2013-05-14T07:52:44-05:00 2012-09-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2011-10-01 562112733 THE OUTER BANKS HOSPITAL INC OUTE 2528475129 2100 STANTONSBURG ROAD GREENVILLE NC 27835 DAVID HUGHES 2524494500 2013-05-13 1 JOHN NORMAN P01506766 7049985200 2011 2016-02-24 21:20:13Z RONALD SLOAN 2100 STANTONSBURG ROAD GREENVILLE NC 27835 50024707 0 X WWW.VIDANTHEALTH.COM X 2002 NC TO PROVIDE A WIDE RANGE OF QUALITY SERVICES TO THE RESIDENTS AND VISITORS OF THE OUTER BANKS. 10 8 367 41 0 0 0 0 48733785 49887752 52862 62754 69274 74201 48855921 50024707 0 0 0 0 19226039 19682933 0 0 0 19726938 20946321 38952977 40629254 9902944 9395453 59742470 60754128 5157270 6273475 54585200 54480653 TO ENHANCE THE QUALITY OF LIFE FOR THE RESIDENTS & VISITORS OF DARE COUNTY & THE SURROUNDING REGION BY PROMOTING WELLNESS & PROVIDING THE HIGHEST QUALITY HEALTHCARE SERVICE. 0 0 26647393 37884481 OUTPATIENT AND EMERGENCY SERVICES:PROVIDED EMERGENCY SERVICES TO 23,871 PATIENTS 24 HOURS A DAY FOR 365 DAYS. PROVIDED OUTPATIENT DIAGNOSTIC AND THERAPEUTIC SERVICES TO 19,268 PATIENTS. PERFORMED 1,759 OUTPATIENT SURGICAL PROCEDURES. PROVIDED A PHYSICIAN CLINIC STAFFED WITH 6 PHYSICIANS THAT CARED FOR 19,268 PATIENTS. 7998336 11371200 INPATIENT SERVICES:PROVIDED INPATIENT CARE 24 HOURS A DAY FOR 365 DAYS TO 1,390 PATIENTS. DELIVERED 404 BABIES. PERFORMED 486 INPATIENT SURGICAL PROCEDURES. 34645729 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 1 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 0 0 0 0 1 0 0 367 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 NC X X TODD WARLITNER 2528475129 2100 STANTONSBURG ROAD GREENVILLE NC 27835 X ROBERT OWENS 4.00 X 0 0 0 LINDA PALOMBO 4.00 X 0 0 0 BEULAH CHARITY ASHBY 2.00 X 0 0 0 DR JEFF C HAMMER 2.00 X 0 0 0 ROGER ROBERTSON 2.00 X 0 0 0 TERRY WHEELER 2.00 X 0 0 0 WYNN DIXON 2.00 X 0 0 0 ERNEST LARKIN 2.00 X 0 0 0 JODY MIDGETTE 2.00 X 0 0 0 ARTHUR KENEY 2.00 X 0 0 0 STEVE RODRIGUEZ 2.00 X 0 0 0 BOB GUANCI 2.00 X 0 0 0 RONALD SLOAN 40.00 X 122104 0 24239 TODD WARLITNER 40.00 X 152736 0 41654 GARY HUNTER 40.00 X 390932 0 7977 JENNIFER HALLORAN 40.00 X 188258 0 13698 DAVID THOMPSON 40.00 X 219340 0 18884 VERN METCALF 40.00 X 276943 0 16058 DAVID LUSTIG 40.00 X 352300 0 1525 1702613 0 124035 15 0 1 1 GE MEDICAL SYSTEMS PO BOX 402076 ATLANTA GA 303842076 SERVICE CONTRACT 385448 AVIATION ANESTHESIA ASSOC INC 158 BATTLEFIELD COURT MANTEO NC 27954 PROVIDE CNAS 325385 OUTER BANKS ANESTHESIA PC 128 WEIR POINT DR MANTEO NC 27954 PROVIDE CNAS 283380 AUREUS RADIOLOGY LLC PO BOX 3037 OMAHA NE 68103 PROFESSIONAL SERVICES 275529 SHARED HOSPITAL SERVICES 3530 ELMHURST LANE PORTSMOUTH VA 23701 CONTRACT EMPLOYEES 168011 5 PATIENT REVENUE 621110 49255681 49255681 632071 632071 49887752 62754 62754 CAFETERIA MEALS 722210 74201 74201 74201 50024707 49887752 0 136955 16056772 15345782 710990 539949 531417 8532 1995611 1925223 70388 1090601 1035144 55457 3814615 3814615 22772 22772 18268 18268 4139809 3138884 1000925 136118 136118 3076001 3076001 11377 11377 880768 880768 223184 223184 564987 564987 2420507 2420507 517899 517899 CHARGEABLE SUPPLIES 4935803 4935803 RECRUITMENT 155987 38753 117234 NON OPERATING 28226 28226 40629254 34645729 5983525 0 4564646 5001596 8493586 8203952 949673 1028991 266669 175039 40741805 22339274 19934489 18402531 23173997 25789275 2359410 2152744 59742470 60754128 4027978 4561626 1129292 1711849 5157270 6273475 X 54585200 54480653 54585200 54480653 59742470 60754128 X 9395453 -9500000 X X 0 1 1 X 0 X 1694182 1694182 28038964 14273816 13765148 11000091 8065458 2934633 8568 8568 18402531 INVESTMENTS 25789275 F 25789275 DUE TO THIRD PARTY PAYORS 1420849 RESERVE FOR PROFESSIONAL LIABILITY LOSSES 291000 1711849 50024707 40629254 9395453 -9500000 -9500000 -104547 50024707 0 50024707 0 50024707 40629254 0 40629254 0 40629254 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE OUTER BANKS HOSPITAL, INC. IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CAPITAL CONTRIBUTIONS AND TRANSFERS WITH AFFILIATES NET -9,500,000 1 1 1 X 1 X 1 1 0 1 1 1962083 1962083 0.04830 4851033 4851033 6813116 4851033 1962083 0.04830 16 4105 546100 12260 533840 0.01310 5 59 53738 53738 0.00130 6 7528 179216 179216 0.00440 27 11692 779054 12260 766794 0.01880 27 11692 7592170 4863293 2728877 0.06710 1 1440 1440 0.00000 1 12777 12777 0.00030 1 20 22604 22604 0.00060 1 318 5947 5947 0.00010 1 2260 2260 0.00010 5 338 45028 45028 0.00110 1 3544272 13825376 11862495 1962881 X 1 1 1 THE OUTER BANKS HOSPITAL MEDICAL OFFICE BUILDING LLC HEALTHCARE 1.00000 2 OUTER BANKS PROFESSIONAL SERVICES LLC HEALTHCARE 1.00000 1 1 THE OUTER BANKS HOSPITAL INC

4800 SOUTH CROATAN HIGHWAY NAGS HEAD NC 27959

X X X THE OUTER BANKS HOSPITAL INC 1 1 1 200.000000000000 1 200.000000000000 1 X X X X X 1 1 X X X X 1 X 1 X X X X X 1 X 0 0 PART I, LINE 3C: CHARITY CARE IS DETERMINED BASED UPON MEETING 200% OF FEDERAL POVERTY GUIDELINES AND HAVING LIMITED ASSETS OTHER THAN A HOME. DISCOUNTS ARE ALSO PROVIDED FOR ANY PATIENTS WITHOUT INSURANCE, REGARDLESS OF INCOME LEVELS. PART I, LINE 6A: IN ADDITION TO THE COMMUNITY BENEFIT REPORT FOR THE OUTER BANKS HOSPITAL, INFORMATION REGARDING THIS ENTITY IS FOUND IN THE ANNUAL REPORT FOR UNIVERSITY HEALTH SYSTEMS OF EASTERN CAROLINA. PART II: SEE SCHEDULE O. PART III, LINE 4: LINE 2 COSTS WERE CALCULATED USING THE ESTIMATED COST TO CHARGE RATIO FROM THE MEDICARE COST REPORT. PART III, LINE 8: ANY SHORTFALL OF MEDICARE REVENUE TO MEDICARE ALLOWABLE COSTS OF CARE COULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE IN THE AREA SERVED BY THE ORGANIZATION OTHER PROVIDERS WOULD NOT BE AVAILABLE TO PROVIDE THE SERVICES REQUIRED. THEREFORE, THE CARE WOULD BECOME A GOVERNMENT OBLIGATION. PART III, LINE 9B: RECOMMENDED PATIENT ACCOUNTS WILL CONTINUE TO GO THROUGH THE ACCOUNTS RECEIVABLE BILLING CYCLE AS NORMAL. WHEN THE ACCOUNT REACHES THE CUSTOMER SERVICE/COLLECTIONS MANAGER, SUPERVISOR FINANCIAL COUNSELING OR PATIENT ACCOUNTS SUPERVISOR, BASED ON THE INFORMATION GIVEN, A DECISION WILL BE MADE WHETHER TO PROCEED WITH COLLECTION OR REFER THE ACCOUNT FOR APPROVAL OF CHARITY CARE. THE PROCESS WILL OCCUR AS FOLLOWS: I. FINANCIAL COUNSELORS WILL TRY TO LOCATE THIRD PARTY PAYORS. IF NOT ELIGIBLE FOR ANY THIRD PARTY COVERAGE (INCLUDING CHARITIES), THEY MAY, BASED UPON THE FINANCIAL INFORMATION RECEIVED, RECOMMEND THE PATIENT FOR CHARITY CARE.II. PATIENT COUNSELORS WILL REVIEW FOR ANY THIRD PARTY PAYORS AND VERIFY EMPLOYMENT AND ASSETS. A CHARITY CARE APPLICATION WILL NEED TO BE COMPLETED ALONG WITH TAX RETURN, PAY STUBS, SOCIAL SECURITY AWARD LETTER AND OTHER FINANCIAL INFORMATION AS MAY BE REQUIRED. III. THE PATIENT ACCOUNTS SUPERVISOR, SUPERVISOR FINANCIAL COUNSELING OR CUSTOMER SERVICE/COLLECTIONS MANAGER, BASED UPON ACCOUNT BALANCE AND THE INFORMATION GIVEN, WILL MAKE A DECISION WHETHER TO PROCEED WITH COLLECTION OR REFER THE PATIENT ACCOUNT FOR APPROVAL FOR CHARITY CARE.PRESUMPTIVE ELIGIBILITY FOR CHARITY CARE THERE ARE OCCASIONS IN WHICH A PATIENT MAY APPEAR ELIGIBLE FOR A CHARITY CARE DISCOUNT, BUT THERE IS NO FINANCIAL ASSISTANCE INFORMATION AVAILABLE TO SUPPORT FINANCIAL AID.A. SOME PATIENTS ARE PRESUMED TO BE ELIGIBLE FOR CHARITY CARE DISCOUNTS ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES (E.G., HOMELESSNESS, PATIENTS WITH NO INCOME, BANKRUPTCY, DECEASED PATIENTS WITH NO ESTATE OR SPOUSE, ETC).B. THROUGH THE ASSISTANCE OF A THIRD PARTY VENDOR AND CERTAIN ALGORITHMS, IN CONJUNCTION WITH OUR CHARITY POLICY GUIDELINES, ALL ACCOUNTS PRIOR TO OUTSIDE COLLECTION AGENCY REFERRAL WILL BE TESTED FOR PRESUMPTIVE CHARITY. C. THE ACCOUNTS DEEMED CHARITY WILL BE ADJUSTED OFF AND THE REMAINING ACCOUNTS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. D. ONCE THE AGENCY HAS HAD THE ACCOUNTS FOR SIX MONTHS AND HAS DEEMED THEM UNCOLLECTIBLE, THE ACCOUNTS WITH BALANCES $1,200.00 AND LESS WILL BE RETURNED TO THE HOSPITAL AND REMOVED FROM THE PATIENTS CREDIT FILE. ACCOUNTS WITH BALANCES ABOVE $1,200.00 WILL REMAIN WITH THE AGENCY AND KEPT ON THE PATIENTS CREDIT FILE. E. THE ACCOUNTS RETURNED TO THE HOSPITAL WILL BE PLACED IN A UNIQUE FINANCIAL CLASS AND WILL NOT BE PURSUED FOR COLLECTIONS. THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 11H: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 13G: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 15E: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 16E: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 17E: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 18C: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 18D: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 19D: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 20: N/A THE OUTER BANKS HOSPITAL, INC. PART V, SECTION B, LINE 21: N/A PART VI, LINE 2: THE ORGANIZATION ASSESSES COMMUNITY NEED IN CONJUNCTION WITH THE STATE AFFILIATED COUNTY HEALTH DEPARTMENTS AND OTHER LOCAL HEALTH CARE ORGANIZATIONS. SEE ALSO SCHEDULE O. PART VI, LINE 3: INFORMATION IS AVAILABLE ON THE ORGANIZATION'S WEBSITE AND AT REGISTRATION FOR PATIENTS. IN ADDITION, FACE TO FACE FINANCIAL COUNSELING IS AVAILABLE TO PATIENTS AND THEIR FAMILIES IN THE CENTRAL BUSINESS OFFICE. PART VI, LINE 4: SEE SCHEDULE O. PART VI, LINE 5: SEE SCHEDULE O. PART VI, LINE 6: SEE SCHEDULE O. REPORTS FILED WITH STATES PART VI, LINE 7 NC X X X X X 0 0 0 0 0 0 0 0 0 TODD WARLITNER 139424 0 13312 0 0 0 30274 0 11380 0 194390 0 0 0 GARY HUNTER 390932 0 0 0 0 0 0 0 7977 0 398909 0 0 0 JENNIFER HALLORAN 188258 0 0 0 0 0 0 0 13698 0 201956 0 0 0 DAVID THOMPSON 219340 0 0 0 0 0 0 0 18884 0 238224 0 0 0 VERN METCALF 276943 0 0 0 0 0 0 0 16058 0 293001 0 0 0 DAVID LUSTIG 352300 0 0 0 0 0 0 0 1525 0 353825 0 0 0 SUPPLEMENTAL INFORMATION PART III RONALD SLOAN WAS COMPENSATED BY UNIVERSITY HEALTH SYSTEMS OF EAST CAROLINA, INC. (D/B/A VIDANT HEALTH) FOR SERVICES RENDERED IN HIS CAPACITY AS PRESIDENT OF THE OUTER BANKS HOSPITAL, INC. VIDANT HEALTH IS AN UNRELATED ORGANIZATION TO THE OUTER BANKS HOSPITAL. RONALD SLOAN'S COMPENSATION IS BROKEN OUT AS FOLLOWS: BASE COMPENSATION $101,800 BONUS & INCENTIVE $ 13,000 OTHER REPORTABLE COMPENSATION $ 7,304 DEFERRED COMPENSATION $ 23,480 NON-TAXABLE BENEFITS $ 759 TOTAL COMPENSATION $146,343 FORM 990, PART VI, SECTION A, LINE 6 ACCORDING TO THE ORGANIZATION'S AMENDED AND RESTATED BYLAWS, ARTICLE II, THE ORGANIZATION HAS TWO MEMBERS, EAST CAROLINA HEALTH AND CHESAPEAKE HOSPITAL AUTHORITY. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS SHALL NOT BE TAKEN WITHOUT UNANIMOUS CONSENT OF THE MEMBERS: POSSESS PROPERTY, INVEST FUNDS, ADDITIONAL CAPITAL CONTRIBUTIONS, ADMIT MEMBERS, MERGER OR DISSOLUTION, AMENDMENT, CON LITIGATION, SALE OF ASSETS, BUSINESS OF CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT FORM 990 WILL BE REVIEWED BY THE PRESIDENT AND THE VP OF BUSINESS OPERATIONS BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE REQUIRED TO BE SUBMITTED ANNUALLY. THESE SUBMISSIONS ARE REVIEWED BY LEGAL COUNSEL AGAINST CORPORATE COMPLIANCE POLICIES. WHEN A CONFLICT ARISES, THE MEMBER OF THE GOVERNING BODY IS RECUSED FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS DETERMINED BY THE BOARD IN CONSULTATION WITH THE MEMBERS, CONSIDERING THE PERFORMANCE AND PREVAILING MARKET RATES. THIS PROCESS WAS LAST PERFORMED IN 2010. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION B, LINE 1: COMBINED FORMS 1099 WERE ISSUED BY THE VIDANT HEALTH SYSTEM TO THE INDEPENDENT CONTRACTORS. THE REPORTED COMPENSATION ON PART VII INCLUDES ONLY THOSE AMOUNTS PAID DIRECTLY BY THE OUTER BANKS HOSPITAL. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CAPITAL CONTRIBUTIONS AND TRANSFERS WITH AFFILIATES NET -9,500,000. TOTAL TO FORM 990, PART XI, LINE 5: -9,500,000. FORM 990, PART XII, LINE 2C NO CHANGE IN METHOD FROM PRIOR YEAR OUTER BANKS PROFESSIONAL SVC LLC 604 AMANDA ST MANTEO NC 27954 270484506 FAMILY PRACTICE NC 425672 4314511 N/A OUTER BANKS MEDICAL OFFICE BUILDING LLC 4810 S CROATAN HWY NAGS HEAD NC 27959 161740979 MED OFFICE BLDG NC 757875 847779 N/A EAST CAROLINA HEALTH INC 2100 STANTONSBURG ROAD GREENVILLE NC 27835 911997979 HEALTHCARE NC 501(C)(3) 509(A)(3) N/A 0 EAST CAROLINA HEALTH INC 2100 STANTONSBURG ROAD GREENVILLE NC 27835 562003393 HEALTHCARE NC 501(C)(3) LINE 3 N/A 0 CHESAPEAKE HOSPITAL AUTHORITY 736 N BATTLEFIELD BLVD CHESAPEAKE VA 23320 237133975 HEALTHCARE VA 501(C)(3) N/A N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 EAST CAROLINA HEALTH INC Q 5700000 ACTUAL CASH PAYMENT CHESAPEAKE HOSPITAL AUTHORITY Q 3800000 ACTUAL CASH PAYMENT