2013-05-15T15:34:30-05:00 2012-06-30 232932984 PARENTEBEARD LLC 400 MARKET STREET WILLIAMSPORT PA 17701 990 2011-07-01 231352202 SCHUYLKILL MEDICAL CTR - SOUTH JACKSON ST F/K/A POTTSVILLE HOSP & WARNE CLINIC SCHU 5706215000 MAUCH CHUNK AND JACKSON STREETS POTTSVILLE PA 17901 JOHN E SIMODEJKA PRESIDENTCEO 5706215000 2013-05-15 1 JULIUS C GREEN CPA JD P00350393 5703236023 2011 2016-02-24 21:20:13Z JOHN E SIMODEJKA MAUCH CHUNK AND JACKSON STREETS POTTSVILLE PA 17901 96258677 0 X WWW.SCHUYLKILLHEALTH.COM X 2008 PA TO MAKE A POSITIVE DIFFERENCE IN THE SCOPE AND QUALITY OF HEALTHCARE FOR THE SCHUYLKILL COMMUNITY. 14 14 1015 62 0 0 754767 634676 88312632 93782441 146522 757229 3778843 1052362 92992764 96226708 8891 6991 0 0 50186039 50252618 0 0 0 42979128 43472537 93174058 93732146 -181294 2494562 53301818 51713293 64218346 75254898 -10916528 -23541605 X SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET'S MISSION IS TO MAKE A POSITIVE DIFFERENCE IN THE SCOPE AND QUALITY OF HEALTHCARE AVAILABLE FOR THE SCHUYLKILL COUNTY COMMUNITY. 1 0 77817071 6991 93983835 IN FISCAL YEAR 2012, SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET ADMITTED 7,805 INPATIENTS, PROVIDED EMERGENCY CARE FOR 31,366 PEOPLE, DELIVERED MORE THAN 1,045 BABIES, DID MORE THAN 13,200 HOME HEALTH CARE VISITS AND PROVIDED MORE THAN 92,500 OUTPATIENT TESTS AND PROCEDURES.THE SCHUYLKILL HEALTH SYSTEM HAS A COMPREHENSIVE CHARITY CARE PROGRAM. CHARGES FOREGONE FOR SERVICES RENDERED AND SUPPLIES FURNISHED UNDER THIS PROGRAM AMOUNTED TO $1,600,000 DURING FISCAL YEAR 2012.THE COSTS ASSOCIATED WITH THE CHARITY CARE SERVICES PROVIDED ARE ESTIMATED BY APPLYING A COST-TO-CHARGE RATIO TO THE AMOUNT OF UNCOMPENSATED CHARGES FOR THE PATIENTS RECEIVING CHARITY CARE. THE LEVEL OF CHARITY CARE PROVIDED BY THE CORPORATION AMOUNTED TO APPROXIMATELY $653,000 DURING FISCAL YEAR 2012.SCHUYLKILL HEALTH IS COMMITTED TO THE PHYSICAL, MENTAL, AND EMOTIONAL HEALTH OF OUR ENTIRE COMMUNITY. AS A HEALTHCARE FACILITY, WE ARE CONCERNED WITH THE HEALTH AWARENESS OF OUR NEIGHBORS, FAMILY, AND FRIENDS.OUR COMMUNITY LOOKS TO US TO HELP EDUCATE THEM ON CURRENT HEALTH CARE TOPICS AS WELL AS THE EVERYDAY HEALTH ISSUES THAT CONCERN EVERYONE. THROUGH OUR INITIATIVES WE CAN REACH OUT AND HELP OTHERS UNDERSTAND WHERE TO GO, WHAT TO ASK, AND WHO TO SEE FOR THEIR HEALTHCARE NEEDS. WE CAN GIVE OUR COMMUNITY THE CONFIDENCE THEY NEED WHEN MAKING WISE CHOICES. SCHUYLKILL MEDICAL CENTER HOSTS APPROXIMATELY TWELVE (12) CHAT (COMMUNITY HEALTH AWARENESS TALKS) A YEAR. MONTHLY PROGRAMS ARE HELD ON CAMPUS OR CHAT ON THE ROADS. CHAT TOPICS HAVE INCLUDED, BUT ARE NOT LIMITED TO NUTRITION, PHYSICAL FITNESS, DIABETES AWARENESS, BREAST CANCER AWARENESS, CANCER, ARTHRITIS, SEIZURE TREATMENTS, AND HEART HEALTH TO NAME A FEW.SCHUYLKILL HEALTH ALSO SPONSORS AN ANNUAL "WOMEN'S DAY"; WOMEN HAVE GATHERED OVER THE PAST SEVEN YEARS TO ATTEND A FREE EVENT. ALL GENERATIONS ENJOY BEING EDUCATED, HAVING THE ABILITY TO ASK QUESTIONS IN A COMFORTABLE SETTING WHILE SPENDING TIME WITH OLD AND NEW FRIENDS, AND SIPPING ON THAT GREAT CUP OF COFFEE. WE EXPLORE THE "WHOLE" PERSON - BODY, MIND, AND SPIRIT AND ENABLE THEM TO CAPTURE INFORMATION TO SHARE WITH OTHERS AT HOME, WORK, OR IN THEIR NEIGHBORHOOD.THE SCHUYLKILL HEALTH AUXILIARY SPONSORED THE "LITTLE RED DRESS" EVENT WHERE MORE THAN 180 WOMEN LEARNED ABOUT THE RISKS OF HEART DISEASE AND PREVENTATIVE MEASURES. THE EVENT FEATURED HEALTH SCREENINGS, VENDORS, FASHION SHOW AND ENTERTAINMENT. SCREENINGS INCLUDED BLOOD PRESSURE, BODY MASS INDEX, OSTEOPOROSIS AS WELL AS A CARDIAC HEALTH ASSESSMENT. PRESENTATIONS INCLUDED MARTIAL ARTS DEMONSTRATIONS AND FITNESS PROGRAM.SCHUYLKILL MEDICAL CENTER HOSTS A CANCER SUPPORT GROUP FOR CANCER SURVIVORS, FAMILY AND CARE GIVERS. EACH MONTH, A GROUP OF SURVIVORS GATHER TO TALK ABOUT RECENT TREATMENT, HOW THEY ARE FEELING AND TO CELEBRATE LIFE. WE ALSO HOST A GENTLE YOGA WELLNESS PROGRAM FOR SURVIVORS AND CARE GIVERS. THOSE IN ATTENDANCE HAVE SLEPT BETTER, THEIR "HOT FLASHES" HAVE CEASED, AND THEY ARE ABLE TO RELAX. WE HOLD A FREE SKIN CANCER SCREENING TO THE GENERAL PUBLIC. WE SCREEN APPROX. 125 PEOPLE; REFER 50 PEOPLE. THIS SCREENING SAVES LIVES. DIABETES NUMBERS CONTINUE TO RISE, ESPECIALLY IN SCHUYLKILL COUNTY. WE OFFER FREE DIABETES EDUCATION ALONG WITH A DIABETES SUPPORT GROUP.WE ALSO HOLD A 5K WALK/RUN FOR DIABETES, THE GOAL IS TO INCREASE THE AWARENESS AND RISKS ASSOCIATED WITH DIABETES. APPROXIMATELY 150 RUNNERS AND 200 WALKERS PARTICIPATE AS WELL AS NUMEROUS FRIENDS AND FAMILY TAKE ADVANTAGE OF INFORMATION PRESENTATIONS.FREE HEALTH SCREENINGS AND WELLNESS PROGRAMS ARE HELD THROUGHOUT THE YEAR AT VARIOUS LOCATIONS IN OUR COMMUNITY. BLOOD PRESSURES, BODY FAT, BONE DENSITY SCREENINGS ARE JUST A FEW OF THE SERVICES WE PROVIDE AT NO COST TO OUR COMMUNITY. 77817071 1 1 0 1 0 0 0 0 0 0 1 1 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 0 1 0 0 0 0 1 32 0 1 1015 1 0 0 0 0 0 0 0 0 0 0 X 14 14 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X BERNIE KOSKULITZ DIRECTOR FINANCE 5706215142 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 X JESSE ACHENBACH 1.00 X 0 0 0 DEBRA BLASCHAK 1.00 X 0 0 0 SARAH CASEY 1.00 X 0 0 0 JAMES GALLAGHER EDD 1.00 X 0 0 0 WILLIAM L JONES III 1.00 X 0 0 0 ALLEN E KIEFER 1.00 X 0 0 0 SYED SHAH MD 1.00 X 0 0 0 ROBERT M ZIMMERMAN JRD 1.00 X 0 0 0 JUDGE JOSEPH F MCCLOSKEY 1.00 X 0 0 0 JUDGE WILLIAM BALDWIN 1.00 X 0 0 0 ANTHONY BARAN 1.00 X X 0 0 0 FRANKLIN K SCHOENEMAN 1.00 X X 0 0 0 JAY M LINARD 1.00 X X 0 0 0 WILLIAM KIRWAN CPA ESQ 1.00 X X 0 0 0 JOHN E SIMODEJKA 37.50 X 398102 0 19734 DIANE BORIS 16.00 X 0 112764 20327 DARNELL FURER 20.10 X 0 179794 19657 RICHARD BINDIE 37.50 X 273691 0 13228 LYNDA L JAKUBCO 37.50 X 218309 0 13205 JULIANNE M TIDMORE 37.50 X 229045 0 14195 MARY R TUNNESSEN 37.50 X 215967 0 13205 SHERRY L BURINSKY BOTTOR 37.50 X 247120 0 14195 1582234 292558 127746 24 0 1 0 INSIGHT HEALTH CORP PO BOX 847687 DALLAS TX 75284 PET SCAN & MRI SERVICE 1403042 QUEST DIAGNOSTICS INC 12436 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 REFERENCE LAB SERVICE 842490 GE HEALTHCARE PO BOX 640944 PITTSBURGH PA 15264 MAINTENANCE SERVICES - RADIOLOGY 829790 SODEXHO INC & AFFILIATES PO BOX 360170 PITTSBURGH PA 15251 DIETARY 785028 ARAMARK 450 WASHINGTON STREET POTTSVILLE PA 17901 CLINICAL ENGINEERING AND ENVIRONMENTAL 717748 23 134711 153478 346487 5075 634676 NET PATIENT SERVICE RE 621400 93184373 93184373 SCHOOL OF NURSING 621400 598068 598068 93782441 710966 710966 40266 31969 8297 8297 8297 46263 0 46263 46263 46263 CAFETERIA & VENDING 561439 337878 337878 TOBACCO SETTLEMENT FUN 561439 321383 321383 AUTOPSY FEES 621400 102801 102801 282003 98593 183410 1044065 96226708 93983835 0 1608197 6316 6316 675 675 39921791 32998730 6923061 2006383 1658445 347938 5453632 5326185 127447 2870812 2384012 486800 93308 93308 24563 24563 10687247 6496515 4190732 86566 86566 11044989 10025180 1019809 1350362 7086 1343276 104084 90408 13676 31883 12033 19850 1645780 1645780 4670673 4670673 1016890 1016890 BAD DEBT EXPENSE 7543968 7543968 DRUGS 2991980 2991980 COLLECTION FEES 643827 643827 FOOD 586077 586077 950340 331555 618785 93732146 77817071 15915075 0 1500 1500 5035733 5284030 9154975 9901895 1092255 1213330 464788 666603 80445703 57192420 24690177 23253283 842343 727153 4996659 5521164 7023388 5144335 53301818 51713293 31535205 41950935 393750 323750 26744238 25439498 1500000 1500000 4045153 6040715 64218346 75254898 X -15269200 -27983738 34724 137549 4317948 4304584 -10916528 -23541605 53301818 51713293 X 2494562 -15119639 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 14063 1 10500 0 0 24563 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF THE HOSPITAL'S DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE HOSPITAL ASSOCIATION OF PENNSYLVANIA (HAP) ARE USED FOR LOBBYING PURPOSES. BOB ALLEN WORKED ON BEHALF OF THE HOSPITAL WITH GOVERNMENTAL OFFICIALS AND REPRESENTATIVES OF AND CONSULTANTS TO STATE AND LOCAL GOVERNMENTAL AGENCIES, BOARDS, COMMITTEES AND COMMISSIONS, INCLUDING WITHOUT LIMITATION MEETINGS WITH SUCH OFFICIALS, REPRESENTATIVES AND CONSULTANTS, REGARDING LEGISLATIVE, REGULATORY AND OTHER ISSUES THAT AFFECT THE INTERESTS AND AFFAIRS OF THE HOSPITAL AS MAY BE ASSIGNED BY THE HOSPITAL FROM TIME TO TIME. BOB ALLEN ALSO ATTENDS AND REPORTS AT HOSPITAL BOARD MEETINGS AND STAFF MEETINGS, IF REQUIRED. BOB ALLEN ALSO PERFORMS SUCH OTHER TASKS AND ACTIVITIES OF A GENERAL GOVERNMENTAL RELATIONS NATURE AS MAY BE ASSIGNED BY THE HOSPITAL FROM TIME TO TIME. 745633 745633 49974904 34820605 15154299 29433194 22371815 7061379 291972 291972 23253283 FEDERAL AGENCY OBLIGATIONS 2181420 F ACCRUED INVESTMENT INCOME 11852 F INVESTMENT IN PENNSYLVANIA COMMUNITY HOSPITAL ASSOCIATION 3327892 C 5521164 BENEFICIAL INTEREST IN PERPETUAL TRUST 3912702 DEFERRED FINANCING COSTS, NET 66240 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 316926 INSURANCE RECOVERIES RECEIVABLE 848467 5144335 OBLIGATION UNDER CAPITAL LEASE 3174399 BLUE CROSS CURRENT FINANCING ADVANCE 479000 ESTIMATED MEDICAL MALPRACTICE CLAIMS LIABILITY 1575267 DUE TO AFFILIATES 812049 6040715 96226708 93732146 2494562 -15119639 -15119639 -12625077 80872156 -15359849 -15359849 96232005 -5297 -5297 96226708 93497233 5297 5297 93491936 240210 240210 93732146 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CORPORATION PRESCRIBES A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY IN RECORDING TAX LIABILITIES IN THE FINANCIAL STATEMENTS. MEASUREMENT AND RECOGNITION OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD HAS BEEN MET. FEDERAL EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURNS FOR THE MEDICAL CENTERS, THE FOUNDATION, SMG, AND THE CENTERS FOR 2011, 2010, AND 2009 REMAIN SUBJECT TO EXAMINATION BY THE IRS. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION LIABILITY ADJUSTMENT -14,421,644. POSTRETIREMENT BENEFIT LIABILITY ADJUSTMENT -684,631. VALUATION GAIN -13,364. TOTAL TO SCHEDULE D, PART XI, LINE 8: -15,119,639. PART XII, LINE 2D - OTHER ADJUSTMENTS: POST RETIREMENT BENEFIT LIABILITY ADJUSTMENT -684,631. VALUATION LOSS -13,364. PENSION LIABILITY ADJUSTMENT -14,421,644. MEANINGFUL USE EXPENSE NETTED AGAINST REVENUE ON F/S -240,210. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -31,969. ACCOUNTING FEES 26,672. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 31,969. ACCOUNTING FEES -26,672. PART XIII, LINE 4B - OTHER ADJUSTMENTS: MEANINGFUL USE EXPENSE NETTED AGAINST REVENUE ON F/S 240,210. 1 1 1 X 250.000000000000 1 X 1 1 0 0 351957 351957 0.00410 14566985 10163376 4403609 0.05110 14918942 10163376 4755566 0.05520 174 125451 125451 0.00150 6050 31262 1800 29462 0.00030 4519318 3277883 1241435 0.01440 6224 4676031 3279683 1396348 0.01620 6224 19594973 13443059 6151914 0.07140 100 507 507 0.00000 232 50 50 0.00000 10 188 188 0.00000 423 423 0.00000 11 22377 22377 0.00030 353 23545 23545 0.00030 1 7543968 2944856 27886450 27860285 26165 X 1 1 1 1 SCHUYLKILL MEDICAL CENTER SOUTH JACKSON

420 SOUTH JACKSON STREET POTTSVILLE PA 17901

X X X SCHUYLKILL MEDICAL CENTER SOUTH JACKSON 1 1 1 250.000000000000 1 250.000000000000 1 X X X X X 1 1 X X 1 X 1 X X 1 X 0 0 PART I, LINE 7: SCHUYLKILL MEDICAL CENTER - SOUTH COMPUTED A COST TO CHARGE RATIO USING INFORMATION FROM THE MOST RECENTLY FILED MEDICARE COST REPORT (FYE 6/30/12) FOR THE CALCULATION OF COSTS FOR CHARITY CARE AND MEDICAID. DIRECT COSTS ARE OBTAINED FROM THE HOSPITAL COMPUTER SYSTEM FOR EACH COST CENTER FOR ALL OTHER BENEFITS. INDIRECT COSTS ARE COMPUTED UTILIZING THE MOST RECENTLY FILED MEDICARE COST REPORT (FYE 6/30/12). PART I, LINE 7G: THERE ARE NO PHYSICIAN CLINICAL SERVICES INCLUDED. 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 $7,543,968. PART II: ECONOMIC DEVELOPMENT - SCHUYLKILL COUNTY CHILD DEVELOPMENT POLICY COUNCIL, CHILD DEVELOPMENT IS A DAY CARE PROGRAM IN SCHUYLKILL COUNTY THAT IS PROVIDED TO ANYONE BUT IS FOCUSED ON CHILDREN OF PARENTS WHO CANNOT AFFORD TO PAY THE FULL COST OF DAYCARE. IF THIS SERVICE WAS NOT AVAILABLE FOR THESE PARENTS, THEY WOULD NOT BE ABLE TO WORK BECAUSE THEY WOULD HAVE TO STAY HOME TO TAKE CARE OF THEIR CHILDREN. WE HAVE A CLINICAL RN CHARGE NURSE WHO ATTENDS THE MEETINGS AND IS A MEMBER OF THIS POLICY COUNCIL.COMMUNITY SUPPORT - BRIDGE HOUSE OF SCHUYLKILL COUNTY - THE BRIDGE HOUSING PROGRAM IS A TRANSITIONAL HOUSING SERVICE LOCATED ON THE GROUNDS OF THE POTTSVILLE HOUSING AUTHORITY AT LAUREL TERRACE, POTTSVILLE, PENNSYLVANIA. BRIDGE HOUSING PROVIDES COMPREHENSIVE SERVICES TO PERSONS FACING LONG-TERM HOMELESSNESS AND PROVIDES A SUPPORTIVE, SAFE ENVIRONMENT FOR ADULTS AND CHILDREN. STUDENTS FROM THE SCHOOL OF NURSING PROVIDE TALKS TO RESIDENTS ABOUT SEVERAL DIFFERENT HEALTH TALKS INCLUDING PARENTING AND HEALTH PREVENTION.COALITION BUILDING - SCHUYLKILL COUNTY CHILD DEVELOPMENT HEALTH ADVISORY - FOR THIS WE HAVE ONE OF OUR SCHOOL OF NURSING INSTRUCTORS ADVISE CHILD DEVELOPMENT ON CERTAIN HEALTH MATTERS. THIS HELPS FORM A PARTNERSHIP OR COALITION WITH SCHUYLKILL COUNTY CHILD DEVELOPMENT.WORKFORCE DEVELOPMENT - SCHUYLKILL TRAINING AND TECHNOLOGY CENTER PROVIDES ASSISTANCE AND GUIDANCE TO THE LPN PROGRAM AT THE TRAINING & TECHNOLOGY CENTER AND ALSO KEEPS THE ADMINISTRATION AND LPN PROGRAM FACULTY UP TO DATE ON HEALTH CARE RELATED INFORMATION. THIS HELPS TO ENSURE THE LPN PROGRAM HAS A BACKGROUND THAT IS UP TO DATE TO PROVIDE THE STUDENTS TO ENTER THE WORKFORCE RIGHT AFTER GRADUATION. PART III, LINE 4: ACCOUNTS RECEIVABLE, OTHER ARE REPORTED AT NET REALIZABLE VALUE. ACCOUNTS ARE WRITTEN OFF WHEN THEY ARE DETERMINED TO BE UNCOLLECTIBLE BASED UPON MANAGEMENT'S ASSESSMENT OF INDIVIDUAL ACCOUNTS. THE ALLOWANCE FOR DOUBTFUL COLLECTIONS IS ESTIMATED BASED UPON A PERIODIC REVIEW OF INDIVIDUAL ACCOUNTS.ALL APPROPRIATE DISCOUNTS AND PAYMENTS ARE REFLECTED ON EACH PATIENTS' ACCOUNT. ONCE A PATIENT IS IDENTIFIED AS BAD DEBT, THE BALANCE THAT IS BAD DEBT WOULD BE CHARGES NET OF ANY PAYMENTS OR ADJUSTMENTS. THE COST OF BAD DEBT EXPENSE IS CALCULATED BY USING THE COST TO CHARGE RATIO FROM THE MOST RECENTLY FILE MEDICARE COST REPORT AND APPLYING THAT TO THE CHARGE.WE BELIEVE THAT A PORTION OF OUR BAD DEBTS RESULTS FROM SERVICES PROVIDED TO PATIENTS WHO MEET THE CHARITY CARE GUIDELINES BUT WERE UNABLE OR UNWILLING TO PROVIDE THE APPROPRIATE DOCUMENTATION TO ALLOW THAT CLASSIFICATION. THESE WOULD BE CLASSIFIED AS BAD DEBT EXPENSE TIMES THE COST TO CHARGE RATIO TO ARRIVE AT THE COST. PART III, LINE 8: THE HOSPITAL USES THE COST-TO-CHARGE RATIO TO DETERMINE THE MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: THE ORGANIZATION DOES HAVE A WRITTEN DEBT COLLECTION POLICY. ALL STAFF INVOLVED IN DEBT COLLECTION (EMPLOYEES OF THE MEDICAL CENTER AND ANY THIRD PARTY AGENCIES) ARE TRAINED ON THE POLICY AS WELL AS THE CHARITY CARE POLICY. IN DEALING WITH PATIENTS IN DEBT COLLECTION, STAFF WILL INFORM PATIENTS OF THE CHARITY CARE POLICY THAT IS AVAILABLE AND ALSO ANY OTHER FINANCIAL ASSISTANCE POLICIES OF THE MEDICAL CENTER THAT MAY BE APPLICABLE TO THE PATIENT. THE STAFF WILL INSTRUCT PATIENTS ON APPROPRIATE PAPERWORK THAT NEEDS TO BE COMPLETED IN REGARDS TO CHARITY CARE OR FINANCIAL ASSISTANCE. SCHUYLKILL MEDICAL CENTER SOUTH JACKSON PART V, SECTION B, LINE 17E: WHEN A PATIENT DOES NOT MAKE A PAYMENT A PATIENT IS EVALUATED TO DETERMINE IF THEY MEET THE GUIDELINES FOR FINANCIAL ASSISTANCE. IF THEY DO, THEY ARE THEN GIVE THE PROPER INFORMATION. SCHUYLKILL MEDICAL CENTER SOUTH JACKSON PART V, SECTION B, LINE 19D: THE SAME POLICY IS USED FOR EMERGENCY OR MEDICALLY NECESSARY CARE THAT IS USED FOR ANY OTHER TYPE OF CARE. THERE IS A STANDARD AMOUNT THAT IS CHARGED FOR PROCEDURES PER THE HOSPITAL'S CHARGE MASTER. PART VI, LINE 2: SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET (SMS-SJS) WORKS WITH SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET (SMS-ENS) IN ASSESSING THE HEALTH NEEDS OF THE COMMUNITY IT IS LOCATED IN AND SERVES; SCHUYLKILL COUNTY IN PENNSYLVANIA. BOTH MEDICAL CENTERS ALSO WORK WITH VARIOUS CITY, COUNTY AND STATE AGENCIES TO SPECIFICALLY IDENTIFY THE HEALTH NEEDS OF THE RESIDENTS OF SCHUYLKILL COUNTY.SMC-SJS IS LOCATED IN POTTSVILLE, WHICH IS THE COUNTY SEAT FOR SCHUYLKILL COUNTY. SCHUYLKILL COUNTY IS A RURAL COUNTY. THE COUNTY HAS AN UNEMPLOYMENT RATE OF OVER 9%, 19% OF THE RESIDENTS ARE COVERED BY MEDICAID, AND 18% OF THE RESIDENTS ARE OVER THE AGE OF 65.SMC-SJS IS A 180 BED ACUTE CARE FACILITY THAT PROVIDES ACUTE MEDICAL SURGICAL CARE, ADOLESCENT AND ADULT BEHAVIORAL HEALTH SERVICES, AND TRANSITIONAL REHAB CARE AND NURSERY SERVICES TO THE COMMUNITY.SMC-SJS WORKS WITH THE SOCIAL SERVICE AGENCIES, LOCAL DEPARTMENT OF HEALTH, THE CHAMBER OF COMMERCE, UNITED WAY, AMERICAN CANCER SOCIETY, LOCAL SCHOOLS, LOCAL SUPPORT GROUPS, PHYSICIAN OFFICES AND OTHER HEALTHCARE ORGANIZATIONS IN IDENTIFYING THE HEALTHCARE NEEDS OF THE LOCAL COMMUNITIES AND THE SERVICES THAT ARE NEEDED. AFTER A NEED HAS BEEN IDENTIFIED, THE MEDICAL CENTER WORKS WITH THESE ORGANIZATIONS TO HELP PROVIDE THE SERVICE TO RESIDENTS.THE MEDICAL CENTER ALSO WORKS WITH HEALTHCARE ORGANIZATIONS OUTSIDE SCHUYLKILL COUNTY TO HELP BRING HEALTHCARE SERVICES TO THE COUNTY. THIS ALLOWS COUNTY RESIDENTS TO OBTAIN NECESSARY SERVICES CONVENIENTLY WITHIN THE COUNTY.THE MEDICAL CENTER ALSO REVIEWS INTERNAL DATA ON ADMISSIONS, EMERGENCY ROOM VISITS, CLINIC VISITS AND DIAGNOSIS TO HELP IDENTIFY COMMUNITY NEEDS. THIS INFORMATION IS REVIEWED ANNUALLY AS PART OF THE BUDGET AND STRATEGIC PLANNING PROCESS.THE BOARD OF THE MEDICAL CENTER IS COMPRISED OF INDIVIDUALS FROM THE COMMUNITY REPRESENTING SOCIAL SERVICE AGENCIES, EDUCATION, ASSISTED LIVING/LONG TERM CARE, PHYSICIANS, MATERNAL/CHILD HEALTH AND LOCAL BUSINESSES. THESE INDIVIDUALS ALSO PROVIDE INPUT ON THE NEEDS OF THE COMMUNITY IN MEETING HEALTHCARE NEEDS. PART VI, LINE 3: EACH PATIENT IS REGISTERED INTO THE HOSPITAL COMPUTER SYSTEM WHEN THEY ARRIVE FOR SERVICES. AS PART OF THE REGISTRATION, INFORMATION IS OBTAINED ON ANY HEALTH INSURANCE THEY HAVE. INDIVIDUALS WITHOUT HEALTH INSURANCE ARE INFORMED AT THAT TIME OF THE MEDICAL CENTER'S CHARITY CARE POLICY. PATIENTS ARE GIVEN INFORMATION ON CONTACTING STAFF WITHIN THE HOSPITAL PATIENT ACCOUNTING DEPARTMENT TO DISCUSS APPLYING FOR THE HOSPITAL CHARITY CARE PROGRAM. SPECIFIC STAFF HAVE BEEN TRAINED AND ARE RESPONSIBLE FOR ADMINISTERING THE CHARITY CARE PROGRAM FOR THE HOSPITAL. HOSPITAL STAFF CONTACT PATIENTS WITHOUT INSURANCE AND EXPLAIN THE POLICY AND THE INFORMATION NEEDED TO APPLY. HOSPITAL STAFF WILL ALSO ASSIST PATIENTS IN APPLYING FOR MEDICAL ASSISTANCE. THEY WILL ALSO ASSIST PATIENTS IN COMPLETING THE APPLICATION AND GATHERING THE NECESSARY FINANCIAL DOCUMENTS.THE MEDICAL CENTER ALSO POSTS INFORMATION WITHIN THE ADMISSION AND EMERGENCY ROOM AREAS INFORMING PATIENTS THAT THERE IS A CHARITY CARE POLICY AVAILABLE. ALL REGISTRATION PERSONNEL ARE TRAINED ON THE POLICY SO THAT THEY ARE ABLE TO INFORM PATIENTS WHEN THEY ARE REGISTERED.OTHER HOSPITAL STAFF MEMBERS THAT MAY COME IN CONTACT WITH PATIENTS ARE ALSO EDUCATED REGARDING THE CHARITY CARE POLICY. THIS WOULD INCLUDE SOCIAL WORKERS, CARE MANAGERS, NURSING STAFF AND ALL DEPARTMENT DIRECTORS. THE CHARITY CARE POLICY IS AVAILABLE ON THE HOSPITAL INTRANET WHICH IS ACCESSIBLE BY ALL EMPLOYEES. THE HOSPITAL IS ALSO IN THE PROCESS OF PLACING THE POLICY ON THE HOSPITAL WEBSITE.ALL PATIENT ACCOUNTING, CASHIERING AND COLLECTION STAFF ARE ALSO EDUCATED ON THE CHARITY CARE POLICY AND CAN ASSIST PATIENTS IN APPLYING FOR CHARITY CARE. ALSO ALL THIRD PARTY ORGANIZATIONS THAT WORK ON BEHALF OF THE MEDICAL CENTER IN PERFORMING COLLECTIONS HAVE ALSO BEEN EDUCATED ON THE CHARITY CARE POLICY AND CAN ALSO ADVISE PATIENTS ON APPLYING FOR THIS BENEFIT. PART VI, LINE 4: SMC-SJS IS LOCATED IN POTTSVILLE, PENNSYLVANIA. THE MEDICAL CENTER SERVES ALL OF SCHUYLKILL COUNTY. SCHUYLKILL COUNTY IS A RURAL COUNTY IN PENNSYLVANIA. POTTSVILLE IS THE LARGEST POPULATION CENTER OF SCHUYLKILL COUNTY AND IS ALSO THE COUNTY SEAT. THE COUNTY IS COMPRISED OF ONE SMALL CITY AS WELL AS SEVERAL BOROUGHS AND TOWNSHIPS.THE POPULATION OF THE COUNTY IS APPROXIMATELY 147,000. APPROXIMATELY 20% OF THE POPULATION IS UNDER THE AGE OF 18 AND 18% IS OVER THE AGE OF 65. THE POPULATION IS 49% FEMALE AND 95% WHITE. APPROXIMATELY 14% OF THE POPULATION HAS A BACHELOR'S DEGREE OR HIGHER. 11.8% OF THE POPULATION IS BELOW THE POVERTY LEVEL. THE UNEMPLOYMENT RATE IS 9.3%.19% OF THE POPULATION IS INSURED BY MEDICAID. 42% OF THAT NUMBER ARE UNDER THE AGE OF 18, 13% ARE OVER THE AGE OF 65 AND 18 % ARE DISABLED. 50% OF THE BIRTHS ARE COVERED BY THE MEDICAID PROGRAM.IN A RECENT REPORT RELEASED BY THE ROBERT WOOD JOHNSON FOUNDATION AND THE UNIVERSITY OF WISCONSIN'S POPULATION HEALTH INSTITUTE, SCHUYLKILL COUNTY WAS RANKED THE 56TH HEALTHIEST OF THE 67 COUNTIES IN PENNSYLVANIA. SCHUYLKILL COUNTY HAD HIGHER THAN THE STATE AND NATIONAL RATES FOR SMOKING, OBESITY, EXCESSIVE DRINKING AND MOTOR VEHICLE CRASH DEATH RATES. THIS REPORT ALSO SHOWED THAT THE COUNTY HAD ACCESS TO FEWER PRIMARY CARE PHYSICIANS.THE DEMOGRAPHICS OF THE PATIENTS ADMITTED TO SMC-SJS ARE 41 % MEDICARE, 24% MEDICAID AND 3% SELF PAY. EMERGENCY PATIENTS AT SMC-SJS ARE 14% MEDICARE, 25% MEDICAID AND 11% SELF PAY.SCHUYLKILL COUNTY HAS FOUR HOSPITALS SERVING THE COUNTY. SMC-SJS AND SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET ARE BOTH LOCATED IN POTTSVILLE AND SERVE THE MAJORITY OF THE COUNTY RESIDENTS. NORTHERN SCHUYLKILL COUNTY AND ST. LUKE'S MINERS MEMORIAL HOSPITAL ARE LOCATED IN COALDALE NEAR THE CARBON COUNTY BORDER. PART VI, LINE 5: THE BOARD OF SMC - SJS IS COMPRISED OF FOURTEEN INDIVIDUALS FROM THE SCHUYLKILL COUNTY COMMUNITY. THESE INDIVIDUALS ARE NOT EMPLOYED BY THE MEDICAL CENTER. THEY ARE INVOLVED IN EDUCATION, SOCIAL SERVICES, GERIATRIC SERVICES, MATERNAL/CHILD SERVICES, PRIMARY MEDICAL CARE, CRIMINAL JUSTICE, SMALL BUSINESS AND MANUFACTURING. ALL PHYSICIANS ARE ENCOURAGED TO APPLY FOR MEDICAL STAFF PRIVILEGES FOR THE MEDICAL CENTER.SMC-SJS ALSO WORKS WITH VARIOUS COMMUNITY ORGANIZATIONS TO HELP IDENTIFY COMMUNITY NEEDS AND WORK TOGETHER TO MEET THOSE NEEDS. THE MEDICAL CENTER HAS INPATIENT ADOLESCENT AND ADULT BEHAVIORAL HEALTH SERVICES AVAILABLE TO THE RESIDENTS OF SCHUYLKILL COUNTY. THIS ALLOWS COUNTY RESIDENTS TO OBTAIN NECESSARY INPATIENT CARE WITHIN THE COUNTY WITHOUT REQUIRING FAMILIES TO TRAVEL OUTSIDE OF THE COUNTY. THE MEDICAL CENTER ALSO HAS A CERTIFIED DIABETES EDUCATOR AVAILABLE TO CONSULT WITH PATIENTS AND ALSO WITH PHYSICIANS WHEN THEY HAVE A PATIENT THAT IS NEWLY DIAGNOSED WITH DIABETES. THE MEDICAL CENTER IS ALSO THE ONLY FACILITY IN THE COUNTY WITH A MATERNITY DEPARTMENT AND NEWBORN NURSERY. THIS ALLOWS COUNTY RESIDENTS TO REMAIN IN THE COUNTY FOR MATERNITY CARE. MORE THAN 50% OF THE BIRTHS EACH YEAR ARE MEDICAID.THE EMERGENCY DEPARTMENT OF SMC-SJS IS A 24 HOUR EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF THEIR ABILITY TO PAY. THE MEDICAL CENTER PARTICIPATES IN MANY INSURANCE PROGRAMS SUCH AS MEDICARE, MEDICAID, CHAMPUS AND VA. THE MEDICAL CENTER ALSO HAS A CHARITY CARE POLICY THAT PROVIDES ASSISTANCE TO ELIGIBLE INDIVIDUALS IN PROVIDING FREE OR DISCOUNTED CARE BASED ON THEIR ABILITY TO PAY AND THE FEDERAL POVERTY GUIDELINES.SMC-ENS ALSO PROVIDES OPPORTUNITIES TO STUDENTS IN HEALTHCARE FIELDS TO GAIN EXPERIENCE WORKING IN THE HEALTH CARE ENVIRONMENT SUCH AS NURSING STUDENTS (RN AND LPN), PHARMACY STUDENTS, PHYSICIAN ASSISTANT STUDENTS, PHYSICAL THERAPY STUDENTS, RADIOLOGY TECHNICIANS AND MEDICAL ASSISTANTS. THE MEDICAL CENTER ALSO PROVIDES A VOLUNTEER PROGRAM FOR JUNIOR HIGH AND HIGH SCHOOL STUDENTS TO BECOME FAMILIAR WITH THE MEDICAL SERVICES OFFERED AND THE EDUCATIONAL OPPORTUNITIES AVAILABLE WITHIN THE HEALTHCARE ENVIRONMENT.THE MEDICAL CENTER ALSO SPONSORS AND PARTICIPATES IN HEALTH FAIRS AT COMMUNITY EVENTS SUCH AS THE COUNTY FAIR, EVENTS AT THE LOCAL MALL, HEALTH SCREENINGS, BLOOD PRESSURE SCREENINGS, VETERAN'S BREAKFAST EVENT, MEALS ON WHEELS, SKIN CANCER SCREENINGS, MAMMOGRAPHY SCREENINGS, BLOOD PRESSURE CLINICS, SUPPORT GROUPS AND LOCAL AMERICAN CANCER SOCIETY RELAY FOR LIFE.ANY EXCESS FUNDS THAT ARE GENERATED FROM OPERATIONS ARE INVESTED BACK INTO THE MEDICAL CENTER BY PURCHASING NECESSARY CAPITAL EQUIPMENT, FUNDING CAPITAL IMPROVEMENT PROJECTS, FUNDING NEW SERVICES, IMPROVING AND EXPANDING EXISTING SERVICES AND ANY OTHER GENERAL IMPROVEMENTS TO PATIENT CARE. PART VI, LINE 6: ON AUGUST 1, 2008, SMC-SJS AND SMC-ENS AFFILIATED UNDER THE CONTROL OF SCHUYLKILL HEALTH SYSTEM, THE PRIMARY SERVICE AREA IS POTTSVILLE AND THE SURROUNDING COMMUNITIES IN SCHUYLKILL COUNTY. THE PURPOSE OF BOTH MEDICAL CENTERS IS TO ENGAGE IN ACTIVITIES RELATED TO THE PROMOTION OF HEALTH OF THE PEOPLE IN THE SERVICE AREA, WORK CHARITABLY TO PROMOTE COMMUNITY HEALTH EDUCATION, PREVENTION OF ILLNESS AND INJURY AND PROVISION OF MEDICAL SERVICES TO THE DIVERSE POPULATION OF THE SERVICE AREA AND ENGAGE IN ANY AND ALL ACTIVITIES CONSISTENT WITH OR IN FURTHERANCE OF THESE PURPOSES.EACH MEDICAL CENTER OPERATES INDEPENDENTLY OF EACH OTHER BUT WORKS IN SYNC WITH EACH OTHER IN PROVIDING HEALTHCARE SERVICES TO THE RESIDENTS OF SCHUYLKILL COUNTY. BOTH MEDICAL CENTERS HAVE WORKED TO PROVIDE A CONTINUUM OF CARE SO THAT HEALTHCARE IS AVAILABLE WITHIN THE COUNTY AND RESIDENTS DO NOT HAVE TO TRAVEL OUTSIDE OF THE COUNTY FOR CARE. THE FOLLOWING SERVICES ARE AVAILABLE AT EITHER SMC-SJS OR SMC-ENS: - ACUTE CARE /MEDICAL SURGICAL SERVICES- INTENSIVE CARE SERVICES- MATERNITY SERVICES- NEWBORN SERVICES- PEDIATRICS SERVICES- ADOLESCENT, ADULT AND GERIATRIC BEHAVIORAL SERVICES- ACUTE REHAB AND TRANSITIONAL REHAB SERVICES- INPATIENT AND OUTPATIENT PHYSICAL THERAPY- INPATIENT AND OUTPATIENT DIAGNOSTIC SERVICES- HOME HEALTH SERVICES- OUTPATIENT DRUG AND ALCOHOL SERVICES- OUTPATIENT BEHAVIORAL HEALTH SERVICES- 24 HOUR EMERGENCY ROOM SERVICES- OUTPATIENT DENTAL CLINIC- INPATIENT AND OUTPATIENT SURGICAL SERVICES- COMMUNITY BENEFIT/CHARITY CARE SERVICES- ADVANCE WOUND CARE - OUTPATIENT SURGERY CENTERSCHUYLKILL MEDICAL GROUP IS AN ORGANIZATION FORMED IN WHICH PHYSICIANS WOULD BE ABLE TO OPEN THEIR OWN PRACTICE BUT NOT INCUR ALL THE EXPENSES THAT THEY WOULD HAD THEY OPENED A PRACTICE ON THEIR OWN. THIS WAS DONE SO THAT MORE PHYSICIANS WOULD BE AVAILABLE TO THE PUBLIC IN THIS AREA. WITHOUT THIS ORGANIZATION THESE PHYSICIANS MAY BE PRACTICING IN A DIFFERENT AREA.SCHUYLKILL HEALTH SYSTEM IS AN ORGANIZATION FORMED TO RAISE FUNDS TO PROVIDE TO BOTH SMC - EAST AND SMC - SOUTH. THE MONEY RAISED IN THIS ORGANIZATION IS USED TO BENEFIT THE COMMUNITY IN VARIOUS WAYS. MONEY FROM THIS ORGANIZATION IS USED TO PURCHASE EQUIPMENT TO MAKE THE PUBLIC SAFER. IT IS ALSO USED TO FUND PROJECTS THAT WILL MAKE HEALTH CARE ACCESS EASIER TO THE PUBLIC. SCHUYLKILL REHAB IS AN ORGANIZATION WHO OFFERS REHABILITATION SERVICES TO THE PUBLIC. ONE SERVICE THAT THEY OFFER THAT BENEFITS THE PUBLIC ARE SEVERAL DIFFERENT PROGRAMS EACH YEAR ON HEALTH CARE TOPICS. THESE PROGRAMS ARE OFFERED FREE TO THE PUBLIC.SCHUYLKILL MEDICAL MALL/DEVELOPMENT CORP IS AN ORGANIZATION WHO OWNS AND OPERATES A MEDICAL OFFICE BUILDING NEAR SMC - EAST. THIS BUILDING OFFERS AN AREA FOR PHYSICIANS TO BE ABLE TO RENT SPACE FOR THEIR PRACTICE INSTEAD OF HAVING TO PURCHASE THEIR OWN SPACE.PART VI, LINE 7: N/A X X X X X 0 0 0 0 0 0 0 0 0 JOHN E SIMODEJKA 383102 0 15000 0 0 0 6125 0 13609 0 417836 0 0 0 DARNELL FURER 0 179794 0 0 0 0 0 4509 0 15148 0 199451 0 0 RICHARD BINDIE 273691 0 0 0 0 0 0 0 13228 0 286919 0 0 0 LYNDA L JAKUBCO 218309 0 0 0 0 0 0 0 13205 0 231514 0 0 0 JULIANNE M TIDMORE 229045 0 0 0 0 0 0 0 14195 0 243240 0 0 0 MARY R TUNNESSEN 215967 0 0 0 0 0 0 0 13205 0 229172 0 0 0 SHERRY L BURINSKY BOTTOR 247120 0 0 0 0 0 0 0 14195 0 261315 0 0 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 SCHUYLKILL HEALTH OFFERED SCHUYLKILL SPORTS AND ORTHOPEDICS WHICH OPENED AUGUST 1, 2011. IT IS A NEW ORTHOPEDIC PRACTICE LEAD BY JASON C PHILLIPS, MD. THE PRACTICE INCLUDES SPORTS MEDICINE, ORTHOPEDIC TRAUMA AND GENERAL ORTHOPEDICS. IN A COLLABORATIVE EFFORT, SCHUYLKILL HEALTH SYSTEM AND THE JANET WEIS CHILDREN'S HOSPITAL OF DANVILLE INTRODUCED A PEDIATRIC HOSPITALIST PROGRAM. ANGELA ZAWISZA, DO JOINED SCHUYLKILL MEDICAL CENTER SOUTH JACKSON STREET JULY 1, 2011. A PEDIATRIC HOSPITALIST IS A PEDIATRICIAN WHOSE PRACTICE IS DEDICATED SOLELY TO TREATING CHILDREN IN A HOSPITAL SETTING. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL HAS DELEGATED MANAGEMENT DUTIES OVER ITS DIETARY SERVICES TO SODEXHO INC. AND AFFILIATES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY MANAGEMENT PRIOR TO ITS FILING WITH THE INTERNAL REVENUE SERVICE. SELECTED MEMBERS OF THE BOARD REVIEWED THE 990 WITH THE TAX RETURN PREPARER AND MANAGEMENT ON BEHALF OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C EACH OFFICER, KEY EMPLOYEE, DIRECTOR OR TRUSTEE WITH BOARD DELEGATED AUTHORITY IS REQUIRED TO ANNUALLY SIGN A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THESE STATEMENTS ARE REVIEWED BY THE PRESIDENT/CEO'S ADMINISTRATIVE ASSISTANT AND ANY CONFLICTS ARE REPORTED TO THE PRESIDENT/CEO. THE STATEMENTS ARE KEPT ON FILE IN THE PRESIDENT/CEO'S OFFICE AFTER REVIEW. BOARD MEMBERS ARE EXPECTED TO EXCUSE THEMSELVES FROM TAKING ANY ACTION OR EVEN DISCUSSING ISSUES OF RELATED PARTIES. IF THEY VIOLATE THESE RULES THEY ARE REMOVED FROM THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY, THE ORGANIZATION CONTRACTS WITH YAFFE AND COMPANY, AN INDEPENDENT CONSULTANT, TO MAKE RECOMMENDATIONS TO THE COMPENSATION COMMITTEE, A SUB COMMITTEE OF THE BOARD, BASED ON MARKET AND INDUSTRY DATA TO ENSURE COMPENSATION DOES NOT EXCEED FAIR MARKET VALUE. THIS PROCESS IS USED FOR THE FOLLOWING POSITIONS PRESIDENT/CEO, VICE PRESIDENT OF OPERATIONS/COO, VICE PRESIDENT OF NURSING/CNO AND THE VICE PRESIDENT OF FINANCE/CFO. THIS REVIEW AND APPROVAL PROCESS IS DOCUMENTED VIA COMMITTEE MINUTES. 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 A: THE FOLLOWING INDIVIDUALS WORK AN AVERAGE OF 40 HOURS PER WEEK FOR ALL SCHUYLKILL RELATED ENTITIES: DARNELL FURER JOHN SIMODEJKA DIANE BORIS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: PENSION LIABILITY ADJUSTMENT -14,421,644. POSTRETIREMENT BENEFIT LIABILITY ADJUSTMENT -684,631. VALUATION GAIN -13,364. TOTAL TO FORM 990, PART XI, LINE 5: -15,119,639. STATEMENT PURSUANT TO SECTION 1.351-3(A): STATEMENT PURSUANT TO SECTION 1.351-3(A) BY SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET 23-1352202 (1) NAME AND EMPLOYER IDENTIFICATION NUMBER OF THE TRANSFEREE CORPORATION: NAME: SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET EIN: 23-1352202 (2) DATE(S) OF TRANSFER(S) OF ASSETS: TRANSFER DATE(S): 07/29/2011 03/09/2012 (3) AGGREGATE FAIR MARKET VALUE AND BASIS OR PROPERTY TRANSFERRED: FAIR MARKET VALUE: $50,000 (7/29/11); $100,000 (3/9/12) BASIS: $50,000 (7/29/11); $100,000 (3/9/12) (4) DATE AND CONTROL NUMBER OF PRIVATE LETTER RULING(S) ISSUED BY THE IRS IN CONNECTION WITH THE EXCHANGE: DATE(S) AND CONTROL NUMBER(S): NONE SCHUYLKILL REHABILITATION CENTER INC 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 232440891 OPERATES A COMPREHENSIVE REHABILITATION FACILITY PA 501(C)(3) 3 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET 700 EAST NORWEGIAN STREET POTTSVILLE PA 17901 230880420 OPERATES A HOSPITAL PROVIDING INPATIENT, OUTPATIENT & EMERGENCY SVCS PA 501(C)(3) 3 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL HEALTH SYSTEM MEDICAL GROUP INC 700 EAST NORWEGIAN STREET POTTSVILLE PA 17901 232866006 TO SUPPORT AND PROMOTE THE PURPOSES OF AFFILIATED ENTITIES PA 501(C)(3) 9 SCHUYLKILL HEALTH SYSTEM 0 SCHUYLKILL HEALTH SYSTEM 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 262990543 TO SUPPORT, PROMOTE, ADVANCE & ENHANCE QUALITY OF LIFE OF SCHUYLKILL CNTY PA 501(C)(3) 11B N/A 0 SCHUYLKILL HEALTH SYSTEM MEDICAL MALL LP EAST NORWEGIAN TREMONT STREETS POTTSVILLE PA 17901 232514813 RENTAL PA N/A SCHUYLKILL HEALTH SYSTEM DEVELOPMENT CORPORATION 700 EAST NORWEGIAN STREET POTTSVILLE PA 17901 232432417 PURSUES, IMPLEMENTS & FURTHERS THE ACTVTIES & PURPOSES OF THE SYS PA SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET C SCHUYLKILL MEDICAL PLAZA - CONDOMINIUM ASSOCIATION 420 SOUTH JACKSON STREET POTTSVILLE PA 17901 232931821 CONDOMINIUM ASSOCIATION PA N/A C 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1