2013-05-14T13:33:06-05:00 2012-09-30 621046406 JOHNSON HICKEY & MURCHISON PC 651 E FOURTH ST STE 200 CHATTANOOGA TN 37403 990 2011-10-01 311131099 OHIO COUNTY HOSPITAL CORPORATION OHIO 2702987411 1211 OLD MAIN STREET HARTFORD KY 42347 JOHN TICHENOR 2702987411 2013-05-14 1 BARRY R HUGGINS P00627334 4237560052 2011 2016-02-24 21:20:13Z BLAINE PIEPER 1211 OLD MAIN STREET HARTFORD KY 42347 31542361 0 X WWW.OHIOCOUNTYHOSPITAL.COM X 1984 KY THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES, MAKING A DIFFERENCE IN THE LIVES OF THE PEOPLE WE SERVE BY PROVIDING POSITIVE LIFE-CHANGING EXPERIENCES. 9 8 427 0 0 0 221615 116998 26949560 29944255 8525 5589 596714 1475519 27776414 31542361 0 0 0 0 13809777 16535223 0 0 0 14174384 14970911 27984161 31506134 -207747 36227 17061058 17467563 8320068 8690346 8740990 8777217 X THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES, MAKING A DIFFERENCE IN THE LIVES OF THE PEOPLE WE SERVE BY PROVIDING POSITIVE LIFE-CHANGING EXPERIENCES. 0 0 28155984 31371941 THE MISSION OF OHIO COUNTY IS TO MAKE A DIFFERENCE IN THE LIVES OF OTHERS BY CARING, SERVING, AND EDUCATING INDIVIDUALS RELATIVE TO THEIR SPECIFIC HEALTH NEEDS. WE BELIEVE THAT THROUGH THESE ACTIONS, THE GENERAL HEALTH OF OHIO COUNTY HOSPITAL IS THE FRONTLINE OF COMMUNITY HEALTHCARE, PROVIDING A SAFETY NET 24 HOURS A DAY THROUGH OUR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES. IN ORDER TO MEET THE CHANGING NEEDS OF THE COMMUNITY AND IMPROVE THE ACCESS TO HEALTH CARE, WE HAVE EXPANDED OUR SERVICES TO INCLUDE PRIMARY CARE AND SPECIALTY PHYSICIAN PRACTICES. AND WHILE PATIENTS BENEFIT FROM OUR BEING CLOSE BY, ULTIMATELY IT IS THE WHOLE COMMUNITY THAT PROSPERS FROM OUR PRESENCE. THE HOSPITAL'S POSITIVE IMPACT ON THE COMMUNITY EXTENDS WELL BEYOND THE FOUR WALLS OF THE FACILITY. OUR COMMUNITY BENEFIT INCLUDES NOT ONLY THE COST OF PROVIDING CARE TO THE UNINSURED AND INDIGENT BUT ALSO BY IDENTIFYING UNMET COMMUNITY OR PUBLIC HEALTH NEEDS AND SEEKING TO ADDRESS THEM. EXAMPLES OF SUCH EFFORTS INCLUDING SUPPLYING CHILDHOOD IMMUNIZATION VACCINES TO OUR LOCAL HEALTH DEPARTMENT AT NO CHARGE. BECOMING A SMOKE-FREE FACILITY, AND OFFERING FREE SMOKING CESSATION COURSES SEVERAL TIMES A YEAR TO ALL COMMUNITY MEMBERS. OHIO COUNTY HOSPITAL WAS THE FOUNDING MEMBER OF A LOCAL HEALTH COALITION WHOSE FOCUS IS TO IMPLEMENT PREVENTATIVE HEALTH ACTIVITIES TO COMBAT THE LACK OF PHYSICAL ACTIVITY AND THE PREVELENCE OF OBESITY IN OUR AREA. WHETHER IT'S THROUGH THE PEOPLE WE EMPLOY, THE LOCAL BUSINESSES WE USE, OR THE CHARITIES AND COMMUNITY ACTIVITIES WE SUPPORT, WE ARE COMMITTED TO MAKING THE OHIO COUNTY ARE A HEALTHIER PLACE TO LIVE AND WORK. DURING 2011, THE HOSPITAL PROVIDED HEALTH CARE SERVICES TO OHIO COUNTY KENTUCKY AND SURROUNDING AREAS, INCLUDING INPATIENT, OUTPATIENT, AND EMERGENCY SERVICES. OHIO COUNTY HOSPITAL PROVIDED $2,397,115 OF CHARITY CARE THROUGH ITS CHARITY CARE PROGRAM. IN ADDITION, THEY PROVIDED $74,183 WORTH OF PROFESSIONAL/HOSPITAL SERVICES THAT WERE NOT REIMBURSED BY ANY STATE PROGRAMS. 28155984 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 27 0 1 427 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 KY X JOHN TICHENOR 2702985495 1211 OLD MAIN STREET HARTFORD KY 42347 JUANITA PARK 2.00 X X 0 0 0 JANE CANARY 2.00 X X 0 0 0 JONATHAN SHREWBURY OD 2.00 X X 0 0 0 LLOYD SPIVEY 2.00 X 0 0 0 WAYNE HUNSAKER 2.00 X 0 0 0 KELLY ROE 2.00 X 0 0 0 CARLA WALLACE 2.00 X 0 0 0 GERALD WESTERFIELD 2.00 X 0 0 0 DRANDERSON ROWLAND 40.00 X 209786 0 0 BLAIN PIEPER 40.00 X 143064 0 16452 JOHN TICHENOR 40.00 X 106378 0 11494 BRENDA NEWCOM 40.00 X 80729 0 11320 HEATHER GARRETT 40.00 X 311050 0 15085 JANNA PATHI 40.00 X 485881 0 12096 DONALD K GREGORY 40.00 X 374556 0 12889 MUKESH DESAI 40.00 X 590749 0 18136 JOSHUA SKIBBA 40.00 X 424392 0 4904 CHARLES RICCIO 40.00 X 351614 0 10056 JOEL JOHNSTON 40.00 X 280944 0 18276 3359143 0 130708 19 0 1 1 EMCARE PHYSICIAN SERVICES 7032 COLLECTION CENTER PLACE CHICAGO IL 60693 ER PHYSICIANS 336218 QUOROM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT FEES 248580 2 84802 32196 116998 NET PATIENT SERVICES 621300 29944255 29944255 29944255 5589 5589 47833 0 47833 47833 47833 PHARMACY SALES 446110 1004311 1004311 MISCELLANEOUS INCOME 621300 348226 348226 CAFETERIA INCOME 722210 57795 57795 17354 17354 1427686 31542361 31371941 0 53422 1193549 916161 277388 12764168 12190372 573796 249854 234863 14991 1388883 1305550 83333 938769 882443 56326 248580 248580 57673 57673 57815 57815 2245112 1645031 600081 66154 66154 93334 80869 12465 2136614 1776087 360527 112963 96813 16150 239647 239647 1070631 1070631 432449 16733 415716 MEDICAL SUPPLIES AND DR 4702232 4702232 BAD DEBT 2597116 2597116 TAXES AND LICENSES 479188 479188 OTHER SUPPLIES 312509 255309 57200 118894 79973 38921 31506134 28155984 3350150 0 2015945 1733210 1455516 1064120 4209202 4417612 775893 739514 833134 150562 171589 23698618 15518019 8258343 8180599 231976 291406 17061058 17467563 1602919 2196201 262927 357694 5455000 4880000 404221 599378 595001 657073 8320068 8690346 X 8740990 8777217 8740990 8777217 17061058 17467563 36227 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2174 2174 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL PAYS DUES TO THE KENTUCKY HOSPITAL ASSSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THESE DUES ARE USED FOR LOBBYING. 441841 441841 8343822 3667571 4676251 14405882 11563863 2842019 507073 286585 220488 8180599 THIRD PARTY SETTLEMENTS 657073 657073 31542361 31506134 36227 36227 31542361 0 31542361 0 31542361 31506134 0 31506134 0 31506134 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740-10 "ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES" WHICH PROVIDES A FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS WITHIN THE FINANCIAL STATEMENTS. THE HOSPITAL MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2012 AND 2011. AS OF SEPTEMBER 30, 2012 AND 2011, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL FILES TAX RETURNS IN THE U.S. FEDERAL JURISDICTIONS. WITH A FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO U.S. FEDERAL EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE 2009. 1 1 1 X 0 1 1 0 0 1797057 470540 1326517 0.04590 4233510 3190939 1042571 0.03610 6030567 3661479 2369088 0.08200 25219 25219 0.00090 22221 22221 0.00080 47440 47440 0.00170 6078007 3661479 2416528 0.08370 1455473 1343317 8799573 8712448 87125 X 1 0 1 1 OHIO COUNTY HOSPITAL CORPORATION

1211 OLD MAIN STREET HARTFORD KY 42347

X X X OHIO HOSPITAL CORPORATION 1 0 1 1 100.000000000000 0 1 X 1 1 X 1 X 0 1 X 0 0 PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2597116. PART II: OHIO COUNTY HOSPITAL IS A MAJOR FINANCIAL CONTRIBUTOR, AS WELL PROVIDES STAFF TO COORDINATE LONGEST DAY OF PLAY AND CELEBRATE THE CHILD, TWO OF THE LARGEST COMMUNITY OUTREACHES TARGETED TO CHILDREN. BOTH OF THESE EVENTS ARE PROVIDED FREE TO THE YOUTH OF THE COMMUNITY. CELEBRATE THE CHILD DRAWS THOUSANDS OF COMMUNITY MEMBERS ANNUALLY AND FOCUS ON COMMUNITY ASSET BUILDING. OHIO COUNTY HOSPITAL SUBSIDIZES THE ADVERTISEMENT AND SUPPLIES FOR THE EVENT AND OUR STAFF PARTICIPATES IN A HOSPITAL BOOTH WHICH FOCUS ON CHILDREN MAKING HEALTHY FOOD CHOICES. LONGEST DAY OF PLAY IS AN ANNUAL SUMMER EVENT WHERE FAMILIES CAN PARTICIPATE IN OVER 30 OUTDOOR PHYSICAL ACTIVITIES. OVER 1000 COMMUNITY MEMBERS ATTEND IN ADDITION TO THE HUNDRED PLUS COMMUNITY VOLUNTEERS. HOSPITAL EMPLOYEES AND MEMBERS OF THE MEDICAL STAFF MAKE UP 25% OF THE VOLUNTEERS AT LONGEST DAY OF PLAY. THE HOSPITAL SUBSIDIZES THE ADVERTISEMENT AND SUPPLIES FOR THE EVENT, AS WELL PROVIDES FOOD FOR THE FREE HEALTHY PICNIC LUNCH. OHIO COUNTY HOSPITAL IS THE LEADER IN PROMOTING HEALTH AND WELLNESS IN THE COMMUNITY. THE HOSPITAL PROVIDES FINANCIAL SPONSORSHIP, AS WELL AS COORDINATES AND PROVIDES EMPLOYEE VOLUNTEERS, FOR THE MAJORITY OF THE HEALTH OUTREACH INITIATIVES IN OHIO COUNTY. EXAMPLES OF THESE PROGRAMS INCLUDE: RELAY FOR LIFE, GO RED HEART EDUCATION LUNCH & LEARN, SENIOR HEALTH FAIR, COMMUNITY-WIDE HEALTH FAIR, BREAST CANCER AWARENESS EVENTS, DIABETES SUPPORT GROUP, GRIEF SUPPORT GROUP THROUGH HOSPICE, GO BLUE PROSTRATE CANCER EDUCATION EVENTS, ANNUAL OCH FALL INTO FITNESS 5K AND OCH SUMMER SIZZLE 5K, COMMUNITY FITNESS CHALLENGE. OHIO COUNTY HOSPITAL ALSO PROVIDES MEETING SPACE FOR RETIRED TEACHERS ASSOCIATION, FREE SMOKING CESSATION PROGRAM, HOSPITAL EMPLOYEE UNITED WAY FUND-DRIVE, AND HABITAT FOR HUMANITY FALL FESTIVAL, HEALTH STUDENTS CAREER DAY; HOSPITAL STAFF PARTICIPATES IN THE COMMUNITY SCHOOL SYSTEM BACK TO SCHOOL BASHES TO DISTRIBUTE INFORMATION ON CHILDHOOD IMMUNIZATIONS. ADDITIONALLY, HOSPITAL STAFF IS INVOLVED IN COMMUNITY READER DAYS, LEADERSHIP OHIO COUNTY REALITY STORE, STUDENT MENTORING PROGRAM THROUGHOUT THE SCHOOL SYSTEM AND THE 4-H BODY WALK - AN INTERACTIVE DISPLAY TO TEACH MIDDLE SCHOOL STUDENTS ABOUT THE HUMAN BODY. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE STATED AT THE AMOUNT THE HOSPITAL EXPECTS TO COLLECT. THE HOSPITAL MAINTAINS ALLOWANCES FOR DOUBTFUL ACCOUNTS FOR ESTIMATED LOSSES RESULTING FROM THE INABILITY OF ITS PATIENTS TO MAKE REQUIRED PAYMENTS. MANAGEMENT CONSIDERS THE FOLLOWING FACTORS WHEN DETERMINING THE COLLECTABILITY OF PATIENT ACCOUNTS: PAYOR CREDIT-WORTHINESS, PAST TRANSACTION HISTORY WITH THE PAYOR, CURRENT ECONOMIC INDUSTRY TRENDS, AND CHANGES IN PAYOR PAYMENT TERMS. IF THE FINANCIAL CONDITION OF THE HOSPITAL'S PAYORS OR PATIENTS WERE TO DETERIORATE, ADVERSELY AFFECTING THEIR ABILITY TO MAKE PAYMENTS, ADDITIONAL ALLOWANCES WOULD BE REQUIRED. BASED ON MANAGEMENT'S ASSESSMENT, THE HOSPITAL PROVIDES FOR ESTIMATED UNCOLLECTIBLE AMOUNTS THROUGH A CHARGE TO EARNINGS AND A CREDIT TO ALLOWANCE. BALANCES THAT REMAIN OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. PART III, LINE 8: THE METHODOLOGY USED TO DETERMINE THE AMOUNT IN BOX 51 WAS THE COST TO CHARGE RATIO. PART III, LINE 9B: IF A PATIENT HAS BEEN APPROVED BY THE CHARITY CARE PROGRAM WITHIN A SIX MONTH TIME FRAME, THE ACCOUNT IS WRITTEN OFF AS A CHARITY CARE ADJUSTMENT. THE FINANCIAL COUNSELORS CHECK EACH PRIVATE PAY ACCOUNT AND WILL FOLLOW UP TO MAKE SURE THAT THEY HAVE RECEIVED AND ARE GOING TO COMPLETE THEIR PAPERWORK. THE HOSPITAL CONTRACTS WITH DMC, INC, AND THEY WILL ASSIST PATIENTS WITH CHARITY CARE PAPERORK IF THEY DO NOT QUALIFY FOR MEDICAID. OHIO HOSPITAL CORPORATION PART V, SECTION B, LINE 15E: THE ONLY FINANCIAL AID PROGRAM IS WHAT THE STATE OFFERS AS THE "DSH" PROGRAM. THE HOSPITAL USE AND OUTSIDE COMPANY-DMC WHO DETERMINES IF ALL OF THE PRIVATE PAY PATIENTS FIRST ARE ELIGIBLE FOR MEDICAID AND IF THEY ARE NOT THEY DETERMINE IF THEY ARE ELIGIBLE FOR THE STATE INDIGENT PROGRAM. IF THEY ARE ELIGIBLE FOR THE STATE PROGRAM THE ENTIRE BALANCE IS WRITTEN OFF. THE HOSPITAL DOES NOT HAVE ANY KIND OF OTHER FAP OR SEPARATE CHARITY CARE POLICY. IF THE PRIVATE PAY PATIENTS ARE ELIGIBLE FOR EITHER OF THE TWO PROGRAMS, THE HOSPITAL HAVE BEGAN OFFERING (OCTOBER 2011), A PRIVATE PAY DISCOUNT WHICH INITIALLY DISCOUNTS 40% OFF THE PATIENT'S ACCOUNT BALANCE. ALL OF THE PRIVATE PAY PATIENTS RECEIVE 3 STATEMENTS, 2 LETTERS AND SOMETIMES A OTHER LETTER BEFORE BEING SENT TO OUR COLLECTIONS AGENCY. THE COLLECTION AGENCY THEN DETERMINES THE ABILITY TO PAY AND THEY TAKE ACTIONS BASED ON THE RESULTS OF THEIR FINDINGS. PART VI, LINE 2: FOR THE PAST SEVERAL YEARS, THE GREEN RIVER REGIONAL HEALTH COUNCIL (GRADD HEALTH COUNCIL), A NETWORK OF ORGANIZATIONS AND INDIVIDUALS COMMITTED TO IMPROVING THE HEALTH OF THE AREA, HAS WORKED ON SOLUTIONS TO ADDRESS A MYRIAD OF HEALTH RELATED CONCERNS IN THE REGION. GRADD HEALTH COUNCIL, IN PART THROUGH A FEDERALLY FUNDED RURAL HEALTH NETWORK GRANT, ESTABLISHED LOCAL HEALTH COUNCILS IN EACH OF THE REGION'S RURAL COUNTIES, INCLUDING OHIO COUNTY. THE OHIO COUNTY HEATH COALITION MET REGULARLY FOCUSING ON SUBSTANCE ABUSE, MATERNAL AND CHILD CARE HEALTH, AND BUSINESS AND INDUSTRIAL WELLNESS. OHIO COUNTY HOSPITAL HAS BEEN ACTIVE IN THIS COALITION SINCE ITS INCEPTION.IN 2012, THE GREEN RIVER DISTRICT HEALTH DEPARTMENT (GRDHD), A MEMBER OF THE GRADD HC, AGREED TO PROVIDE LEADERSHIP TO BRING ABOUT A MORE SCIENTIFIC APPROACH TO ASSESSING THE COMMUNITY NEEDS IN EACH OF THE SEVEN COUNTIES IN THE DISTRICT. UTILIZING A PROCESS KNOWN AS MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP), GRDHD PARTNERED WITH UNIVERSITY OF KENTUCKY'S APPALACHIA PUBLIC HEALTH TRAINING CENTER. IN OHIO COUNTY, THE MAPP PROCESS INCLUDED THE FOLLOWING KEY STEPS:COMMUNITY PARTNERS WERE IDENTIFIED FROM THE OHIO COUNTY HEALTH COALITION, OTHER HEALTH CARE AGENCIES, LOCAL GOVERNMENT, SCHOOLS, BUSINESSES, CIVIC ORGANIZATIONS, AND VOLUNTEERS FROM THE GENERAL PUBLIC. COMPLETED A SEARCH OF EXISTING HEALTH CARE-RELATED INFORMATION AND DATA FROM PUBLIC INFORMATION SOURCES;THE PARTNERS MET IN AN INITIAL PUBLIC HEALTH FORUM DESIGNED TO REVIEW KEY HEALTH-RELATED STATISTICS FOR THE COUNTY AND TO COMPLETE A STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS (SWOT) ANALYSIS FOR THE COUNTY;COMPLETED A PAPER SURVEY, DISTRIBUTED IN LOCAL HEALTH DEPARTMENT CLINICS, AND AN ON-LINE SURVEY, TO OBTAIN WIDER INPUT FROM INDIVIDUALS INTO THE COMMUNITY'S HEALTH NEEDS.HELD A SECOND MEETING OF COMMUNITY PARTNERS TO EVALUATE THE SWOT ANALYSIS PREVIOUSLY COMPLETED AND TO CONSIDER RESULTS FROM THE COMPLETED SURVEYS. THIS FORUM WORKED TO IDENTIFY AND GROUP SIMILAR HEALTH RELATED CONCERNS FOR THE COUNTY AS FOLLOWS: 1) IMPROVE COMMUNITY LIFESTYLE CHOICES; 2) INCREASE HEALTH CARE ACCESS; AND 3) REDUCE SUBSTANCE ABUSE. THE OHIO COUNTY HEALTH COALITION WAS DETERMINED TO BE THE ORGANIZATION WITH PRIME RESPONSIBILITY FOR ADDRESSING THESE STRATEGIC HEALTH CARE INITIATIVES ON AN ON-GOING BASIS.A GREEN RIVER COMMUNITY HEALTH ASSESSMENT HEALTH IMPROVEMENT PLAN WAS DEVELOPED FOR THE REGION AND EACH OF THE DISTRICT'S COUNTIES. THIS PLAN WAS REVIEWED WITH THE OHIO COUNTY HEALTH COALITION AND OTHER COMMUNITY PARTNERS. IN DECEMBER 2012, THE OHIO COUNTY HEALTH COALITION MET IN A STRATEGIC PLANNING RETREAT TO REVIEW THE THREE STRATEGIC INITIATIVES OBTAINED THROUGH THE MAPP PROCESS. THE COALITION BEGAN TO IDENTIFY ACTION PLANS TO FOCUS COALITION MEMBER'S EFFORTS. FURTHERMORE, SPECIFIC MEASURES ARE BEING IDENTIFIED TO TRACK PROGRESS. THE COALITION WILL CONTINUE TO MEET REGULARLY TO FURTHER DEVELOP AND RESOLVE THESE MATTERS. PART VI, LINE 3: OHIO COUNTY HOSPITAL'S ADMITTING AND BUSINESS OFFICE STAFF PROVIDES CHARITY CARE APPLICATIONS TO ANY PATIENT THAT DOESN'T HAVE INSURANCE DURING THE REGISTRATION PROCESS. IF THE PATIENT DOESN'T COMPLETE THE APPLICATION AT THAT TIME, THEIR DEMOGRAPHIC INFORMAITON IS THEN SENT TO AN OUTSIDE COMPANY, DMC, INC, AND THEY DETERMINE IF THE PATIENT IS ELIGIBLE FOR EITHER MEDICAID OR CHARITY CARE. DMC WILL FOLLOW-UP WITH THE PATIENT TO GET ADDITIONAL INFORMATION AS NEEDED. ONCE THE ACCOUNT IS BILLED AND IS IN THE COLLECTION PROCESS, OUR PRIVATE PAY COUNSELORS CHECK EACH ACCOUNT TO MAKE SURE THAT IT HAS BEEN CHECKED FOR INDIGENT CARE ELIGIBILITY. PART VI, LINE 4: HISTORICALLY 90% OF ALL ADMISSIONS AND 95% OF ALL OUTPATIENT SERVICES PERFORMED AT OHIO COUNTY HOSPITAL ARE PROVIDED TO RESIDENTS OF OHIO COUNTY. THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES THE RESIDENTS OF THE INCORPORATED CITIES OF HARTFORD, BEAVER DAM, ROSINE, FORDSVILLE, HORSE BRANCH AND CROMWELL. OHIO COUNTY IS GEOGRAPHICALLY THE FIFTH LARGEST COUNTY IN KENTUCKY. TOTAL POPULATION AS OF 2012 WAS 24,103. THE PER CAPITA INCOME (MEAN INCOME FOR EVERY MAN, WOMAN, AND CHILD IN A PARTICULAR GROUP) FOR OHIO COUNTY IS $20,401 COMPARED TO THE KENTUCKY AVERAGE OF $27,625 AND NATIONAL AVERAGE OF $33,689. OHIO COUNTY HAS BEEN DESIGNATED A HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) AND A MEDICALLY UNDERSERVICED AREA / POPULATION (MUA/P). 19% OF OHIO COUNTY'S POPULATION FALLS BELOW THE POVERTY LEVEL, COMPARED TO 13.8% NATIONWIDE. 29% OF HOUSEHOLDS IN OUR COMMUNITY INCLUDE CHILDREN LIVING IN A SINGLE PARENT HOME. ACCORDING TO KENTUCKY HEALTH FACTS, THE RATE FOR UNINSURED ADULTS (UNDER 65 YEARS) IS 22%, WHICH IS SECOND HIGHEST IN THE GRADD REGION, AND THE RATE FOR UNINSURED CHILDREN (UNDER 19 YEARS) IS 7%. STATISTICS ALSO REPORT THAT 17% OF ADULTS IN THE OHIO COUNTY COMMUNITY EXPERIENCED A TIME IN THE PAST YEAR NEEDED TO SEE A DOCTOR BUT DID NOT BECAUSE OF THE COST. PART VI, LINE 5: OHIO COUNTY HOSPITAL'S BOARD OF DIRECTORS IS COMPRISED OF COMMUNITY VOLUNTEERS WHO ARE COMMITTED TO THE HEALTH AND WELFARE OF THE COMMUNITY AND DEDICATED TO ENSURING THE VIABILITY OF THE HOSPITAL FOR YEARS TO COME. THE BOARD EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE SERVICE AREA. SURPLUS FUNDS PROVIDE FOR CONTINUITY OF HEALTHCARE SERVICES DURING PERIODS OF ECONOMIC DOWNTURN, RECRUITMENT OF ADDITIONAL PROVIDERS TO IMPROVE THE ACCESS TO HEALTHCARE, AND REINVESTED IN NEW TECHNOLOGY AND EQUIPMENT AS NEEDED. THE HOSPITAL OPERATES AN EMERGENCY DEPARTMENT THAT IS STAFFED 24 HOURS A DAY/7 DAYS A WEEK AND SERVES ALL CITIZENS REGARDLESS OF THEIR ABILITY TO PAY. OHIO COUNTY HOSPITAL HAS ESTABLISHED A HEALTH IMPROVEMENT PROGRAM WHICH PROVIDES A PRIMARY-CARE HOME, PREVENTIVE SCREENINGS, DIETARY AND PHYSICAL FITNESS COUNSELING TO THE UN-INSURED AND UNDER-INSURED POPULATION OF OUR COMMUNITY. THE HOSPITAL RESEARCHES AND COMPLETES NUMEROUS GRANT APPLICATIONS APPLICABLE TO PROMOTING THE HEALTH OF OUR COMMUNITY. THE HOSPITAL PROVIDES REPRESENTATION AND SUPPORT TO THE OHIO COUNTY CHAMBER BOARD OF DIRECTORS, OHIO COUNTY TOURISM, OHIO COUNTY INDUSTRIAL FOUNDATION, AND LEADERSHIP OHIO COUNTY PROGRAM, WHICH ARE ORGANIZATIONS WORKING TOWARDS THE ECONOMIC GROWTH OF OUR AREA. X X 0 0 0 0 0 0 0 0 0 DRANDERSON ROWLAND 179051 0 30735 0 0 0 0 0 0 0 209786 0 0 0 BLAIN PIEPER 143064 0 0 0 0 0 0 0 16452 0 159516 0 0 0 HEATHER GARRETT 216818 0 94232 0 0 0 0 0 15085 0 326135 0 0 0 JANNA PATHI 485881 0 0 0 0 0 8331 0 3765 0 497977 0 0 0 DONALD K GREGORY 374556 0 0 0 0 0 0 0 12889 0 387445 0 0 0 MUKESH DESAI 590749 0 0 0 0 0 8231 0 9905 0 608885 0 0 0 JOSHUA SKIBBA 424392 0 0 0 0 0 4904 0 0 0 429296 0 0 0 CHARLES RICCIO 351614 0 0 0 0 0 0 0 10056 0 361670 0 0 0 JOEL JOHNSTON 280944 0 0 0 0 0 6199 0 12077 0 299220 0 0 0 SUPPLEMENTAL INFORMATION PART III JOHN TICHENOR AND BLAINE PIEPER ARE CONTRACTED THROUGH QUORUM HEALTH RESOURCES, INC FOR THEIR MANAGEMENT SERVICES. OHIO COUNTY PUBLIC FACILITIES CORPORATION 616000805 000677292 2005-08-01 4240000 HOSPITAL CONSTRUCTION 0 0 0 OHIO COUNTY PUBLIC FACILITIES CORPORATION 616000805 2010-09-29 3620000 MEDICAL OFFICE BUILDING CONSTRUCTION 0 0 0 1445000 424000 74823 3741177 2006 1 0 1 1 3435000 273400 70000 3550000 2011 0 0 1 1 0 0 0 0 1 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 DR DAVID RIZK STUDENT LOAN/BONUS X 121500 83531 0 1 1 DR DESAI SIGNON BONUS X 145737 106874 0 1 1 190405 FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL CONTRACTS WITH QUORUM HEALTH RESOURCES, INC (QHR)TO PROVIDE MANAGEMENT SERVICES UNDER AN AGREEMENT WHICH EXPIRES IN 2013. THE CONTRACT REQUIRED QHR TO SUPPLY A CHIEF EXECUTIVE OFFICER AND A CHIEF FINANCIAL OFFICER WHOSE SALARY AND BENEFITS COST ARE PASSED DIRECTLY THROUGH TO THE HOSPITAL. THE HOSPITAL'S EXPENSE FOR THE MANAGEMENT FEE TOTALED APPOXIMATELY $236,743 FOR THIS YEAR. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS PROVIDED TO THE FULL BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS ARE COVERED UNDER THIS POLICY AND ANY CONFLICTS ARE RESOLVED AT MONTHLY BOARD MEETINGS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S TOP MANAGEMENT OFFICIALS RECEIVED A COMPENSATION REVIEW BY QHR AND THE GOVERNING BOARD.OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION RECEIVE ANNUAL REVIEWS BASED ON CURRENT MARKET DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC.