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    </IRS990ScheduleD>
    <IRS990ScheduleI documentId="IRS990ScheduleI" softwareId="10000105" softwareVersion="2010v3.2">
      <RecordsMaintained>true</RecordsMaintained>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>Leadership Tyler</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>315 N Broadway</AddressLine1>
          <City>Tyler</City>
          <State>TX</State>
          <ZIPCode>75702</ZIPCode>
        </AddressUS>
        <AmountOfCashGrant>25000</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Donation</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>ETMC - Trinity</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>PO Box 3169</AddressLine1>
          <City>Trinity</City>
          <State>TX</State>
          <ZIPCode>75862</ZIPCode>
        </AddressUS>
        <EINOfRecipient>752715898</EINOfRecipient>
        <IRCSection>501 (c)(3)</IRCSection>
        <AmountOfCashGrant>1125000</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Contribution</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>ETMC - Mount Vernon</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>PO Box 477</AddressLine1>
          <City>Mount Vernon</City>
          <State>TX</State>
          <ZIPCode>75457</ZIPCode>
        </AddressUS>
        <EINOfRecipient>752250730</EINOfRecipient>
        <IRCSection>501 (c)(3)</IRCSection>
        <AmountOfCashGrant>375000</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Contribution</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>ETMC - Fairfield</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>PO Box 1090</AddressLine1>
          <City>Fairfield</City>
          <State>TX</State>
          <ZIPCode>75840</ZIPCode>
        </AddressUS>
        <EINOfRecipient>752753454</EINOfRecipient>
        <IRCSection>501 (c)(3)</IRCSection>
        <AmountOfCashGrant>795000</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Contribution</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>ETMC - Crockett</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>1100 Loop 304 East</AddressLine1>
          <City>Crockett</City>
          <State>TX</State>
          <ZIPCode>75835</ZIPCode>
        </AddressUS>
        <EINOfRecipient>752602621</EINOfRecipient>
        <IRCSection>501 (c)(3)</IRCSection>
        <AmountOfCashGrant>3750000</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Contribution</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>Bethesda Health Clinic</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>PO Box 1999</AddressLine1>
          <City>Tyler</City>
          <State>TX</State>
          <ZIPCode>75710</ZIPCode>
        </AddressUS>
        <AmountOfCashGrant>7500</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Donation</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>American Heart Association</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>PO Box 59</AddressLine1>
          <City>Longview</City>
          <State>TX</State>
          <ZIPCode>75606</ZIPCode>
        </AddressUS>
        <IRCSection>501 (c)(3)</IRCSection>
        <AmountOfCashGrant>7500</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Donation</PurposeOfGrant>
      </RecipientTable>
      <RecipientTable>
        <RecipientNameBusiness>
          <BusinessNameLine1>American Cancer Society</BusinessNameLine1>
        </RecipientNameBusiness>
        <AddressUS>
          <AddressLine1>1301 S Broadway</AddressLine1>
          <City>Tyler</City>
          <State>TX</State>
          <ZIPCode>75701</ZIPCode>
        </AddressUS>
        <EINOfRecipient>741185665</EINOfRecipient>
        <IRCSection>501 (c)(3)</IRCSection>
        <AmountOfCashGrant>12500</AmountOfCashGrant>
        <AmountOfNonCashAssistance>0</AmountOfNonCashAssistance>
        <PurposeOfGrant>Donation</PurposeOfGrant>
      </RecipientTable>
      <TotalNbrOf501C3AndGovtGrants>6</TotalNbrOf501C3AndGovtGrants>
      <TotalNbrOfOtherOrganizations>2</TotalNbrOfOtherOrganizations>
      <Form990ScheduleIPartIV>
        <Identifier>Grantmaker's Description of How Grants are Used</Identifier>
        <Explanation>Senior management will review the needs and give approval to support a variety of agencies, service organziations and projects related to meeting health and human service needs for Tyler and East Texas, as well as those contributing to overall quality of life for the community. Contributions were made in terms of financial and in-kind donations, agencies and organizations supported are non-profit.</Explanation>
      </Form990ScheduleIPartIV>
    </IRS990ScheduleI>
    <IRS990ScheduleJ documentId="IRS990ScheduleJ" softwareId="10000105" softwareVersion="2010v3.2">
      <ClubDuesOrFees>X</ClubDuesOrFees>
      <WrittenPolicyReTAndEExpenses>true</WrittenPolicyReTAndEExpenses>
      <SubstantiationRequired>true</SubstantiationRequired>
      <CompensationCommittee>X</CompensationCommittee>
      <Form990OfOtherOrganizations>X</Form990OfOtherOrganizations>
      <CompensationSurvey>X</CompensationSurvey>
      <BoardOrCommitteeApproval>X</BoardOrCommitteeApproval>
      <SeverancePayment>false</SeverancePayment>
      <SupplementalNonqualRetirePlan>true</SupplementalNonqualRetirePlan>
      <EquityBasedCompArrangement>false</EquityBasedCompArrangement>
      <CompBasedOnRevenueOfFilingOrg>false</CompBasedOnRevenueOfFilingOrg>
      <CompBasedOnRevenueRelatedOrgs>false</CompBasedOnRevenueRelatedOrgs>
      <CompBasedNetEarningsFilingOrg>false</CompBasedNetEarningsFilingOrg>
      <CompBasedNetEarningsRelateOrgs>true</CompBasedNetEarningsRelateOrgs>
      <AnyNonFixedPayments>false</AnyNonFixedPayments>
      <InitialContractException>false</InitialContractException>
      <RebuttablePresumptionProcedure>false</RebuttablePresumptionProcedure>
      <Form990ScheduleJPartII>
        <NamePerson>Stephen Rydzak MD</NamePerson>
        <CompBasedOnRelatedOrgs>490049</CompBasedOnRelatedOrgs>
        <BonusRelatedOrgs>129365</BonusRelatedOrgs>
        <OtherCompensationRelatedOrgs>2678</OtherCompensationRelatedOrgs>
        <NontaxableBenefitsRelatedOrgs>731</NontaxableBenefitsRelatedOrgs>
        <TotalCompensationRelatedOrgs>622823</TotalCompensationRelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Robert Layton</NamePerson>
        <BaseCompensationFilingOrg>219071</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>65003</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>16085</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>300159</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Robert Hampton</NamePerson>
        <BaseCompensationFilingOrg>207176</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>41011</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>19398</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>267585</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Paula Anthony</NamePerson>
        <BaseCompensationFilingOrg>322028</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>136218</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>26421</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>484667</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Mike Thomas</NamePerson>
        <BaseCompensationFilingOrg>312857</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>189606</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>29797</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>532260</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Mike Gray</NamePerson>
        <BaseCompensationFilingOrg>293954</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>358150</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>25465</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>677569</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Kim Pearson-Wahl</NamePerson>
        <BaseCompensationFilingOrg>299838</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>108349</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>25415</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>433602</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Jerry Massey</NamePerson>
        <BaseCompensationFilingOrg>358354</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>146850</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>29753</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>534957</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Freddie Sanchez</NamePerson>
        <BaseCompensationFilingOrg>294999</BaseCompensationFilingOrg>
        <BonusRelatedOrgs>150500</BonusRelatedOrgs>
        <OtherCompensationFilingOrg>165921</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>25517</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>486437</TotalCompensationFilingOrg>
        <TotalCompensationRelatedOrgs>150500</TotalCompensationRelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Elmer G Ellis</NamePerson>
        <BaseCompensationFilingOrg>1054558</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>940573</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>38281</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>2033412</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Elizabeth Smith</NamePerson>
        <BaseCompensationFilingOrg>133082</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>74513</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>19003</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>226598</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Byron Hale</NamePerson>
        <BaseCompensationFilingOrg>492708</BaseCompensationFilingOrg>
        <OtherCompensationFilingOrg>155679</OtherCompensationFilingOrg>
        <NontaxableBenefitsFilingOrg>33711</NontaxableBenefitsFilingOrg>
        <TotalCompensationFilingOrg>682098</TotalCompensationFilingOrg>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartIII>
        <Identifier>Sch J, Part I, Line 6b</Identifier>
        <ReturnReference>Part I, Line 6b: Explanation of organization compensation contingent on net earnings from related or</ReturnReference>
        <Explanation>Schedule J, Part I, Line 6bFreddie Sanchez received incentive compensation based on net earnings of First Choice Management Services.</Explanation>
      </Form990ScheduleJPartIII>
      <Form990ScheduleJPartIII>
        <Identifier>Sch J, Part I, Line 1a</Identifier>
        <ReturnReference>Part I, Line 1a: Relevant information in regards to selections on 1a.</ReturnReference>
        <Explanation>Schedule J, Part I, Line 1aCountry club dues are paid for business purpose. Any personal use is reimbursed by the employee.</Explanation>
      </Form990ScheduleJPartIII>
    </IRS990ScheduleJ>
    <IRS990ScheduleK documentId="IRS990ScheduleK.1" softwareId="10000105" softwareVersion="2010v3.2">
      <Form990ScheduleKPartI>
        <IssuerName>
          <BusinessNameLine1>HCDC of Central Texas Inc</BusinessNameLine1>
        </IssuerName>
        <IssuerEIN>371453424</IssuerEIN>
        <DateIssued>2006-09-21</DateIssued>
        <IssuePrice>9701720</IssuePrice>
        <DescriptionOfPurpose>Health facilities equipment</DescriptionOfPurpose>
        <Defeased>false</Defeased>
        <OnBehalfOfIssuer>false</OnBehalfOfIssuer>
        <PoolFinancing>false</PoolFinancing>
      </Form990ScheduleKPartI>
      <Form990ScheduleKPartI>
        <IssuerName>
          <BusinessNameLine1>Tyler Health Facilities Development Corporation</BusinessNameLine1>
        </IssuerName>
        <IssuerEIN>521315814</IssuerEIN>
        <CUSIPNumber>902261HJ8</CUSIPNumber>
        <DateIssued>2007-11-05</DateIssued>
        <IssuePrice>283017726</IssuePrice>
        <DescriptionOfPurpose>Bond issues and finance health facilities</DescriptionOfPurpose>
        <Defeased>false</Defeased>
        <OnBehalfOfIssuer>false</OnBehalfOfIssuer>
        <PoolFinancing>false</PoolFinancing>
      </Form990ScheduleKPartI>
      <Form990ScheduleKPartII>
        <AmountRetired>9521696</AmountRetired>
        <TotalProceeds>9909492</TotalProceeds>
        <WorkingCapitalExpenditures>5820</WorkingCapitalExpenditures>
        <CapitalExpenditures>9903672</CapitalExpenditures>
        <YearOfSubstCompletion>2008</YearOfSubstCompletion>
        <CurrentRefunding>false</CurrentRefunding>
        <AdvanceRefunding>false</AdvanceRefunding>
        <FinalAllocationMade>true</FinalAllocationMade>
        <AdequateBooksAndRecdsMaintaind>true</AdequateBooksAndRecdsMaintaind>
      </Form990ScheduleKPartII>
      <Form990ScheduleKPartII>
        <AmountRetired>13085000</AmountRetired>
        <TotalProceeds>284478785</TotalProceeds>
        <AmountInReserveFund>19075286</AmountInReserveFund>
        <RefundingEscrow>173177531</RefundingEscrow>
        <IssuanceCostsFromProceeds>3053621</IssuanceCostsFromProceeds>
        <CapitalExpenditures>105221059</CapitalExpenditures>
        <YearOfSubstCompletion>2011</YearOfSubstCompletion>
        <CurrentRefunding>true</CurrentRefunding>
        <AdvanceRefunding>true</AdvanceRefunding>
        <FinalAllocationMade>true</FinalAllocationMade>
        <AdequateBooksAndRecdsMaintaind>true</AdequateBooksAndRecdsMaintaind>
      </Form990ScheduleKPartII>
      <Form990ScheduleKPartIII>
        <OwningBondFinancedProperty>false</OwningBondFinancedProperty>
        <AnyLeaseArrangements>false</AnyLeaseArrangements>
        <MngmentCntrctBondFinancdPrprty>false</MngmentCntrctBondFinancdPrprty>
        <AnyResearchAgreements>false</AnyResearchAgreements>
        <PostIssuanceComplianceProcdrs>true</PostIssuanceComplianceProcdrs>
      </Form990ScheduleKPartIII>
      <Form990ScheduleKPartIII>
        <OwningBondFinancedProperty>false</OwningBondFinancedProperty>
        <AnyLeaseArrangements>false</AnyLeaseArrangements>
        <MngmentCntrctBondFinancdPrprty>false</MngmentCntrctBondFinancdPrprty>
        <AnyResearchAgreements>false</AnyResearchAgreements>
        <PostIssuanceComplianceProcdrs>true</PostIssuanceComplianceProcdrs>
      </Form990ScheduleKPartIII>
      <Form990ScheduleKPartIV>
        <Form8038TFiled>false</Form8038TFiled>
        <VariableRateIssue>false</VariableRateIssue>
        <HedgeIdentifiedInBooksAndRecds>false</HedgeIdentifiedInBooksAndRecds>
        <GrossProceedsInvestedInGIC>false</GrossProceedsInvestedInGIC>
        <GrossProceedsInvested>false</GrossProceedsInvested>
        <ExceptionToRebate>false</ExceptionToRebate>
      </Form990ScheduleKPartIV>
      <Form990ScheduleKPartIV>
        <Form8038TFiled>false</Form8038TFiled>
        <VariableRateIssue>false</VariableRateIssue>
        <HedgeIdentifiedInBooksAndRecds>false</HedgeIdentifiedInBooksAndRecds>
        <GrossProceedsInvestedInGIC>false</GrossProceedsInvestedInGIC>
        <GrossProceedsInvested>false</GrossProceedsInvested>
        <ExceptionToRebate>false</ExceptionToRebate>
      </Form990ScheduleKPartIV>
      <Form990ScheduleKPartV>
        <Explanation>Part II, Line 3Total Proceeds exceed the issue price due to investment earnings.</Explanation>
      </Form990ScheduleKPartV>
    </IRS990ScheduleK>
    <IRS990ScheduleL documentId="IRS990ScheduleL" softwareId="10000105" softwareVersion="2010v3.2">
      <Form990ScheduleLPartIV>
        <NameOfInterestedPerson>
          <NamePerson>Southside Bank</NamePerson>
        </NameOfInterestedPerson>
        <Relationship>Dir. as Bank Offic</Relationship>
        <AmountOfTransaction>544203</AmountOfTransaction>
        <DescriptionOfTransaction>Interest on Loans - ETMCRS</DescriptionOfTransaction>
        <SharingOfRevenues>false</SharingOfRevenues>
      </Form990ScheduleLPartIV>
      <Form990ScheduleLPartIV>
        <NameOfInterestedPerson>
          <NamePerson>Adams Coker PC</NamePerson>
        </NameOfInterestedPerson>
        <Relationship>Family Member</Relationship>
        <AmountOfTransaction>249047</AmountOfTransaction>
        <DescriptionOfTransaction>Legal Services to ETMCRHS</DescriptionOfTransaction>
        <SharingOfRevenues>false</SharingOfRevenues>
      </Form990ScheduleLPartIV>
      <Form990ScheduleLPartIV>
        <NameOfInterestedPerson>
          <NamePerson>Laban Graves</NamePerson>
        </NameOfInterestedPerson>
        <Relationship>Family Member</Relationship>
        <AmountOfTransaction>29261</AmountOfTransaction>
        <DescriptionOfTransaction>Employment at ETMCRHS</DescriptionOfTransaction>
        <SharingOfRevenues>false</SharingOfRevenues>
      </Form990ScheduleLPartIV>
      <Form990ScheduleLPartIV>
        <NameOfInterestedPerson>
          <NamePerson>Monica Graves</NamePerson>
        </NameOfInterestedPerson>
        <Relationship>Family Member</Relationship>
        <AmountOfTransaction>64067</AmountOfTransaction>
        <DescriptionOfTransaction>Employment at ETMCRHS</DescriptionOfTransaction>
        <SharingOfRevenues>false</SharingOfRevenues>
      </Form990ScheduleLPartIV>
      <Form990ScheduleLPartIV>
        <NameOfInterestedPerson>
          <NamePerson>Robert Gray II</NamePerson>
        </NameOfInterestedPerson>
        <Relationship>Family Member</Relationship>
        <AmountOfTransaction>61270</AmountOfTransaction>
        <DescriptionOfTransaction>Employment at ETMCRHS</DescriptionOfTransaction>
        <SharingOfRevenues>false</SharingOfRevenues>
      </Form990ScheduleLPartIV>
      <Form990ScheduleLPartIV>
        <NameOfInterestedPerson>
          <NamePerson>Elizabeth Smith</NamePerson>
        </NameOfInterestedPerson>
        <Relationship>Family Member</Relationship>
        <AmountOfTransaction>207595</AmountOfTransaction>
        <DescriptionOfTransaction>Employment at ETMCRHS</DescriptionOfTransaction>
        <SharingOfRevenues>false</SharingOfRevenues>
      </Form990ScheduleLPartIV>
    </IRS990ScheduleL>
    <IRS990ScheduleO documentId="IRS990ScheduleO" softwareId="10000105" softwareVersion="2010v3.2">
      <GeneralExplanation>
        <ReturnReference>Fundraising Expenses</ReturnReference>
        <Explanation>Fundraising is conducted at the related organization, ETMC Foundation for all ETMC Regional Healthcare System organizations, including ETMC Regional Healthcare System. The expenses are not charged back to the organization.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990 Part IV, Line 24b - Tax exempt bonds</ReturnReference>
        <Explanation>Tax exempt bond proceeds designated for capital projects that remain beyond the temporary period exception due to construction delays were spent in FY 2011. These proceeds were invested in short-term liquid money market investments with yields less than the bond yields.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Audited Financial Statements</ReturnReference>
        <Explanation>The organization was included in consolidated, independent audited financial statements for the tax year.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 19</Identifier>
        <ReturnReference>Form 990, Part VI, Line 19: Other Organization Documents Publicly Available</ReturnReference>
        <Explanation>The organization's governing documents, conflict of interest policy and financial statements are provided upon request.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 15b</Identifier>
        <ReturnReference>Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees</ReturnReference>
        <Explanation>Compensation for other officers and key employees are reviewed and approved by independent directors, after considering the results of a compensation survey of comparable positions at comparable entities. The evaluation and determination process, as well as a description of the comparable information utilized, is documented in meeting minutes promptly following the conclusion of the meeting of the directors.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 12c</Identifier>
        <ReturnReference>Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts</ReturnReference>
        <Explanation>The organization has a written conflict of interest policy for all employees, officers and trustees. Annually all officers, key employees and trustees are required to complete a conflict of interest form disclosing any actual or potential conflict of interest with the organization. Should any transaction arise that may create a conflict, the transaction is reviewed and appropriate measures are taken.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 11</Identifier>
        <ReturnReference>Form 990, Part VI, Line 11: Form 990 Review Process</ReturnReference>
        <Explanation>The return is prepared by our staff accountant and is reviewed by senior management. It is then presented to the board for their review and comments. The final return is provided to the board prior to filing.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 7a</Identifier>
        <ReturnReference>Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body</ReturnReference>
        <Explanation>ETMC Regional Healthcare System is the parent and sole member of the ETMC System affiliates and appoints certain members to the board.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 6</Identifier>
        <ReturnReference>Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder</ReturnReference>
        <Explanation>ETMC Regional Healthcare System is the parent and sole member of the ETMC System affiliates and appoints certain members to the board.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Form 990, Part VI, Line 2</Identifier>
        <ReturnReference>Form 990, Part VI, Line 2: Description of Business or Family Relationship of Officers, Directors, Et</ReturnReference>
        <Explanation>The following members of ETMC Regional Healthcare System are also board members of entities affiliated with ETMC Regional Healthcare System: Elmer G. Ellis, Byron Hale, B.G. Hartley, Larry Durrett, Ron Donaldson, M.D., Stephen Rydzak, M.D., Wade Ridley and James Wynne.</Explanation>
      </GeneralExplanation>
    </IRS990ScheduleO>
    <IRS990ScheduleR documentId="IRS990ScheduleR" softwareId="10000105" softwareVersion="2010v3.2">
      <Form990ScheduleRPartII>
        <NameOfDisregardedEntity>
          <BusinessNameLine1>FirstNet Exchange</BusinessNameLine1>
        </NameOfDisregardedEntity>
        <AddressUS>
          <AddressLine1>1000 S Beckham Ave</AddressLine1>
          <City>Tyler</City>
          <State>TX</State>
          <ZIPCode>75701</ZIPCode>
        </AddressUS>
        <EIN>451436671</EIN>
        <PrimaryActivities>Health Services</PrimaryActivities>
        <LegalDomicileState>TX</LegalDomicileState>
        <ExemptCodeSection>501(C)(3)</ExemptCodeSection>
        <PublicCharityStatus>Exempt</PublicCharityStatus>
        <DirectControllingEntityName>
          <BusinessNameLine1>ETMCRHS</BusinessNameLine1>
        </DirectControllingEntityName>
        <ControlledOrg>false</ControlledOrg>
      </Form990ScheduleRPartII>
      <Form990ScheduleRPartII>
        <NameOfDisregardedEntity>
          <BusinessNameLine1>ETMC - Quitman</BusinessNameLine1>
        </NameOfDisregardedEntity>
        <AddressUS>
          <AddressLine1>PO Box 1000</AddressLine1>
          <City>Quitman</City>
          <State>TX</State>
          <ZIPCode>75783</ZIPCode>
        </AddressUS>
        <EIN>752766160</EIN>
        <PrimaryActivities>Health Services</PrimaryActivities>
        <LegalDomicileState>TX</LegalDomicileState>
        <ExemptCodeSection>501 (C)(3)</ExemptCodeSection>
        <PublicCharityStatus>Exempt</PublicCharityStatus>
        <DirectControllingEntityName>
          <BusinessNameLine1>ETMCRHS</BusinessNameLine1>
        </DirectControllingEntityName>
        <ControlledOrg>false</ControlledOrg>
      </Form990ScheduleRPartII>
      <Form990ScheduleRPartII>
        <NameOfDisregardedEntity>
          <BusinessNameLine1>ETMC - Pittsburg</BusinessNameLine1>
        </NameOfDisregardedEntity>
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        <TransactionType>p</TransactionType>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
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          <BusinessNameLine1>ETMC - Fairfield</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
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          <BusinessNameLine1>ETMC - Crockett</BusinessNameLine1>
        </NameOfOtherOrganization>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Crockett</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>439885</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Clarksville</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>632143</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Clarksville</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>29640</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
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          <BusinessNameLine1>ETMC - Carthage</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>1150192</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Carthage</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>46870</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Athens</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>4220621</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
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          <BusinessNameLine1>ETMC - Athens</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Healthcare Associates</BusinessNameLine1>
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        <TransactionType>p</TransactionType>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Healthcare Associates</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Foundation</BusinessNameLine1>
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      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Specialty Hospital</BusinessNameLine1>
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        <TransactionType>p</TransactionType>
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        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Home Services</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>481012</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Home Services</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>105594</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Rehabilitation Hospital</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>1850987</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Rehabilitation Hospital</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>2878375</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Cancer Institute</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>277153</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Cancer Institute</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>399159</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Tyler</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>p</TransactionType>
        <AmountInvolved>34038006</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Tyler</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>o</TransactionType>
        <AmountInvolved>19942</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
      <TransactionsRelatedOrgsTable>
        <NameOfOtherOrganization>
          <BusinessNameLine1>ETMC - Tyler</BusinessNameLine1>
        </NameOfOtherOrganization>
        <TransactionType>i</TransactionType>
        <AmountInvolved>8985962</AmountInvolved>
        <MethodOfAmtDetermination>FMV</MethodOfAmtDetermination>
      </TransactionsRelatedOrgsTable>
    </IRS990ScheduleR>
  </ReturnData>
</Return>