S) FOR WHICH THEY MAY BE QUALIFIED PRIOR TO THEIR EVALUATION FOR CHARITY CARE. FEDERAL AND/OR STATE ASSISTANCE MAY BE AVAILABLE TO THOSE WHO MEET QUALIFICATIONS. BEFORE CHARITY CARE IS CONSIDERED, ALL AVAILABLE AVENUES OF ASSISTANCE FROM THIRD-PARTY PAYORS MUST BE EXHAUSTED.ALL SERVICES MUST BE MEDICALLY NECESSARY IN ORDER TO QUALIFY FOR A CHARITY CARE DISCOUNT (E.G., ELECTIVE PROCEDURES SUCH AS COSMETIC SURGERY DO NOT QUALIFY FOR A CHARITY DESIGNATION). ELIGIBLE SERVICES WILL BE BASED ON THOSE SERVICES FOR WHICH MEDICARE PROVIDES COVERAGE. PATIENTS OR THE RESPONSIBLE PARTY MUST VERIFY THE INCOME REPORTED ON THE FINANCIAL ASSISTANCE APPLICATION IN ACCORDANCE WITH THE DOCUMENTATION REQUIREMENTS SET FORTH BELOW:A. IN ORDER TO BE CONSIDERED FOR CHARITY CARE, CREDIT REPORT AND INCOME INFORMATION MAY BE OBTAINED REGARDING THE PATIENT. HOSPITAL MAY OBTAIN A CREDIT REPORT ON PATIENTS TO CONFIRM THE INCOME DOCUMENTATION PATIENT PROVIDES. ELIGIBILITY DOCUMENTATION MUST BE MAINTAINED IN THE PATIENT'S FINANCIAL FILE IN ADDITION TO THE CREDIT REPORT. THE HOSPITAL MAY OBTAIN, FOR EACH PATIENT, ONE OR MORE OF THE FOLLOWING DOCUMENTS IN ORDER TO DETERMINE INCOME AND ASSETS OF THE PATIENT.I. IRS FORM W-2;II. WAGE AND EARNINGS STATEMENT;III. PAYCHECK REMITTANCE;IV. INDIVIDUAL TAX RETURNS;V. UNEMPLOYMENT INSURANCE;VI. SOCIAL SECURITY AWARD LETTER, OR COPY OF SOCIAL SECURITY CHECK;VII. TELEPHONE VERIFICATION BY EMPLOYER OF THE PATIENTS INCOME;VIII. VETERAN'S ADMINISTRATION LETTER, OR COPY OF VA CHECK;IX. PHYSICIAN DISABILITY STATEMENT LISTING TERM OF DISABILITY AND DOCUMENTATION OR PROOF OF THREE OR MORE MONTHS WITH NO INCOME FOR THE PERIOD OF DISABILITY;X. BANK ACCOUNTS AND RECORDS; ORXI. OTHER APPROPRIATE INDICATORS OF YEARLY, MONTHLY, WEEKLY, OR HOURLY INCOME.B. BY THE PROVISION OF DOCUMENTATION SHOWING CURRENT PARTICIPATION IN A PUBLIC BENEFIT PROGRAM SUCH AS WORKER'S COMPENSATION, MEDICAID, COUNTY INDIGENT HEALTH PROGRAM, TANF, WIC, TEXAS HEALTHY KIDS, CHILDREN'S HEALTH INSURANCE PROGRAM, UNEMPLOYMENT COMPENSATION DETERMINATION LETTER, UNEMPLOYMENT INSURANCE, OR OTHER SIMILAR INDIGENCY-RELATED PROGRAMS. PROOF OF PARTICIPATION IN ANY OF THE ABOVE PROGRAMS INDICATES THAT THE PATIENT HAS BEEN DEEMED FINANCIALLY INDIGENT AND THEREFORE, IS NOT REQUIRED TO PROVIDE HIS OR HER "GROSS MONTHLY INCOME" OF THE FINANCIAL ASSISTANCE APPLICATION, OR PROVIDE ANY OF THE INCOME DOCUMENTATION VERIFICATION LISTED ABOVE. THE HOSPITAL MAY ALSO USE THIRD-PARTY VERIFICATION OF A PATIENT'S PARTICIPATION IN A PUBLIC BENEFIT PROGRAM IF THE CHARITY CARE APPLICANT IS UNABLE TO PROVIDE THAT DOCUMENTATION. BELLVILLE GENERAL HOSPITAL PART V, SECTION B, LINE 14G: THE HOSPITAL'S CHARITY CARE DISCOUNT POLICY MUST BE AVAILABLE TO THE PUBLIC. IN ADDITION TO THE PROMINENT POSTING OF A CHARITY CARE NOTICE IN THE ADMISSIONS AND EMERGENCY ROOM AREA, A COPY OF THE CHARITY CARE DISCOUNT POLICY SHOULD BE DISSEMINATED TO ALL PATIENTS WHO REQUEST IT. PART VI, LINE 2: NEEDS OF THE COMMUNITY ARE ASSESSED BY GEOGRAPHIC INFORMATION AVAILABLE TO THE HOSPITAL, STATISTICAL INFORMATION THAT THE HOSPITAL CAN USE TO FURTHER IT'S BENEFIT TO THE COMMUNITY. PART VI, LINE 3: THERE ARE SEVERAL WAYS THAT THE HOSPITAL EDUCATES THE PUBLIC ABOUT ITS CHARITY CARE PROGRAMS. THE WEBSITE PROVIDES A PHONE NUMBER TO CONTACT A BUSINESS OFFICE REPRESENTATIVE FOR ASSISTANCE. THERE ARE ALSO SIGNS IN BOTH ENGLISH AND SPANISH THAT DIRECT PATIENTS TO THE ASSISTANCE THEY COULD QUALIFY FOR. PART VI, LINE 4: BELLVILLE GENERAL HOSPITAL SERVES BELLVILLE AND THE SURROUNDING COMMNUITIES WITHIN AUSTIN COUNTY. 24,893 OR 87.6% OF THE 28,417 PEOPLE LIVING IN AUSTIN COUNTY ARE WHITE ACCORDING TO THE LATEST CENSUS. BELLVILLE GENERAL HOSPITAL IS LOCATED IN BELLVILLE WHICH IS APPROXIMATELY 60 MILES WEST OF HOUSTON. AS OF THE LATEST CENSUS, MEDIAN HOUSEHOLD INCOME WAS $53,263. 8.8% OF PERSONS WERE BELOW THE POVERTY LINE. PART VI, LINE 5: THE HOSPITAL OPERATES AS AN EXEMPT HOSPITAL AND PROVIDES INPATIENT AND OUTPATIENT SERVICES AS WELL AS OTHER AFFILIATED SERVICES TO THE COMMUNITY. 0 0 0 0 0 0 0 0 0 MICHAEL MORRIS 151365 0 0 0 0 0 22033 0 0 0 173398 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE COMMITTEES THAT ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S TAX RETURN IS REVIEWED AND APPROVED BY MANAGEMENT. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED AND APPROVED BY MANAGEMENT BEFORE PRESENTATION TO THE BOARD WHERE THE BOARD REVIEWS AND APPROVES THE FILING OF THE 990. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE ANY CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A AN EXECUTIVE COMMITTEE REVIEWS MANAGEMENT PERFORMANCE ANNUALLY AND MAY RECOMMEND A SALARY INCREASE TO THE BOARD OF DIRECTORS WHO THEN MAKES A DECISION. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS OTHER THAN THE 990 IS AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G PROFESSIONAL & PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,281,888. MANAGEMENT AND GENERAL EXPENSES 266,835. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,548,723.