2012-08-13T13:44:51-05:00 2011-09-30 Berry Dunn McNeil & Parker LLC 1000 Elm Street 15th Floor Manchester NH 03101 990 2010-10-01 030266986 Northwestern Medical Center NORT 8025245911 133 Fairfield St St Albans VT 05478 Ted Sirotta 8025245911 2012-08-06 1 Rachel Williamson CPA 6036697337 2012-08-06 2010 2016-02-24 21:20:13Z Ted Sirotta 133 Fairfield St St Albans VT 05478 90261323 0 X www.northwesternmedicalcenter.org X 1977 VT Northwestern Medical Center's mission is to provide exceptional healthcare for our community. 12 12 645 110 2229471 -48015 249111 536175 76581990 78541161 1654835 1699251 356763 323363 78842699 81099950 0 0 0 0 35478977 37434844 0 0 0 35401037 35115470 70880014 72550314 7962685 8549636 83114924 89040961 24709903 24615163 58405021 64425798 X Northwestern Medical Center's mission is to provide exceptional healthcare for our community. 0 0 57570452 76622153 Providing inpatient and outpatient services to the general public in a full-service 70-bed hospital. The Hospital publishes an annual report. Please refer to the annual report for additional explanation of the Hospital's programs and achievements. Charity Care - The Hospital provides care to patients who meet certain criteria under its charity care policy. Because the Hospital does not pursue collection or amounts determined to qualify as charity care they are not reported in revenue. The Hospital maintains records to identify and monitor the level of charity care it provides. The records include the amount of charges foregone for services and supplies furnished under its charity care policy, the estimated cost of those services and supplies and equivalent service statistics. The following information measures the level of charity care provided during the year ended September 30, 2011.See continuation on Schedule O. Estimated costs and expenses incurred to provide charity care: $702,985.Number of charity care patients served: 504The Hospital provides health care services to residents of St. Albans, Vermont, and the surrounding area, without regard to the individual's ability to pay for their services. 57570452 1 0 0 1 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 1 0 0 0 1 88 0 1 645 1 1 1 0 0 0 0 0 0 0 1 0 X 12 12 0 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Ted Sirotta CFO 8025241042 133 Fairfield Street St Albans VT 05478 X Judy Ashley-McLaughlin 5.00 X X 0 0 0 Peter Rath 5.00 X X 0 0 0 Kevin Manahan 5.00 X X 0 0 0 Michelle Lawrence 5.00 X X 0 0 0 Paul Clark 5.00 X X 0 0 0 John Edwards 3.00 X 0 0 0 John Hango 3.00 X 0 0 0 Paula Kane 3.00 X 0 0 0 Frank Zsoldos 3.00 X 0 0 0 Lowrey Sullivan 3.00 X 0 0 0 Patrick Talcott 3.00 X 0 0 0 William O'Connor 3.00 X 0 0 0 John Casavant 3.00 X 0 0 0 Jill Berry Bowen 40.00 X 281627 0 0 Ted Sirotta 40.00 X 184880 0 0 Michael Barnum 40.00 X 697184 0 24179 Jeremy Hatch 40.00 X 408793 0 23537 Peter Burke 40.00 X 360219 0 29079 Thomas Suppan 40.00 X 321652 0 19448 Sherry Cipriano 40.00 X 283861 0 7882 Peter Hofstetter 40.00 X 0 0 0 Wesley Oswald 40.00 X 0 0 0 2538216 0 104125 30 0 1 1 Fletcher Allen Health Care PO Box 1902 Burlington VT 05402 Lab & Stress Test Services 1067640 Quorum Health Resources 105 Continental Place Brentwood TN 37027 Mgmt/Consulting (incl. Officers' comp.) 1047211 Brandthropology 266 Pine Street Suite 5 Burlington VT 05401 Community Communications 869432 Barton Associates 10 Dearborn Road Peabody MA 01960 Locum Physician Service 494800 Locumtenenscom PO Box 405547 Atlanta GA 30384 Locum Physician Service 432929 62 536175 10960 536175 Net Patient Service Re 900099 77585222 75581959 2003263 Other Operating Revenu 900099 538953 312745 226208 Cafeteria 900099 416986 416986 78541161 986727 986727 311620 1157 310463 310463 310463 9872740 9160216 712524 712524 712524 12900 0 12900 12900 81099950 76622153 2229471 1712151 466507 466507 29835802 23979705 5856097 1050866 898911 151955 4063506 3475923 587583 2018163 1726337 291826 592580 592580 124178 124178 105233 105233 100171 100171 7185680 5646574 1539106 542902 542902 306633 173246 133387 656171 458910 197261 249696 150390 99306 629458 538438 91020 3353160 2868293 484867 898852 138882 759970 Supplies 8927421 8637278 290143 Healthcare improvement 3964661 3964661 NOH 2407842 2407842 Maintenance Contracts 1490676 626735 863941 Utilities 832065 709991 122074 2748091 1068165 1679926 72550314 57570452 14979862 0 2986 14728324 20164203 6128498 7398595 42203 40461 1553943 1654532 1474462 1440174 65476930 35875421 30266573 29601509 28807860 28635623 110075 105864 83114924 89040961 7603453 7318985 13200000 12960390 3906450 4335788 24709903 24615163 X 56837480 62639492 719941 901676 847600 884630 58405021 64425798 83114924 89040961 X 8549636 -2528859 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 20143 20143 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: Northwestern Medical Center is a member of the Vermont Association of Hospitals and Health Systems and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of Northwestern Medical Center and other member organizations in furtherance of their exempt purposes. Northwestern Medical Center does not directly perform any lobbying activities. 847600 37030 884630 806185 41415 847600 913985 -107800 806185 1.00000 1 0 1020531 1020531 36655983 17714153 18941830 25510274 16928383 8581891 2290142 1232885 1057257 29601509 Estimated Third Party Settlement 2627000 Interest Rate Swaps 1708788 4335788 81099950 72550314 8549636 -2265331 -263528 -2528859 6020777 78470920 -2265331 37131 -2228200 80699120 100171 300659 400830 81099950 72450143 0 72450143 100171 100171 72550314 Description of Intended Use of Endowment Funds: Part V, Line 4: The organization intends to use the endowment funds in the manner prescribed by the donors. Part XI, Line 8 - Other Adjustments: Unrealized Loss on Interest Rate Swaps -300,659. Increase in Perpetual Trusts 37,131. Part XII, Line 2d - Other Adjustments: Increase in Perpetual Trusts 37,131. Part XII, Line 4b - Other Adjustments: Unrealized Loss on Interest Rate Swaps 300,659. 1 1 1 X 300.000000000000 1 X 1 1 1 0 0 702985 702985 0.00970 18316969 13816521 4500448 0.06200 19019954 13816521 5203433 0.07170 3527403 1274067 2253336 0.03110 55283 55283 0.00080 3582686 1274067 2308619 0.03190 22602640 15090588 7512052 0.10360 1 2221640 18758559 16856962 1901597 X 1 1 1 1 Northwestern Medical Center

133 Fairfield Street St Albans VT 05478

X X X Not required 1 4 Northwestern Walk-in Clinic

927 Ethan Allen Hwy Ste 2 Georgia VT 05468

Diagnostic Imaging, Physical Therapy & Urgent Care Branon's Pools & Spa

248 North Main Street St Albans VT 05478

Physical Therapy Physical Therapy Services

44 Center Street Enosburg VT 05450

Physical Therapy Northwestern Georgia Health Center

4178 Highbridge Road Georgia VT 05486

Primary Care Part I, Line 7g: Subsidized health services includes the Medicare shortfall from physician practices that are not included in the Hospital's cost reporting reflected on Part III, Line 7. Part III, Line 4: Management provides for probable uncollectible amounts through a charge to operations and a credit to a valuation allowance based on its assessment of individual accounts and historical adjustments. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable. Part III, Line 8: The cost was determined using the cost to charge ratio. Part III, Line 9b: During the collection process, financial assistance, a payment plan or a discount may be offered to the patient, if appropriate, and in accordance with established hospital policy. The Medicare surplus of $1,901,597, reported on line 7 of Part III, does not represent all Medicare services provided by the Hospital, as required by IRS instructions. When taking all Medicare services into account, the Hospital has a Medicare shortfall in the amount of $1,638,813, as calculated using an internal costing methodology. Part VI, Line 2: The Hospital currently participates in 2 community needs assessment initiatives. The Hospital partners with another local non-profit organization to complete a formal community needs assessment focused on health, education, and income. This assessment takes place approximately every three years. The Hospital also completes an informal community needs assessment with each renewal of its strategic plan that focuses on community needs related to specific healthcare providers and services. The Hospital will complete a formal community needs assessment in alignment with the Federal mandate by September 30, 2012. Part VI, Line 3: The Hospital uses a variety of methods of communication to inform and educate patients about the eligibility requirements for financial assistance and charity care. For example, information related to financial assistance and charity care is available on the Hospital's website, included on the back of patient statements, posted on signs at registration areas, and patients may speak on the phone with a collection specialist. Part VI, Line 4: The Hospital serves the greater Franklin and Grand Isle counties in northwestern Vermont. The service area consists of approximately 54,000 people and the area is primarily rural and agricultural in nature with some light industry. Part VI, Line 6: The Hospital maintains an open medical staff and a community based Board of Directors. The Hospital's Board of Directors is elected by the Hospital's Board of Incorporators, which consists of approximately 150 local residents. The Hospital created and funds a program known as The Center for Health and Wellness, which is committed to a collaborative approach to community health improvement. 0 Champlain Drug & Alcohol Services 20 Ampersand Drive Plattsburgh NY 12901 141638308 501(c)(3) 12000 Support programs complimentary to the Hospital's exempt purpose. Franklin Grande Isle United Way 40 Lower Newton Street St Albans VT 05478 030273929 501(c)(3) 27000 Support programs complimentary to the Hospital's exempt purpose. American Heart Association Two Wall Street Manchester NH 03101 135613797 501(c)(3) 10000 Support programs complimentary to the Hospital's exempt purpose. 24 X 1 1 X X X 0 0 0 0 0 0 0 0 0 Jill Berry Bowen 281627 0 0 0 0 0 0 0 0 0 281627 0 0 0 Ted Sirotta 184880 0 0 0 0 0 0 0 0 0 184880 0 0 0 Michael Barnum 697184 0 0 0 0 0 7350 0 16829 0 721363 0 0 0 Jeremy Hatch 408793 0 0 0 0 0 12250 0 11287 0 432330 0 0 0 Peter Burke 359959 0 0 0 260 0 12250 0 16829 0 389298 0 0 0 Thomas Suppan 321652 0 0 0 0 0 12250 0 7198 0 341100 0 0 0 Sherry Cipriano 283471 0 0 0 390 0 7350 0 532 0 291743 0 0 0 Part I, Line 1a Northwestern Medical Center provides fitness club membership automatically for all employees. The employees are required to sign in at the fitness club and those records are provided regularly to the Hospital to determine the amount of payment due to the fitness club. Supplemental Information Part III Jill Berry Bowen, CEO, was compensated through a contract with Quorum Health Resources. Her total compensation for the period ended December 31, 2010 was $281,627, which includes moving and housing allowances applicable to her first year of employment with the Hospital. Ted Sirotta, CFO, was compensated through a contract with Quorum Health Resources. His total compensation for the period ended December 31, 2010 was $184,880. Vermont Educational & Health Building Financing Agency 227154467 2010-09-01 13200000 Refund 2005A Bond and new capital projects 0 0 0 495476 13200000 10795501 110300 2294199 2012 1 0 0 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 John Casavant Board Member 884544 John Casavant is employed by an insurance company which the hospital purchases insurance products at market rates. 0 Jane Catton Chief Quality Officer 129114 Northwestern Medical Center leases space in the doctors' office buildings owned by Jane Catton. The lease has a one-year term, has provisions for early termination without cause and is made a market rate. 0 Jane Catton Chief Quality Officer 266766 Northwestern Medical Center purchases doctors' office staff support from a company owned by Jane Catton. The support agreement has a one-year term, has a provision for early termination without cause and is made at market rate. 0 X 8 10960 FMV 0 0 0 Form 990, Part VI, Section A, line 3 The CEO and CFO are employees of Quorum Health Resources. Form 990, Part VI, Section A, line 6 The organization has a maximum of 150 members, elected at the annual meeting from a slate of candidates nominated by the Nominating Committee. Other candidates for membership may be nominated from the floor at the annual meeting. Any person whose term as a Corporation Director has expired shall automatically become a member if that person consents to become a member. Form 990, Part VI, Section A, line 7a The membership elects a presiding membership officer, an alternate presiding membership officer and a membership secretary. Said officers are designated as Chair, Vice Chair and Recording Secretary of the membership. Form 990, Part VI, Section B, line 11 The CFO reviews the 990 and compares it to the audited financial statements. In addition, a copy of the 990 is provided to all members of the Hospital's Board of Directors before it is filed. Form 990, Part VI, Section B, line 12c Regular monitoring occurs at a minimum annually when each individual must complete the annual disclosure form. Form 990, Part VI, Section B, line 15 The CEO and CFO are not employees of Northwestern Medical Center. They are employees of Quorum Health Resources and their respective contracts, including compensation, are approved by the Board of Directors on an annual basis. Form 990, Part VI, Section C, line 19 Northwestern Medical Center does not formally make its governing documents and conflict of interest policy available to the public. Financial information is available to the public through the annual tax return filing, annual Medicare and Medicaid cost report filing, and financial data published by the Vermont Department of Banking, Insurance, Securities, and Health Care Administration and available on the Hospital's website, as well as summarized financial information and statistics published in the Hospital's annual report distributed to local communities and published on the Hospital's website. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -2,265,331. Unrealized Loss on Interest Rate Swaps -300,659. Increase in Perpetual Trusts 37,131. Total to Form 990, Part XI, Line 5: -2,528,859. Form 990, Page 11, Part XI, Line 2c No change was made in the way the independent auditor was selected or in the oversight of the audit. Northwest Occupational Health LLC 133 Fairfield street St Albans VT 05478 030360669 Medical rehabilitative and urgent care services VT 0 1421846 Northwestern Medical Center