2013-05-13T13:26:51-05:00 2012-06-30 232932984 PARENTEBEARD LLC 400 MARKET STREET WILLIAMSPORT PA 17701 990 2011-07-01 240786657 THE MEMORIAL HOSPITAL INC OF TOWANDA PA MEMO 5702652191 91 HOSPITAL DRIVE TOWANDA PA 188489703 GARY A BAKER 5702652191 2013-05-09 1 JULIUS C GREEN CPA JD P00350393 5703236023 2011 2016-02-24 21:20:13Z GARY A BAKER 91 HOSPITAL DRIVE TOWANDA PA 188489703 41208473 0 X WWW.MEMORIALHOSPITAL.ORG X 1946 PA TO OPERATE AN ACUTE CARE HOSPITAL AND LONG TERM CARE FACILITY IN TOWANDA, PENNSYLVANIA. 28 25 587 22 0 0 277713 122234 40025437 40120588 292127 283227 702016 326935 41297293 40852984 0 0 0 0 21459214 21861118 0 0 0 18843904 19682470 40303118 41543588 994175 -690604 46198397 43935309 20936803 19735323 25261594 24199986 X THE MISSION OF MEMORIAL HOSPITAL, INC., A NONPROFIT ORGANIZATION, IS TO PROVIDE SUPERIOR QUALITY HEALTH CARE SERVICES IN A CARING, EFFICIENT, AND FINANCIALLY RESPONSIBLE MANNER THAT WILL IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 39114237 40120588 MEMORIAL HOSPITAL, INC. OF TOWANDA, PA IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL AND LONG TERM CARE FACILITY LOCATED IN TOWANDA, PA. THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, EMERGENCY CARE, LONG-TERM CARE AND HOME HEALTH SERVICES TO RESIDENTS OF TOWANDA, PA AND SURROUNDING COMMUNITIES. OUR DOCTORS CONTINUOUSLY WORK WITH OUR OWN QUALIFIED SPECIALISTS AND MANY OTHERS WITHIN THE BRADFORD AND SULLIVAN COUNTY MEDICAL COMMUNITY AS WELL AS OUTSIDE OF THIS AREA TO PROVIDE ACCESS TO QUALITY SPECIALTY CARE.WE ROUTINELY WORK WITH SPECIALISTS IN SAYRE, PA; ELMIRA, NY; BINGHAMTON, NY; WILLIAMSPORT, PA; SCRANTON, PA; DANVILLE, PA; AND PHILADELPHIA, PA, TO MEET OUR PATIENTS' HEALTHCARE NEEDS.IN FEBRUARY 2008, COMMUNITY HEALTH ASSOCIATES, LLC, A SINGLE MEMBER LLC OWNED SOLELY BY MEMORIAL HOSPITAL, INC. WAS ESTABLISHED. THE PURPOSE OF COMMUNITY HEALTH ASSOCIATES, LLC IS TO EMPLOY PHYSICIANS TO ASSIST THE HOSPITAL WITH MEETING ITS MISSION AND TO IMPROVE THE RECRUITING AND RETENTION OF PHYSICIANS IN THE AREA.IN THE YEAR ENDING JUNE 30, 2012, THE HOSPITAL ADMITTED 1,781 PATIENTS AND HAD A TOTAL OF 53,151 PATIENT DAYS. TOTAL PATIENT DAYS WERE COMPRISED OF 5,631 ACUTE CARE; 388 NURSERY; 25,672 PERSONAL CARE HOME, AND 22,770 SKILLED NURSING. WE CONDUCTED 4,972 HOME HEALTH VISITS AND RECEIVED 53,196 OTHER OUTPATIENT VISITS. THE MATERNITY CENTER DELIVERED 171 NEWBORNS. THE ER SAW 11,313 VISITS DURING THE YEAR. DURING THE FISCAL YEAR JUNE 30, 2012, THE HOSPITAL PROVIDED APPROXIMATELY $182,500 IN CHARITY CARE (COST BASIS) TO THE COMMUNITIES IT SERVES. MEMORIAL HOSPITAL IS DIRECTED BY A BOARD OF COMMUNITY LEADERS KNOWN AS TRUSTEES AND IS SUPPORTED BY THE SERVICE OF DOZENS OF VOLUNTEERS INCLUDING A VERY ACTIVE AUXILIARY.MANY OF MEMORIAL HOSPITAL'S ACTIVE MEDICAL STAFF PHYSICIANS ARE BOARD CERTIFIED IN THEIR RESPECTIVE SPECIALTIES, REFLECTING A DEDICATION AND COMMITMENT TO PROVIDE THE HIGHEST QUALITY OF CARE TO MEMORIAL HOSPITAL'S PATIENTS. ALL THREE LEADERSHIP GROUPS OF THE HOSPITAL - THE BOARD OF TRUSTEES, MEDICAL STAFF AND ADMINISTRATION - CONTINUOUSLY WORK TOGETHER TO IDENTIFY AND DIRECT THE PRIORITIES OF THE HOSPITAL THROUGH THE DEVELOPMENT AND IMPLEMENTATION OF STRATEGIC PLANS WITHIN THE SCOPE OF OUR MISSION. FROM EMERGENCY SERVICES TO OUR MATERNITY CENTER, FROM TOP-NOTCH RADIOLOGY DIAGNOSTICS TO LONG-TERM CARE, FROM HOME HEALTH TO OUTPATIENT THERAPIES, WE ARE HERE FOR FAMILIES AND INDIVIDUALS IN OUR COMMUNITIES. WE ARE COMMITTED TO MEETING THE HEALTH CARE NEEDS OF OUR RESIDENTS AND WILL DO OUR BEST TO MEET AND EXCEED THEIR EXPECTATIONS.MEMORIAL HOSPITAL, INC. PROVIDES HEALTH CARE TO RESIDENTS IN THE BRADFORD AND SULLIVAN COUNTY AREAS. THE HOSPITAL PROVIDES A WIDE RANGE OF SERVICES TO PATIENTS WITHOUT REGARD TO THE INDIVIDUAL'S ABILITY TO PAY. THE HOSPITAL'S EMERGENCY DEPARTMENT IS AVAILABLE ON A 7 DAY A WEEK, 24 HOUR A DAY BASIS FOR THE EMERGENT, AS WELL AS NON-EMERGENT, NEEDS OF THOSE THAT SEEK CARE. THE HOSPITAL HAS A HOSPITAL-BASED SKILLED NURSING FACILITY THAT CARES FORA VERY HIGH PERCENTAGE OF MEDICAL ASSISTANCE RESIDENTS, AS WELL AS SOME MEDICARE RESIDENTS. 39114237 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 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 1 1 1 1 0 0 1 30 0 1 587 1 0 0 0 0 0 0 0 0 0 0 X 28 25 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X WILLIAM ROHRBACH 5702682207 91 HOSPITAL DRIVE TOWANDA PA 18848 X RONALD BLACK MD 5.00 X 0 0 0 DONALD BRENNAN 5.00 X 0 0 0 PETER BRODERICK 5.00 X 0 0 0 BRIAN GROVE 5.00 X 0 0 0 RAY DEPAOLA 5.00 X 0 0 0 HANK DUNN 5.00 X 0 0 0 BRIAN EMICK 5.00 X 0 0 0 MARK GANNON 5.00 X 0 0 0 LEWIS HOPE 5.00 X 0 0 0 MARJORY KREISCHER 5.00 X 0 0 0 LEO LAMBERT 5.00 X 0 0 0 WILLIAM MCNETT 5.00 X 0 0 0 JODY PLACE 5.00 X 0 0 0 GERALD E SHAFFER 5.00 X 0 0 0 MARGUERITE SHANER 5.00 X 0 0 0 BARBARA YANAK OD 5.00 X 0 0 0 JAMES PARKS 5.00 X X 0 0 0 JOHN L SCHOONOVER III 5.00 X X 0 0 0 ROBERT FERRARIO 5.00 X X 0 0 0 DAVID PACKARD 5.00 X X 0 0 0 WILLIAM ROHRBACH 40.00 X X 168951 0 12093 ALFREDO LLINAS 40.00 X 137446 0 9191 LISA CERAOLO 40.00 X 186054 0 11144 JOSEPH CAMA MD 5.00 X 0 0 0 TOM THOMPSON 5.00 X 0 0 0 STACY L GARRITY 5.00 X 0 0 0 JAMES RODENHIZER 5.00 X 0 0 0 ERIC R ROWE 5.00 X 0 0 0 GARY A BAKER 40.00 X 237246 0 52018 LARRY LINNELL 40.00 X 188023 0 11660 GEETA KRISHNAN 22.00 X 149500 0 0 TIMOTHY DENNEN 40.00 X 170136 0 12947 JAI NAIDU 40.00 X 145362 0 15940 CYNTHIA LAMBERT 40.00 X 122923 0 17105 1505641 0 142098 11 0 1 0 TEAM CARE PC 2031 ORANGE HILL ROAD ATHENS PA 18810 EMERGENCY PHYSICIAN SERVICES 1051200 GULFSTREAM ANESTHESIA CONSULTANTS PO BOX 212110 ROYAL PALM BEACH FL 33421 ANESTHESIA SERVICES 853811 KINGS MEDICAL GROUP PO BOX 72483 CLEVELAND OH 44192 MRI SERVICES 305060 MORRISON MANAGEMENT SPECIALIST PO BOX 102289 ATLANTA GA 30368 DIETARY MANAGEMENT SERVICES 215962 ASSOCIATED RADIOLOGISTS 100 EAST FOURTEENTH STREET ELMIRA HEIGHTS NY 14903 RADIOLOGY SERVICES 182908 9 18366 103868 9700 122234 NET PATIENT SVC REV 621990 40058377 40058377 THERAPIES & PROGRAMS 621990 62211 62211 40120588 351082 351082 119367 68299 51068 51068 51068 211905 279760 -67855 -67855 -67855 11961 7430 4531 4531 CAFETERIA/VENDING 722210 118559 118559 PURCHASE DISCOUNTS 900099 91139 91139 PHARMACY REVENUE 900099 20485 20485 41153 41153 271336 40852984 40120588 0 610162 502352 502352 16152288 15131802 1020486 1014149 952978 61171 3006794 2821736 185058 1185535 1114403 71132 441229 245754 195475 33482 33482 81400 81400 3294 3294 4833372 4498121 335251 66131 52107 14024 3501953 3300827 201126 933729 916584 17145 156384 154570 1814 46203 41913 4290 483702 483702 2313547 2313547 877658 877658 BAD DEBT EXPENSE 4696903 4696903 DIETARY EXPENSE 499660 483470 16190 REPAIRS & MAINTENANCE 357012 357012 ADMIN ALLOCATION 97189 97189 259622 71609 188013 41543588 39114237 2429351 0 1351 1339 2871330 697478 5073889 5676009 545393 529251 228509 583445 45093531 24782369 21778753 20311162 80167 70627 289586 579075 15329419 15486923 46198397 43935309 2536021 2180617 11575250 10294177 6825532 7260529 20936803 19735323 X 24440400 23631966 756194 503020 65000 65000 25261594 24199986 46198397 43935309 X -690604 -371004 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 3294 0 0 0 3294 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE MEMORIAL HOSPITAL, INC. OF TOWANDA, PA INCURS LOBBYING EXPENSES ONLY AS A PORTION OF THEIR HAP DUES APPLICABLE TO THE YEAR ENDED 6/30/12. THESE EXPENSES ARE APPROX. 25.04% OF DUES FOR THE YEAR. 1 7144 113932 111786 9290 247164 247164 25766744 10161691 15605053 18743250 14620678 4122572 336373 336373 20311162 DEFERRED FINANCING COSTS, NET 33922 BENEFICIAL INTEREST IN ASSETS HELD BY MEMORIAL HOSPITAL FDN 15351323 OTHER CURRENT ASSETS 101678 15486923 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 649456 AMTS W/H FROM EMPLOYEES FOR TAXES, ETC. 76295 BLUE CROSS ADVANCE 184441 PENSION LIABILITY 2508154 AMOUNTS DUE TO AFFILIATES 3085353 ESTIMATED MED MALPRACTICE CLAIMS LIAB 756830 7260529 40852984 41543588 -690604 -5960 -365044 -371004 -1061608 40625564 -5960 -365044 -371004 40996568 -143584 -143584 40852984 41687172 143584 143584 41543588 0 41543588 PART IV, LINE 1B: THE HOSPITAL MAINTAINS A SEPARATE ACCOUNT WITH SKILLED NURSING FACILITY RESIDENT FUNDS OF WHICH WE ARE THE REPRESENTATIVE PAYEE. FUNDS ARE USED TO PAY PATIENTS' BILLS AND PERSONAL EXPENSES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION ACCOUNTS FOR UNCERTAINTY IN INCOME TAXES USING A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN NOT TO BE SUSTAINTED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY. MEASUREMENT OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD IS MET. MANAGEMENT DETERMINED THAT THERE WERE NO TAX UNCERTAINTIES THAT MET THE RECOGNITION THRESHOLD IN 2012 & 2011. THE ORGANIZATION'S FEDERAL INCOME TAX RETURNS FOR JUNE 30, 2011, 2010, AND 2009 REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION LIABILITY ADJUSTMENT -892,068. CHANGE IN INTEREST IN MEMORIAL HOSPITAL FOUNDATION 508,561. CHANGE IN TEMPORARILY RESTRICTED INTEREST IN MEMORIAL HOSPITAL FOUNDATION 18,463. TOTAL TO SCHEDULE D, PART XI, LINE 8: -365,044. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN MEMORIAL HOSPITAL FOUNDATION 508,561. PENSION LIABILITY ADJUSTMENT -892,068. CHANGE IN TEMPORARILY RESTRICTED INTEREST IN MEMORIAL HOSPITAL FOUNDATION 18,463. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -68,299. LOSS ON DISPOSAL OF EQUIPMENT -67,855. GAMING EXPENSES -7,430. PART XIII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON DISPOSAL OF EQUIPMENT 67,855. RENTAL EXPENSES 68,299. GAMING EXPENSES 7,430. 1 1 1 X 1 X 1 1 1 0 0 182498 182498 0.00500 3945955 1999706 1946249 0.05280 4128453 1999706 2128747 0.05780 46203 46203 0.00130 6226536 4649219 1577317 0.04280 6272739 4649219 1623520 0.04410 10401192 6648925 3752267 0.10190 0 1670219 71120 347369 330865 16504 X 1 1 1 1 THE MEMORIAL HOSP INC OF TOWANDA PA

91 HOSPITAL DRIVE TOWANDA PA 18848

X X X THE MEMORIAL HOSPITAL INC OF TOWANDA 1 1 1 200.000000000000 1 200.000000000000 1 X X X 1 1 X X X X 1 0 1 X 0 1 PART I, LINE 7: THE RATIO OF COST TO CHARGES WAS COMPUTED USING PATIENT CHARGES AND PATIENT COST EXCLUDING RELATED BAD DEBT COSTS COUNTED ELSEWHERE IN THE COMMUNITY BENEFIT NUMBERS. THE NUMBERS USED IN THE CALCULATION OF THE RATIO WERE OBTAINED FROM THE MEDICARE COST REPORT FOR THE RELATED PERIOD. THIS RATIO IS USED IN THE CALCULATION OF CHARITY CARE, MEDICAID, OTHER MEANS-TESTED GOVERNMENT PROGRAMS AND SUBSIDIZED HEALTH SERVICES. FOR THE REMAINING LINES, DIRECT EXPENSES WERE IDENTIFIED BY PROGRAM BASED ON PROGRAM RECORDS. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25 COLUMN (A) BUT SUBTRACTED OUT FOR PURPOSES OF CALCULATING THE PERCENTAGE ON SCH H, PART I, LINE 7, COLUMN (F) IS $4,696,903. PART III, LINE 4: ACCOUNTS RECEIVABLE, PATIENTS ARE REPORTED AT NET REALIZABLE VALUE. ACCOUNTS ARE WRITTEN OFF WHEN THEY ARE DETERMINED TO BE UNCOLLECTIBLE BASED UPON THE ORGANIZATION'S APPROVED WRITE-OFF POLICY. THE ALLOWANCE FOR DOUBTFUL COLLECTIONS IS ESTIMATED BASED UPON A PERIODIC REVIEW OF THE ACCOUNTS RECEIVABLE AGING, PAYOR CLASSIFICATIONS, AND APPLICATION OF HISTORICAL WRITE-OFF PERCENTAGES.TOTAL RATIO OF COST TO CHARGES (BAD DEBT EXPENSE WAS BACKED OUT TO CALCULATE THE RATIO) WAS USED TO CALCULATE BAD DEBT EXPENSE.MEMORIAL HOSPITAL OF TOWANDA PROVIDES CARE TO ALL PATIENTS WHO NEED IT, REGARDLESS OF THEIR ABILITY TO PAY. THIS IS PART OF THE HOSPITAL'S MISSION. PART III, LINE 8: MEDICARE ALLOWABLE COST AMOUNT DETERMINED FROM MEDICARE COST REPORT. PART III, LINE 9B: IF UPON REGISTRATION, PATIENT IS DETERMINED TO HAVE NO INSURANCE AND QUALIFIES FOR FINANCIAL ASSISTANCE THEY ARE ASKED TO PROVIDE COPIES OF A W-2, PAY STUB, OR INCOME TAX RETURN TO COMPLETE OUR CHARITY CARE APPLICATION. DETERMINATION IS MADE BASED ON INFORMATION RECEIVED AND FINANCIAL GUIDELINES. THE MEMORIAL HOSPITAL, INC. OF TOWANDA PART V, SECTION B, LINE 19D: ALL PATIENTS ARE CHARGED GROSS CHARGES FOR SERVICES PROVIDED THE MEMORIAL HOSPITAL, INC. OF TOWANDA PART V, SECTION B, LINE 21: ALL PATIENTS ARE CHARGED GROSS CHARGES FOR SERVICES PROVIDED. PART VI, LINE 2: MEMORIAL HOSPITAL CONDUCTS ITS OWN HEALTH CARE ASSESSMENT ON AN ONGOING BASIS FOR THE HOSPITAL'S PRIMARY (ZIP CODES: 18837, 18854, 18815, 18853, 18814, 18848, 18832, 18833, 18614, 16947, 16926, 17743, 17724 AND 17735) AND SECONDARY (16914, 18817, 18840, 18831, 18850, 18851, 18829, 18845, 18818, 18828, 18839, 18801, 18843, 18846, 18616 AND 18632) SERVICE AREA. THE HOSPITAL USES ITS BOARD OF TRUSTEES, PHYSICIANS ON STAFF, EMPLOYEES AND COMMUNITY MEMBERS TO IDENTIFY NEEDS BASED ON INFORMATION OBTAINED BY THESE INDIVIDUALS OR GROUPS. BASED ON WHAT IS OBTAINED, THE HOSPITAL CAN THEN DETERMINE WHAT HEALTHCARE SERVICES SHOULD BE CONSIDERED TO BE OFFERED IN THE COMMUNITY.IN ACCORDANCE WITH THE AFFORDABLE CARE ACT, THE HOSPITAL IS UNDERGOING A COMMUNITY NEEDS ASSESSMENT WITH THE GUIDANCE OF PARENTEBEARD FOR FISCAL YEAR 2013. THE FINAL COMMUNITY MEETING IS SCHEDULED TO BE HELD ON MAY 16, 2013 AND A FINAL REPORT WILL BE ISSUED SOON AFTER. PART VI, LINE 3: INFORMATION IS PROVIDED THROUGHOUT THE HOSPITAL REGARDING THE CHARITY CARE PROGRAM. TELEPHONE CALLS ARE MADE TO ALL SELF PAY PATIENTS AS WELL AS SEEING THEM PERSONALLY IF THEY HAPPEN TO BE AN INPATIENT OF THE HOSPITAL. EVERY INTAKE AREA OF THE HOSPITAL HAS INFORMATION REGARDING THE FINANCIAL ASSISTANCE THE HOSPITAL CAN PROVIDE AND THE CONTACT INFORMATION FOR THE HOSPITAL'S FINANCIAL COUNSELOR IS MADE AVAILABLE. ALL NEW HIRED EMPLOYEES IN INTAKE AREAS ARE TRAINED IN THE FINANCIAL ASSISTANCE POLICIES AS PART OF THEIR ORIENTATION PROCESS. A NOTICE FOR FINANCIAL AID IS POSTED ON THE HOSPITAL'S WEB SITE FOR THOSE SEEKING THE INFORMATION VIA THE WEB. IN THE EVENT AN INTERPRETER IS NEEDED TO ASSIST A PATIENT WHO DOES NOT SPEAK ENGLISH, ONE CAN BE PROVIDED. PART VI, LINE 4: MEMORIAL HOSPITAL SERVES A RURAL PORTION OF BRADFORD AND SULLIVAN COUNTIES IN NORTHEAST PA. THE TOTAL POPULATION FOR BOTH COUNTIES IS APPROXIMATELY 67,000. THE HOSPITAL SERVES A HIGH PERCENTAGE OF MEDICAL ASSISTANCE PATIENTS AND IS ELIGIBLE FOR DSH REIMBURSEMENT AS A RESULT. ACCORDING TO THE PENNSYLVANIA HEALTH CARE COST CONTAINMENT COUNCIL (PHC4), MEMORIAL HOSPITAL HAD A 13.86% SHARE OF NET PATIENT REVENUE COMING FROM MEDICAL ASSISTANCE PATIENTS. THE AVERAGE FOR THE REGION MEMORIAL HOSPITAL IS LOCATED IN IS 8.03%. MEMORIAL HOSPITAL ALSO HAD, ACCORDING TO PHC4, AN UNCOMPENSATED CARE PERCENTAGE OF 4.86% WITH THE REGION AVERAGE BEING 2.97%. THE HOSPITAL'S 24 HOUR EMERGENCY ROOM CARES FOR MANY PATIENTS SEEKING PRIMARY CARE WHO DO NOT HAVE AN EXISTING PRIMARY CARE PHYSICIAN. WITHIN BRADFORD AND SULLIVAN COUNTIES THERE ARE AREAS DESIGNATED AS MEDICALLY UNDERSERVED, WITH THE HOSPITAL CARING FOR MANY PATIENTS WITHIN THOSE AREAS. PART VI, LINE 5: MEMORIAL HOSPITAL IS GOVERNED BY A 30 MEMBER VOLUNTEER BOARD OF TRUSTEES WITH THE MAJORITY OF THOSE TRUSTEES RESIDING IN THE HOSPITAL'S PRIMARY SERVICE AREA. THE CFO AND 2 EMPLOYED PHYSICIANS ARE MEMBERS OF THE BOARD OF TRUSTEES. THE REMAINING 27 MEMBERS ARE COMMUNITY MEMBERS OF THE AREAS THE HOSPITAL SERVES THAT ARE NEITHER EMPLOYEES, CONTRACTORS OF THE ORGANIZATION, OR FAMILY MEMBERS THEREOF. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY WHO SEEK THOSE PRIVILEGES. ANY SURPLUS FUNDS GENERATED BY THE HOSPITAL ARE USED FOR FUNDING IMPROVEMENTS IN PATIENT CARE. THE HOSPITAL'S 24 HOUR EMERGENCY ROOM TREATS ALL PATIENTS WHO PRESENT REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL PARTICIPATES WITH ALL GOVERNMENT SPONSORED HEALTH CARE PROGRAMS AND OFFERS FINANCIAL ASSISTANCE TO PATIENTS WHO SEEK ASSISTANCE AND MEET THE GUIDELINES. PART VI, LINE 6: MEMORIAL HOSPITAL IS SUPPORTED BY THE MEMORIAL HOSPITAL FOUNDATION, WHICH WAS ESTABLISHED IN 2003 TO FOSTER AND SUPPORT SPECIFIC PROJECTS AND PROGRAMS TO IMPROVE THE HOSPITAL'S SERVICES TO ITS PATIENTS. THE MISSION OF THE MEMORIAL HOSPITAL FOUNDATION IS TO GENERATE RESOURCES FOR THE SUSTAINABILITY AND ADVANCEMENT OF HEALTHCARE IN THE COMMUNITIES IT HAS THE PRIVILEGE OF SERVING.PART VI, LINE 7: AT PRESENT THE HOSPITAL DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATE. THE HOSPITAL PLANS TO FILE A COMMUNITY BENEFIT REPORT WITH THE COMMONWEALTH OF PA BEGINNING WITH THE JUNE 30, 2013 RETURN. X X X X X 0 0 0 0 0 0 0 0 0 WILLIAM ROHRBACH 143931 0 25020 0 0 0 6063 0 6030 0 181044 0 0 0 LISA CERAOLO 186054 0 0 0 0 0 0 0 11144 0 197198 0 0 0 GARY A BAKER 187590 0 49656 0 0 0 11948 0 40070 0 289264 0 0 0 LARRY LINNELL 188023 0 0 0 0 0 5677 0 5983 0 199683 0 0 0 TIMOTHY DENNEN 170136 0 0 0 0 0 0 0 12947 0 183083 0 0 0 JAI NAIDU 145362 0 0 0 0 0 0 0 15940 0 161302 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 JIM PARKS (CHAIRMAN) IS THE BROTHER-IN-LAW OF ROBERT FERRARIO (SECRETARY). FORM 990, PART VI, SECTION A, LINE 3 MEMORIAL HOSPITAL HAS A MANAGEMENT CONTRACT WITH QUORUM HEALTH RESOURCES. GARY BAKER, PRESIDENT/CEO, IS EMPLOYED BY QUORUM HEALTH RESOURCES. FORM 990, PART VI, SECTION B, LINE 11 REVIEWED IN DETAIL BY MANAGEMENT WITH THE HELP OF PARENTEBEARD. A COPY OF THE RETURN WAS EMAILED TO THE MEMBERS OF THE FINANCE COMMITTEE OF THE BOARD OF TRUSTEES FOR THEIR REVIEW BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C OUR TRUSTEES, MEDICAL STAFF AND MANAGEMENT STAFF ALL ARE REQUIRED TO DISCLOSE CONFLICTS OF INTEREST THROUGH A FORMAL PROCESS OF REVIEWING THE POLICY & DISCLOSING & SIGNING A STATEMENT. THEY ARE ENCOURAGED TO PARTICIPATE IN DISCUSSION, BUT WILL ABSTAIN DURING VOTES. FAILURE TO FULLY DISCLOSE ANY CONFLICTS OF INTEREST ARE REVIEWED BY MANAGEMENT. DISCIPLINARY ACTIONS RESULTING FROM INADEQUATE DISCLOSURE ARE DETERMINED ON A CASE BY CASE MANNER AND COULD RESULT IN TERMINATION OF EMPLOYMENT. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE REVIEWS AND APPROVES THE SALARIES OF THE CEO, CFO AND VP'S. MEMBERS OF THE BOARD, AS WELL AS THE VP OF THE MANAGEMENT COMPANY, ARE INVOLVED IN SETTING COMPENSATION. SURVEYS ARE USED TO COMPARE THE SALARIES TO MAINTAIN APPROPRIATENESS OF WAGES. REVIEW AND APPROVAL IS DOCUMENTED IN COMMITTEE MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND/OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION A: AVERAGE HOURS PER WEEK FOR THE FOUNDATION AND RELATED ORGANIZATIONS ARE AS FOLLOWS: WILLIAM ROHRBACH - 42 HOURS GARY A. BAKER - 42 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -5,960. PENSION LIABILITY ADJUSTMENT -892,068. CHANGE IN INTEREST IN MEMORIAL HOSPITAL FOUNDATION 508,561. CHANGE IN TEMPORARILY RESTRICTED INTEREST IN MEMORIAL HOSPITAL FOUNDATION 18,463. TOTAL TO FORM 990, PART XI, LINE 5: -371,004. COMMUNITY HEALTH ASSOCIATES LLC 91 HOSPITAL DRIVE TOWANDA PA 18848 262096228 EMPLOYS PHYSICIANS FOR THE HOSPITAL PA 1999045 851049 THE MEMORIAL HOSPITAL INC OF TOWANDA THE MEMORIAL HOSPITAL FOUNDATION 91 HOSPITAL DRIVE TOWANDA PA 188489703 651160811 SUPPORTS THE ACTIVITIES AND PURPOSES OF THE HOSPITAL PA 501(C)(3) 11A THE MEMORIAL HOSPITAL INC OF TOWANDA 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 THE MEMORIAL HOSPITAL FOUNDATION C 18366 CASH THE MEMORIAL HOSPITAL FOUNDATION D 6348156 CASH