2024-08-15T15:04:08-05:00 2023-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-10-01 020276210 UPPER CONNECTICUT VALLEY HOSPITAL UPPE 6032374971 181 CORLISS LANE COLEBROOK NH 03576 MATTHEW STREETER SYSTEM CFO 6032374971 2024-08-15 1 0 MICHAEL J PETERSON CPA P01833529 2187224705 2024-08-14 2022 2024-08-08 14:25:15Z SCOTT COLBY 181 CORLISS LANE COLEBROOK NH 03576 37307307 0 X WWW.UCVH.ORG X 1969 NH UPPER CONNECTICUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 14 11 166 8 0 0 1482685 477868 26393144 35980776 1059454 740186 142420 108477 29077703 37307307 140045 249399 0 0 13868190 12087222 0 0 0 12591581 19042315 26599816 31378936 2477887 5928371 40304391 41887833 11536994 6581227 28767397 35306606 UPPER CONNECTICUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 0 0 23696997 249399 35892258 UPPER CONNECTICUT VALLEY HOSPITAL PROVIDED HOSPITAL CARE AND INPATIENT AND OUTPATIENT SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2023 WAS $294,184. 23696997 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 29 0 166 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X MATTHEW STREETER 6033265610 8 CLOVER LANE WHITEFIELD NH 03598 EDWARD LAVERTY PA-C CHIEF MEDICAL OFFICER 40.00 X 337261 0 45786 ROBERT DAWSON PRESIDENT OF MEDICAL STAFF 1.00 39.00 X 0 23256 0 LYNN BREWER CHAIR 39.00 1.00 X X 12294 0 0 MORGAN WADE VICE CHAIR 1.00 X X 0 0 0 JAMES WELLS TREASURER 1.00 X X 0 0 0 ERIC STOHL SECRETARY 1.00 1.00 X X 0 0 0 JEANNINE BURNS DIRECTOR 1.00 X 0 0 0 FR CRAIG CHENEY DIRECTOR 1.00 X 0 0 0 E HARLAN CONNARY DIRECTOR 1.00 X 0 0 0 SHARON ELLINGWOOD WHITE DIRECTOR 1.00 X 0 0 0 GAIL FISHER DIRECTOR 1.00 X 0 0 0 MAGGIE FITZGERALD DIRECTOR 1.00 X 0 0 0 LAURA MILLS DIRECTOR 1.00 X 0 0 0 DAVID THATCHER DIRECTOR 1.00 X 0 0 0 THOMAS MEE SYSTEM CEO 1.00 45.00 X 0 681354 28979 SCOTT COLBY PRESIDENT/CEO 40.00 X 325861 0 25725 MATTHEW STREETER SYSTEM CFO 1.00 45.00 X 0 300812 10917 THOMAS COCHRAN PHYSICIAN 40.00 X 383566 0 46137 DARIN C BROWN ED SERVICES PROVIDER 40.00 X 307529 0 16895 LINDSAY LEA CNO 40.00 X 190107 0 16965 ARNOLD ALBERT DNP 40.00 X 156108 0 10564 ALEXIS COCHRAN PHYSICIAN 40.00 X 153785 0 0 CELESTE PITTS FORMER CFO 16.00 24.00 X 0 175540 19714 1866511 1180962 221682 23 1 1 0 MEDICAL SOLUTIONS LLC 1010 N 102ND ST OMAHA NE 68114 CONTRACT LABOR 795325 CATHOLIC MEDICAL CENTER 100 MCGREGOR ST MANCHESTER NH 03102 CONTRACT LABOR 569254 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL RD BERLIN NH 03570 LABOR AND OTHER PURCHASED SERVICES 426347 BE SMITH LLC PO BOX 74007636 CHICAGO IL 60674 CONTRACT LABOR 389326 NORTH COUNTRY HEALTHCARE 8 CLOVER LANE WHITEFIELD NH 03598 MANAGEMENT SERVICES 370355 13 457080 20788 477868 PATIENT SERVICE REVENUE 621400 35588698 35588698 CONTRACTED SERVICE REVENUE 621400 299083 299083 CAFETERIA REVENUE 722514 88518 88518 PHARMACY REVENUE 456110 2996 2996 1481 1481 35980776 53562 53562 108477 0 108477 108477 108477 686624 0 686624 686624 686624 37307307 35892258 0 937181 X 249399 249399 684059 347772 336287 8475239 7748247 726992 146757 131040 15717 2098114 1880492 217622 683053 609903 73150 99283 5413 93870 5612 5612 4370328 4160457 209871 146188 129869 16319 132110 37566 94544 1365840 1293868 71972 1522603 1381525 141078 248316 239642 8674 5039 5039 995 830 165 2046607 1707741 338866 297093 297093 ENHANCEMENT TAX 2858214 2858214 INTERCOMPANY ALLOCATION 2491078 251440 2239638 PHARMACEUTICAL EXPENSE 1430540 1430540 BAD DEBT EXPENSE 786217 786217 1236252 1002904 233348 31378936 23696997 7681939 0 1146241 835 4653666 2119340 2444717 3322628 349994 269311 251470 455200 32879194 15540239 15056740 17338955 15608358 17113896 793205 1267668 40304391 41887833 1479140 4592707 282848 71927 316401 292329 9458605 1624264 11536994 6581227 X 28477452 34985711 289945 320895 28767397 35306606 40304391 41887833 X 5928371 1343686 3 -732851 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5612 5612 0 PART II-B, LINE 1: THE 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 THE HOSPITAL AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. THE HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITIES. 259755 30950 290705 299038 -39283 259755 263236 35802 299038 240915 24066 1745 263236 232266 13836 5187 240915 0.00000 0.59535 0.40465 0 0 69700 69700 14792212 4517264 10274948 14812998 11022975 3790023 3204284 3204284 17338955 DUE TO RELATED PARTIES 1624264 1624264 37766043 1343686 -884950 458736 37307307 0 37307307 30493986 0 30493986 884950 884950 31378936 PART V, LINE 4: THE ORGANIZATION'S ENDOWMENTS ARE USED FOR STAFF EDUCATION, NURSING PROJECTS AND INDIGENT CARE. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -786,217. GRANT EXPENSE -98,733. PART XII, LINE 2D - OTHER ADJUSTMENTS: GRANT EXPENSE NETTED WITH REVENUE PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 786,217. GRANT EXPENSE 98,733. 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 201563 201563 0.00660 5973907 1638836 4335071 0.14170 6175470 1638836 4536634 0.14830 3826686 4111338 0 0.00000 3826686 4111338 0 0.00000 10002156 5750174 4536634 0.14830 1 333746 9561133 9619733 -58600 X 1 1 1 1 UPPER CONNECTICUT VALLEY HOSPITAL 181 CORLISS LANE COLEBROOK NH 03576 WWW.UCVH.ORG 00592 X X X X UPPER CONNECTICUT VALLEY HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X 1 21 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 300.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X HTTPS://WWW.UCVH.ORG/PATIENTS-VISITORS/FINANCIAL-INFORMATION/ X HTTPS://WWW.UCVH.ORG/PATIENTS-VISITORS/FINANCIAL-INFORMATION/ X HTTPS://WWW.UCVH.ORG/PATIENTS-VISITORS/FINANCIAL-INFORMATION/ X X X X X 1 X 0 X X X X 1 X 0 0 UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 5: AN ELECTRONIC SURVEY WAS SENT TO A SELECT GROUP OF LOCAL EXPERTS THAT INCLUDED INFORMATION FROM WELL-RESPECTED SECONDARY SOURCES ON THE CURRENT STATE OF HEALTH CARE IN THE COMMUNITY. INDIVIDUALS AND AGENCIES INVOLVED IN PUBLIC HEALTH AND STATE & LOCAL HEALTH WERE INCLUDED AS WERE INDIVIDUALS FROM PRIORITY POPULATIONS, CHRONIC DISEASE GROUPS AND OTHER COMMUNITY MEMBERS. UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 6A: THE HOSPITAL'S CHNA WAS CONDUCTED ALONG WITH WEEKS MEDICAL CENTER AND ANDROSCOGGIN VALLEY HOSPITAL. UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS CONDUCTED ALONG WITH COOS COUNTY FAMILY HEALTH AND NORTH COUNTRY HOME HEALTH & HOSPICE AGENCY. THE FIRST IS A LOCAL FQHC. UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 7D: LINE 7A: HTTPS://WWW.UCVH.ORG/COMMUNITY-BENEFITS-REPORT/LINE 10A: HTTPS://WWW.UCVH.ORG/COMMUNITY-BENEFITS-REPORT/ UPPER CONNECTICUT VALLEY HOSPITAL PART V, SECTION B, LINE 11: UPPER CONNECTICUT VALLEY HOSPITAL TOOK THE FOLLOWING STEPS DURING FY 2023 TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENT CHNA, COMPLETED IN TAX YEAR 2021:- ADDITIONAL PROVIDERS ADDED TO EXISTING WMC BEHAVIORAL HEALTH PRACTICE- CONTINUANCE OF FINANCIAL ASSISTANCE- PA-C ADDED TO BERLIN AND COLEBROOK MARKET TO REPLACE PREVIOUS PA-C. (CHRONIS DISEASE MANAGEMENT HEART DISEASE)- WE HAVE CONDUCTED VIRTUAL LECTURES ON VARIOUS HEALTH-RELATED TOPICS, BASED ON PROVIDER AVAILABILITY. NOT NECESSARILY CHRONIC DISEASE EDUCATION. WE HAVE HAD A PRESENCE (AND WILL LATER THIS MONTH AND NEXT) AT LANCASTER FAIR TO CONDUCT BLOOD PRESSURE SCREENINGS, PROVIDE INFORMATION. COMMUNITY WELLNESS FAIR WAS SCHEDULED EARLIER THIS SUMMER, BUT POSTPONED DUE TO EXTREME HEAT.- UNDER ACCESS TO HEALTHCARE- WE ADDED A NEW POSITION: CLINICAL LIAISON, WHO IS A NURSE, SHE ROUNDS AT EACH HOSPITAL DAILY TO FACILITATE DISCHARGES TO HOME HEALTH, PALLIATIVE CARE AND HOSPICE.- UNDER CHRONIC DISEASE MANAGEMENT: WEEKS HIRED A PALLIATIVE APRN IN MARCH. PALLIATIVE CARE CAN HELP OUR COMMUNITY GREATLY BY ASSISTING PATIENTS WHO HAVE CHRONIC ILLNESSES ACHIEVE SYMPTOM CONTROL, COMPLETE ADVANCED DIRECTIVES AND STAY OUT OF THE HOSPITAL- ALZHEIMER'S AND DEMENTIA- NCHHHA STARTED AN ALZHEIMER'S AND DEMENTIA SUPPORT GROUP FOR CAREGIVERS PART I, LINE 7: THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES PART I, LINES 7E-I. THE HOSPITAL DETERMINES COST BY COMBINING DIRECT EXPENSES IDENTIFIED BY ITS ACCOUNTING SYSTEM WITH AN ESTIMATED OVERHEAD ALLOCATION. PART I, LINE 7G: THE COSTS OF SUBSIDIZED HEALTH SERVICES ARE RELATED TO THE EMERGENCY SERVICES UNIT AND SPECIALTY CLINICS. 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 $ 786,217. PART II, COMMUNITY BUILDING ACTIVITIES: THE COMMUNITY BUILDING ACTIVITIES UNDERTAKEN BY UCVH CONSIST OF SUPPORTING LOCAL GOVERNMENT AND OTHER HEALTH CARE PROVIDERS, COORDINATION OF DISASTER DRILLS, EMERGENCY PREPAREDNESS, AND SUPPORT OF OTHER LOCAL ORGANIZATIONS WITHIN THE COMMUNITY. IN ADDITION, IN AN EFFORT TO PROVIDE THE NECESSARY HEALTH CARE SERVICES FOR THE POPULATION WITHIN A REASONABLE DRIVING DISTANCE, UCVH HAS ENTERED INTO A COLLABORATION WITH THE OTHER TWO COOS COUNTY HOSPITALS TO PROVIDE NECESSARY PRIMARY CARE, BEHAVIORAL HEALTH, AND SPECIALTY SERVICES FOR THE UCVH SERVICE AREA. PART III, LINE 2: THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. THE CCR WAS THEN APPLIED TO BAD DEBT EXPENSE AT CHARGE VALUE IN ORDER TO ARRIVE AT THE ESTIMATED EXPENSE REPORTED. PART III, LINE 8: THE HOSPITAL IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND, AS SUCH, A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN BASED ON THE IRS 990 INSTRUCTIONS INCLUDES ONLY A PORTION OF THE TOTAL MEDICARE REVENUE OF THE HOSPITAL. THE COSTING METHOD USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES AND THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: IF KNOWN TO QUALIFY FOR CHARITY OR FINANCIAL ASSISTANCE, PATIENTS ARE GIVEN THE ASSISTANCE NEEDED. PART VI, LINE 2: EVERY 3 YEARS, UPPER CONNECTICUT VALLEY HOSPITAL PARTICIPATES IN A COMMUNITY NEEDS ASSESSMENT WITH THREE OTHER MEMBERS OF THE COMMUNITY'S HEALTH CARE SYSTEM. USING INFORMATION FROM THAT ASSESSMENT ALLOWS THE HOSPITAL TO PROVIDE HEALTHCARE SERVICES TO THE NORTH COUNTRY COMMUNITY ON AN ONGOING BASIS. PART VI, LINE 3: UCVH HAS A PATIENT FINANCIAL COUNSELOR WHO IS RESPONSIBLE FOR WORKING WITH PATIENTS AND ANY WHO MAY BE BILLED FOR THEIR CARE TO DETERMINE THEIR ELIGIBILITY, ON A CASE BY CASE BASIS. FOR ANY GOVERNMENT PROGRAMS, SUCH AS MEDICAID OR THE UCVH FINANCIAL ASSISTANCE PROGRAM ALL STAFF AT UCVH, PARTICULARLY REGISTRATION STAFF WHO WILL BE THE FIRST ONES TO NOTICE IF A PATIENT DOES NOT HAVE INSURANCE, ARE TRAINED TO REFER THE PATIENT TO THE FINANCIAL COUNSELOR. IN ADDITION, BROCHURES ARE AVAILABLE, AS IS CONTACT INFORMATION ON THE WEBSITE. PART VI, LINE 4: UCVH IS THE SMALLEST CRITICAL ACCESS HOSPITAL IN NEW HAMPSHIRE THAT SERVES THE LARGEST GEOGRAPHIC SERVICE AREA (OVER 850 SQUARE MILES) INCLUDING COMMUNITIES IN THE STATES OF NEW HAMPSHIRE, VERMONT, AND MAINE. ACCORDING TO THE NEW HAMPSHIRE STATE HEALTH PROFILE, OUR RESIDENTS ARE THE MOST FRAGILE OF ALL CITIZENS IN NEW HAMPSHIRE AS IT RELATES TO HEALTH OUTCOMES AND ECONOMIC CONDITIONS. UCVH IS DEPENDENT ON PUBLIC FUNDING AND DISPROPORTIONATE SHARE FUNDING TO SUBSIDIZE THE CARE PROVIDED TO THE PATIENTS WE SERVE. PART VI, LINE 6: THE HOSPITAL IS AFFILIATED WITH OTHER ENTITIES UNDER THE NORTH COUNTRY HEALTHCARE WHICH OVERSEES THREE CRITICAL ACCESS HOSPITALS AND ONE HOME HEALTH AND HOSPICE AGENCY IN NORTHERN NEW HAMPSHIRE. PART VI, LINE 7, REPORTS FILED WITH STATES NH 1 FOUNDATION FOR HEALTHY COMMUNITIES 125 AIRPORT RD CONCORD NH 03301 020275078 501C3 94280 0 SUBSTANCE USE DISORDER AND COVID-19 VACCINATION PROJECT TRI-COUNTY CAP 30 EXCHANGE ST BERLIN NH 03570 020267404 501C3 26364 0 NEMT GRANT - MOBILITY MANAGER 2 0 PART I, LINE 2: THE HOSPITAL WAS MANDATED BY THE STATE OF NH TO CONTRIBUTE FUNDS TO THE ALCOHOL AND DRUG PREVENTION TREATMENT FUND IN ORDER TO CONTINUE THE MEDICAID EXPANSION PROGRAM. THESE FUNDS GO TOWARDS VARIOUS PROGRAMS SURROUNDING RECOVERY, TREATMENT AND PREVENTION FOR SUBSTANCE MISUSE IN NEW HAMPSHIRE. ADDITIONALLY, EACH OF THE HOSPITALS AFFILIATED WITH NORTH COUNTRY HEALTHCARE ELECTED TO PARTICIPATE IN AN INITIATIVE WITH THE BOWLER-BARTLETT FOUNDATION TO PURCHASE A MOBILE MEDICAL UNIT TO BE MADE AVAILABLE FOR USE THROUGHOUT NEW HAMPSHIRE. 0 1 0 0 0 0 0 1 0 THOMAS MEE SYSTEM CEO 0 537600 0 131095 0 12659 0 1891 0 27088 0 710333 0 0 THOMAS COCHRAN PHYSICIAN 382940 0 100 0 526 0 10250 0 35887 0 429703 0 0 0 EDWARD LAVERTY PA-C CHIEF MEDICAL OFFICER 300786 0 35265 0 1210 0 8761 0 37025 0 383047 0 0 0 SCOTT COLBY PRESIDENT/CEO 250427 0 61627 0 13807 0 864 0 24861 0 351586 0 0 0 DARIN C BROWN ED SERVICES PROVIDER 305294 0 0 0 2235 0 9329 0 7566 0 324424 0 0 0 MATTHEW STREETER SYSTEM CFO 0 276715 0 23655 0 442 0 2631 0 8286 0 311729 0 0 LINDSAY LEA CNO 158110 0 25238 0 6759 0 5012 0 11953 0 207072 0 0 0 CELESTE PITTS FORMER CFO 0 142945 0 32595 0 0 0 5399 0 14315 0 195254 0 0 ARNOLD ALBERT DNP 156008 0 100 0 0 0 3844 0 6720 0 166672 0 0 0 ALEXIS COCHRAN PHYSICIAN 153685 0 100 0 0 0 0 0 0 0 153785 0 0 0 PART I, LINE 3 NORTH COUNTRY HEALTHCARE, A RELATED ORGANIZATION, USES THE FOLLOWING METHODS TO ESTABLISH COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL OF THE FILING ORGANIZATION: - COMPENSATION COMMITTEE - FORM 990 OF OTHER ORGANIZATIONS - INDEPENDENT COMPENSATION CONSULTANT - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B THOMAS MEE, SYSTEM CEO, PARTICIPATED IN A 457(F) PLAN ADMINISTERED BY NORTH COUNTRY HEALTHCARE, A RELATED ORGANIZATION. THERE WERE NO CONTRIBUTIONS OR DISTRIBUTIONS IN 2022. PART I, LINE 7 PART OF THE COMPENSATION PROGRAM OVERSEEN BY THE COMPENSATION COMMITTEE AND APPROVED BY THE CORPORATION BOARD AND AFFILIATE BOARDS INCLUDES VARIABLE INCENTIVE COMPENSATION FOR EXECUTIVES. THIS VARIABLE COMPENSATION IS A WITHHOLD OF TOTAL COMPENSATION AND EARNED BACK BY EXECUTIVES BASED ON STRATEGIC GOAL PERFORMANCE. SHARI PARKER FAMILY MEMBER OF BOARD MEMBER ERIC STOHL 120248 EMPLOYMENT WAGES 0 SCHEDULE L, PART IV, LINE 1 (A) NAME OF PERSON: SHARI PARKER(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: FAMILY MEMBER OF BOARD SECRETARY ERIC STOHL(D) DESCRIPTION OF TRANSACTION: EMPLOYMENTWAGES: $99,287BENEFITS: $20,961 FORM 990, PART VI, SECTION A, LINE 6 AS THE PARENT ORGANIZATION, NORTH COUNTRY HEALTHCARE (NCH) IS THE SOLE MEMBER OF UPPER CONNECTICUT VALLEY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER OF THE CORPORATION BOARD SHALL BE NOMINATED BY ACTION OF AN AFFILIATE BOARD, OR BY THE CORPORATION BOARD, AS THE CASE MAY BE, IN ACCORDANCE WITH THE NOMINATION POWERS INDICATED IN THE CORPORATION'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE CORPORATION BYLAWS INCLUDE MAJOR MATTERS WHICH INCLUDE SPECIFIC DUTIES AND RESPONSIBILITIES WHICH ARE SHARED BY THE CORPORATION BOARD AND THE AFFILIATE BOARDS. THESE MAJOR MATTERS ARE FURTHER DISTINGUISHED BETWEEN MAJOR ORGANIZATIONAL MATTERS AND MAJOR OPERATIONAL MATTERS. IN BOTH CASES, THE BYLAWS CONTAIN THE PROVISIONS FOR THE APPROVAL OF THESE MATTERS INCLUDING WHETHER THEY ARE APPROVED BY A MAJORITY VOTE OR SUPER MAJORITY VOTE OF ALL BOARDS. IN ALL CASES, THE MAJOR MATTERS REQUIRE APPROVAL BY THE CORPORATION BOARD AND THE AFFILIATE BOARDS. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WILL BE SHARED ELECTRONICALLY WITH THE ENTIRE NCH BOARD AND FINANCE COMMITTEE BEFORE FILING, WITH ADEQUATE TIME FOR QUESTIONS TO BE ASKED. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST PROCESS: - CONFLICT OF INTEREST DISCLOSURE COMPLETED VIA BOARDPAQ (ELECTRONIC MEANS). - RESULTS COMPILED INTO CONFLICT MATRIX WHICH IS REVIEWED AND APPROVED BY THE BOARD. - CONFLICTS THAT MEET THE PECUNIARY BENEFIT CRITERIA ARE IDENTIFIED, SHARED WITH THE BOARD AND APPROVED. - DISCLOSURE NOTICES ARE PLACED IN LOCAL PAPERS. - THE NH DIVISION OF CHARITABLE TRUSTS IS NOTIFIED OF THE PECUNIARY BENEFIT AND COPIES OF THE PUBLIC NOTICES ARE ATTACHED. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE IS A SUBCOMMITTEE OF THE FINANCE COMMITTEE OF THE CORPORATION BOARD. THIS COMMITTEE OVERSEES THE EXECUTIVE COMPENSATION POLICY AND PRACTICES OF THE ORGANIZATION INCLUDING THE CEO, THE AFFILIATE PRESIDENTS, AND THE CEO CABINET WHICH INCLUDES KEY EXECUTIVE POSITIONS FOR THE ORGANIZATION. THE COMPENSATION COMMITTEE ENGAGES WITH AN OUTSIDE CONSULTANT TO DETERMINE COMPENSATION BENCHMARKS AND BEST PRACTICES WHICH GUIDE THE COMPENSATION PROCESSES FOR THESE EXECUTIVE POSITIONS. THE COMPARISON BENCHMARK DATA AND GUIDANCE ARE REVIEWED BY THE COMMITTEE AND RECOMMENDATIONS ARE MADE TO THE CORPORATION BOARD AND AFFILIATE BOARDS. THIS IS DONE ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION HAS IMPLEMENTED ALL POLICIES AND THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 3,015,274. MANAGEMENT AND GENERAL EXPENSES 59,806. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,075,080. OTHER SERVICES: PROGRAM SERVICE EXPENSES 1,145,183. MANAGEMENT AND GENERAL EXPENSES 150,065. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,295,248. FORM 990, PART XI, LINE 9: EQUITY TRANSFER TO NORTH COUNTRY HEALTHCARE, INC. -732,851. ANDROSCOGGIN VALLEY HOSPITAL INC 59 PAGE HILL ROAD BERLIN NH 03570 020280367 CRITICAL ACCESS HOSPITAL NH 501(C)(3) LINE 3 NORTH COUNTRY HEALTHCARE INC 1 NORTH COUNTRY HEALTHCARE INC 8 CLOVER LANE WHITEFIELD NH 03598 812225283 HEALTHCARE MANAGEMENT NH 501(C)(3) LINE 12A, I N/A 0 WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 020222242 CRITICAL ACCESS HOSPITAL NH 501(C)(3) LINE 3 NORTH COUNTRY HEALTHCARE INC 1 NORTH COUNTRY HOME HEALTH & HOSPICE AGENCY INC 536 COTTAGE STREET LITTLETON NH 03561 020300637 HOME HEALTH AGENCY NH 501(C)(3) LINE 10 NORTH COUNTRY HEALTHCARE INC 1 NORTHCARE INC 59 PAGE HILL ROAD BERLIN NH 03570 521596952 SUPPORTING SERVICES NH 501(C)(3) LINE 12B, II ANDROSCOGGIN VALLEY HOSPITAL INC 1 ANDROSCOGGIN VALLEY HOSPITAL FOUNDATION 59 PAGE HILL ROAD BERLIN NH 03570 223035216 MANAGEMENT AND FINANCIAL SUPPORT NH 501(C)(3) LINE 12B, II ANDROSCOGGIN VALLEY HOSPITAL INC 1 GREAT NORTHWOODS COMMUNITY FOUNDATION 59 PAGE HILL ROAD BERLIN NH 03570 020452547 HEALTHCARE SERVICES NH 501(C)(3) LINE 12B, II ANDROSCOGGIN VALLEY HOSPITAL INC 1 LANCASTER PATIENT CARE CENTER 173 MIDDLE STREET LANCASTER NH 03584 832130386 SUPPORTING ORGANIZATION NH 501(C)(3) LINE 12A, I WEEKS MEDICAL CENTER 1 0 0 0 1 0 0 0 0 0 1 0 0 1 0 1 1 0 1 0