2013-08-15T11:08:52-05:00 2012-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2012-01-01 150532054 AUBURN COMMUNITY HOSPITAL AUBU 3152557245 17 LANSING STREET AUBURN NY 13021 PATRICK FACTEAU 3152557245 2013-08-15 1 JOSEPH J SCHLEGEL P00301329 3154463600 2012 2016-02-24 21:20:13Z PATRICK FACTEAU 17 LANSING STREET AUBURN NY 13021 92143076 0 X WWW.AUBURNHOSPITAL.ORG X 1878 NY THE MISSION OF AUBURN MEMORIAL HOSPITAL IS TO PROVIDE COMPASSIONATE, QUALITY CARE AND IMPROVE THE HEALTH OF OUR COMMUNITY INCLUDING RESIDENTS OF AUBURN, NY AS WELL AS SURROUNDING AREAS. 14 14 1013 100 0 0 1086795 346088 83692625 88347253 7284 6909 2802274 3442826 87588978 92143076 0 0 0 0 50437321 51099726 0 0 142502 36530851 37632346 86968172 88732072 620806 3411004 52102984 60976727 30468821 28998721 21634163 31978006 OUR MISSION IS TO PROVIDE COMPASSIONATE, QUALITY CARE AND IMPROVE THE HEALTH OF OUR COMMUNITY INCLUDING AUBURN, NY AS WELL AS SURROUNDING AREAS. 0 0 76624210 THE PURPOSE OF AUBURN MEMORIAL HOSPITAL IS TO TREAT THE ILL AND INJURED OF AUBURN, NY AND THE IMMEDIATE ENVIRONS. TO THAT END, THE HOSPITAL TREATED 5,849 INPATIENTS FOR A TOTAL OF 56,114 PATIENT DAYS AND A TOTAL OF 151,732 OUTPATIENTS IN 2012. 76624210 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 128 0 1 1013 1 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 NY X AUBURN MEMORIAL HOSPITAL 3152557245 17 LANSING STREET AUBURN NY 13021 WILLIAM FORESMAN MD 1.00 X 0 0 0 MICHAEL RIFANBURG 1.00 X 0 0 0 WILLIAM DUGAN III 1.00 X 0 0 0 ELANE M DALY 1.00 X 0 0 0 PETER J EMERSON 1.00 X 0 0 0 RAMA GODISHALA MD 1.00 X 0 0 0 LISA RYERSON 1.00 X 0 0 0 WILLIAM SIMMONDS MDM 1.00 X 0 0 0 JOHN RICCIO MD 1.00 X 0 0 0 DEMETRA VOUNAS MD 1.00 X 0 0 0 ERIC R ALLYN 1.00 X X 0 0 0 JOSEPH BARTOLOTTA 1.00 X X 0 0 0 ANTHONY D FRANESCHELLI 1.00 X X 0 0 0 WILLIAM DORR 1.00 X X 0 0 0 SCOTT BERLUCCHI 38.00 X 381804 0 23923 PATRICK FACTEAU 38.00 X 46242 0 5736 JOHN BARAN 38.00 X 222000 0 0 WILLIAM CHILDRES MD 38.00 X 352814 0 18924 ADAM DUCKETT MD 38.00 X 281018 0 5242 TODD LENTZ MD 38.00 X 290079 0 10700 JOSEPH APONE MD 38.00 X 274787 0 18436 MARY BAKER 38.00 X 196874 0 357 2045618 0 83318 15 1 1 0 PEGASUS MEDICINE GROUP EMPIRE STATE 1007 EAST MAIN STREET BOZEMAN MT 59715 EMERGENCY ROOM PHYSICIANS 1175611 AUBURN MEDICAL PC 17 LANSING STRET AUBURN NY 13021 MEDICAL PAYMENTS 840053 SYRACUSE PSYCHIATRIC SERVICE LLC 109 SOUTH WARREN STREET SYRACUSE NY 13202 PHYSCIATRIC PHYSICIANS 625000 ALLIANCE HEALTHCARE SERVICES 100 BAYVIEW CIRCLE SUITE 400 NEWPORT BEACH CA 92660 MRI SERVICES 481505 MMODAL SERVICES LTD PO BOX 102467 ATLANTA GA 30368 TRANSCRIPTION SERVICES 329723 18 101668 244420 114716 346088 PATIENT SERVICE 623000 88347253 88347253 88347253 6909 6909 OTHER REVENUE 623000 3442826 3442826 3442826 92143076 91796988 0 0 679705 679705 37145458 32667844 4387602 90012 1748150 1545695 198196 4259 8840476 7686249 1133049 21178 2685937 2335257 344246 6434 523428 523428 255196 255196 267059 235919 31140 4005631 3538565 467066 57327 50643 6684 181813 160613 21200 981364 981364 3742313 3742313 1163923 696824 467099 SUPPLIES 12359281 10918161 1441120 PURCHASED SERVICES 6668502 5890939 777563 OTHER FEES 3825354 2593288 1232066 BAD DEBT 3580536 3580536 20619 20619 88732072 76624210 11965360 142502 2677675 4725950 10797563 10270764 1042814 10970676 2297906 2425549 539092 813241 87496234 61813386 27638209 25682848 7109725 6087699 52102984 60976727 14789143 15091579 15247536 13477418 432142 429724 30468821 28998721 X 21561790 31887659 72373 90347 21634163 31978006 52102984 60976727 X 3411004 6932839 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 72372 120842 102867 90347 2153040 1086795 3167463 72372 58431 2496008 401399 2153040 58431 58431 58431 58431 1.00000 0 0 823418 823418 34707073 20192094 14514979 1500965 1421140 79825 48282445 40200152 8082293 2182333 2182333 25682848 AGENCY RELATIONSHIPS/ DEBT SERVICE, OPER & REPLACEMENT 2622463 ESTIMATED THIRD PARTY SETTLEMENTS -256535 PLEDGE RECEIVABLE, NET 202705 UNAMORTIZED DEBT ISSUANCE COST/ OTHER ASSETS 3519066 6087699 FUNDS HELD FOR OTHERS 147816 ASSET RETIREMENT OBLIGATION 281908 429724 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: AS OF DECEMBER 31, 2012 AND 2011, THE HOSPITAL DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2009 THROUGH 2012. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 X 1 X 1 X 1 1 1 0 1 1 207436 0 207436 0.00230 12084790 10609456 1475334 0.01660 12292226 10609456 1682770 0.01890 15821 4035 11786 0.00010 15821 4035 11786 0.00010 12308047 10613491 1694556 0.01900 1 3527329 207436 36265891 39616941 -3351050 X 1 1 1 1 AUBURN COMMUNITY HOSPITAL

17 LANSING STREET AUBURN NY 13021

X X X AUBURN COMMUNITY HOSPITAL 1 1 1 100.000000000000 1 300.000000000000 1 X X X X 1 1 X X X X 1 X 1 X X X X X 1 X 0 0 3 FINGER LAKES CENTER FOR LIVING

20 PARK AVENUE AUBURN NY 13021

SHORT-TERM REHABILITATION AND LONG-TERM RESIDENTIAL CARE CENTER FINGER LAKES MEDICAL CARE CENTER

303 GRANT AVENUE AUBURN NY 13021

URGENT CARE CENTER URGENT MEDICAL CARE OF SKANEATELES

803 GENESEE STREET SKANEATELES NY 13152

URGENT CARE CENTER PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COST-TO-CHARGE RATIO. THIS COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. PART III, LINE 4: 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. DOUBTFUL ACCOUNTS ARE CHARGED AGAINST THE ALLOWANCE WHEN MANAGEMENT BELIEVES THE UNCOLLECTIBILITY OF A RECEIVABLE BALANCE IS CONFIRMED. SUBSEQUENT RECOVERIES, IF ANY, ARE CREDITED TO THE ALLOWANCE. THE BAD DEBT RESERVE IS BASED OFF HISTORIAL PERCENTAGES AS WELL AS PREVIOUS COLLECTION PERCENTAGES FOR SELF PAY PATIENTS. PART III, LINE 8: THE SHORTFALL SHOWN ABOVE SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS ALL PATIENTS WILL BE SEEN AND TREATED AT AUBURN COMMUNITY HOSPITAL REGARDLESS OF ABILITY TO PAY. THEREFORE, THE FACT THAT THE COSTS TO TREAT MEDICARE PATIENTS EXCEEDED THE REVENUES GENERATED FROM MEDICARE PATIENTS SHOULD ALL BE VIEWED AS A BENEFIT TO THE MEDICARE PATIENTS OF THE COMMUNITY. THE AMOUNT ABOVE WAS CALCULATED BY MULTIPLYING THE GROSS MEDICARE CHARGES FOR THE YEAR BY THE RATIO OF PATIENT CARE COST TO CHARGES AS CALULATED ON WORKSHEET 2. PART III, LINE 9B: PATIENTS ELIGIBLE ARE REASSESSED AT EACH ADMISSION AND NO FURTHER COLLECTIONS ARE DONE. AUBURN COMMUNITY HOSPITAL PART V, SECTION B, LINE 20D: THERE IS A 50% DISCOUNT GIVEN. PART VI, LINE 2: A STRATEGIC PLANNING PROCESS WHICH INCLUDES AN ANALYSIS BY TREO SOLUTIONS IS USED TO HELP DETERMINE THE NEEDS OF OUR GEOGRAPHIC AREA. THIS ANALYSIS HELPS AUBURN COMMUNITY HOSPITAL IN DETERMINING WHETHER WE HAVE ADEQUATE PHYSICIAN STAFFING TO PROVIDE THE APROPRIATE LEVEL OF CARE TO OUR COMMUNITY. PART VI, LINE 3: PATIENTS OF AUBURN COMMUNITY HOSPITAL ARE PROVIDED WITH FINANCIAL ASSISTANCE INFORMATION UPON BEING ADMITTED TO THE HOSPITAL, BOTH INPATIENT AND OUTPATIENT. FINANCIAL ASSISTANCE IS EVALUATED EVERY TIME A PERSON PRESENTS AT THE FACILITY. PACKETS ARE PROVIDED TO ANY PATIENT THAT IS DETERMINED TO NEED OR POTENTIALLY NEED FINANIAL ASSISTANCE. PART VI, LINE 4: AUBURN COMMUNITY HOSPITAL SERVES THE AUBURN, NY COMMUNITY AS WELL AS THE IMMEDIATE SURROUNDING AREAS. PART VI, LINE 5: AUBURN COMMUNITY HOSPITAL PROMOTES HEALTH TO THE COMMUNITY BY HOSTING EVENTS WHENEVER MONEY PERMITS. THIS INCLUDES AN ANNUAL HEART EXPO TO EDUCATE THE COMMUNITY ON HEART HEALTH. AUBRUN COMMUNITY HOSPITAL ALSO PROMOTES WOMEN'S HEALTH CARE THROUGH THE WOMEN'S HEALTH INSTITUTE. PART VI, LINE 6: AUBURN COMMUNITY HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X X 0 0 0 0 0 0 0 0 0 SCOTT BERLUCCHI 375304 0 2000 0 4500 0 11025 0 12898 0 405727 0 0 0 JOHN BARAN 222000 0 0 0 0 0 0 0 0 0 222000 0 0 0 WILLIAM CHILDRES MD 324814 0 28000 0 0 0 10142 0 8782 0 371738 0 0 0 ADAM DUCKETT MD 257465 0 23553 0 0 0 0 0 5242 0 286260 0 0 0 TODD LENTZ MD 262079 0 28000 0 0 0 10700 0 0 0 300779 0 0 0 JOSEPH APONE MD 246787 0 28000 0 0 0 11818 0 6618 0 293223 0 0 0 MARY BAKER 196874 0 0 0 0 0 0 0 357 0 197231 0 0 0 X MEDICAL EQUIP-MONITORS 1 63013 FAIR MARKET VALUE X MEDICAL EQUIP-VENTILLATORS 1 51701 FAIR MARKET VALUE 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 990 IS REVIEWED BY THE BOARD OF TRUSTEES PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED TO REVIEW CONFLICT OF INTEREST FORMS AND SIGN THEM ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS DETERMINE THE PRESIDENT/ CEO COMPENSATION. OTHER TOP OFFICIALS' COMPENSATION IS DETERMINED BY THE BOARD OF DIRECTORS, CEO AND IS ALSO BASED OFF OF EXPERIENCE AND OTHER QUALIFICATIONS. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST, COPIES OF DOCUMENTS WILL BE PROVIDED. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CORRECTION OF DECONSOLIDATION OF RELATED ENTITIES 6,932,839. AUBURN COMMUNITY COMPANIES INC 17 LANSING STREET AUBURN NY 13021 223271881 PROVIDES NURSING HOME ACCOMMODATIONS NY 501(C)(3) LINE 9 AUBURN COMMUNITY HOSPITAL 0 AUBURN COMMUNITY HOSPITAL FOUNDATION INC PO BOX 918 AUBURN NY 13021 161599892 PROVIDES FUNDS TO AUBURN COMMUNITY HOSPITAL, INC. AND RELATED ENTITIES NY 501(C)(3) LINE 11 AUBURN COMMUNITY HOSPITAL 0 ACH PROPERTIES INC 5-19 LANSING STREET AUBURN NY 13021 161335941 PROMOTE AND SUPPORT CHARITABLE PURPOSE OF AUBURN COMMUNITY HOSPITAL, INC. NY 501(C)(3) N/A AUBURN COMMUNITY HOSPITAL 0 AUBURN MEMORIAL MEDICAL SERVICES PC 17 LANSING STREET AUBURN NY 13021 261193842 PRACTICE OF MEDICINE NY 501(C)(3) LINE 11 AUBURN COMMUNITY HOSPITAL 0 AUBURN MEDICAL PC 17 LANSING STREET AUBURN NY 13021 205111805 ANESTHESIOLOGY SERVICES NY N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0