2018-11-15T13:44:17-06:00 2017-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-01-01 581667166 OKEFENOKEE HEALTH INC OKEF 9123375821 3163 ORION DRIVE WAYCROSS GA 315038908 P OWEN HERRIN JR VICE PRESIDENT 9123375821 2018-11-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2018-11-15 74.87.127.216 2018-11-15 13:21:57 CS P A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 B2BBC66CE798CC4B98B5BAE532B86AFD0426F743 2017 2019-02-21 02:37:17Z 3163 ORION DRIVE WAYCROSS GA 315038908 224076775 0 X N/A X 1985 GA FROM JANUARY THROUGH APRIL OF 2017, THE ORGANIZATION OPERATED A HOSPITAL TO PROMOTE HEALTH AND WELLNESS IN THE COMMUNITY. FOLLOWING THE SALE OF ALL THE HOSPITAL ASSETS AND THE ASSIGNMENT OF ALL THE NURSING HOME OPERATIONS EFFECTIVE MAY 1, 2017, OKEFENOKEE HEALTH, INC. CONTINUED IN AN ADMINISTRATIVE FUNCTION TO COMPLETE ITS OBLIGATIONS CONNECTED WITH ITS PRIOR BUSINESS OPERATIONS AS THE OWNER AND OPERATOR OF A HOSPITAL AND NURSING HOMES INCLUDING COLLECTING RELATED REVENUES AND SATISFYING ITS EXPENSES. IN ADDITION, OKEFENOKEE HEALTH, INC. CONTINUED TO MONITOR THE ACTIVITIES OF THE HOSPITAL BUYER TO ENSURE THAT THE HOSPITAL BUYER (I) CONTINUES TO OPERATE THE HOSPITAL AS AN ACUTE CARE HOSPITAL; (II) REMAINS ENROLLED IN THE MEDICARE AND MEDICAID PROGRAMS; (III) CONTINUES THE PROVISION OF INDIGENT CARE SERVICES AT A MINIMUM CONSISTENT WITH OHI'S PREVIOUS POLICIES; (IV) MAINTAINS IDENTIFIED CORE SERVICES FOR THE BENEFIT OF THE COMMUNITY; AND (V) MAKES CAPITAL EXPENDITURES AS AGREED UPON. X 4 3 1178 71 8050 0 944717 90706204 175189949 56442914 484648 -20945391 684679 307959 177303993 126511686 18648 76457208 0 0 90793426 24760448 0 0 0 111828623 39616752 202640697 140834408 -25336704 -14322722 156090990 2707828 139921832 940714 16169158 1767114 X NONE 0 1 117496329 76417625 595931 SEE SCHEDULE O 14522018 39583 55975987 SEE SCHEDULE O 132018347 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 0 0 1 101 0 1 1178 1 1 1 0 0 0 0 0 0 0 0 0 X 4 3 1 1 1 0 1 1 1 1 0 1 1 1 0 1 1 1 1 1 0 0 1 1 GA X P OWEN HERRIN JR 9123375821 3163 ORION DRIVE WAYCROSS GA 315038908 BYRON C MAY MD DIRECTOR 1.00 40.00 X 0 563769 83277 DANIEL L TOMLINSON DIRECTOR 1.00 40.00 X 0 245431 67344 ROBERT M WALTERS DIRECTOR 1.00 40.00 X 0 334892 86237 DONALD WATERS MD PRESIDENT 10.00 0.00 X X 0 0 0 P OWEN HERRIN JR VICE PRESIDENT 5.00 0.00 X X 0 0 0 JAMES W DYE MD SECRETARY 5.00 0.00 X X 17500 0 0 ZIBIA A MUSIC TREASURER 5.00 0.00 X X 0 0 0 RICHARD J PRESUTTI DO CHAIR 1.00 40.00 X X 0 487916 70920 MICHAEL C DEITSCHMANN SECRETARY/TREASURER 1.00 40.00 X X 0 178988 67611 HOLLI H SWEAT ASSISTANT SECRETARY 40.00 0.00 X 102685 0 7983 ROGER FORGEY CEO 40.00 0.00 X 0 0 0 GE HOFFMAN JR CFO 40.00 0.00 X 0 0 0 TIMOTHY T CATCHINGS MD PHYSICIAN 40.00 0.00 X 389034 0 14347 HOWARD GRIFFIN MD PHYSICIAN 40.00 0.00 X 242523 0 4657 ASIT K JHA MD PHYSICIAN 40.00 0.00 X 287392 0 17553 BRIAN A SINGLETON MD PHYSICIAN 40.00 0.00 X 291653 0 12984 SRIDHAR SRINIVASAN MD PHYSICIAN 40.00 0.00 X 257392 0 12703 TERESA B BEARD FORMER OFFICER 1.00 40.00 X 0 119628 33191 KENNETH T CALAMIA MD FORMER OFFICER 1.00 40.00 X 0 215798 56224 CHERYL R CROFT FORMER OFFICER 1.00 40.00 X 0 227461 69593 NANCY L DAWSON MD FORMER OFFICER 1.00 40.00 X 0 313936 80540 STEPHEN M LANGE MD FORMER OFFICER 1.00 40.00 X 0 508189 39402 KEVIN M LOCKETT FORMER OFFICER 1.00 40.00 X 0 260407 64985 MCGREGOR N LOTT MD FORMER KEY EMPLOYEE 40.00 0.00 X 229121 0 14952 WINDELL R SMITH JR FORMER KEY EMPLOYEE 1.00 40.00 X 0 192961 62618 DAVID J WYKSTRA MD FORMER KEY EMPLOYEE 40.00 0.00 X 218701 0 14106 MICHAEL P BAKER MD FORMER KEY EMPLOYEE 1.00 40.00 X 0 142744 0 2036001 3792120 881227 8 1 1 0 NELSON MULLINS RILEY & SCARBROUG PO DRAWER 11009 COLUMBIA SC 29211 LEGAL SERVICES 921080 WEATHERBY LOCUMS INC PO BOX 972634 DALLAS TX 75398 PHYSICIAN SERVICES 484430 DIAGNOSTIC PET LLC 1256 SHILOH ROAD WILLAVILLE GA 31806 DIAGNOSTIC SERVICES 355500 BENCURA INC 125 TOWN PARK DR SUITE 300 KENNESAW GA 30144 REHABILIATION SERVICES 313604 EMCARE INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 PHYSICIAN SERVICES 300000 17 90494660 204630 6914 90706204 NET PATIENT REVENUE 620000 56373142 56365092 8050 EDUCATION REVENUE 611600 69772 69772 56442914 165859 165859 57179 0 57179 57179 57179 73136720 94247970 -21111250 -21111250 -21111250 3280905 3317119 -36214 -36214 CAFETERIA/VENDING 722514 128893 128893 MEDICAL RECORD/TRANSCRIPTION FEE 900099 197 197 157904 7964 149940 286994 126511686 56571918 8050 -20774486 76457208 76457208 2632360 2632360 545640 545640 16972834 15096443 1876391 127184 127184 3261872 3172698 89174 1220558 1220558 1854754 1854754 2660 2660 168 168 14024809 9908347 4116462 36034 227 35807 1980321 1552170 428151 30221 30221 589618 536463 53155 51707 4588 47119 5563 5563 81955 60854 21101 MEDICAL SUPPLIES 10671968 10671968 BAD DEBT EXPENSE 9359741 9359741 MEDICAL SURCHARGE 574598 574598 EMPLOYEE RELATED EXPENS 107383 97181 10202 245252 119 245133 140834408 132018347 8816061 0 4707965 2407828 28784639 0 5794 0 2656743 0 641544 0 0 0 62263618 0 36497976 0 4199464 0 16333247 300000 156090990 2707828 39569434 199029 1281 741685 100351117 0 139921832 940714 X 16124595 1762134 44563 4980 0 0 16169158 1767114 156090990 2707828 -14322722 -79322 0 X 0 1 X 0 0 X 0 0 0 0 0 0 0 0 1 1525 1525 0 PART II-B, LINE 1: PRIOR TO MAY 1, 2017 THE ORGANIZATION HAD ONE EMPLOYEE WHO DEVOTED APPROXIMATELY 5% OF HIS TIME TO LOBBYING. LOBBYING ACTIVITIES CONSISTED OF CONTACT WITH STATE GOVERNMENT OFFICIALS AND/OR THEIR STAFF TO DISCUSS VARIOUS HEALTH CARE RELATED ISSUES. 0 SUNTRUST ESCROW ACCOUNT 300000 300000 1 1 X 1 X 1 X 1 0 0 1199937 1199937 0.02040 12365721 7042022 5323699 0.09030 13565658 7042022 6523636 0.11070 89025 89025 0.00150 256381 125350 131031 0.00220 4543808 2094667 2449141 0.04150 4889214 2220017 2669197 0.04520 18454872 9262039 9192833 0.15590 0 9359740 9681734 9707559 -25825 X 1 1 1 1 MAYO CLINIC HEALTH SYSTEM IN WAYCROSS 1900 TEBEAU STREET WAYCROSS GA 31501 148-416 X X X MAYO CLINIC HEALTH SYSTEM IN WAYCROSS 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X MAYOCLINICHEALTHSYSTEM.ORG X 1 16 0 1 0 1 X 200.000000000000 400.000000000000 X X X X X X X 1 1 X X X X 1 X MAYOCLINIC.ORG X MAYOCLINIC.ORG X MAYOCLINIC.ORG X X X X X X X 1 X 0 X X X X 1 X 0 0 MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 5: PRIMARY DATA COLLECTION METHODS INCLUDED INTERVIEWS AND A FOCUS GROUP WITH KEY COMMUNITY REPRESENTATIVES. TO GATHER INPUT FROM AN EXTENSIVE RANGE OF PEOPLE WHO REPRESENT THE BROAD INTERESTS OF WARE AND PIERCE COUNTIES, A FOCUS GROUP AND ONE-ON-ONE INTERVIEWS WERE CONDUCTED IN MARCH 2016. IN TOTAL, INTERVIEWS WERE CONDUCTED WITH 18 INDIVIDUALS AND 6 FOCUS GROUP PARTICIPANTS WHO WERE KEY COMMUNITY REPRESENTATIVES. THE PURPOSE OF THE INTERVIEWS AND FOCUS GROUP WAS TO GAIN DIRECT INPUT FROM THESE INDIVIDUALS REGARDING HEALTH NEEDS, COMMUNITY ASSETS, AND OTHER RELATED TOPICS, INCLUDING PRIMARY AND CHRONIC DISEASE NEEDS AND OTHER HEALTH ISSUES ASSOCIATED WITH UNINSURED PERSONS, LOW-INCOME PERSONS, AND MINORITY GROUPS. FOCUS GROUP AND INTERVIEW PARTICIPANTS INCLUDED COMMUNITY STAKEHOLDERS REPRESENTING HEALTH CARE AND SOCIAL SERVICES PROVIDERS, SCHOOL SYSTEMS, RELIGIOUS ORGANIZATIONS, ECONOMIC ORGANIZATIONS, POLITICAL AND OTHER COMMUNITY OFFICIALS AND THE ELDERLY/SENIOR POPULATION. MANY OF THE FOCUS GROUP AND INTERVIEW PARTICIPANTS REPRESENTED, AND WERE VERY FAMILIAR WITH, THE HEALTH NEEDS ASSOCIATED WITH THE MEDICALLY UNDERSERVED, LOW INCOME, MINORITY, AND POPULATIONS WITH CHRONIC AND ACUTE DISEASES IN WARE AND PIERCE COUNTIES. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 11: ADDRESSING OBESITY IN OUR COMMUNITY: WITH OBESITY AS ONE OF THE MOST SIGNIFICANT RISK FACTORS FOR SEVERAL DISEASES AFFECTING RESIDENTS OF WARE AND PIERCE COUNTIES, IT INCLUDES CARDIOVASCULAR DISEASE, DIABETES, AND HYPERTENSION. A MAJOR FACTOR CAUSING THE SUBSTANTIAL CARDIOVASCULAR DISEASE MORTALITY RATES IN THE REGION IS THE LEVEL OF OBESITY, WITH ONE-THIRD OF THE ADULT POPULATION IN WARE AND PIERCE COUNTIES CONSIDERED OBESE. MCHS IN WAYCROSS CONTINUES TO WORK WITH THE YMCA IN SUPPORT OF CAMP REVEILLE, A CAMP FOR UNDERSERVED CHILDREN, TO PROMOTE HEALTHY EATING AND EXERCISE. TO ADDRESS THE ADULT POPULATION, MCHS IN WAYCROSS HAS REACHED OUT TO COMMUNITY MEMBERS AND COMMUNITY ORGANIZATIONS THROUGH EDUCATIONAL TALKS, LECTURES AND PRESENTATIONS ON HEALTH ISSUES CONDUCTED BY PHYSICIANS AND CLINICAL STAFF, RAISING THE AWARENESS OF HEALTHY EATING CHOICES AMONG COMMUNITY MEMBERS. AT ALL MCHS IN WAYCROSS COMMUNITY EVENTS, A HEALTHY SNACK AND EDUCATIONAL LITERATURE ARE OFFERED TO REINFORCE OUR MISSION.ADDRESSING SMOKING/TOBACCO USAGE: TO ENCOURAGE THE DEVELOPMENT OF HEALTHY EATING HABITS AND LIFESTYLES, MCHS IN WAYCROSS WORKS WITH MEMORIAL DRIVE ELEMENTARY AND BLACKSHEAR ELEMENTARY SCHOOLS TO ENGAGE STUDENTS IN EDUCATION PROGRAMS ABOUT THE DANGERS OF OBESITY AND TOBACCO USE. AN ADDITIONAL GOAL OF THESE EFFORTS IS TO ENCOURAGE STUDENTS TO STRESS THE IMPORTANCE OF HEALTHY LIFESTYLES TO THEIR PARENTS.MCHS IN WAYCROSS' RESPIRATORY DEPARTMENT COLLABORATES WITH WARE AND PIERCE COUNTY SCHOOL SYSTEMS TO OFFER EDUCATION ON SMOKING AND GENERAL TOBACCO USE AS AN ONGOING PUBLIC EDUCATION PROGRAM THAT IS OFFERED TO ALL RESPIRATORY PATIENTS AND THEIR FAMILIES REGARDLESS OF A REPORTED INCIDENCE OF SMOKING. ALL PATIENTS ARE PRESENTED WITH A DISCHARGE PACKET REGARDING THE USE OF TOBACCO AND SMOKING, WHICH FURTHER ASSISTS COMMUNITY MEMBERS IN QUITTING AND/OR NEVER STARTING TO USE TOBACCO.MCHS IN WAYCROSS IS A SMOKE FREE CAMPUS.ADDRESSING HEALTH CARE ACCESS AND COST: INCREASING ACCESS TO HEALTH CARE IS A CHALLENGING GOAL GIVEN LIMITED RESOURCES AND STRONG DEMAND. IN RESPONSE, MCHS IN WAYCROSS HAS RECRUITED NEW PHYSICIANS AND PHYSICIAN ASSISTANTS TO EXPAND SERVICES OFFERED AT OUR FACILITY, AND COMMUNICATED THE AVAILABILITY OF MCHS IN WAYCROSS SERVICES TO COMMUNITY LEADERS AND CITIZENS. MCHS IN WAYCROSS PHYSICIANS AND CLINICAL STAFF HAVE ALSO MADE MANY HEALTH EDUCATION PRESENTATIONS TO THE COMMUNITY. NEEDS THAT ARE NOT BEING ADDRESSED: SUBSTANCE ABUSE AND MENTAL HEALTH WERE MENTIONED BY MANY FOCUS GROUP AND INTERVIEW PARTICIPANTS AS A SIGNIFICANT HEALTH ISSUE IN WARE AND PIERCE COUNTIES. ALTHOUGH THERE IS LITTLE SECONDARY DATA TO SUPPORT THESE CONCERNS, IT IS APPARENT THAT TREATMENT OPTIONS TO ADDRESS THIS HEALTH ISSUE ARE LIMITED. DUE TO SEVERAL FACTORS, INCLUDING A LIMITED OPPORTUNITY TO INTERVENE AT THE PREVENTION LEVEL, RELATIVELY LOW EXPECTED EFFECTIVENESS OF POSSIBLE INTERVENTIONS, AND LACK OF COMPETENCY TO ADDRESS THESE NEEDS BEYOND THE SERVICES PROVIDED THROUGH ITS SENIOR BEHAVIORAL UNIT, MAYO CLINIC HEALTH SYSTEM IN WAYCROSS BELIEVES IT IS MOST APPROPRIATE TO FOCUS ITS EFFORTS ON OBESITY, SMOKING/TOBACCO CESSATION AND ACCESS TO HEALTH CARE. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 13B: MEDICAL INDIGENCY MAY BE USED TO DETERMINE ELIGIBILITY. IF A PATIENT BALANCE EXCEEDS 25% OF THE ANNUAL HOUSEHOLD INCOME, BUT THE PATIENT DOES NOT QUALIFY BASED ON FPG, CHARITY WILL BE ADJUSTED TO A MINIMUM OF THE AMOUNT GENERALLY BILLED (AGB). THE AGB IS DETERMINED USING THE LOOK-BACK METHOD AND CALCULATED USING ALL CLAIMS ALLOWED BY PRIVATE PAY INSURERS (INCLUDING MEDICARE ADVANTAGE) AND MEDICARE (TRADITIONAL) FOR INPATIENT AND OUTPATIENT SERVICES. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 13H: THE REGIONAL PROXIMITY OF A PATIENT'S RESIDENCY IS A FACTOR FOR PRESCHEDULED SERVICES ONLY AND SECONDARY TO MEDICAL NEED. REGIONAL PROXIMITY IS NOT A FACTOR FOR EMERGENCY CARE PROVIDED. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 15E: REFER PATIENT TO APPLY FOR MEDICAL ASSISTANCE PROGRAMS. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 16J: UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE ARE DISCUSSED WITH THE PATIENT. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS PART V, SECTION B, LINE 20E: FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE TO EVERY PATIENT VIA MAYO'S PUBLIC WEBSITE, FROM CUSTOMER SERVICE AND PATIENT ACCESS LOCATIONS, AND IS REFERENCED ON MAYO'S AUTHORIZATION FORMS, STATEMENTS, AND LETTERS. IN ADDITION, BROCHURES ARE AVAILABLE IN THE ADMISSIONS AREA AND THE PROCESS OF HOW TO APPLY IS AVAILABLE ON THE MAYO CLINIC WEBSITE.UPON ADMISSION, IF THE PATIENT DOES NOT HAVE INSURANCE OR EXPRESSES AN INABILITY TO PAY, MAYO DISCUSSES ALL AVAILABLE OPTIONS INCLUDING STATE AND FEDERAL FUNDING AS WELL AS CHARITY CARE.MONTHLY STATEMENTS ARE SENT TO PATIENTS THAT OUTLINE CURRENT CHARGES AND ACTIONS WITH INSURANCE AND INCLUDES INFORMATION ABOUT MAYO'S CHARITY CARE POLICY. SOME MAYO SITES UTILIZE ADVOCATES TO CONTACT THE PATIENT UPON DISCHARGE TO HELP THEM SECURE GOVERNMENTAL ASSISTANCE OR FINANCIAL ASSISTANCE.EACH CHARITY CARE REVIEW IS DOCUMENTED IN MAYO'S BILLING SYSTEM AND COMMUNICATED TO THE PATIENT. COMPLETED CHARITY CARE FORMS ARE MAINTAINED EITHER IN PAPER OR ELECTRONIC FORMAT. THE PATIENT IS INFORMED REGARDING THE OUTCOME OF THE REVIEW.MAYO OFTEN IDENTIFIES CHARITY CARE OPPORTUNITIES AFTER THE PATIENT HAS BEEN DISMISSED. IN MANY CASES, THIS IS DUE TO LIMITED INSURANCE COVERAGE OR INSURANCE DENIALS AFTER THE SERVICE WAS PERFORMED. IN THESE CASES, WHEN A PATIENT EXPRESSES AN INABILITY TO PAY FOR THEIR SERVICES, STAFF WILL INITIATE A CHARITY REVIEW AS INDICATED BY THE FINANCIAL ASSISTANCE POLICY, WHICH IS AVAILABLE FOR EVERY PATIENT AT MAYOCLINIC.ORG. 22 1 - SATILLA CARE CENTER 1600 RIVERSIDE AVENUE WAYCROSS GA 31501 SKILLED NURSING FACILITY 2 - PIERCE COUNTY NURSING HOME 221 EAST CARTER AVENUE BLACKSHEAR GA 31516 SKILLED NURSING FACILITY 3 - SATILLA REGIONAL REHAB INSTITUTE 2500 SATILLA PARKWAY WAYCROSS GA 31501 REHAB UNIT 4 - MCHSW - FAMILY PSYCHIATRY 1707 CITY BOULEVARD SQUARE WAYCROSS GA 31501 PSYCHIATRY CLINIC 5 - MCHSW - NEUROLOGY 2101 TEBEAU STREET WAYCROSS GA 31501 NEUROLOGY CLINIC 6 - MCHSW - PULMONOLOGY 2005 PIONEER STREET WAYCROSS GA 31501 PULMONOLOGY CLINIC 7 - MCHSW - SURGICAL ASSOCIATES 1908 ALICE STREET WAYCROSS GA 31501 SURGICAL OFFICE 8 - MCHSW - ORTHOPEDICS 305 PINEVIEW DRIVE WAYCROSS GA 31501 ORTHOPEDICS CLINIC 9 - MCHSW - OPHTHALMOLOGY 413 LISTER STREET WAYCROSS GA 31501 OPTHALMOLOGY CLINIC 10 - MCHSW - CARDIOLOGY 2004 PIONEER STREET WAYCROSS GA 31501 CARDIOLOGY CLINIC 11 - MCHSW - INFECTIOUS DISEASES 411 LISTER STREET WAYCROSS GA 31501 INFECTIOUS DISEASES CLINIC 12 - MCHSW - OBGYN 505 CITY BLVD WAYCROSS GA 31501 OB/GYN CLINIC 13 - MCHSW - FAMILY MEDICINE 1921 ALICE STREET WAYCROSS GA 31501 FAMILY MEDICINE CLINIC 14 - MCHSW - CONVENIENT CARE 1921 ALICE STREET WAYCROSS GA 31501 CONVENIENT CARE CLINIC 15 - MCHSW - HEMATOLOGYONCOLOGY 1706 ALICE STREET WAYCROSS GA 31501 HEMATOLOGY/ONCOLOGY CLINIC 16 - MCHSW - RADIATION ONCOLOGY 1451 CHURCH STREET WAYCROSS GA 31501 RADIATION ONCOLOGY CLINIC 17 - MCHSW - HEMATOLOGYONCOLOGY - DOUGLAS SHIRLEY AVENUE SUITES XXX-XX-XXXX DOUGLAS GA 31535 HEMATOLOGY/ONCOLOGY CLINIC 18 - MCHSW - OUTREACH CLINIC 396 KINGSLAND DRIVE FOLKSTON GA 31537 OUTREACH CLINIC 19 - MCSHW - FAMILY MEDICINE 808 BEACON STREET WAYCROSS GA 31501 PRIMARY CARE CLINIC 20 - MCSHW - HEMATOLOGYONCOLOGY 1206 ALICE STREET WAYCROSS GA 31501 HEMATOLOGY/ONCOLOGY CLINIC 21 - MCHSW - HEMATOLOGYONCOLOGY 101 SEYMOUR ST DOUGLAS GA 31533 HEMATOLOGY/ONCOLOGY CLINIC 22 - MCHSW - OUTPATIENT IMAGING CENTER 410 ZACHARY STREET WAYCROSS GA 31501 RADIOLOGY/IMAGING PART I, LINE 3C: MEDICAL INDIGENCY MAY BE USED TO DETERMINE ELIGIBILITY. IF A PATIENT BALANCE EXCEEDS 25% OF THE ANNUAL HOUSEHOLD INCOME, BUT THE PATIENT DOES NOT QUALIFY BASED ON FPG, CHARITY WILL BE ADJUSTED TO A MINIMUM OF THE AMOUNT GENERALLY BILLED (AGB). THE AGB IS DETERMINED USING THE LOOK-BACK METHOD AND CALCULATED USING ALL CLAIMS ALLOWED BY PRIVATE PAY INSURERS (INCLUDING MEDICARE ADVANTAGE) AND MEDICARE (TRADITIONAL) FOR INPATIENT AND OUTPATIENT SERVICES PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A-7C (FINANCIAL ASSISTANCE, MEDICAID SHORTFALL, AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS).THE AMOUNTS FOR LINES 7E-7I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND WOULD NOT BE BASED ON A COST-TO-CHARGE RATIO. PART I, LINE 7G: THE FOLLOWING NET COMMUNITY BENEFIT COST ATTRIBUTED TO A PHYSICIAN CLINIC WAS INCLUDED AS SUBSIDIZED HEALTH SERVICES: $211,318. PART I, LINE 7, COLUMN (F) THE ORGANIZATION IS USING THE TOTAL EXPENSES FOR JANUARY THROUGH APRIL WHEN CALCULATING THE PERCENT OF TOTAL EXPENSES. THIS AMOUNT REFLECTS THE EXPENSES OF THE ORGANIZATION WHILE OPERATING THE HOSPITAL. PART III, LINE 2: BAD DEBT EXPENSE IS DETERMINED BASED ON GAAP AND IS EXPLAINED IN THE ACCOUNTS RECEIVABLE FOOTNOTE OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART III, LINE 4: PLEASE SEE NOTE 2 ON PAGE 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE MEDICARE SHORTFALL REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT (USING A MEDICARE COST REPORT STEP-DOWN METHODOLOGY). PART III, LINE 9B: MAYO CLINIC AND ITS AFFILIATES STRIVE TO ASSIST ALL PATIENTS IN MEETING THEIR FINANCIAL OBLIGATION AND CONSIDERING FINANCIAL ASSISTANCE PRIOR TO ENLISTING THE ASSISTANCE OF A COLLECTION AGENCY. MAYO CLINIC AND AFFILIATES ALSO MAKE REASONABLE ATTEMPTS TO COLLECT FROM INSURANCE COMPANIES AND OTHER THIRD-PARTY PAYORS BEFORE REQUESTING PAYMENT FROM A PATIENT. IN ADDITION, MAYO CLINIC AND ITS AFFILIATES ACCEPT REASONABLE PAYMENT PLANS FROM PATIENTS WHEN AN ACCOUNT IS THE PATIENT'S RESPONSIBILITY AND TRY TO IDENTIFY THOSE PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. FINANCIAL ASSISTANCE IS OFFERED TO ANY PATIENT IF THE FACTS AND CIRCUMSTANCES SUGGEST THAT THE PATIENT DOES NOT HAVE THE ABILITY TO PAY THEIR BILL IN WHOLE OR IN PART. IN THE EVENT THAT AN ACCOUNT IS REFERRED TO A COLLECTION AGENCY, GUIDELINES ARE FOLLOWED; INCLUDING SUSPENDING ALL COLLECTION ACTIVITY IF A FINANCIAL ASSISTANCE APPLICATION HAS BEEN SUBMITTED AFTER THE ACCOUNT HAS BEEN REFERRED FOR COLLECTION. IF A COLLECTION AGENCY IDENTIFIES A PATIENT AS POTENTIALLY MEETING MAYO CLINIC'S FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA OR THE PATIENT ASKS TO APPLY FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY IS SUSPENDED UNTIL MAYO REVIEWS THE ACCOUNT FOR FINANCIAL ASSISTANCE ELIGIBILITY BASED ON SUBMISSION OF REQUESTED INFORMATION. COLLECTION ACTIVITY WOULD ONLY RESUME IF THE PATIENT IS DETERMINED TO BE INELIGIBLE FOR FINANCIAL ASSISTANCE OR IS ELIGIBLE FOR ONLY PARTIAL FINANCIAL ASSISTANCE AND DOES NOT AGREE TO PAY THE REMAINING BALANCE. PART VI, LINE 2: MAYO CLINIC HEALTH SYSTEM IN WAYCROSS' EFFORTS TO ASSESS THE HEALTH CARE NEEDS OF ITS LOCAL COMMUNITY RESTS ON FOUR GUIDING PRINCIPLES DEVELOPED IN CONJUNCTION WITH COMMUNITY PARTNERS AND AFFIRMED BY MAYO CLINIC LEADERSHIP:1. HEALTH IS VALUED BY BOTH THE COMMUNITY AND MAYO CLINIC.2. "HEALTH" IS DETERMINED BY BOTH MEDICAL AND NON-MEDICAL (E.G., SOCIAL AND BEHAVIORAL) FACTORS AND BOTH CATEGORIES OF FACTORS MUST BE ADDRESSED.3. MAYO CLINIC IS COMMITTED TO PRODUCING MEASURABLE IMPROVEMENTS IN THE HEALTH OF LOCAL COUNTY RESIDENTS AND BEYOND.4. STRATEGIES TO IMPROVE COMMUNITY HEALTH ARE BEST DETERMINED AND IMPLEMENTED THROUGH PARTNERSHIPS BETWEEN HEALTH CARE PROVIDERS AND COMMUNITY MEMBERS.WITH THESE PRINCIPLES AS THE BASIS OF ITS DECISION MAKING, AND CONSISTENT WITH ITS PRIMARY VALUE OF "THE NEEDS OF THE PATIENT COME FIRST", MAYO CLINIC HEALTH SYSTEM IN WAYCROSS' APPROACH TO ASSESS THE NEEDS OF THE COMMUNITY IS ORGANIZED INTO TWO MAIN FUNCTIONS: 1) MECHANISMS TO ENGAGE AND UTILIZE INPUT FROM THE COMMUNITY AND 2) MECHANISMS TO SUPPORT AND COORDINATE INITIATIVES WITHIN MAYO CLINIC HEALTH SYSTEM IN WAYCROSS. PART VI, LINE 3: MAYO CLINIC IS COMMITTED TO OFFERING FINANCIAL ASSISTANCE TO ELIGIBLE PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY FOR THEIR MEDICAL SERVICES IN WHOLE OR IN PART. IN ORDER TO ACCOMPLISH THIS CHARITABLE GOAL, MAYO CLINIC AND MAYO CLINIC HEALTH SYSTEM SITES WIDELY PUBLICIZE THE FINANCIAL ASSISTANCE POLICY IN THE COMMUNITIES THAT THE INDIVIDUAL MAYO CLINIC AFFILIATED SITES SERVE. MAYO CLINIC AFFILIATED SITES MAKE COPIES OF THIS POLICY AND APPLICATIONS AVAILABLE ON THEIR WEBPAGES, INCLUDING THE ABILITY TO DOWNLOAD A COPY OF THE POLICY AND APPLICATION FREE OF CHARGE. INDIVIDUALS IN THE COMMUNITY SERVED WILL BE ABLE TO OBTAIN A COPY OF THE POLICY IN LOCATIONS THROUGHOUT EACH MAYO CLINIC AFFILIATED SITE OR UPON REQUEST IN PERSON OR BY PHONE. THE FINANCIAL ASSISTANCE POLICY (FAP) AND THE PLAIN LANGUAGE SUMMARY (PLS) EXPLAIN THE FINANCIAL ASSISTANCE PROGRAM AND OUTLINES ELIGIBILITY CRITERIA AND PROVIDES INSTRUCTIONS TO SUBMIT AN APPLICATION. WITHIN EACH HOSPITAL FACILITY, A BROCHURE IS MADE AVAILABLE IN NUMEROUS LOCATIONS THROUGHOUT THE FACILITY WHICH DESCRIBES THE FINANCIAL ASSISTANCE POLICY, HOW TO APPLY FOR FINANCIAL ASSISTANCE, AND GIVES THE INTERNET ADDRESS WHERE THE COMPLETE POLICY CAN BE OBTAINED. ADDITIONALLY, CHARITABLE CARE AND FINANCIAL ASSISTANCE IS REFERENCED ON PATIENT CORRESPONDENCE INCLUDING: THE MONTHLY STATEMENT OF ACCOUNT, ACCOUNT BALANCE LETTERS, AND LATE PAYMENT NOTIFICATIONS. ALL PATIENT CORRESPONDENCE REFERENCING CHARITABLE CARE AND FINANCIAL ASSISTANCE INCLUDE INTERNET, PHONE, AND MAILING ADDRESS CONTACT INFORMATION. PATIENTS MAY ALSO BE MADE AWARE OF THE FAP VIA THEIR PROVIDER AND/OR OTHER MAYO CLINIC EMPLOYEES, WHO CAN PUT A PATIENT IN CONTACT WITH RESOURCES AVAILABLE TO ASSIST WITH THE APPLICATION PROCESS. PART VI, LINE 4: MCHS IN WAYCROSS SERVES A NINE-COUNTY REGION IN SOUTHEAST GEORGIA WITH THE MAJORITY OF PATIENTS COMING FROM WARE COUNTY.DEMOGRAPHICS: BASED ON U.S. CENSUS BUREAU QUICK FACTS AS OF JULY 1, 2016, WARE COUNTY HAD AN ESTIMATED POPULATION OF 35,738, OF WHICH AN ESTIMATED 23.9% OF THE POPULATION WAS UNDER THE AGE OF 18 AND AN ESTIMATED 16.7% WAS 65 YEARS OF AGE OR OLDER. THE ESTIMATED MEDIAN HOUSEHOLD INCOME FOR 2011 TO 2015 WAS $34,747 WITH APPROXIMATELY 28.4% OF THE POPULATION BELOW THE POVERTY LEVEL. PART VI, LINE 5: MAYO CLINIC AND ITS AFFILIATES ARE LARGE, MULTI-FACETED, INTEGRATED, NOT-FOR-PROFIT GROUP PRACTICES AND HEALTH SYSTEMS. AT MAYO CLINIC, DOCTORS FROM EVERY MEDICAL SPECIALTY WORK TOGETHER TO CARE FOR PATIENTS, JOINED BY COMMON SYSTEMS AND A PHILOSOPHY OF "THE NEEDS OF THE PATIENT COME FIRST." THE ORGANIZATIONS (INCLUDING HOSPITAL AND NON-HOSPITAL ENTITIES) WORK TOGETHER TO SERVE THEIR COMMUNITIES AT THE LOCAL, REGIONAL, NATIONAL, AND GLOBAL LEVELS. THIS COMMUNITY BENEFIT HAPPENS THROUGH ITS FOCUS ON PATIENT CARE, EDUCATION, AND RESEARCH. SPECIFICALLY, THE TAX-EXEMPT PURPOSE OF MAYO CLINIC AND ITS AFFILIATES IS THREE-FOLD:PRACTICE - PRACTICE MEDICINE AS AN INTEGRATED TEAM OF COMPASSIONATE, MULTI-DISCIPLINARY PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS WHO ARE FOCUSED ON THE NEEDS OF PATIENTS FROM OUR COMMUNITIES, REGIONS, THE NATION AND THE WORLD.EDUCATION - EDUCATE PHYSICIANS, SCIENTISTS AND ALLIED HEALTH PROFESSIONALS AND BE A DEPENDABLE SOURCE OF HEALTH INFORMATION FOR OUR PATIENTS AND THE PUBLIC.RESEARCH - CONDUCT BASIC AND CLINICAL RESEARCH PROGRAMS TO IMPROVE PATIENT CARE AND TO BENEFIT SOCIETY, INCLUDING PARTNERING WITH MAYO CLINIC HEALTH SYSTEM PRACTICES TO PERFORM PRACTICE-BASED RESEARCH DESIGNED TO IMPROVE PATIENT CARE.THROUGH ITS MISSION, MAYO CLINIC AND ITS AFFILIATES ENRICH THE COMMUNITIES IN WHICH THEY OPERATE AS WELL AS THE BROADER COMMUNITY IMPROVING MEDICINE THROUGH RESEARCH, EDUCATING PHYSICIANS AND OTHER HEALTH CARE PROVIDERS, AND PROVIDING CARE AND SUPPORT TO PEOPLE IN NEED.PLEASE REFER TO THE PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, FOR FURTHER DESCRIPTION OF THE FILING ORGANIZATION'S ACTIVITIES.SURPLUS FUNDS - MAYO CLINIC AND ITS AFFILIATES REINVEST THEIR NET OPERATING INCOME TO ADVANCE MEDICAL RESEARCH AND TEACH THE NEXT GENERATION OF HEALTH CARE PROFESSIONALS, AS WELL AS TO ALLOW THE INDIVIDUAL ENTITY TO SUSTAIN ITS MISSION AND PREPARE FOR THE FUTURE.COMMUNITY REPRESENTATION ON GOVERNING BODY - THE BOARD OF TRUSTEES IS THE GOVERNING BODY OF MAYO CLINIC. A MAJORITY OF ITS MEMBERS ARE EXTERNAL, INDEPENDENT TRUSTEES. IT HAS OVERALL RESPONSIBILITY FOR THE CHARITABLE, CLINICAL PRACTICE, SCIENTIFIC AND EDUCATIONAL MISSION AND PURPOSES OF MAYO CLINIC AND ITS AFFILIATES AS SET FORTH IN ITS ARTICLES OF INCORPORATION AND BYLAWS. BECAUSE OF MAYO CLINIC'S NATIONAL PRESENCE, THESE TRUSTEES ARE SELECTED BASED ON THEIR AREAS OF EXPERTISE, EXPERIENCE, AND OTHER CRITERIA ESTABLISHED BY THE INDEPENDENT NOMINATING COMMITTEE OF THE BOARD OF TRUSTEES. AREAS OF EXPERTISE AND EXPERIENCE INCLUDE SUCH AREAS AS HEALTH CARE POLICY, RESEARCH, EDUCATION, BUSINESS, AND GOVERNMENT. MAYO CLINIC HEALTH SYSTEM IN WAYCROSS, WHICH IS CONTROLLED BY MAYO CLINIC, RELIES ON THE COMMUNITY REPRESENTATION OF THE MAYO CLINIC BOARD OF TRUSTEES TO FULFILL THIS REQUIREMENT. OPEN V. CLOSED STAFF MODEL - SEVERAL OF MAYO CLINIC'S HOSPITAL ENTITIES HAVE OBTAINED LETTER RULINGS APPROVING A STAFF MODEL IN WHICH ONLY MAYO CLINIC EMPLOYED PHYSICIANS ARE GIVEN STAFF PRIVILEGES IN ORDER TO MAINTAIN STANDARD METHODS OF PRACTICE AND PROTOCOLS. FOR THOSE ENTITIES, THE PHYSICIANS ARE SALARIED EMPLOYEES AND THUS THE ISSUE OF PRIVATE INUREMENT AND PRIVATE BENEFIT ADDRESSED BY THE OPEN STAFF REQUIREMENT ARE OTHERWISE ADDRESSED. EMERGENCY ROOM MAYO CLINIC HEALTH SYSTEM IN WAYCROSS MAINTAINS AN EMERGENCY ROOM WITHIN THE HOSPITAL FACILITY 24 HOURS A DAY, 7 DAYS A WEEK, WHICH IS OPEN TO ALL WITHOUT REGARD TO THE ABILITY TO PAY. PART VI, LINE 6: MAYO CLINIC IS THE FIRST AND LARGEST INTEGRATED, NOT-FOR-PROFIT GROUP PRACTICE IN THE WORLD. DOCTORS FROM EVERY MEDICAL SPECIALTY WORK TOGETHER TO CARE FOR PATIENTS, JOINED BY COMMON SYSTEMS AND A PHILOSOPHY OF "THE NEEDS OF THE PATIENT COME FIRST." MORE THAN 4,500 STAFF PHYSICIANS AND SCIENTISTS AND OVER 58,000 ADMINISTRATIVE AND ALLIED HEALTH STAFF WORK AT MAYO CLINIC, WHICH HAS SITES IN ROCHESTER, MINNESOTA, JACKSONVILLE, FLORIDA, AND SCOTTSDALE/PHOENIX, ARIZONA, AS WELL AS A REGIONAL NETWORK OF HOSPITALS AND CLINICS IN MINNESOTA, WISCONSIN, IOWA, AND GEORGIA. COLLECTIVELY, MORE THAN 1.3 MILLION PEOPLE ARE TREATED EACH YEAR. MAYO CLINIC AND ITS AFFILIATES PROVIDE ONE OR MORE OF THE FOLLOWING SERVICES AT THEIR RESPECTIVE LOCATIONS: MEDICAL EDUCATION, RESEARCH, HOSPITAL AND CLINIC SERVICES. PART VI, LINE 7 NEITHER THE FILING ORGANIZATION, NOR ANY RELATED ORGANIZATION, FILES A COMMUNITY BENEFIT REPORT WITH ANY STATE OTHER THAN THE EXTENT TO WHICH COMMUNITY BENEFIT INFORMATION IS INCLUDED IN OTHER REPORTING REQUIREMENTS SUCH AS INFORMATION PROVIDED TO A STATE HOSPITAL ASSOCIATION. 1 SATILLA HEALTH FOUNDATION INC 1900 TEBEAU STREET WAYCROSS GA 31501 582008998 501(C)(3) 39583 GENERAL SUPPORT SATILLA HEALTH PARTNERS INC 3163 ORION DRIVE WAYCROSS GA 31503 814882114 501(C)(4) 76417625 ENSURE PROVISION OF ESSENTIAL HEALTH CARE SERVICES. 1 1 PART I, LINE 2: THE FILING ORGANIZATION CONSIDERS REQUESTS FOR FUNDING AND IN-KIND SUPPORT TO ORGANIZATIONS IN THE COMMUNITY WITH PROGRAMS THAT ENHANCE THE MISSION OF THE FILING ORGANIZATION. THE FILING ORGANIZATION ONLY CONSIDERS REQUESTS FOR FUNDING AND IN-KIND SUPPORT TO ORGANIZATIONS IN THE COMMUNITY THAT ADDRESS UNMET OR UNDER-FUNDED COMMUNITY NEEDS IN THE AREAS OF HEALTHCARE, EDUCATION, RESEARCH, DIVERSITY AND EQUALITY OF OPPORTUNITY. FORM 990, SCH I, PART II, LINE 1 PURSUANT TO A GRANT AGREEMENT BETWEEN OKEFENOKEE HEALTH, INC. AND SATILLA HEALTH PARTNERS, INC., A NON-PROFIT, TAX-EXEMPT 501(C)(4) ORGANIZATION ("SHP"), OHI GRANTED APPROXIMATELY $76,417,625 TO SHP WHICH OHI HAD RECEIVED IN CONNECTION WITH THE SALE OF THE HOSPITAL-RELATED ASSETS AND NURSING HOME RELATED ASSETS. TWO FUNDS WERE ESTABLISHED, THE COMMUNITY RESERVES FUND ("CRF") AND THE COMMUNITY HEALTH FUND ("CHF"). WITH THE CRF, SHP IS CHARGED WITH USING THE FUNDS TO ENSURE THE CONTINUED PROVISION OF ESSENTIAL HEALTH SERVICES IN THE COMMUNITY IN A MANNER THAT IS EXCLUSIVELY FOR THE PROMOTION OF SOCIAL WELFARE WITHIN THE MEANING OF IRC SECTION 501(C)(4) AND CONSISTENT WITH CHARITABLE PURPOSES WITHIN THE MEANING OF IRC SECTION 501(C)(3). WITH THE CHF, SHP IS CHARGED WITH USING THE FUNDS TO ACCOMPLISH THE FOLLOWING PURPOSES OF: (W) IMPROVING ACCESS TO HEALTHCARE FOR INDIVIDUALS IN THE COMMUNITY; (X) PROMOTING HEALTH AND WELLNESS IN THE COMMUNITY; (Y) PROVIDING HEALTH AND SAFETY EDUCATION TO THE PEOPLE OF THE COMMUNITY; AND (Z) ENSURING THE CONTINUED PROVISION OF ESSENTIAL HEALTH SERVICES IN THE COMMUNITY IN A MANNER THAT IS EXCLUSIVELY FOR THE PROMOTION OF SOCIAL WELFARE WITHIN THE MEANING OF IRC SECTION 501(C)(4) AND CONSISTENT WITH CHARITABLE PURPOSES WITHIN THE MEANING OF IRC SECTION 501(C)(3). X X X 1 1 0 1 0 0 0 0 0 0 0 BYRON C MAY MD DIRECTOR 0 559330 0 0 0 4439 0 55089 0 28188 0 647046 0 0 DANIEL L TOMLINSON DIRECTOR 0 227693 0 0 0 17738 0 41403 0 25941 0 312775 0 0 ROBERT M WALTERS DIRECTOR 0 316720 0 0 0 18172 0 66570 0 19667 0 421129 0 0 RICHARD J PRESUTTI DO CHAIR 0 434394 0 0 0 53522 0 43893 0 27027 0 558836 0 0 MICHAEL C DEITSCHMANN SECRETARY/TREASURER 0 178288 0 0 0 700 0 31335 0 36276 0 246599 0 0 TIMOTHY T CATCHINGS MD PHYSICIAN 358333 0 0 0 30701 0 7177 0 7170 0 403381 0 0 0 HOWARD GRIFFIN MD PHYSICIAN 223424 0 0 0 19099 0 4472 0 185 0 247180 0 0 0 ASIT K JHA MD PHYSICIAN 268542 0 0 0 18850 0 8109 0 9444 0 304945 0 0 0 BRIAN A SINGLETON MD PHYSICIAN 272554 0 0 0 19099 0 5475 0 7509 0 304637 0 0 0 SRIDHAR SRINIVASAN MD PHYSICIAN 240626 0 0 0 16766 0 3654 0 9049 0 270095 0 0 0 TERESA B BEARD FORMER OFFICER 0 118754 0 0 0 874 0 18379 0 14812 0 152819 0 0 KENNETH T CALAMIA MD FORMER OFFICER 0 159162 0 0 0 56636 0 34844 0 21380 0 272022 0 0 CHERYL R CROFT FORMER OFFICER 0 211094 0 0 0 16367 0 48731 0 20862 0 297054 0 0 NANCY L DAWSON MD FORMER OFFICER 0 293388 0 0 0 20548 0 61409 0 19131 0 394476 0 0 STEPHEN M LANGE MD FORMER OFFICER 0 417711 0 0 0 90478 0 10800 0 28602 0 547591 0 0 KEVIN M LOCKETT FORMER OFFICER 0 257900 0 0 0 2507 0 39496 0 25489 0 325392 0 0 MCGREGOR N LOTT MD FORMER KEY EMPLOYEE 212132 0 0 0 16989 0 4330 0 10622 0 244073 0 0 0 WINDELL R SMITH JR FORMER KEY EMPLOYEE 0 192205 0 0 0 756 0 34503 0 28115 0 255579 0 0 DAVID J WYKSTRA MD FORMER KEY EMPLOYEE 204756 0 0 0 13945 0 2647 0 11459 0 232807 0 0 0 MICHAEL P BAKER MD FORMER KEY EMPLOYEE 0 0 0 0 0 142744 0 0 0 0 0 142744 0 0 PART I, LINE 1A HOLLI SWEAT RECEIVED A BONUS OF $10,000 THAT WAS GROSSED UP. THIS WAS INCLUDED IN TAXABLE WAGES. ROGER FORGEY WAS REIMBURSED FOR $15,743 FOR HOUSING ALLOWANCES. THIS WAS INCLUDED IN TAXABLE WAGES. ROGER FORGEY WAS REIMBURSED $150 FOR CLUB DUES. THIS WAS INCLUDED IN TAXABLE WAGES. PART I, LINE 4B THE FOLLOWING RECEIVED NQDC PAYMENTS IN 2017: BYRON C. MAY M.D. $21,035 ROBERT M. WALTERS $12,021 RICHARD J. PRESUTTI D.O. $31,319 MCGREGOR N. LOTT M.D. $16,863 DAVID J. WYKSTRA M.D. $13,819 KENNETH T. CALAMIA M.D. $30,444 NANCY L. DAWSON M.D. $7,022 STEPHEN M. LANGE M.D. $74,965 TIMOTHY T CATCHINGS M.D. $30,575 HOWARD GRIFFIN M.D. $18,973 ASIT K. JHA M.D. $18,724 BRIAN A. SINGLETON M.D. $18,973 SRIDHAR SRINIVASAN M.D. $16,640 MEDICAL CONSULTING RESOURCES LLC ENTITY OWNED BY ROGER FORGEY 153659 MANAGEMENT SERVICES PROVIDED TO OHI. 0 JH ENTERPRISES OF INDIANA LLC ENTITY OWNED BY G.E. HOFFMAN JR 164148 MANAGEMENT SERVICES PROVIDED TO OHI. 0 ALL ASSETS ASSOCIATED WITH THE OWNERSHIP AND OPERATION OF TWO NURSING HOMES 2017-09-01 14000000 APPRAISAL 611816654 WAYCROSS REALTY HOLDINGS LLC 3163 ORION DRIVE WAYCROSS GA 31503 LIMITED LIABILITY COMPANY ALL ASSETS ASSOCIATED WITH THE OWNERSHIP AND OPERATION OF A HOSPITAL 2017-05-01 62417625 APPRAISAL 814223395 SOUTHEAST GEORGIA HEALTH SERVICES LLC PO BOX 570 NASHVILLE TN 37202 501(C)(3) CASH - SEE SCH I, PART IV (FOR SCH I, PART II, LINE 1) FOR DETAIL EXPLANATION OF TRANSACTION 2017-05-01 62417625 CASH 814882114 SATILLA HEALTH PARTNERS INC 3163 ORION DRIVE WAYCROSS GA 31503 501(C)(4) CASH - SEE SCH I, PART IV (FOR SCH I, PART II, LINE 1) FOR DETAIL EXPLANATION OF TRANSACTION 2017-09-01 14000000 CASH 814882114 SATILLA HEALTH PARTNERS INC 3163 ORION DRIVE WAYCROSS GA 31503 501(C)(4) 1 1 0 1 PART II, LINE 2E: PERSON(S) INVOLVED: P. OWEN HERRIN, JR.SATILLA HEALTH PARTNERS, INC.JAMES W. DYE, M.D. ZIBIA A. MUSICDONALD WATERS M.D. PART II, LINE 2E: EXPLANATION OF INVOLVEMENT: SATILLA HEALTH PARTNERS, INC.P. OWEN HERRIN, JR. BECAME AN OFFICER OF THE SUCCESSOR CORPORATION AND RECEIVED COMPENSATION AS AN INDEPENDENT CONTRACTOR FOR OTHER SERVICES PROVIDED. JAMES W. DYE, M.D. BECAME AN OFFICER OF THE SUCCESSOR CORPORATION AND RECEIVED COMPENSATION.ZIBIA A. MUSIC BECAME AN OFFICER OF THE SUCCESSOR CORPORATION AND RECEIVED COMPENSATION.DONALD WATERS M.D. BECAME AN OFFICER OF THE SUCCESSOR CORPORATION AND RECEIVED COMPENSATION. FORM 990, PART III, LINE 3 IN THE FIRST FOUR MONTHS OF THE YEAR, OKEFENOKEE HEALTH, INC. (FKA MAYO CLINIC HEALTH SYSTEM IN WAYCROSS) SERVED A NINE-COUNTY REGION IN SOUTHEAST GEORGIA. OKEFENOKEE HEALTH, INC. OPERATED A 231-BED HOSPITAL, A 96-BED SKILLED NURSING FACILITY, A REHAB UNIT AND A PSYCHIATRIC UNIT IN WAYCROSS, GEORGIA ALONG WITH AN ADDITIONAL 78-BED SKILLED NURSING FACILITY IN BLACKSHEAR, GEORGIA. DURING THE YEAR, THE ORGANIZATION SOLD ALL THE ASSETS ASSOCIATED WITH THESE OPERATIONS. OKEFENOKEE HEALTH, INC. IS NOW A PUBLIC CHARITY WHOSE PURPOSE IS TO PROMOTE COMMUNITY HEALTH THROUGH ACTIVITIES DESIGNED TO ENSURE AND IMPROVE ACCESS TO HEALTHCARE FOR ALL INDIVIDUALS IN THE COMMUNITY AND TO PROMOTE HEALTHCARE AND WELLNESS IN THE COMMUNITIES. FORM 990, PART III, LINE 4A IN THE FIRST FOUR MONTHS OF THE YEAR, OKEFENOKEE HEALTH, INC. (FKA MAYO CLINIC HEALTH SYSTEM IN WAYCROSS) SERVED A NINE-COUNTY REGION IN SOUTHEAST GEORGIA. OKEFENOKEE HEALTH, INC. OPERATED A 231-BED HOSPITAL, A 96-BED SKILLED NURSING FACILITY, A REHAB UNIT AND A PSYCHIATRIC UNIT IN WAYCROSS, GEORGIA ALONG WITH AN ADDITIONAL 78-BED SKILLED NURSING FACILITY IN BLACKSHEAR, GEORGIA. OKEFENOKEE HEALTH, INC. PROVIDED CARE TO PATIENTS WHO MET CERTAIN CRITERIA UNDER ITS FINANCIAL ASSISTANCE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. SERVICES ARE ALSO PROVIDED TO MEDICAID AND MEDICARE PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. SATILLA ADVOCACY SERVICES, A RAPE CRISIS AND CHILD ADVOCACY CENTER, OPERATES UNDER THE UMBRELLA OF OKEFENOKEE HEALTH, INC. AND SERVED VICTIMS OF SEXUAL ASSAULT AND OTHER VIOLENT CRIMES IN THE SIX COUNTIES THAT MAKE UP THE WARE JUDICIAL CIRCUIT. A FULL RANGE OF SERVICES WERE OFFERED FROM THE TIME A VICTIM REPORTS AN INCIDENT, INCLUDING EMERGENCY DEPARTMENT SERVICES, FOLLOW UP AT THE RAPE CRISIS/CHILD ADVOCACY. FORM 990, PART III, LINE 4B FOLLOWING THE SALE OF ALL THE HOSPITAL ASSETS AND THE ASSIGNMENT OF ALL THE NURSING HOME OPERATIONS EFFECTIVE MAY 1, 2017, OKEFENOKEE HEALTH, INC. CONTINUED IN AN ADMINISTRATIVE FUNCTION TO COMPLETE ITS OBLIGATIONS CONNECTED WITH ITS PRIOR BUSINESS OPERATIONS AS THE OWNER AND OPERATOR OF A HOSPITAL AND NURSING HOMES INCLUDING COLLECTING RELATED REVENUES AND SATISFYING ITS EXPENSES. IN ADDITION, OKEFENOKEE HEALTH, INC. CONTINUED TO MONITOR THE ACTIVITIES OF THE HOSPITAL BUYER TO ENSURE THAT THE HOSPITAL BUYER (I) CONTINUES TO OPERATE THE HOSPITAL AS AN ACUTE CARE HOSPITAL; (II) REMAINS ENROLLED IN THE MEDICARE AND MEDICAID PROGRAMS; (III) CONTINUES THE PROVISION OF INDIGENT CARE SERVICES AT A MINIMUM CONSISTENT WITH OHI'S PREVIOUS POLICIES; (IV) MAINTAINS IDENTIFIED CORE SERVICES FOR THE BENEFIT OF THE COMMUNITY; AND (V) MAKES CAPITAL EXPENDITURES TO IMPROVE THE HOSPITAL IN A MINIMUM AMOUNT OF $21.6 MILLION. OHI IS REQUIRED TO PERFORM THESE SERVICES UNDER THE TRANSACTION DOCUMENTS RELATING TO THE SALE OF THE HOSPITAL ASSETS, AND IN A SIMILAR MANNER IS CHARGED WITH MONITORING THE OBLIGATIONS OF THE NURSING HOME BUYER. FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING INDIVIDUALS ARE EMPLOYED BY A RELATED ORGANIZATION: BYRON C. MAY M.D. RICHARD J. PRESUTTI D.O. THE FOLLOWING INDIVIDUALS HAVE A BUSINESS RELATIONSHIP WITH A RELATED ORGANIZATION AS AN OFFICER, DIRECTOR OR TRUSTEE: MICHAEL C. DEITSCHMANN DANIEL L. TOMLINSON ROBERT M. WALTERS BYRON C. MAY M.D. RICHARD J. PRESUTTI D.O. FORM 990, PART VI, SECTION A, LINE 3 FOR THE FIRST FOUR MONTHS OF THE YEAR, MAYO CLINIC, MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH, MAYO CLINIC JACKSONVILLE AND OTHER RELATED ENTITIES PROVIDE MANAGEMENT SERVICES FOR MCHS-WAYCROSS. SINCE THE ENTITIES ARE RELATED ORGANIZATIONS, COMPENSATION FOR THE OFFICERS, DIRECTORS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES HAS BEEN DISCLOSED IN PART VII AND SCHEDULE J. FORM 990, PART VI, SECTION A, LINE 4 AS OF MAY 1, 2017, THE ORGANIZATION ADOPTED NEW BYLAWS TO REFLECT ITS CHANGE IN ACTIVITIES AS REPORTED TO THE IRS WITH FORM 1023. THE CHANGES INCLUDED (1) AN EXEMPT PURPOSE OF ENHANCING COMMUNITY HEALTHCARE AND ACCESS TO HEALTHCARE, ESPECIALLY FOR POOR AND INDIGENT INDIVIDUALS; (2) THE NAME OF THE ORGANIZATION WAS CHANGED TO OKEFENOKEE HEALTH, INC.; (3) THE NUMBER OF INITIAL BOARD OF DIRECTORS WILL BE FOUR. ONCE THE NUMBER OF BOARD MEMBERS REACHES SEVEN, THE COMPOSITION OF THE BOARD MEMBERS SHALL BE THAT AT LEAST TWO ARE RESIDENTS OF PIERCE COUNTY, GA, AT LEAST TWO ARE RESIDENTS OF WARE COUNTY, GA, AT LEAST TWO ARE PHYSICIANS AND AT LEAST ONE MEMBER OF THE PIERCE COUNTY HOSPITAL AUTHORITY OR ITS SUCCESSOR, AT LEAST ONE MEMBER OF THE WARE COUNTY HOSPITAL AUTHORITY OR ITS SUCCESSOR AND AT LEAST ONE INDIVIDUAL THAT SERVES AS A DIRECTOR ON THE BOARD OF SATILLA HEALTH PARTNERS, INC. OR ITS SUCCESSOR. BOARD MEMBERS MUST HAVE EXPERTISE IN CRITICAL AREAS INVOLVING ACCOUNTING, FINANCE, COMPENSATION AND ETHICS. THE OFFICERS OF THE ORGANIZATION SHALL BE THE PRESIDENT, VICE PRESIDENT, A SECRETARY, A TREASURER AND ANY OTHER OFFICERS DEEMED APPROPRIATE BY THE BOARD. THE OFFICERS SHALL BE VESTED WITH THE AUTHORITY TO ADMINISTER AND IMPLEMENT DUTIES, RESPONSIBILITIES AND DIRECTIVES IN CONFORMITY WITH RESPECTIVE OFFICES IN FURTHERANCE OF THE PURPOSES SET FORTH IN THE BYLAWS AND ARTICLES. UPON LIQUIDATION, ALL PROPERTY AND ASSETS SHALL BE DISTRIBUTED TO AN ENTITY EXEMPT UNDER 501(C)(3) THAT WILL FULFILL A HEALTH CARE MISSION IN THE COMMUNITY CURRENTLY SERVED BY THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF MCHS-WAYCROSS (DURING THE FIRST FOUR MONTHS OF THE YEAR) WAS MAYO CLINIC JACKSONVILLE. OKEFENOKEE HEALTH, INC. HAS NO MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A WHILE MCHS-WAYCROSS (DURING THE FIRST 4 MONTHS OF THE REPORTING YEAR), THE SOLE CORPORATE MEMBER APPOINTED MEMBERS TO THE BOARD OF DIRECTORS THROUGH MULTIPLE PROCESSES AS SPECIFIED IN THE BYLAWS. THERE ARE NO MEMBERS OF OKEFENOKEE HEALTH INC. FORM 990, PART VI, SECTION A, LINE 7B WHILE MCHS-WAYCROSS (DURING THE FIRST 4 MONTHS OF THE REPORTING YEAR), THE ARTICLES AND BYLAWS PROVIDED THE SOLE CORPORATE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, DEBT, AMENDMENT OF ARTICLES AND BYLAWS AND GENERAL OPERATIONAL DECISIONS. IN ADDITION DURING THAT TIME, THE COMMUNITY DIRECTORS HAVE THE AUTHORITY TO ENFORCE CERTAIN PROVISIONS OF THE INTEGRATION AGREEMENT. THERE WERE NO MEMBERS AS OKEFENOKEE HEALTH, INC. FORM 990, PART VI, SECTION A, LINE 8B OKEFENOKEE HEALTH, INC. HAS NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S MANAGEMENT WILL RECEIVE A COPY OF THE 990 PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C AS OF MAY 1, 2017, ANY DIRECTOR, PRINCIPAL OFFICER, MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS OR A PERSON WITH FINANCIAL INTEREST DIRECTLY OR INDIRECTLY, THROUGH BUSINESS, INVESTMENT, OR FAMILY IS COVERED BY THE CONFLICT OF INTEREST POLICY. ANY PERSON COVERED UNDER THE CONFLICT OF INTEREST POLICY IS REQUIRED TO DISCLOSE A CONFLICT OF INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH POWERS DELEGATED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS OR COMMITTEE SET BY THE BOARD OF DIRECTORS IS RESPONSIBLE FOR REVIEWING AND DISCUSSING THE MATERIAL FACTS OF THE CONFLICT OF INTEREST PRESENTED BY THE INTERESTED PERSON. AFTER EXERCISING DUE DILIGENCE, THE BOARD OF DIRECTORS OR APPOINTED COMMITTEE SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLE THE BOARD OF DIRECTORS OR APPOINTED COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE WHETHER OR NOT THE TRANSACTION OR ARRANGEMENT WITH THE INTERESTED PERSON SHALL BE ENTERED INTO. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION REVIEW AND APPROVAL PROCESS FOR EMPLOYEES OF THE ORGANIZATION WAS CONDUCTED BY MAYO CLINIC'S BOARD OF TRUSTEES GOVERNANCE AND NOMINATING COMMITTEE, NOT BY ANY COMMITTEE OF MCHS-WAYCROSS OR OKEFENOKEE HEALTH, INC. FORM 990, PART VI, SECTION C, LINE 19 FOR THE FIRST FOUR MONTHS OF THE TAX YEAR THE FILING ORGANIZATION WAS AN AFFILIATE OF MAYO CLINIC. MAYO CLINIC'S CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST AND ALSO ON THE MAYOCLINIC.ORG WEBSITE. FORM 990, PART VII CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC BYRON C. MAY M.D. - 4500 SAN PABLO ROAD, JACKSONVILLE, FL 32224. DANIEL L. TOMLINSON - 200 FIRST STREET SW, ROCHESTER, MN 55905. ROBERT M. WALTERS - 4500 SAN PABLO ROAD, JACKSONVILLE, FL 32224. DONALD WATERS M.D. - 3366 TWIN LAKE ROAD, BLACKSHEAR, GA 31516. JAMES W. DYE, M.D. - 6215 TALL PINES DRIVE, BLACKSHEAR, GA 31516. ZIBIA A. MUSIC - 5963 DOUGLAS HIGHWAY, MILLWOOD, GA 31552. RICHARD J. PRESUTTI D.O. - 4500 SAN PABLO ROAD, JACKSONVILLE, FL 32224. MICHAEL C. DEITSCHMANN - 4500 SAN PABLO ROAD, JACKSONVILLE, FL 32224. SATILLA RELIANT PSYCHIATRIC SERVICES LLC 6 OFFICE PARK CIRCLE SUITE 100 BIRMINGHAM AL 35223 205721155 PSYCHIATRIC SERVICES AL 0 0 OKEFENOKEE HEALTH INC BLOOMER LAKEVIEW INC 2110 DUNCAN ROAD BLOOMER WI 54724 391450617 LOW INCOME HOUSING WI 501(C)(3) LINE 7 MCHS CHIPPEWA VALLEY INC 1 CHARTERHOUSE INC 200 FIRST STREET SW ROCHESTER MN 55905 411405254 RETIREMENT LIVING CENTER MN 501(C)(3) LINE 10 MAYO CLINIC 1 DESTINATION MEDICAL CENTER EDA 50 SOUTH SIXTH STREET SUITE 1500 MINNEAPOLIS MN 55402 464893585 ECONOMIC DEVELOPMENT MN 501(C)(3) LINE 12A, I MAYO CLINIC 1 GOLD CROSS AMBULANCE SERVICE 200 FIRST STREET SW ROCHESTER MN 55905 411917516 AMBULANCE SERVICE MN 501(C)(3) LINE 10 MFMER 1 MCHS SPRINGFIELD 625 NORTH JACKSON AVENUE SPRINGFIELD MN 56087 411893827 HOSPITAL AND CLINIC MN 501(C)(3) LINE 3 MCHS MANKATO 1 MCHS ST JAMES 1101 MOULTON PARSONS DR PO BOX 46 ST JAMES MN 56081 410797368 HOSPITAL AND CLINIC MN 501(C)(3) LINE 3 MCHS MANKATO 1 MCHS WASECA 501 NORTH STATE STREET WASECA MN 56093 363606405 HOSPITAL AND CLINIC MN 501(C)(3) LINE 3 MCHS MANKATO 1 LUTHER LAKESIDE APARTMENTS INC PO BOX 1510 EAU CLAIRE WI 54702 391409024 LOW INCOME HOUSING FOR ELDERLY WI 501(C)(3) LINE 10 MCHS NORTHWEST WISCONSIN REGION INC 1 MAYO CLINIC 200 FIRST STREET SW ROCHESTER MN 55905 416011702 PATIENT CARE - 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