2012-08-10T10:52:44-05:00 2011-09-30 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-10-01 341048666 COMMUNITY HOSPITALS & WELLNESS CENTERS COMM 4196361131 433 W HIGH STREET BRYAN OH 43506 CHAD D TINKEL 4196361131 2012-05-01 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z PHILIP ENNEN 433 W HIGH STREET BRYAN OH 43506 78241948 0 X WWW.CHWCHOSPITAL.ORG X 1969 OH TO PROVIDE QUALITY PATIENT CARE AT EVERY POINT OF SERVICE; TO RESPECT THE DIGNITY AND UNIQUENESS OF ALL PATIENTS; TO PROMOTE SAFE MEDICAL PRACTICES; TO ENCOURAGE MEDICAL RESEARCH; TO PERMIT ACCESS TO ALL SEEKING HEALTHCARE; AND TO MAINTAIN FISCAL SOUNDNESS. 10 7 821 89 0 0 1123659 30524 74779970 76342979 727125 794546 447951 728417 77078705 77896466 114429 315777 0 0 44010495 38781948 0 0 0 33325778 33814506 77450702 72912231 -371997 4984235 151452576 154388057 91343806 89658090 60108770 64729967 X TO PROVIDE QUALITY PATIENT CARE AT EVERY POINT OF SERVICE; TO RESPECT THE DIGNITY AND UNIQUENESS OF ALL PATIENTS; TO PROMOTE SAFE MEDICAL PRACTICES; TO ENCOURAGE MEDICAL RESEARCH; TO PERMIT ACCESS TO ALL SEEKING HEALTHCARE; AND TO MAINTAIN FISCAL SOUNDNESS. 0 1 59887929 315777 76388344 SEE SCHEDULE OCOMMUNITY HOSPITALS AND WELLNESS CENTERS PROVIDED SERVICES TO APPROXIMATELY 2,800 INPATIENTS AND APPROXIMATELY 46,000 OUTPATIENTS DURING THIS FISCAL YEAR. THE HOSPITAL UTILIZES A BOARD APPROVED CHARITABLE CARE PROGRAM THAT MEASURES INDIVIDUAL AND FAMILY NEEDS BASED ON FEDERAL POVERTY GUIDELINES. THE PROGRAM IS APPLIED UNIFORMLY ACROSS ALL LEVELS OF HOSPITAL SERVICES. THE PROGRAM EXTENDS BEYOND THE FEDERAL POVERTY DEFINITIONS TO ALLOW THE HOSPITAL TO PROVIDE FREE AND/OR SUBSIDIZED CARE FOR PERSONS FALLING WITHIN AND BEYOND THE FEDERAL GUIDELINES. THIS PROGRAM PROVIDED ASSISTANCE TO APPROXIMATELY 3,970 ACCOUNTS DURING THIS FISCAL YEAR.IN ADDITION, THE HOSPITAL PROVIDES THE FOLLOWING:COMMUNITY EDUCATION:ADVANCED CARDIAC LIFE SUPPORT (ACLS) AND PEDIATRIC ADVANCED LIFE SUPPORT (PALS) COURSES FOR PHYSICIANS, FOR OUR COUNTY EMS PROVIDERS, AND FOR EMPLOYEES OF OTHER HOSPITALS AT NO CHARGE.CPR COURSES TO AREA LIFEGUARDS AND COACHES AT NO CHARGE. PROVIDE CPR EQUIPMENT TO AREA SCHOOLS TO ALLOW THEM TO PROVIDE TRAINING. CHILDBIRTH EDUCATION CLASSES (INCLUDING PREPARED CHILDBIRTH, BABY CARE, SIBLING READINESS, AND BREAST FEEDING) AT NO CHARGE.HOSPITAL REPRESENTATIVES GAVE OVER 50 COMMUNITY PRESENTATIONS ON A VARIETY OF HEALTH CARE TOPICS.PHARMACY REPRESENTATIVES VISITED AREA PRESCHOOLS AND KINDERGARTENS AND PROVIDED 35 POISON PREVENTION PROGRAMS TO APPROXIMATELY 499 CHILDREN. HOSPITAL STAFF TIME WAS APPROXIMATELY 62 HOURS AMONGST SIX STAFF.PHARMACY PRECEPTOR STUDENTS WERE MADE AVAILABLE TO VISIT AREA SENIOR CENTERS AND EDUCATE SENIORS ON MEDICATION USE.OFFERED SPEAKERS FOR SMOKING CESSATION PROGRAMS.HOST CAREER DAY FOR LOCAL SCHOOLS EDUCATING STUDENTS ON OPPORTUNITIES IN HEALTH CARE PROFESSIONS.PROVIDE A FIELD PLACEMENT SETTING FOR SOCIAL WORK STUDENTS FROM AREA UNIVERSITIES. LACTATION CONSULTANT PROVIDED FOLLOW UP AND HOME VISITS WHEN NEEDED AT NO CHARGE.COUNSELING SERVICES AT NO CHARGE PROVIDED STRESS MANAGEMENT PRESENTATIONS FOR AREA BUSINESSES, PROVIDED DE-ESCALATION TRAINING FOR AREA COMMUNITY MENTAL HEALTH AGENCIES, AND OFFERED CRISIS STABILIZATION TO AREA SCHOOLS AFTER SUICIDE.OFFERED A DIABETIC SUPPORT GROUP THAT PROVIDES FREE MONTHLY MEETINGS TO APPROXIMATELY 20 PEOPLE OFFERING PROFESSIONAL SPEAKERS SHARING THEIR AREA OF EXPERTISE.OFFERED NUTRITION PRESENTATIONS TO VARIOUS COMMUNITY GROUPS.COMMUNITY SUPPORT:CONTINUED OUR SOCIAL SERVICES PROGRAM THAT ASSISTS INDIVIDUALS IN OBTAINING MEDICATIONS WHEN PERSONAL FUNDS ARE NOT AVAILABLE.PROVIDED HEALTH INFORMATION AND HOSPITAL STAFF TO SUPPORT AREA INDUSTRIES EMPLOYEE HEALTH FAIRS. CONTINUED OUR SOCIAL SERVICES PROGRAM THAT ASSISTED INDIVIDUALS IN COMPLETING THEIR OWN ADVANCED DIRECTIVES (E.G. LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE).CONTINUED OUR SOCIAL SERVICES PROGRAM FOR A GRIEF SUPPORT GROUP FOR THE COMMUNITY.PROVIDED FREE INDIVIDUAL COUNSELING SERVICES TO 25 INDIVIDUALS FROM THE COMMUNITY.OFFERED A SATURDAY SPORTS INJURY ASSESSMENT CLINIC AND PROVIDE THE CLINIC ASSESSMENT FREE OF CHARGE TO AT LEAST 75 AREA HIGH SCHOOL ATHLETES.PROVIDED FREE BLOOD PRESSURE CHECKS THROUGH OUR EMERGENCY AND CARDIOPULMONARY DEPARTMENTS.PROVIDED 9,551 MEALS ON WHEELS FOR HOMEBOUND PEOPLE AT NO CHARGE. IN OUR WILLIAMS COUNTY AREA PROGRAM THIS INCLUDES PROVIDING STAFF AND VEHICLES TO DELIVER THE MEALS TO HOMES.PROVIDED RENT-FREE LIVING SPACE IN BRYAN, OHIO TO UT STUDENTS ASSOCIATED WITH BAHEC, TOTAL ANNUAL RELIEF TO 45 UT STUDENTS WAS $6,650.THE HOSPITAL COORDINATES OUTPATIENT SERVICES FOR CLIENTS OF THE LOCAL COMPASSION MEDICAL CLINIC, WHICH IS A NON-PROFIT CLINIC SERVING UNDER INSURED AND UNINSURED RESIDENTS OF WILLIAMS COUNTY.PAID UNITED COLLECTION AGENCY $35 PER UNRESPONSIVE ACCOUNT THAT THEY WERE ABLE TO REGISTER WITH HCAP OR MEDICAID. PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. PROVIDED HEALTH INFORMATION AND HOSPITAL STAFF TO PROVIDE BLOOD PRESSURE AND BMI CHECKS FOR THE COUNTY HEALTH DEPARTMENT'S HEART HEALTH WALK/RUN AND FOR THE COUNTY FAIR.THE CARDIOPULMONARY REHABILITATION DEPARTMENT CONDUCTED 30 FITNESS ASSESSMENTS ON MEMBERS OF THE BRYAN FIRE DEPARTMENT AT NO CHARGE.PROVIDED FREE LUNCHES TO AREA TEACHERS AND STUDENTS TO RECOGNIZE STUDENTS OF THE MONTH TOTAL COSTS $800.PROVIDED FREE LABORATORY TESTING (977 BLOOD PROFILES, 300 PSA TESTS, AND 275 HEMOGLOBIN A1C) FOR THE BI-ANNUAL HEALTH AWARENESS COMMUNITY EVENT. PROVIDED BASIC SUPPLIES AND MEDICATIONS FOR VARIOUS MISSION TRIPS CONDUCTED BY EMPLOYEES AND MEDICAL STAFF. 59887929 1 1 0 1 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 28 0 1 821 1 0 0 0 0 0 0 0 0 0 0 X 10 7 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X CHAD TINKEL 4196361131 433 W HIGH STREET BRYAN OH 43506 JIM WYSE 1.00 X 0 0 0 ROGER L SANEHOLTZ OD 1.00 X 0 0 0 KATRINA P HESTER 1.00 X X 0 0 0 CHRISTOPHER CULLIS 1.00 X 0 0 0 ALBERT H HORN 1.00 X 0 0 0 JAMES A RUPP 1.00 X X 0 0 0 BRUCE SPANGLER 1.00 X 0 0 0 DIANE CONRAD MD 1.00 X 0 0 0 KEVIN KOLOVICH MD 1.00 X 0 0 0 PHILIP L ENNEN 40.00 X X 459337 0 34972 C NICHOLAS WALZ 40.00 X 249593 0 21535 JANICE A DAVID 40.00 X 270886 0 38917 GREGORY E SLATTERY 40.00 X 317730 0 34941 MICHAEL CULLER 40.00 X 188022 0 36232 CHAD D TINKEL 40.00 X 206106 0 28841 SHANNON KEIL 40.00 X 351142 0 20400 SCOTT FREDERICK 40.00 X 355846 0 32875 LARRY SIMON 40.00 X 240873 0 18396 CRAIG BUELL 40.00 X 186285 0 18396 MARILYN NUSSBAUMER 40.00 X 162441 0 18396 RUSTY BRUNICARDI 1.00 X 254121 0 0 3242382 0 303901 34 1 1 0 AMERISOURCE BERGEN 1300 MORRIS DRIVE CHESTERBROOK PA 19087 PHARMACEUTICAL SERVICES 2017345 VARIAN MEDICAL SYSTEMS 1678 SOUTH 2350 WEST SALT LAKE CITY UT 84104 MEDICAL MANUFACTURER 1454348 SENECA MEDICAL 85 SHAFFER PARK DRIVE TIFFIN OH 44883 MEDICAL DISTRIBUTOR 1445183 BOSTON SCIENTIFIC ONE BOSTON SCIENTIFIC PLACE NATICK MA 01760 MEDICAL MANUFACTURER 1047638 ZIMMER 1800 WEST CENTER STREET WARSAW IN 46581 HEALTHCARE PROVIDER 950595 18 30524 30524 NET PATIENT REVENUES 621400 76169817 76169817 DISCOUNTS EARNED 621400 160011 160011 MEDICAL RECORD FEES 621400 13151 13151 76342979 676859 676859 217299 198565 18734 18734 18734 9974 254630 146917 9974 107713 117687 117687 CAFETERIA/VENDING 621400 342702 342702 INSURANCE REFUNDS 999999 236861 236861 CSV OF SERP 621400 81195 81195 48925 45365 3560 709683 77896466 76388344 0 1477598 4000 4000 311777 311777 1613638 1613638 28703814 23542868 5160946 6263412 5137251 1126161 2201084 1805329 395755 48876 48876 161345 161345 3469091 2051620 1417471 102204 83828 18376 13384571 12909419 475152 4312326 3536970 775356 120251 98630 21621 39946 32764 7182 2015429 1653055 362374 7387405 6059150 1328255 586545 481084 105461 BAD DEBT EXPENSE 1163746 1163746 OHIO FRANCHISE FEE 564507 564507 AGENCY FEES 170784 170784 JOINT COMMISSION 40400 40400 SALES & USE TAX 35221 28888 6333 211859 211859 72912231 59887929 13024302 0 2964132 3207974 18196139 25686150 70000 40000 9588571 9565612 1191830 1159889 960183 883882 151841968 54557810 88689814 97284158 28101617 15104281 174523 263242 1515767 1192869 151452576 154388057 7236374 5835702 45000000 44305000 30249718 31376219 8857714 8141169 91343806 89658090 X 60108770 64729967 60108770 64729967 151452576 154388057 X 4984235 -363038 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 10383 0 1 2115 12498 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF OHA DUES RELATE TO LOBBYING FEES. PART IV, SUPPLEMENTAL INFORMATION: PART II-B, LINE 1(G): SENT LETTERS TO TWO UNITED STATES SENATORS AND A MEMBER OF THE HOUSE OF REPRESENTATIVES REGARDING THE EXTENSION OF TOPS (TRANSITION OUTPATIENT PAYMENTS) FOR 2012. 138612 3071458 3210070 95769923 16840506 78929417 4307451 2656844 1650607 48112702 34923372 13189330 441822 137088 304734 97284158 SETTLEMENTS PAYABLE UNDER THIRD PARTY REIMBURSEMENT CONTRACTS 3616018 DEFERRED COMPENSATION 393727 CONSTRUCTION AND RETAINAGE PAYABLE 1275309 INTEREST RATE SWAP 2856115 8141169 1 1 X 1 X 1 X 1 1 1 0 1 1 2683590 1808675 874915 0.01220 7497611 3659315 3838296 0.05350 10181201 5467990 4713211 0.06570 17 1000 132657 132657 0.00180 13 600 110000 110000 0.00150 45000 45000 0.00060 30 1600 287657 287657 0.00390 30 1600 10468858 5467990 5000868 0.06960 0 1309303 130930 22496431 28777855 -6281424 X 1 1 2 1 BRYAN HOSPITAL

433 WEST HIGH STREET BRYAN OH 43506

X X X 3 MONTPELIER HOSPITAL

909 EAST SNYDER AVENUE MONTPELIER OH 43543

X X X BRYAN HOSPITAL 1 1 X X X X X X X X X 10 1 1 1 X X X X X X X X 0 1 1 200.000000000000 1 300.000000000000 1 X X X 1 1 X X X X 1 X X 1 X X X X X X X 1 X 0 1 MONTPELIER HOSPITAL 2 1 X X X X X X X X X 10 1 1 1 X X X X X X X X 0 1 1 200.000000000000 1 300.000000000000 1 X X X 1 1 X X X X 1 X X 1 X X X X X X X 1 X 0 1 3 ARCHBOLD MEDICAL CENTER

121 WESTFIELD DR ARCHBOLD OH 43502

OP SURGERY CENTER, OP RADIOLOGY, OP LAB, OP THERAPIES, AND MOB RADIATION ONCOLOGY CENTER

524 WEST HIGH ST BRYAN OH 43506

RADIATION ONCOLOGY WAUSEON INTERNAL MEDICINE CLINIC

447 NORTH SHOOP AVE WAUSEON OH 43567

PHYSICIAN OFFICE PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO (54%) WHICH WAS DERIVED FROM WORKSHEET 2. PART I, LINE 7G: NOT APPLICABLE PART I, L7 COL(F): THE PERCENTAGE CALCULATED ON LINE 7F IS BASED ON TOTAL EXPENSES FROM FORM 990, PART IX, LESS BAD DEBTS IN THE AMOUNT OF $1,163,746. PART II: NOT APPLICABLE PART III, LINE 4: BAD DEBT AT COST WAS CALCULATED USING A COST TO CHARGE RATIO. CHWC USES AN ESTIMATE OF 10% OF TOTAL BAD DEBT EXPENSE AT COST IN ORDER TO CALCULATE THE AMOUNT RECORDED AS BAD DEBT THAT WOULD BE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. NONE OF THE BAD DEBT EXPENSE IS TREATED AS A COMMUNITY BENEFIT.FOOTNOTE TO FINANCIAL STATEMENTS: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY).FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDE BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: MEDICARE COSTS WERE CALCULATED USING A COST TO CHARGE RATIO BASED ON METHODOLOGY REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. NONE OF THE SHORTFALL IS TREATED AS A COMMUNITY BENEFIT. PART III, LINE 9B: ALL SELF-PAY BALANCES ARE BILLED ON STATEMENTS AT THIRTY DAY INTERVALS. THE PATIENT REP WILL SET UP MONTHLY PAYMENTS ACCORDING TO THE FOLLOWING GUIDELINES: THE GUARANTOR IS ASKED TO PAY IN FULL. IF PAYMENT IN FULL IS NOT POSSIBLE, THE GUARANTOR IS ASKED TO MAKE MONTHLY PAYMENTS TO PAY THE ACCOUNT IN FULL WITHIN 18 MONTHS, WITH A MINIMUM PAYMENT OF $50 PER MONTH. IF THE GUARANTOR IS NOT ABLE TO AGREE TO THESE ARRANGEMENTS, HE/SHE IS ASKED TO COMPLETE A FINANCIAL APPLICATION TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE.IF NO PAYMENT IS RECEIVED OR ARRANGEMENT ESTABLISHED WITHIN 60 DAYS OF THE INITIAL STATEMENT, A "PAST DUE LETTER" IS SENT TO THE GUARANTOR WITH A REQUEST TO PAY IN FULL OR CONTACT PATIENT ACCOUNTS WITHIN 30 DAYS. IF THE GUARANTOR DOES NOT RESPOND BY THE DUE DATE ON THIS LETTER OR ACCEPTABLE PAYMENTS HAVE NOT BEEN ESTABLISHED, THE VISIT IS REVIEWED BY THE PATIENT ACCOUNTS DIRECTOR TO DETERMINE ELIGIBILITY FOR BAD DEBT AND COLLECTION AGENCY PROCESSING."PRIOR TO SENDING THE ACCOUNT TO COLLECTION, THE PATIENT ACCOUNTS DIRECTOR SENDS THE ACCOUNTS TO "I-SOLUTIONS" TO REVIEW ACCOUNTS FOR COLLECTABILITY. IF ANY ACCOUNT IS DETERMINED THROUGH THIS PROCESS TO BE ELIGIBLE FOR CHARITY, THE ACCOUNT WILL RECEIVE A 100% CHARITY WRITE OFF. ANY ACCOUNT ON THE REPORT THAT LISTS A MAXIMUM PAYMENT AMOUNT THAT IS LESS THAN THE ACCOUNT BALANCE AND THAT FALLS IN THE "BD" OR "LOW" PROPENSITY TO PAY CATEGORY WILL RECEIVE A CHARITY ADJUSTMENT THAT REDUCES THE BALANCE ON THE ACCOUNT TO THE I-SOLUTIONS CALCULATED MAXIMUM PAYMENT AMOUNT. BEGINNING OCTOBER 1, 2008, ACCOUNTS WITH NO LISTED PROPENSITY TO PAY AND A MAXIMUM PAYMENT LESS THAN THE CHARGES WILL ALSO RECEIVE THE SAME CHARITY DISCOUNT. THE BALANCE EQUAL TO THE MAXIMUM PAYMENT AMOUNT IS THEN ADJUSTED TO BAD DEBT AND SENT TO COLLECTION ALONG WITH ALL OTHER ACCOUNTS ELIGIBLE FOR BAD DEBT WRITE OFF.THE HOSPITAL HAS ADDED A STATEMENT TO THE ADMISSION FORM AUTHORIZING THE HOSPITAL TO REVIEW THE GUARANTOR'S CREDIT INFORMATION. IF THIS IS NOT SIGNED BY THE PATIENT, THE ACCOUNT WILL NOT BE SENT TO I-SOLUTIONS FOR COLLECTABILITY REVIEW. IT WILL BE FORWARDED DIRECTLY TO THE COLLECTION AGENCY.ACCOUNTS LISTED IN BAD DEBT ARE NOT CONSIDERED TO BE ACTIVE ACCOUNTS ON THE HOSPITAL SYSTEM. THE COLLECTION AGENCY MAKES ARRANGEMENTS FOR PAYMENTS AND MONITORS THE PAYMENTS. THE HOSPITAL CAN ACCEPT DIRECT PAYMENTS ON THE ACCOUNTS, BUT THE GUARANTOR SHOULD BE ENCOURAGED TO MAKE PAYMENT DIRECT TO THE COLLECTION AGENCY. A REPORT OF PAYMENTS MADE DIRECT TO THE HOSPITAL IS FAXED TO THE COLLECTION AGENCY EVERY MONDAY THRU FRIDAY. THE PATIENT ACCOUNTS DIRECTOR AUTHORIZES THE COLLECTION AGENCY TO FILE A LEGAL SUIT IN ORDER TO OBTAIN PAYMENT WHEN THE GUARANTOR IS UNCOOPERATIVE.IF AN ACCOUNT SENT TO COLLECTION IS LATER DETERMINED TO QUALIFY FOR CHARITY CARE, COLLECTION EFFORTS STOP ON THE APPROVED AMOUNT. RECONCILIATION OF MEDICARE REVENUES & COSTS NOT REPORTED IN COST REPORT PART III, LINES 5-6: MEDICARE REVENUE RECEIVED AS REPORTED ON LN 5: $22,496,431PLUS MEDICARE MANAGED CARE REVENUE: $5,324,684TOTAL MEDICARE REVENUE: $27,821,115MEDICARE ALLOWABLE COSTS OF CARE AS REPORTED ON LN 6: $28,777,855PLUS MEDICARE MANAGED CARE COSTS: $6,811,183TOTAL MEDICARE COSTS: $35,589,038 TOTAL MEDICARE SHORTFALL: -$7,767,923 BRYAN HOSPITAL PART V, SECTION B, LINE 1J: THE OVERALL GOAL OF THE NEEDS ASSESSMENT WAS TO PERFORM A COMMUNITY HEALTH ASSESSMENT THAT WILL LEAD TO IMPROVED QUALITY OF PUBLIC AND PRIVATE HEALTH SERVICES. IN ADDITION, THE HEALTH ASSESSMENT CAN BE USED FOR A VARIETY OF PURPOSES SUCH AS THE FOLLOWING:- TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS.- TO ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH.- TO MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS. - TO PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. THE STUDY CAN ASSIST STAKEHOLDERS WORKING COLLABORATIVELY IN THE COMMUNITY TO ADDRESS ISSUES THAT AFFECT HEALTH.THE COMMUNITY HEALTH ASSESSMENT WILL CONTINUE TO BE REPEATED EVERY THREE YEARS TO DETERMINE IF ACTIONS TAKEN BY COMMUNITIES ARE IMPACTING THE BEHAVIORS THAT LEAD TO POOR HEALTH. MONTPELIER HOSPITAL PART V, SECTION B, LINE 1J: THE OVERALL GOAL OF THE NEEDS ASSESSMENT WAS TO PERFORM A COMMUNITY HEALTH ASSESSMENT THAT WILL LEAD TO IMPROVED QUALITY OF PUBLIC AND PRIVATE HEALTH SERVICES. IN ADDITION, THE HEALTH ASSESSMENT CAN BE USED FOR A VARIETY OF PURPOSES SUCH AS THE FOLLOWING:- TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS.- TO ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH.- TO MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS. - TO PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. THE STUDY CAN ASSIST STAKEHOLDERS WORKING COLLABORATIVELY IN THE COMMUNITY TO ADDRESS ISSUES THAT AFFECT HEALTH.THE COMMUNITY HEALTH ASSESSMENT WILL CONTINUE TO BE REPEATED EVERY THREE YEARS TO DETERMINE IF ACTIONS TAKEN BY COMMUNITIES ARE IMPACTING THE BEHAVIORS THAT LEAD TO POOR HEALTH. BRYAN HOSPITAL PART V, SECTION B, LINE 3: THE CENTER FOR URBAN AND PUBLIC AFFAIRS (CUPA) AT WRIGHT STATE UNIVERSITY (WSU) CONDUCTED A COMMUNITY HEALTH ASSESSMENT FOR THE WILLIAMS COUNTY COMBINED HEALTH DISTRICT (WCCHD), CHWC BRYAN AND CHWC MONTPELIER HOSPITALS. THE SURVEY WAS BASED UPON THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS) CONDUCTED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC), AS WELL AS HEALTH ASSESSMENTS CONDUCTED BY NEIGHBORING COUNTIES.THE PURPOSE OF THE HEALTH NEEDS ASSESSMENT IS TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS, ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH, MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS AND PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. MONTPELIER HOSPITAL PART V, SECTION B, LINE 3: THE CENTER FOR URBAN AND PUBLIC AFFAIRS (CUPA) AT WRIGHT STATE UNIVERSITY (WSU) CONDUCTED A COMMUNITY HEALTH ASSESSMENT FOR THE WILLIAMS COUNTY COMBINED HEALTH DISTRICT (WCCHD), CHWC BRYAN AND CHWC MONTPELIER HOSPITALS. THE SURVEY WAS BASED UPON THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS) CONDUCTED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC), AS WELL AS HEALTH ASSESSMENTS CONDUCTED BY NEIGHBORING COUNTIES.THE PURPOSE OF THE HEALTH NEEDS ASSESSMENT IS TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS, ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH, MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS AND PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. BRYAN HOSPITAL PART V, SECTION B, LINE 4: MONTPELIER HOSPITAL MONTPELIER HOSPITAL PART V, SECTION B, LINE 4: BRYAN HOSPITAL BRYAN HOSPITAL PART V, SECTION B, LINE 5C: THE NEEDS ASSESSMENT WAS A COMBINED ASSESSMENT WITH THE WILLIAMS COUNTY OHIO PUBLIC HEALTH DEPARTMENT AND MIDWEST COMMUNITY HEALTH ASSOCIATES MEDICAL GROUP. ALL THREE ENTITIES MADE THE REPORT WIDELY AVAILABLE IN THEIR ORGANIZATIONS. THE PUBLIC HEALTH DEPARTMENT MADE PRESENTATIONS TO COMMUNITY GROUPS AND ORGANIZATIONS. MONTPELIER HOSPITAL PART V, SECTION B, LINE 5C: THE NEEDS ASSESSMENT WAS A COMBINED ASSESSMENT WITH THE WILLIAMS COUNTY OHIO PUBLIC HEALTH DEPARTMENT AND MIDWEST COMMUNITY HEALTH ASSOCIATES MEDICAL GROUP. ALL THREE ENTITIES MADE THE REPORT WIDELY AVAILABLE IN THEIR ORGANIZATIONS. THE PUBLIC HEALTH DEPARTMENT MADE PRESENTATIONS TO COMMUNITY GROUPS AND ORGANIZATIONS. BRYAN HOSPITAL PART V, SECTION B, LINE 6I: THE SURVEY IDENTIFIED 3 SPECIFIC HEALTH NEED ISSUES: FIRST, WILLIAMS COUNTY ADULTS (11.4 PERCENT) WERE SIGNIFICANTLY MORE LIKELY THAN ADULTS NATIONALLY (8.4 PERCENT) TO INDICATE THAT THEY HAVE DIABETES. THE HOSPITAL (IN COLLABORATION WITH WILLIAMS COUNTY PUBLIC HEALTH AND THE LOCAL MEDICAL GROUP) DETERMINED TO COMMIT RESOURCES TO THIS ISSUE BY DESIGNING AND IMPLEMENTING A HEALTH AND WELLNESS ASSESSMENT THAT WOULD TARGET RISK FOR DIABETES. THE COLLABORATIVE GROUP USED 2011 TO CREATE THE DESIGN FOR A SIMPLE WELLNESS ASSESSMENT THAT WOULD LEAD TO TARGETED ONE ON ONE COACHING BASED ON THE ASSESSMENT OUTCOMES. THE GROUP PLANS TO IMPLEMENT ASSESSMENTS IN 2012.SECOND, ONLY 33.3 PERCENT OF ADULTS IN WILLIAMS COUNTY SAID THEY HAVE RECEIVED THE FLU SHOT IN THE PAST 12 MONTHS. SLIGHTLY OVER HALF (59.3 PERCENT) OF THE ADULTS AGED 65 OR OLDER HAVE RECEIVED THE VACCINATION, WHICH IS MUCH LOWER THAN THE STATE (67.4 PERCENT) AND NATIONAL (70.1 PERCENT) PERCENTAGES. THE HOSPITAL DETERMINED TO TAKE A MORE AGGRESSIVE APPROACH WITH ITS OWN EMPLOYEE WORKFORCE DURING THE 2011/2012 FLU SEASON. WE SET A GOAL OF 75% OF STAFF RECEIVING THE VACCINATION AND ACHIEVED 71%. FOR THE 2012/2013 FLU SEASON WE ARE CONSIDERING A MANDATED FLU SHOT POLICY.THIRD, TWO-THIRDS OF WILLIAMS COUNTY RESPONDENTS (67.0 PERCENT) ARE CLASSIFIED AS OVERWEIGHT OR OBESE. THIS RESPONSE IS SLIGHTLY HIGHER THAN THE STATE (66.6 PERCENT) AND SIGNIFICANTLY HIGHER THAN THE NATION (63.1 PERCENT). THE HOSPITAL (IN COLLABORATION WITH WILLIAMS COUNTY PUBLIC HEALTH AND THE LOCAL MEDICAL GROUP) DETERMINED TO COMMIT RESOURCES TO THIS ISSUE BY DESIGNING AND IMPLEMENTING A HEALTH AND WELLNESS ASSESSMENT THAT WOULD TARGET RISK FOR OBESITY. THE COLLABORATIVE GROUP USED 2011 TO CREATE THE DESIGN FOR A SIMPLE WELLNESS ASSESSMENT THAT WOULD LEAD TO TARGETED ONE ON ONE COACHING BASED ON THE ASSESSMENT OUTCOMES. WE ARE USING THE MEASUREMENT OF BODY MASS INDEX (BMI) TO ASSESS AN INDIVIDUAL'S CURRENT OBESITY STATUS AND RISK FOR WEIGHT CONTROL. THE GROUP PLANS TO IMPLEMENT ASSESSMENTS IN 2012. MONTPELIER HOSPITAL PART V, SECTION B, LINE 6I: THE SURVEY IDENTIFIED 3 SPECIFIC HEALTH NEED ISSUES: FIRST, WILLIAMS COUNTY ADULTS (11.4 PERCENT) WERE SIGNIFICANTLY MORE LIKELY THAN ADULTS NATIONALLY (8.4 PERCENT) TO INDICATE THAT THEY HAVE DIABETES. THE HOSPITAL (IN COLLABORATION WITH WILLIAMS COUNTY PUBLIC HEALTH AND THE LOCAL MEDICAL GROUP) DETERMINED TO COMMIT RESOURCES TO THIS ISSUE BY DESIGNING AND IMPLEMENTING A HEALTH AND WELLNESS ASSESSMENT THAT WOULD TARGET RISK FOR DIABETES. THE COLLABORATIVE GROUP USED 2011 TO CREATE THE DESIGN FOR A SIMPLE WELLNESS ASSESSMENT THAT WOULD LEAD TO TARGETED ONE ON ONE COACHING BASED ON THE ASSESSMENT OUTCOMES. THE GROUP PLANS TO IMPLEMENT ASSESSMENTS IN 2012.SECOND, ONLY 33.3 PERCENT OF ADULTS IN WILLIAMS COUNTY SAID THEY HAVE RECEIVED THE FLU SHOT IN THE PAST 12 MONTHS. SLIGHTLY OVER HALF (59.3 PERCENT) OF THE ADULTS AGED 65 OR OLDER HAVE RECEIVED THE VACCINATION, WHICH IS MUCH LOWER THAN THE STATE (67.4 PERCENT) AND NATIONAL (70.1 PERCENT) PERCENTAGES. THE HOSPITAL DETERMINED TO TAKE A MORE AGGRESSIVE APPROACH WITH ITS OWN EMPLOYEE WORKFORCE DURING THE 2011/2012 FLU SEASON. WE SET A GOAL OF 75% OF STAFF RECEIVING THE VACCINATION AND ACHIEVED 71%. FOR THE 2012/2013 FLU SEASON WE ARE CONSIDERING A MANDATED FLU SHOT POLICY.THIRD, TWO-THIRDS OF WILLIAMS COUNTY RESPONDENTS (67.0 PERCENT) ARE CLASSIFIED AS OVERWEIGHT OR OBESE. THIS RESPONSE IS SLIGHTLY HIGHER THAN THE STATE (66.6 PERCENT) AND SIGNIFICANTLY HIGHER THAN THE NATION (63.1 PERCENT). THE HOSPITAL (IN COLLABORATION WITH WILLIAMS COUNTY PUBLIC HEALTH AND THE LOCAL MEDICAL GROUP) DETERMINED TO COMMIT RESOURCES TO THIS ISSUE BY DESIGNING AND IMPLEMENTING A HEALTH AND WELLNESS ASSESSMENT THAT WOULD TARGET RISK FOR OBESITY. THE COLLABORATIVE GROUP USED 2011 TO CREATE THE DESIGN FOR A SIMPLE WELLNESS ASSESSMENT THAT WOULD LEAD TO TARGETED ONE ON ONE COACHING BASED ON THE ASSESSMENT OUTCOMES. WE ARE USING THE MEASUREMENT OF BODY MASS INDEX (BMI) TO ASSESS AN INDIVIDUAL'S CURRENT OBESITY STATUS AND RISK FOR WEIGHT CONTROL. THE GROUP PLANS TO IMPLEMENT ASSESSMENTS IN 2012. BRYAN HOSPITAL PART V, SECTION B, LINE 7: FIRST, THE PERCENTAGE OF WILLIAMS COUNTY WOMEN OVER THE AGE OF 40 (65.3 PERCENT) WHO HAVE HAD A MAMMOGRAM IS SIGNIFICANTLY LOWER THAN THE STATE (75.8 PERCENT) AND NATION (76.0 PERCENT). THE HOSPITAL ELECTED NOT TO PURSUE THIS NEED AS THE HOSPITAL DOES NOT PROVIDE DIAGNOSTIC MAMMOGRAPHY SCREENING. THE PHYSICIAN MEDICAL GROUP IS ATTEMPTING TO ADDRESS THIS NEED BY SEEKING A GRANT FROM THE SUSAN G. KOMEN FOUNDATION TO CREATE MORE ACCESS TO DIAGNOSTIC MAMMOGRAPHY SCREENING.SECOND, WILLIAMS COUNTY RESIDENTS 50 AND OLDER (53.1 PERCENT) ARE OBTAINING SIGMOIDOSCOPY OR COLONOSCOPY EXAMS AT A RATE SIGNIFICANTLY LOWER THAN THE STATE (60.8 PERCENT) AND NATION (62.2 PERCENT). THE HOSPITAL DID NOT HAVE RESOURCES IN 2011 TO ADDRESS THIS COMMUNITY NEED. THE HOSPITAL HAS STRUGGLED FINANCIALLY SINCE THE 2008 RECESSION AND DETERMINED TO COMMIT OUR LIMITED RESOURCES FIRST TO THE ISSUES OF DIABETES AND OBESITY. MONTPELIER HOSPITAL PART V, SECTION B, LINE 7: FIRST, THE PERCENTAGE OF WILLIAMS COUNTY WOMEN OVER THE AGE OF 40 (65.3 PERCENT) WHO HAVE HAD A MAMMOGRAM IS SIGNIFICANTLY LOWER THAN THE STATE (75.8 PERCENT) AND NATION (76.0 PERCENT). THE HOSPITAL ELECTED NOT TO PURSUE THIS NEED AS THE HOSPITAL DOES NOT PROVIDE DIAGNOSTIC MAMMOGRAPHY SCREENING. THE PHYSICIAN MEDICAL GROUP IS ATTEMPTING TO ADDRESS THIS NEED BY SEEKING A GRANT FROM THE SUSAN G. KOMEN FOUNDATION TO CREATE MORE ACCESS TO DIAGNOSTIC MAMMOGRAPHY SCREENING.SECOND, WILLIAMS COUNTY RESIDENTS 50 AND OLDER (53.1 PERCENT) ARE OBTAINING SIGMOIDOSCOPY OR COLONOSCOPY EXAMS AT A RATE SIGNIFICANTLY LOWER THAN THE STATE (60.8 PERCENT) AND NATION (62.2 PERCENT). THE HOSPITAL DID NOT HAVE RESOURCES IN 2011 TO ADDRESS THIS COMMUNITY NEED. THE HOSPITAL HAS STRUGGLED FINANCIALLY SINCE THE 2008 RECESSION AND DETERMINED TO COMMIT OUR LIMITED RESOURCES FIRST TO THE ISSUES OF DIABETES AND OBESITY. BRYAN HOSPITAL PART V, SECTION B, LINE 17E: PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. MONTPELIER HOSPITAL PART V, SECTION B, LINE 17E: PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. BRYAN HOSPITAL PART V, SECTION B, LINE 19D: OFFERED PROMPT PAY DISCOUNT THAT IS EQUAL TO THE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE. MONTPELIER HOSPITAL PART V, SECTION B, LINE 19D: OFFERED PROMPT PAY DISCOUNT THAT IS EQUAL TO THE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE. BRYAN HOSPITAL PART V, SECTION B, LINE 21: A PATIENT WITHOUT INSURANCE THAT DID NOT PROMPTLY PAY WOULD PAY 100% OF THE GROSS CHARGE. MONTPELIER HOSPITAL PART V, SECTION B, LINE 21: A PATIENT WITHOUT INSURANCE THAT DID NOT PROMPTLY PAY WOULD PAY 100% OF THE GROSS CHARGE. PART VI, LINE 2: THE NEEDS ASSESSMENT WAS A COMBINED ASSESSMENT WITH THE WILLIAMS COUNTY OHIO PUBLIC HEALTH DEPARTMENT AND MIDWEST COMMUNITY HEALTH ASSOCIATES MEDICAL GROUP. ALL THREE ENTITIES MADE THE REPORT WIDELY AVAILABLE IN THEIR ORGANIZATIONS. THE PUBLIC HEALTH DEPARTMENT MADE PRESENTATIONS TO COMMUNITY GROUPS AND ORGANIZATIONS. PART VI, LINE 3: AT THE TIME OF REGISTRATION, FORMS ARE GIVEN TO ALL PATIENTS WITH NO INSURANCE, EXPLAINING OUR FINANCIAL ASSISTANCE PROGRAM. ALSO, SOCIAL WORKERS HAVE THESE FORMS TO GIVE TO PATIENTS THEY ARE WORKING WITH. THEY ARE ALSO GIVEN TO PATIENTS WITH INSURANCE WHEN REQUESTED.FOR ALL PATIENTS WITH NO THIRD PARTY COVERAGE, OR MEDICARE PATIENTS WITH NO SUPPLEMENT INSURANCE, A LETTER WILL BE SENT AT THE TIME THE ACCOUNT IS FINAL BILLED IF PRIOR ARRANGEMENTS HAVE NOT BEEN MADE. THE LETTER EXPLAINS THE HOSPITAL CARE ASSURANCE PROGRAM THROUGH THE STATE OF OHIO AND THE HOSPITAL CHARITABLE CARE PROGRAM. ENCLOSED WITH THE LETTER IS A COPY OF THE FINANCIAL APPLICATION, A COPY OF THE PATIENT'S SUMMARIZED BILL AND A BUSINESS CARD WITH THE NAME AND PHONE NUMBER OF THE PATIENT REPRESENTATIVE RESPONSIBLE FOR THE PATIENT'S ACCOUNT. THIS PACKET MAY ALSO BE SENT TO ANY GUARANTOR WITH A BALANCE AFTER INSURANCE THAT HE/SHE IS NOT ABLE TO PAY ACCORDING TO THE HOSPITAL GUIDELINES.DEPENDING ON THE PATIENT TYPE, SOCIAL SERVICES PATIENTS ARE MADE AWARE OF FINANCIAL ASSISTANCE POLICY AND FINANCIAL ASSISTANCE CONTACT INFORMATION IN THEIR DISCHARGE MATERIALS AS PART OF THE PACKET OF INFORMATION THEY RECEIVE. GOVERNMENT OR COMMERCIAL PATIENTS ARE NOT MADE AWARE IN THEIR DISCHARGE MATERIALS AS IT IS NOT INCLUDED IN THEIR DISCHARGE PACKET. HOWEVER, THE PATIENT ACCOUNT WOULD BE BROUGHT UP AGAIN IF THERE WAS A PATIENT RESPONSIBILITY PORTION AFTER THE PRIMARY CARE PROVIDER WAS BILLED. PART VI, LINE 4: HOSPITALS ARE LOCATED IN BRYAN AND MONTPELIER, OHIO, IN ADDITION TO A MEDICAL CENTER LOCATED IN ARCHBOLD. ALSO, THERE ARE PHYSICIANS OFFICES LOCATED IN WAUSEON, OHIO. APPROXIMATELY 16.0% OF THE POPULATION IS 65 YEARS OR OLDER AND 11.8% IS BELOW POVERTY LEVEL. PART VI, LINE 6: COMMUNITY HOSPITALS AND WELLNESS CENTERS PROVIDED SERVICES TO APPROXIMATELY 2,800 INPATIENTS AND APPROXIMATELY 46,000 OUTPATIENTS DURING THIS FISCAL YEAR. THE HOSPITAL UTILIZES A BOARD APPROVED CHARITABLE CARE PROGRAM THAT MEASURES INDIVIDUAL AND FAMILY NEEDS BASED ON FEDERAL POVERTY GUIDELINES. THE PROGRAM IS APPLIED UNIFORMLY ACROSS ALL LEVELS OF HOSPITAL SERVICES. THE PROGRAM EXTENDS BEYOND THE FEDERAL POVERTY DEFINITIONS TO ALLOW THE HOSPITAL TO PROVIDE FREE AND/OR SUBSIDIZED CARE FOR PERSONS FALLING WITHIN AND BEYOND THE FEDERAL GUIDELINES. THIS PROGRAM PROVIDED ASSISTANCE TO APPROXIMATELY 3,970 ACCOUNTS DURING THIS FISCAL YEAR.IN ADDITION THE HOSPITAL PROVIDES THE FOLLOWING:COMMUNITY EDUCATION:- ADVANCED CARDIAC LIFE SUPPORT (ACLS) AND PEDIATRIC ADVANCED LIFE SUPPORT (PALS) COURSES FOR PHYSICIANS, FOR OUR COUNTY EMS PROVIDERS, AND FOR EMPLOYEES OF OTHER HOSPITALS AT NO CHARGE.- CPR COURSES TO AREA LIFEGUARDS AND COACHES AT NO CHARGE. PROVIDE CPR EQUIPMENT TO AREA SCHOOLS TO ALLOW THEM TO PROVIDE TRAINING. - CHILDBIRTH EDUCATION CLASSES (INCLUDING PREPARED CHILDBIRTH, BABY CARE, SIBLING READINESS, AND BREAST FEEDING) AT NO CHARGE.- HOSPITAL REPRESENTATIVES GAVE OVER 50 COMMUNITY PRESENTATIONS ON A VARIETY OF HEALTH CARE TOPICS.- PHARMACY REPRESENTATIVES VISITED AREA PRESCHOOLS AND KINDERGARTENS AND PROVIDED 35 POISON PREVENTION PROGRAMS TO APPROXIMATELY 499 CHILDREN. HOSPITAL STAFF TIME WAS APPROXIMATELY 62 HOURS AMONGST NINE STAFF. - PHARMACY PRECEPTOR STUDENTS WERE MADE AVAILABLE TO VISIT AREA SENIOR CENTERS AND EDUCATE SENIORS ON MEDICATION USE.- OFFERED SPEAKERS FOR SMOKING CESSATION PROGRAMS.- HOST CAREER DAY FOR LOCAL SCHOOLS EDUCATING STUDENTS ON OPPORTUNITIES IN HEALTH CARE PROFESSION. - PROVIDE A FIELD PLACEMENT SETTING FOR SOCIAL WORK STUDENTS FROM AREA UNIVERSITIES. - LACTATION CONSULTANT PROVIDED FOLLOW UP AND HOME VISITS WHEN NEEDED AT NO CHARGE.- COUNSELING SERVICES AT NO CHARGE PROVIDED STRESS MANAGEMENT PRESENTATIONS FOR AREA BUSINESSES, PROVIDED DE-ESCALATION TRAINING FOR AREA COMMUNITY MENTAL HEALTH AGENCIES, AND OFFERED CRISIS STABILIZATION TO AREA SCHOOLS AFTER SUICIDE.- OFFERED A DIABETIC SUPPORT GROUP THAT PROVIDES FREE MONTHLY MEETINGS TO APPROXIMATELY 20 PEOPLE OFFERING PROFESSIONAL SPEAKERS SHARING THEIR AREA OF EXPERTISE.- OFFERED NUTRITION PRESENTATIONS TO VARIOUS COMMUNITY GROUPS.COMMUNITY SUPPORT:- CONTINUED OUR SOCIAL SERVICES PROGRAM THAT ASSISTS INDIVIDUALS IN OBTAINING MEDICATIONS WHEN PERSONAL FUNDS ARE NOT AVAILABLE.- PROVIDED HEALTH INFORMATION AND HOSPITAL STAFF TO SUPPORT AREA INDUSTRIES EMPLOYEE HEALTH FAIRS. - CONTINUED OUR SOCIAL SERVICES PROGRAM THAT ASSISTED INDIVIDUALS IN COMPLETING THEIR OWN ADVANCED DIRECTIVES (E.G. LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE).- CONTINUED OUR SOCIAL SERVICES PROGRAM FOR A GRIEF SUPPORT GROUP FOR THE COMMUNITY.- PROVIDED FREE COUNSELING SERVICES TO 25 INDIVIDUALS FROM THE COMMUNITY.- OFFERED A SATURDAY SPORTS INJURY ASSESSMENT CLINIC AND PROVIDE THE CLINIC ASSESSMENT FREE OF CHARGE TO AT LEAST 75 AREA HIGH SCHOOL ATHLETES.- PROVIDED FREE BLOOD PRESSURE CHECKS THROUGH OUR EMERGENCY AND CARDIOPULMONARY DEPARTMENTS.- PROVIDED 9,551 MEALS ON WHEELS FOR HOMEBOUND PEOPLE AT NO CHARGE. IN OUR BRYAN AREA PROGRAM THIS INCLUDES PROVIDING STAFF AND VEHICLES TO DELIVER THE MEALS TO HOMES.- PROVIDED RENT-FREE LIVING SPACE IN BRYAN, OHIO TO UT STUDENTS ASSOCIATED WITH BAHEC, TOTAL ANNUAL RELIEF TO 45 UT STUDENTS WAS $6650.- THE HOSPITAL COORDINATES OUTPATIENT SERVICES FOR CLIENTS OF THE LOCAL COMPASSION MEDICAL CLINIC, WHICH IS A NON-PROFIT CLINIC SERVING UNDERINSURED AND UNINSURED RESIDENTS OF WILLIAMS COUNTY.- PAID UNITED COLLECTION AGENCY $35 PER UNRESPONSIVE ACCOUNT THAT THEY WERE ABLE TO REGISTER WITH HCAP OR MEDICAID. - PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. - PROVIDED HEALTH INFORMATION AND HOSPITAL STAFF TO PROVIDE BLOOD PRESSURE AND BMI CHECKS FOR THE COUNTY HEALTH DEPARTMENTS HEART HEALTH WALK/RUN.- THE CARDIOPULMONARY REHABILITATION DEPARTMENT CONDUCTED 30 FITNESS ASSESSMENTS ON MEMBERS OF THE BRYAN FIRE DEPARTMENT AT NO CHARGE. - PROVIDED FREE LUNCHES TO AREA TEACHERS AND STUDENTS TO RECOGNIZE "STUDENTS OF THE MONTH" TOTAL COSTS $800.- PROVIDED FREE LABORATORY TESTING (977 BLOOD PROFILES, 300 PSA TESTS, AND 275 HEMOGLOBIN A1C) FOR THE BI-ANNUAL HEALTH AWARENESS COMMUNITY EVENT. - PROVIDED BASIC SUPPLIES AND MEDICATIONS FOR VARIOUS MISSION TRIPS CONDUCTED BY EMPLOYEES AND MEDICAL STAFF. PART VI, LINE 7: NOT APPLICABLE 1 0 0 HEALTH SERVICE FUND, FINANCIAL ASSISTANCE TO STUDENTS 55 305127 RENT-FREE LIVING TO COLLEGE STUDENTS 45 6650 FMV RENT-FREE LIVING PROVIDED TO UNIVERSITY OF TOLEDO STUDENTS. OTHER INFORMATION: PART IV: PART III, FINANCIAL ASSISTANCE TO STUDENTS: SCHOLARSHIPS ARE AWARDED TO STUDENTS PURSUING CERTAIN DEGREE PROGRAMS, OR FOR PAYING BACK LOANS FROM THOSE PROGRAMS. RECIPIENTS ARE DETERMINED BASED ON REVIEW OF APPLICATIONS BY THE PRESIDENT AND CEO. X X X X 0 1 0 0 0 0 0 0 0 PHILIP L ENNEN 373516 0 0 0 85821 0 0 0 34972 0 494309 0 85821 0 C NICHOLAS WALZ 249593 0 0 0 0 0 0 0 21535 0 271128 0 0 0 JANICE A DAVID 184993 0 0 0 85893 0 0 0 38917 0 309803 0 85893 0 GREGORY E SLATTERY 231880 0 0 0 85850 0 0 0 34941 0 352671 0 85850 0 MICHAEL CULLER 188022 0 0 0 0 0 0 0 36232 0 224254 0 0 0 CHAD D TINKEL 206106 0 0 0 0 0 0 0 28841 0 234947 0 0 0 SHANNON KEIL 351142 0 0 0 0 0 0 0 20400 0 371542 0 0 0 SCOTT FREDERICK 269223 0 0 0 86623 0 0 0 32875 0 388721 0 86623 0 LARRY SIMON 240873 0 0 0 0 0 0 0 18396 0 259269 0 0 0 CRAIG BUELL 186285 0 0 0 0 0 0 0 18396 0 204681 0 0 0 MARILYN NUSSBAUMER 162441 0 0 0 0 0 0 0 18396 0 180837 0 0 0 RUSTY BRUNICARDI 254121 0 0 0 0 0 0 0 0 0 254121 0 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457F RETIREMENT PLAN: VESTED DISTRIBUTIONS PHILIP ENNEN $85,821 JANICE DAVID $85,893 GREGORY SLATTERY $85,850 MICHAEL CULLER $ 0 CHAD TINKEL $ 0 SCOTT FREDERICK $86,623 NO CONTRIBUTIONS WERE MADE TO THE 457F PLANS DURING THE CALENDAR YEAR. DURING 2010, PHILIP ENNEN, JANICE DAVID, GREGORY SLATTERY, AND SCOTT FREDERICK RECEIVED A VESTED 457F DISTRIBUTION AS NOTED ABOVE. THESE AMOUNTS HAVE BEEN PROPERLY INCLUDED IN OFFICERS' COMPENSATION ON SCHEDULE J, PART II, COLUMN B(III). THE HOSPITAL HAS A SUPPLEMENTAL EXECUTIVE RETENTION PLAN FOR THESE EXECUTIVES UNDER IRC SECTION 457(F). THE AMOUNTS DEFERRED UNDER THIS PLAN WILL BE TAXABLE TO THE EXECUTIVE WHEN VESTED AND THERE IS NO LONGER A SUBSTANTIAL RISK OF FORFEITURE. IN ORDER TO HAVE THE RIGHT TO FUTURE PAYMENT OF ANY EMPLOYER DEFERRAL, THE EXECUTIVE WILL HAVE TO REMAIN IN SERVICE UNTIL THE ACCOUNT BECOMES VESTED AS PROVIDED IN THE PLAN DOCUMENT. COUNTY OF WILLIAMS OH 346401595 2005-09-07 9447848 CURRENTLY REFUND TAXABLE LOANS 0 0 0 CITY OF BRYAN OH 346400228 2008-07-01 10000000 SEE PART V 0 0 0 COUNTY OF WILLIAMS OH 346401595 96948QAA3 2008-07-17 45000000 SEE PART V 0 0 0 VILLAGE OF ARCHBOLD OH 646400063 2008-08-20 10000000 SEE PART V 0 0 0 9447848 9392848 55000 9392848 2011 1 0 1 1 10208153 10208153 2011 0 0 1 1 47467738 303337 316607 45157323 1690471 2011 0 0 0 1 10208153 10208153 0 0 1 1 0 0 1 0 1 0.00000 0.00000 0.00000 1 0 0 1 0 1 0.00000 0.00000 0.00000 1 0 0 1 0 1 0.00000 0.00000 0.00000 1 0 0 1 0 1 0.00000 0.00000 0.00000 1 0 1 0 0 0 1 0 1 0 0 0 0 0 1 1 FIFTH THIRD BANK 9.500000000000 0 0 0 1 0 0 1 0 0 0 0 SCHEDULE K SUPPLENTAL INFORMATION PART I, ISSUE B, COLUMN F: CONSTRUCTION, EQUIPPING, EXPANSION, IMPROVEMENT, INSTALLATION, AND SUBSTANTIAL RENOVATION OF THE ORGANIZATION'S CAMPUS. PART I, ISSUE C, COLUMN F: ACQUISITION, CONSTRUCTION, FURNISHING, AND EQUIPPING OF NEW FACILITIES AND ADDITIONS AND IMPROVEMENTS TO THE ORGANIZATION'S CAMPUS. PART I, ISSUE D, COLUMN F: CONSTRUCTION, EQUIPPING, EXPANSION, IMPROVEMENT, INSTALLATION, AND SUBSTANTIAL RENOVATION OF THE ORGANIZATION'S CAMPUS. PART II, ISSUE B, LINE 3: TOTAL PROCEEDS OF ISSUE ARE $10,208,153, WHICH ARE SALE PROCEEDS OF $10,000,000 PLUS INVESTMENT EARNINGS OF $208,153. PART II, ISSUE C, LINE 3: TOTAL PROCEEDS OF ISSUE ARE $47,467,738, WHICH ARE SALE PROCEEDS OF $45,000,000 PLUS INVESTMENT EARNINGS OF $2,467,738. PART II, ISSUE D, LINE 3: TOTAL PROCEEDS OF ISSUE ARE $10,208,153, WHICH ARE SALE PROCEEDS OF $10,000,000 PLUS INVESTMENT EARNINGS OF $208,153. PART II, ISSUE A, LINE 6: THE ESCROW WAS SPENT ON THE DAY OF CLOSING OF THE 2005 ISSUE. PART IV, ISSUES B AND D, LINE 6: THE ORGANIZATION IS WORKING WITH A REBATE ANALYST TO DETERMINE IF THE BOND ISSUES QUALIFIED FOR AN EXCEPTION TO REBATE. MIDWEST COMMUNITY HEALTH ASSOCIATES SEE SCH L, PART V 83527 MCHA RENTS SPACE FROM COMMUNITY HOSPITALS & WELLNESS CENTERS. 0 MIDWEST COMMUNITY HEALTH ASSOCIATES SEE SCH L, PART V 610786 MCHA PROVIDES MEDICAL SERVICES TO COMMUNITY HOSPITALS & WELLNESS CENTERS. 0 FORM 990, SCHEDULE L, PART IV, COLUMN B DR. KOLOVICH AND DR. CONRAD ARE BOTH VOTING MEMBERS OF CHWC. DR. KOLOVICH IS A VOTING MEMBER OF MCHA AND DR. CONRAD IS A MEDICAL DIRECTOR OF MCHA. CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 COMMUNITY HOSPITALS & WELLNESS CENTERS CLOSED THE IP AND ED AT THEIR ARCHBOLD FACILITY IN SEPTEMBER 2010. FORM 990, PART VI, SECTION A, LINE 2 KEVIN KOLOVICH AND DIANE CONRAD HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING, FORM 990 IS PROVIDED TO THE BOARD, AND A SUMMARY OF THE DISCLOSURES AND CHANGES TO THE FORM IS PRESENTED BY THE CFO AT A MONTHLY BOARD MEETING. IF A BOARD MEMBER IS NOT IN ATTENDANCE FOR THIS PRESENTATION, THAT INDIVIDUAL WILL RECEIVE A COPY OF FORM 990 AT A LATER DATE, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS AND VOTING MEMBERS OF THE BOARD ARE COVERED BY THE CONFLICT OF INTEREST POLICY. CONFLICTS OF INTEREST ARE REVIEWED ON A CASE BY CASE BASIS. IF A TRANSACTION ARISES THAT WOULD RESULT IN A CONFLICT, THE INTERESTED INDIVIDUAL SIGNS A CONFLICT OF INTEREST STATEMENT NOTING THAT THEY ARE NOT INDEPENDENT WITH RESPECT TO THE TRANSACTION, AND THEY ABSTAIN FROM VOTING ON THAT MATTER. THE POLICY IS MONITORED BY ALL BOARD MEMBERS AND OFFICERS. THE POLICY IS REVIEWED WITH ANY NEW BOARD MEMBERS OR OFFICERS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S AND VICE PRESIDENTS' COMPENSATION IS REVIEWED ANNUALLY AND APPROVED BY THE COMPENSATION COMMITTEE. THE DECISIONS REGARDING COMPENSATION ARE DOCUMENTED IN THE MINUTES FROM THE COMPENSATION COMMITTEE MEETINGS. OHA SURVEY DATA IS USED FOR COMPARABILITY PURPOSES. THE PROCESS WAS LAST UNDERTAKEN IN NOVEMBER OF 2010 AND JANUARY OF 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -249,793. CHANGE IN FAIR VALUE OF INTEREST SWAP AGREEMENTS -113,245. TOTAL TO FORM 990, PART XI, LINE 5: -363,038. FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS AN AUDIT COMMITTEE THAT OVERSEES THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SHARE FOUNDATION 433 WEST HIGH STREET BRYAN OH 43506 341596175 ASSIST COMMUNITY HOSPITALS AND WELLNESS CENTERS WITH FUNDRAISING OH 501(C)(3) 11A COMMUNITY HOSPITALS AND WELLNESS CENTERS 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0