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HOLZER HOSPITAL FOUNDATION: Form 990, tax year 2009

View the entire original 990 at ProPublica ↗

Organization
HOLZER HOSPITAL FOUNDATION (EIN 31-4379491)
Tax period
2009-07-01 to 2010-06-30
Filed
2011-05-16
IRS object ID
201111369349303586
Schema version
2009v1.7
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2011-05-16T12:36:50-05:00Timestamp
Tax Period End Date2010-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1PLANTE & MORAN PLLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line165 EAST STATE STREET SUITE 600AddressLine1
CityCOLUMBUSCity
StateOHState
ZIP Code43215ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2009-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN314379491EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1HOLZER HOSPITAL FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlHOLZNameControl
Phone7404465060Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1100 JACKSON PIKEAddressLine1
CityGALLIPOLISCity
StateOHState
ZIP Code45631ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameKENNETH PAYNEName
TitleCFOTitle
Phone7404465060Phone
Date Signed2011-05-16DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameBernie OstrowskiName
Phone6148493000Phone
FieldValueIRS element (for citing)
Tax Year2009TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

Doing Business As DoingBusinessAs

FieldValueIRS element (for citing)
Business Name Line1SEE SCHEDULE OBusinessNameLine1
FieldValueIRS element (for citing)
Name Of Principal Officer PersonKENNETH PAYNENameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1100 JACKSON PIKEAddressLine1
CityGALLIPOLISCity
StateOHState
ZIP Code45631ZIPCode
FieldValueIRS element (for citing)
Gross Receipts120795910GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501cXOrganization501c
Web SiteWWW.HOLZER.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1910YearFormation
State Legal DomicileOHStateLegalDomicile
Activity Or Mission DescriptionTO ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE.ActivityOrMissionDescription
Nbr Voting Members Governing Body15NbrVotingMembersGoverningBody
Nbr Independent Voting Members11NbrIndependentVotingMembers
Total Nbr Employees1279TotalNbrEmployees
Total Nbr Volunteers7TotalNbrVolunteers
Total Gross UBI305936TotalGrossUBI
Net Unrelated Business Txbl Income11131NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year15983ContributionsGrantsPriorYear
Contributions Grants Current Year1032065ContributionsGrantsCurrentYear
Program Service Revenue Prior Year107489031ProgramServiceRevenuePriorYear
Program Service Revenue CY117612082ProgramServiceRevenueCY
Investment Income Prior Year324219InvestmentIncomePriorYear
Investment Income Current Year187373InvestmentIncomeCurrentYear
Other Revenue Prior Year2818535OtherRevenuePriorYear
Other Revenue Current Year1811010OtherRevenueCurrentYear
Total Revenue Prior Year110647768TotalRevenuePriorYear
Total Revenue Current Year120642530TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year2000GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY161000GrantsAndSimilarAmntsCY
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year49565196SalariesEtcPriorYear
Salaries Etc Current Year45999778SalariesEtcCurrentYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year64985406OtherExpensePriorYear
Other Expenses Current Year73054862OtherExpensesCurrentYear
Total Expenses Prior Year114552602TotalExpensesPriorYear
Total Expenses Current Year119215640TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-3904834RevenuesLessExpensesPriorYear
Revenues Less Expenses CY1426890RevenuesLessExpensesCY
Total Assets BOY82884368TotalAssetsBOY
Total Assets EOY84287923TotalAssetsEOY
Total Liabilities BOY26616958TotalLiabilitiesBOY
Total Liabilities EOY26648001TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY56267410NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY57639922NetAssetsOrFundBalancesEOY
Mission DescriptionWE WILL ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense100157183Expense
Grants161000Grants
Revenue117729027Revenue
DescriptionTHE HOSPITAL ACCEPTS ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. A PATIENT IS CLASSIFIED AS A CHARITY PATIENT BY REFERENCE TO CERTAIN ESTABLISHED POLICIES OF THE HOSPITAL. IN ASSESSING A PATIENT'S INABILITY TO PAY, THE HOSPITAL COMPARES INCURRED CHARGES WITH GENERALLY RECOGNIZED POVERTY INCOME LEVELS AND THE PATIENT'S FINANCIAL RESOURCES. BECAUSE THE HOSPITAL DOES NOT EXPECT TO RECEIVE PAYMENT FOR AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THESE AMOUNTS ARE NOT REPORTED AS NET PATIENT SERVICE REVENUES. CHARITY CARE PROVIDED, BASED ON ESTABLISHED RATES, WAS APPROXIMATELY $7,587,147 AND $4,710,610 IN FISCAL 2010 AND 2009 RESPECTIVELY.CONSISTENT WITH ITS MISSION, THE HOSPITAL PROVIDES COMMUNITY SERVICES INTENDED TO BENEFIT THE UNDERSERVED AND ENHANCE THE HEALTH STATUS OF THE COMMUNITY. THE HOSPITAL OPERATES A 24 HOUR PER DAY, 7 DAY PER WEEK EMERGENCY ROOM PROVIDING CARE TO ALL PATIENTS. THE HOSPITAL OPERATES HOLZER HOSPICE.CONTINUING EDUCATION, CERTIFICATION PROGRAMS, AND INFORMATIONAL SEMINARS ARE CONDUCTED FOR BOTH HOSPITAL AND MEDICAL STAFF. HEALTH FAIRS ARE CONDUCTED AT NO CHARGE. ADDITIONALLY, THE HOSPITAL'S MOBILE UNIT IS TAKEN TO COMMUNITY EVENTS TO PERFORM FREE SCREENINGS, AND DISPENSE EDUCATIONAL MATERIALS. HOSPITAL STAFF ALSO RESPONDS TO REQUESTS FROM EMPLOYERS AND COMMUNITY GROUPS, ALONG WITH SENIOR CITIZEN CENTERS, FOR SCREENINGS AND INFORMATIONAL PROGRAMS. EDUCATIONAL SUPPORT GROUPS, SUCH AS DIABETES AND CANCER, AND AN EDUCATIONAL GROUP MEETING FOR STROKES, ARE SPONSORED BY THE HOSPITAL. THE HOSPITAL'S MEETING ROOMS ARE MADE AVAILABLE TO ORGANIZATIONS AT NO CHARGE FOR HEALTH-RELATED PROGRAMMING AND MEETINGS. ADDITIONALLY, CIVIC AND PROFESSIONAL ORGANIZATIONS ARE INVITED TO THE HOSPITAL REGULARLY FOR PROGRAMS THAT ARE EDUCATIONAL AND INFORMATIONAL ON HEALTH CARE SERVICES AS DEVELOPED.SPEAKERS FROM THE HOSPITAL STAFF ARE AVAILABLE AND RESPOND TO SPEAKING INVITATIONS FOR GROUPS AND ORGANIZATIONS IN THE HOSPITAL'S SERVICE AREA. THE HOSPITAL OFFERS MANY SERVICES TO THE COMMUNITY AT NOMINAL OR NO CHARGE, INCLUDING BLOOD PRESSURE AND BLOOD SUGAR SCREENINGS, CHOLESTEROL CHECKS, HEMOGLOBIN, PULSE OXIMETRY, PROSTATE CHECKS, BONE DENSITY, AND TUMOR REGISTRY. THE PEDIATRIC UNIT WORKS IN CONJUNCTION WITH THE GALLIA COUNTY HEALTH DEPARTMENT IN PROMOTING FREE IMMUNIZATIONS. THE HOSPITAL ALSO PROVIDES EDUCATIONAL PROGRAMS AND SCREENINGS, AND DISCOUNTS AT THE HOSPITAL'S GIFT SHOP, CAFETERIA, AND PHARMACY IN CONJUNCTION WITH ITS MAXWELL 50 PROGRAM. ASSISTANCE IS ALSO PROVIDED TO SENIOR CITIZENS AND OTHER PATIENTS AND THEIR FAMILIES WITH THE SUBMISSIONS OF FORMS FOR INSURANCE, FINANCIAL COUNSELING, AND APPLICATION TO THE MEDICARE AND MEDICAID PROGRAMS FOR HEALTH SERVICE COVERAGE. COSTS ASSOCIATED WITH THESE PROGRAMS ARE INCLUDED IN THE HOSPITAL'S EXPENSES.Description
Total Program Service Expense100157183TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Balance Sheet Amounts Reported1BalanceSheetAmountsReported
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities1FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Grants To Organizations1GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP1LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity1RelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109631NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees1279NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income1UnrelatedBusinessIncome
Form990-T Filed1Form990-TFiled
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Nbr Voting Governing Body Members15NbrVotingGoverningBodyMembers
Number Independent Voting Members11NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledOHStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1KENNETH PAYNEBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number7404465060TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1100 JACKSON PIKEAddressLine1
CityGALLIPOLISCity
StateOHState
ZIP Code45631ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (26 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationHighest Compensated EmployeeHighestCompensatedEmployeeFormerFormer
JAMES R PHILLIPPE
CEO40.00XX254346029913
BRENT SAUNDERS
PRES/CEO-HCHS(7/1-12/31)0.80XX1232769500276
ALAN A STOCKMEISTER
VICE CHAIRMAN0.80XX0120000
PHIL A BOWMAN
SECRETARY0.80XX0140000
STEVE CHAPMAN CPA
CHAIRMAN0.80XX0140000
THOMAS TOPE
FORMER PRES/CEO-HCHS0.80X65488306370
DANNY HOLSCHUH
TRUSTEE0.80X000
LARRY KIDD
TRUSTEE0.80X040000
M SUZANNE MIZE MD
TRUSTEE0.80X000
PAUL M REED
TRUSTEE0.80X000
GARY ROACH
TRUSTEE0.80X000
REX E SHENEFIELD
TRUSTEE0.80X000
RYAN SMITH
TRUSTEE0.80X035000
VERLIN L SWAIN
TRUSTEE0.80X000
JAMAL HADDAD MD
TRUSTEE0.80X000
JAMES MAGNUSSEN
TRUSTEE0.80X000
KENNETH PAYNE
CFO40.00X5490002379
INNA MAKIEVSKY
VP PATIENT CARE SERVICES40.00X15959605743
JOHN V VIALL MD
VP MEDICAL AFFAIRS40.00X152211011424
JOHN ALLEN
VP INFORMATION SYSTEMS40.00X216770494
TIMOTHY A DAMRON
PHYSICIAN40.0045640604551X
GERALD VALLEE
PHYSICIAN40.0018529703095X
SHANE E EPHLIN
PHARMACIST40.00146328016932X
ELAINE K BROWN
PHARMACIST40.0014488603545X
JILL D STRAUCH
PHARMACIST40.00146594018853X
KEVIN YEAGER
FORMER VP FINANCE-HCHS40.0019706300X
FieldValueIRS element (for citing)
Total Reportable Comp From Org2697463TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs57000TotalReportableCompFrmRltdOrgs
Total Other Compensation103575TotalOtherCompensation
Number Individuals GT100 K23NumberIndividualsGT100K
Formers Listed1FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
HOLZER CLINIC
90 JACKSON PIKEGALLIPOLISOH45631PHYSICIANS8627684
REHABCARE
7733 FORSYTH BLVD SUITE 2300ST LOUISMO63105MGMT OF REHAB UNIT611162
PLANTE & MORAN PLLC
67400 NORTHWESTERN HIGHWAYSOUTHFIELDMI48034ACCOUNTING444671
B E SMITH
9777 RIDGE DRIVE SUITE 300LENEXAKS66219RECRUITING & STAFFING343843
MAXIT HEALTHCARE LLC
LOCKBOX KK PO BOX 2589FORT WAYNEIN46801STAFFING279311
FieldValueIRS element (for citing)
Number Of Contractors GT100 K17NumberOfContractorsGT100K
Fundraising Events19856FundraisingEvents
All Other Contributions1012209AllOtherContributions
Total Contributions1032065TotalContributions

Program Service Revenue ProgramServiceRevenue (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
NET PATIENT SERVICES622110114896248114896248
HCAP62211014182471418247
LIFELINE INCOME62211012975871297587
FieldValueIRS element (for citing)
Total Program Service Revenue117612082TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column231372TotalRevenueColumn
Exclusion$231,372ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real483507Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real60697Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real422810Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column422810TotalRevenueColumn
Unrelated Business Revenue11400UnrelatedBusinessRevenue
Exclusion$411,410ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Other7100Other

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities49187Securities
Other1912Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities-49187Securities
Other5188Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column-43999TotalRevenueColumn
Exclusion-$43,999ExclusionAmount
FieldValueIRS element (for citing)
Gross Income Fundraising Events16900GrossIncomeFundraisingEvents
Cntrbtns Rprtd Fundraising Events19856CntrbtnsRprtdFundraisingEvents
Fundraising Direct Expenses41584FundraisingDirectExpenses

Net Income From Fundraising Events NetIncomeFromFundraisingEvents

FieldValueIRS element (for citing)
Total Revenue Column-24684TotalRevenueColumn
Exclusion-$24,684ExclusionAmount

Other Revenue Misc OtherRevenueMisc (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnUnrelated Business RevenueUnrelatedBusinessRevenueExclusionExclusionAmount
CAFETERIA SALES72232096123381531$879,702
LAUNDRY INCOME812300173174173174
GIFT SHOP SALES900099119853$119,853

Miscellaneous Revenue MiscellaneousRevenue

FieldValueIRS element (for citing)
Total Revenue Column158624TotalRevenueColumn
Related Or Exempt Function Income116945RelatedOrExemptFunctionIncome
Unrelated Business Revenue39831UnrelatedBusinessRevenue
Exclusion$1,848ExclusionAmount
FieldValueIRS element (for citing)
Total Other Revenue1412884TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column120642530TotalRevenueColumn
Related Or Exempt Function Income117729027RelatedOrExemptFunctionIncome
Unrelated Business Revenue305936UnrelatedBusinessRevenue
Exclusion$1,575,502ExclusionAmount

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total159000Total
Program Services159000ProgramServices

Grants To Domestic Individuals GrantsToDomesticIndividuals

FieldValueIRS element (for citing)
Total2000Total
Program Services2000ProgramServices

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total1861477Total
Management And General1861477ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total35325917Total
Program Services29313446ProgramServices
Management And General6012471ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total1482914Total
Program Services1230522ProgramServices
Management And General252392ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total4223376Total
Program Services3504557ProgramServices
Management And General718819ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total3106094Total
Program Services2577437ProgramServices
Management And General528657ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total1483070Total
Management And General1483070ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total408268Total
Management And General408268ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total76216Total
Management And General76216ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total29593097Total
Program Services24035513ProgramServices
Management And General5557584ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total18880933Total
Program Services17801321ProgramServices
Management And General1079612ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total76048Total
Program Services61766ProgramServices
Management And General14282ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total2015623Total
Program Services1814061ProgramServices
Management And General201562ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total499740Total
Program Services405889ProgramServices
Management And General93851ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total463386Total
Program Services417047ProgramServices
Management And General46339ManagementAndGeneral

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total6119173Total
Program Services5507256ProgramServices
Management And General611917ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total704160Total
Program Services633744ProgramServices
Management And General70416ManagementAndGeneral

Other Expenses OtherExpenses (5 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServices
BAD DEBTS97609999760999
FRANCHISE FEE12718721271872
LIFELINE EXPENSES992915992915
RECRUITMENT192647192647
BOND ISSUE EXPENSES188200188200

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total328515Total
Program Services286991ProgramServices
Management And General41524ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total119215640Total
Program Services100157183ProgramServices
Management And General19058457ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY64619BOY
EOY2768EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY7609182BOY
EOY10167894EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY11779000BOY
EOY11020489EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY1341303BOY
EOY1559419EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY910700BOY
EOY1902643EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY1520040BOY
EOY939569EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis126931536LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec99881921LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY32416580BOY
EOY27049615EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY3639876BOY
EOY3672724EOY

Investments Program Related InvestmentsProgramRelated

FieldValueIRS element (for citing)
BOY7602094BOY
EOY7630173EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY16000974BOY
EOY20342629EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY82884368BOY
EOY84287923EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY14927754BOY
EOY16955247EOY

Deferred Revenue DeferredRevenue

FieldValueIRS element (for citing)
EOY35585EOY

Tax Exempt Bond Liabilities TaxExemptBondLiabilities

FieldValueIRS element (for citing)
BOY9571142BOY
EOY7831142EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY1536132BOY
EOY832506EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY581930BOY
EOY993521EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY26616958BOY
EOY26648001EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY55369374BOY
EOY57470080EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY898036BOY
EOY169842EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY56267410BOY
EOY57639922EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY82884368BOY
EOY84287923EOY
FieldValueIRS element (for citing)
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members0MailingsMembers
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations1GrantsOtherOrganizations
Grants Other Organizations$1,297GrantsOtherOrganizationsAmount
Direct Contact Legislators0DirectContactLegislators
Rallies Demonstrations0RalliesDemonstrations
Other Activities0OtherActivities
Total Lobbying Expenditures IIB1297TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierPart II-B, Line 1i:Identifier
Return ReferenceExplanation of Other Lobbying Activities:ReturnReference
ExplanationA PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION RELATES TO LOBBYING.Explanation

Schedule D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis451456OtherCostOrOtherBasis
Book Value451456BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis35654940OtherCostOrOtherBasis
Depreciation22423869Depreciation
Book Value13231071BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis87127352OtherCostOrOtherBasis
Depreciation74548782Depreciation
Book Value12578570BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis3697788OtherCostOrOtherBasis
Depreciation2909270Depreciation
Book Value788518BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings27049615TotalOfBookValueLandBuildings

Other Assets OtherAssets (3 entries)

DescriptionDescriptionBook ValueBookValue
Other assets1097591
BOND ISSUE COSTS132349
RELATED PARTY RECEIVABLE19112689
FieldValueIRS element (for citing)
Total Book Value Other Assets20342629TotalBookValueOtherAssets

Other Liabilities OtherLiabilities (2 entries)

DescriptionDescriptionAmountAmount
COST REPORT SETTLEMENTS$131,906
RELATED PARTY PAYABLE$861,615
FieldValueIRS element (for citing)
Total Of Amounts993521TotalOfAmounts
Total Revenue120642530TotalRevenue
Total Expenses119215640TotalExpenses
Excess Or Deficit For Year1426890ExcessOrDeficitForYear
Net Unrealized GL On Investments-54378NetUnrealizedGLOnInvestments
Total Adjustments-54378TotalAdjustments
Excess Or Deficit Per FS1372512ExcessOrDeficitPerFS

Schedule G IRS990ScheduleG

Events Information EventsInformation

FieldValueIRS element (for citing)
Name Of Event1GOLF OUTINGNameOfEvent1
Gross Receipts Event136756GrossReceiptsEvent1
Charitable Contributions Event119856CharitableContributionsEvent1
Gross Revenue Event116900GrossRevenueEvent1
Other Direct Expenses Event141584OtherDirectExpensesEvent1
Gross Receipts Total36756GrossReceiptsTotal
Charitable Contributions Total19856CharitableContributionsTotal
Gross Revenue Total Events16900GrossRevenueTotalEvents
Other Direct Expenses Total Events41584OtherDirectExpensesTotalEvents
Direct Expense Summary Events41584DirectExpenseSummaryEvents
Net Income Summary-24684NetIncomeSummary

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
Policy Applied To All HospitalsXPolicyAppliedToAllHospitals
FPG Reference Free Care1FPGReferenceFreeCare
Pcent100XPcent100
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent300XPcent300
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget1ExpensesExceededBudget
Unable To Provide Care0UnableToProvideCare
Annual Community Benefit Report0AnnualCommunityBenefitReport

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense3752823TotalCommunityBenefitExpense
Direct Offsetting Revenue2283287DirectOffsettingRevenue
Net Community Benefit Expense1469536NetCommunityBenefitExpense
Percent Of Total Expense0.01340PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense15123615TotalCommunityBenefitExpense
Direct Offsetting Revenue7925723DirectOffsettingRevenue
Net Community Benefit Expense7197892NetCommunityBenefitExpense
Percent Of Total Expense0.06580PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense18876438TotalCommunityBenefitExpense
Direct Offsetting Revenue10209010DirectOffsettingRevenue
Net Community Benefit Expense8667428NetCommunityBenefitExpense
Percent Of Total Expense0.07920PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Persons Served9046PersonsServed
Total Community Benefit Expense181648TotalCommunityBenefitExpense
Direct Offsetting Revenue0DirectOffsettingRevenue
Net Community Benefit Expense181648NetCommunityBenefitExpense
Percent Of Total Expense0.00170PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Persons Served9046PersonsServed
Total Community Benefit Expense181648TotalCommunityBenefitExpense
Net Community Benefit Expense181648NetCommunityBenefitExpense
Percent Of Total Expense0.00170PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Persons Served9046PersonsServed
Total Community Benefit Expense19058086TotalCommunityBenefitExpense
Direct Offsetting Revenue10209010DirectOffsettingRevenue
Net Community Benefit Expense8849076NetCommunityBenefitExpense
Percent Of Total Expense0.08090PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported0BadDebtExpenseReported
Bad Debt Expense$3,613,319BadDebtExpenseAmount
Amount Attributable To0AmountAttributableTo
Amount Reimbursed By Medicare33389747AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare38678893CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall-5289146MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
Cost To Charge RatioXCostToChargeRatio
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare

Form990 Schedule H Part V Form990ScheduleHPartV (4 entries)

Address Line1Address/AddressLine1CityAddress/CityStateAddress/StateZIP CodeAddress/ZIPCodeLicensed HospitalLicensedHospitalGeneral Medical And SurgicalGeneralMedicalAndSurgicalEr24 HoursEr24Hours
HOLZER HOSPITAL FOUNDATION
100 JACKSON PIKEGALLIPOLISOH45631XXX
PHYSICIAN'S OFFICE-DR TIMOTHY DAMRON
2881 SR 160GALLIPOLISOH45631X
PHYSICIAN'S OFFICE-DR LINDA ALSTON
2881 SR 160GALLIPOLISOH45631X
MEDICAL PLAZA
100 JACKSON PIKEGALLIPOLISOH45631X

Form990 Schedule H Part VI Form990ScheduleHPartVI

FieldValueIRS element (for citing)
Income Based CriteriaPart I, Line 3c: NOT APPLICABLEIncomeBasedCriteria
Annual Community Benefit ExplnPart I, Line 6a: NOT APPLICABLEAnnualCommunityBenefitExpln
Costing Method UsedPart I, Line 7: EXPENSES WERE CALCULATED USING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2.CostingMethodUsed
Subsidized Health Services ExplnPart I, Line 7g: NOT APPLICABLESubsidizedHealthServicesExpln
Percent Of Total Expense ExplnPart I, Line 7f: BAD DEBT OF $9,760,999 FROM PART IX OF FORM 990 WAS EXCLUDED FROM THE TOTAL EXPENSES IN THIS CALCULATION.PercentOfTotalExpenseExpln
Bad Debt FootnotePart III, Line 4: BAD DEBT WAS RECORDED AT GROSS CHARGES ONCE AN ACCOUNT HAD BEEN THROUGH MULTIPLE ATTEMPTS FOR PAYMENT. IT WAS THEN SUBMITTED FOR COLLECTIONS, LESS ANY AMOUNTS THAT MAY HAVE BEEN PAID THROUGH INSURANCE OR PRIVATE PAYMENTS. BAD DEBT AT COST WAS CALCULATED USING A COST-TO-CHARGE RATIO. NONE OF THE BAD DEBT AT COST IS TREATED AS COMMUNITY BENEFIT. NONE OF THE BAD DEBT AT COST IS LIKELY ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE. IF IT IS UNCLEAR WHETHER AN ACCOUNT MAY QUALIFY AS CHARITY, IT IS FIRST ASSUMED TO BE CHARITY, NOT BAD DEBT, UNTIL ADDITIONAL INFORMATION SHOWS OTHERWISE.FOOTNOTE FROM FINANCIAL STATEMENTS: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE SYSTEM'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.BadDebtFootnote
Shortfall As Community BenefitPart III, Line 8: MEDICARE COSTS AS REPORTED IN THE MEDICARE COST REPORT WERE CALCULATED USING A COST-TO-CHARGE RATIO METHODOLOGY AS REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. NONE OF THE MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT.ShortfallAsCommunityBenefit
Debt Collection PolicyPart III, Line 9b: FOUR PATIENT STATEMENTS ARE SENT TO NON-MEDICARE ACCOUNTS. FIVE PATIENT STATEMENTS ARE SENT TO MEDICARE ACCOUNTS. IF NO PATIENT PAYMENT RESPONSE, ACCOUNTS ARE SELECTED AND PROCESSED TO BAD DEBT. THIS POLICY APPLIES TO PATIENTS WHO QUALIFY UNDER THE CHARITY CARE/FINANCIAL ASSISTANCE POLICY.DebtCollectionPolicy
Needs AssessmentPart VI, Line 2: NO NEEDS ASSEMSSMENT WAS PERFORMED DURING THE FISCAL YEAR.NeedsAssessment
Patient Education AssistancePart VI, Line 3: NOTICES ARE POSTED THAT SPECIFY THE RIGHTS OF THESE INDIVIDUALS TO RECEIVE WITHOUT CHARGE BASIC, MEDICALLY NECESSARY HOSPITAL-LEVEL SERVICES. THE POSTINGS ARE PRINTED IN ENGLISH AND SPANISH AND ARE LOCATED IN ADMISSIONS AREAS, THE BUSINESS OFFICE, AND THE EMERGENCY DEPARTMENT. PATIENT STATEMENTS CONTAIN FEDERAL POVERTY GUIDELINES, AN EXPLANATION OF WHAT SERVICES MAY QUALIFY FOR FREE CARE, AND INFORMATION ON HOW TO APPLY. THE ORGANIZATION ALSO EMPLOYS FINANCIAL ADVOCATES AND BENEFIT ELIGIBILITY COORDINATORS TO ASSIST IN THE INFORMATION/EDUCATION PROCESS.PatientEducationAssistance
Community InformationPart VI, Line 4: THE PRIMARY SERVICE AREA FOR HOLZER HOSPITAL FOUNDATION IS COMPRISED OF THE FOUR-COUNTRY AREA OF GALLIA, JACKSON, AND MEIGS COUNTIES IN OHIO, AND MASON COUNTY IN WEST VIRGINIA. THE SECONDARY SERVICE AREA INCLUDES PARTS OF VINTON, LAWRENCE, ATHENS, AND SCIOTO COUNTIES IN OHIO, AND JACKSON COUNTY IN WEST VIRGINIA.CommunityInformation
Community Building ActivitiesPart VI, Line 5: NOT APPLICABLECommunityBuildingActivities
Other InformationPart VI, Line 6: HOLZER MEDICAL CENTER BELIEVES THAT EDUCATIONAL AND PREVENTATIVE SERVICES ARE IMPERITIVE TO IMPROVING THE HEALTH OF OUR COMMUNITY. AS SUCH, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT AT HOLZER MEDICAL CENTER ORGANIZES AND PROVIDES HEALTH SCREENINGS THROUGHOUT THE YEAR AT OUR CAMPUS, AT VARIOUS FAIRS AND FESTIVALS IN THE COMMUNITY, AT OUR LOCAL SCHOOLS AND ALSO AT AREA BUSINESSES. NO-COST HEALTH SCREENINGS INCLUDE: BLOOD PRESSURE, GLUCOSE, CHOLESTEROL, BONE DENSITY AND BODY COMPOSITION SCREENINGS. SOME OF OUR LARGER COMMUNITY EVENTS INCLUDE: GALLIA COUNTY FAIR, MEIGS COUNTY FAIR, MASON COUNTY FAIR, BUCKEYE RURAL ELECTRIC EMPLOYEE HEALTH FAIR, BUCKEYE RURAL ELECTRIC ANNUAL MEETING AND HOLZER CENTER FOR CANCER FAIR. HOLZER MEDICAL CENTER ALSO HOSTS A MONTHLY DIABETES EDUCATION MEETING, MS SUPPORT GROUP, CANCER SUPPORT GROUP AND PROVIDES HEALTH SCREENING TO SENIOR CITIZENS IN OUR SERVICE AREA AND SPEAKERS THROUGHOUT THE YEAR TO DISCUSS VARIOUS MEDICAL TOPICS TO COMMUNITY GROUPS. ALONG WITH THESE NO-COST SCREENINGS, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT PROVIDES EDUCATIONAL INFORMATION TO LOCAL ORGANIZATIONS TO PROMOTE HEALTH AND WELLNESS FOR THEIR EMPLOYEES. IN ALL, APPROXIMATELY 4,500 SCREENINGS WERE PERFORMED BY HOLZER MEDICAL CENTER NURSES OR TECHNICIANS IN FISCAL YEAR 2010.OtherInformation
Affiliated Health Care SystemPart VI, Line 7: HOLZER MEDICAL CENTER AND HOLZER MEDICAL CENTER-JACKSON COMPRISE THE TWO HOSPITALS IN THE SYSTEM, WITH HOLZER MEDICAL CENTER ACCOUNTING FOR 82% OF HOSPITAL ADMISSIONS. HOLZER MEDICAL CENTER IS LOCATED IN GALLIA COUNTY AND HOLZER MEDICAL CENTER-JACKSON IS LOCATED IN JACKSON COUNTY. ALL HEALTH SCREENINGS AND PATIENT EDUCATION IS PROVIDED BY STAFF IN AREAS WITHIN OUR PRIMARY SERVICE AREA WHICH INCLUDES GALLIA, JACKSON AND MEIGS COUNTIES IN OHIO AND MASON COUNTY, WEST VIRGINIA AS WELL AS SOME SERVICES PROVIDED IN OUR SECONDARY SERVICE AREA.AffiliatedHealthCareSystem

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records Maintained1RecordsMaintained

Recipient Table RecipientTable

Recipient Name Business RecipientNameBusiness

FieldValueIRS element (for citing)
Business Name Line1HOLZER CONSOLIDATED HEALTH SYSTEMSBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1100 JACKSON PIKEAddressLine1
CityGALLIPOLISCity
StateOHState
ZIP Code45631ZIPCode
FieldValueIRS element (for citing)
EIN Of Recipient311156690EINOfRecipient
IRC Section501(C)(3)IRCSection
Amount Of Cash Grant159000AmountOfCashGrant
Purpose Of GrantGENERAL SUPPORTPurposeOfGrant
FieldValueIRS element (for citing)
Total Nbr Of501 C3 And Govt Grants1TotalNbrOf501C3AndGovtGrants
Total Nbr Of Other Organizations0TotalNbrOfOtherOrganizations

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierProcedure for Monitoring Grants in the U.S.:Identifier
Return ReferencePart I, Line 2:ReturnReference
ExplanationSchedule I, Part I, Line 2: THE ORGANIZATION MAY PROVIDE FUNDS TO RELATED, EXEMPT ORGANIZATIONS.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Independent ConsultantXIndependentConsultant
Written Employment ContractXWrittenEmploymentContract
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment1SeverancePayment
Supplemental Nonqual Retire Plan1SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (9 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
JAMES R PHILLIPPE
2543460000024500054130284259000
THOMAS TOPE
000065488300063700661253000
INNA MAKIEVSKY
159596000000057430165339000
JOHN V VIALL MD
152211000002393090310163635000
TIMOTHY A DAMRON
456406000000045510460957000
GERALD VALLEE
185297000003095000188392000
SHANE E EPHLIN
1463280000013052038800163260000
JILL D STRAUCH
146594000001874101120165447000
KEVIN YEAGER
000019706300000197063000

Form990 Schedule J Part III Form990ScheduleJPartIII

FieldValueIRS element (for citing)
Return ReferencePart I, Line 4aReturnReference
ExplanationPART I, LINE 4A: DURING THE FISCAL YEAR, THOMAS TOPE RECEIVED SEVERANCE PAY IN THE AMOUNT OF $500,335 AND KEVIN YEAGER SEVERANCE PAY IN THE AMOUNT OF $102,064. PART I, LINE 4B: DURING THE FISCAL YEAR, THOMAS TOPE WITHDREW FUNDS FROM A NON-QUALIFIED RETIREMENT PLAN (457F) IN THE AMOUNT OF $136,343.Explanation

Schedule L IRS990ScheduleL

Loan Table LoanTable

FieldValueIRS element (for citing)
Name PersonSHANE EPHLINNamePerson
Purpose Of LoanSTUDENT LOANPurposeOfLoan
Loan From OrganizationXLoanFromOrganization
Original Principal$118,162OriginalPrincipalAmount
Balance Due37873BalanceDue
Default0Default
Approved By Board1ApprovedByBoard
Written Agreement1WrittenAgreement
FieldValueIRS element (for citing)
Total Balance Due37873TotalBalanceDue

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

IdentifierIdentifierExplanationExplanation
Form 990, Part VI, Section A, line 6HOLZER CONSOLIDATED HEALTH SYSTEMS IS THE SOLE MEMBER OF THE ORGANIZATION.
Form 990, Part VI, Section A, line 7bHOLZER HOSPITAL FOUNDATION DECISIONS THAT ARE MADE BY THEIR BOARD OF DIRECTORS CAN BE OVERRULED BY HOLZER CONSOLIDATED HEALTH SYSTEM'S BOARD OF DIRECTORS.
Form 990, Part VI, Section B, line 11THE CONTROLLER AND THE CFO OF HOLZER CONSOLIDATED HEALTH SYSTEMS REVIEW FORM 990. A COPY WILL BE PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING.
Form 990, Part VI, Section B, line 12cCONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY AND ARE REVIEWED BY THE CONFLICT OF INTEREST REVIEW COMMITTEE. MEMBERS OF THE BOARD ARE AWARE THAT THEY SHOULD DISCLOSE CONFLICTS WHEN THEY ARISE, AND MEMBERS ABSTAIN FROM PARTICIPATING IN DISCUSSIONS OR VOTING ON MATTERS WHERE A CONFLICT IS PRESENT.
Form 990, Part VI, Section B, line 15THE HOLZER CONSOLIDATED HEALTH SYSTEM BOARD APPROVES COMPENSATION OF THE CEO AND OTHER OFFICERS. THE BOARD UTILIZES WAGE RECOMMENDATIONS FROM AN UNRELATED CONSULTANT TO DETERMINE THE COMPENSATION. THE CEO MAY BE INVOLVED IN DETERMINING OTHER OFFICERS' COMPENSATION, HOWEVER THE ULTIMATE DECISION RESTS WITH THE BOARD. THE PROCESS WAS LAST UNDERTAKEN DURING DECEMBER 2010.
Form 990, Part VI, Section C, line 19THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 2C:THE AUDIT OVERSIGHT PROCESS AND THE PROCESS OF SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR.
FORM 990, PAGE 1, PART C:DOING BUSINESS AS: HOLZER MEDICAL CENTER HOLZER MEDICAL CENTER - GALLIPOLIS
FORM 990, PAGE 7, PART VII:THE FOLLOWING TRUSTEES DEVOTED TIME TO HOLZER CONSOLIDATED HEALTH SYSTEMS: ALAN A. STOCKMEISTER 1 HRS PHIL A. BOWMAN 1 HRS STEVE CHAPMAN, CPA 1 HRS LARRY KIDD 1 HRS RYAN SMITH 1 HRS THE FOLLOWING OFFICERS DEVOTED TIME TO HOLZER CONSOLIDATED HEALTH SYSTEMS: BRENT SAUNDERS 40 HRS

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (4 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusBusiness Name Line1DirectControllingEntityName/BusinessNameLine1Direct Controlling Entity NADirectControllingEntityNA
HOLZER MEDICAL CENTER - JACKSON
100 JACKSON PIKEGALLIPOLISOH45631311724085HEALTH CAREOH501(C)(3)Line 3HOLZER CONSOLIDATED HEALTH SYSTEMS
HOLZER FOUNDATION
100 JACKSON PIKEGALLIPOLISOH45631310927482CONTINUING ADVANCEMENT OF HEALTH AND MEDICAL CAREOH501(C)(3)Line 7HOLZER CONSOLIDATED HEALTH SYSTEMS
HOLZER CONSOLIDATED HEALTH SYSTEMS
100 JACKSON PIKEGALLIPOLISOH45631311156690MANAGEMENT SERVICESOH501(C)(3)Line 11a, IN/A
HOLZER SENIOR CARE CENTER
380 COLONIAL DRIVEBIDWELLOH45614311534051SKILLED NURSING FACILITYOH501(C)(3)Line 9HOLZER CONSOLIDATED HEALTH SYSTEMS

Form990 Schedule R Part III Form990ScheduleRPartIII

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1HOLZER CARDIOVASCULAR LLCBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line190 JACKSON PIKEAddressLine1
CityGALLIPOLISCity
StateOHState
ZIP Code45631ZIPCode
FieldValueIRS element (for citing)
EIN311780671EIN
Primary ActivityMEDICALPrimaryActivity
Legal Domicile StateOHLegalDomicileState
Direct Controlling Entity NAN/ADirectControllingEntityNA

Form990 Schedule R Part IV Form990ScheduleRPartIV

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1HOLZER VANGUARDBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1100 JACKSON PIKEAddressLine1
CityGALLIPOLISCity
StateOHState
ZIP Code45631ZIPCode
FieldValueIRS element (for citing)
EIN311192567EIN
Primary ActivitySTOCK HOLDING COMPANYPrimaryActivity
Legal Domicile StateOHLegalDomicileState
Direct Controlling Entity NAN/ADirectControllingEntityNA
Type Of EntityCTypeOfEntity
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties1ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org1GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs1RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org1ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (5 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolved
HOLZER CONSOLIDATED HEALTH SYSTEMS
A251339
HOLZER CONSOLIDATED HEALTH SYSTEMS
J373933
HOLZER CONSOLIDATED HEALTH SYSTEMS
L1657178
HOLZER CONSOLIDATED HEALTH SYSTEMS
B159000
HOLZER FOUNDATION
P100406