2012-08-15T11:42:34-05:00 2011-09-30 990 2010-10-01 540261840 MARTHA JEFFERSON HOSPITAL MART 4346548198 500 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911 J Michael Burris 4346547000 2012-08-14 2010 2016-02-24 21:20:13Z JAMES HADEN 500 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911 249593737 0 X WWW.MARTHAJEFFERSON.ORG X 1929 VA IMPROVE HLTH STATUS OF COMMUNITY BY MAINTAINING, ENHANCING & RESTORING PERSONAL HEALTH & WELL BEING. 15 12 1761 813 140823 0 5875354 4176406 224324967 233790096 739801 719922 2617942 3681439 233558064 242367863 0 317500 0 0 101044888 105001460 0 0 0 125600436 116397603 226645324 221716563 6912740 20651300 485162429 317788638 349759822 359534902 135402607 -41746264 X THE ORGANIZATION'S MISSION IS TO IMPROVE THE HEALTH STATUS OF OUR COMMUNITY AND SET THE STANDARD FOR CLINICAL QUALITY AND PERSONALIZED HEALTHCARE SERVICES. IT IS DEDICATED TO PROVIDING THE BEST CLINICAL QUALITY WHILE MAINTAINING EXTRAORDINARY CUSTOMER SERVICE. 0 0 189163348 235459537 AT THE HEART OF MARTHA JEFFERSON'S MISSION AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL IS OUR ROLE AND RESPONSIBILITY TO ADDRESS THE HEALTH NEEDS OF OUR COMMUNITY. MARTHA JEFFERSON IS ENTRUSTED WITH RESOURCES AND SKILLS THAT CAN HELP THE PEOPLE OF OUR COMMUNITY ACHIEVE AND MAINTAIN THEIR BEST POSSIBLE HEALTH. THE HOSPITAL'S BOARD OF TRUSTEES IN 2011 REAFFIRMED THE FOLLOWING COMMITMENTS THAT ARE FUNDAMENTAL TO OUR ABILITY TO MEET THESE CHALLENGES: AS AN INTEGRAL PART OF THE STRATEGIC PLANNING PROCESS, THE MISSION OF MARTHA JEFFERSON HOSPITAL WILL BE REVIEWED ALONG WITH SPECIFIC INITIATIVES, GOALS AND OBJECTIVES TO CONSIDER INCORPORATING SPECIFIC STATEMENTS AIMED AT HELPING TO RESOLVE COMMUNITY PROBLEMS ADVERSELY AFFECTING THE HEALTH STATUS OF THE COMMUNITIES WE SERVE. MARTHA JEFFERSON WILL CONDUCT, OR GAIN ACCESS TO, COMMUNITY-NEEDS ASSESSMENTS TO IDENTIFY PROBLEMS ADVERSELY AFFECTING OUR COMMUNITIES' HEALTH STATUS. MARTHA JEFFERSON WILL REGULARLY INVENTORY HOSPITAL-SPONSORED AND COMMUNITY PROGRAMS WORKING TO MEET THE IDENTIFIED NEEDS OF MEDICALLY UNDERSERVED OR DISADVANTAGED POPULATIONS. AS APPROPRIATE, THESE PROGRAMS WILL BE TRACKED AND EVALUATED FOR THEIR IMPACT ON IDENTIFIED HEALTH STATUS ISSUES. MARTHA JEFFERSON WILL REGULARLY ASSESS ITS ABILITY TO COMMIT RESOURCES, FINANCIAL AND HUMAN, TOWARD HELPING MEET IDENTIFIED NEEDS. ACCESS TO HEALTHCARE: MARTHA JEFFERSON ACCEPTS PATIENTS REGARDLESS OF THEIR ABILITY TO PAY FOR HEALTHCARE SERVICES. THE HOSPITAL ASSISTS PATIENTS WITH FINANCIAL NEEDS THROUGH THE MARTHA JEFFERSON HEALTHTRUST, A PROGRAM THAT PROVIDES A SLIDING FEE SCALE FOR HOSPITAL PATIENTS WHO QUALIFY BASED ON FAMILY INCOME UP TO 300 PERCENT OF POVERTY LEVEL. FINANCIAL ASSISTANCE IS BASED ON A REVIEW OF THE PATIENT'S FINANCIAL CIRCUMSTANCES UPON ADMISSION OR THE SERVICE DATE. BECAUSE MARTHA JEFFERSON DOES NOT PURSUE COLLECTION OF THE AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, SUCH AMOUNTS ARE NOT REPORTED AS A COMPONENT OF PATIENT SERVICE REVENUES. MARTHA JEFFERSON DEFINES CHARITY CARE AS CARE FOR WHICH COLLECTION IS NOT ATTEMPTED (I.E. INDIGENT CARE) AND OPERATING COSTS FOR SERVICES RENDERED FOR MEDICAID PATIENTS THAT ARE IN EXCESS OF REIMBURSEMENT FROM STATE AGENCIES. THE PERCENTAGE OF PATIENTS RECEIVING SOME FORM OF CHARITY ASSISTANCE 14.67%. ADDITIONAL CHARITY CARE INFORMATION IS PROVIDED ON SCHEDULE H. IN ADDITION TO PROVIDING UNCOMPENSATED CARE, MARTHA JEFFERSON HAS ESTABLISHED SPECIAL ACCOUNTS TO PROVIDE FREE DIAGNOSTIC SERVICES FOR PATIENTS REFERRED BY THE CHARLOTTESVILLE FREE CLINIC AND THE FREE CLINIC OF GREENE COUNTY. THROUGHOUT THE YEAR, COMMUNITY HEALTH SCREENINGS AND REDUCED-FEE SERVICES PROVIDED OTHER MEANS OF ACCESS TO HEALTHCARE FOR PEOPLE ACROSS CENTRAL VIRGINIA. PHYSICIANS EMPLOYED BY MARTHA JEFFERSON HOSPITAL HAVE OFFICES THROUGHOUT CHARLOTTESVILLE AND IN SEVEN SURROUNDING COUNTIES INCLUDING ALBEMARLE, BUCKINGHAM, LOUISA, MADISON, GREENE, FLUVANNA AND NELSON, WHICH PROVIDE ACCESS TO HEALTHCARE IN MANY RURAL AREAS WITHOUT REGARD TO ONE'S ABILITY TO PAY. DURING 2011, THE MEDICAL STAFF CONSISTED OF JUST OVER 400 PHYSICIANS REPRESENTING 35 MEDICAL SPECIALTIES. MARTHA JEFFERSON HOSPITAL ALSO OPERATES AN EMERGENCY DEPARTMENT, WHICH IS STAFFED 24-HOURS A DAY/7 DAYS A WEEK BY BOARD-CERTIFIED PHYSICIANS AND SPECIALLY TRAINED NURSES AND SUPPORT STAFF. ADDITIONALLY, THE HOSPITAL OPERATES A FREE-STANDING EMERGENCY DEPARTMENT. IN FISCAL YEAR 2011, MARTHA JEFFERSON HOSPITAL SERVED THE COMMUNITY BY WAY OF 10,982 INPATIENT ADMISSIONS; 223,229 OUTPATIENT ACCOUNTS; 51,189 EMERGENCY DEPARTMENT VISITS; 6,194 OPERATING ROOM VISITS; AND 152,079 PHYSICIAN OFFICE VISITS. IN ADDITION, MARTHA JEFFERSON OFFERED OR SUPPORTED MANY PROGRAMS AND SERVICES IN OUR COMMUNITY, WHICH ARE DETAILED BELOW.EDUCATIONAL PROGRAMS: AN IMPORTANT PART OF OUR COMMUNITY OUTREACH IS CENTERED ON EDUCATIONAL PROGRAMS AND TRAINING. WHEN A FAMILY IS PREPARING TO DELIVER A BABY AT MARTHA JEFFERSON, SIBLING TOURS, BREASTFEEDING CLASSES AND PEDIATRIC CPR ARE OFFERED AS WELL AS CLASSES CENTERED ON PREPARING FOR CHILDBIRTH AND BECOMING A PARENT. ONCE THE BABY HAS BEEN DELIVERED HOWEVER, THE EDUCATION DOESN'T STOP. A BRUNCH IS HELD DAILY FOR NEW FAMILIES BEFORE THEY ARE DISCHARGED. DURING THIS TIME FAMILIES LEARN HOW TO CALM THEIR CRYING BABY, THE DANGERS OF SUDDEN INFANT DEATH SYNDROME AND HOW TO GET A BIG BROTHER OR SISTER WARMED UP TO THE IDEA OF SHARING MOM AND DAD. OTHER EDUCATIONAL CLASS OFFERINGS AT MARTHA JEFFERSON INCLUDE; POSTOPERATIVE BREAST REHABILITATION, PREPARING FOR A HYSTERECTOMY, POST-HYSTERECTOMY REHAB, ADVANCED MEDICAL PLANNING, STRESS MANAGEMENT, UNDERSTANDING VASCULAR DISEASE, CARDIAC REHABILITATION AND PULMONARY REHABILITATION.CONTINUED IN PROGRAM SERVICE TWO CONTINUED FROM PROGRAM SERVICE ONESCHOOL PROGRAMS: MARTHA JEFFERSON HOSPITAL UNDERSTANDS MANY OF THE HEALTH DECISIONS WE MAKE AS ADULTS ARE A RESULT OF THE SITUATIONS WE EXPERIENCE AS CHILDREN. THROUGH OUR SCHOOL PROGRAMS WE ARE ABLE TO TEACH CHILDREN AND LEAVE AN IMPRESSION THAT WILL HOPEFULLY STAY WITH THEM AS THEY GROW UP.IN OUR ELEMENTARY SCHOOL OUTREACH, AN EMPLOYEE OF MARTHA JEFFERSON ENGAGES STUDENTS IN THEIR CLASSROOM IN LESSONS ON HEALTH AND WELLNESS THAT DIRECTLY RELATE TO THE VIRGINIA STANDARDS OF LEARNING TEST. PROFESSIONAL EDUCATION SUPPORT: AS A WAY TO PROVIDE CONTINUED PROFESSIONAL EDUCATION, MARTHA JEFFERSON SUPPORTS THE PIEDMONT VIRGINIA COMMUNITY COLLEGE SONOGRAPHY PROGRAM AND PROVIDES CLINICAL PLACEMENTS FOR NURSING STUDENTS OF UVA, JMU, PVCC, BLUE RIDGE COMMUNITY COLLEGE, BRYANT AND STRATTON SCHOOL OF NURSING, WALDEN UNIVERSITY AND GERMANNA COMMUNITY COLLEGE.HOSPITAL SERVICES: MARTHA JEFFERSON HOSPITAL OFFERS MANY PROGRAMS THAT HELP PATIENTS BOTH GET ACCLIMATED WITH OUR SYSTEM, AND ALSO NAVIGATE THE HOSPITAL AS NEEDS ARISE.HEALTH CONNECTION, OUR PHYSICIAN REFERRAL, PATIENT EDUCATION AND INFORMATION SERVICE TAKES 120 CALLS ON A DAILY BASIS. THEY'RE ABLE TO HELP NEW MEMBERS OF THE COMMUNITY FIND A PHYSICIAN, ENROLL PEOPLE IN THE VARIOUS CLASSES THE HOSPITAL OFFERS AND PROVIDE SUPPORT FOR SPECIFIC MEDICAL NEEDS.FOR PEOPLE UNDERGOING CANCER TREATMENTS AT MARTHA JEFFERSON HOSPITAL, WE PROVIDE A CANCER CARE CENTER. THE CENTER SERVES AS A RESOURCE FOR PATIENTS FROM THE MOMENT THEY ARE DIAGNOSED THROUGH THEIR ENTIRE LINE OF INTERACTIONS AT THE HOSPITAL, AND IN MANY CASES EVEN CONTINUES AFTER THEY ARE ARE NO LONGER COMING FOR VISITS. STAFF MEMBERS ARE DEDICATED TO HELPING PATIENTS DEAL WITH THE EMOTIONS THAT GO ALONG WITH BEING DIAGNOSED WITH CANCER, FITTING THEM WITH COMPLIMENTARY WIGS AND SCARVES TO USE DURING TREATMENT AND JUST BEING FRIENDS THROUGHOUT THE PROCESS.MARTHA JEFFERSON HOSPITAL ALSO OFFERS A PALLIATIVE CARE PROGRAM. WHEN A PERSON IS FACING A SERIOUS OR ADVANCING ILLNESS, THE ACCOMPANYING PHYSICAL, EMOTIONAL AND SPIRITUAL ISSUES CAN DRAMATICALLY AFFECT THE EXPERIENCE AND OFTEN QUALITY OF LIFE FOR PATIENTS AND LOVED ONES. OVER THE PAST FIVE YEARS MORE THAN 1,000 LOCAL FAMILIES HAVE BENEFITTED FROM CONSULTATIONS BY A MULTIDISCIPLINARY TEAM PROVIDING PALLIATIVE CARE AT MARTHA JEFFERSON HOSPITAL. THE CAREGIVERS FOCUS ON DELIVERING A UNIQUE COMBINATION OF SPECIAL EXPERTISE IN PAIN AND SYMPTOM MANAGEMENT AND COORDINATE CARE AMONG A MULTIPLICITY OF PHYSICIANS INVOLVED WHEN AN INDIVIDUAL IS SERIOUSLY ILL AND DEDICATE THE TIME NEEDED FOR PATIENT-FAMILY COMMUNICATION ABOUT GOALS OF CARE AND THE EMOTIONAL AND SPIRITUAL STRUGGLES THAT OFTEN ACCOMPANY A LIFE-CHANGING ILLNESS. IN ADDITION TO THE ABOVE MENTIONED PROGRAMS, MARTHA JEFFERSON HOSPITAL ALSO OFFERS THE FOLLOWING: CHAPLAINCY PROGRAM, PATIENT ADVOCATE PROGRAM, WEBSITE WITH INTEGRATED HEALTH INFORMATION (WWW.MARTHAJEFFERSON.ORG), A HEALTH SOURCE LIBRARY AND A WOMEN'S MIDLFE RESOURCE CENTER. MARTHA JEFFERSON HOSPITAL HELD 'UNWANTED MEDICATION TAKE BACK DAY' WHICH WAS A DRIVE-THROUGH EVENT ALLOWING ANY AND ALL IN OUR COMMUNITY TO DROP OFF UNWANTED MEDICATIONS AND MEDICAL SHARPS FOR PROPER DISPOSAL.COMMUNITY EVENTS AND HEALTH SCREENINGS: HEALTH SCREENINGS ARE AN IMPORTANT SERVICE OFFERED BY MARTHA JEFFERSON. THE FOLLOWING SCREENINGS ARE HELD ANNUALLY: SKIN CANCER SCREENING, BREAST HEALTH SCREENING, DIABETES SCREENING.IN ADDITION TO THE SCREENING EVENTS, WE ALSO HOST EVENTS FOR THE COMMUNITY THAT PROMOTE WELLNESS. EACH SPRING THE CELEBRATION OF LIFE IS HELD FOR CANCER PATIENTS, SURVIVORS AND THEIR FAMILIES. THE AFTERNOON IS FILLED WITH FOOD, SALSA DANCING, GAMES AND MUSIC AND PROVIDES A CHANCE FOR MEMBERS OF THE COMMUNITY TO CELEBRATE THEIR LIFE. WE ALSO HOLD FOOD AND SHOE DRIVES TO HELP PROVIDE MUCH NEEDED ITEMS TO PEOPLE IN OUR COMMUNITY. ANNUALLY, WE HOST THE MJ8K RUN AND WALK TO BENEFIT COMMUNITY EDUCATION SERVICES AND MARTHA'S MARKET, WHICH HELPS FUND CANCER SERVICES AND SUPPORT WELLNESS INITIATIVES.NUTRITION PROGRAMS: AS HEALTHCARE PROVIDERS, OUR GOAL IS TO KEEP THE MEMBERS OF OUR COMMUNITY HEALTHY AND FEELING WELL. AT MARTHA JEFFERSON HOSPITAL WE OFFER A VARIETY OF PROGRAMS THAT ALLOW PEOPLE ACCESS TO INFORMATION THAT THEN HELPS THEM MAKE EDUCATED NUTRITION CHOICES.FOR STARTERS, ONE OF OUR REGISTERED DIETICIANS TAKES LEARNING ON LOCATION THROUGH OUR SUPERMARKET SMARTS CLASSES. THROUGH A PARTNERSHIP WITH GIANT FOOD, PEOPLE ARE ABLE TO GET HANDS-ON EXPERIENCE WHEN IT COMES TO MAKING HEALTHY DECISIONS AT THE GROCERY. WE ALSO PROVIDE HEART HEALTHY NUTRITION, DIABETES NUTRITION AND NUTRITION TIPS FOR INDIVIDUALS WITH CANCER.IN ADDITION TO OUR CLASSES, MARTHA JEFFERSON HAS A PRESENCE ACROSS THE LOCAL MEDIA AIRWAVES. NUTRITION TIPS AND TIMELY INFORMATION IS GIVEN BY ONE OF OUR REGISTERED DIETICIANS THROUGH DAILY RADIO SPOTS, A WEEKLY TELEVISION SEGMENT, AND VARIOUS PRINT OPPORTUNITIES.SUPPORT GROUPS: MARTHA JEFFERSON HOSPITAL OFFERS SUPPORT GROUPS OF A WIDE VARIETY TO OUR PATIENTS AND MEMBERS OF THE COMMUNITY. GROUPS MEET ON A REGULAR BASIS AND HELP PROVIDE A SAFE COMMUNITY WHERE PEOPLE CAN SHARE STORIES, REFLECT ON THEIR EXPERIENCES, AND GAIN KNOWLEDGE FROM WHAT OTHERS ARE GOING THROUGH. THE FOLLOWING ARE JUST SOME OF THE TOPICS WE OFFER: WELCOME TO MOTHERHOOD, BREAST CANCER SUPPORT, FAMILY CANCER SUPPORT, HODGKIN'S AND LYMPHOMA SUPPORT, CARDIAC REHAB SUPPORT AND SLEEP APNEA SUPPORT.PROGRAM SUPPORT/UNDERWRITING: MARTHA JEFFERSON PROVIDES MEDICAL IMAGING, LABORATORY SERVICE AND OUTPATIENT DIAGNOSTIC SERVICE ACCESS TO THE CLIENTS OF THE CHARLOTTESVILLE FREE CLINIC (CFC) AND GREENE FREE CLINIC (GFC). THIS ACCESS SUPPORTS PRIMARY CARE SERVICES FOR THE WORKING UNINSURED MEMBERS OF OUR COMMUNITIES. THE HOSPITAL IS ALSO DEDICATED TO SUPPORTING HEADSTART WHICH FOCUSES ON CHILD DENTAL SERVICES AND GIVES IN-KIND DONATIONS TO THE WOMEN'S INITIATIVE, PACEM (PEOPLE AND CONGREGATIONS ENGAGED IN MINISTRY) AND EMT TRAINING THROUGH THE THOMAS JEFFERSON EMERGENCY MEDICAL COUNCIL. 189163348 1 1 0 1 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 1 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 1 178 0 1 1761 1 1 1 1 CJ 0 0 0 1 1 0 0 0 0 X 15 12 1 0 1 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 VA X J MICHAEL BURRIS CHIEF FINANCIAL 4346547304 500 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911 X JOHN P CHAMALES 2.00 X 0 0 0 JAMES P CRAIG 2.00 X 0 0 0 DR GREGORY G DEGNAN 2.00 X 0 0 0 MARK GILES 2.00 X 0 0 0 CAROL B HURT 2.50 X X 0 0 0 ARTHUR KISER 2.00 X 0 0 0 Dr JOHN LIGUSH 2.00 X X 0 0 0 DR JOHN M CARPENTER 2.00 X 0 0 0 DR JOSEPH ORLICK 2.00 X 0 0 0 KATHRYN B PARKER 2.00 X 0 0 0 DR JOSH FISCHER 2.00 X 0 0 0 DR BURKHARD SPIEKERMANN 2.00 X 0 0 0 DR R HUNT MACMILLAN 2.00 X 0 0 0 DR KEVIN R MCCONNELL 2.00 X 0 0 0 DR TIMOTHY B SHORT 2.00 X 0 0 0 WILLIAM L ACHENBACH 2.00 X 0 0 0 DAVID BERND 2.00 X 0 0 0 LILLIAN R BEVIER 2.00 X 0 0 0 PETER BROOKS 2.00 X 0 0 0 GREGORY DOULL MD 2.00 X 0 0 0 EARNEST EDWARDS 2.00 X 0 0 0 RICHARD GILLIAM 2.00 X 0 0 0 HOWARD KERN 2.00 X 0 0 0 KENNETH KRAKAUR 2.00 X 0 0 0 E RAY MURPHY 2.00 X 0 0 0 BRUCE MURRAY 2.00 X 0 0 0 CHARLES ROTGIN JR 2.00 X 0 0 0 DAVID G SUTTON 2.00 X 0 0 0 JAMES E HADEN 50.00 X 615116 0 195462 AMY BLACK 65.00 X 231437 0 27742 J MICHAEL BURRIS 54.00 X 277357 0 76539 ELLIOT H KUIDA 63.00 X 325286 0 26915 MARIJO LECKER 65.00 X 245167 0 28626 RONALD J COTTRELL 65.00 X 236620 0 58649 FINLAY M ASHBY 65.00 X 238872 0 21111 SUSAN CABELL MAINS 65.00 X 226588 0 100054 RAY R MISHLER 65.00 X 180865 0 60718 DEBORAH L THEXTON 65.00 X 163661 0 12357 JOHN Z EDWARDS 40.00 X 483201 0 24342 CHRISTOPHER D WILLMS 40.00 X 477508 0 27717 TEJA SANDEEP 40.00 X 475247 0 19760 JACOB N YOUNG 40.00 X 445631 0 14499 GORDON L MORRIS 40.00 X 376029 0 17209 4998585 0 711700 111 0 1 0 MA MORTENSON COMPANY 17975 WEST SARAH LANE BROOKFIELD WI 53045 CONSTRUCTION 64223672 KAHLERSLATER 111 W WISCONSIN AVENUE MILWAUKEE WI 532032501 ARCHITECTS 2057584 QUEST DIAGNOSTICS 12436 COLLECTIONS CENTER DRIVE CHICAGO IL 606932436 LAB SERVICES 1268392 INSCRIBE LLC PO BOX 1427 MURRAY KY 42071 TRANSCRIPTION SERVICE 938572 MCCANDLISH HOLTON PC PO BOX 796 RICHMOND VA 232180796 LEGAL SERVICES 778377 43 286304 3890102 108168 4176406 PATIENT SERVICES 621500 233790096 233711046 79050 233790096 338943 61773 277170 312326 312326 1486834 873205 613629 613629 613629 6317601 6248948 68653 68653 68653 153208 286304 103721 49487 49487 CAFETERIA & GIFT SHOP 722210 1162439 1162439 PHYSICIAN TELEPHONE SV 621110 105072 105072 NETWORK ACCESS FEES 561000 96364 96364 1654448 1547055 107393 3018323 242367863 235459537 140823 2591097 317500 317500 2859602 2859602 77691944 72635848 5056096 5288992 4747143 541849 13283965 12112502 1171463 5876957 5380940 496017 1087895 1087895 1125722 -14846 1140568 246304 66774 179530 17873510 12186160 5687350 591155 561650 29505 45784791 44270747 1514044 4802020 3742661 1059359 6250808 5021368 1229440 195730 159206 36524 118033 93073 24960 6791725 6791725 9110468 7941835 1168633 738386 799172 -60786 PROV FOR BAD DEBT 13433514 13437406 -3892 EQUIPMENT MAINTENANCE 4394318 4009275 385043 DUES & SUBSCRIPTIONS 1040629 334650 705979 RECRUITMENT 499783 265207 234576 2312812 7182 2305630 221716563 189163348 32553215 0 93355036 23184335 21315310 24830779 2417703 1819634 3422784 3627267 2843927 3228468 189090363 2701067 297162443 186389296 54656615 64645226 20052244 485162429 317788638 88869316 42471418 230148275 230137799 30742231 86925685 349759822 359534902 X 131166311 -46106689 3696776 3849557 539520 510868 135402607 -41746264 485162429 317788638 X 20651300 -197800171 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 35 0 1 11014 11049 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: $9,014 REPRESENTS A PORTION OF MJH'S DUES PAID TO VIRGINIA HOSPITAL AND HEALTHCARE ASSOCIATION (VHHA) ALLOCABLE TO LOBBYING ACTIVITIES CONDUCTED BY VHHA. DUES TO VHHA TOTALED $92,923. THE REMAINING $2,000 REPRESENTS THE LOBBYING PORTION OF DUES PAID TO MEDICAL ASSOCIATIONS ON BEHALF OF MJH EMPLOYEES. 29368803 29368803 1.00000 0 1 1 30248829 30248829 109988770 317406 109671364 434239 11074 423165 48199786 2372587 45827199 218739 218739 186389296 MISCELLANEOUS ACCOUNTS RECEIVABLE 1101929 DEPOSITS 778363 OTHER ASSETS 5292802 ASSETS HELD FOR SALE 11583150 DUE FROM AFFILIATE 1296000 20052244 CLAIMS ACCRUAL 750000 PENSION LIABILITY 29149071 CAPITAL LEASE OBLIGATIONS 1623707 LONG TERM LIABILITIES 7607733 INTEREST RATE SWAP LIABILITY 47795174 86925685 Description of Uncertain Tax Positions Under FIN 48: Part X: THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. THERE WERE NO UNCERTAIN TAX POSITIONS RECORDED AT SEPTEMBER 30, 2011. CENTRAL AMERICA AND THE CARIBBEAN PROGRAM SERVICES INSURANCE CAPTIVE 0 EUROPE PROGRAM SERVICE INVESTMENTS 38702000 0 0 0 38702000 0 38702000 1 0 1 0 0 0 Other Information Schedule F, Part V AS OF SEPTEMBER 30, 2011 MARTHA JEFFERSON HOSPITAL HAS A 17% OWNERSHIP IN VIRGINIA SOLUTION SPC LTD, AN INSURANCE CAPTIVE, WHICH OPERATES IN THE CAYMAN ISLANDS. IN ACCORDANCE WITH MARTHA JEFFERSON HOSPITAL'S INTEREST RATE SWAP AGREEMENTS WITH UBS, MARTHA JEFFERSON HOSPITAL IS REQUIRED TO PROVIDE COLLATERAL WHEN THE FAIR VALUE OF THE SWAP AGREEMENTS EXCEEDS A PREDETERMINED THRESHOLD AMOUNT. WHEN MARTHA JEFFERSON IS REQUIRED TO PROVIDE COLLATERAL, IT IS HELD BY UBS AND EARNS INTEREST. 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X X X 2 MARTHA JEFFERSON OUTPATIENT SURGERY CENT

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X AMBULATORY SURGERY CENTER NOT REQUIRED 2 19 MARTHA JEFFERSON OUTPATIENT CARE CENTER

595 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911

DIAGNOSTIC CENTER THE SOMETHING SPECIAL SHOP

500 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911

DME MJ SURGICAL ASSOCIATES

500 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911

PHYSICIAN CLINIC MARTHA JEFFERSON SLEEP CENTER

1793 RICHMOND ROAD CHARLOTTESVILLE VA 22911

DIAGNOSTIC CENTER FOREST LAKES FAMILY MEDICINE

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PHYSICIAN CLINIC GREENE FAMILY MEDICINE

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PHYSICIAN CLINIC CROZET FAMILY MEDICINE

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PHYSICIAN CLINIC PALMYRA MEDICAL ASSOCIATES

17 CENTRE COURT PALMYRA VA 229632330

PHYSICIAN CLINIC MADISON FAMILY MEDICINE

2503 SOUTH SEMINOLE TRAIL MADISON VA 227272690

PHYSICIAN CLINIC MJH IVF LAB

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FERTILITY LABORATORY AFTON FAMILY MEDICINE

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PHYSICIAN CLINIC BUCKINGHAM FAMILY MEDICINE

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PHYSICIAN CLINIC BLUE RIDGE INTERNAL MEDICINE

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PHYSICIAN CLINIC MJ INTERNAL MEDICINE

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PHYSICIAN CLINIC MJ ORTHOPAEDICS

310 OLD IVY WAY SUITE 202 CHARLOTTESVILLE VA 229034896

PHYSICIAN CLINIC MJ MEDICAL ONCOLOGY ASSOCIATES

500 MARTHA JEFFERSON DRIVE CHARLOTTESVILLE VA 22911

PHYSICIAN CLINIC MARTHA JEFFERSON HEALTH SERVICES

3263 PROFFIT ROAD CHARLOTTESVILLE VA 22902

DIAGNOSTIC CENTER WOUND CARE AT MARTHA JEFFERSON

1490 PANTOPS MOUNTAIN PLACE CHARLOTTESVILLE VA 22911

WOUND CENTER MJ SPRING CREEK

29 JEFFERSON COURT GORDONSVILLE VA 22942

PHYSICIAN CLINIC Part I, Line 7: A COMBINATION OF A RATIO OF COSTS TO CHARGES AND A COST ACCOUNTING PROCESS WHICH ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICARE, MEDICAID, UNINSURED AND SELF PAY) WAS USED TO DETERMINE ALL AMOUNTS REPORTED ON LINE 7. Part I, Line 7g: INCLUDES PRIMARY CARE PRACTICES COSTS OF $8,357,949. Part I, L7 Col(f): THE AMOUNT OF BAD DEBT EXPENSE SUBTRACTED FROM THE DENOMINATOR WHEN CALCULATING COLUMN F PERCENTAGES IS $13,433,514. Part II: WE OFFER A VARIETY OF COMMUNITY BUILDING ACTIVITIES INCLUDING THOSE DESIGNED TO HELP MEET THE BASIC NEEDS OF OUR COMMUNITY SUCH AS FOOD DRIVES AND OUR SHOES FOR THE HOMELESS ANNUAL CAMPAIGN. WE OFFER AN ANNUAL CELEBRATION OF LIFE EVENT FOR CANCER SURVIVORS TO GIVE THEM THE OPPORTUNITY TO INTERACT WITH THE PHYSICIANS AND STAFF WHO WERE RESPONSIBLE FOR THEIR CARE. WE HAVE HAD FOUR ANNUAL UNWANTED MEDICATION AND SHARPS DROP-OFF EVENTS. WE HAVE STEADILY INCREASED THE AMOUNT OF MEDICATIONS AND SHARPS WE ARE TAKING OUT OF HOMES IN OUR COMMUNITY AT EACH EVENT. Part III, Line 4: WORKSHEET A IN THE INSTRUCTIONS WAS USED TO COMPUTE THE AMOUNT REPORTED ON LINE 2.IN COMPUTING LINE 3, THE ORGANIZATION USES PRESUMPTIVE CRITERIA FOR ACCOUNTS IN BAD DEBT, BASED ON PREVIOUS QUALIFICATIONS FOR MEDICAID, EXISTENCE OF INSURANCE, EMPLOYMENT STATUS, AND HISTORY OF BAD DEBT WRITE-OFFS. BAD DEBT SHOULD BE INCLUDED IN COMMUNITY BENEFIT AS HOSPITALS OFTEN FACE A BARRIER TO CLASSIFYING A PATIENT ACCOUNT AS CHARITY CARE DUE TO THEIR ABILITY TO OBTAIN FROM PATIENTS THE NECESSARY INFORMATION TO EVALUATE THEIR ELIGIBILITY FOR CHARITY CARE. AS SUCH, SOME PORTION OF BAD DEBT EXPENSE MAY, IN FACT, MORE ACCURATELY BE CONSIDERED TO BE CHARITY CARE.THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE DESCRIBING BAD DEBT EXPENSE. THE FINANCIAL STATEMENTS ACCOUNT FOR BAD DEBT BY RESERVING 72% OF THE SELF PAY A/R BALANCES. BAD DEBT EXPENSE IS REPORTED NET OF ANY DISCOUNTS OR COLLECTIONS ON ACCOUNTS THAT WERE PREVIOUSLY WRITTEN-OFF (I.E. BAD DEBT WRITE-OFFS - DISCOUNTS - PAYMENTS RECEIVED). Part III, Line 8: THE MEDICARE COST REPORT WAS USED TO DETERMINE THE MEDICARE COSTS REPORTED ON LINE 6. MEDICARE MARGINS HAVE BEEN DECLINING AT THE SAME TIME THAT HOSPITALS HAVE BEEN ENGAGED IN CONCERTED EFFORTS TO IMPROVE EFFICIENCY, WHICH POINTS TO THE FACT THAT THE LOSSES ARE MOST LIKELY THE RESULT OF INADEQUATE REIMBURSEMENT BY THE FEDERAL GOVERNMENT, THUS, SHOULD BE INCLUDED IN COMMUNITY BENEFIT. Part III, Line 9b: COLLECTION PRACTICES ARE GEARED TOWARDS PATIENTS THAT HAVE A HIGH PROBABILITY OF BEING ABLE TO PAY FOR SERVICES BASED ON INCOME LEVEL AND INELIGIBILITY FOR CHARITY PROGRAMS. IT IS THE POLICY OF MARTHA JEFFERSON HOSPITAL TO REVIEW ACCOUNTS TO ENSURE ALL POSSIBLE METHODS OF PAYMENT HAVE BEEN EXHAUSTED, I.E. MEDICAL ASSISTANCE, FINANCIAL ASSISTANCE, PAYMENT PLANS AND SELF-PAY DISCOUNTS, PRIOR TO AN ACCOUNT BEING DEEMED AS "BAD DEBT". THE ORGANIZATION USES OUTSIDE COLLECTION AGENCIES ON A PRIMARY PLACEMENT BASIS. THE ORGANIZATION DETERMINES WHICH PATIENTS ARE SENT TO OUTSIDE AGENCIES AND GUIDES THE AGENCIES IN PERFORMING REASONABLE COLLECTION EFFORTS. Part VI, Line 2: MARTHA JEFFERSON WAS INVITED BY THE THOMAS JEFFERSON HEALTH DISTRICT TO PARTICIPATE ON THE STEERING COMMITTEE OF THE CITY OF CHARLOTTESVILLE/ALBEMARLE COUNTY COMMUNITY HEALTH STATUS ASSESSMENT. THE STEERING COMMITTEE WAS INCLUSIVE, WITH REPRESENTATIVES FROM ALL LOCAL AGENCIES AND ORGANIZATIONS THAT IMPACT THE OVERALL HEALTH OF OUR COMMUNITY. THE PURPOSE OF COMMUNITY HEALTH STATUS ASSESSMENT WAS TO ANSWER THREE MAIN QUESTIONS: 1) WHO COMPRISES THE COMMUNITY, AND WHAT DO THE COMMUNITY MEMBERS BRING TO THE TABLE? 2) WHAT ARE THE STRENGTHS AND RISK FACTORS IN THE COMMUNITY THAT CONTRIBUTE TO HEALTH? 3) WHAT IS THE STATUS OF THE COMMUNITY?THIS ASSESSMENT WAS PUBLISHED IN 2008 AND CAN BE FOUND ON THE THOMAS JEFFERSON HEALTH DISTRICT'S WEBSITE LOCATED AT WWW.VDH.STATE.VA.US/LHD/THOMASJEFFERSON.WE ARE CURRENTLY PLANNING A SIMILAR COLLABORATIVE EFFORT TO MEET THE REQUIREMENTS FOR A NEW ASSESSMENT BY OCTOBER 2013. Part VI, Line 3: THE HOSPITAL PROVIDES PAMPHLETS AT REGISTRATION AREAS, PAYMENT AREAS AND WAITING ROOMS DESCRIBING THE HOSPITAL'S BILLING PROCESS AND FINANCIAL ASSISTANCE. IN ADDITION, INFORMATION IS AVAILABLE ON THE HOSPITAL'S WEBSITE DISCUSSING ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE, THE FULL FINANCIAL ASSISTANCE POLICY, AS WELL AS INFORMATION ON THE APPLICATION PROCESS. FINANCIAL COUNSELORS AT THE HOSPITAL MAY REACH OUT TO PATIENTS TO DETERMINE IF THEY WOULD LIKE TO APPLY FOR ASSISTANCE, WHICH APPLICATION MAY BE MADE PRIOR TO, DURING OR SUBSEQUENT TO RECEIVING SERVICES. Part VI, Line 4: MARTHA JEFFERSON HOSPITAL SERVES THE THOMAS JEFFERSON AREA PLANNING DISTRICT (PD10), INCLUDING THE CITY OF CHARLOTTESVILLE, AND THE COUNTIES OF ALBEMARLE, FLUVANNA, GREENE, LOUISA, AND NELSON, ALL OF WHICH ARE FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREAS. THIS DISTRICT INCLUDES URBAN, RURAL AND SUBURBAN GEOGRAPHIC AREAS. PD10 CONSISTS OF APPROXIMATELY 230,000 PEOPLE (U.S. CENSUS BUREAU 2009), WITH ALBEMARLE COUNTY BY FAR THE MOST HIGHLY POPULATED AREA, DISTANTLY FOLLOWED BY THE CITY OF CHARLOTTESVILLE AND THE OTHER COUNTIES. IN GENERAL, THE PLANNING DISTRICT IS GROWING IN POPULATION, WITH AN INCREASE OF OVER 30,000 PEOPLE FROM 2000-2009 (U.S. CENSUS BUREAU 2009). APPROXIMATELY 75 PERCENT OF CITY RESIDENTS AND 90 PERCENT OF ALBEMARLE COUNTY RESIDENTS LIVE ABOVE THE FEDERAL POVERTY LEVEL, WITH CHILDREN BEING THE MOST AFFECTED GROUP BY AGE OF PERSONS LIVING IN POVERTY. WHILE ABOUT 10 PERCENT OF CITY HOUSEHOLDS RECEIVE ASSISTANCE THROUGH FOOD STAMPS, OVER 50 PERCENT OF CITY SCHOOL CHILDREN QUALIFY FOR FREE OR REDUCED-COST LUNCH PROGRAMS (2008 CITY OF CHARLOTTESVILLE/ALBEMARLE COUNTY COMMUNITY HEALTH STATUS ASSESSMENT). MEDICAID AND SELF PAY PATIENTS COMPRISE APPROXIMATELY 9% OF THE HOSPITAL'S PATIENTS. THE COMMUNITY IS SERVED BY TWO HOSPITALS. Part VI, Line 6: MARTHA JEFFERSON FURTHERS ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY THROUGH WORKPLACE HEALTHY INITIATIVES, AN OPEN MEDICAL STAFF, BOARDS OF DIRECTORS COMPRISED OF COMMUNITY MEMBERS AND PHYSICIANS, CHARITY CARE POLICIES AND OUTREACH, AND USE OF SURPLUS FUND DISPERSAL. WORKFORCE DEVELOPMENT PROGRAMS CONTINUE AS DOES OUR SUPPORT OF ORGANIZATIONS CHAMPIONING CHILD DENTAL, INDIGENT PRESCRIPTION DRUG, COMMUNITY MENTAL HEALTH SERVICES AND FREE CLINIC ACCESS EFFORTS.MARTHA JEFFERSON HOSPITAL STAFF SERVE ON COMMITTEES AND BOARDS RELATED TO COMMUNITY HEALTH INCLUDING THE CHARLOTTESVILLE FREE CLINIC, JEFFERSON AREA BOARD FOR AGING, THE SENIOR CENTER, THE CHARLOTTESVILLE OBESITY TASK FORCE, HOSPICE OF THE PIEDMONT, AND THE WOMEN'S INITIATIVE. PARTNERSHIPS ARE IMPORTANT TO US. WE PARTNER WITH ORGANIZATIONS THAT HAVE A TRACK RECORD OF IMPROVING HEALTH IN OUR COMMUNITY INCLUDING BUT NOT LIMITED TO THE CHARLOTTESVILLE FREE CLINIC, GREENE FREE CLINIC, CHARLOTTESVILLE/ALBEMARLE RESCUE SQUAD, THE UNITED WAY, AND THE WOMEN'S INITIATIVE (MENTAL HEALTH SERVICES). WE MAXIMIZE OUR REACH THROUGH FINANCIAL AND IN-KIND DONATIONS TO ORGANIZATIONS SUCH AS THE CHARLOTTESVILLE CITY SCHOOLS, HOSPICE OF THE PIEDMONT, JEFFERSON AREA BOARD FOR AGING AND HEAD START PROGRAMS IN SEVERAL SURROUNDING COUNTIES. OUR PARTNERSHIPS HELP BUILD AND STRENGTHEN EXISTING PROGRAMS, AS WELL AS LEADING TO THE DEVELOPMENT OF NEW PROGRAMS. OUR PARTNERSHIPS WITH OTHER NON-PROFITS IN THE COMMUNITY ALSO HELP US STAY ABREAST OF COMMUNITY NEEDS.MARTHA JEFFERSON HOSPITAL WELCOMES AND ENCOURAGES SIGNIFICANT COMMUNITY INVOLVEMENT THROUGH THE ESTABLISHMENT OF NUMEROUS GOVERNING COMMITTEES AND A COMMUNITY LEADERSHIP COUNCIL. THERE ARE 100 COMMUNITY MEMBERS ANNUALLY INVOLVED DIRECTLY WITH THESE COMMITTEES.MARTHA JEFFERSON HOSPITAL MAINTAINS AN OPEN MEDICAL STAFF TO ALL WHO SEEK PRIVILEGES HERE. THERE ARE OVER 450 PHYSICIANS AND ALLIED STAFF ON THE MARTHA JEFFERSON HOSPITAL MEDICAL STAFF.MARTHA JEFFERSON HOSPITAL UTILIZES SURPLUS FUNDS TO PURCHASE MEDICAL EQUIPMENT AND FACILITIES DESIGNED TO MEET THE NEEDS OF THE COMMUNITY IT SERVES. Part VI, Line 7: IN ORDER TO INCREASE ITS ABILITY TO PROVIDE HIGH QUALITY, COMPREHENSIVE HELATH CARE SERVICES TO PATIENTS, THE ORGANIZATION AFFILIATED WITH SENTARA HEALTHCARE SYSTEM EFFECTIVE JUNE 1, 2011. SENTARA, A NOT-FOR-PROFIT HEALTH SYSTEM, OPERATES MORE THAN 100 SITES OF CARE SERVING RESIDENTS ACROSS VIRGINIA AND NORTHEASTERN NORTH CAROLINA. THE SYSTEM IS COMPRISED OF 10 ACUTE CARE HOSPITALS, INCLUDING SEVEN IN HAMPTON ROADS, ONE IN NORTHERN VIRGINIA AND TWO IN THE BLUE RIDGE REGION, ADVANCED IMAGING CENTERS, NURSING AND ASSISTED LIVING CENTERS, OUTPATIENT CAMPUSES, TWO HOME HEALTH AND HOSPICE AGENCIES, A 3,680-PROVIDE MEDICAL STAFF, AND THREE MEDICAL GROUPS WITH 618 PROVIDERS.THE ORGANIZATION, ALONG WITH ITS SUBSIDIARIES, HAS JOINED WITH SENTARA IN ORDER TO ENHANCE ITS ABILITY TO ACHIEVE BEST PRACTICES IN HEALTHCARE DELIVERY; ACQUIRE CUTTING EDGE TECHNOLOGY AND INTEGRATED INFORMATION SYSTEMS, AND PROVIDE A HIGHER LEVEL OF MEDICAL CARE TO VIRGINIA'S BLUE RIDGE REGION COMMUNITY. COMBINED, THESE ATTRIBUTES BETTER POSITION THE ORGANIZATION TO ADDRESS HELATH CARE REFORM AND OTHER PROFOUND CHANGES AFFECTING THE HEALTHCARE ENVIRONMENT. 1 VIRGINIA HEALTH CARE FOUNDATION 707 EAST MAIN STREET STE 1350 RICHMOND VA 23219 541639924 501(c)(3) 60000 COMMUNITY HEALTH BLUE RIDGE MEDICAL CENTER 4038 THOMAS NELSON HWY ARRINGTON VA 22922 541222147 501(c)(3) 25000 DENTAL SERVICES BOYS & GIRLS CLUB OF CENTRAL VIRGINIA PO BOX 707 CHARLOTTESVILLE VA 22902 541602004 501(c)(3) 7500 NUTRITIONAL PROGRAMS CHARLOTTESVILLE CITY SCHOOLS 1562 DAILY ROAD CHARLOTTESVILLE VA 22903 546001203 15000 SPECIAL EDUCATION, STUDENT SERVICES CHARLOTTESVILLE FREE CLINIC 1138 ROSE HILL DRIVE CHARLOTTESVILLE VA 22903 541610405 501(c)(3) 40000 RX RELIEF PROGRAM COUNTY OF ALBEMARLE 401 MCINTIRE ROAD CHARLOTTESVILLE VA 22903 546001102 12000 BRIGHT STARS PROGRAM, DEPT OF SOCIAL SERVICES, PRESCHOOL NETWORK GREENE CARE CLINIC 39 STANDARD STREET STANDARDSVILLE VA 22973 721602744 501(c)(3) 15000 COMMUNITY HEALTH MADISON FREE CLINIC 410 NORTH MAIN STREET MADISON VA 22727 311654015 501(c)(3) 15000 COMMUNITY HEALTH MONTICELLO AREA COMMUNITY ACTION AGENCY 1025 PARK STREET CHARLOTTESVILLE VA 22901 540799964 501(c)(3) 21000 DENTAL SERVICES FOR UNDERSERVED CHILDREN ORANGE COUNTY FREE CLINIC 13296-A JAMES MADISON HWY ORANGE VA 22960 251922019 501(c)(3) 15000 COMMUNITY HEALTH REGION TEN COMMUNITY SERVICES BOARD 502 OLD LYNCHBURG ROAD CHARLOTTESVILLE VA 22902 541625290 501(c)(3) 40000 PHYCHIATRIC SERVICES THE WOMEN'S INITIATIVE 1101 EAST HIGH STREET STE A CHARLOTTESVILLE VA 22902 205913090 501(c)(3) 20000 MENTAL HEALTH SERVICES THOMAS JEFFERSON PARTNERSHIP FOR ECONOMIC DEVELOPMENT 2211 HYDRAULIC ROAD STE 104 CHARLOTTESVILLE VA 22901 263895424 501(c)(3) 5000 COMMUNITY HEALTH AMERICAN HEART ASSOCIATION 4217 PARK PLACE COURT GLEN ALLEN VA 23060 135613797 501(c)(3) 6000 COMMUNITY HEALTH FIRST TEE CHARLOTTESVILLE 1400 PEN PARK ROAD CHARLOTTESVILLE VA 22901 546001202 501(c)(3) 5000 COMMUNITY HEALTH UNITED WAY 806 EAST HIGH STREET CHARLOTTESVILLE VA 22902 540505882 501(c)(3) 15000 COMMUNITY HEALTH 16 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: MARTHA JEFFERSON HOSPITAL DONATES FUNDS IN FURTHERANCE OF THE HOSPITAL'S MISSION TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY BY MAINTAINING, ENHANCING AND RESTORING PERSONAL HEALTH AND WELL BEING. ASSISTANCE IS GIVEN BASED ON DIRECTION FROM THE BOARD OF DIRECTORS AND COMMUNITY NEED. X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 JAMES E HADEN 487616 0 127500 0 0 0 182914 0 12548 0 810578 0 0 0 AMY BLACK 187916 0 43521 0 0 0 16321 0 11421 0 259179 0 0 0 J MICHAEL BURRIS 225091 0 52266 0 0 0 64925 0 11614 0 353896 0 0 0 ELLIOT H KUIDA 262731 0 62555 0 0 0 17150 0 9765 0 352201 0 0 0 MARIJO LECKER 200424 0 44743 0 0 0 17150 0 11476 0 273793 0 0 0 RONALD J COTTRELL 191490 0 45130 0 0 0 47172 0 11477 0 295269 0 0 0 FINLAY M ASHBY 199869 0 39003 0 0 0 16721 0 4390 0 259983 0 0 0 SUSAN CABELL MAINS 185824 0 40764 0 0 0 88763 0 11291 0 326642 0 0 0 RAY R MISHLER 146932 0 33933 0 0 0 49510 0 11208 0 241583 0 0 0 DEBORAH L THEXTON 142857 0 20804 0 0 0 11456 0 901 0 176018 0 0 0 JOHN Z EDWARDS 483201 0 0 0 0 0 17150 0 7192 0 507543 0 0 0 CHRISTOPHER D WILLMS 477508 0 0 0 0 0 17150 0 10567 0 505225 0 0 0 TEJA SANDEEP 475247 0 0 0 0 0 9800 0 9960 0 495007 0 0 0 JACOB N YOUNG 445631 0 0 0 0 0 7350 0 7149 0 460130 0 0 0 GORDON L MORRIS 376029 0 0 0 0 0 7350 0 9859 0 393238 0 0 0 Part I, Line 1a THE INDICATED BENEFITS ARE PROVIDED TO CERTAIN SENIOR EXECUTIVES OF THE ORGANIZATION AS PART OF OVERALL COMPENSATION PACKAGES AND ARE CONSIDERED IN EVALUATING THE REASONABLENESS OF COMPENSATION (SEE FORM 990, PART VI, LINE 15, FOR A DESCRIPTION OF THE PROCESS USED TO DETERMINE EXECUTIVE COMPENSATION). COUNTRY CLUB MEMBERSHIP FEES AND DUES: PROVIDED FOR CEO, COO AND VICE PRESIDENT, DEVELOPMENT ONLY. SOCIAL CLUB DUES PAID ON BEHALF OF THE ORGANIZATION'S SENIOR EXECUTIVES ARE ALLOCATED BETWEEN BUSINESS AND PERSONAL USE, THE PERSONAL USE OF WHICH IS TREATED AS ADDITIONAL COMPENSATION AND REPORTED ON FORM W-2 AS TAXABLE WAGES. PERSONAL SERVICES: FINANCIAL PLANNING - THE CEO RECEIVES ANNUAL PAYMENTS UP TO $4,000, VICE PRESIDENTS RECEIVE UP TO $2,500 EVERY FOUR YEARS AT THE DISCRETION OF THE PRESIDENT/CEO. FINANCIAL PLANNING (I.E. PERSONAL SERVICES) EXPENSES PAID BY OR ON BEHALF OF THE ORGANIZATION'S SENIOR EXECUTIVES ARE TREATED AS ADDITIONAL COMPENSATION AND REPORTED ON FORM W-2 AS TAXABLE WAGES. Part I, Line 7 THE MANAGEMENT AND SENIOR MANAGEMENT INCENTIVE PLANS RECOGNIZE INDIVIDUALS BASED ON SPECIFIC CRITERIA AND DEFINED ORGANIZATION PERFORMANCE STANDARDS. THOSE PLANS ARE NOT ANNUALLY GUARANTEED AND IMPLEMENTATION WILL DEPEND ON ORGANIZATION-WIDE PERFORMANCE. IF ORGANIZATION-WIDE GOALS ARE NOT MET, THE PRESIDENT/CEO WILL HAVE THE DISCRETION TO DETERMINE ANY VARIATIONS TO THE PLAN. Supplemental Information Part III PART 1, LINE 4b: SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN 457(f): JAMES HADEN PARTICIPATES IN THE MARTHA JEFFERSON HEALTH SERVICES CORPORATION NONQUALIFIED RETIREMENT PLAN. THIS IS A SERP WITH TARGET BENEFIT OFFSET BY THE QUALIFIED PENSION PLAN AND SOCIAL SECURITY. ELLIOT KUIDA, FINLAY ASHBY, MICHAEL BURRIS, MARIJO LECKER, AMELIA BLACK, RONALD COTTRELL, SUSAN CABELL MAINS, RAY MISHLER AND DEBORAH THEXTON PARTICIPATE IN THE MARTHA JEFFERSON HEALTH SERVICES CORPORATION NONQUALIFIED DEFERRED COMPENSATION ARRANGEMENT. THIS PLAN REWARDS THE INDIVIDUALS LISTED FOR MEETING TARGET FINANCIAL GOALS ESTABLISHED FOR EACH OF THEM BY THE CEO WITH THE APPROVAL OF THE BOARD, AND AS AN INCENTIVE FOR THE EMPLOYEES TO REMAIN WITH THE EMPLOYER UNTIL THEIR VESTING DATE. INDUSTRIAL DEVELOPMENT AUTHORITY OF ALBEMARLE COUNTY VIRGINIA 521297503 012677CE8 2003-09-25 34192283 REFUNDED BONDS ISSUED JULY 1993 0 0 0 ECONOMIC DEVELOPMENT AUTHORITY OF ALBEMARLE COUNTY VIRGINIA 521297503 012663AD2 2008-10-30 160795000 FINANCING FOR REPLACEMENT HOSPITAL CONSTRUCTION 0 0 0 35257603 4093857 30758484 405262 2003 1 0 1 1 160910173 20817708 1424688 199290 137812586 655901 2011 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 1 WACHOVIA BANK 16.500000000000 1 0 1 0 1 1 UBS AG STAMFORD BRANCH 40.000000000000 1 0 0 NA 0 0 PART II, LINE 3, COLUMN A TOTAL PROCEEDS INCLUDES DSRF EARNINGS SINCE 2003 OF $1,063,168 INTEREST FUND EARNINGS OF $1,454, AND RESIDUAL COI RESERVE TRANSFER FOR DSRF OF $67,410 PART II, LINE 3, COLUMN B TOTAL PROCEEDS FROM ISSUANCE INCLUDES $115,173 OF EARNINGS ON THE COI, PROJECT AND INTEREST FUNDS FROM 2009; THERE WERE NO EARNINGS IN 2010/2011. PART III, COLUMN A N/A: POST 12/31/2002 REFUNDING ISSUE OF AN ORIGINAL ISSUANCE PRIOR TO 1/1/2003. TAX PREPARATION SOFTWARE WOULD NOT ACCOMODATE LEAVING THIS SECTION BLANK AND ANSWERED ALL QUESTIONS "NO". MARTHA JEFFERSON PHYSICIAN HOSPITAL ORGANIZATION INC SEE BELOW 144813 ACCOUNTING SERVICE 0 MARTHA JEFFERSON OUTPATIENT SURGERY CENTER LLC SEE BELOW 465719 RENT AND CLEANING SERVICE 0 PART IV (b) TRANSACTIONS WITH INTERESTED PERSONS - BOARD/OFFICER/KEY EMPLOYEE OVERLAP WITH TAXABLE ENTITIESBOARD MEMBERS CAROL HURT AND CHARLES ROTGIN, JR. AND OFFICERS JAMES HADEN AND J. MICHAEL BURRIS ALSO SERVE AS BOARD MEMBERS AND/OR OFFICERS OF MARTHA JEFFERSON PHYSICIAN HOSPITAL ORGANIZATION, INC., A JOINT VENTURE OF THE ORGANIZATION.BOARD MEMBERS LILLIAN BEVIER AND PETER BROOKS, OFFICER J. MICHAEL BURRIS, AND KEY EMPLOYEE RONALD COTTRELL SERVE AS BOARD MEMBERS OF MARTHA JEFFERSON OUTPATIENT SURGERY CENTER, LLC, A JOINT VENTURE OF THE ORGANIZATION.DIRECTORS/OFFICERS/KEY EMPLOYEES OF THE ORGANIZATION MAY ALSO SERVE AS DIRECTORS/OFFICERS/KEY EMPLOYEES OF RELATED TAXABLE ENTITIES WITHIN THE SENTARA HEALTHCARE SYSTEM. SEE FORM 990 SCHEDULE R FOR A LISTING OF TRANSACTIONS THE ORGANIZATION HAD WITH THESE RELATED TAXABLE ENTITIES. X 3 21999 APPRAISAL X 15 49596 COST OR SELLING PRICE X GIFTS IN KIND 113 36573 COST OR SELLING PRICE OF DONATED PROPERTY 3 0 1 1 Method for Determining Number of Contributors: Part I, Column (b): THE NUMBER OF CONTRIBUTIONS FOR EACH TYPE OF PROPERTY RECEIVED IS CALCULATED USING THE NUMBER OF CONTRIBUTIONS RECORDED, WHICH MAY INCLUDE MULTIPLE ITEMS RECEIVED. CONTRIBUTIONS FROM DONORS WHO GIVE ITEMS THROUGHOUT THE YEAR ARE COUNTED AS SEPARATE CONTRIBUTIONS ON EACH NEW DATE RECEIVED. Third Party Use: Part I, Line 32b: MARTHA JEFFERSON HOSPITAL USES EXTERNAL PARTIES TO COORDINATE AN ARMS-LENGTH SALE OF NON-CASH CONTRIBUTIONS. FOR EXAMPLE, A LICENSED STOCK BROKER WAS USED THIS YEAR TO SELL GIFTS OF STOCK. Form 990, Part VI, Section A, line 2 THE ORGANIZATION'S OFFICERS AND DIRECTORS SERVE TOGETHER ON THE BOARDS OF OTHER TAXABLE ORGANIZATIONS WITHIN THE SENTARA HEALTHCARE SYSTEM ("THE SYSTEM"), AS WELL AS JOINT VENTURES IN WHICH THE SYSTEM HAS AN OWNERSHIP INTEREST. SEE SCHEDULE R FOR A LISTING OF SUCH ENTITIES. Form 990, Part VI, Section A, line 4 ON APRIL 1, 2011, THE ORGANIZATION ENTERED INTO AN AFFILIATION AGREEMENT WITH SENTARA HEALTHCARE, A 501(c)(3) ORGANIZATION ("SENTARA"), WHEREBY SENTARA REPLACED MARTHA JEFFERSON HEALTH SERVICES CORPORATION ("MJHSC") AS THE SOLE MEMBER OF THE ORGANIZATION EFFECTIVE JUNE 1, 2011. AS A RESULT OF THE AFFILIATION, THE ORGANIZING AND GOVERNING DOCUMENTS WERE CHANGED IN THE FOLLOWING MANNER: - MJHSC WAS REPLACED BY SENTARA AS SOLE MEMBER OF THE ORGANIZATION. - THE TWELVE-MEMBER BOARD OF TRUSTEES, WHICH WAS SELECTED BY MJHSC AS SOLE MEMBER AND WAS COMPRISED OF SIX ACTIVE MEDICAL STAFF MEMBERS AND SIX LAY PERSONS, WAS REPLACED WITH A FIFTEEN-MEMBER BOARD OF DIRECTORS, TWELVE SELECTED BY MJHSC AND THREE APPOINTED BY SENTARA. THOSE SELECTED BY MJHSC SHALL ALSO SERVE AS DIRECTORS OF MJHSC DURING THE COVENANT PERIOD DEFINED IN THE AFFILIATION AGREEMENT AND SHALL ULTIMATELY BE REDUCED TO SIX THROUGH TERM EXPIRATIONS. - SENTARA, AS SOLE MEMBER, SHALL HAVE EXCLUSIVE AUTHORITY TO DIRECT AND MANAGE THE OPERATIONS AND AFFAIRS OF THE ORGANIZATION AND TO MAKE ALL DECISIONS REGARDING THE BUSINESS OF THE ORGANIZATION, SUBJECT TO BOARD OVERSIGHT TO THE EXTENT AND IN THE MANNER SET FORTH IN THE ORGANIZATION'S BYLAWS. THE BOARD OF DIRECTORS SHALL FUNCTION IN AN ADVISORY CAPACITY, PROVIDING RECOMMENDATIONS TO SENTARA REGARDING THE ESTABLISHMENT OF ORGANIZATION POLICIES, THE MAINTENANCE OF QUALITY PATIENT CARE, AND THE PROVISION OF INSTITUTIONAL PLANNING IN A MANNER RESPONSIVE TO LOCAL COMMUNITY NEEDS. - UPON ANY LIQUIDATION OR DISSOLUTION OF THE ORGANIZATION, ITS REMAINING ASSETS SHALL BE DISTRIBUTED TO SENTARA. - DURING THE COVENANT PERIOD DEFINED IN THE AFFILIATION AGREEMENT, ORGANIZING OR ENABLING DOCUMENTS OR BYLAWS MAY ONLY BE ALTERED, AMENDED, RESTATED OR REPEALED THROUGH APPROVAL OF A MAJORITY OF THE BOARD MEMBERS SELECTED BY MJHSC VOTING AS A SEPARATE CLASS, AND SENTARA. Form 990, Part VI, Section A, line 6 SENTARA HEALTHCARE, A 501(c)(3) TAX EXEMPT ORGANIZATION, IS THE SOLE MEMBER OF MARTHA JEFFERSON HOSPITAL. Form 990, Part VI, Section A, line 7a BOARD CANDIDATES IDENTIFIED BY THE ORGANIZATION'S NOMINATION COMMITTEE MUST BE RATIFIED BY THE BOARD OF DIRECTORS OF THE ORGANIZATION'S SOLE MEMBER, SENTARA HEALTHCARE, PRIOR TO ELECTION. Form 990, Part VI, Section A, line 7b THE ORGANIZATION MAY NOT TAKE OR ALLOW ANY OF THE FOLLOWING GOVERNANCE ACTIONS WITHOUT THE CONSENT OF ITS 501(c)(3) SOLE MEMBER, SENTARA HEALTHCARE: APPROVAL OR ADOPTION OF ANY PLAN OR MERGER OR CONSOLIDATION, ANY SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, THE PROPERTY AND ASSETS OF THE ORGANIZATION, THE VOLUNTARY DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION, REVOCATION OF ANY SUCH VOLUNTARY DISSOLUTION PROCEEDINGS, OR ANY DECISION TO FILE A PETITION REQUESTING OR CONSENTING TO AN ORDER FOR RELIEF UNDER THE FEDERAL BANKRUPTCY LAWS OR SIMILAR STATE LAWS FOR THE ORGANIZATION; ELECTION OF NEW BOARD MEMBERS; OR ALTERATION, AMENDMENT, RESTATEMENT OR REPEAL OF ANY ORGANIZING OR ENABLING DOCUMENTS OR BYLAWS. THE APPROVAL OF THE SOLE MEMBER IS ALSO REQUIRED FOR CERTAIN OPERATIONAL ACTIONS, AS OUTLINED IN THE ORGANIZATION'S BYLAWS. SUCH ACTIONS INCLUDE, BUT ARE NOT LIMITED TO, APPROVAL OF LONG-RANGE AND STRATEGIC PLANS AND ANNUAL OPERATING AND CAPITAL BUDGETS; TRANSACTIONS WITH INTERESTED PERSONS; CREATION OR ACQUISITION OF SUBSIDIARIES OR INTERESTS IN WHICH THE ORGANIZATION WILL BE A MEMBER; ENTRANCE INTO JOINT VENTURE OR OTHER SIMILAR ARRANGEMENTS; EMPLOYMENT MATTERS CONCERNING THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER; AND THE COMMENCEMENT OR SETTLEMENT OF LITIGATION. SENTARA HEALTHCARE HAS EXCLUSIVE AUTHORITY TO DIRECT AND MANAGE THE OPERATIONS AND AFFAIRS OF THE HOSPITAL AND TO MAKE ALL DECISIONS REGARDING THE BUSINESS OF THE ORGANIZATION, SUBJECT TO BOARD OVERSIGHT TO THE EXTENT AND IN THE MANNER SET FORTH IN THE ORGANIZATION'S BYLAWS. Form 990, Part VI, Section B, line 11 THE ANNUAL AUDITED FINANCIALS OF MARTHA JEFFERSON HOSPITAL ARE REVIEWED BY SENTARA HEALTHCARE IN ADDITION TO THE MARTHA JEFFERSON HOSPITAL BOARD'S REVIEW. PRIOR TO FILING THE FORM 990 WITH THE IRS, IT IS REVIEWED BY THE FINANCE TEAM, INCLUDING THE CHIEF FINANCIAL OFFICER. IT IS ALSO REVIEWED BY SENTARA HEALTHCARE'S TAX DIRECTOR. MARTHA JEFFERSON HOSPITAL WILL SUBMIT THE INTERNAL REVENUE SERVICE FORM 990 FOR THE PRECEEDING FISCAL YEAR TO THE CEO EVALUATION COMMITTEE OF THE MARTHA JEFFERSON HOSPITAL BOARD OF DIRECTORS IN THE RESPECTIVE MEETING FOLLOWING THE FILING OF THE FORM 990. IN ADDITION, THE FORM 990 WILL BE PROVIDED TO THE MARTHA JEFFERSON HOSPITAL BOARD OF DIRECTORS AT THE MEETING FOLLOWING THE FILING OF THE FORM 990. MARTHA JEFFERSON HOSPITAL WILL ALSO ADVISE BOARD MEMBERS OF THE WEBSITE ADDRESS AT WHICH THE FILED FORM 990 WILL BE POSTED (WWW.GUIDESTAR.ORG/990). Form 990, Part VI, Section B, line 12c MARTHA JEFFERSON HOSPITAL'S CONFLICT OF INTEREST POLICY IS ADMINISTERED BY THE CORPORATE COMPLIANCE OFFICER. ON AN ANNUAL BASIS ALL DIRECTORS, TRUSTEES, OFFICERS, KEY EMPLOYEES, MEDICAL STAFF MEMBERS WITH ADMINISTRATIVE RESPONSIBILITIES AND OTHER EMPLOYEES COMPLETE A DETAILED CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING ANY REPORTABLE ACTIVITIES AND INVESTMENTS. THESE QUESTIONNAIRES ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER. IN ADDITION, ALL PERSONS LISTED ABOVE ARE ANNUALLY PROVIDED A COPY OF THE CONFLICT OF INTEREST POLICY. IF CHANGES TO PERSONNEL OCCUR BETWEEN ANNUAL COMPLETION OF THE CONFLICT OF INTEREST QUESTIONNAIRE, NEW PERSONNEL ARE ALSO REQUIRED TO COMPLETE THE QUESTIONNAIRE. ALL DISCLOSURE STATEMENTS ARE REVIEWED FOR REPORTABLE TRANSACTIONS. Form 990, Part VI, Section B, line 15 THE ORGANIZATION HAS AN ESTABLISHED CEO EVALUATION COMMITTEE MADE UP OF HOSPITAL BOARD MEMBERS AND COMMITTEE MEMBERS. ON AN ANNUAL BASIS, A THIRD PARTY COMPENSATION CONSULTING FIRM PROVIDES AN INDEPENDENT REVIEW AND ANALYSIS OF BASE AND TOTAL COMPENSATION AND EXECUTIVE PERQUISITES USING MARKET COMPARABILITY DATA. THE CONSULTING FIRM RENDERS AN OPINION ON THE FAIR MARKET VALUE OF COMPENSATION PAID AND BENEFITS PROVIDED WITH RESPECT TO THE IRS INTERMEDIATE SANCTIONS REGULATIONS. THE PROCESS IS FOLLOWED FOR THE FOLLOWING POSITIONS: CEO, VICE PRESIDENTS, EMPLOYED PHYSICIANS. FORM 990, PART VI, SECTION B, LINE 16b AT SEPTEMBER 30, 2011 MARTHA JEFFERSON HOSPITAL DID NOT HAVE A SPECIFIC JOINT VENTURE POLICY. ANY PROPOSED JOINT VENTURE PARTICIPATION IS EVALUATED WITHIN THE CONTEXT OF THE ADMINISTRATIVE POLICY ENTITLED "AUTHORITY TO COMMIT AND EXPEND FUNDS". THIS POLICY DEPICTS THE TYPES AND LEVELS OF EXPENDITURES AND COMMITMENTS THAT MANAGEMENT CAN UNDERTAKE. ALL PROPOSED JOINT VENTURES ARE REVIEWED BY EXTERNAL LEGAL COUNSEL TO ENSURE COMPLIANCE WITH THE APPROPRIATE FEDERAL, STATE AND REGULATORY LAW. ANY JOINT VENTURE PARTICIPATION MUST BE EVALUATED AND APPROVED BY THE MARTHA JEFFERSON HOSPITAL BOARD OF DIRECTORS. A SPECIFIC JOINT VENTURE PARTICIPATION POLICY IS CURRENTLY IN PROCESS OF DEVELOPMENT. Form 990, Part VI, Section C, line 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A JAMES HADEN DEVOTED AN AVERAGE OF 15 HOURS PER WEEK TO RELATED ORGANIZATIONS. J. MICHAEL BURRIS DEVOTED AN AVERAGE OF 11 HOURS PER WEEK TO RELATED ORGANIZATIONS. ELLIOT KUIDA DEVOTED AN AVERAGE OF 2 HOURS PER WEEK TO RELATED ORGANIZATIONS. FORM 990, PART VII, SECTION A THE EFFECTIVE DATE OF THE ORGANIZATION'S AFFILIATION WITH SENTARA HEALTHCARE, ITS NEW 501(c)(3) SOLE MEMBER, WAS JUNE 1, 2011. SINCE THE COMPENSATION REQUIRED TO BE REPORTED IN PART VII SECTION A IS FROM THE 2010 CALENDAR YEAR, AND SENTARA HEALTHCARE WAS NOT RELATED TO THE ORGANIZATION AT ANY TIME DURING 2010, NO RELATED COMPENSATION HAS BEEN REPORTED IN PART VII SECTION A FOR VICE CHAIRMAN HOWARD KERN AND BOARD MEMBERS DAVID BERND AND KENNETH KRAKAUR, WHO ARE EMPLOYED OFFICERS OF SENTARA HEALTHCARE. FORM 990, PART X CERTAIN BALANCE SHEET ITEMS WERE RECLASSIFIED IN THE CURRENT YEAR DUE TO AFFILIATION WITH SENTARA HEALTHCARE. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: TRANSFER FROM MJH FOUNDATION 3007292. INCREASE IN ADDITIONAL MINIMUM PENSION LIABILITY -5870375. NET UNREALIZED GAINS ON CHARITABLE TRUSTS -43422. NET UNREALIZED GAINS ON INVESTMENTS 899. ASU 2010-07 FAIR MARKET VALUE ADJUSTMENTS -XXX-XX-XXXX. NET PLEDGE ACTIVITY 25130. FY10 CAPITALIZED INTEREST RESTATED -11423820. DEEMED DISTRIBUTION FROM CFC NOT ON BOOKS -33850. INTEREST RATE SWAP VALUATION -11631070. Total to Form 990, Part XI, Line 5: -XXX-XX-XXXX. FORM 990, PART XII, LINE 2C DURING THE YEAR, MARTHA JEFFERSON HOSPITAL AFFILIATED WITH SENTARA HEALTHCARE WHO ASSUMED RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTED THE INDEPENDENT ACCOUNTANT. 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