2013-02-05T15:57:07-06:00 2012-06-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2011-07-01 010211503 Franklin Memorial Hospital FRAN 2077792500 111 Franklin Health Commons Farmington ME 04938 Wayne Bennett 2077792500 2013-01-31 1 Barbara J McGuan CPA P00219457 2077752387 2013-01-31 2011 2016-02-25 16:41:14Z Rebecca Ryder 111 Franklin Health Commons Farmington ME 04938 90080837 0 X www.fchn.org X 1926 ME Community Hospital 19 13 986 155 0 0 559721 761215 85002975 89240432 -40911 -17445 23610 3244 85545395 89987446 420103 20000 0 0 50844233 56453831 0 0 0 32884219 33510034 84148555 89983865 1396840 3581 71470727 76169004 30225199 34936190 41245528 41232814 X To provide high-quality, cost-effective, patient-centered healthcare to our west central Maine community. We work with our community and other healthcare providers to integrate services and ensure the health of our community. 0 0 74578169 20000 89240432 Franklin Memorial Hospital is a progressive, friendly, non-for-profit community hospital which provides high-quality, cost-effective, patient-centered healthcare services to the west central Maine community. The 65-bed hospital is fully qualified and accredited to handle a broad range of medical, surgical, pediatric, women's care and diagnostic services. Franklin Memorial Hospital offers top quality specialty care including oncology, hematology, cardiology, otolaryngology, orthopaedics, behavioral services, occupational health, dermatology, pulmonology, pain management, pediatric endocrinology, physical rehabilitation, sports medicine and wound care. During the fiscal year 2012 there were 2,850 discharges, 1,880 outpatient surgeries, 208,000 outpatient lab tests, 36,000 outpatient imaging procedures and 16,650 emergency room visits. Franklin Memorial Hospital identified access to primary care as a central community need and is committed to providing high quality physician services of family practice, internal medicine, pediatrics and women's care. During the year Franklin Memorial Hospital provided 59,200 primary care visits and 23,500 specialty care visits in the Franklin Health physician practices. 74578169 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 178 0 1 986 1 0 0 0 0 0 0 0 0 0 0 X 19 13 0 0 0 0 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 ME X Wayne Bennett 2077792613 111 Franklin Health Commons Farmington ME 04938 Rebecca Ryder 40.00 X X 351125 0 31178 Joseph Bujold 1.00 X X 0 0 0 Jef Howell 1.00 X X 0 0 0 Waine Whittier 1.00 X 0 0 0 Dr Wil Eastman 1.00 X 0 0 0 Tim Wallace 1.00 X 0 0 0 Carol Timberlake 1.00 X X 0 0 0 Meredith Tipton 1.00 X 0 0 0 Gilly Hitchcock 1.00 X 0 0 0 Darryl Brown 1.00 X 0 0 0 Doug Walrath 1.00 X 0 0 0 Shannon Smith 1.00 X 0 0 0 Peter Judkins 1.00 X 0 0 0 Tom Saviello 1.00 X 0 0 0 Dr Peter Cordner 40.00 X 218020 0 7115 Sheena Bunnell 1.00 X 0 0 0 Ronald Aseltine 1.00 X 14022 0 0 Dr Connie Adler 40.00 X X 204534 0 22244 Dr David Hyde 40.00 X 264235 0 22455 Paul Soucie 1.00 X 0 0 0 Dr Robert O'Reilley 40.00 X 177822 0 19810 Gerald Cayer 40.00 X 224837 0 22764 Eric Martinsen 40.00 X 181857 0 19509 Wayne Bennett 40.00 X 0 0 0 Nancy Cummings 40.00 X 444661 0 25442 Joshua D Sparling 40.00 X 491519 0 20230 Larry Michael Fraley 40.00 X 332577 0 20253 Stephen P Zanella 40.00 X 336202 0 29335 Heather DeCarolis 40.00 X 332563 0 24401 Dr Armand Auger 40.00 X 213000 0 20637 3786974 0 285373 65 1 1 0 Hebert Construction LLC 9 Gould Road Lewiston ME 04240 Construction 2070695 Weatherby Locums PO Box 972633 Dallas TX 75397 Physician Contract Staffing 766037 Quest Diagnostics 5763 Collection Center Drive Chicago IL 60693 Lab Diagnostic Services 430414 Developers Collaborative Predevelopment 17 Chestnut St Portland ME 04101 Real Estate Development 390897 Balanced Healthcare Receivables LLC 141 Burke Street Nashua NH 03060 Billing and Collections 271520 22 474996 149199 137020 761215 Patient Services 621990 175789240 175789240 Meaningful Use Revenue 621990 3491633 3491633 Other 621990 1631608 1631608 Ambulance Subsidies 621910 883197 883197 Contract/Char./Bad Dbt 621990 -92555246 -92555246 89240432 36241 32997 3244 3244 3244 42949 60394 -17445 -17445 -17445 89987446 89240432 0 -14201 20000 20000 1781528 792890 988638 43803159 37388139 6415020 1435714 1258514 177200 6357573 5456869 900704 3075857 2625394 450463 121219 121219 88011 88011 5953 5953 8771913 6978533 1793380 165589 165589 1811403 1278198 533205 2618831 2371178 247653 2192087 1866221 325866 174551 152138 22413 482594 323260 159334 1150298 981836 168462 4684359 3998330 686029 1406591 1341920 64671 Medical Supplies 7054354 7054354 Hospital Tax and Match 1740420 1740420 Other 1041861 690395 351466 89983865 74578169 15405696 0 4722 3580 9778896 5553570 10001878 10470970 1270140 1219194 1309548 2459056 85165647 46544522 35746536 38621125 2507643 2497648 261950 306316 10589414 15037545 71470727 76169004 5861337 6293976 22444495 21905514 0 3763867 1919367 2972833 30225199 34936190 X 38736147 38723155 1063840 1077560 1445541 1432099 41245528 41232814 71470727 76169004 X 3581 -16295 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 2337 0 1 5953 8290 0 Explanation of Lobbying Activities: Part II-B, Line 1: Rebecca Ryder, President/CEO of the Organization, spent time meeting with members of the congressional delegation. A proportional amount of her time spent engaging in these activities has been calculated to arrive at the total lobbying expense amount. In addition, The Organization pays dues to various associations, a portion of which is attributable to lobbying expenses. 2341310 216215 -63416 169094 2325015 2007058 12117 335279 13144 2341310 1903822 60144 135979 93491 2007058 1895540 120033 -66109 45642 1903822 0.00000 0.62000 0.38000 0 1 1 1268949 1268949 47984193 20042227 27941966 10517 10517 0 30642913 24012012 6630901 5259075 2479766 2779309 38621125 Estimated Settlements from MaineCare 14155887 Deferred Compensation Asset 858472 Due from Related Parties 23186 15037545 Deferred Compensation 858472 Estimated Third-Party Payor Settlements 2114361 2972833 Description of Intended Use of Endowment Funds: Part V, Line 4: The Organization's endowment funds are held by the Franklin Community Health Network and are intended to support various programs offered by the Organization, such as the charity program, community outreach, education, medical library, Martha B. Webber Breast Care Center, and others. 1 1 1 X 1 X 0 1 0 1 1 3492000 3492000 0.03880 17846985 15251828 2595157 0.02880 21338985 15251828 6087157 0.06760 501007 85369 415638 0.00460 401372 401372 0.00450 10253219 6503606 3749613 0.04170 20000 20000 0.00020 11175598 6588975 4586623 0.05100 32514583 21840803 10673780 0.11860 2000 2000 0.00000 2000 2000 1 1718221 344000 22027961 24236438 -2208477 X 1 0 1 Western Maine PHO Physician Hospital Organization 0.50000 0.00000 0.00000 2 Scorekeeper LLC Wellness Software 0.40000 0.00000 0.00000 1 1 Franklin Memorial Hospital

111 Franklin Health Commons Farmington ME 04938

X X X Franklin Memorial Hospital 1 1 1 200.000000000000 1 300.000000000000 1 X 1 1 X 1 0 1 X 0 0 19 Franklin Hlth Livermore Falls Fam Pract

21 Main Street Livermore Falls ME 04254

Family Practice Franklin Health Wilton Family Practice

75 Allen Street Wilton ME 04294

Family Practice Franklin Hlth Farmington Family Practice

111 Franklin Health Commons Farmington ME 04938

Family Practice Franklin Health Internal Medicine

131 Franklin Health Commons Farmington ME 04938

Internal Medicine Practice Franklin Health Pediatrics

111 Franklin Health Commons Farmington ME 04938

Pediatrician Practice Franklin Health Orthopaedics

111 Franklin Health Commons Farmington ME 04938

Orthopaedic Practice Franklin Health Surgery

111 Franklin Health Commons Farmington ME 04938

General Surgery Practice Rangeley Region Physical Rehabilitation

25 Dallas Hill Road Rangeley ME 04970

Outpatient Physical Therapy Outpatient Services at Livermore Falls

21 Main Street Livermore Falls ME 04254

Outpatient Clinic NorthStar

15 School Street Rangeley ME 04970

Ambulance Base NorthStar

138C Park Street Phillips ME 04966

Ambulance Base NorthStar

119 Federal Road Livermore ME 04254

Ambulance Base NorthStar

1001 Carriage Road Carrabasset Valley ME 04947

Ambulance Base NorthStar

111 Franklin Health Commons Farmington ME 04938

Ambulance Base Franklin Health Women's Care

111 Franklin Health Commons Farmington ME 04938

OB/GYN Franklin Health Child Developmental Prog

131 Franklin Health Commons Farmington ME 04938

Child Developmental Program Franklin Health Behavioral Services

131 Franklin Health Commons Farmington ME 04938

Behavioral Health Practice Franklin Health Dermatology

111 Franklin Health Commons Farmington ME 04938

Dermatology Practice Franklin Health Ear Nose & Throat

111 Franklin Health Commons Farmington ME 04938

ENT Part I, Line 7: The Organization used an overall cost to charge ratio for lines 7a and 7b. A cost to charge ratio using the internal financial accounting of the practices by group was used to calculate the amount reported on line 7g. Part I, Line 7g: The Organization has included costs associated with primary care (Family practice, Pediatrics, Internal Medicine and Women's Care), Behavioral Services, Child & Adolescent Developmental Pediatrics and physical therapy services provided in Rangeley, ME as subsidized health services. Part II: See 990, Schedule H, Part VI, line 5. Part III, Line 4: Patient accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to operations and a credit to a valuation allowance based on its assessment of individual accounts and historical adjustments. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable.Franklin Memorial Hospital used the RCC calculated from Worksheet 2 and multiplied it by the bad debts expense per the financials. Bad debts include 100% of the charges written off due to no payment. If a payment is made on a bad debt account, then that payment reduces the bad debt expense in the year received. FMH has estimated that approximately 20% of the bad debt accounts is attributable to patients who are likely to qualify for charity care. This estimate is based on discussion with financial counselors regarding the number of denied applications due to incomplete documentation as well as overall demographic situation in the service area. Part III, Line 8: The Medicare Principles of Reimbursement were used to determine the Medicare inpatient and outpatient costs based on the Organization's cost report. Part III, Line 9b: Patient balances are screened for eligibility for financial assistance by outside collection agency and are transferred back to Franklin Memorial Hospital for follow up with a counselor as needed. Balances that are owed to the Hospital after applying any financial assistance are collected in the same manner as any other self pay balances. Franklin Memorial Hospital Part V, Section B, Line 13g: Franklin Memorial Hospital takes a number of steps to publicize the availability of the financial assistance to patients: 1. Notices of the availability of financial assistance are posted in locations within the hospital at which members of the public generally transact business with the Hospital or present themselves to receive or request hospital services, including admitting areas, waiting rooms, business offices and outpatient reception areas. 2. With respect with inpatient admissions, individual written notice of the availability of financial assistance is presented to each patient upon admission or in the case of emergency admission before discharge. In addition, all uninsured inpatients are visited by an Advanced Patient Advocacy representative to discuss availability of financial assistance and government coverage options. 3. Availability of financial assistance is publicized on the patient invoices supplying patients with a contact number to obtain further information about available options. 4. Financial assistance options are outlined on the hospitals' website and are readily available to the public. 5. Rack cards & Financial Assistance Applications are located throughout the Hospital & physician practices6. Hospital booklets are available in all patient rooms with there is a section regarding Financial Assistance7. Business office staff and contracted third party collection agency notify all patients with self pay balances about Hospital's financial assistance resources and encourages them to apply for such assistance. Part VI, Line 2: The Franklin Memorial Hospital Network conducts a health visioning process every two years that is used to identify needs and perceived priorities in the community. A physician survey is conducted periodically to assist in gathering information about clinical care needs, referral patterns, specialist needs, etc. The Long-Range Planning Committee, board of directors, and senior leadership use this and other data in developing goals and priorities, making decisions, and setting long-term goals and strategies. The Organization seeks to meet the needs of the population whenever feasible through direct provision of services, contractual relationships, or through referral. Part VI, Line 3: When patients are registered there are brochures available that describe Franklin Memorial Hospital's charity care programs. When a patient is admitted with no insurance, registration sends a financial counselor up to the patient's room to meet the patient. Each bill provided to a patient has the phone number to call if the patient needs financial assistance. The Organization's billers also refer patients to the Organization's financial counselors when a patient is identified as needing assistance. The Organization's pre-collection and collection agencies also educate patients and help to set them up with financial assistance when needed. Part VI, Line 4: Franklin Memorial Hosptial's service area covers 2,200 square miles which extends to the Canadian border. It is one of the most rural and economically challenged regions in Maine, including several areas that have been federally designated as health professional shortage and medically underserved areas. Part VI, Line 5: Community BuildingPhysical Improvements and Housing:1. Development and maintenance of the rail trail which is on FMH property - available to the public to encourage health and wellness. Economic Development:1. Member of Greater Franklin Development Corporation - an organization committed to economic developmentCommunity Support:1. Perform disaster drills with the community 1-2 times a year2. Community Dental (provide low cost rental space)Coalition building:1. Healthy Community Coalition of Greater Franklin County, founded in 1989, is one of the oldest health coalitions in the country. Its mission is to measurably improve the well-being of all people in Greater Franklin County and neighboring towns using a coordinated public health approach of education, promotion, and outreach. With its qualified staff of public health professionals, Healthy Community Coalition offers health screenings, health information, and programs and events to support healthy lifestyles that prevent disease and improve quality of life. Its community outreach efforts appear in every town and corner of the region.In the past year, more than 8,000 individuals benefited from the outreach activities of the Coalition with 3,572 seeking services of the Mobile Health Unit, where health risk appraisals (HRAs) are routinely offered. HRAs include a blood pressure and cholesterol check and individualized health education. Additional outreach events were held throughout the region such as: bone density screenings, flu immunizations, body composition analyzation, free clinical breast exams, education on tobacco, nutrition, physical activity and substance abuse, and education on the prevention of breast, cervical, colon, lung, prostate, and skin cancer.2. AHEC Education Center - Established in 2004 the Franklin AHEC program was developed out of great interest from employees and community members requesting local opportunities to pursue careers in the health field and educational programs for retention and professional growth. The Franklin AHEC allows us to meet the needs of the rural population. It also brings to the Maine AHEC Network the resources of a large innovative rural health system that include a community hospital, Maine's oldest Healthy Community Coalition and the Ben Franklin Center which houses a state of the art education center, medical library facilities, and distance learning opportunities. The program has greatly expanded to include many aspects and activities for retention and recruitment forhealth careers in our vast rural catchment area. Becoming an AHEC center allows us to partner with youth programs, public schools, multiple colleges, adult education, a local career center and other health career programs to offer community members, displaced workers and current healthcare employees the opportunity to continue or pursue careers.3. HealthInfoNet: Twenty-six out of thirty-nine Maine hospitals, including FMH, and more than 240 physician practices in Maine now have access to a new consolidated electronic health record made possible by HealthInfoNet that contains critical information drawn from records that have traditionally been separately maintained in physician practices, hospitals and other settings. Armed with more complete and timely information about a patient, clinicians can provide better quality care and improve the coordination of care, particularly for those patients who see several providers and receive care in more than one community or setting.4. ScoreHealth Screenings - ScoreHealth is a health risk assessment program that helps individuals evaluate many different areas affecting their health, including but not limited to diabetes, cancer, asthma and osteoporosis. The screenings are offered part of the mobile health outreach program conducted by the Healthy Community Coalition of Greater Franklin County and offer cholesterol, blood pressure, BMI and bone density assessments along with counseling on tobacco use and exposure, benefits of physical activity, healthy nutrition and stress management.5. Health Works! Worksite Wellness Award Program is a new and free aware program offered by Healthy Community Coalition of Greater Franklin County. The award program provides businesses and organizations with the opportunity to be recognized as a community leader in health promotion. The purpose of the Healthy Maine Works (HMW) is to guide and support Maine employers in developing worksite wellness programs that support the health of employees. HWM is a project of Maine's Center for Disease Control, Office of Substance Abuse, and Department of Education and is delivered in collaboration with local Healthy Maine Partnerships across the state. Part VI, Line 6: Franklin Communith Health Network: Supporting OrganizationFranklin Memorial Hospital: Community hospitalHealthy Community Coalition: A subsidiary of FCHN - HCC's mission is to measurably improve the health and well-being of all people in Greater Franklin County using a coordinated approach of education, health promotion, and outreach. HCC offers health screenings, health information, and programs and events to support healthy lifestyles that prevent disease and improve quality of life.Evergreen Behavioral Services: Operates 24/7 emergency mental health response services for the Greater Franklin County area as well as bordering towns of Androscoggin & Oxford counties. 1 LifeFlight Foundation PO Box 940 Bangor ME 044020940 522377085 501(c)(3) 20000 Organizational Support 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: All assistance is given to either 501(c)(3) public charities or governmental units and their affiliates. Therefore, additional monitoring is not deemed necessary. X X X X X X 0 0 0 0 0 0 0 0 0 Rebecca Ryder 339125 0 12000 0 0 0 22013 0 9165 0 382303 0 0 0 Dr Peter Cordner 218020 0 0 0 0 0 2890 0 4225 0 225135 0 0 0 Dr Connie Adler 195993 0 8541 0 0 0 9524 0 12720 0 226778 0 0 0 Dr David Hyde 264235 0 0 0 0 0 8570 0 13885 0 286690 0 0 0 Dr Robert O'Reilley 177822 0 0 0 0 0 5025 0 14785 0 197632 0 0 0 Gerald Cayer 222341 0 2496 0 0 0 8636 0 14128 0 247601 0 0 0 Eric Martinsen 165357 0 0 0 16500 0 7528 0 11981 0 201366 0 0 0 Nancy Cummings 425561 0 19100 0 0 0 9800 0 15642 0 470103 0 0 0 Joshua D Sparling 310937 0 164098 0 16484 0 5513 0 14717 0 511749 0 0 0 Larry Michael Fraley 332577 0 0 0 0 0 5513 0 14740 0 352830 0 0 0 Stephen P Zanella 336202 0 0 0 0 0 14700 0 14635 0 365537 0 0 0 Heather DeCarolis 332563 0 0 0 0 0 9800 0 14601 0 356964 0 0 0 Dr Armand Auger 179600 0 33400 0 0 0 9069 0 11568 0 233637 0 0 0 Maine Health & Higher Ed Facilities Authority 010314384 560425G20 2006-09-07 15270692 MRI, Medical Office Building 0 0 1 Maine Health & Higher Ed Facilities Authority 010314384 560427NM4 2011-11-30 10452958 Refunding of Series 2001A 0 0 1 1952929 15270692 622363 221065 13274282 2008 0 0 1 1 1865207 10452958 687452 117007 9633963 2002 1 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part I, Lines 8-18: Prior year numbers have been restated to present revenue net of Bad Debt Expense. Form 990, Part VI, Section A, line 6 The Organization consists of one Member, Franklin Community Health Network. Action of the Member shall be evidenced by written consents that are executed on its behalf by any officer of the Member who is authorized so to act by the board of directors of the Member. The written consent evidencing the annual meeting of the Member shall be adopted and effective as of a date immediately following the annual meeting of the board of directors of the Member or such later date as may be set forth in such written consent. The effective date set forth in such written consent shall be the date of the annual meeting of the year in question. Form 990, Part VI, Section A, line 7a The Member has rights and powers to establish the size of the board of directors of the Organization within the limits prescribed by the Articles of Incorporation and to elect and remove certain directors of the Organization in accordance with the Articles of Incorporation and Bylaws. Form 990, Part VI, Section B, line 11 A complete copy of the form 990 was distributed to each member of the board prior to filing with IRS. In addition, the 990 was reviewed with the board of directors prior to filing the tax return in a form of a presentation and a Q&A session to address any questions or concerns. Form 990, Part VI, Section B, line 12c On an annual basis board members and officers are required to submit a conflict of interest statement which is then reviewed by the compliance committee. The compliance committee is responsible for regularly and consistently monitoring and enforcing compliance with the conflict of interest policy. Form 990, Part VI, Section B, line 15 Executive compensation is determined by the compensation committee which consists of the Board Chair and several board members. The compensation committee uses an independent executive search firm that assists with executive salary determination by providing compensation survey results, along with review of executive compensation reported by other health care organizations on their Form 990. The compensation committee approves the executive compensation package prior to contract execution. Form 990, Part VI, Section C, line 19 The Organization's 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: Change in Net Assets of Affiliate -2,853. Net Change in Perpetual Trust -13,442. Total to Form 990, Part XI, Line 5: -16,295. Oversight of Audit Form 990, Part XI, Line 2c: The audit process has not changed from the prior year. Franklin Community Health Network 111 Franklin Health Commons Farmington ME 04938 223209406 Supporting Organization ME 501(c)(3) Line 11b, II N/A 0 Healthy Community Coalition 105 Mt Blue Circle Suite 1 Farmington ME 04938 223305743 Community Outreach ME 501(c)(3) Line 7 Franklin Community Health Network 0 Pine Tree Medical Associates 131 Franklin Health Commons Farmington ME 04938 010469478 Community Health Agency ME 501(c)(3) Line 9 Franklin Community Health Network 0 Evergreen Behavioral Services 131 Franklin Health Commons Farmington ME 04938 010492747 Mental Health Agency ME 501(c)(3) Line 9 Franklin Community Health Network 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0