2011-10-17T12:33:57-05:00 2010-12-31 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2010-01-01 314387577 COSHOCTON COUNTY MEMORIAL HOSPITAL COSH 7406234144 1460 ORANGE STREET COSHOCTON OH 43812 ROBERT MILLER 7406234144 2011-10-07 1 STEPHEN A SHERIDAN 6148852583 2010 2016-03-07 17:11:31Z ROBERT MILLER 1460 ORANGE STREET COSHOCTON OH 43812 64657753 0 X WWW.CCMH.COM X 1946 OH COSHOCTON COUNTY MEMORIAL HOSPITAL OPERATES IN A MANNER CONSISTENT WITH THE REQUIREMENTS OF REVENUE RULING 69-545, THROUGH ITS PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. 9 8 647 141 0 0 143028 0 64093722 61545649 170020 1755772 922290 1330797 65329060 64632218 5000 5000 0 0 31131048 30103511 0 0 0 32837423 31615925 63973471 61724436 1355589 2907782 46412459 45755141 19717168 18359235 26695291 27395906 COSHOCTON COUNTY MEMORIAL HOSPITAL OPERATES IN A MANNER CONSISTENT WITH THE REQUIREMENTS OF REVENUE RULING 69-545, THROUGH ITS PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. 0 0 51435563 63795487 PHARMACYEMERGENCY DEPARTMENTLABORATORY 51435563 1 0 0 1 1 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 38 0 1 647 1 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 OH X BENJAMIN ADAMS 7406234010 19892 STATE ROUTE 16 COSHOCTON OH 43812 MARCIA WALTERS 2.00 X 0 0 0 JAMES BROWN 3.00 X 0 0 0 DIANE JONES 2.00 X 0 0 0 JASON BRADFORD 2.00 X 0 0 0 DRJEROLD MEYER 37.50 X 137511 0 34378 GREGORY NOWAK 37.50 X X 244059 0 61015 ROBERT MILLER 37.50 X X 124071 0 31018 TODD BROWN 2.00 X 0 0 0 MAX CROWN 2.00 X 0 0 0 KAREN SIMPSON 2.00 X 0 0 0 SHARON POLAND 2.00 X 0 0 0 DRROBERT GWINN 37.50 X 192111 0 48028 DRDOUGLAS VIROSTKO 37.50 X 162510 0 40628 DR TERRY OVERHOLSER 37.50 X 188118 0 47030 DR CHRISTOPHER COULSON 37.50 X 183700 0 45925 DR DOUGLAS HAMILTON 37.50 X 164814 0 41204 1396894 0 349226 15 0 1 0 PREMIER HEALTHCARE SERVICES PO BOX 631606 CINCINNATI OH 45263 ER PHYSICIAN SERVICES 2200758 ARAMARK 2500 WARRENVILLE ROAD DOWNERS GROVE IL 60515 HOUSEKEEPING SERVICES 939237 JACOBS VANAMAN AGENCY INC PO BOX 370 COSHOCTON OH 43812 INSURANCE SERVICES 695697 COSHOCTON ANESTHESIA ASSOC PO BOX 850 COSHOCTON OH 43812 ANESTHESIA SERVICES 669611 QUADRAMED PO BOX 1915 MERRIFIELD VA 22116 SOFTWARE SERVICES 425742 5 PROGRAM SERVICE REVENU 623990 61545649 61545649 61545649 413772 413772 1342000 1342000 1342000 1342000 55625 25535 30090 30090 MISCELLANEOUS 900099 632773 632773 CAFETERIA REVENUE 900099 304890 304890 BOND PROCEEDS 900099 143826 143826 219218 131239 87979 1300707 64632218 63795487 0 836731 5000 5000 1396893 1396893 19382451 16475083 2907368 687231 591019 96212 6958157 5914433 1043724 1678779 1426962 251817 45002 45002 4640477 3990810 649667 117263 100846 16417 490340 421692 68648 1868913 1607265 261648 95087 81775 13312 301283 256091 45192 3175897 2731271 444626 695313 591016 104297 SUPPLIES 7277203 6185623 1091580 BAD DEBTS 4254337 3658730 595607 MEDICAL PROFESSIONAL FE 4135789 3556779 579010 MISCELLANEOUS 2344583 1992896 351687 REPAIRS AND MAINTENANCE 2174438 1848272 326166 61724436 51435563 10288873 0 1332969 1119262 10211893 8960900 257262 289416 521669 1255551 73270373 48068466 25960360 25201907 6369581 4233266 1758725 4694839 46412459 45755141 7435775 8081712 8180000 8270254 3381393 2007269 720000 0 19717168 18359235 X 26034845 26668607 585446 652299 75000 75000 26695291 27395906 46412459 45755141 X 2907782 -2207167 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 1266 1266 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PERCENTAGE OF OHA DUES IS USED FOR LOBBYING PURPOSES. 6 47300 144 696142 1 1 961957 961957 38710097 38710097 48068466 -48068466 33507414 33507414 90905 90905 25201907 CORPORATE BONDS 878840 F MARKETABLE EQUITY SECURITIES 3354426 F 4233266 ESTIMATED THIRD PARTY SETTLEMENTS 3862234 OTHER ASSETS 832605 4694839 CCMH GOLF OUTING 55625 55625 17450 3722 2685 1353 325 55625 55625 17450 3722 2685 1353 325 25535 30090 1 1 1 X 1 X 150.000000000000 1 1 1 1 0 4998085 4998085 0.08100 9309857 1634572 7675285 0.12430 14307942 1634572 12673370 0.20530 72866 810210 59995 750215 0.01220 10530 10530 0.00020 72866 820740 59995 760745 0.01240 72866 15128682 1694567 13434115 0.21770 1 1914452 12495774 14203098 -1707324 X 1 1 1 EAST OHIO HOSPITAL ALLIANCE PURCHASING VENTURE 0.33330 2 COSHOCTON COUNTY MEMORIAL HOSPITAL AND GENESIS SLEEP LAB LLC OPERATION OF A SLEEP LAB DEPARTMENT 0.60000 1 1 COSHOCTON COUNTY MEMORIAL HOSPITAL

1460 ORANGE STREET COSHOCTON OH 43812

X X X EXTEND CARE COSHOCTON COUNTY MEMORIAL HOSPITAL 1 PART II: WE HOLD SEVERAL HEALTH CARE SUPPORT GROUPS AND HAVE MULTIPLE HEALTH FAIRS THROUGHOUT THE COMMUNITY OVER THE YEAR. PART III, LINE 4: THE ASSOCIATION PROVIDES SERVICES TO PATIENTS WHO RESIDE PRIMARILY IN THE LOCAL GEOGRAPHIC REGION. PATIENT ACCOUNTS RECEIVABLE AND PATIENT SERVICE REVENUES ARE RECORDED WHEN PATIENT SERVICES ARE PERFORMED AND ARE REPORTED BASED ON GROSS CHARGES, NET OF CERTAIN DEDUCTIONS FROM THOSE CHARGES. DEDUCTIONS ARE BASED ON THE DIFFERENCE BETWEEN CHARGES AT ESTABLISHED RATES AND AMOUNTS ESTIMATED BY MANAGEMENT TO BE REIMBURSABLE UNDER APPLICABLE LAWS, REGULATIONS AND PROGRAM INSTRUCTIONS. REIMBURSABLE AMOUNTS ARE GENERALLY LESS THAN THE ESTABLISHED GROSS CHARGES. FINAL DETERMINATION OF AMOUNTS EARNED FOR PATIENTS IS SUBJECT TO AUDIT BY THE GOVERNMENTAL AGENCIES. SUBSEQUENT ADJUSTMENTS, IF ANY, ARISING FROM SUCH REVIEWS ARE RECORDED IN THE YEAR THEY BECOME KNOWN. THE ASSOCIATION ESTIMATES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON AN EVALUATION OF HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO THEIR OPERATIONS. PART III, LINE 8: ANY SHORT FALL WOULD BE A COMMUNITY BENEFIT BECAUSE THE SHORT FALL REFLECTS THE $ AMOUNT OF UNCOMPENSATED CARE PROVIDED THAT WE CAN NOT GET REIMBURSED FOR. WE HAVE NO ABILITY TO PASS THIS DOLLAR AMOUNT ONWARD FOR COLLECTION. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED [AUGUST 31, 2010] REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: THE COLLECTION DOES NOT DIFFER FOR THOSE INDIVIDUALS, IT REMAINS THE SAME. IF THERE IS NO PAYMENT IN 120 DAYS IT GOES TO COLLECTION AS A BAD DEBT. IF THEY ARE MAKING PAYMENTS IN ACCORDANCE WITH OUR GUIDELINES IT REMAINS ACTIVE A/R AT CCMH. IF THE PAYMENTS FALL SHORT OF PP THEN IT WILL GO TO COLLECTIONS. PART VI, LINE 2: WE HAVE NOT DONE A NEEDS ASSESSMENT AT THIS TIME. PART VI, LINE 3: YES, WE HAVE A LADY FROM MEDASSIST TO ASSIST PATIENTS ON THIS MATTER. PART VI, LINE 4: THE SERVICE AREA COVERS COSHOCTON COUNTY AND SOME OF TUSCARAWAS COUNTY. COSHOCTON'S POPULATION IS AROUND 37,000 PEOPLE WITH A TOTAL SERVICE AREA OF 50,000. PART VI, LINE 6: WE PURCHASED A LARGE PCP IN THE COMMUNITY AND MOVED THIS CLINIC TO A HOSPITAL BASED CLINIC. PART VI, LINE 7: N/A 0 X TUITION PAYMENTS ARE MADE FOR EMPLOYEES OR POTENTIAL EMPLOYEES WITH AGREEMENT TO REPAY WITH SERVICE 20 12957 X 1 1 X 0 0 0 0 0 0 0 0 0 DRJEROLD MEYER 137511 0 0 0 0 0 0 0 34378 0 171889 0 0 0 GREGORY NOWAK 244059 0 0 0 0 0 0 0 61015 0 305074 0 0 0 ROBERT MILLER 124071 0 0 0 0 0 0 0 31018 0 155089 0 0 0 DRROBERT GWINN 192111 0 0 0 0 0 0 0 48028 0 240139 0 0 0 DRDOUGLAS VIROSTKO 162510 0 0 0 0 0 0 0 40628 0 203138 0 0 0 DR TERRY OVERHOLSER 188118 0 0 0 0 0 0 0 47030 0 235148 0 0 0 DR CHRISTOPHER COULSON 183700 0 0 0 0 0 0 0 45925 0 229625 0 0 0 DR DOUGLAS HAMILTON 164814 0 0 0 0 0 0 0 41204 0 206018 0 0 0 TODD BROWN BANKING OFFICIAL AT THE BANK THE HOSPITAL USES N/A 0 DR JERALD MEYER HOSPITALIST 30500 HOSPITALIST COVERAGE 0 FORM 990, PART VI, SECTION B, LINE 11 REVIEW OF FORM 990 IS DONE BY THE CFO. FORM 990, PART VI, SECTION B, LINE 12C THE POLICIES ARE VIEWED ANNUALLY BY THE BOARD. EACH BOARD MEMBER SIGNS A CONFLICT OF INTEREST POLICY AND CONFIDENTIALITY POLICY AS WELL AS PARTICIPATING IN CONFLICT MANAGEMENT EDUCATION. THE EXECUTIVE SECRETARY OBTAINS ALL SIGNED COPIES BY THE BOARD MEMBERS. ANY CONFLICTS THAT ARISE DURING THE YEAR ARE DIRECTED TO THE BOARD CHAIRPERSON. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED BY A WRITE UP FROM MANAGEMENT PERFORMANCE INTERNATIONAL (MPI). THE OTHER COMPENSATION IS DETERMINED BY SALARY SURVEYS BY MPI AND DATA FROM THE OHIO HOSPITAL ASSOCIATION (OHA). THE HUMAN RESOURCE DIRECTOR AND CEO REVIEW THOSE DETERMINATIONS. FORM 990, PART VI, SECTION C, LINE 19 IF AN INDIVIDUAL REQUESTS TO SEE THIS INFORMATION HE/SHE WILL CONTACT THE ADMINISTRATION OFFICE. IT IS THEN APPROVED BY THE CEO OR CFO AND THE INFORMATION REQUESTED MUST BE REVIEWED ON THE HOSPITAL PREMISES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 108,943. CONTRIBUTIONS TO SUBSIDIARIES -2,382,963. CHANGE IN TEMPORARILY RESTRICTED NET ASSETS 66,853. TOTAL TO FORM 990, PART XI, LINE 5: -2,207,167. FORM 990, PART XI, LINE 2C NO CHANGE FROM PRIOR YEAR. CCMH GENESIS SLEEP LAB LLC 1460 ORANGE STREET COSHOCTON OH 43812 113682744 SLEEP DISORDERS OH COSHOCTON COUNTY MEMORIAL HOSPITAL 52879 27815 0 0 0.60000 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 CCMH GENESIS SLEEP LAB I CCMH GENESIS SLEEP LAB K