2012-05-14T13:48:45-05:00 2011-06-30 SCHAFFNER KNIGHT MINNAUGH & CO PC 1001 STATE STREET SUITE 1300 ERIE PA 16501 990 2010-07-01 251002937 MILLCREEK COMMUNITY HOSPITAL MILL 8148644031 5515 PEACH STREET ERIE PA 16509 RICHARD P OLINGER 8148644031 2012-05-11 1 MATTHEW J MINNAUGH CPA 8144541997 2010 2016-02-24 21:20:13Z MARY L ECKERT 5515 PEACH STREET ERIE PA 16509 58742679 0 X WWW.MILLCREEKCOMMUNITYHOSPITAL.ORG X 1948 PA THE ORGANIZATION PROVIDES THE COMMUNITY WITH HEALTHCARE SERVICES AND EDUCATION. 12 7 641 13 0 0 351844 404184 40370256 41406725 1396554 1621145 1762233 1742647 43880887 45174701 0 0 0 0 19593218 21097744 0 0 0 19327350 19133771 38920568 40231515 4960319 4943186 76728883 82175161 7740058 6905612 68988825 75269549 X MILLCREEK COMMUNITY HOSPITAL PROVIDES QUALITY HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONALITY, ORIGIN, HANDICAPS, AGE OR ABILITY TO PAY. THE ORGANIZATION'S MISSION IS TO SERVE THE COMMUNITY BY PROVIDING HEALTHCARE SERVICES AND EDUCATION. 0 0 11711187 13395687 ACUTE INPATIENT CARE: MILLCREEK COMMUNITY HOSPITAL (THE HOSPITAL) IS A COMMUNITY BASED HOSPITAL PROVIDING QUALITY HEALTH CARE FOR PATIENTS WITH ILLNESSES, PROMOTING HEALING, AND IMPROVING THE QUALITY OF LIFE AT AFFORDABLE COST. THE HOSPITAL INPATIENT SERVICES INCLUDE, BUT ARE NOT LIMITED TO, SURGERY, RADIOLOGY, INTENSIVE CARE, PHYSICAL THERAPY, ENDOSCOPY, AND A CATH LAB. THE FACILITY HAS 80 BEDS ACCOMODATING THE WELLNESS OF THE COMMUNITY. FOR FISCAL YEAR ENDED JUNE 30, 2011, 10,032 PATIENT DAYS WERE PROVIDED. REFER TO SCHEDULE O FOR ADDITIONAL INFORMATION REGARDING ACUTE INPATIENT CARE.THE HOSPITAL DEMONSTRATES FISCAL RESPONSIBILITY BY PURSUING COST REIMBURSEMENT FOR THOSE PATIENTS WHO HAVE THE MEANS AND ABILITY TO PAY WHILE PROVIDING CARE FOR THOSE WHO LACK THE FINANCIAL RESOURCES TO PAY FOR SOME OR ALL OF THE COST. FOR THE FISCAL YEAR ENDED JUNE 30, 2011, 164 DAYS OF CHARITY CARE WERE PROVIDED AMOUNTING TO $821,649 OF FORGONE REVENUE AT A COST OF $278,081 TO THE HOSPITAL. BAD DEBT CHARGES INCLUDED IN ACUTE CARE - MEDICAL SURGICAL WERE $1,779,817 AT A COST OF $602,290 TO THE HOSPITAL. THE HOSPITAL ACTIVELY COMMITS TO ITS UNINSURED/UNDERINSURED AND CHARITY DISCOUNT POLICIES, AND IT DOES NOT DISCRIMINATE AGAINST THOSE INDIVIUDALS WHO ARE IN NEED OF FINANCIAL ASSISTANCE FROM THE FACILITY OR THOSE IN NEED OF GOVERNMENT ASSISTANCE.THE HOSPITAL'S COMMUNITY ACTIVITIES INCLUDED SEVERAL BLOOD PRESSURE SCREENING EVENTS HELD AT SENIOR DAY, THE ANNUAL CONSUMER FAIR, AND NATIONAL SENIOR HEALTH & FITNESS DAY. A BLOOD DRIVE IS CONDUCTED TWICE A YEAR TO ASSIST IN THE COMMUNITY NEED FOR BLOOD. THE HOSPITAL PARTICIPATES IN PREVENTIVE HEALTH EDUCATION CLASSES AND PROVIDES LITERATURE FOR HEALTHY LIVING. IN ADDITION, THE HOSPITAL PLAYS A PROACTIVE ROLE IN THE DISASTER/BIOTERRORISM PREPAREDNESS PROGRAM.FOR INDIVIDUALS NEEDING FINANCIAL ASSISTANCE, TRANSPORTATION IS PROVIDED TO THE HOSPITAL'S FACILITIES FOR PHYSICIAN VISITS EITHER BY THE HOSPITAL VAN, BUS TOKENS, OR A CAB. PRESCRIPTIONS AND CLOTHING ARE ALSO PROVIDED TO THOSE IN NEED. 7353878 8425725 BEHAVIORAL UNIT CARE: IN 2001, A LARGE LOCAL BEHAVIORAL HEALTH INPATIENT PROVIDER ANNOUNCED THAT IS WAS DISCONTINUING ITS LINE OF SERVICE. A COMMUNITY TASK FORCE WAS FORMED TO ADDRESS THE VOID AND, AT THIS GROUP'S REQUEST, MILLCREEK COMMUNITY HOSPITAL FILLED A CRITICAL NEED FOR MENTAL HEALTH CARE FACILITIES IN THE AREA. TODAY, THE HOSPITAL'S BEHAVIORAL HEALTH OFFERINGS INCLUDE A 10 BED DETOXIFICATION UNIT, 62 BEDS OF LICENSED ACUTE PSYCHIATRIC CARE, AND AN ACUTE ADULT PARTIAL HOSPITALIZATION PROGRAM. THE HOSPITAL'S CHILD/ADOLESCENT UNIT IS THE REGION'S ONLY SUCH BEHAVIORAL HEALTH ACUTE CARE FACILITY. REFER TO SCHEULDE O FOR ADDITIONAL INFORMATION REGARDING BEHAVIORAL CARE.FOR THE FISCAL YEAR ENDED JUNE 30, 2011, 1,970 DISCHARGES TOTALING 11,771 PATIENT DAYS WERE PROVIDED.THE HOSPITAL PURSUES COLLABORATION WITH THE ERIE HEALTH CARE AND HUMAN SERVICES COMMUNITY. THE HOSPITAL IS REPRESENTED ON MANY COUNTY-SPONSORED AND OTHER PLANNING COMMITTEES, AND IS PART OF INITIATIVES TO IMPROVE OUTCOMES FOR MUTUAL CLIENTS. THE HOSPITAL IS ALSO REPRESENTED AT COMMUNITY CLINICAL FORUMS TO PROVIDE EXPERT INFORMATION AND INPUT ON DIFFICULT SITUATIONS AND CASES. THE HOSPITAL HOSTS MEETINGS AT THE FACILITY IN ORDER TO IMPROVE CONTINUITY OF CARE; THESE MEETINGS ARE ATTENDED BY REPRESENTATIVES FROM MORE THAN TWENTY LOCAL SCHOOLS, SCHOOL DISTRICTS, AND SERVICE PROVIDERS. THE HOSPITAL ALSO WELCOMES REPRESENTATIVES FROM JUVENILE JUSTICE, THE OFFICE OF CHILDREN AND YOUTH, AND OTHER GOVERNMENTAL ORGANIZATIONS IN THE INTEREST OF IMPROVING THE LIVES OF ITS PATIENTS. WORKING AGREEMENTS ARE DEVELOPED WITH LOCAL SERVICE AGENCIES TO ALLOW BOTH PATIENTS AND RECEIVING PROVIDERS TO BE LINKED WITH EACH OTHER WHILE THE PATIENT IS AT THE HOSPITAL RECEIVING CARE. 4241592 3280589 RESIDENT TRAINING:IN AN EFFORT TO ADDRESS THE CRITICAL SHORTAGE OF PHYSICIANS, MILLCREEK COMMUNITY HOSPITAL ACTS AS A TEACHING HOSPITAL AND OFFERS MORE PHYSICIAN RESIDENCY PROGRAMS THAN ANY OTHER HOSPITAL IN NORTHWESTERN PENNSYLVANIA. FOR THE FISCAL YEAR ENDED JUNE 30, 2011, THE HOSPTIAL UTILIZED 65 INTERNS ACROSS A WIDE RANGE OF MEDICAL CARE SPECIALTIES INCLUDING FAMILY PRACTICE, EAR/NOSE/THROAT, INTERNAL MEDICINE, OPHTHALMOLOGY, ORTHOPEDICS, PSYCHIATRY, GASTROINTESTINAL, PODIATRY, SPORTS MEDICINE, AND NEUROMUSCULOSKETAL MEDICINE. 12725509 16304724 OTHER PROGRAM ACTIVITIES:OTHER PROGRAM ACTIVITIES INCLUDED 27,599 OUTPATIENT VISITS INCLUDING 1,230 OUTPATIENT SURGERIES, 15,027 EMERGENCY ROOM VISITS, 304 ADMISSIONS FOR 4,095 DAYS TO THE TRANSITIONAL CARE UNIT, 455 OBSTETRICAL DAYS, AND 711 ADMISSIONS FOR 2,765 DAYS TO THE DETOX UNIT. 12725509 16304724 36032166 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 1 85 0 1 641 1 0 0 0 0 0 0 0 0 0 0 X 12 7 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 PA X RICHARD P OLINGER 8148644031 5515 PEACH STREET ERIE PA 16509 MARY L ECKERT 72.00 X X 427418 3859 29123 RICHARD P OLINGER 31.00 X X 205666 190435 35179 JOHN M FERRETTI DO 10.00 X X 0 501737 29168 SILVIA M FERRETTI DO 2.00 X 0 658129 29168 MARIO EJ LANNI DSC 1.00 X 0 0 0 NANCY Z O'NEILL 1.00 X 0 0 0 MARK R RENDULIC 1.00 X 0 0 0 JAMES A SCHAFFNER 1.00 X X 0 0 0 DALE P SPARBER 1.00 X 0 0 0 WILLIAM F MCCARTHY 1.00 X 0 0 0 RICHARD B SEAGER 1.00 X 0 0 0 JOHN J KALATA DO 7.00 X 35000 0 0 PAUL A KOHUT DO 40.00 X 229611 0 29850 RONALD BRADLEY DO 40.00 X 169499 0 6116 THOMAS ZIEGLER MD 40.00 X 238793 0 23995 ELISEO ROQUIZ MD 40.00 X 350212 0 34432 MARVIN WIELAND DO 40.00 X 325262 0 25089 MICHELLE MACKENZIE 40.00 X 135261 0 6952 TIMOTHY ZURN 40.00 X 120004 0 23913 2236726 1354160 272985 10 0 1 0 BUILDING CONTROLS AND SERVICES 4 PEUQUET PARKWAY TONAWANDA NY 14150 CONSTRUCTION 2060153 AMERISOURCE BERGEN PO BOX 959 VALLEY FORGE PA 19482 PROFESSIONAL PHARMACEUTICAL SERVICES 832134 CLINICAL PATHOLOGY INSTITUTE 1526 PEACH STREET ERIE PA 16501 PROFESSIONAL PATHOLOGY SERVICES 817763 CHURCH & MURDOCK ELECTRIC COMPANY PO BOX 10908 ERIE PA 16514 CONSTRUCTION 803723 PRESQUE ISLE PSYCHIATRIC 2808 STATE STREET ERIE PA 16508 PSYCHIATRIC AND BEHAVIORAL HEALTH SERVIC 518634 26 155600 239192 9392 404184 NET PATIENT REVENUE 900099 39444169 39444169 RESIDENT CONTRACT REV 900099 1962556 1962556 41406725 1118029 1118029 890892 83608 807284 807284 807284 13984857 2629 13484370 500487 2629 503116 503116 CAFETERIA REVENUE 900099 326790 326790 MISCELLANEOUS REVENUE 900099 258692 258692 SNACKBAR/ VEND MACH RE 900099 190835 190835 159046 159046 935363 45174701 41406725 0 3363792 1158870 965926 192944 16201066 14465407 1735659 368715 321396 47319 2033513 1775773 257740 1335580 1175655 159925 62662 55957 6705 9116 9116 86146 86146 183040 183040 4681948 4180980 500968 49161 43901 5260 3895803 3478952 416851 504427 450453 53974 685318 611989 73329 51105 45637 5468 2120919 1893981 226938 841576 748331 93245 PROVISION FOR BAD DEBT 3796430 3796430 REPAIRS AND MAINTENANCE 841313 751293 90020 PHARMACY DRUGS 669010 669010 MISCELLANEOUS 278394 248606 29788 MRI EXPENSE 180000 180000 197403 172489 24914 40231515 36032166 4199349 0 2928743 1922884 5312728 6229488 4409323 4333748 731802 641882 630043 630108 61429595 23070485 35623057 38359110 16378309 18708918 917581 917581 9797297 10431442 76728883 82175161 3262971 3108034 42259 42922 4434828 3754656 7740058 6905612 X 68978825 75247914 10000 21635 68988825 75269549 76728883 82175161 X 4943186 1337538 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8990321 8990321 35603648 11153607 24450041 15375850 11666967 3708883 1459776 249911 1209865 38359110 IRREVOCABLE SELF-INSURED TRUST FUND 8916502 OTHER RECEIVABLES 994126 DUE FROM AFFILIATES 520814 10431442 ACCRUED MEDICAL MALPRACTICE 3708679 DUE TO THIRD PARTY PAYERS 45977 3754656 45174701 40231515 4943186 1825903 -488365 1337538 6280724 46901172 1825903 1825903 45075269 99432 99432 45174701 40132083 83608 83608 40048475 183040 183040 40231515 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED. THE HOSPITAL ADOPTED THE STANDARD FOR ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN A COMPANY'S FINANCIAL STATEMENTS THAT PRESCRIBES A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITY. MEASUREMENT OF THE TAX UNCERTAINTY OCCURS IF THE RECOGNITION THRESHOLD HAS NOT BEEN MET. THE STANDARD ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING FOR INTERIM PERIODS, AND DISCLOSURE. MANAGEMENT HAS DETERMINED THAT ADOPTION OF THE STANDARD DID NOT HAVE A MATERIAL EFFECT ON THE FINANCIAL STATEMENTS. THE HOSPITAL'S INCOME TAX RETURNS FOR THE YEARS ENDED 2010, 2009, AND 2008 REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE AND STATE AGENCIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY TRANSFER TO AFFILIATE -500,000. INCREASE IN TEMPORARILY RESTRICTED NET ASSETS 11,635. PART XII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT MANAGEMENT FEES NETTED AGAINST DIVIDEND INCOME 183,040. DEPRECIATION EXPENSE RELATED TO RENTAL INCOME -83,608. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DEPRECIATION EXPENSE REFLECTED ON STMT OF REVENUE 83,608. PART XIII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT MANAGEMENT FEES NETTED AGAINST DIVIDEND INCOME 183,040. 1 1 1 X 140.000000000000 1 X 1 0 0 14 457 278081 0 278081 0.00760 14 1710 9451093 9445082 6011 0.00020 0 0 28 2167 9729174 9445082 284092 0.00780 0 0 10 65 4241592 3280589 961003 0.02640 3 496 3685519 2199299 1486220 0.04080 13 561 7927111 5479888 2447223 0.06720 41 2728 17656285 14924970 2731315 0.07500 0 1284875 642438 10198390 9125902 1072488 X 1 1 1 1 MILLCREEK COMMUNITY HOSPITAL

5515 PEACH STREET ERIE PA 16509

X X X X SKILLED NURS BEHAV UNIT; HOSPITALZ PROG MILLCREEK COMMUNITY HOSPITAL 1 1 1 140.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X 1 X X X X 1 X 0 1 PART I, LINE 7: LINE 7A CHARITY CARE - RATIO OF PATIENT CARE COSTS TO CHARGESLINE 7B MEDICAID - RATIO OF PATIENT CARE COSTS TO CHARGESLINE 7F HEALTH PROFESSIONAL EDUCATION - A COMBINATION OF ACTUAL COST AND COST TO CHARGES IS USED. ACTUAL IS USED FOR DIRECT EXPENSE AND COST TO CHARGES FOR COMMON EXPENSE FROM THE MEDICARE COST REPORT.LINE 7G SUBSIDIZED HEALTH SERVICES - THE COSTING METHODOLOGY WAS DETERMINED BASED ON THE PARTICULAR ACTIVITY/PROGRAM AND THE TYPE OF EXPENSE. ACTUAL COST WAS USED WHERE DIRECT EXPENSES WERE IDENTIFIABLE. A RATIO OF PATIENT CARE COST TO CHARGES WAS USED IN THE CASE OF INDIRECT EXPENSES. PART I, LINE 7G: EXPENSE INCLUDES $521,477 FOR MEDICAL ASSISTANCE CLINICS PART I, L7 COL(F): BAD DEBT OF $3,796,430 IS EXCLUDED FROM THE DENOMINATOR FOR PURPOSES OF PART 1, LINE 7, COLUMN F - "PERCENT OF TOTAL EXPENSE" PART III, LINE 4: ACCOUNTS RECEIVABLE ARE STATED AT THE AMOUNT THE HOSPITAL EXPECTS TO COLLECT. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS EQUAL TO THE ESTIMATED UNCOLLECTIBLE AMOUNTS. THE HOSPITAL'S ESTIMATE IS BASED ON HISTORICAL COLLECTION EXPERIENCE AND REVIEW OF THE CURRENTS STATUS OF PATIENT ACCOUNTS RECEIVABLE. IT IS REASONABLY POSSIBLE THAT THE HOSPITAL'S ESTIMATE OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS WILL CHANGE. PATIENT ACCOUNTS RECEIVABLE ARE PRESENTED NET OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS OF $1,119,025 AND $911,317 AS OF JUNE 2011 AND 2010, RESPECTIVELY.THE METHODOLOGY FOR DETERMINING THE COST OF BAD DEBT FOR LINE 2 IS THE RATIO OF PATIENT CARE COSTS TO CHARGES TIMES THE GROSS CHARGES ATTRIBUTABLE TO THE BAD DEBT PATIENT ACCOUNTS. OFFERED DISCOUNTS RELATING TO CHARITY CARE EXPENSES ARE RECORDED AS PART OF THE CONTRACTUAL ALLOWANCE OFFSET AGAINST GROSS CHARGES. ACCORDINGLY, A DISCOUNT IN NOT INCLUDED AS PART OF BAD DEBT EXPENSE. BAD DEBT EXPENSE AT COST ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE IS BASED ON ESTIMATES. PART III, LINE 8: EXPENSE RELATED TO ACUTE SERVICES WAS BASED ON THE RATIO OF ACUTE MEDICARE CHARGES TO TOTAL PAYOR CHARGES. COST FOR OTHER SERVICES WAS BASED ON A COMBINATION OF ACTUAL DIRECT CHARGES TIMES THE RATIO OF MEDICARE DAYS TO TOTAL DAYS, INDIRECT COSTS BASED ON A COST TO CHARGE RATIO, AND OVERHEAD COSTS BASED ON ALLOCATED COSTS FROM THE MEDICARE REPORT. PART III, LINE 9B: CHARITY CARE IS NOT CONSIDERED A SUBSTITUTE FOR PERSONAL RESPONSIBILITY. PATIENTS ARE EXPECTED TO FOLLOW THE HOSPITAL'S BILLING PROCEDURES AND PAY HIS/HER SHARE BASED ON FINANCIAL ABILITY. MILLCREEK COMMUNITY HOSPITAL'S COLLECTION PRACTICES TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM MILLCREEK COMMUNITY HOSPITAL, AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH MILLCREEK COMMUNITY HOSPITAL. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR HOSPITAL BILLS, MILLCREEK COMMUNITY HOSPITAL MAY OFFER EXTENDED PAYMENT PLANS TO ELIGIBLE PATIENTS, WILL NOT IMPOSE WAGE GARNISHMENTS OR LIENS ON PRIMARY RESIDENCES, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES, AND WILL CEASE ALL COLLECTION EFFORTS. MILLCREEK COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: AN AMOUNT THAT EQUALS OR NEARS MEDICAID RATES MILLCREEK COMMUNITY HOSPITAL PART V, SECTION B, LINE 21: GROSS CHARGES ARE BILLED ON SERVICES TO PATIENTS NOT QUALIFYING FOR FINANCIAL ASSISTANCE AND WHO ARE NOT ACTIVELY COOPERATING WITH THE PROCESSES AND PROCEDURES OF THE HOSPITAL TO SATISFY THEIR OBLIGATION FOR PAYMANT. PART VI, LINE 2: THE HOSPITAL IS CURRENTLY WORKING WITH OTHER HOSPITALS AND INSTITUTIONS WITH SPECIAL KNOWLEDGE REGARDING PUBLIC HEALTH IN ERIE COUNTY TO DEVELOP A FORMAL COMMUNITY HEALTH NEEDS ASSESSMENT AND WILL HAVE THE REPORT IN PLACE DURING FISCAL YEAR-END JUNE 2013. PART VI, LINE 3: THE HOSPITAL UTILIZES THE FOLLOWING PROCEDURES TO INFORM AND EDUCATE ITS PATIENTS AND PERSONS, WHO MAY BE BILLED FOR PATIENT CARE, ABOUT THEIR ELIGIBLITY FOR ASSISTANCE:- A HOSPITAL EMPLOYEE WITH KNOWLEDGE OF GOVERNMENT PROGRAMS PERSONALLY VISITS APPLICABLE INPATIENTS AND EXPLAINS THE MEDICAL ASSISTANCE ALTERNATIVES AVAILABLE TO THE INPATIENT- PATIENT BILLING STATEMENTS INCLUDE A NOTATION REGARDING THE FACT DISCOUNTS OR SPECIAL PAYMENT ARRANGEMENTS ARE AVAILABLE TO QUALIFYING INDIVIDUALS- A CHARITY CARE CONTACT PHONE NUMBER IS PHYSICALLY POSTED IN THE HOSPITAL'S EMERGENCY ROOM AND PRINTED ON THE PATIENT'S BILLING STATEMENT. THE APPROPRIATE HOSPITAL EMPLOYEES ASSIST PATIENTS IN THE COMPLETION OF THE REQUIRED FORMS. PART VI, LINE 4: THE HOSPITAL SERVES ERIE COUNTY, PENNSYLVANIA AND PERIPHERAL AREAS SURROUNDING THE COUNTY. BASED ON 2010 INFORMATION PUBLISHED ON ERIEVITALSIGNS.ORG, 17% OF ERIE COUNTY RESIDENTS WERE BELOW THE POVERTY LEVEL DURING THE STUDIED TIME FRAME. POVERTY RATES FOR THE SAME TIME PERIOD EXCEEDED 25% IN THE CITY OF ERIE. MEDIAN HOUSEHOLD INCOME IN ERIE COUNTY WAS $42,519, WHICH WAS 12.8% BELOW MEDIAN HOUSEHOLD INCOME IN PENNSYLVANIA AND 9.6% BELOW THE NATIONAL AVERAGE.ACCORDING TO A FORECASTED CENSUS STUDY, THE POPULATION OF ERIE COUNTY IS 282,224 AND IS EXPECTED TO DECREASE BY 2.1% BY 2015 WHILE THE POPULATION GROUP AGED 65 AND OVER IS EXPECTED TO INCREASE BY 7.6%. ACCORDINGLY, THE HOSPITAL WILL LIKELY SEE ITS MEDICARE PERCENTAGE OF NET PATIENT REVENUE INCREASE FROM ITS CURRENT PERCENTAGE OF 40.16%.THE HOSPITAL SERVICES A DISPROPORTIONATE SHARE OF LOW INCOME HOUSEHOLDS. MEDICAL ASSISTANCE COMPRISED APPROXIMATELY 19.6% OF THE HOSPITAL'S NET PATIENT REVENUE. THE HOSPITAL'S UNCOMPENSATED CARE IS APPROXIMATELY 4.58%. PART VI, LINE 6: THE FILING ORGANIZATION IS THE ONLY HOSPITAL IN ITS SERVICE AREA THAT OPERATES UNDER THE PRINCIPLES OF OSTEOPATHIC HEALTH CARE. OSTEOPHATHIC MEDICINE'S ROOTS CENTER ON THE BELIEF OF THE BODY BEING ABLE TO HEAL ITSELF. THIS HOLISTIC APPROACH TO MEDICINE WAS BROUGHT TO ERIE, PENNSYLVANIA IN THE FORM OF A COMMUNITY HOSPITAL OVER 50 YEARS AGO THROUGH THE VISION AND EFFORTS OF SIX OSTEOPATHIC PHYSICIANS. THE FOUNDING PHYSICIANS BELIEVED IT WAS NOT UP TO THE PUBLIC TO GIVE THEM A PLACE TO WORK. THEY WANTED TO SUPPLY THE COMMUNITY WITH A PLACE. IN 1950, THE PREDECESSOR TO MILLCREEK COMMUNITY HOSPITAL, ERIE OSTEOPATHIC HOSPITAL, WAS OPENED.THE HOSPITAL EXPERIENCED RAPID GROWTH AND MOVED TO A LARGER FACILITY IN 1958 TO BETTER ACCOMODATE THE NEEDS OF THE COMMUNITY. IN 1981, MILLCREEK COMMUNITY HOSPITAL BECAME A REALITY AFTER 31 YEARS OF COMMUNITY SERVICES AS ERIE OSTEOPATHIC HOSPITAL. THE HOSPITAL PRIDES ITSELF IN ITS COMMITMENT TO PROVIDE THE BEST PERSONAL CARE POSSIBLE FOR ITS PATIENTS.IN RECENT YEARS, THE HOSPITAL HAS CONTINUED TO EXPAND THEREBY IMPROVING THE SERVICES IT PROVIDES TO THE COMMUNITY. SMALLER EXPANSION PROJECTS IN THE AREAS OF PARTIAL HOSPITALIZATION, THE DIETARY DEPARTMENT AND NURSING ADMINISTRATION/SOCIAL SERVICES HAVE ALL BEEN COMPLETED. THE HOSPITAL HAS ALSO UNDERGONE SEVERAL MAJOR EXPANSION PROJECTS IN RECENT YEARS:- A THREE-STORY ADDITION TO THE SOUTHEAST SIDE OF THE HOSPITAL, WHICH INCLUDES A TRANSITIONAL CARE UNIT TO SERVE PATIENTS WHO NO LONGER NEED ACUTE CARE, BUT WHO ARE NOT WELL ENOUGH TO RETURN HOME; A MEDICAL LIBARY; ADDITIONAL CONFERENCE ROOMS AND OFFICES. - AN EMERGENCY ROOM EXPANSION TO BETTER HANDLE ACUTE MEDICAL AND PSYCHIATRIC EMERGENCIES. - A FIFTH-FLOOR ADDITION TO THE MAIN HOSPITAL TOWER FOR A 12-BED GERIATRIC BEHAVIORAL HEALTH CARE UNIT AND AN 18-BED CHILD/ADOLESCENT PSYCHIATRIC UNIT, WHICH WILL SERVE AS THE ONLY CHILD/ADOLESCENT UNIT OF ITS KIND IN NORTHWESTERN PA. THE HOSPITAL'S 4TH FLOOR SERVES AS A 32 BED GENERAL PSYCHIATRIC UNIT. MILLCREEK COMMUNITY HOSPITAL PROVIDES QUALITY HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONALITY, ORIGIN, HANDICAPS, AGE OR ABILITY TO PAY. IT DOES NOT DISCRIMINATE AGAINST THOSE INDIVIUDALS WHO ARE IN NEED OF FINANCIAL ASSISTANCE FROM THE FACILITY OR THOSE IN NEED OF GOVERNMENT ASSISTANCE. FOR INDIVIDUALS NEEDING FINANCIAL ASSISTANCE, TRANSPORTATION IS PROVIDED TO THE HOSPITAL'S FACILITIES FOR PHYSICIAN VISITS EITHER BY THE HOSPITAL VAN, BUS TOKENS, OR A CAB. PRESCRIPTIONS AND CLOTHING ARE ALSO PROVIDED TO THOSE IN NEED.IN AN EFFORT TO ADDRESS THE CRITICAL SHORTAGE OF PHYSICIANS, MILLCREEK COMMUNITY HOSPITAL ACTS AS A TEACHING HOSPITAL AND WORKS CLOSELY WITH ITS AFFILIATE, LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE. FOR THE FISCAL YEAR ENDED JUNE 30, 2011, THE HOSPITAL UTILIZED 65 INTERNS ACROSS A WIDE RANGE OF MEDICAL CARE SPECIALTIES INCLUDING FAMILY PRACTICE, EAR/NOSE/THROAT, INTERNAL MEDICINE, OPHTHALMOLOGY, ORTHOPEDICS, PSYCHIATRY, GASTROINTESTINAL, PODIATRY, SPORTS MEDICINE, AND NEUROMUSCULOSKETAL MEDICINE. IN ADDITION, THE HOSPITAL HAS A SHORT TERM SKILLED TRANSITIONAL CARE UNIT, AND IT WORKS IN CONJUNCTION WITH ITS AFFILIATE, MILLCREEK MANOR, TO PROVIDE LONG TERM RESIDENTIAL NURSING HOME CARE.MILLCREEK COMMUNITY HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN AN EFFORT TO ENSURE HIGH QUALITY CARE IS ACCESSIBLE IN A VARIETY OF PRIMARY AND SPECIALTY CARE AREAS.THE HOSPITAL'S COMMUNITY ACTIVITIES INCLUDED SEVERAL BLOOD PRESSURE SCREENING EVENTS HELD AT SENIOR DAY, THE ANNUAL CONSUMER FAIR, NATIONAL SENIOR HEALTH & FITNESS DAY, AND THE SALVATION ARMY'S ANGEL TREE GIFT PROGRAM. A BLOOD DRIVE IS CONDUCTED TWICE A YEAR TO ASSIST IN THE COMMUNITY NEED FOR BLOOD. THE HOSPITAL HOSTS EVENTS, SUCH AS SMOKE CESSATION CLASSES SPONSORED BY THE AMERICAN LUNG ASSOCIATION AND THE CHIEF RESIDENT WORKSHOP, WHICH IS A TRAINING SESSION FOR CHIEF RESIDENTS FROM VARIOUS HOSPITALS. IN ADDITION, THE HOSPTIAL PARTICIPATES IN PREVENTIVE HEALTH EDUCATION CLASSES, PROVIDES LITERATURE FOR HEALTHY LIVING, AND PLAYS A PROACTIVE ROLE IN THE DISASTER/BIOTERRORISM PREPAREDNESS PROGRAM.THE HOSPITAL IS ACTIVE IN THE BEHAVIORAL HEALTH FIELD AS IT IS REPRESENTED ON MANY COUNTY-SPONSORED AND OTHER PLANNING COMMITTEES. THE HOSPITAL IS ALSO REPRESENTED AT COMMUNITY CLINICAL FORUMS TO PROVIDE EXPERT INFORMATION AND INPUT ON DIFFICULT SITUATIONS AND CASES. PART VI, LINE 7: MEDICAL ASSOCIATES OF ERIE (MAE), AN AFFILIATE OF THE HOSPITAL, SERVES OVER 23,000 PATIENTS ANNUALLY. THE PATIENTS TREATED ARE PREDOMINANTLY LOW INCOME AND RESIDE IN THREE UNDERSERVED AREAS OF ERIE COUNTY. FOR 57% OF MAE'S PATIENTS, THEIR MEDICAL CHARGES ARE EITHER COVERED BY MEDICAL ASSISTANCE OR THE PATIENTS QUALIFY FOR CHARITY CARE. U.S. CENSUS STUDIES INDICATE HOUSEHOLD INCOME IN SOME OF MAE'S PRACTICE AREAS IS ONLY 2/3 OF THE NATIONAL AVERAGE, AND THE THE PERCENTAGE OF THE POPULATION UNDER THE FEDERAL POVERTY GUIDELINES IS 150% OF THE NATIONAL AVERAGE. MAE PATIENTS ALSO INCLUDE A LARGE NUMBER OF REFUGEES FROM AFRICA, THE MIDDLE EAST, AND NAPAL.DESPITE THE RIGORS OF THEIR TRAINING TO BECOME PHYSICIANS AND PHARMACISTS, STUDENTS ATTENDING THE LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE (LECOM), AN AFFILIATE OF MILLCREEK COMMUNITY HOSPITAL, PROVIDE MORE THAN 30,000 HOURS ANNUALLY FOR COMMUNITY SERVICE. THE PRESIDENT'S HIGHER EDUCATION COMMUNITY SERVICE HONOR ROLL HAS RECOGNIZED THE VOLUNTEER EFFORTS BY LECOM STUDENTS. STUDENTS WORK WITH LOCAL SCHOOL CHILDREN DELIVERING HEALTH CARE EDUCATION THROUGH POISON PREVENTION, TOBACCO CESSATION, MINI-MEDICAL SCHOOL AND FIT-FOR-LIFE EXERCISE AND NUTRITION TRAINING.LECOM PARTICIPATES IN BRIDGING THE GAPS, A SUMMER INTERNSHIP PROGRAM THAT PLACES MEDICAL STUDENTS WITH SOCIAL SERVICE AND HEALTHCARE AGENCIES WHO DEAL DIRECTLY WITH UNDERSERVED POPULATIONS. STUDENTS DELIVER HEALTH EDUCATION TO ADULTS AND CHILDREN SERVED BY THESE AGENCIES.THE COLLEGE HAS UNDERWRITTEN A SIX-HOUR BLOCK OF HEALTH, NUTRITION AND FITNESS PROGRAMMING AIRED DAILY BY WQLN-TV IN ERIE AS PART OF THE PUBLIC BROADCASTING CREATE NETWORK. IN ADDITION, LECOM PHYSICIANS HOST TWO MONTHLY, HALF-HOUR HEALTH EDUCATION PROGRAMS CALLED MEET THE DOCTORS, ON WQLN-TV.LECOM FURTHER DEMONSTRATED ITS COMMITMENT TO THE COMMUNITY WHEN IT CONSTRUCTED AND OPENED AN 82,000 SQUARE FOOT STATE-OF-THE-ART MEDICALLY INTEGRATED FITNESS AND WELLNESS CENTER IN MARCH 2009. THE FACILITY FEATURES CARDIOVASCULAR EQUIPMENT, CIRCUIT/FREE WEIGHT TRAINING AREAS, FOUR GROUP EXERCISE STUDIOS, THREE SWIMMING POOLS: A LAP POOL, EXERCISE POOL, AND THERAPY POOL, A THREE LANE WALKING/RUNNING TRACK, A FULL-SIZED BASKETBALL GYMNASIUM, RACQUETBALL COURTS, AND INDOOR GOLF SIMULATOR. THE FACILITY IS STAFFED BY HEALTH PROMOTION EXPERTS, AND EACH TRAINER IN THE FACILITY POSSESSES AT LEAST A BACHELOR DEGREE IN A FIELD RELATED TO THE MISSION OF THE WELLNESS CENTER. THE WELLNESS CENTER ALSO OFFERS SPA AND MASSAGE THERAPY SERVICES, A HEALTHY CAFE WITH A COOKING DEMONSTRATION KITCHEN, A CONFERENCE/EDUCATION CENTER, AND A SAFE ENVIRONMENT FOR CHILDREN TO PLAY WHILE THEIR RESPONSIBLE ADULTS UTILIZE THE FACILITY. THE FACILITY ALSO HOUSES A DESIGNATED PHYSICAL THERAPY AREA OPERATED BY THE HOSPITAL, AND PHYSICAN OFFICES STAFFED BY DOCTORS EMPLOYED BY THE HOSPITAL'S AFFILIATE, MEDICAL ASSOCIATES OF ERIE.LECOM ANNOUNCED PLANS TO OPEN A SCHOOL OF DENTAL MEDICINE AND INVEST $52 MILLION AT THE BRADENTON CAMPUS SO THAT THE DENTAL SCHOOL CAN OPEN IN JULY 2012. THE SCHOOL OF DENTAL MEDICINE WILL HAVE A COMMUNITY BASED CURRICULLUM WHERE STUDENTS WILL HAVE CLINICAL EXPERIENCES IN OFF-CAMPUS DENTAL CLINICS SERVING POPULATIONS LACKING ADEQUATE DENTAL CARE.LECOM INTRODUCED ITS SECOND THREE-YEAR MEDICAL DEGREE PROGRAM. THE ACCELERATED PHYSICIAN ASSISTANT PATHWAY WILL ALLOW CERTIFIED PHYSICIAN ASSISTANTS (PA-C) TO EARN THE DOCTOR OF OSTEOPATHIC MEDICINE DEGREE IN THREE YEARS TAKING INTO ACCOUNT THE PA-C CLINICAL EXPERIENCE PRIOR TO ENTERING MEDICAL SCHOOL.THE LECOM COLLEGE OF OSTEOPATHIC MEDICINE, THE SCHOOL OF PHARMACY AND THE NEW SCHOOL OF DENTAL MEDICINE ALL RECEIVED ACCREDITATION DURING THE 2010-2011 ACADEMIC YEAR. THE AMERICAN OSTEOPATHIC ASSOCIATION COMMISSION ON COLLEGE ACCREDITATION, THE AMERICAN DENTAL ASSOCIATION COMMISSION ON DENTAL ACCREDITATION AND THE ACCREDITATION COUNCIL FOR PHARMACY EDUCATION GAVE THEIR APPROVAL FOR THE EDUCATIONAL PROGRAMS OFFERED BY LECOM.US NEWS AND WORLD REPORT BEST MEDICAL SCHOOLS RANKED LECOM #63 IN THE NATION FOR PRIMARY CARE. THE MAGAZINE LISTED LECOM AS #3 IN THE COUNTRY FOR THE PERCENTAGE OF GRADUATES WHO GO INTO PRIMARY CARE.FOR MORE INFORMATION REGARDING THE ACTIVITIES OF THE HOSPITAL AND ITS AFFILIATES, PLEASE VIST THE MILLCREEK COMMUNITY HOSPITAL WEBSITE AT WWW.MILLCREEKCOMMUNITYHOSPITAL.COM. WEBSITE LINKS TO THE HOSPITAL'S AFFILIATES ARE AVAILABLE ON THE HOSPITAL'S WEBSITE. X X X X X 0 0 0 0 0 0 0 0 0 MARY L ECKERT 405978 0 0 0 21440 3859 19600 0 5227 4296 452245 8155 0 0 RICHARD P OLINGER 205666 161300 0 0 0 29135 16453 0 14430 4296 236549 194731 0 0 JOHN M FERRETTI DO 0 481621 0 0 0 20116 0 19600 0 9568 0 530905 0 0 SILVIA M FERRETTI DO 0 639273 0 0 0 18856 0 19600 0 9568 0 687297 0 0 PAUL A KOHUT DO 229611 0 0 0 0 0 15328 0 14522 0 259461 0 0 0 RONALD BRADLEY DO 169499 0 0 0 0 0 0 0 6116 0 175615 0 0 0 THOMAS ZIEGLER MD 238793 0 0 0 0 0 18628 0 5367 0 262788 0 0 0 ELISEO ROQUIZ MD 350212 0 0 0 0 0 19600 0 14832 0 384644 0 0 0 MARVIN WIELAND DO 325262 0 0 0 0 0 19600 0 5489 0 350351 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART II, COLUMN F: IN ACCORDANCE WITH THE SCHEDULE J INSTRUCTIONS, COLUMN F REPRESENTS ANY PAYMENT REPORTED IN THE CURRENT YEAR'S COLUMN (B) TO THE EXTENT SUCH PAYMENT WAS ALREADY REPORTED AS COMPENSATION TO THE LISTED PERSON ON A PRIOR FORM 990. VANTAGE INDEPENDENT CONTRACTOR - SHARES ONE COMMON TRUSTEE WITH THE FILING ORG. 477335 INDEPENDENT CONTRACTOR - SELLS MEDICAL SUPPLIES AND SERVICES TO MILLCREEK COMMUNITY HOSPITAL. 0 FORM 990, PART VI, SECTION A, LINE 2 DR. JOHN M. FERRETTI, D.O. AND DR. SILVIA M. FERRETTI, D.O. - FAMILY RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 MILLCREEK HEALTH SYSTEM, THE FILING ORGANIZATION'S PARENT CORPORATION, IS THE SOLE MEMBER OF THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B MILLCREEK HEALTH SYSTEM IS THE PARENT ORGANIZATION OF MILLCREEK COMMUNITY HOSPITAL. IN ACCORDANCE WITH MILLCREEK HEALTH SYSTEM'S BY-LAWS, ITS BOARD OF TRUSTEES HAS THE RIGHT TO APPROVE ANY AND ALL TRANSACTIONS THAT CHANGE, OR HAVE THE EFFECT OF CHANGING, THE OWNERSHIP AND/OR CONTROL OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING ITS FORM 990, THE ORGANIZATION PROVIDED ITS BOARD MEMBERS WITH ACCESS TO AN ELECTRONIC COPY OF THE TAX RETURN AND INVITED COMMENTS AND QUESTIONS FROM THE BOARD MEMBERS. PRIOR TO FILING FORM 990, MEMBERS OF THE ORGANIZATION'S FINANCIAL MANAGEMENT CONDUCTED A DETAILED REVIEW OF THE TAX FILING. THROUGHOUT THE REVIEW PROCESS, THERE WAS ONGOING DISCUSSION BETWEEN THE ORGANIZATION'S FINANCIAL MANAGEMENT AND THE TAX PREPARER. FORM 990, PART VI, SECTION B, LINE 12C EACH MEMBER OF THE BOARD OF TRUSTEES IS REQUIRED TO COMPLETE A STANDARDIZED CONFLICT OF INTEREST FORM ON AN ANNUAL BASIS. ANY POTENTIAL CONFLICTS OF INTEREST ARE ADDRESSED BY AN APPOINTED COMMITTEE WHOSE MEMBERS ARE INDEPENDENT WITH REGARD TO THE MATTER BEING EXAMINED. IF A POTENTIAL CONFLICT OF INTEREST ARISES, IT IS REVIEWED AND DOCUMENTED BY THE APPOINTED COMMITTEE, AND THEN THE APPOINTED COMMITTEE REPORTS THE RESULTS OF ITS REVIEW TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S BUDGET/FINANCE COMMITTEE, WHICH ALSO FUNCTIONS AS THE COMPENSATION COMMITTEE, REVIEWED A STUDY PERFORMED BY AN INDEPENDENT COMPENSATION CONSULTANT IN MARCH 2007. IN ADDITION, THE COMMITTEE ALSO REVIEWED VARIOUS FORM 990 FILINGS BY COMPARATIVE ORGANIZATIONS IN ORDER TO MAKE EXECUTIVE PAY COMPARISONS. FOR FISCAL YEARS ENDED JUNE 30, 2008, 2009, 2010 AND 2011, THE COMMITTEE REVIEWED THE SAME FORM 990 COMPARISONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,825,903. EQUITY TRANSFER TO AFFILIATE -500,000. INCREASE IN TEMPORARILY RESTRICTED NET ASSETS 11,635. TOTAL TO FORM 990, PART XI, LINE 5: 1,337,538. FORM 990, PART XI, LINE 2C: THE FINANCE COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE ORGANIZATION'S INDEPENDENT FINANCIAL STATEMENT AUDIT. THE PROCESS ASSOCIATED WITH THE OVERSIGHT OF THE INDEPENDENT FINANCIAL STATEMENT AUDIT REMAINS CONSISTENT WITH THE PRIOR FISCAL YEAR. ESTIMATE OF AVERAGE HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A: DR. JOHN M. FERRETTI, D.O.: MEDICAL ASSOCIATES OF ERIE - 5 HOURS PER WEEK MILLCREEK HEALTH SYSTEM MEDICAL PROFESSIONAL LIABILITY SELF-INSURANCE TRUST - 1 HOUR PER WEEK MILLCREEK MANOR - 5 HOURS PER WEEK MILLCREEK HEALTH SYSTEM - 1 HOUR PER WEEK LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE - 58 HOURS PER WEEK DR. SILVIA M. FERRETTI, D.O.: MEDICAL ASSOCIATES OF ERIE - 1 HOUR PER WEEK MILLCREEK MANOR - 1 HOUR PER WEEK MILLCREEK HEALTH SYSTEM - 1 HOUR PER WEEK LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE - 75 HOURS PER WEEK MARY L. ECKERT: MEDICAL ASSOCIATES OF ERIE - 1 HOUR PER WEEK MILLCREEK HEALTH SYSTEM MEDICAL PROFESSIONAL LIABILITY SELF-INSURANCE TRUST - 1 HOUR PER WEEK MILLCREEK MANOR - 1 HOUR PER WEEK MILLCREEK HEALTH SYSTEM - 1 HOUR PER WEEK LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE - 4 HOURS PER WEEK RICHARD P. OLINGER: MEDICAL ASSOCIATES OF ERIE - 1 HOUR PER WEEK MILLCREEK HEALTH SYSTEM MEDICAL PROFESSIONAL LIABILITY SELF-INSURANCE TRUST - 1 HOUR PER WEEK MILLCREEK MANOR - 1 HOUR PER WEEK MILLCREEK HEALTH SYSTEM - 1 HOUR PER WEEK LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE -30 HOURS PER WEEK SUPPLEMENTAL DISCLOSURE REGARDING BUSINESS TRANSACTIONS FORM 990, PART IV, LINE 28C: CERTAIN PERSONS LISTED ON FORM 990, PART VII, SECTION A ARE EMPLOYED OR HAVE AN OWNERSHIP INTEREST IN ORGANIZATIONS WITH WHOM MILLCREEK COMMUNITY HOSPITAL (THE HOSPITAL) TRANSACTS BUSINESS. BASED ON THE REPORTING THRESHOLDS STATED IN THE FILING INSTRUCTIONS, THESE BUSINESS TRANSACTIONS ARE NOT REQUIRED TO BE REPORTED ON SCHEDULE L, PART IV. THE HOSPITAL'S BOARD OF TRUSTEES VOLUNTARILY DISCLOSES THE FOLLOWING BUSINESS RELATIONSHIPS: JAMES A. SCHAFFNER, CPA/ABV, CFF, CVA: MR. SCHAFFNER'S EMPLOYER, SCHAFFNER KNIGHT MINNAUGH & CO, P.C., WAS ENGAGED TO PREPARE THE HOSPITAL'S TAX RETURNS AS WELL THE TAX FILINGS FOR RELATED ORGANIZATIONS. MR. SCHAFFNER'S FIRM IS ALSO ENGAGED FOR CONSULTING SERVICES AS NEEDED. THE HOSPITAL PAID ACCOUNTING FEES TOTALING $18,725 TO SCHAFFNER KNIGHT MINNAUGH & COMPANY, P.C. DURING THE FISCAL YEAR ENDED JUNE 30, 2011. AT JUNE 30, 2011, MR. SCHAFFNER'S OWNERSHIP INTEREST IN SCHAFFNER KNIGHT MINNAUGH AND COMPANY, P.C. EXCEEDED 5%. DR. JOHN M. FERRETTI, D.O.: THE HOSPITAL ENGAGED OSTEOPATHIC INTERNAL MEDICINE ASSOCIATES (OIMA) TO PERFORM SPECIFIED MEDICAL SERVICES DURING THE FISCAL YEAR ENDED JUNE 30, 2011. THE HOSPITAL PAID OIMA $52,000 FOR THOSE SERVICES. OIMA IS A PROFESSIONAL CORPORATION IN WHICH DR. FERRETTI HOLDS A 100% OWNERSHIP INTEREST. NANCY Z. O'NEILL: THE HOSPITAL ENGAGED ENGEL & O'NEILL TO PERFORM ADVERTISING SERVICES DURING THE FISCAL YEAR ENDED JUNE 30, 2011. THE HOSPITAL PAID ENGEL & O'NEILL $27,000 FOR THOSE SERVICES. NANCY O'NEILL OWNS 50% OF ENGEL & O'NEILL. SUPPLEMENTAL BALANCE SHEET DISCLOSURE: FORM 990, PART X: THE ASSETS OF A RELATED ORGANIZATION, MILLCREEK HEALTH SYSTEM MEDICAL PROFESSIONAL LIABILITY SELF-INSURANCE TRUST (EIN 57-6204119), ARE INCLUDED ON THE BALANCE SHEET OF THE FILING ORGANIZATION. LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE 5515 PEACH STREET ERIE PA 16509 251698677 MEDICAL SCHOOL AND SCHOOL OF PHARMACY PA 501(C)(3) LINE 2 MILLCREEK HEALTH SYSTEM 0 MILLCREEK HEALTH SYSTEM 5515 PEACH STREET ERIE PA 16509 251766164 PARENT CORPORATION PA 501(C)(3) LINE 11C, III-FI N/A 0 MILLCREEK MANOR 5515 PEACH STREET ERIE PA 16509 251619204 LONG TERM CARE NURSING FACILITY PA 501(C)(3) LINE 3 MILLCREEK HEALTH SYSTEM 0 MILLCREEK HEALTH SYSTEM MEDICAL PROF LIABILITY SELF-INS TRUST 5515 PEACH STREET ERIE PA 16509 576204119 PROVIDES MANDATORY PROFESSIONAL LIABILITY COVERAGE TO AFFILIATE ORGS PA 501(C)(3) LINE 11D, III-O N/A 0 MEDICAL ASSOCIATES OF ERIE ONE LECOM PLACE ERIE PA 16505 113716896 PHYSICIAN PRACTICE CORPORATION PA 501(C)(3) LINE 9 MILLCREEK HEALTH SYSTEM 0 MCH CORPORATION 5515 PEACH STREET ERIE PA 16509 251549695 LESSOR OF REAL ESTATE PA N/A C 0 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 1 0 LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE B 6500 ACTUAL AMOUNT CONTRIBUTED LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE I 518892 ACTUAL AMOUNT PAID BASED ON USAGE MEDICAL ASSOCIATES OF ERIE I 60000 ACTUAL AMOUNT PAID BASED ON USAGE MILLCREEK MANOR K 357498 ACTUAL COST OF SERVICES LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE O 63031 ACTUAL EXPENSES REIMBURSED LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE P 1012659 ACTUAL EXPENSES REIMBURSED MILLCREEK MANOR P 397820 ACTUAL EXPENSES REIMBURSED MCH CORPORATION P 31890 ACTUAL EXPENSES REIMBURSED MILLCREEK HEALTH SYSTEM Q 500000 ACTUAL AMOUNT TRANSFERRED MILLCREEK HEALTH SYSTEM MEDICAL PROF LIAB SELF-INS TRUST Q 68000 ACTUAL AMOUNT TRANSFERRED LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE J 95760 ACTUAL AMOUNT PAID BASED ON USAGE MILLCREEK MANOR O 30184 ACTUAL EXPENSES REIMBURSED LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE C 155600 ACTUAL AMOUNT CONTRIBUTED MEDICAL ASSOCIATES OF ERIE O 161220 ACTUAL EXPENSES REIMBURSED