2017-05-12T12:38:39-04:00 2016-06-30 990 2015-07-01 621816368 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC WELL 4232308200 1905 AMERICAN WAY KINGSPORT TN 37660 TODD J DOUGAN SECRETARY/CFO 4232308200 2017-05-12 2015 2021-01-29 14:40:06Z TODD J DOUGAN 1905 AMERICAN WAY KINGSPORT TN 37660 68035417 false X WWW.WELLMONT.ORG X 2000 TN WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION. 3 0 242 7 0 21590 4672 61128864 67636477 -3138 598292 385132 61748746 68023143 606 0 8537196 9039241 0 0 38709382 43217833 47246578 52257680 14502168 15765463 27048922 23410991 6225268 6300213 20823654 17110778 X WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION. false false 39237021 606 67636477 WELLMONT HEALTH SYSTEM PREPARES A CONSOLIDATED COMMUNITY BENEFIT REPORT, WHICH INCLUDES THE ACTIVITIES OF ALL ITS OPERATIONS AND AFFILIATES. IN CONTRAST, AN INTERNAL REVENUE SERVICE (IRS) FORM 990 IS FILED FOR EACH TAX EXEMPT CORPORATION (7 SEPARATE FORM 990S), AND THERE IS NO SUCH IRS FORM FOR THE TAXABLE CORPORATIONS. IN ADDITION, THE IRS INSTRUCTIONS TO FORM 990 HAVE SPECIFIC DEFINITIONS, METHODS AND WORKSHEETS TO CALCULATE THE COMMUNITY BENEFITS TO BE INCLUDED ON THE FORM 990. AS A RESULT, THERE ARE SIGNIFICANT DIFFERENCES BETWEEN THE COMMUNITY BENEFITS REPORTED IN THE CONSOLIDATED COMMUNITY BENEFIT REPORT AND THE VARIOUS FORM 990S. THERE ARE ALSO FUNDS AND SERVICES THAT ARE PROVIDED THAT DO NOT MEET THE SPECIFIC DEFINITIONS OF THE IRS INSTRUCTIONS, SUCH AS (CON'T ON SCHEDULE O) CONTRIBUTIONS TO COMMUNITY ORGANIZATIONS THAT DO NOT MEET THE DEFINITION OF "RESTRICTED TO ONE OR MORE OF THE ACTIVITIES DESCRIBED IN THE TABLE IN PART I, LINE 7" OF SCHEDULE H-HOSPITALS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A PUBLIC TRUST. THIS HOSPITAL, LIKE THE OTHER WELLMONT HEALTH SYSTEM FACILITIES OF WHICH IT IS A MEMBER, WAS BORN OF ITS COMMUNITY'S COMMITMENT TO PROVIDE SUPERIOR HEALTH CARE FOR ITS CITIZENS. IT IS OUR MISSION TO DELIVER SUPERIOR HEALTH CARE WITH COMPASSION TO THE PEOPLE WE SERVE, AND IT IS OUR VISION TO DELIVER THE BEST HEALTH CARE ANYWHERE. CONSISTENT WITH THIS MISSION, WE HAVE WORKED TOWARD IMPROVING OUR COMMUNITY'S ACCESS TO QUALITY, AFFORDABLE HEALTH CARE, EDUCATING OUR REGION'S CAREGIVERS, IMPROVING THE HEALTH STATUS OF OUR COMMUNITIES AND CONTRIBUTING TO THE OVERALL QUALITY OF LIFE IN THE AREAS WE SERVE. OVERALL, WE RETURNED MORE THAN 6,188,407 IN BENEFITS TO OUR COMMUNITY IN FISCAL YEAR 2016, INCLUDING 6,149,780 OF UNREIMBURSED COSTS FOR INDIGENT AND MEDICAID PATIENTS AND 38,627 FOR OTHER COMMUNITY ACTIVITIES. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A 50-BED FACILITY IN ROGERSVILLE, TENNESSEE. WE PROVIDE A WIDE VARIETY OF SERVICES, INCLUDING EMERGENCY CARE, PHYSICAL, STROKE AND OCCUPATIONAL THERAPIES, SURGERY, INTERMEDIATE MEDICAL CARE, OUTPATIENT SPECIALTY CLINICS, LABORATORY SERVICES, AUDIOLOGY SERVICES, CARDIOVASCULAR SERVICES, RESPIRATORY THERAPY, SLEEP EVALUATIONS AND TREATMENT, INFUSION, SPINE REHABILITATION SERVICES AND DIAGNOSTIC IMAGING. IN MARCH 2014, HAWKINS COUNTY MEMORIAL OPENED A SECOND INFUSION CENTER IN JOHNSON CITY, TENNESSEE. THE INFUSION CENTERS IN HAWKINS COUNTY AND JOHNSON CITY OFFER PATIENTS CONVENIENT ACCESS TO CANCER SERVICES IN A HEALING ENVIRONMENT. AMENITIES IN THE INFUSION CENTERS INCLUDE HEATED CHAIRS AND MASSAGES. IN FISCAL YEAR 2016, WE PROVIDED SERVICES TO 803 INPATIENTS, HAD 235 INPATIENT AND OUTPATIENT SURGICAL CASES, AND HAD 16,902 EMERGENCY ROOM VISITS. WE ARE MINDFUL OF OUR RESPONSIBILITIES AS ONE OF HAWKINS COUNTY'S LARGEST COMPANIES. HUNDREDS OF FAMILIES COUNT ON US FOR THEIR LIVELIHOODS. OUR AREA RELIES ON US AS A DRIVER OF ECONOMIC DEVELOPMENT. IT IS OUR DUTY AS A CORPORATE CITIZEN TO SUPPORT THOSE ENDEAVORS AND CAUSES THAT IMPROVE THE QUALITY OF LIFE IN OUR REGION. AND WE ALSO RECOGNIZE IT IS OUR RESPONSIBILITY TO CARE FOR THOSE IN NEED - REGARDLESS OF THEIR ABILITY TO PAY. IT IS OUR COMMITMENT - INDEED, IT IS IMPLICIT IN OUR MISSION - TO SUPPORT THE CAUSES AND DEVELOP THE INITIATIVES THAT WILL PROPEL OUR COMMUNITY TOWARD A BETTER, BRIGHTER, HEALTHIER AND MORE VIBRANT FUTURE. REGARDLESS OF RACE, RELIGION, ETHNICITY OR ABILITY TO PAY, WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. TREATS ALL PATIENTS FOR MEDICALLY NECESSARY CONDITIONS. RECOGNIZING SOME PATIENTS CANNOT AFFORD ESSENTIAL MEDICAL SERVICES, WE PROVIDED CARE FOR INDIGENT PATIENTS, WRITING OFF 5,087,105 OF CHARGES AND INCURRING COSTS OF 851,079. WE SUPPORT AND ENCOURAGE OUR EMPLOYEES TO GIVE THEIR TIME TO AREA NOT-FOR- PROFIT ORGANIZATIONS, WHICH INCLUDED THE AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY, THE ROGERSVILLE HERITAGE ASSOCIATION, CIVIC GROUPS SUCH AS KIWANIS AND ROTARY, VARIOUS UNITED WAY AGENCIES AND THE ROGERSVILLE AREA CHAMBER OF COMMERCE AND ITS PROGRAMS. MANY OF OUR EMPLOYEES ALSO SERVE IN COMMUNITY RESCUE SQUADS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. WILL SUCCEED IN OUR MISSION BY CONTINUALLY REINVESTING IN OUR MOST PRECIOUS RESOURCE - OUR PEOPLE. TO THAT END, WE PROVIDED ON-THE-JOB TRAINING TO NURSING CANDIDATES. THIS PROGRAM UTILIZES NURSING STAFF THAT HAVE COMPLETED A DEGREE BUT NOT YET PASSED BOARD CERTIFICATION. THIS PROVIDES INVALUABLE EXPERIENCE FOR NEW NURSES, WHO ARE SUPERVISED BY BOARD-CERTIFIED NURSES. WE ALSO PROVIDED EDUCATIONAL OPPORTUNITIES TO STUDENTS IN OTHER MEDICAL DISCIPLINES, SUCH AS RADIOLOGY. FOREWARNED IS FOREARMED. THE BEST WAY TO KEEP OUR COMMUNITIES HEALTHY IS TO PROVIDE THEM WITH THE LATEST INFORMATION ABOUT THEIR HEALTH. WE STRIVE TO PROVIDE INFORMATION ABOUT EVERYTHING FROM DISEASE AND INJURY PREVENTION TO THE LATEST TREATMENTS AND TECHNOLOGIES AVAILABLE TO COPING WITH DISEASE AND ITS SYMPTOMS. OUR TOTAL COMMUNITY BENEFIT FOR COMMUNITY HEALTH IMPROVEMENT SERVICES HAD A DIRECT COST OF 26,145. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. PROVIDED CASH AND IN-KIND CONTRIBUTIONS AT A DIRECT COST OF 33,839. IN-KIND SERVICES INCLUDED CONFERENCE ROOM SPACE DONATED TO NON-PROFIT COMMUNITY GROUPS SUCH AS ALCOHOLICS ANONYMOUS, HAWKINS COUNTY CHAMBER OF COMMERCE AND THE ROTARY CLUB. OTHER IN-KIND SERVICES PROVIDED WERE RESTOCKING SUPPLIES OF EMS VEHICLES. 39237021 true false false false false false false false false false true false false false false false false true false false false false false false false false true true false false true false false false false false false false false false false false false false true false false false true 12 0 true 242 true false false false false false false false false false false X 3 0 false false false false true true true true true true false true true true true true true true true false X TODD J DOUGAN 4232308200 1905 AMERICAN WAY KINGSPORT TN 37660 BARTON A HOVE PRESIDENT/WH 1.00 39.00 X X 0 1382592 38571 GARY D MILLER TREAS/SR VP 1.00 39.00 X X 0 476682 19789 TODD J DOUGAN SECRETARY/CF 1.00 39.00 X X 0 372338 20628 REBECCA BECK PRESIDENT-WH 32.00 8.00 X 37603 112810 17631 REGINA DAY FINANCE DIRE 10.00 30.00 X 27838 83514 7081 GEORGIA SHUCK PHARMACIST 40.00 X 137313 0 5123 ALEXANDER GEORGE PHARMACIST 40.00 X 133188 0 8453 ALICE POPE TERMED 42216 SEC/EVP & CF 1.00 39.00 X 0 622401 30564 MARGARET DENARVAEZ TERMED 91614 PRESIDENT/WH X 0 146211 0 FRED PELLE TRF TO HVMC 32315 PRES-COMM DI 40.00 X 0 345139 21693 335942 3541687 169533 3 true true false QUEST DIAGNOSTICS 1201 S COLLEGEVILLE ROAD COLLEGEVILLE PA 19426 MEDICAL SERVICE 995655 MEDSTREAM ANESTHESIA 82 PATTON AVENUE SUITE 510 ASHEVILLE NC 28801 MEDICAL SERVICE 317100 NEW MILLENIUM HEALTHCARE 555 MT CARMEL ROAD MOSHEIM TN 37818 MRI SCANS 280225 SODEXO INC & AFFLILIATES P O BOX 536922 ATLANTA GA 30353 DIETARY MGMT 194116 COMFORT SYSTEMS USA P O BOX 757 BRISTOL VA 242030757 HVAC MAINT 173951 6 4672 4672 PATIENT CARE REVENUE - NET 621990 67634157 67634157 PHYSICAL THERAPY REVENUE 621990 2320 2320 67636477 27059 9136 17923 17923 17923 3138 -3138 -3138 -3138 MEANINGFUL USE FUNDS 900099 208496 208496 CAFETERIA/ VENDING REVENUE 900099 71174 71174 MISCELLANEOUS REVENUE 900099 46503 46503 41036 41036 367209 68023143 67882871 135600 X 606 606 164830 164830 7199891 7066868 133023 198207 193952 4255 961725 935072 26653 514588 495342 19246 3739 3739 14797515 2313182 12484333 938297 872429 65868 987171 987171 37393 32856 4537 378458 378458 1109953 1054455 55498 28793 28793 MEDICAL SUPPLIES 22179020 22179020 PROVISION FOR BAD DEBTS 2675807 2675807 MISCELLANEOUS EXPENSE 81687 23010 58677 52257680 39237021 13020659 0 57372 34487 18709560 15431381 1044712 1063231 48015 46416 19977275 13141799 7189263 6835476 27048922 23410991 6225268 6300213 6225268 6300213 X 20823654 17110778 20823654 17110778 27048922 23410991 15765463 -19478339 X false true X true false X 30500 30500 8711831 5951322 2760509 3780491 932844 2847647 6977885 5845205 1132680 476568 412428 64140 6835476 true true X true X false true true false true true 851079 851079 0.01630 10010528 4711827 5298701 0.10140 10861607 4711827 6149780 0.11770 124 167 26145 41036 123 197 4788 4788 0.00010 204 491 33839 33839 0.00060 451 855 64772 41036 38627 0.00070 451 855 10926379 4752863 6188407 0.11840 false 447666 12102278 11552232 550046 X true true 1 1 WELLMONT HAWKINS CO MEM HOSPINC 851 LOCUST STREET ROGERSVILLE TN 37857 X X WELLMONT HAWKINS CO MEM HOSPINC 1 false false true X X X X X X X X X X 16 true true false true X WWW.WELLMONT.ORG true 16 true WWW.WELLMONT.ORG false false true X 200.000000000000 false true X X X true X WWWWELLMONTORG X WWWWELLMONTORG X WWWWELLMONTORG X X X true X true X X X X true X false false FACILITY 1, WELLMONT HAWKINS CO MEM HOSP,INC - PART V, LINE 5 INFORMATION FOR THE CHNA ASSESSMENT WAS GATHERED FROM A VARIETY OF SOURCES, INCLUDING: -PHYSICIAN NEEDS ASSESSMENT -COMMUNITY HEALTH FACILITY ASSESSMENT -MENTAL HEALTH NEEDS ASSESSMENT -PUBLICLY AVAILABLE POPULATION AND DEMOGRAPHIC INFORMATION -PUBLICLY AVAILABLE POPULATION HEALTH INFORMATION, INCLUDING AMERICA'S HEALTH RANKINGS AND THE COUNTY HEALTH RANKINGS -STATE AND REGIONAL HEALTH DEPARTMENT DATA -THE SOUTHWEST VIRGINIA HEALTH AUTHORITY'S BLUEPRINT FOR HEALTH ENABLED PROSPERITY -THE ETSU, WELLMONT, MOUNTAIN STATES COMMUNITY WORK GROUP PROJECT -OTHER STUDIES SIGNIFICANT INFORMATION WAS GLEANED FROM A PROCESS CONDUCTED BY THE ETSU COLLEGE OF PUBLIC HEALTH AND SUPPORTED BY BOTH WELLMONT HEALTH SYSTEM AND MOUNTAIN STATES HEALTH ALLIANCE. COMMUNITY WORKGROUPS WERE FORMED, INVOLVING A CROSS SECTION OF SUBJECT MATTER EXPERTS TO ASSESS REGIONAL HEALTH NEEDS, INCLUDING THOSE OF UNDERSERVED PEOPLE, FAMILIES, CHILDREN AND THOSE SUFFERING FROM MENTAL HEALTH AND SUBSTANCE ABUSE CHALLENGES. REGIONAL MEETINGS WERE ALSO HELD WHICH INCLUDED REPRESENTATIVES OF THE COMMUNITY AT LARGE, PATIENTS AND MINORITIES OR AGENCIES SERVING THEM. FINDINGS FROM THIS WORK WERE TAKEN INTO ACCOUNT IN BOTH THE ASSESSMENT AND IMPLEMENTATION PLAN. THE INFORMATION WAS THEN COLLATED AND ASSESSED TO DETERMINE THE GREATEST UNMET HEALTH NEEDS FACING OUR REGION. STRATEGIES TO ADDRESS THESE NEEDS WERE THEN DEVELOPED, UTILIZING INTERNAL RESOURCES AND PARTNERSHIPS WITH OTHER HEALTH CARE ORGANIZATIONS AND PHYSICIANS. FACILITY 1, WELLMONT HAWKINS CO MEM HOSP,INC - PART V, LINE 6A - BRISTOL REGIONAL MEDICAL CENTER - HOLSTON VALLEY MEDICAL CENTER - LONESOME PINE HOSPITAL - HANCOCK COUNTY HOSPITAL - MOUNTAIN VIEW REGIONAL MEDICAL CENTER FACILITY 1, WELLMONT HAWKINS CO MEM HOSP,INC - PART V, LINE 11 KEY FINDINGS NOTED DURING THE CHNA WERE THE LOW RANKINGS OF THE COUNTIES WE SERVE IN SEVERAL CATEGORIES RELATED TO HEALTH AND WELLNESS, INCLUDING PREVALENCE OF CHRONIC DISEASE MANAGEMENT, TOBACCO USE, DIET AND EXERCISE, AS WELL AS A NEED FOR EXPANDED AND ENHANCED MENTAL SERVICES. THEY ALSO EMPHASIZED THE VULNERABILITY OF OUR UNDERINSURED AND UNINSURED POPULATIONS, AND THAT IF OUR COMMUNITIES ARE TO THRIVE, WE MUST FOCUS ON ENCOURAGING HEALTHY CHILDREN AND FAMILIES. TO HELP MEET THESE NEEDS, WELLMONT WILL CONTINUE TO STRENGTHEN OUR PARTNERSHIPS AND CONTINUUM OF CARE OPPORTUNITIES WITH AREA HEALTH DEPARTMENTS, FEDERALLY QUALIFIED HEALTH CENTERS AND FRONTIER HEALTH, THE REGION'S LEADING PROVIDER OF BEHAVIORAL HEALTH SERVICES. FACILITY 1, WELLMONT HAWKINS CO MEM HOSP,INC - PART V, LINE 22D WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. FOLLOWS TENNESSEE STATUTE WHICH IS 175% OF AVERAGE COST FOR ITS HOSPITAL. PART I, LINE 7, COLUMN (F) - EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE BAD DEBT EXPENSE OF 2,675,807 WAS INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN A, BUT WAS SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN THIS COLUMN. PART I, LINE 7 - FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST FOR WORKSHEET 2, THE RATIO OF PATIENT CARE COST-TO-CHARGES WAS USED TO DETERMINE THE COSTS FOR AMOUNTS IN LINES 7A AND 7B, COLUMN C. THE COSTS INCLUDED IN THE COST-TO-CHARGE RATIO INCLUDED THE COSTS FROM ALL PATIENT SEGMENTS. ACTUAL COSTS FROM THE GENERAL LEDGER WERE USED FOR AMOUNTS IN LINES 7F AND 7I, COLUMN C. PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGY THE COST REPORTED ON LINE 2 IS CALCULATED AS THE BAD DEBT EXPENSE FROM THE GENERAL LEDGER TIMES THE RATIO OF COST TO CHARGES AS CALCULATED ON WORKSHEET 2. THERE ARE NO AMOUNTS REPORTED ON LINE 3. DISCOUNTS ON PATIENT ACCOUNTS ARE NOT INCLUDED IN BAD DEBT EXPENSE. PAYMENTS ON PATIENT ACCOUNTS THAT HAVE PREVIOUSLY BEEN WRITTEN OFF AS BAD DEBT ARE USED TO REDUCE BAD DEBT EXPENSE. A THIRD PARTY VENDOR IS USED TO HELP DETERMINE THE AMOUNT THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE POLICY. TEXT OF NOTE TO FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE: NET PATIENT SERVICE REVENUE IS REPORTED ON THE ACCRUAL BASIS IN THE PERIOD IN WHICH SERVICES ARE PROVIDED AT THE ESTIMATED NET REALIZABLE AMOUNTS EXPECTED TO BE COLLECTED. NET PATIENT SERVICE REVENUE INCLUDES AMOUNTS ESTIMATED BY MANAGEMENT TO BE REIMBURSABLE BY PATIENTS AND VARIOUS THIRD-PARTY PAYORS UNDER PROVISIONS OF REIMBURSEMENT FORMULAS IN EFFECT, INCLUDING RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS. ESTIMATED RETROACTIVE ADJUSTMENTS ARE ACCRUED IN THE PERIOD RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL AND OTHER SETTLEMENTS ARE DETERMINED. WELLMONT PROVIDES CARE TO PATIENTS WHO MEET CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE WELLMONT DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT INCLUDED IN NET PATIENT SERVICE REVENUE. PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF BOTH AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS. THE CONTRACTUAL ALLOWANCE REPRESENTS THE DIFFERENCE BETWEEN ESTABLISHED BILLING RATES AND ESTIMATED REIMBURSEMENT FROM MEDICARE, TENNCARE, MEDICAID, AND OTHER THIRD-PARTY PAYMENT PROGRAMS. WELLMONT'S POLICY DOES NOT REQUIRE COLLATERAL OR OTHER SECURITY FOR PATIENT ACCOUNTS RECEIVABLE. WELLMONT ROUTINELY OBTAINS ASSIGNMENT OF, OR IS OTHERWISE ENTITLED TO RECEIVE, PATIENT BENEFITS PAYABLE UNDER HEALTH INSURANCE PROGRAMS, PLANS, OR POLICIES. PART VI, LINE 2 - NEEDS ASSESSMENT LINE NUMBER 1, PART VI, LINE 2 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. EXAMINES THE HEALTHCARE NEEDS OF THE COMMUNITIES IT SERVES BY CONDUCTING PHYSICIAN NEEDS ASSESSMENTS FOR ITS HOSPITALS. AS PART OF THIS EFFORT, WELLMONT REVIEWS ITS SERVICE AREA AND DEMOGRAPHICS, EXAMINES PHYSICIAN DEMOGRAPHICS AND CONDUCTS FOCUS GROUPS. IT MAKES A DETERMINATION OF PHYSICIAN NEED WHILE CALCULATING ITS PHYSICIAN SURPLUSES AND DEFICITS AND HIGHLIGHTING ITS RECRUITMENT PRIORITIES AND PLANS. WELLMONT ANNUALLY DETERMINES ITS PRIMARY, SECONDARY AND TERTIARY MARKETS THROUGH THE USE OF COUNTY-BY-COUNTY ANALYSIS TO IDENTIFY THE FOLLOWING CUSTOMER GROUPS: PATIENTS AND POTENTIAL PATIENTS, COMMUNITY/EMPLOYER GROUPS AND LOCAL PHYSICIANS. THE HEALTH SYSTEM ALSO RELIES ON THE EXPERTISE OF CONSULTANTS TO PERIODICALLY REVIEW ALL FACETS OF OPERATIONS AND MAKE RECOMMENDATIONS FOR CHANGES. PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE LINE NUMBER 1, PART VI, LINE 3 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. PROACTIVELY INFORMS PATIENTS OF THE FINANCIAL ASSISTANCE POLICY BY POSTING THE POLICY ON ITS WEBSITE AS WELL AS POSTING THE POLICY AT POINTS OF REGISTRATION IN THE HOSPITAL. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. USES PROGRAM ELIGIBILITY SPECIALISTS WHO CONTACT THE UNINSURED PATIENT POPULATION. THESE SPECIALISTS DISCUSS THE VARIOUS GOVERNMENTAL ASSISTANCE PROGRAMS THAT ARE AVAILABLE TO PATIENTS IN ORDER TO DETERMINE IF THE PATIENT WOULD QUALIFY FOR ANY OF THESE PROGRAMS. THE SPECIALISTS WILL WORK WITH THE PATIENTS TO COMPLETE ANY NECESSARY APPLICATIONS AND WILL HELP THEM THROUGH THE QUALIFICATION PROCESS. PART VI, LINE 4 - COMMUNITY INFORMATION LINE NUMBER 1, PART VI, LINE 4 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S PRIMARY SERVICE AREA IS HAWKINS AND HANCOCK COUNTIES OF TENNESSEE. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS THE ONLY HOSPITAL IN HAWKINS COUNTY AND ITS SISTER FACILITY, HANCOCK COUNTY HOSPITAL IS THE ONLY HOSPITAL IN HANCOCK COUNTY. THE DEMOGRAPHICS OF THESE COUNTIES ARE AS FOLLOWS: HAWKINS - POPULATION 56,471; MEDIAN HOUSEHOLD INCOME 36,927. HANCOCK - POPULATION 6,572; MEDIAN HOUSEHOLD INCOME 26,898. APPROXIMATELY 23.9% OF OUR PATIENTS ARE MEDICAID RECIPIENTS AND 7.3% ARE UNINSURED, AND HAWKINS COUNTY IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA. PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTH LINE NUMBER 1, PART VI, LINE 5 THE MEDICAL STAFF OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC., LIKE ALL WELLMONT HEALTH SYSTEM HOSPITALS, IS OPEN TO ALL QUALIFIED PHYSICIANS, EXCEPT FOR SOME OF ITS HOSPITAL BASED DEPARTMENTS, SUCH AS ANESTHESIOLOGY, EMERGENCY MEDICINE, PATHOLOGY, AND RADIOLOGY. ANY SURPLUS OF REVENUES AND GAINS IN EXCESS OF EXPENSES AND LOSSES FOR WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC., LIKE ALL WELLMONT HEALTH SYSTEM HOSPITALS, IS USED TO FURTHER THE WELLMONT HEALTH SYSTEM MISSION AND VISION, WHICH ARE "WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION- AND "WE WILL DELIVER THE BEST HEALTH CARE ANYWHERE". THIS WOULD INCLUDE IMPROVEMENTS IN FACILITIES AS WELL AS OPERATIONS FOR PATIENT CARE. PART VI, LINE 6 - AFFILIATED HEALTH CARE SYSTEM LINE NUMBER 1, PART VI, LINE 6 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL IS AN AFFILIATE OF WELLMONT HEALTH SYSTEM. WELLMONT HEALTH SYSTEM ("WELLMONT") IS A TENNESSEE NON-PROFIT CORPORATION BASED IN KINGSPORT, TENNESSEE AND A PREMIER PROVIDER OF HEALTHCARE SERVICES IN NORTHEAST TENNESSEE AND SOUTHWEST VIRGINIA. WELLMONT WAS FORMED IN JULY 1996 WITH THE MERGER OF BRISTOL MEMORIAL HOSPITAL IN BRISTOL, TENNESSEE AND HOLSTON VALLEY MEDICAL CENTER IN KINGSPORT, TENNESSEE. WELLMONT HAS GROWN TO INCLUDE FIVE ADDITIONAL HOSPITALS, AN INTEGRATED PHYSICIAN NETWORK AND SEVERAL AMBULATORY SITES. WELLMONT HOSPITALS OFFER A BROAD SCOPE OF SERVICES RANGING FROM COMMUNITY-BASED ACUTE CARE TO HIGHLY SPECIALIZED TERTIARY SERVICES INCLUDING TWO TRAUMA CENTERS, COMPREHENSIVE HEART CARE AND CANCER CARE CENTERS. WELLMONT OWNS AND OPERATES AN INTEGRATED HEALTH CARE DELIVERY SYSTEM PROVIDING INPATIENT, OUTPATIENT AND OTHER HEALTH CARE SERVICES AT MULTIPLE LOCATIONS IN NORTHEAST TENNESSEE AND SOUTHWEST VIRGINIA. CURRENTLY, WELLMONT OWNS AND OPERATES FIVE ACUTE CARE HOSPITAL FACILITIES AND ONE CRITICAL ACCESS HOSPITAL WITH A TOTAL OF 1,091 LICENSED BEDS AND, THROUGH A JOINT VENTURE, PARTNERS TO OPERATE AN ADDITIONAL ACUTE CARE HOSPITAL FACILITY WITH 100 LICENSED BEDS. THE ACUTE CARE FACILITIES OWNED BY WELLMONT INCLUDE HOLSTON VALLEY MEDICAL CENTER, BRISTOL REGIONAL MEDICAL CENTER, MOUNTAIN VIEW REGIONAL MEDICAL CENTER IN NORTON, VIRGINIA, LONESOME PINE HOSPITAL IN BIG STONE GAP, VIRGINIA, WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL IN ROGERSVILLE, TENNESSEE AND THE CRITICAL ACCESS HOSPITAL, HANCOCK COUNTY HOSPITAL IN SNEEDVILLE, TENNESSEE. WELLMONT ALSO, DIRECTLY OR INDIRECTLY, CONTROLS, OWNS OR IS AFFILIATED WITH VARIOUS NONPROFIT AND FOR-PROFIT CORPORATIONS AND OTHER ORGANIZATIONS THAT CURRENTLY PROVIDE HEALTH CARE AND HEALTH CARE-RELATED SERVICES THROUGHOUT THE SERVICE AREA. IN ADDITION TO THE HOSPITAL CAMPUSES AND AMBULATORY CARE CENTERS DESCRIBED ABOVE, WELLMONT ALSO OPERATES MEDICAL CLINICS, AMBULATORY SURGERY CENTERS, COMPREHENSIVE CANCER CARE CENTERS, AND IMAGING FACILITIES. PART VI, LINE 7 - STATE FILING OF COMMUNITY BENEFIT REPORT TENNESSEE X true true false true false false false false true false false BARTON A HOVE PRESIDENT/WHS CEO 798729 520000 63863 28581 9990 1421163 GARY D MILLER TREAS/SR VP GEN COUN 342340 132500 1842 15992 3797 496471 TODD J DOUGAN SECRETARY/CFO 262307 109891 140 10638 9990 392966 REBECCA BECK PRESIDENT-WHCMH&HCH 34356 103069 3204 9612 43 129 1404 4212 3004 9011 42011 126033 ALICE POPE TERMED 42216 SEC/EVP & CFO 429481 184100 8820 18549 12015 652965 MARGARET DENARVAEZ TERMED 91614 PRESIDENT/WHS CEO 136339 9872 146211 FRED PELLE TRF TO HVMC 32315 PRES-COMM DIV/HV COO 304710 37005 3424 11703 9990 366832 SCHEDULE J, PAGE 1, PART I, LINE 1A HEALTH OR SOCIAL CLUB DUES DURING THE FISCAL YEAR ENDED JUNE 30, 2016, WELLMONT HEALTH SYSTEM PROVIDED A COUNTRY CLUB MEMBERSHIP TO BARTON A. HOVE. THE AMOUNT IS INCLUDED IN TAXABLE COMPENSATION. SCHEDULE J, PAGE 1, PART I, LINE 3 WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF ALL PERSONS LISTED ON FORM 990, PART VIII, SECTION A AS MORE FULLY DESCRIBED IN SCHEDULE O. SCHEDULE J, PAGE 1, PART I, LINE 6B INCENTIVE COMPENSATION IS BASED ON MEETING BUDGETED OPERATING MARGIN GOALS. SCHEDULE J, PART III PART I, LINE 4A - SEVERANCE PAYMENT MARGARET DENARVAEZ, FORMER CEO OF WELLMONT HEALTH SYSTEM, ENTERED INTO A CONFIDENTIAL SEPARATION AGREEMENT AND GENERAL RELEASE (THE "AGREEMENT") AS OF SEPTEMBER 16, 2014. THERE WERE OTHER PAYMENTS FOR EARNED INCENTIVE COMPENSATION AND REIMBURSEMENT OF RELOCATION COSTS THAT ARE NOT CONSIDERED "SEVERANCE". PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN ALICE POPE TERMINATED EMPLOYMENT WITH WELLMONT HEALTH SYSTEM IN APRIL 2016. WELLMONT HEALTH SYSTEM HAS AN EXECUTIVE RETIREMENT PROGRAM THAT INCLUDED ALICE POPE UNTIL APRIL 2016. THERE WERE NO PAYMENTS MADE AND THERE ARE NO CURRENT PARTICIPANTS IN THIS PROGRAM. FORM 990, PAGE 2, PART III, LINE 4A CONTRIBUTIONS TO COMMUNITY ORGANIZATIONS THAT DO NOT MEET THE DEFINITION OF "RESTRICTED TO ONE OR MORE OF THE ACTIVITIES DESCRIBED IN THE TABLE IN PART I, LINE 7" OF SCHEDULE H-HOSPITALS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A PUBLIC TRUST. THIS HOSPITAL, LIKE THE OTHER WELLMONT HEALTH SYSTEM FACILITIES OF WHICH IT IS A MEMBER, WAS BORN OF ITS COMMUNITY'S COMMITMENT TO PROVIDE SUPERIOR HEALTH CARE FOR ITS CITIZENS. IT IS OUR MISSION TO DELIVER SUPERIOR HEALTH CARE WITH COMPASSION TO THE PEOPLE WE SERVE, AND IT IS OUR VISION TO DELIVER THE BEST HEALTH CARE ANYWHERE. CONSISTENT WITH THIS MISSION, WE HAVE WORKED TOWARD IMPROVING OUR COMMUNITY'S ACCESS TO QUALITY, AFFORDABLE HEALTH CARE, EDUCATING OUR REGION'S CAREGIVERS, IMPROVING THE HEALTH STATUS OF OUR COMMUNITIES AND CONTRIBUTING TO THE OVERALL QUALITY OF LIFE IN THE AREAS WE SERVE. OVERALL, WE RETURNED MORE THAN 6,188,407 IN BENEFITS TO OUR COMMUNITY IN FISCAL YEAR 2016, INCLUDING 6,149,780 OF UNREIMBURSED COSTS FOR INDIGENT AND MEDICAID PATIENTS AND 38,627 FOR OTHER COMMUNITY ACTIVITIES. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A 50-BED FACILITY IN ROGERSVILLE, TENNESSEE. WE PROVIDE A WIDE VARIETY OF SERVICES, INCLUDING EMERGENCY CARE, PHYSICAL, STROKE AND OCCUPATIONAL THERAPIES, SURGERY, INTERMEDIATE MEDICAL CARE, OUTPATIENT SPECIALTY CLINICS, LABORATORY SERVICES, AUDIOLOGY SERVICES, CARDIOVASCULAR SERVICES, RESPIRATORY THERAPY, SLEEP EVALUATIONS AND TREATMENT, INFUSION, SPINE REHABILITATION SERVICES AND DIAGNOSTIC IMAGING. IN MARCH 2014, HAWKINS COUNTY MEMORIAL OPENED A SECOND INFUSION CENTER IN JOHNSON CITY, TENNESSEE. THE INFUSION CENTERS IN HAWKINS COUNTY AND JOHNSON CITY OFFER PATIENTS CONVENIENT ACCESS TO CANCER SERVICES IN A HEALING ENVIRONMENT. AMENITIES IN THE INFUSION CENTERS INCLUDE HEATED CHAIRS AND MASSAGES. IN FISCAL YEAR 2016, WE PROVIDED SERVICES TO 803 INPATIENTS, HAD 235 INPATIENT AND OUTPATIENT SURGICAL CASES, AND HAD 16,902 EMERGENCY ROOM VISITS. WE ARE MINDFUL OF OUR RESPONSIBILITIES AS ONE OF HAWKINS COUNTY'S LARGEST COMPANIES. HUNDREDS OF FAMILIES COUNT ON US FOR THEIR LIVELIHOODS. OUR AREA RELIES ON US AS A DRIVER OF ECONOMIC DEVELOPMENT. IT IS OUR DUTY AS A CORPORATE CITIZEN TO SUPPORT THOSE ENDEAVORS AND CAUSES THAT IMPROVE THE QUALITY OF LIFE IN OUR REGION. AND WE ALSO RECOGNIZE IT IS OUR RESPONSIBILITY TO CARE FOR THOSE IN NEED - REGARDLESS OF THEIR ABILITY TO PAY. IT IS OUR COMMITMENT - INDEED, IT IS IMPLICIT IN OUR MISSION - TO SUPPORT THE CAUSES AND DEVELOP THE INITIATIVES THAT WILL PROPEL OUR COMMUNITY TOWARD A BETTER, BRIGHTER, HEALTHIER AND MORE VIBRANT FUTURE. REGARDLESS OF RACE, RELIGION, ETHNICITY OR ABILITY TO PAY, WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. TREATS ALL PATIENTS FOR MEDICALLY NECESSARY CONDITIONS. RECOGNIZING SOME PATIENTS CANNOT AFFORD ESSENTIAL MEDICAL SERVICES, WE PROVIDED CARE FOR INDIGENT PATIENTS, WRITING OFF 5,087,105 OF CHARGES AND INCURRING COSTS OF 851,079. WE SUPPORT AND ENCOURAGE OUR EMPLOYEES TO GIVE THEIR TIME TO AREA NOT-FOR- PROFIT ORGANIZATIONS, WHICH INCLUDED THE AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY, THE ROGERSVILLE HERITAGE ASSOCIATION, CIVIC GROUPS SUCH AS KIWANIS AND ROTARY, VARIOUS UNITED WAY AGENCIES AND THE ROGERSVILLE AREA CHAMBER OF COMMERCE AND ITS PROGRAMS. MANY OF OUR EMPLOYEES ALSO SERVE IN COMMUNITY RESCUE SQUADS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. WILL SUCCEED IN OUR MISSION BY CONTINUALLY REINVESTING IN OUR MOST PRECIOUS RESOURCE - OUR PEOPLE. TO THAT END, WE PROVIDED ON-THE-JOB TRAINING TO NURSING CANDIDATES. THIS PROGRAM UTILIZES NURSING STAFF THAT HAVE COMPLETED A DEGREE BUT NOT YET PASSED BOARD CERTIFICATION. THIS PROVIDES INVALUABLE EXPERIENCE FOR NEW NURSES, WHO ARE SUPERVISED BY BOARD-CERTIFIED NURSES. WE ALSO PROVIDED EDUCATIONAL OPPORTUNITIES TO STUDENTS IN OTHER MEDICAL DISCIPLINES, SUCH AS RADIOLOGY. FOREWARNED IS FOREARMED. THE BEST WAY TO KEEP OUR COMMUNITIES HEALTHY IS TO PROVIDE THEM WITH THE LATEST INFORMATION ABOUT THEIR HEALTH. WE STRIVE TO PROVIDE INFORMATION ABOUT EVERYTHING FROM DISEASE AND INJURY PREVENTION TO THE LATEST TREATMENTS AND TECHNOLOGIES AVAILABLE TO COPING WITH DISEASE AND ITS SYMPTOMS. OUR TOTAL COMMUNITY BENEFIT FOR COMMUNITY HEALTH IMPROVEMENT SERVICES HAD A DIRECT COST OF 26,145. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. PROVIDED CASH AND IN-KIND CONTRIBUTIONS AT A DIRECT COST OF 33,839. IN-KIND SERVICES INCLUDED CONFERENCE ROOM SPACE DONATED TO NON-PROFIT COMMUNITY GROUPS SUCH AS ALCOHOLICS ANONYMOUS, HAWKINS COUNTY CHAMBER OF COMMERCE AND THE ROTARY CLUB. OTHER IN-KIND SERVICES PROVIDED WERE RESTOCKING SUPPLIES OF EMS VEHICLES. FORM 990, PAGE 6, PART VI, LINE 6 THE BUSINESS AND AFFAIRS OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. (THE CORPORATION) SHALL BE GOVERNED EXCLUSIVELY BY THE BOARD OF DIRECTORS. THE CORPORATION'S BOARD OF DIRECTORS IS DESIGNATED BY WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION. IN ADDITION TO SUCH RIGHTS OF APPROVAL AND CONSENT AS MAY BE RESERVED TO THE SOLE MEMBER OF THE CORPORATION PURSUANT TO APPLICABLE LAW, TRANSACTIONS OF THE FOLLOWING MATTERS BY THE CORPORATION SHALL REQUIRE THE PRIOR APPROVAL OF WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION: A) IMPLEMENTATION OF CORPORATION'S ANNUAL BUDGET, B) INCURRING ANY LOAN OR OTHER INDEBTEDNESS FOR BORROWED MONEY, C) ACQUISITION OF ANY EQUIPMENT OR PERSONAL PROPERTY FOR A PURCHASE PRICE IN EXCESS OF 50,000 OR THE ACQUISITION OF ANY REAL ESTATE, REGARDLESS OF PURCHASE PRICE, D) THE UNDERTAKING OF CERTAIN CONTRACTUAL COMMITMENTS, E) ENTERING INTO ANY PLAN OF MERGER OR CONSOLIDATION, F) ACQUISITION OF SUBSTANTIALLY ALL OF THE ASSETS OF ANY OTHER LEGAL ENTITY, AND G) INSTITUTION OF ANY LITIGATION BY OR ON BEHALF OF CORPORATION. FORM 990, PAGE 6, PART VI, LINE 7A SEE FORM 990, PART VI, SECTION A, LINE 6 FOR EXPLANATION. FORM 990, PAGE 6, PART VI, LINE 7B SEE FORM 990, PART VI, SECTION A, LINE 6 FOR EXPLANATION. FORM 990, PAGE 6, PART VI, LINE 9 SHERRI IVES (TERMED 7/11/14) 1905 AMERICAN WAY KINGSPORT, TN 37660 TRACEY P. MOFFATT (TERMED 10/3/14) 1905 AMERICAN WAY KINGSPORT, TN 37660 MARGARET DENARVAEZ (TERMED 9/16/14) 1905 AMERICAN WAY KINGSPORT, TN 37660 ROBERT MATTHEW TAVENNER (TM 2/6/15) 1905 AMERICAN WAY KINGSPORT, TN 37660 ALICE POPE (TERMED 4/22/16) 1905 AMERICAN WAY KINGSPORT, TN 37660 FORM 990, PAGE 6, PART VI, LINE 11B WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S FORM 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER, THE CORPORATE CONTROLLER, AND THE MANAGER OF ACCOUNTING FOR WELLMONT HEALTH SYSTEM, AND THE BOARD OF DIRECTORS OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. PRIOR TO FILING. ANY QUESTIONS OR COMMENTS ARISING FROM THE INITIAL REVIEW ARE ADDRESSED TO ENSURE THE RETURN IS COMPLETE AND ACCURATE. ANY CHANGES OR CORRECTIONS ARE IDENTIFIED, REVISED IN THE RETURN, AND REVIEWED BY THE INDIVIDUALS LISTED ABOVE PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PAGE 6, PART VI, LINE 12C OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT. ANY POTENTIAL CONFLICTS ARE DISCUSSED WITH THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT AS THEY ARISE. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE GOVERNED BY WELLMONT HEALTH SYSTEM'S CONFLICT OF INTEREST POLICY. WELLMONT HEALTH SYSTEM ALSO HAS A POLICY ON BUSINESS PRACTICES THAT DISCUSSES CONFLICT OF INTEREST AND INFORMS THE WORKFORCE TO DISCLOSE ANY ISSUES TO THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT, FOR RESOLUTION. WELLMONT HEALTH SYSTEM ALSO USES A HOTLINE THAT ALLOWS ANONYMOUS REPORTING OF POSSIBLE CONFLICT OF INTEREST SITUATIONS FOR INVESTIGATION BY THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT. FORM 990, PAGE 6, PART VI, LINE 15A THE COMPENSATION OF BARTON A. HOVE, THE PRESIDENT AND CEO OF WELLMONT HEALTH SYSTEM, IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND THE BOARD OF DIRECTORS. BARTON A. HOVE IS ALSO ON THE BOARD OF DIRECTORS OF WELLMONT FOUNDATION, INC. THE LAST COMPENSATION DELIBERATION AND REVIEW PROCESS FOR BARTON A. HOVE WAS COMPLETED AND APPROVED BY THE BOARD OF DIRECTORS OF WELLMONT HEALTH SYSTEM ON MARCH 20, 2015. REBECCA BECK IS THE PRESIDENT AND CEO OF WELLMONT COMMUNITY HOSPITAL DIVISION THAT INCLUDES WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. REBECCA BECK'S COMPENSATION IS PAID BY WELLMONT HEALTH SYSTEM THROUGH INTERCOMPANY TRANSACTIONS. WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF REBECCA BECK. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THIS PROCESS IS COMPLETED ON AN ANNUAL BASIS. FORM 990, PAGE 6, PART VI, LINE 15B THE COMPENSATION OF GARY MILLER, THE SENIOR VP GENERAL COUNSEL FOR WELLMONT HEALTH SYSTEM,AND TODD DOUGAN, CHIEF FINANCIAL OFFICER OF WELLMONT HEALTH SYSTEM IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS. GARY MILLER IS ALSO THE TREASURER OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. AND TODD DOUGAN IS ALSO THE SECRETARY OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THIS PROCESS IN COMPLETED ON AN ANNUAL BASIS. THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS REVIEWED THE SALARY AND MARKET COMPENSATION DATA ON NOVEMBER 18, 2016. FORM 990, PAGE 6, PART VI, LINE 19 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. WELLMONT HEALTH SYSTEM'S AUDITED FINANCIAL STATEMENTS AND QUARTERLY UNAUDITED FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ELECTRONIC MUNICIPAL MARKET ACCESS WEBSITE. FORM 990, PART IX, LINE 11G FEES FOR SERVICES 2,313,182 22,100 0 SUPPORT SERVICES 0 11,399,325 0 TN COVERAGE FEES 0 1,062,908 0 FORM 990, PART XI, LINE 9 CAPITAL DISTRIBUTION -12,367,425 INTERCOMPANY TRANSACTIONS -7,110,914 TOTAL -19,478,339 WELLMONT HEALTH SYSTEM 1905 AMERICAN WAY KINGSPORT TN 37660 621636465 HEALTHCARE TN 501C3 3 WHS false WELLMONT CARDIOLOGY SERVICES 1905 AMERICAN WAY KINGSPORT TN 37660 263557623 HEALTHCARE TN 501C3 3 WHS false WELLMONT MEDICAL ASSOCIATES INC 1905 AMERICAN WAY KINGSPORT TN 37660 270898372 HEALTHCARE TN 501C3 7 WHS false WELLMONT INTEGRATED NETWORK LLC 1905 AMERICAN WAY KINGSPORT TN 37664 455443060 HEALTHCARE TN 501C3 3 WHS false WELLMONT SLEEP SERVICES 1905 AMERICAN WAY KINGSPORT TN 37660 273777167 HEALTHCARE TN 501C3 3 WHS false WELLMONT FOUNDATION INC 1905 AMERICAN WAY KINGSPORT TN 37660 581594191 HEALTHCARE TN 501C3 7 WHS false WELLMONT MADISON HOUSE 1905 AMERICAN WAY KINGSPORT TN 37660 621308216 HEALTHCARE TN 501C3 9 WHS false WELLMONT WEXFORD HOUSE 1905 AMERICAN WAY KINGSPORT TN 37660 581589039 HEALTHCARE TN 501C3 9 WHS false WELLMONT IMAGING SERVICES INC 1905 AMERICAN WAY KINGSPORT TN 37660 861103148 HEALTHCARE TN 501C3 11A WHS false HOLSTON VALLEY IMAGING CENTER 103 WEST STONE DRIVE KINGSPORT TN 37660 202043285 HEALTHCARE TN N/A false false SAPLING GROVE AMBULATORY SURGERY 220 MEDICAL PARK BOULEVARD BRISTOL TN 37620 204450153 HEALTHCARE TN N/A false false HOLSTON VALLEY AMBULATORY SURGERY 103 WEST STONE DRIVE KINGSPORT TN 37660 621816864 HEALTHCARE TN N/A false false WELLMONT INC 1905 AMERICAN WAY KINGSPORT TN 37660 621320035 PHYS SVCS TN N/A false MCOT INC 1905 AMERICAN WAY KINGSPORT TN 37660 621325938 MED SVCS TN N/A false MEDICAL MALL PHARMACY INC 1905 AMERICAN WAY KINGSPORT TN 37660 621565006 MED SVCS TN N/A false WELLMONT PHYSICIAN SERVICES INC 1905 AMERICAN WAY KINGSPORT TN 37660 621567353 PHYS SVCS TN N/A false WPS PROVIDERS INC 1905 AMERICAN WAY KINGSPORT TN 37660 205564642 PHYS SVCS TN N/A false WELLMONT HEALTH SERVICES INC 1905 AMERICAN WAY KINGSPORT TN 37660 621254373 HEALTHCARE TN N/A false false true true false false false false false true false true true true false false false false false false WELLMONT HEALTH SYSTEM B 12367425 CAPITAL CONTRIBUTION WELLMONT HEALTH SYSTEM K 323713 LEASE AGREEMENT WELLMONT HEALTH SYSTEM M 82460 SERVICE AGREEMENTS WELLMONT HEALTH SYSTEM M 58058 INVOICES WELLMONT HEALTH SYSTEM M 11399324 CORPORATE SUPPORT SERVICE WELLMONT HEALTH SYSTEM O 184057 SALARY ALLOCATION SCHEDULE R PART V, LINE 2: RELATED ORGANIZATION TRANSACTIONS WITH WELLMONT FOUNDATION, WELLMONT HEALTH SYSTEM AND WELLMONT MEDICAL ASSOCIATES DURING THE FISCAL YEAR ENDED JUNE 30, 2016 THAT DID NOT MEET THE 50,000 THRESHOLD AMOUNT FOR SEPARATE DISCLOSURE. TRANS ORGANIZATION TYPE AMOUNT METHOD DETERMINATION WELLMONT FOUNDATION C 5,567 NEED WELLMONT HEALTH SYSTEM I 23,552 ASSET TRANSFER WELLMONT HEALTH SYSTEM L 2,721 INVOICES WELLMONT MEDICAL ASSOCIATES L 3,709 INVOICES