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COMMUNITY MEMORIAL HOSPITAL INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
COMMUNITY MEMORIAL HOSPITAL INC (EIN 15-0548010)
Tax period
2012-01-01 to 2012-12-31
Filed
2013-09-12
IRS object ID
201322559349300147
Schema version
2012v2.1
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-09-12T13:58:40-05:00Timestamp
Tax Period End Date2012-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN161226221EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1FUST CHARLES CHAMBERS LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line15784 WIDEWATERS PARKWAYAddressLine1
CitySYRACUSECity
StateNYState
ZIP Code13214ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN150548010EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY MEMORIAL HOSPITAL INCBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlCOMMNameControl
Phone3158246081Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1150 BROAD STREETAddressLine1
CityHAMILTONCity
StateNYState
ZIP Code13346ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameRICHARD S KIRBYName
TitleEXEC VP/CFOTitle
Phone3158246081Phone
Date Signed2013-09-05DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameANGELA M FRANCOName
PTINP00589741PTIN
Phone3154463600Phone
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonRICHARD S KIRBYNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1150 BROAD STREETAddressLine1
CityHAMILTONCity
StateNYState
ZIP Code13346ZIPCode
FieldValueIRS element (for citing)
Gross Receipts41400350GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteCOMMUNITYMEMORIAL.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1949YearFormation
State Legal DomicileNYStateLegalDomicile
Activity Or Mission DescriptionCOMMUNITY MEMORIAL HOSPITAL'S PRIMARY EXEMPT PURPOSE IS TO PROVIDE EMERGENCY AND INPATIENT CARE TO THE GENERAL POPULATION WITHOUT REGARD TO ABILITY TO PAY.ActivityOrMissionDescription
Nbr Voting Members Governing Body16NbrVotingMembersGoverningBody
Nbr Independent Voting Members14NbrIndependentVotingMembers
Total Nbr Employees417TotalNbrEmployees
Total Nbr Volunteers25TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year531766ContributionsGrantsPriorYear
Contributions Grants Current Year744789ContributionsGrantsCurrentYear
Program Service Revenue Prior Year40370075ProgramServiceRevenuePriorYear
Program Service Revenue CY40204010ProgramServiceRevenueCY
Investment Income Prior Year32555InvestmentIncomePriorYear
Investment Income Current Year32047InvestmentIncomeCurrentYear
Other Revenue Prior Year302629OtherRevenuePriorYear
Other Revenue Current Year325442OtherRevenueCurrentYear
Total Revenue Prior Year41237025TotalRevenuePriorYear
Total Revenue Current Year41306288TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year22683919SalariesEtcPriorYear
Salaries Etc Current Year21769730SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year20162988OtherExpensePriorYear
Other Expenses Current Year19178114OtherExpensesCurrentYear
Total Expenses Prior Year42846907TotalExpensesPriorYear
Total Expenses Current Year40947844TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-1609882RevenuesLessExpensesPriorYear
Revenues Less Expenses CY358444RevenuesLessExpensesCY
Total Assets BOY20007959TotalAssetsBOY
Total Assets EOY19681324TotalAssetsEOY
Total Liabilities BOY12413722TotalLiabilitiesBOY
Total Liabilities EOY11587385TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY7594237NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY8093939NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionCOMMUNITY MEMORIAL HOSPITAL'S PRIMARY EXEMPT PURPOSE IS TO PROVIDE EMERGENCY AND INPATIENT CARE TO THE GENERAL POPULATION WITHOUT REGARD TO ABILITY TO PAY.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense22705655Expense
Revenue21418628Revenue
DescriptionOPERATION OF AN ACUTE CARE GENERAL HOSPITAL WITH AN ATTACHED SKILLED NURSING FACILITY. ACUTE CARE SNFBEDS 36 40PATIENT DAYS OF CARE 5317 14104ADMISSIONS 1680 58COMMUNITY MEMORIAL HOSPITAL HAS RECEIVED MANY AWARDS FOR OUTSTANDING CARE TO INCLUDE: 1) A LEADER IN UPSTATE NEW YORK IN PATIENT SATISFACTION2) JUDGED OUTSTANDING IN PATIENT CARE AND PATIENT SAFETY BY BOTH STATE AND FEDERAL SURVEYORS3) HEALTHGRADES MULTI-YEAR 5 STAR RATING IN ORTHOPEDIC SURGERY INCLUDING HIP AND KNEE REPLACEMENTS. 4) VHA AWARD FOR QUALITY OF CARE A) LOW RATE OF SURGICAL COMPLICATIONS B) LOW RATE OF HOSPITAL ACQUIRED INFECTIONS5) JOINT COMMISSION RECOGNITION AS TOP PERFORMER IN QUALITY MEASURES6) LEAPFROG GROUP A RATING ON PATIENT SAFETYCOMMUNITY MEMORIAL HOSPITAL STRIVES TO IMPROVE THE HEALTH OF THE COMMUNITY BY:1) PARTICIPATING IN LOCAL HEALTH FAIRS2) IMPROVING ACCESS TO PRIMARY CARE3) IMPROVING THE CARE OF CHRONIC ILLNESSES SUCH AS DIABETES4) IMPROVING HEALTH CARE LITERACY5) HEALTH CAREER SUMMER PROGRAM FOR AREA CHILDREN6) INCREASING ACCESS TO SPECIALTY SERVICESCOMMUNITY MEMORIAL HOSPITAL HAS A CHARITY CARE PROGRAM FOR PATIENTS WHO CANNOT AFFORD TO PAY HOSPITAL BILLS AND FALL WITHIN THE NATIONAL POVERTY GUIDELINES, UP TO 300% OF THE POVERTY GUIDELINES. IN 2012 COMMUNITY MEMORIAL HOSPITAL PROVIDED CHARITY CARE IN THE AMOUNT OF $336199 TO APPROXIMATELY 251 PATIENTS.Description

Activity2 Activity2

FieldValueIRS element (for citing)
Expense4474021Expense
Revenue5858497Revenue
DescriptionOPERATION OF AN AMBULATORY SURGERY UNITTOTAL VISITS 1762Description

Activity3 Activity3

FieldValueIRS element (for citing)
Expense6711031Expense
Revenue9183810Revenue
DescriptionOPERATION OF EMERGENCY SERVICES AND OUTPATIENT REFERRED AMBULATORY TESTING EMERGENCY ROOM VISITS 9352REFERRED AMBULATORY VISITS 35866Description

Activity Other ActivityOther

FieldValueIRS element (for citing)
Expense3392799Expense
Revenue3743075Revenue
DescriptionOPERATION OF PRIMARY CARE CLINICS TOTAL VISITS 53818Description
FieldValueIRS element (for citing)
Total Of Other Program Service Exp3392799TotalOfOtherProgramServiceExp
Total Of Other Program Service Rev3743075TotalOfOtherProgramServiceRev
Total Program Service Expense37283506TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments1TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Financial Stmt Attached1FinancialStmtAttached
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109613NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees417NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members16NbrVotingGoverningBodyMembers
Number Independent Voting Members14NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs1ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body0Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledNYStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1RICHARD S KIRBYBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number3158246081TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1150 BROAD STREETAddressLine1
CityHAMILTONCity
StateNYState
ZIP Code13346ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (23 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficerHighest Compensated EmployeeHighestCompensatedEmployee
LAWRENCE BAKER
TRUSTEE1.00X000
SUSAN BARRETT
TRUSTEE1.00X000
PATRICIA CAPRIO
TRUSTEE1.00X000
IVAN GOWAN
TRUSTEE1.00X000
SUSIE GUSTAFSON
TRUSTEE1.00X000
WILLIAM MAGEE
TRUSTEE1.00X000
JANE PINCHIN
TRUSTEE1.00X000
KERRI TAYLOR
TRUSTEE40.00X170250023588
BRADFORD WHELER
TRUSTEE1.00X000
LAWRENCE TULLY
CHAIRMAN1.00X000X
WILLIAM GETMAN
VICE CHAIRMAN1.00X000X
DAVID HALE
TREASURER1.00X000X
JEFFREY RUBENSTEIN
SECRETARY1.00X000X
MATTHEW NORRIS
TRUSTEE1.00X000
EVE ANN SCHWARTZ
TRUSTEE1.00X000
SEAN FADALE
PRESIDENT/CEO40.00X101923020904X
DAVID FELTON
PRESIDENT/CEO40.00298772031935X
RICHARD KIRBY
EXEC VP/COO/CFO40.00206036037990X
RAYMOND CARLSON
PHYSICIAN40.00364300023588X
ROBERT DELORME
PHYSICIAN40.00258200023588X
CHERYL MATTERN
PHYSICIAN40.00215579023588X
EDWARD MCDONALD
PHYSICIAN40.00224810023588X
EUFROSINA YOUNG
PHYSICIAN40.00295210023588X
FieldValueIRS element (for citing)
Total Reportable Comp From Org2135080TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation232357TotalOtherCompensation
Number Individuals GT100 K21NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation

Name Of Contractor NameOfContractor

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1HAMILTON CRITICAL CARE & EMERGENCYBusinessNameLine1

Address Of Contractor AddressOfContractor

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1PO BOX 605AddressLine1
CityDEWITTCity
StateNYState
ZIP Code13214ZIPCode
FieldValueIRS element (for citing)
Description Of ServicesEMERGENCY ROOM SERVICESDescriptionOfServices
Compensation120000Compensation
FieldValueIRS element (for citing)
Number Of Contractors GT100 K1NumberOfContractorsGT100K
Government Grants744789GovernmentGrants
Total Contributions744789TotalContributions

Program Service Revenue ProgramServiceRevenue (4 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
INPATIENT6221102141862821418628
REFERRED AMBULATORY62199091838109183810
AMBULATORY SURGERY62199058584975858497
CLINIC62111037430753743075
FieldValueIRS element (for citing)
Total Program Service Revenue40204010TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column14047TotalRevenueColumn
Exclusion$14,047ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real189369Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real94062Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real95307Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column95307TotalRevenueColumn
Exclusion$95,307ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Other18000Other

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Other0Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Other18000Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column18000TotalRevenueColumn
Exclusion$18,000ExclusionAmount

Other Revenue Misc OtherRevenueMisc (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnExclusionExclusionAmount
TOBACCO STLMT FNDS900099123480$123,480
CAFETERIA SALES90009949595$49,595
WELLNESS CTR DUES90009938606$38,606

Miscellaneous Revenue MiscellaneousRevenue

FieldValueIRS element (for citing)
Total Revenue Column18454TotalRevenueColumn
Exclusion$18,454ExclusionAmount
FieldValueIRS element (for citing)
Total Other Revenue230135TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column41306288TotalRevenueColumn
Related Or Exempt Function Income40204010RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$357,489ExclusionAmount

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total768571Total
Program Services193838ProgramServices
Management And General574733ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total15739312Total
Program Services14465413ProgramServices
Management And General1273899ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total979485Total
Program Services900147ProgramServices
Management And General79338ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total3142617Total
Program Services2888065ProgramServices
Management And General254552ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total1139745Total
Program Services1020411ProgramServices
Management And General119334ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total122827Total
Management And General122827ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total115241Total
Management And General115241ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total101198Total
Management And General101198ManagementAndGeneral

Fees For Services Lobbying FeesForServicesLobbying

FieldValueIRS element (for citing)
Total75361Total
Management And General75361ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total841286Total
Program Services721781ProgramServices
Management And General119505ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total139596Total
Program Services45347ProgramServices
Management And General94249ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total302495Total
Program Services75198ProgramServices
Management And General227297ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total328711Total
Program Services121305ProgramServices
Management And General207406ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total714316Total
Program Services710373ProgramServices
Management And General3943ManagementAndGeneral

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total46999Total
Program Services22432ProgramServices
Management And General24567ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total17429Total
Program Services17429ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total1406585Total
Program Services1356011ProgramServices
Management And General50574ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total451740Total
Program Services451740ProgramServices

Other Expenses OtherExpenses (3 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
SUPPLIES91980549198054
PURCHASED SERVICES37543833605322149061
PROVISION FOR BAD DEBTS825998825998

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total735895Total
Program Services664642ProgramServices
Management And General71253ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total40947844Total
Program Services37283506ProgramServices
Management And General3664338ManagementAndGeneral
Fundraising0Fundraising

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY4342398BOY
EOY5323754EOY

Pledges And Grants Receivable PledgesAndGrantsReceivable

FieldValueIRS element (for citing)
BOY80417BOY
EOY178128EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY4158027BOY
EOY3613435EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY804115BOY
EOY695119EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY458701BOY
EOY776142EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis36981983LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec28809269LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY9208127BOY
EOY8172714EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY956174BOY
EOY922032EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY20007959BOY
EOY19681324EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY5579215BOY
EOY5237672EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY3768822BOY
EOY2844080EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY3065685BOY
EOY3505633EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY12413722BOY
EOY11587385EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY7513820BOY
EOY7942787EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY80417BOY
EOY151152EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY7594237BOY
EOY8093939EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY20007959BOY
EOY19681324EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses358444ReconcilationRevenueExpenses
Reconcilation Other Changes141258ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement ConsolidatedXFinancialStatementConsolidated
FieldValueIRS element (for citing)
Audit Committee1AuditCommittee
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members1MailingsMembers
Mailings Members$15,361MailingsMembersAmount
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations0GrantsOtherOrganizations
Direct Contact Legislators1DirectContactLegislators
Direct Contact Legislators$0DirectContactLegislatorsAmount
Rallies Demonstrations0RalliesDemonstrations
Other Activities1OtherActivities
Other Activities$60,000OtherActivitiesAmount
Total Lobbying Expenditures IIB75361TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierEXPLANATION OF LOBBYING ACTIVITIES:Identifier
Return ReferencePART II-B, LINE 1:ReturnReference
ExplanationCOMMUNITY MEMORIAL HOSPITAL HAS LIMITED LOBBYING ACTIVITIES. SEVERAL ACTIVITIES ARE CONDUCTED ON BEHALF OF THE ORGANIZATION THROUGH MEMBERSHIP IN THE IROQUOIS HEALTHCARE ALLIANCE AND HEALTHCARE ASSOCIATION OF NYS. THESE ACTIVITIES INCLUDE ADVERTISEMENTS AND CONTACT WITH THE LEGISLATORS ON VARIOUS HEALTHCARE ISSUES. IROQUOIS HEALTHCARE ALLIANCE - MEMBERSHIP DUES $12143 OF WHICH $5392 WAS FOR LOBBYING. HEALTHCARE ASSOCIATION OF NYS - MEMBERSHIP DUES $20694 OF WHICH $5918 WAS FOR LOBBYING. AHA-MEMBERSHIP DUES $16893 OF WHICH $4051 WAS FOR LOBBYING. LOBBYIST WILSON,ELSER,MARKOWITZ,ET AL RETAINED FOR $60000 FOR STATE LOBBYING REGARDING ENHANCEMENT OF ACUTE CARE MEDICAL RATES.Explanation

Schedule D IRS990ScheduleD

Current Year CurrentYear

FieldValueIRS element (for citing)
Beginning Of Year Balance798751BeginningOfYearBalance
Contributions430594Contributions
Investment Earnings Or Losses35937InvestmentEarningsOrLosses
Other Expenditures187836OtherExpenditures
End Of Year Balance1077446EndOfYearBalance

Current Year Minus1 Year CurrentYearMinus1Year

FieldValueIRS element (for citing)
Beginning Of Year Balance488980BeginningOfYearBalance
Contributions557783Contributions
Investment Earnings Or Losses11988InvestmentEarningsOrLosses
Other Expenditures260000OtherExpenditures
End Of Year Balance798751EndOfYearBalance

Current Year Minus2 Years CurrentYearMinus2Years

FieldValueIRS element (for citing)
Beginning Of Year Balance638615BeginningOfYearBalance
Contributions244911Contributions
Investment Earnings Or Losses5454InvestmentEarningsOrLosses
Other Expenditures400000OtherExpenditures
End Of Year Balance488980EndOfYearBalance

Current Year Minus3 Years CurrentYearMinus3Years

FieldValueIRS element (for citing)
Beginning Of Year Balance682787BeginningOfYearBalance
Contributions250127Contributions
Investment Earnings Or Losses5701InvestmentEarningsOrLosses
Other Expenditures300000OtherExpenditures
End Of Year Balance638615EndOfYearBalance

Current Year Minus4 Years CurrentYearMinus4Years

FieldValueIRS element (for citing)
Beginning Of Year Balance150835BeginningOfYearBalance
Contributions529522Contributions
Investment Earnings Or Losses2430InvestmentEarningsOrLosses
End Of Year Balance682787EndOfYearBalance
FieldValueIRS element (for citing)
Board Designated EOY Balance0.00000BoardDesignatedEOYBalance
Permanent Endowment EOY Balance0.00000PermanentEndowmentEOYBalance
Term Endowment EOY Balance1.00000TermEndowmentEOYBalance
Endowments Held By Unrelated Orgs0EndowmentsHeldByUnrelatedOrgs
Endowments Held By Related Orgs1EndowmentsHeldByRelatedOrgs
Are Related Orgs Listed Schedule R1AreRelatedOrgsListedScheduleR

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis62115OtherCostOrOtherBasis
Book Value62115BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis18408753OtherCostOrOtherBasis
Depreciation12638519Depreciation
Book Value5770234BookValue

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis45346OtherCostOrOtherBasis
Depreciation29571Depreciation
Book Value15775BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis17168800OtherCostOrOtherBasis
Depreciation15380013Depreciation
Book Value1788787BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis1296969OtherCostOrOtherBasis
Depreciation761166Depreciation
Book Value535803BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings8172714TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities (2 entries)

DescriptionDescriptionAmountAmount
ACCRUED RETIREMENT OBLIGATIONS, NET$2,879,772
OTHER LONG-TERM LIABILITIES$625,861
FieldValueIRS element (for citing)
Total Of Amounts3505633TotalOfAmounts
Footnote In Part XIIIXFootnoteInPartXIII

Form990 Schedule D Part XIII Form990ScheduleDPartXIII (2 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS:PART V, LINE 4:ENDOWMENT FUNDS ARE USED TO FURTHUR THE HOSPITAL'S TAX EXEMPT PURPOSE, SUCH AS FOR THE PURCHASE OF CAPITAL ASSETS.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X, LINE 2:THE HOSPITAL AND FOUNDATION QUALIFY AS TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2012 AND 2011, THE HOSPITAL AND FOUNDATION DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2009 THROUGH 2012. THE HOSPITAL AND FOUNDATION DO NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS.

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
FPG Reference Free Care1FPGReferenceFreeCare
Pcent150XPcent150
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent300XPcent300
Free Disc Care Medically Indigent0FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget0ExpensesExceededBudget
Annual Community Benefit Report1AnnualCommunityBenefitReport
Report Publically Available1ReportPublicallyAvailable

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense329223TotalCommunityBenefitExpense
Direct Offsetting Revenue184026DirectOffsettingRevenue
Net Community Benefit Expense145197NetCommunityBenefitExpense
Percent Of Total Expense0.00360PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense4939405TotalCommunityBenefitExpense
Direct Offsetting Revenue4098041DirectOffsettingRevenue
Net Community Benefit Expense841364NetCommunityBenefitExpense
Percent Of Total Expense0.02100PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense5268628TotalCommunityBenefitExpense
Direct Offsetting Revenue4282067DirectOffsettingRevenue
Net Community Benefit Expense986561NetCommunityBenefitExpense
Percent Of Total Expense0.02460PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Total Community Benefit Expense112880TotalCommunityBenefitExpense
Direct Offsetting Revenue38606DirectOffsettingRevenue
Net Community Benefit Expense74274NetCommunityBenefitExpense
Percent Of Total Expense0.00180PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense112880TotalCommunityBenefitExpense
Direct Offsetting Revenue38606DirectOffsettingRevenue
Net Community Benefit Expense74274NetCommunityBenefitExpense
Percent Of Total Expense0.00180PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense5381508TotalCommunityBenefitExpense
Direct Offsetting Revenue4320673DirectOffsettingRevenue
Net Community Benefit Expense1060835NetCommunityBenefitExpense
Percent Of Total Expense0.02640PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported1BadDebtExpenseReported
Bad Debt Expense$825,998BadDebtExpenseAmount
Amount Attributable To605457AmountAttributableTo
Amount Reimbursed By Medicare9332939AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare10165864CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall-832925MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
Cost To Charge RatioXCostToChargeRatio
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare
Number Of Hospital Facilities1NumberOfHospitalFacilities

Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA

FieldValueIRS element (for citing)
Facility Number1FacilityNumber

Name Name

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY MEMORIAL HOSPITAL INCBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line1150 BROAD STAddressLine1
CityHAMILTONCity
StateNYState
ZIP Code13346ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Er24 HoursXEr24Hours

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY MEMORIAL HOSPITAL INCBusinessNameLine1
FieldValueIRS element (for citing)
Hospital Facility Number1HospitalFacilityNumber
Eligibility Criteria Explained1EligibilityCriteriaExplained
Uses FPG Free1UsesFPGFree
FPG Free Percent150.000000000000FPGFreePercent
Uses FPG Discounted1UsesFPGDiscounted
FPG Discount Percent300.000000000000FPGDiscountPercent
Explains Basis1ExplainsBasis
Income LevelXIncomeLevel
State RegulationXStateRegulation
Explains Application Method1ExplainsApplicationMethod
Includes Publicity Measures1IncludesPublicityMeasures
Posted On WebsiteXPostedOnWebsite
Posted In Emergency RoomXPostedInEmergencyRoom
Posted In Admission OfficeXPostedInAdmissionOffice
Provided On AdmissionXProvidedOnAdmission
Available On RequestXAvailableOnRequest
Other PublicityXOtherPublicity
Actions On Nonpayment1ActionsOnNonpayment
Collection Activities0CollectionActivities
Nondiscrim Emergency Care Policy1NondiscrimEmergencyCarePolicy
Used Other MethodXUsedOtherMethod
Amounts Generally Billed0AmountsGenerallyBilled
Gross Charges0GrossCharges

Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC

FieldValueIRS element (for citing)
Number Of Other Facilities5NumberOfOtherFacilities

Other Facilities OtherFacilities (5 entries)

Address Line1Address/AddressLine1CityAddress/CityStateAddress/StateZIP CodeAddress/ZIPCodeFacility TypeFacilityType
COMMUNITY MEMORIAL HOSPITAL SNF
150 BROAD STHAMILTONNY13346ATTACHED SKILLED NURSING FACILITY
COMMUNITY MEMORIAL HOSPITAL FHC
164 BROAD STHAMILTONNY13346PRIMARY CARE PHYSICIAN OFFICE
COMMUNITY MEMORIAL HOSPITAL FHC
3460 SOUTH STMORRISVILLENY13408PRIMARY CARE PHYSICIAN OFFICE
COMMUNITY MEMORIAL HOSPITAL FHC
117 WEST MAIN STWATERVILLENY13480PRIMARY CARE PHYSICIAN OFFICE
COMMUNITY MEMORIAL HOSPITAL FHC
4180 SOUTH MAIN STMUNNSVILLENY13409PRIMARY CARE PHYSICIAN OFFICE

Form990 Schedule H Part VI Form990ScheduleHPartVI (12 entries)

ExplanationExplanationIdentifierIdentifierReturn ReferenceReturnReference
PART I, LINE 7: LINE 7A - A COST-TO-CHARGE RATIO WAS USED, DERIVED FROM WORKSHEET 2LINE 7B - A COST-TO-CHARGE RATIO WAS USED, DERIVED FROM WORKSHEET 2.LINE 7E - WE USED OUR ACTUAL EXPENSES AND ACTUAL REVENUE FROM OUR WELLNESS CENTER.
PART I, L7 COL(F): BAD DEBT EXPENSE OF 825998 WAS SUBTRACTED FROM FORM 990, PART IX, LINE 25, COLUMN A
PART III, LINE 4: THE FOOTNOTES TO THE FINANCIAL STATEMENTS STATE "AN ALLOWANCE FOR DOUBTFUL ACCOUNTS RECEIVABLE IS ESTIMATED BY MANAGEMENT BASED ON PERIODIC REVIEWS OF THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE CONSIDERING HISTORICAL EXPERIENCE AND PREVAILING ECONOMIC CONDITIONS."LINE 2 METHODOLOGY- THE HOSPITAL ESTIMATES BAD DEBT EXPENSE BASED ON HISTORICAL EXPERIENCE EXPRESSED AS A PERCENTAGE OF CURRENT YEAR GROSS REVENUE..LINE 3 METHODOLOGY- WE TOOK THE APPROVAL PERCENTAGE OF 73.3% ON ALL PATIENTS WHO APPLIED FOR CHARITY CARE IN 2012 AND MULTIPLIED IT BY THE AMOUNT ON LINE 2. THE RATIONAL BEING THAT THAT % WOULD HOLD ACROSS ALL OF OUR BAD DEBTS EXPENSE IF THOSE PATIENTS HAD APPLIED FOR CHARITY CARE. WE DID NOT INCLUDE BAD DEBT AMOUNTS IN COMMUNITY BENEFITS. BAD DEBTS EXPENSE IS NET OF DISCOUNTS AND PAYMENTS.
PART III, LINE 8: FOR LINE 6 - THE HOSPITAL USED THE 2012 MEDICARE COST REPORT IN DETERMINING MEDICARE COSTS. THE MEDICARE COST REPORT CALCULATES A COST-TO-CHARGE RATIO FOR EACH COST CENTER USING HOSPITAL TOTAL ALLOWABLE CHARGES AND TOTAL ALLOWABLE COSTS; THESE RATIOS ARE THEN APPLIED AGAINST MEDICARE CHARGES IN EACH COST CENTER RESULTING IN MEDICARE COSTS.THE SHORTFALL OF $832925 ON LINE 7 REPRESENTS UNRECOGNIZED COMMUNITY BENEFIT INHERENT IN PROVIDING MEDICAL CARE TO THE COMMUNITY. OUR UNREIMBURSED COSTS FROM MEDICARE ARE INCURRED BY PROVIDING SERVICES TO OUR RURAL COMMUNITIES THAT HAVE A HIGHER THAN AVERAGE MEDICARE POPULATION, MANY OF WHOM ARE INDIGENT.
PART III, LINE 9B: IN THE COLLECTION POLICY FOR COMMUNITY MEMORIAL HOSPITAL IT STATES THAT WHEN A SELF-PAY STATEMENT GENERATES FOR A PATIENT KNOWN TO HAVE RECEIVED UNCOMPENSATED SERVICE AID FROM COMMUNITY MEMORIAL WITHIN THE LAST YEAR, THE STATEMENT IS PULLED AND AN UNCOMPENSATED SERVICE APPROVAL LETTER IS MAILED TO THE PATIENT.
PART V, SECTION B, LINE 14G: A MESSAGE IS PRINTED ON PATIENTS' BILLS THAT STATES "COMMUNITY MEMORIAL HOSPITAL OFFERS FINANCIAL ASSISTANCE TO QUALIFYING PATIENTS. PLEASE CALL 315-824-6553."COMMUNITY MEMORIAL HOSPITAL, INC
PART V, SECTION B, LINE 20D: WE USED THE NEGOTIATED COMMERCIAL INSURANCE RATE OF OUR HIGHEST VOLUME COMMERCIAL PAYOR.COMMUNITY MEMORIAL HOSPITAL, INC
PART VI, LINE 2: COMMUNITY MEMORIAL HOSPITAL'S ANNUAL REVIEW OF IT'S STRATEGIC PLANNING PROCESS DRIVES OUR ASSESSMENT OF COMMUNITY HEALTH NEEDS. OUR COMMUNITY SERVICE PLAN WAS REVIEWED AND UPDATED UTILIZING THE FOLLOWING INFORMATION. COMMUNITY MEMORIAL CONTINUES TO BE AN ACTIVE PARTNER WITH THE MADISON COUNTY HEALTH DEPARTMENT, OTHER HEALTH AND HUMAN SERVICE AGENCIES, AND AREA COMMUNITY AND INDUSTRY LEADERS IN CONTINUOUSLY ASSESSING THE HEALTH NEEDS OF OUR AREA. THE SHARED INFORMATION COLLECTED HAS BEEN USEFUL IN OUR EFFORTS TO PLAN FOR THE CHANGING NEEDS AND DEMOGRAPHICS OF OUR SERVICE AREA POPULATIONS. INFORMATION USED IN OUR PLANNING AND ASSESSMENT IS DERIVED FROM THE FOLLOWING SOURCES: 1)PRIMARY - PATIENT SATISFACTION SURVEYS, BOARD OF DIRECTORS, AUXILIARY MEMBERSHIP, MEDICAL STAFF, AND EMPLOYEES 2)SECONDARY- MADISON COUNTY DEPARTMENT OF HEALTH AND COMMUNITY NEEDS ASSESSMENT PLAN 2004, 2000 CENSUS OF POPULATION AND HOUSING, HEALTH CENSUS COMPARING 1999 AND 2009 BASSETT HEALTHCARE RESEARCH INSTITUTE PUBLISHED JULY 2011, MADISON COUNTY PRIORITIES COUNCIL, SPARCS, NYSDOH REPORTS AND DATA SOURCES, PHYSICIAN AND HEALTH SERVICES USAGE DATA BASES, MARKET SHARE AND DEMOGRAPHICS DATA BASES, HEALTHCARE ASSOCIATION OF NYS, AMERICAN HOSPITAL ASSOCIATION, IROQUOIS HEALTH ASSOCIATION, AND VOLUNTARY HOSPITALS OF AMERICA STATISTICAL REPORTS.
PART VI, LINE 3: SIGNS ARE POSTED IN OUR ADMITTING/REGISTRATION AREA REGARGING OUR POLICY OF PROVIDING SERVICES AT A REDUCED CHARGE OR NO CHARGE TO PATIENTS WHO HAVE FAMILY INCOME BELOW CERTAIN FEDERAL STANDARDS, INCLUDING A PHONE NUMBER TO CALL IN OUR CREDIT DEPARTMENT. A SUMMARY OF OUR UNCOMPENSATED CARE PROGRAM IS AVAILABLE FOR THEM TO TAKE. PATIENTS THAT ARE SELF PAY ON ADMISSION ARE SEEN BY THE CREDIT DEPARTMENT PERSONNEL AND THE UNCOMPENSATED SERVICE PROGRAM IS DISCUSSED AND AN APPLICATION IS GIVEN. PATIENTS THAT RECEIVE OUTPATIENT SERVICES ARE CALLED TO ADVISE THEM OF OUR POLICY WHEN THE FIRST ITEMIZED STATEMENT PRINTS AND WHEN SUBSEQUENT COLLECTION PHONE CALLS ARE MADE. A MESSAGE IS AUTOMATICALLY PRINTED ON ALL PATIENT STATEMENTS THAT FINANCIAL ASSISTANCE IS AVAILABLE FOR THOSE WHO QUALIFY, WITH THE PHONE NUMBER TO CALL. PATIENTS ARE MADE AWARE THAT THEY MAY APPLY TO THE COUNTY IN WHICH THEY RESIDE FOR MEDICAID ASSISTANCE.
PART VI, LINE 4: COMMUNITY MEMORIAL HOSPITAL IN HAMILTON, NY, SERVES 45000 PEOPLE IN 27 CENTRAL NEW YORK COMMUNITIES. THE REGION IS NOTED FOR ITS RICH AGRICULTURAL HISTORY AND A STRONG TRADITION OF HIGHER EDUCATION. TODAY, IN ADDITION TO THE DAIRY INDUSTRY, THERE ARE HORSE FARMS, GRASS FED BEEF AND HOMESTEADS PRODUCING ORGANIC FRUITS AND VEGETABLES. COLGATE UNIVERSITY, MORRISVILLE STATE COLLEGE, AND CAZENOVIA COLLEGE OFFER CURRICULUMS THAT ARE RENOWN NATIONWIDE. THE COMMUNITIES WE SERVE ALSO HAVE A SIGNIFICANT NUMBER OF FRAIL AND POOR ELDERLY, MEDICAID OF ALL AGES AND WORKING POOR. COMMUNITY MEMORIAL HOSPITAL PROVIDES CARE TO ALL OF THESE GROUPS REGARDLESS OF ABILITY TO PAY. THIS APPLIES TO ALL HOSPITAL AND OUTPATIENT SERVICES. COMMUNITY MEMORIAL HOSPITAL HAS A CHARITY CARE PROGRAM FOR THOSE WHO CANNOT AFFORD TO PAY FOR THEIR HOSPITAL BILLS.
PART VI, LINE 5: A MAJORITY OF COMMUNITY MEMORIAL HOSPITAL'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL, NOR FAMILY MEMBERS. COMMUNITY MEMORIAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. THE HOSPITAL USES SURPLUS FUNDS TO BUY STATE-OF-THE-ART CAPITAL EQUIPMENT, I.E. CARDIAC MONITOR FOR SPECIAL CARE UNIT, PHARMACY COMPUTER SYSTEM, SURGICAL EQUIPMENT, AND ADDITIONAL COMPUTERS/SERVERS.IN 1989, COMMUNITY MEMORIAL HOSPITAL EXPANDED ITS MISSION TO PROVIDE PRIMARY CARE IN THE RURAL COMMUNITIES OF ITS SERVICE AREA. SEVERAL PHYSICIANS HAD RETIRED OR WERE ABOUT TO CLOSE THEIR PRACTICES AND MANY SMALL TOWNS AND VILLAGES WERE LEFT WITHOUT ANY COVERAGE. THE HOSPITAL HAS A NETWORK OF FOUR FAMILY HEALTH CENTERS( IN HAMILTON, MORRISVILLE, MUNNSVILLE AND WATERVILLE). THE HOSPITAL EMPLOYS FIVE FAMILY PRACTICE SPECIALISTS, ONE PEDIATRICIAN, ONE CARDIOLOGIST, ONE NEUROLOGIST, AND NURSE PRACTIONERS/PHYSICIAN ASSISTANTS. ALL PATIENTS WHO COME TO THE FAMILY HEALTH CENTERS ARE SERVED WITHOUT REGARD TO THEIR ABILITY TO PAY. THE HOSPITAL HAS DEVELOPED A SAFETY NET FOR LOW INCOME, UNINSURED AND/OR UNDERINSURED PATIENTS WHILE ENSURING PRIMARY CARE WILL REMAIN AVAILABLE IN RURAL CENTRAL NEW YORK.
NYREPORTS FILED WITH STATESPART VI, LINE 7

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Substantiation Required1SubstantiationRequired
Independent ConsultantXIndependentConsultant
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (8 entries)

TitleTitleBase Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
KERRI TAYLOR
TRUSTEE15000002025000000235880193838000
DAVID FELTON
PRESIDENT/CEO2987720000000319350330707000
RICHARD KIRBY
EXEC VP/COO/CFO2060360000000379900244026000
RAYMOND CARLSON
PHYSICIAN3595000480000000235880387888000
ROBERT DELORME
PHYSICIAN21284604535400000235880281788000
CHERYL MATTERN
PHYSICIAN2155790000000235880239167000
EDWARD MCDONALD
PHYSICIAN2248100000000235880248398000
EUFROSINA YOUNG
PHYSICIAN22920006601000000235880318798000

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (7 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 4THE BYLAWS WERE CHANGED IN 2012 TO NAME THE CEO AS A VOTING BOARD MEMBER.
FORM 990, PART VI, SECTION B, LINE 11THE CEO AND THE CFO PRESENT THE 990 TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS PRIOR TO SUBMISSION TO THE IRS. THE FINANCE COMMITTEE ADVISES THE FULL BOARD OF IT'S REVIEW.
FORM 990, PART VI, SECTION B, LINE 12CTHE CEO AND THE PRESIDENT OF THE BOARD OF DIRECTORS REVIEW THE CONFLICT OF INTEREST POLICIES ANNUALLY WITH THE FULL BOARD. ANY POSSIBLE CONFLICTS ARE REVIEWED AND APPROPRIATE ACTION TAKEN.
FORM 990, PART VI, SECTION B, LINE 15THE COMPENSATION OF THE CEO AND THE CFO IS DETERMINED BY THE BOARD OF DIRECTORS. THE BOARD REVIEWS COMPARATIVE DATA PROVIDED BY HOSPITAL TRADE ORGANIZATIONS SUCH AS HANYS. THE BOARD USES SALARY SURVEYS COMPLETED BY INDEPENDANT CONSULTANTS GAFFE & ASSOCIATES.THE BOARD EMPLOYS THE SERVICES OF OUTSIDE CONSULTANT, HARBRIDGE CONSULTING.THE BOARD REVIEWS SALARIES FOR SIMILAR POSTIONS AT OTHER COMPARABLE HOSPITALS.THE BOARD SETS BOTH QUALITY AND FINANCIAL GOALS AND REVIEWS PERFORMANCE ANNUALLY.
FORM 990, PART VI, SECTION C, LINE 19FINANCIAL STATEMENTS ARE FILED WITH THE CHARITIES BUREAU AND ARE PART OF THE PUBLIC RECORD. IN ADDITION, THE ORGANIZATION PROVIDES ALL DOCUMENTS REQUIRED BY THE INTERNAL REVENUE CODE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 9:RETIREMENT PLAN OBLIGATION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS 141,258.CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XII, LINE 2CCOMMUNITY MEMORIAL HOSPITAL DID NOT CHANGE ITS OVERSIGHT PROCESS FOR THE AUDIT, REVIEW, OR COMPILATION OF ITS FINANCIAL STATEMENTS OR FOR ITS SELECTION PROCESS OF AN INDEPENDENT ACCOUNTANT.

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY MEMORIAL HOSPITAL FOUNDATIONBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1150 BROAD STAddressLine1
CityHAMILTONCity
StateNYState
ZIP Code13346ZIPCode
FieldValueIRS element (for citing)
EIN161603283EIN
Primary ActivitiesFUNDRAISINGPrimaryActivities
Legal Domicile StateNYLegalDomicileState
Exempt Code Section501 C 3ExemptCodeSection
Public Charity Status11- TYPE IIIPublicCharityStatus
Direct Controlling Entity NAN/ADirectControllingEntityNA
Controlled Org0ControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Dividends Related Organization0DividendsRelatedOrganization
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg