2011-08-12T14:12:20-05:00 2010-09-30 Tyler Simms & StSauveur CPAS PC 19 Morgan Drive Lebanon NH 03766 990 2009-10-01 020276210 Upper Connecticut Valley Hospital UPPE 6032374971 Corliss Lane Colebrook NH 03576 JAMES TIBBETTS 6032374971 2011-08-12 1 W JAY SIMMS 6036530044 2009 2016-02-24 21:20:13Z WINSTON YOUNG Corliss Lane Colebrook NH 03576 15984747 0 X www.dartmouth-hitchcock.org/ucvh X 1969 NH TO PROVIDE HEALTH CARE SERVICES. 12 11 181 10 0 0 82132 289409 15395908 15311159 -116502 -90458 460518 381051 15822056 15891161 0 0 8144676 7462102 0 15801 8586381 8119979 16731057 15582081 -909001 309080 14933689 15323454 4543148 4077709 10390541 11245745 UPPER CONNECTIBUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURUAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 0 1 12655052 15657229 UPPER CONNECTICUT VALLEY HOSPTIAL PROVIDED HOSPITAL CARE AND INPATIENTS AND OUTPATIENTS SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2010 WAS $674,556 FOR 805 PATIENTS. 12655052 1 1 0 1 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 42 0 1 181 1 0 0 0 0 0 0 0 0 0 0 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X THE ORGANIZATION 6032374971 UCVH CORLISS LANE COLEBROOK NH 03576 JOHN FOTHERGILL MD 1.00 X 0 0 0 GREG PLACY 1.00 X X 0 0 0 E HARLAN CONNARY 1.00 X X 0 0 0 JAMES TIBBETTS 1.00 X X 0 0 0 NEIL P COUTURE 1.00 X 0 0 0 THE REV CRAIG CHENEY 1.00 X 0 0 0 PALMER LEWIS 1.00 X 0 0 0 LOUISE MCCLEERY 40.00 X X 140359 0 9986 BRUCE BEAN 1.00 X 0 0 0 WINSTON YOUNG 1.00 X X 0 0 0 ODETTE CRAWFORD 1.00 X 0 0 0 SHIRLEY POWELL 1.00 X 0 0 0 FERIAL LADAK MD 34.00 X X 182321 0 9868 GERALD WESTOVERMD 30.00 X 176712 0 16315 WILLIAM SPINA MD 42.00 X 249765 0 16454 ROBERT SOUCY MD 47.00 X 207746 0 25823 ROBERT GOOCH 47.00 X 162070 0 2867 1118973 0 81313 11 0 1 0 0 46882 242527 289409 NET PATIENT REVENUE 621990 15311159 15311159 15311159 3128 3128 67030 26556 -67030 -26556 -93586 -93586 SCHOOL NURSE PROGRAM 900099 141644 141644 CAFETERIA 900099 34981 34981 MEDICAL RECORD SERVICE 900099 2823 2823 201603 201603 381051 15891161 15657229 0 -55477 390618 253503 137115 5670619 5009028 661591 998570 873233 125337 402295 349639 52656 34646 34646 71600 71600 1394204 1275895 118309 259869 259869 81368 67535 13833 69866 69866 727526 727526 110505 110505 PURCHASED SERVICES 1913817 1337825 575992 PROVISION FOR BAD DEBT 1284760 1284760 MEDICAID ENHANCEMENT TA 743001 743001 MISCELLANEOUS 424790 405459 3530 15801 PHYSICIAN fees 332073 261623 70450 671954 549157 122797 15582081 12655052 2911228 15801 585595 294199 189323 1053141 41575 2555674 1746800 300141 274613 174959 226949 11241395 6523037 5208726 4718358 5390644 6068555 378438 579110 108614 361729 14933689 15323454 1439405 741642 114472 85173 2004687 1863899 984584 1386995 4543148 4077709 X 9157670 9872249 1163686 1304311 69185 69185 10390541 11245745 14933689 15323454 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4801 4801 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Upper connecticut valley hospital is a member of the new hampshire hospital association and THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF UCVH AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT DIRECLTY PERFORM ANY LOBBYING ACTIVITIES. 112258 12856 125114 111704 554 112258 0.00000 0.55000 0.45000 0 0 9700 9700 4233668 1809148 2424520 347676 189407 158269 6650351 4524482 2125869 4718358 DUE TO THIRD PARTY PAYERS 1347485 CAPITAL LEASE 39510 1386995 15891161 15582081 309080 546124 546124 855204 16421484 546124 546124 15875360 15801 15801 15891161 15566280 0 15566280 15801 15801 15582081 Part V, Line 4: Description of Intended Use of Endowment Funds: THE INVESTMENTS ARE TO BE HELD IN PERPETUITY. THE INCOME FROM THE INVESTMENTS IS EXPENDABLE TO SUPPORT THE HOSPITAL'S HEALTH CARE SERVICES. Part XII, Line 4b - Other Adjustments: FUNDRAISING EXPENSES: 15801. Part XIII, Line 4b - Other Adjustments: FUNDRAISING EXPENSES: 15801. 1 1 1 X 1 X 1 1 0 1 1 470266 470266 0.03290 470266 470266 0.03290 50048 50048 0.00350 106606 106606 0.00750 156654 156654 0.01100 626920 626920 0.04390 1 1284760 128476 5081231 6608299 -1527068 X 1 0 UPPER CONNECTICUT VALLEY HOSPITAL

181 CORLISS LANE COLEBROOK NH 03576

X X X X Part III, Line 8: ALLOWABLE COSTS COME FROM THE FILED COST REPORT. AS UCVH OPERATES AT A LOSS FROM MEDICARE, THE SHORTFALL COULD BE TREATED AS COMMUNITY BENEFIT AS THERE ARE NO OTHER FUNDS AVAILABLE TO SUBSIDIZE THE LOSS. Part VI, Line 2: UCVH ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES THROUGH A VARIETY OF METHODOLOGIES. FOR EXAMPLE, UCVH CONDUCTS COMMUNITY HEALTH CARE SCREENINGS AT BUSINESSES AND SCHOOLS FOR "REAL TIME" ASSESSMENTS. THESE SCREENING ASSESS HEALTH THROUGH SUCH THINGS AS BLOOD TESTING FOR GLUCOSE AND CHOLESTEROL, BLOOD PRESSURE CHECKS, AND SKIN CANCER AWARENESS EDUCATION. VOUCHERS ARE OFFERED FOR COUNSELING ABOUT THE TEST RESULTS, AND DIRECT FEEDBACK FROM THE PARTICIPANTS ABOUT THEIR HEALTH CARE NEEDS IS RECEIVED ONE-ON-ONE IN A PRIVATE AREA. FEEDBACK FROM THE SCREENINGS IS USED TO PREPARE EDUCATIONAL TOPICS FOR PUBLIC EDUCATION, AND TO HELP PLAN FOR FUTURE SCREENINGS. ANOTHER METHODOLOGY USED BY UCVH IS A COMMUNITY NEEDS ASSESSEMENT USING FOCUS GROUP INTERVIEWS, AN ANAYLSIS OF COOS COUNTY BEHAVIORAL AND RISK FACTOR SURVEILLANCE STATISTICS, AND COMPARISONS OF PREVIOUS COMMUNITY NEEDS ASSESSMENTS. Part VI, Line 3: UCVH IS A CHARITABLE HEALTH CARE ORGANIZATION AND A DESIGNATED CRITICAL ACCESS HOSPITAL. UCVH WILL TREAT PATIENTS WHO COME TO US FOR NON-ELECTIVE, MEDICALLY NECESSARY CARE, REGARDLESS OF THEIR FINANCIAL STATUS. WE OFFER FINANCIAL ASSISTANCE FOR THESE SERVICES - IN THE FORM OF FREE OR DISCOUNTED CARE - TO THOSE PATIENTS WHO ARE UNABLE TO PAY THEIR BILLS.THE PATIENTS OR THEIR FAMILY REPRESENTATIVES MUST COMPLETE AN APPLICATION AND PROVIDE INFORMATION THAT SUPPORTS THEIR FINANCIAL NEED. ALL APPLICATIONS RECEIVED WILL BE PROCESSED UNDER BOTH THE NHHAN GUIDELINES AS PUBLISHED IN THE NHHAN MANUAL AND THE UCVH GUIDELINES. PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE NHHAN GUIDELINES WILL RECEIVE A PORTABLE CARD THAT WILL BE HONORED AT OTHER NEW HAMPSHIRE PARTICIPATING MEDICAL FACILITIES. UCVH GUIDELINES ARE ONLY APPLICABLE TO SERVICE RENDERED AT OUR SERVICE LOCATIONS AND ARE NOT PORTABLE. Part VI, Line 4: THE UCVH SERVICE AREA IS COMPRISED OF SIX COMMUNITIES IN NORTHERN NEW HAMPSHIRE (COLEBROOK, STRATFORD, PITTSBURG, STREWARTSTOWN, COLUMBIA, AND CLARKSVILLE), AS WELL AS EIGHT OTHER SMALL COMMUNITIES IN VERMONT AND TWO IN MAINE. THE REGIONAL HEALTH PROFILE ASSESSED OUR POPULATION AT APPROXIMATELY 8,500 COVERING 850 SQUARE MILES. THE MAJOR ISSUES OF THE COMMUNITY THAT UCVH SERVES ARE GEOGRAPHIC AND ECONOMIC BARRIERS, AND THE POVERTY-RELATED ISSUES OF SUBSTANCE ABUSE AND TEEN PREGNANCY. NH X X 0 0 0 0 0 0 0 0 0 LOUISE MCCLEERY 140359 0 0 0 0 0 2800 0 7186 0 150345 0 0 0 FERIAL LADAK MD 182321 0 0 0 0 0 0 0 9868 0 192189 0 0 0 GERALD WESTOVERMD 176712 0 0 0 0 0 0 0 16315 0 193027 0 0 0 WILLIAM SPINA MD 249765 0 0 0 0 0 480 0 15974 0 266219 0 0 0 ROBERT SOUCY MD 207746 0 0 0 0 0 3580 0 22243 0 233569 0 0 0 ROBERT GOOCH 162070 0 0 0 0 0 2496 0 371 0 164937 0 0 0 Form 990, Part III, line 3 Changes in Program Services HOME HEALTH WAS DISCONTINUED BY UCVH ON 6/30/10. THROUGH COLLABORATION WITH WEEKS MEDICAL CENTER, AN EXPANDED HOME HEALTH SERVICE WILL BE OFFERED TO THOSE SAME COMMUNITIES. Form 990, Part VI, Section B, line 11 THE 990 IS PROVIDED TO THE FINANCE COMMITTEE FOR REVIEW AND APPROVAL BEFORE IT IS FILED. Form 990, Part VI, Section B, line 12c OFFICERS, DIRECTORS, AMD KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST DOCUMENT. Form 990, Part VI, Section B, line 15 THE HOSPITAL CEO'S COMPENSATION AND BENEFIT PACKAGE WAS REVIEWED PERIODICALLY BY COMMUNITY BOARD MEMBERS WHO GOVERN THE NON-PROFIT ORGANZATION AS UNPAID, INDEPENDENT VOLUNTEERS. THE PERIODIC REVIEW INCLUDED COMPARABILITY DATA, AND THE DELIBERATION AND DECISION-MAKING was SUBSTANTIATED BY WRITTEN MINUTES. Form 990, Part VI, Section C, line 18 UVCH MAKES ITS 990 AVAILABLE UPON REQUEST AND ON THE GUIDESTAR WEBSITE Form 990, Part VI, Section C, line 19 AVAILABLE UPON REQUEST WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 020222242 HOSPITAL NH 501C(3) 170(B)(1)(A)III MARY HITCHCOCK MEMORIAL HOSPITAL 1 MEDICAL CENTER DRIVE LEBANON NH 03756 020222140 HOSPITAL NH 501C(3) 170(B)(1)(A)III DARTMOUTH-HITCHCOCK CLINIC 1 MEDICAL CENTER DRIVE LEBANON NH 03756 222519596 MEDICAL CLINIC NH 501C(3) 509(A)(2) 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 MARY HITCHCOCK MEMORIAL HOSPITAL E 252174 MARY HITCHCOCK MEMORIAL HOSPITAL L 14715 NEW ENGLAND ALLIANCE FOR HEALTH L 158080 DARTMOUTH-HITCHCOCK CLINIC L 21029 WEEKS MEDICAL CENTER L 6497