2011-11-10T11:52:56-06:00 2010-12-31 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-01-01 344428205 THE BELLEVUE HOSPITAL BELL 4194834040 1400 WEST MAIN STREET BELLEVUE OH 44811 MARK PIFER OD 4194834040 2011-10-26 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z MICHAEL K WINTHROP 1400 WEST MAIN STREET BELLEVUE OH 44811 45349750 0 X WWW.BELLEVUEHOSPITAL.COM X 1956 OH THE BELLEVUE HOSPITAL IS A COMMUNITY BASED GENERAL ACUTE CARE HOSPITAL THAT PROVIDES CARE TO THE BELLEVUE AND SURROUNDING AREA WITHOUT REGARD TO ABILITY TO PAY. 16 15 470 124 848 0 575637 160422 44820830 44514219 194183 110156 370424 333320 45961074 45118117 513500 35000 0 0 21811828 20519344 0 0 0 26108118 23239678 48433446 43794022 -2472372 1324095 53760774 54550412 29163287 29135676 24597487 25414736 X WE CARE FOR PATIENTS AS MEMBERS OF OUR FAMILY. WE WORK TO HEAL THE SICK, TREAT THE INJURED, AND PREVENT ILLNESS. WE PROTECT THE TRUST OF OUR COMMUNITY AND EMPLOYEES, TO BE A PROGRESSIVE, QUALITY HEALTH CARE ORGANIZATION. OUR PRIMARY GOAL IS AND ALWAYS WILL BE TO CARE. 0 0 38239123 35000 44564690 SEE SCHEDULE OTHE BELLEVUE HOSPITAL IS A COMMUNITY BASED GENERAL ACUTE CARE HOSPITAL THAT PROVIDES CARE TO THE BELLEVUE AND SURROUNDING COMMUNITY WITHOUT REGARD TO ABILITY TO PAY.OUR IMPACT ON THE BELLEVUE COMMUNITY: FOR THE CALENDAR YEAR ENDING DECEMBER 31, 2010, THE BELLEVUE HOSPITAL EMPLOYED A TOTAL OF 470 INDIVIDUALS AND MAINTAINED A MEDICAL STAFF MEMBERSHIP OF OVER 200 PHYSICIANS. THE HOSPITAL PAID A TOTAL OF ALMOST $16 MILLION IN WAGES AND SALARIES. OUR EMPLOYEES PAID A TOTAL OF $226,403 IN BELLEVUE CITY INCOME TAX AND AN ADDITIONAL $33,227 IN BELLEVUE CITY SCHOOL TAXES TO SUPPORT THE BELLEVUE COMMUNITY INFRASTRUCTURE AND EDUCATIONAL NEEDS. OUR EMPLOYEES LIVING IN OTHER LOCAL SCHOOL DISTRICTS PAID $18,580 IN CLYDE-GREEN SPRINGS LOCAL SCHOOL DISTRICT TAXES, $7,882 IN FREMONT LOCAL SCHOOL DISTRICT TAXES, AND $6,026 IN SENECA EAST SCHOOL DISTRICT TAXES. IN ADDITION, A TOTAL OF $581,296 OF THE HOSPITAL'S TOTAL GOODS AND SERVICES EXPENSED DURING 2010 WERE PURCHASED LOCALLY FROM BELLEVUE BUSINESSES AS WELL AS $85,098 FROM CLYDE BUSINESSES.SERVING THE BELLEVUE COMMUNITY: A TOTAL OF 2,091 COMMUNITY MEMBERS WERE ADMITTED TO OUR FACILITY DURING 2010. IN ADDITION, A TOTAL OF 58,105 VISITS WERE MADE FOR OUTPATIENT CARE. OUR EMERGENCY ROOM TREATED AN ADDITIONAL 16,334 PATIENTS DURING 2010 AND WE ASSISTED IN THE DELIVERY OF 372 BABIES. WE PROVIDED A TOTAL OF $17,691,693 IN FREE CARE TO 9,086 UNINSURED OR UNDERINSURED PATIENTS. 38239123 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 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 50 0 1 470 1 0 0 0 0 0 0 0 0 0 0 X 16 15 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X RACHEL HERMAN 4194834040 1400 W MAIN ST BELLEVUE OH 44811 MICHAEL K WINTHROP 40.00 X X 572730 0 20953 MARK PIFER OD 1.00 X X 0 0 0 GORDON GIBBS 1.00 X X 0 0 0 JAMES SHELLEY 1.00 X X 0 0 0 JOE WILSON 1.00 X X 0 0 0 JOHN BACON 1.00 X 0 0 0 DEAN MILLER 1.00 X 0 0 0 PAUL DOUGLAS 1.00 X 0 0 0 NANCY GREENSLADE 1.00 X 0 0 0 DWIGHT HOGUE 1.00 X 0 0 0 PAUL HOWARD 1.00 X 0 0 0 DOUG HOY MD 1.00 X 0 0 0 PATRICK MARTIN 1.00 X 0 0 0 BENJAMIN BALL DO 1.00 X X 0 0 0 NANCY BEIER 1.00 X 0 0 0 J WILLIAM SPRINGER 1.00 X 0 0 0 TIMOTHY BUIT 40.00 X 216471 0 1923 PATRICIA SEMER 40.00 X 124254 0 23044 JANET RUNNER 40.00 X 163119 0 16656 DEBORAH GANCI 40.00 X 177143 0 10489 DEBORAH O'TOOLE 40.00 X 95332 0 16746 CHRIS HIRT 40.00 X 112273 0 9612 ANDREW HUDDLESTON DO 1.00 X 0 0 0 1365990 0 82677 4 0 1 0 GENZYME GENETICS PO BOX 223614 PITTSBURGH PA 15251 LAB SERVICES 260969 KAUFMAN HALL 5202 OLD ORCHARD RD SUITE N700 SKOKIE IL 60077 CONSULTING 176572 THE HMC GROUP 29065 CLEMONS RD SUITE 200 WESTLAKE OH 44145 A/R COLLECTIONS 168973 PLANTE MORAN PLLC 16060 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 AUDIT/CONSULTING 125668 BELLEVUE ANESTHESIA ASSOCIATES LLC 2001 W MAIN STREET BELLEVUE OH 44811 ANESTHESIA SERVICES 122116 5 109463 50959 18863 160422 PATIENT SERVICES 621110 44290236 44290236 HEALTH DEPARTMENT 621110 83276 83276 COMMUNITY EDUCATION 621110 63802 63802 CONTRACT THERAPY 621110 21627 21627 55278 55278 44514219 118492 118492 200540 222193 -21653 -21653 -21653 1104 9440 -8336 -8336 -8336 CAFETERIA/CAFE 621110 257420 257420 VENDING MACHINES 621110 18619 18619 DIET CONSULTATION 621110 9669 9669 69265 50471 848 17946 354973 45118117 44564690 848 392157 20000 20000 15000 15000 808714 808714 14701278 12888939 1812339 423796 367889 55907 3443407 3018912 424495 1142149 1011534 130615 75170 75170 90811 90811 4415444 3871118 544326 188012 165450 22562 6194925 5575433 619492 31066 27338 3728 2952758 2515994 436764 18292 16097 2195 897023 786440 110583 2668742 2339746 328996 415563 412042 3521 BAD DEBT EXPENSE 4147126 4147126 FRANCHISE FEE 538158 538158 RECRUITMENT 393251 386723 6528 PROF DEVELOPMENT 93154 93154 GRANT-FUNDED EXPENSES 39060 39060 81123 2970 78153 43794022 38239123 5554899 0 2188391 4664604 4050926 4004563 268380 24776 321525 314835 381767 409001 60161103 23229506 39069890 36931597 6352053 6748272 1127842 1452764 53760774 54550412 4144966 4736499 11500 23598462 22788326 284877 153161 1134982 1446190 29163287 29135676 X 24597487 25414736 24597487 25414736 53760774 54550412 X 1324095 -506846 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1863 1863 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: FIVE PERCENT OF DUES TO THE OHIO HOSPITAL ASSOCIATION WAS ALLOCATED TO LOBBYING ACTIVITIES BY THAT ORGANIZATION. 2031679 2031679 37244484 6926932 30317552 14418499 11285073 3133426 6466441 5017501 1448940 36931597 THIRD PARTY SETTLEMENT 756153 DERIVATIVE LIABILITY 577714 OTHER LIABILITIES 112323 1446190 45118117 43794022 1324095 139119 -645965 -506846 817249 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN FMV OF INTEREST RATE SWAP AGREEMENTS -79,965. CONTRIBUTION OF CAPITAL TO BELLEVUE PROFESSIONAL SERVICES, INC. -566,000. 1 1 X 1 X 1 X 1 1 0 1 1 1010698 915936 94762 0.00240 5215112 3607077 1608035 0.04060 6225810 4523013 1702797 0.04300 133679 42233 91446 0.00230 6562 0 6562 0.00020 48708 0 48708 0.00120 23167 0 23167 0.00060 212116 42233 169883 0.00430 6437926 4565246 1872680 0.04730 13000 13000 0.00030 5327 5327 0.00010 18327 18327 0.00040 0 1771237 120196 8105553 11025559 -2920006 X 1 1 1 1 THE BELLEVUE HOSPITAL

1400 WEST MAIN STREET BELLEVUE OH 44811

X X X SWING BED - SNF HOME HEALTH NA 1 PART I, LINE 3C: THE HOSPITAL USES FEDERAL POVERTY GUIDELINES. PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 2 METHOD TO CALCULATE THE COST TO CHARGE RATIO. PART I, LINE 7G: NOT APPLICABLE PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 4147126. PART II: OUR HOSPITAL PARTICIPATES IN SEVERAL COMMUNITY BUILDING ACTIVITIES WHICH ARE INCLUDED IN PART II. THESE ACTIVITIES INCLUDE: ECONOMIC DEVELOPMENT: ACTIVE ROLE WITH BELLEVUE, CLYDE AND SANDUSKY COUNTY ECONOMIC DEVELOPMENT ORGANIZATIONS TO CREATE NEW EMPLOYMENT OPPORTUNITIES, INCLUDING HEALTHCARE COVERAGE, IN AN AREA EXPERIENCING HIGH JOBLESS RATES. COMMUNITY SUPPORT: PROVIDE SUPPORT FOR LOCAL UNITED SELECTIVE FUND CAMPAIGN AND OTHER LOCAL NON-PROFIT ORGANIZATIONS. PART III, LINE 4: FOOTNOTE IN FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE: 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 HOSPITAL'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. BAD DEBT EXPENSE REPORTED IN PART III, LINE 2, IS RECORDED AT COST USING THE COST TO CHARGE RATIO CALCULATED ON WORKSHEET 2. IT IS ESTIMATED THAT $120,196 OF OUR ORGANIZATION'S BAD DEBT EXPENSE (AT COST) MAY BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE AND SHOULD BE COUNTED AS COMMUNITY BENEFIT. THIS ESTIMATE IS BASED ON PATIENTS IDENTIFIED WITH UNDOCUMENTED OR INCOMPLETE INFORMATION. AS A NOT-FOR-PROFIT HOSPITAL, PATIENT CARE IS PROVIDED TO ALL PATIENTS, REGARDLESS OF THEIR ECONOMIC MEANS, WHICH QUALIFIES BAD DEBT AS A COMMUNITY BENEFIT. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING THE MEDICARE COST REPORT, WHICH USES A COST TO CHARGE RATIO ALLOWED UNDER MEDICARE COST REPORT METHODOLOGY. THE HOSPITAL BELIEVES THAT THE $2,920,006 SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE PAYMENTS THAT ARE LESS THAN COST MUST BE ABSORBED BY THE HOSPITAL IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITY. IN 2010, MEDICARE ACCOUNTED FOR 37.57% OF HOSPITAL REVENUES. THE HOSPITAL PROVIDES CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVES THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. PART III, LINE 9B: COLLECTION POLICIES ARE THE SAME FOR ALL PATIENTS. THE HOSPITAL WILL PURSUE PAYMENT FOR CARE FROM EVERY REASONABLE SOURCE, GOVERNMENTAL AND PRIVATE. TO ENSURE THIS IS COMPLETED, INSURANCE VERIFICATION IS PERFORMED, A SYSTEM REVIEW IS MADE OF THE PATIENT'S INSURANCE HISTORY, AND TELEPHONE CALLS ARE MADE TO THE PATIENT. IF THE PATIENT IS ELIGIBLE FOR HCAP, THE COVERED CHARGES ARE WRITTEN OFF TO HCAP. IF THE PATIENT IS LATER FOUND TO BE ELIGIBLE FOR MEDICAID, THE HCAP WRITE-OFF IS REVERSED AND THE ACCOUNT BILLED TO MEDICAID. BAD DEBT ACCOUNTS ELIGIBLE FOR CHARITY ARE REINSTATED FROM BAD DEBT AND POSTED TO THE APPROPRIATE ADJUSTMENT OR CHARITY WRITE-OFF CODES. PART VI, LINE 2: THE BELLEVUE HOSPITAL IS A MEMBER OF HEALTH PARTNERS, A GROUP OF HEALTH ORGANIZATION CEO'S IN SANDUSKY COUNTY. THE GROUP DETERMINES THE ONGOING NEEDS OF THE COMMUNITY BY CONDUCTING COMPREHENSIVE HEALTH ASSESSMENTS FOR ADULTS AGES 19-75 EVERY FOUR YEARS, AND EVERY TWO YEARS FOR YOUTH AGES 12-18. IN ADDITION, THE BOARD STRATEGIC PLANNING COMMITTEE IS COMPRISED OF SEVERAL COMMUNITY BUSINESS LEADERS WHO ASSESS THE NEEDS 0F THE COMMUNITY AND MAKES RECOMMENDATIONS. THE HOSPITAL ALSO USES ITS PATIENT SATISFACTION SURVEY TO OBTAIN SUGGESTIONS FOR SERVICES. PART VI, LINE 3: THE HOSPITAL POSTS NOTICES IN APPROPRIATE AREAS IN THE FACILITY, INCLUDING BUT NOT LIMITED TO THE ADMISSIONS AREAS, THE PATIENT FINANCE OFFICE, AND THE EMERGENCY DEPARTMENT. THE NOTICE SPECIFIES THE RIGHTS OF PERSONS WITH INCOMES AT OR BELOW THE FEDERAL POVERTY GUIDELINES (FPG) TO RECEIVE, WITHOUT CHARGE TO THE INDIVIDUAL, BASIC, MEDICALLY NECESSARY HOSPITAL-LEVEL SERVICES AT THE HOSPITAL. THE INITIAL BILL AND AT LEAST THE FIRST FOLLOW-UP BILL HAS A WRITTEN STATEMENT THAT EXPLAINS THAT INDIVIDUALS WITH INCOME AT OR BELOW THE FPG ARE ELIGIBLE FOR SERVICE WITHOUT CHARGE, SPECIFIES THE FPG FOR INDIVIDUALS AND FAMILIES OF VARIOUS SIZES AT THE TIME THE BILL IS SENT, AND DESCRIBES THE PROCEDURE TO APPLY FOR FREE CARE. THE PATIENT FINANCE OFFICE AND PATIENT ACCESS DEPARTMENTS WILL PROVIDE APPLICATIONS FOR FINANCIAL ASSISTANCE TO PATIENTS. A DETERMINATION OF EVERY APPLICATION WILL BE COMPLETED BY THE PATIENT FINANCE OFFICE AND A COPY SENT TO THE PATIENT. PART VI, LINE 4: BELLEVUE, OHIO IS A CITY IN ERIE, HURON, SANDUSKY AND SENECA COUNTIES OF OHIO. IT IS THE ONLY MUNICIPALITY IN THE STATE OF OHIO TO SPAN FOUR COUNTIES. ACCORDING TO THE U.S. CENSUS BUREAU, THE FOUR COUNTY AREA HAS A TOTAL LAND AREA OF 1707.34 SQUARE MILES. AS OF THE 2010 CENSUS, THE FOUR COUNTY POPULATION WAS 254,394, A 2.01% DECLINE SINCE THE 2000 CENSUS, WITH A DENSITY OF 149 PEOPLE PER SQUARE MILE, PREDOMINANTLY WHITE, HIGH SCHOOL EDUCATED. THE FOUR COUNTY AREA HAS BEEN HIT EXTREMELY HARD DURING THE RECENT ECONOMIC RECESSION. MANY AREA MANUFACTURING COMPANIES HAVE CLOSED THEIR DOORS AND THE FEW COMPANIES THAT ARE NEW TO THE AREA PAY MINIMUM WAGE OR SLIGHTLY HIGHER. THE U.S. DEPARTMENT OF LABOR, BUREAU OF LABOR STATISTICS, REPORTS THE UNEMPLOYMENT RATE FOR THE FOUR COUNTY AREA WAS 10.6% FOR DECEMBER 2010, DOWN FROM 13.6% IN DECEMBER 2009, AND SLIGHTLY HIGHER THAN OHIO'S STATEWIDE UNEMPLOYMENT RATE OF 10.1% AND THE NATIONWIDE UNEMPLOYMENT RATE OF 9.6%. HURON COUNTY RANKED 10TH IN THE STATE OF OHIO IN 2010 WITH AN ANNUAL AVERAGE UNEMPLOYMENT RATE OF 13.5%. MEDIAN HOUSEHOLD INCOMES RANGED FROM $39,481 IN SENECA COUNTY TO $46,542 IN HURON COUNTY. ACCORDING TO THE BUREAU OF THE CENSUS, 2009 POVERTY RATES, THE LATEST AVAILABLE, RANGED FROM 12.2% FOR SANDUSKY COUNTY TO 14.6% FOR ERIE COUNTY. OHIO DEPARTMENT OF JOB & FAMILY SERVICES REPORTED THAT 55,100 RESIDENTS, OR 21.66% OF RESIDENTS IN THE FOUR COUNTY AREA WERE ENROLLED IN MEDICAID DURING 2009. SANDUSKY COUNTY IS ALSO DESIGNATED AS BOTH A MEDICALLY UNDERSERVED AREA AND AS A PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREA. PART VI, LINE 6: MEDICAL STAFF PRIVILEGES ARE OPEN TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. THE HOSPITAL BOARD OF DIRECTORS IS COMPRISED OF LOCAL MEDICAL AND BUSINESS PROFESSIONALS WHO VOLUNTEER COUNTLESS HOURS OF SERVICE TO THE HOSPITAL IN THEIR OVERSIGHT ROLE OF GENERAL STEWARDSHIP. THE HOSPITAL EXPANDS ACCESS POINTS OF CARE THROUGHOUT THE COMMUNITY BY PROVIDING FREE OR LOW-COST BLOOD PRESSURE, DIABETES, CHOLESTEROL, SKIN CANCER, PROSTATE CANCER AND OTHER SCREENINGS. EDUCATIONAL PROGRAMS AND SUPPORT GROUPS ARE HELD TO PROVIDE INFORMATION ON SUCH TOPICS AS TOBACCO CESSATION, WEIGHT MAINTENANCE, DIABETES, CHILDBIRTH, INFANT CARE, AND MORE. HOSPITAL EMPLOYEES SERVE ON THE BOARDS OF MANY COMMUNITY AND HEALTH-ORIENTED ORGANIZATIONS. THE HOSPITAL ALSO PARTICIPATES IN COMMUNITY-WIDE AND REGIONAL-WIDE MASS CASUALTY AND DISASTER PREPAREDNESS WITH 33 OTHER REGIONAL HOSPITALS AS A MEMBER OF THE HOSPITAL COUNCIL OF NORTHWEST OHIO, TO ASSURE THE SAFETY AND HEALTH OF COMMUNITY RESIDENTS IN THE EVENT OF A NATURAL DISASTER, INDUSTRIAL ACCIDENT, BIOTERRORISM OR OTHER LARGE SCALE EMERGENCY. MEMBERSHIP BENEFITS INCLUDE INCREASED PURCHASING POWER FOR DISASTER SUPPLIES, EMERGENCY RESPONSE TRAINING, INCIDENT COMMAND, AND INFORMATION SHARING TO KEEP COMPLIANT WITH HOMELAND SECURITY REGULATIONS. PART VI, LINE 7: BELLEVUE HOSPITAL IS A GENERAL ACUTE CARE PROVIDER AT ONE FACILITY IN THE BELLEVUE, OHIO AREA. BELLEVUE HOSPITAL IS THE PARENT ORGANIZATION OF THE BELLEVUE HOSPITAL ASSOCIATION, BELLEVUE PROFESSIONAL SERVICES, AND THE SOLE BENEFICIARY OF THE BELLEVUE HOSPITAL FOUNDATION.THE BELLEVUE HOSPITAL ASSOCIATION MEETS ANNUALLY IN FEBRUARY TO ELECT THE BELLEVUE HOSPITAL BOARD OF TRUSTEES AND TO CONDUCT ANY NECESSARY BUSINESS.BELLEVUE PROFESSIONAL SERVICES PROVIDES CLINICAL AND MEDICAL PROFESSIONAL SERVICES TO RESIDENTS OF BELLEVUE AND CLYDE, OHIO AND THE SURROUNDING AREA.THE BELLEVUE HOSPITAL FOUNDATION SUPPORTS THE BELLEVUE HOSPITAL WITH FINANCIAL TRANSFERS IN THE FORM OF BOTH CASH AND NON-CASH TRANSFERS. 1 BELLEVUE DEVELOPMENT CORPORATION 110 WEST MAIN STREET BELLEVUE OH 44811 341397769 501(C)(3) 5000 SUPPORT OF ECONOMIC DEVELOPMENT PROGRAMS IN BELLEVUE CLYDESCOPE ECONOMIC DEVELOPMENT CORP 222 N MAIN STREET CLYDE OH 43410 341811627 501(C)(6) 5000 SUPPORT OF ECONOMIC DEVELOPMENT PROGRAMS IN CLYDE TERRA COLLEGE FOUNDATION 2830 NAPOLEON RD FREMONT OH 43420 341650500 501(C)(3) 10000 FUNDING FOR LABORATORY EQUIPMENT FOR THEIR NEW ALLIED HEALTH PROGRAM 2 1 EMPLOYEE CHILDREN'S SCHOLARSHIPS 10 15000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: PART II: THE HOSPITAL HAS REPRESENTATION ON THE BOARDS OF LOCAL ECONOMIC DEVELOPMENT CORPORATIONS. IN ADDITION IT PROVIDED FUNDS TO A RELATED ORGANIZATION, BELLEVUE PROFESSIONAL SERVICES, INC. PART III: SCHOLARSHIP PAYMENTS ARE MADE DIRECTLY TO THE COLLEGES AFTER PROOF OF ENROLLMENT IS RECEIVED. X X X X X 0 1 0 0 0 0 0 0 0 MICHAEL K WINTHROP 545668 0 20000 0 7062 0 5513 0 15440 0 593683 0 0 0 TIMOTHY BUIT 203971 0 12500 0 0 0 0 0 1923 0 218394 0 0 0 JANET RUNNER 163119 0 0 0 0 0 2761 0 13895 0 179775 0 0 0 DEBORAH GANCI 173143 0 4000 0 0 0 2679 0 7810 0 187632 0 0 0 PART I, LINE 4B DURING 2010 THE FOLLOWING PEOPLE RECEIVED DEFERRED COMPENSATION FROM THE BELLEVUE HOSPITAL FOR THE FOLLOWING AMOUNT: MICHALE WINTHROP 457(F) $251,409 DEBORAH GANCI 457(F) 58,568 JANET RUNNER 457(F) 44,034 THE AMOUNT LISTED ABOVE IS INCLUDED IN COMPENSATION REPORTED IN SCHEDULE J, PART II. THE PLAN PROVIDES THAT A PARTICIPANT BECOMES ENTITLED TO PAYMENT IN LUMP SUM AT THE EARLIER OF HIS OR HER ENTITLEMENT DATE OR THE DATE OF A TRIGGERING SEVERANCE, PROVIDED THAT A PARTICIPANT FORFEITS HIS OR HER ENTIRE BENEFIT IF HE OR SHE SEVERS SERVICE WITH THE EMPLOYER FOR ANY REASON PRIOR TO COMPLETING FIVE YEARS OF SERVICE. ELIGIBLE PARTICIPANTS WERE ENTITLED TO A PAYMENT IN A SINGLE LUMP-SUM ON OR BEFORE MARCH 15, 2010 (OR SUCH LATER DATE DURING 2010 AS OF WHICH THE EMPLOYER HAS SUFFICIENT FUNDS TO MAKE THE PAYMENTS WITHOUT JEOPARDIZING THE EMPLOYER'S CONTINUATION AS A GOING CONCERN). PAYMENT OF THESE AMOUNTS SATISFIES THE EMPLOYER'S OBLIGATIONS UNDER THE PLAN. BECAUSE OF CHANGES IN THE TAX LAWS, TERMINATION OF THE PLAN EFFECTIVE UPON THE MAKING OF SUCH PAYMENTS IS IN THE CORPORATION'S BEST INTEREST. CITY OF BELLEVUE 346400096 079277BC2 2003-08-01 11000000 FINANCE NEW HOSPITAL FACILITY 0 0 0 CITY OF CLYDE 346400315 9940680S4 2003-07-01 10000000 FINANCE NEW HOSPITAL FACILITY 0 0 0 CITY OF SANDUSKY 346401312 9940680T2 2003-08-01 6000000 FINANCE NEW HOSPITAL FACILITY 0 0 0 2060068 11323999 218941 97199 11105058 2005 0 0 1 1 1920194 10023197 77750 9945447 2004 1 0 1 1 1082449 6055301 44500 6010801 2004 0 0 1 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 PRESIDENT MICHAEL WINTHROP AND TRUSTEE DEAN MILLER HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS MADE AVAILABLE TO THE PRESIDENT & VP FINANCE AT THE FINANCE MEETING FOR REVIEW AS WELL AS PRESENTATION TO THE BOARD OF DIRECTORS AT THE OCTOBER MEETING. IN ADDITION, EACH BOARD MEMBER RECEIVES A COPY OF FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, THE PRESIDENT SHALL SEND TO ALL EXECUTIVE STAFF AND SELECTED EMPLOYEES, A COPY OF THE BOARD OF TRUSTEES CONFLICT OF INTEREST POLICY TO BE COMPLETED AND RETURNED. IN ADDITION, NEW BOARD MEMBERS THAT JOIN DURING THE YEAR FILL OUT AND COMPLETE THE CONFLICT OF INTEREST POLICY WHEN THEY FIRST JOIN. AN APPROPRIATE REPORT SHALL BE SUBMITTED TO THE BOARD OF TRUSTEES CONCERNING ANY INTERESTS TO BE DISCLOSED. IF ANY CONFLICTS DO ARISE, THAT TRUSTEE WILL ABSTAIN FROM VOTING ON THE ISSUE. PERIODIC REVIEWS ARE ALSO CONDUCTED TO ENSURE THAT THE CORPORATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES, AND THAT IT DOES NOT ENGAGE IN ACTIVITIES THAT COULD JEOPARDIZE ITS STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD HAS A COMPENSATION COMMITTEE COMPRISED OF INDEPENDENT DIRECTORS. THE COMMITTEE UTILIZES AN OUTSIDE HEALTHCARE COMPENSATION CONSULTING COMPANY COMPARING COMPARABLE SIZED ORGANIZATIONS CONSISTENT WITH THE BOARD OF TRUSTEE COMPENSATION PHILOSOPHY STATEMENT. RECOMMENDATIONS ARE MADE FROM THE COMPENSATION COMMITTEE TO THE BOARD OF TRUSTEES. ANY COMPENSATION DECISIONS THAT ARE MADE ARE DOCUMENTED IN THE MINUTES OF THE EXECUTIVE COMPENSATION COMMITTEE AND EXECUTIVE SESSION MINUTES. THIS PROCESS WAS LAST UNDERTAKEN IN NOVEMBER 2010. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 1023 AND FORM 990, AND FORM 990-T AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND THE FINANCIAL STATEMENTS ARE NOT CURRENTLY AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 139,119. CHANGE IN FMV OF INTEREST RATE SWAP AGREEMENTS -79,965. CONTRIBUTION OF CAPITAL TO BELLEVUE PROFESSIONAL SERVICES, INC. -566,000. TOTAL TO FORM 990, PART XI, LINE 5: -506,846. FORM 990, PART XII, LINE 2C THE PROCESS FOR OVERSIGHT OF THE AUDIT AS WELL AS SELECTION OF THE INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. THE BELLEVUE HOSPITAL FOUNDATION 1400 WEST MAIN STREET BELLEVUE OH 44811 341745374 SUPPORT OH 501(C)(3) LINE 11A, I N/A 1 THE BELLEVUE HOSPITAL ASSOCIATION 1400 WEST MAIN STREET BELLEVUE OH 44811 753102199 ADMINISTRATIVE SUPPORT OH 501(C)(3) LINE 11A, I N/A 1 BELLEVUE HEALTH NETWORK LLC 1400 WEST MAIN STREET BELLEVUE OH 44811 341870470 INSURANCE CONTRACTS OH N/A RELATED -2600 44 0 1 0.55560 BELLEVUE PROFESSIONAL SERVICES INC 1400 WEST MAIN STREET BELLEVUE OH 44811 341828724 PHYSICIAN SERVICES OH N/A C 1711038 452078 1.00000 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 0 1 BELLEVUE PROFESSIONAL SERVICES INC A 47562 LEASE PAYMENT BELLEVUE PROFESSIONAL SERVICES INC B 566000 FMV - CASH THE BELLEVUE HOSPITAL FOUNDATION C 90600 FMV - CASH THE BELLEVUE HOSPITAL FOUNDATION C 18863 FMV - BOOK