2012-08-15T08:49:54-05:00 2011-09-30 SASLOW LUFKIN & BUGGY LLP TEN TOWER LANE AVON CT 06001 990 2010-10-01 060646559 BRISTOL HOSPITAL INC BRIS 8605853000 BREWSTER RD BRISTOL CT 06011 GEORGE W EIGHMY 8605853000 2012-08-14 1 BETH THURZ 8606789200 2010 2016-02-24 21:20:13Z KURT BARWIS BREWSTER RD BRISTOL CT 06011 134512605 0 X WWW.BRISTOLHOSPITAL.ORG X 1920 CT TO PROVIDE QUALITY HEALTHCARE SERVICES TO THE COMMUNITY. 17 13 1343 350 1135597 -742724 1947224 1812490 128738355 126737955 285251 516585 2531894 5445575 133502724 134512605 0 0 0 0 70523697 64766097 0 0 0 60463936 67128430 130987633 131894527 2515091 2618078 97645788 103125741 89425255 95110053 8220533 8015688 X BRISTOL HOSPITAL IS COMMITTED TO PROVIDING THE BEST PATIENT EXPERIENCE IN THE REGION. OUR 134-BED, FULL-SERVICE HEALTH CARE INSTITUTION PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT CARE FOR THE GREATER BRISTOL, CONNECTICUT AREA. 0 0 113317317 129958172 AS A SHORT-TERM ACUTE CARE COMMUNITY HOSPITAL, BRISTOL HOSPITAL PROVIDES A BROAD SPECTRUM OF HEALTHCARE SERVICES TO ANY INDIVIDUAL REGARDLESS OF THE INDIVIDUAL'S ABILITY TO PAY. THE HOSPITAL PROVIDED MORE THAN $223,700 IN CHARITY CARE DURING THE OPERATING YEAR. THE HOSPITAL ALSO PROVIDES EDUCATION AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE ACTIVITIES TYPICALLY REACH ABOUT 1,600 INDIVIDUALS PER QUARTER. THESE ACTIVITIES INCLUDE: WELLNESS CENTER - SPECIAL CENTER FOR EDUCATIONAL OUTREACH PROGRAMMING SERVING HUNDREDS OF INDIVIDUALS PER MONTH. - COMMUNITY HEALTH SCREENINGS - ONGOING FREE AND REDUCED PRICE SCREENINGS FOR MAMMOGRAMS, BLOOD PRESSURE, CHOLESTEROL, PROSTATE CANCER, SKIN CANCER AND A FLU CLINIC PROVIDING FREE FLU SHOTS IN THE FALL. - SPEAKERS BUREAU - A COMMUNITY SERVICE WHERE THE HOSPITAL PROVIDES SPEAKERS ON A VARIETY OF TOPICS TO SERVE THE COMMUNITY'S EDUCATIONAL NEEDS. - PERIODIC COMMUNITY SERVICE PROJECTS - THE HOSPITAL HAS SPONSORED TWO MAJOR OUTREACH EFFORTS, ONE TO PROMOTE EARLY DETECTION OF BREAST CANCER AND ONE TARGETED TO PREVENT COLON CANCER. BOTH PROGRAMS HAVE INCREASED THE COMMUNITY'S COMPLIANCE WITH THE RECOMMENDED CANCER SCREENINGS AND HAVE BEEN RECOGNIZED WITH STATE, REGIONAL AND NATIONAL AWARDS. 113317317 1 1 0 1 0 0 0 0 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 0 0 0 1 86 0 1 1343 1 1 1 0 0 0 0 0 0 0 0 0 X 17 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X GEORGE EIGHMY 8605853000 BREWSTER ROAD BRISTOL CT 06011 KENNETH BENOIT MD 2.00 X 0 0 0 NANCY BLANCHETTE 2.00 X X 0 0 0 MARK BLUM 2.00 X X 0 0 0 BALA SHANMUGAM MD 2.00 X 4375 235565 2917 LESLIE KISH MD 2.00 X 0 0 0 MORRIS LAVIERO 2.00 X 0 0 0 JOHN J LEONE JR 2.00 X 0 0 0 GLENN HEISER 2.00 X 0 0 0 KURT BARWIS 60.00 X X 586031 0 105220 JOHN LODOVICO JR 2.00 X 0 0 0 MARIE O'BRIEN 2.00 X X 0 0 0 PETER VALERIO 2.00 X 0 0 0 KENNETH RHEE MD 40.00 X 71088 0 0 RICK ABBOTT 2.00 X 0 0 0 JACK ADLER MD 2.00 X 0 0 0 DOUGLAS DEVNEW 2.00 X 0 0 0 DANIEL S SACCU 2.00 X 0 0 0 LEONARD BANCO MD 40.00 X 370194 0 16946 JEANINE RECKDENWALD 40.00 X 177750 0 1738 DAVE RACKLIFF 40.00 X 168188 0 18194 EVA WICKWIRE 40.00 X 151934 0 8082 SUE SYLVESTRE 40.00 X 167978 0 14467 MARC EDELMAN 40.00 X 202494 0 7747 JEFFREY SHELTON 40.00 X 183365 0 13210 MARIE MARCIANO 40.00 X 129062 0 16942 LYNNE RAMER 40.00 X 127146 0 10756 DIANE BOUFFARD 40.00 X 128932 0 1066 PETER FREYTAG 40.00 X 392797 0 11148 2861334 235565 228433 32 1 1 0 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 603966485 PET/CT SCANS 362193 HOSPITAL INTERNISTS OF BRISTOL LLC 3 MICHELLE LANE MYSTIC CT 06355 MEDICAL SERVICES 255000 TOTAL LAUNDRY COLLABORATIVE LLC 114 WOODLAND STREET HARTFORD CT 06105 LAUNDRY SERVICES 237210 DIALYSIS CTR OF NEWINGTON C/O DSD - NE REGIONAL OFFICE BOSTON MA 022413696 MEDICAL SERVICES 195784 BRISTOL PATHOLOGY CONSULTANTS PC PO BOX 1599 HARTFORD CT 061441599 MEDICAL CONSULT SERVICES 187060 17 402204 1410286 25338 1812490 PATIENT SERVICE REVENU 900099 125941019 124766502 1174517 OCCUPATIONAL HEALTH RE 621990 796936 796936 126737955 516585 516585 373912 373912 373912 373912 MISC. PROGRAM AND HEAL 621990 2829132 2829132 JOINT VENTURES 900099 1526682 1565602 -38920 CAFETERIA 722210 402475 402475 313374 313374 5071663 134512605 129958172 1135597 1606346 1983916 1983916 54522950 47134432 7388518 3734851 2987881 746970 386890 309512 77378 4137490 3309992 827498 3798498 3798498 540268 540268 101881 101881 74353 74353 4629882 3878259 751623 1045838 1042509 3329 14935494 14786139 149355 1894085 1894085 3456868 2972906 483962 204528 153396 51132 34499 34499 1833355 1833355 5725556 5654038 71518 7462558 5970046 1492512 BAD DEBT 9847024 9847024 MEDICAL SERVICES FEES 6532866 6532866 REPAIR AND MAINTENANCE 1663662 1663662 OTHER EXPENSES 1448733 1448733 COLLECTION FEES 783031 783031 1115451 1115451 131894527 113317317 18577210 0 8286702 4272881 96165 96343 15483112 20427829 1439654 1696559 2581093 2119071 139215994 99185736 37000469 40030258 12001102 11618379 12654647 12513653 5465804 5034092 2637040 5316676 97645788 103125741 23412362 29472454 607691 1186812 25042967 24658242 312490 305407 2749252 2351228 37300493 37135910 89425255 95110053 X 755592 427122 800850 1021495 6664091 6567071 8220533 8015688 97645788 103125741 X 2618078 -2822923 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 4629 0 1 69725 74354 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE HOSPITAL IS A MEMBER OF THE CONNECTICUT HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. $20,024 REPRESENTS THE PORTION OF THE DUES PAID TO THESE ASSOCIATIONS WHICH WERE USED FOR LOBBYING PURPOSES. THE HOSPITAL ENGAGED CAMILLIERE, CLOUD & KENNEDY, A CONNECTICUT LOBBYING AND BUSINESS DEVELOPMENT FIRM, FOR CONSULTING SERVICES IN THE AMOUNT OF $49,700. 12881077 40613 185211 12736479 12016137 1587194 722254 12881077 13256619 570728 -523731 1287479 12016137 0.40400 0.51600 0.08000 0 0 1506976 1506976 57576637 36232092 21344545 1006331 633794 372537 76698658 60220582 16478076 2427392 2099268 328124 40030258 FUNDS HELD FOR MALPRACTICE SELF-INSURANCE 6406972 F ASSETS HELD IN TRUST BY OTHERS 2743115 F FUNDS HELD UNDER BOND INDENTURE 2506470 F DONOR RESTRICTED INVESTMENTS 394142 F DEBT SERVICE FUND 462954 C 12513653 OTHER RECEIVABLES 677818 DUE FROM AFFILIATES 2258921 ESTIMATED SETTLEMENTS WITH THIRD-PARTY PAYERS 2379937 5316676 ACCRUED POSTRETIREMENT BENEFIT LIABILITY 5855356 LINE OF CREDIT 3541944 ASSET RETIREMENT OBLIGATIONS 2116281 ACCRUED PENSION LIABILITY 25622329 37135910 134512605 131894527 2618078 -866399 -1956524 -2822923 -204845 134085063 0 134085063 427542 427542 134512605 131894527 0 131894527 0 131894527 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF MULTIPLE FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES, SUCH AS CAPITAL EXPENDITURES, OPERATING EXPENSES, AND OTHER SPECIFIED DONOR AND BOARD RESTRICTED USES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740, "INCOME TAXES" WHICH PROVIDES A FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS IN THEIR 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 SEPTEMBER 30, 2011 AND 2010. IT IS THE HOSPITAL'S POLICY TO RECORD PENALTIES AND INTEREST ASSOCIATED WITH UNCERTAIN TAX PROVISIONS AS A COMPONENT OF OPERATING EXPENSES. AS OF SEPTEMBER 30, 2011 AND 2010, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL'S PRIOR THREE TAX YEARS ARE OPEN AND SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: DECREASE IN PERMANENTLY RESTRICTED NET ASSETS -97,020. TRANSFER TO BHMSG -825,477. PENSION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS -1,184,961. CHANGES IN POSTRETIREMENT HEALTH & WELFARE BENEFITS 278,391. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 300,085. NONCASH VACCINE CONTRIBUTIONS -25,338. CONTRIBUTION FROM BRISTOL HOSPITAL DEVELOPMENT FOUNDATION -402,204. PART XII, LINE 4B - OTHER ADJUSTMENTS: NONCASH VACCINE CONTRIBUTIONS 25,338. CONTRIBUTION FROM BRISTOL HOSPITAL DEVELOPMENT FOUNDATION 402,204. 1 1 1 X 1 X 1 1 0 0 809874 680000 129874 0.00100 23270010 18924907 4345103 0.03290 24079884 19604907 4474977 0.03390 95660 95660 0.00070 95660 95660 0.00070 24175544 19604907 4570637 0.03460 1 3306197 826549 47069698 50538043 -3468345 X 1 1 1 BRISTOL MSO LLC RADIOLOGY SERVICES 0.50000 2 MEDWORKS LLC REHAB & OCCUPATIONAL HEALTH 0.50000 0.00000 0.00000 3 CT OCCUPATIONAL MEDICAL PARTNERS OCCUPATIONAL HEALTH 0.33000 4 MEDCONN COLLECTION AGENCY COLLECTION SERVICES 0.20000 0.00000 0.00000 6 TOTAL LAUNDRY COLLABORATIVE LLC LAUNDRY SERVICES 0.09000 7 CENTRAL CT ENDOSCOPY CENTER MEDICAL SERVICES 0.06500 8 HEALTH CT LLC MEDICAL SERVICES 0.05400 0.00000 0.00000 1 1 BRISTOL HOSPITAL INC

BREWSTER ROAD BRISTOL CT 06010

X X X X BRISTOL HOSPITAL INC 1 9 BRISTOL BEHAVIORAL HEALTH SERVICES

10 N MAIN STREET SUITE 210 BRISTOL CT 06010

BEHAVIORAL HEALTH BRISTOL HOSPITAL CENTER FOR DIABETES

102 NORTH STREET BRISTOL CT 06010

DIABETES MEDICAL CARE AND EDUCATION BRISTOL HOSPITAL COUNSELING CENTER

440-C NORTH MAIN STREET BRISTOL CT 06010

THERAPY AND COUNSELING BRISTOL HOSPITAL WELLNESS CENTER

842 CLARK AVENUE BRISTOL CT 06010

MEDICAL AND FITNESS SERVICES BRISTOL RADIOLOGY CENTER

25 COLLINS ROAD BRISTOL CT 06010

MAMMOGRAPHY AND MRI MED HELP

539 FARMINGTON AVENUE BRISTOL CT 06010

URGENT CARE MEDWORKS LLC

375 CEDAR STREET NEWINGTON CT 06111

OCCUPATIONAL HEALTH SERVICES PARENT & CHILD CENTER - BRISTOL HOSPITA

9 PROSPECT STREET BRISTOL CT 06010

CHILDREN AND FAMILY SERVICES REHAB DYNAMICS

975 FARMINGTON AVENUE BRISTOL CT 06010

PHYSICAL THERAPY AND SPORTS MEDICINE PART III, LINE 8: THE CALCULATED MEDICARE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE IT REPRESENTS UNREIMBURSED COSTS FOR PATIENT SERVICES. THESE UNREIMBURSED COSTS ARE BRISTOL HOSPITAL EXPENSES THAT ULTIMATELY BENEFIT THE COMMUNITY BRISTOL HOSPITAL SERVICES. PART III, LINE 9B: IT IS THE POLICY OF BRISTOL HOSPITAL TO PROVIDE EVERY PATIENT FROM THE COMMUNITY WE SERVE WITH MEDICALLY NECESSARY HEALTH SERVICES REGARDLESS OF THEIR ABILITY TO PAY. THE POLICY SETS SPECIFIC GUIDLINES FOR THE COLLECTION OF PATIENT PAYMENTS AND ESTABLISHES A HIERARCHY FOR PAYMENT METHODS THAT ARE BOTH FRIENDLY TO THE PATIENT AND BENEFICIAL TO THE HOSPITAL. PATIENTS WHO ARE UNABLE TO PAY THEIR LIABILITY ARE REFERRED TO A FINANCIAL COUNSELOR WHO WILL ASSESS THE PATIENT'S ELIGIBILITY FOR CHARITY CARE OR ALTERNATIVE FUNDING SOURCES. FUNDING SOURCES INCLUDE CHARITY CARE, OUTSIDE FINANCING, HOSPITAL PAYMENT PLANS, FEDERAL, STATE AND LOCAL PROGRAMS AND THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 2: HOSPITAL ASSESSMENT OF THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES IS A DYNAMIC PROCESS THAT INVOLVES ALL LEVELS OF HOSPITAL ADMINISTRATION, STAFF, THE BOARD OF DIRECTORS (BOD), AND MEDICAL STAFF. VARIOUS COMMITTEES AND GROUPS AT THE HOSPITAL MEET PERIODICALLY TO DISCUSS THE NEEDS OF THE COMMUNITY WE SERVE AS WELL AS THE RESOURCES AND SERVICES AVAILABLE AT THE HOSPITAL AND OTHER AGENCIES IN THE AREA. THE HOSPITAL IS REPRESENTED AT COMMUNITY LEVEL ORGANIZATIONS AND GROUPS THAT ARE ALSO INVOLVED WITH ASSESSMENT OF THE COMMUNITY NEEDS. HOSPITAL RESOURCES ARE FREQUENTLY CALLED UPON TO PARTICIPATE IN PROGRAMS AND PROJECTS PUT TOGETHER TO ADDRESS THOSE NEEDS. PART VI, LINE 3: AT BRISTOL HOSPITAL, PATIENTS ARE NOTIFIED OF THEIR ABILITY TO DISCUSS FINANCIAL ASSISTANCE OPTIONS INCLUDING CHARITY CARE IN ALL OF THEIR BILLING STATEMENTS. THE HOSPITAL ENCOURAGES PATIENTS TO FIND OUT THEIR ELIGIBILITY FOR ASSISTANCE AND PROVIDES FINANCIAL COUNSELORS TO ASSIST PATIENTS IN APPLYING FOR CHARITY CARE.PATIENTS CAN CONTACT THE FINANCIAL ASSISTANCE DEPARTMENT WITHIN THE HOSPITAL AT 860-585-3878. THIS SUPPORT ALSO INCLUDES A REPRESENTATIVE THROUGH THE STATE OF CONNECTICUT (REPRESENTATIVE PAID BY BRISTOL HOSPITAL) SO WE ENSURE THAT ALL ASPECTS OF ASSISTANCE ARE PROVIDED FOR EACH PATIENT.THE FINANCIAL ASSISTANCE DEPARTMENT ALSO DISCUSSES GOVERNMENT BENEFITS WITH PATIENTS THAT THEY MAY BE ELIGIBLE FOR.CONTACT INFORMATION FOR OUR FINANCIAL COUNSELOR IS ALSO INCLUDED ON THE HOSPITAL WEBSITE FOR PATIENTS TO REFERENCE. THE HOSPITAL ALSO OFFERS MANY FREE PROGRAMS FOR THE UNINSURED INCLUDING FREE BLOOD PRESSURE CLINICS, SKIN CANCER SCREENING CLINICS AND SEMINARS TO PROVIDE PATIENTS ACCESS TO AS MUCH FREE HEALTH INFORMATION AS POSSIBLE. PART VI, LINE 4: BRISTOL HOSPITAL IS COMMITTED TO PROVIDING THE BEST PATIENT EXPERIENCE IN THE REGION. OUR 134-BED, FULL-SERVICE HEALTH CARE INSTITUTION PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT CARE FOR THE GREATER BRISTOL, CONNECTICUT AREA.BRISTOL IS A SUBURBAN CITY LOCATED IN HARTFORD COUNTY, CONNECTICUT, UNITED STATES 20 MILES SOUTHWEST OF HARTFORD. BRISTOL HAS A TOTAL AREA OF 26.8 SQUARE MILES AND A POPULATION OF APPROX 62K. IN BRISTOL, 84.2% OF THE PEOPLE SPEAK ENGLISH AND 4.8% OF PEOPLE SPEAK SPANISH. IN BRISTOL, 54.6% OF PEOPLE ARE MARRIED AND 92.2% OF RESIDENTS WERE BORN IN THE US.COMMUNITY INFORMATION:THE PRIMARY SERVICE AREA (PSA) FOR OUR HOSPITAL INCLUDES:BRISTOL (ZIP CODE 06010,06011)- 2011 CENSUS 62,078BURLINGTON (ZIP CODE 06013)- 2011 CENSUS- 10,011PLAINVILLE (ZIP CODE 06062)- 2011 CENSUS 17,767PLYMOUTH (ZIP CODE 06781,06782,06786)- 2011 CENSUS 12,605THE TOTAL POPULATION FROM THE 2011 CENSUS FOR OUR PSA IS- 102,461IN 2010, THE LATEST DATE DATA BECAME AVAILABLE AND THE FOLLOWING DATA POINTS WERE PROVIDED FOR THE FOLLOWING COMMUNITIES: BRISTOL:MEDIAN HOUSEHOLD INCOME: $58,537FAMILIES BELOW POVERTY LEVEL- 5.6%INDIVIDUALS BELOW POVERTY LEVEL- 7.7%RACE: WHITE- 87.6%, BLACK OR AFRICAN AMERICAN- 3.6%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 1.8%, OTHER RACE- 3.9%BURLINGTON: MEDIAN HOUSEHOLD INCOME: $116,419 FAMILIES BELOW POVERTY LEVEL- 1.2% INDIVIDUALS BELOW POVERTY LEVEL- 1.9% RACE: WHITE- 98%, BLACK OR AFRICAN AMERICAN- 0.2%,AMERICAN INDIAN OR ALASKA NATIVE- 0.1%, ASIAN- 1.2%PLAINVILLE: MEDIAN HOUSEHOLD INCOME: $62,440 FAMILIES BELOW POVERTY LEVEL- 4.1% INDIVIDUALS BELOW POVERTY LEVEL- 5.0% RACE: WHITE- 93.1%, BLACK OR AFRICAN AMERICAN- 2.5%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 1.3%, OTHER RACE- 0.6% PLYMOUTH: MEDIAN HOUSEHOLD INCOME: $70,132 FAMILIES BELOW POVERTY LEVEL- 2.9% INDIVIDUALS BELOW POVERTY LEVEL- 5.6% RACE: WHITE- 96.7%, BLACK OR AFRICAN AMERICAN- 0.5%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 0.6%, OTHER RACE- 0.7% THE SECONDARY SERVICE AREA (SSA) FOR OUR HOSPITAL INCLUDES:FARMINGTON (ZIP CODE 06085,06087)- 2011 CENSUS 6,058SOUTHINGTON (ZIP CODE 06489)- 2011 CENSUS 33,560WOLCOTT (ZIP CODE 06716)- 2011 CENSUS 17,458THOMASTON (ZIP CODE 06787)- 2011 CENSUS 8,512HARWINTON (ZIP CODE 06791)- 2011 CENSUS 5,938THE TOTAL POPULATION FROM THE 2011 CENSUS FOR OUR SSA IS- 71,526BOTH THE PSA (PRIMARY SERVICE AREA) AND SSA (SECONDARY SERVICE AREA) ARE PRIMARILY SUBURBAN AND RURAL AREAS BUT ALSO INCLUDE SOME URBAN AREAS AS WELL. SOME OF THE MAJOR HEALTH PROBLEMS PREVALENT IN OUR PSA ARE ASSOCIATED WITH BEHAVIORAL HEALTH, CHEMICAL DEPENDENCY, OBESITY, AND PULMONARY DISEASE. PART VI, LINE 6: BRISTOL HOSPITAL TAKES GREAT PRIDE IN SERVING THE COMMUNITY. AS PART OF ITS MISSION, BRISTOL HOSPITAL INCORPORATES A BROAD ARRAY OF COMMUNITY OUTREACH AND WELLNESS ACTIVITIES, DELIVERING EDUCATIONAL MATERIAL AND COUNSELING, OFFERING FREE OR LOW COST HEALTH SCREENINGS AND HOSTING PATIENT AND FAMILY SUPPORT GROUPS. WE UNDERSTAND THE IMPORTANCE AND VALUE OF EMPHASIZING GOOD HEALTH, FITNESS, SAFETY AND THE PROMOTION OF EARLY DETECTION OF ILLNESS OR DISEASE. THEREFORE, ALL OF OUR OUTREACH EFFORTS REFLECT OUR STRONG DESIRE TO IMPROVE THE QUALITY OF LIFE FOR ALL WHO LIVE AND WORK IN THE COMMUNITIES WE SERVE. BRISTOL HOSPITAL PROVIDES FINANCIAL SUPPORT AND ACCESS TO APPROPRIATE CLINICAL CARE FOR SEVERAL LIFE-SAVING INITIATIVES, INCLUDING THE BRISTOL COMMUNITY BREAST HEALTH PROJECT AND THE COLON CANCER AWARENESS PROJECT OF GREATER BRISTOL, WHICH ALLOW US TO OFFER FREE BREAST, AND COLORECTAL CANCER SCREENINGS TO THOSE WHO, DUE TO INSURANCE OR INCOME FACTORS, MIGHT NOT OTHERWISE HAVE ACCESS TO THESE VALUABLE DIAGNOSTIC SCREENING SERVICES. THE EYE CARE PROJECT OF GREATER BRISTOL PROVIDES VITAL ACCESS TO SERVICES FOR THOSE SUFFERING FROM VISION IMPAIRMENT.AT BRISTOL HOSPITAL WE UNDERSTAND THE IMPORTANCE OF OUR ROLE AS AN EXEMPT HEALTHCARE PROVIDER TO THE COMMUNITY WE SERVICE. OUR LEADERSHIP TEAM IS COMMITTED TO PROVIDING OUTSTANDING PATIENT CARE AND PROMOTING THE HEALTH OF THE COMMUNITY. BRISTOL HOSPITAL ATTEMPTS TO PROMOTE OUR FREE AND NON-REVENUE GENERATING PROGRAMS IN A VARIETY OF WAYS. THREE TIMES A YEAR, THE HOSPITAL MAILS A "PATHWAYS TO YOUR HEALTH" CATALOG. THE CATALOG CONTAINS A LISTING OF PROGRAMS AVAILABLE TO THE GREATER BRISTOL COMMUNITY. THIS CATALOG IS MAILED TO OVER 60,000 RESIDENTS AND PROVIDES INFORMATION ON FREE HEALTH SCREENINGS, SUPPORT GROUPS, HEALTH EDUCATION, WELLNESS PROGRAMS, ETC. THE CATALOG IS ALSO INCLUDED ON OUR HOSPITAL WEBSITE TO PROVIDE INCREASED ACCESS TO PATIENTS. THE PATHWAYS CATALOG IS DELIVERED AND DISPLAYED IN EACH DEPARTMENT WITHIN THE HOSPITAL AND IS FREE FOR ALL PATIENTS TO TAKE. PROGRAMS ARE ALSO LISTED ON OUR WEBSITE UNDER AN "EVENTS" SECTION WHERE PATIENTS CAN REGISTER FOR FREE, DIRECTLY ONLINE. WE ALSO PROMOTE OUR PROGRAMS MONTHLY IN THE BRISTOL PRESS, BRISTOL OBSERVER, HARTFORD COURANT AND PLYMOUTH CONNECTION. WE SUBSCRIBE TO AN "ON-HOLD" SYSTEM FOR OUR PHONES WHICH ALLOWS US TO RECORD MESSAGES FOR PATIENTS WHEN THEY CALL THE HOSPITAL. MANY OF THESE MESSAGES ARE ABOUT FREE PROGRAMS AND SERVICES, HEALTH EDUCATION FACTS AND SERVICES TO THE COMMUNITY. PART VI, LINE 7: N/A REPORTS FILED WITH STATES PART VI, LINE 7 CT X 1 0 X X X X X 0 1 0 0 0 1 0 0 0 BALA SHANMUGAM MD 0 218065 0 17500 4375 0 0 2917 0 0 4375 238482 0 0 KURT BARWIS 429555 0 156476 0 0 0 86628 0 18592 0 691251 0 0 0 LEONARD BANCO MD 293369 0 76825 0 0 0 2450 0 14496 0 387140 0 0 0 JEANINE RECKDENWALD 146371 0 31379 0 0 0 807 0 931 0 179488 0 0 0 DAVE RACKLIFF 144910 0 23278 0 0 0 1428 0 16766 0 186382 0 0 0 EVA WICKWIRE 130206 0 21728 0 0 0 1248 0 6834 0 160016 0 0 0 SUE SYLVESTRE 142547 0 25431 0 0 0 7615 0 6852 0 182445 0 0 0 MARC EDELMAN 187094 0 15400 0 0 0 0 0 7747 0 210241 0 0 0 JEFFREY SHELTON 178365 0 5000 0 0 0 0 0 13210 0 196575 0 0 0 PETER FREYTAG 354363 0 38434 0 0 0 0 0 11148 0 403945 0 0 0 PART I, LINE 1A THE HOSPITAL PAID $5,382 IN GOLF CLUB MEMBERSHIP FEES FOR ITS PRESIDENT DURING FISCAL 2011. PART I, LINE 4B KURT BARWIS, PRESIDENT, PARTICIPATES IN THE HOSPITAL'S 457(F) DEFINED CONTRIBUTION PLAN. PART I, LINE 6 THE BASE COMPENSATION OF THE HOSPITAL'S PRESIDENT, KURT BARWIS, IS BASED IN PART ON THE NET EARNINGS OF THE HOSPITAL. MORRIS LAVIERO PURCHASE BUILDING X 350000 305407 0 1 1 305407 X 1 25338 REPORT FROM DHHS 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 A COMPLETED 990 IS PROVIDED TO EACH BOARD MEMBER PRIOR TO SUBMISSION. THIS PROVIDES AN OPPORTUNITY FOR MEMBERS TO ASK QUESTIONS, ADD COMMENTS, AND FOLLOW UP WITH THE FINANCE TEAM REGARDING ANY ISSUES OR CONCERNS. THE 990 IS ALSO REVIEWED INTERNALLY BY MEMBERS OF THE FINANCE AND MANAGEMENT TEAMS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL APPLICABLE PARTIES ARE REQUIRED TO RECEIVE AND SIGN A STATEMENT ACKNOWLEDGING THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO COMPLY WITH THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMPENSATION COMMITTEE IS AUTHORIZED UNDER THE BRISTOL HOSPITAL AND HEALTH CARE GROUP BYLAWS AND IS RESPONSIBLE FOR (1) DETERMINING THE OVERALL TOTAL COMPENSATION STRATEGY FOR ALL CORPORATE OFFICERS, (2) APPROVING ALL COMPENSATION AND BENEFITS DECISIONS FOR CORPORATE OFFICERS, AND (3) REPORTING SUCH ACTIONS TO THE FULL BRISTOL HOSPITAL AND HEALTH CARE GROUP BOARD ON AN ANNUAL BASIS. IN ADDITION, THE EXECUTIVE COMPENSATION COMMITTEE EXPRESSLY DETERMINES THE REASONABLENESS OF TOTAL COMPENSATION AND BENEFITS FOR ALL CORPORATE OFFICERS AND ASSURES THAT ALL OFFICER COMPENSATION DECISIONS ARE MADE AFTER THOROUGH CONSIDERATION OF AND COMPARISON TO THE MARKET PRACTICES OF OTHER SIMILARLY SITUATED NOT-FOR-PROFIT HEALTHCARE EXECUTIVES IN COMPARABLE ORGANIZATIONS. THE EXECUTIVE COMPENSATION COMMITTEE CONSISTS OF BOARD MEMBERS WHO DO NOT HAVE MATERIAL FINANCIAL INTERESTS THAT COULD BE AFFECTED BY THE OFFICER COMPENSATION DECISIONS MADE BY THE COMMITTEE. THE COMPARABILITY DATA USED TO ASSIST THE EXECUTIVE COMPENSATION COMMITTEE IN ITS COMPENSATION DELIBERATIONS ARE COMPILED BY AN INDEPENDENT, NATIONAL COMPENSATION CONSULTING FIRM THAT IS RETAINED BY AND REPORTS DIRECTLY TO THE EXECUTIVE COMPENSATION COMMITTEE. THE DATA COLLECTED BY THE CONSULTANT CONSISTS OF MARKET INFORMATION FOR EXECUTIVES IN FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS. THE DELIBERATIONS AND DECISIONS OF THE EXECUTIVE COMPENSATION COMMITTEE ARE CONTEMPORANEOUSLY DOCUMENTED, REVIEWED AND APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE AND PROVIDED TO THE BOARD ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -866,399. DECREASE IN PERMANENTLY RESTRICTED NET ASSETS -97,020. TRANSFER TO BHMSG -825,477. PENSION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS -1,184,961. CHANGES IN POSTRETIREMENT HEALTH & WELFARE BENEFITS 278,391. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 300,085. NONCASH VACCINE CONTRIBUTIONS -25,338. CONTRIBUTION FROM BRISTOL HOSPITAL DEVELOPMENT FOUNDATION -402,204. TOTAL TO FORM 990, PART XI, LINE 5: -2,822,923. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESSES OF OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. HG PROPERTY HOLDINGS LLC 41 BREWSTER RD BRISTOL CT 06010 272548373 REAL ESTATE CT 7500 276130 BRISTOL HOSPITAL INC BRISTOL HOSPITAL AND HEALTH CARE GROUP INC BREWSTER ROAD BRISTOL CT 06010 222577726 HEALTHCARE PARENT COMPANY CT 501 (C) (3) 11B, TYPE II 0 BRISTOL HOSPITAL DEVELOPMENT FOUNDATION INC BREWSTER ROAD BRISTOL CT 06010 222577740 FUNDRAISING CT 501 (C) (3) 7 BRISTOL HOSPITAL AND HEALTH CARE GROUP INC 0 BRISTOL HEALTH CARE INC 400 NORTH MAIN STREET BRISTOL CT 06010 222577731 NURSING HOME CT 501 (C) (3) 9 BRISTOL HOSPITAL AND HEALTH CARE GROUP INC 0 BRISTOL HOSPITAL MULTISPECIALTY GROUP INC BREWSTER ROAD BRISTOL CT 06010 061466555 HEALTHCARE SERVICES CT 501 (C) (3) 9 BRISTOL HOSPITAL AND HEALTH CARE GROUP INC 0 MEDWORKS LLC 375 EAST CEDAR STREET NEWINGTON CT 06111 061490483 REHAB & OCCUPATIONAL HEALTH CT RELATED -62234 709 0 0 0.50000 BRISTOL MSO LLC 25 COLLINS ROAD BRISTOL CT 06010 061506024 RADIOLOGY SERVICES CT RELATED 435315 838425 0 0 0.50000 BRISTOL HOSPITAL EMS LLC PO BOX 977 BRISTOL CT 06011 061547648 EMERGENCY MEDICAL SERVICES CT BRISTOL HEALTH SERVICES INC C BRISTOL HEALTH SERVICES INC PO BOX 977 BRISTOL CT 06011 203919173 HOLDING COMPANY CT BRISTOL HOSPITAL AND HEALTH CARE GROUP INC C CENTRAL CONNECTICUT MEDICAL MANAGEMENT INC 200 MAIN STREET BRISTOL CT 06011 222577728 MANAGEMENT SERVICES CT BRISTOL HEALTH SERVICES INC C GREATER BRISTOL PRIMARY CARE GROUP PC 200 MAIN STREET BRISTOL CT 06011 061466555 PRIMARY CARE SERVICES CT C BRISTOL PSYCHIATRIC SERVICES PC 200 MAIN STREET BRISTOL CT 06011 061511379 PSYCHIATRIC SERVICES CT C MED-HELP PC 200 MAIN STREET BRISTOL CT 06011 061484522 URGENT CARE CENTER CT C 1 0 1 0 0 0 0 0 1 0 0 1 0 1 0 0 1 1 BRISTOL HOSPITAL EMS LLC Q 339223 COST BRISTOL HOSPITAL EMS LLC N 73592 COST BRISTOL HOSPTIAL MULTISPECIALTY GROUP Q 825477 COST BRISTOL HEALTH CARE Q 1325293 COST BRISTOL HEALTH CARE N 255276 COST BRISTOL HOSPITAL DEVELOPMENT FOUNDATION N 338064 COST BRISTOL HOSPITAL DEVELOPMENT FOUNDATION L 1115807 COST GREATER BRISTOL PRIMARY CARE GROUP INC A 217784 COST GREATER BRISTOL PRIMARY CARE GROUP INC Q 3963835 COST BRISTOL HOSPITAL DEVELOPMENT FOUNDATION C 402204 COST