2016-08-15T09:22:06-05:00 2015-09-30 111986323 MARCUM LLP CITY PLACE II 185 ASYLUM STREET HARTFORD CT 06103 990 2014-10-01 060647014 GRIFFIN HOSPITAL GRIF 2037327528 130 DIVISION STREET DERBY CT 06418 JAMES DOWNEY CONTROLLER 2037327528 2016-08-12 1 DOUGLAS FARRINGTON P00370668 8607600600 2014 2016-09-27 15:27:22Z PATRICK CHARMEL 130 DIVISION STREET DERBY CT 06418 153074211 0 X GRIFFINHEALTH.ORG X 1908 CT GRIFFIN HOSPITAL IS COMMITTED TO PROVIDING PERSONALIZED, HUMANISTIC, CONSUMER-DRIVEN HEALTH CARE IN A HEALING ENVIRONMENT. 19 13 1471 432 3631396 0 1883920 2304322 138777765 147861773 323608 390781 554385 2517335 141539678 153074211 0 0 0 0 72464593 77228070 0 0 0 59780750 67748671 132245343 144976741 9294335 8097470 119095066 115933017 135761625 145509400 -16666559 -29576383 X GRIFFIN HOSPITAL IS COMMITTED TO PROVIDING PERSONALIZED, HUMANISTIC, CONSUMER-DRIVEN HEALTH CARE IN A HEALING ENVIRONMENT, TO EMPOWERING INDIVIDUALS TO BE ACTIVELY INVOLVED IN DECISIONS AFFECTING THEIR CARE AND WELL-BEING THROUGH ACCESS TO INFORMATION AND EDUCATION, AND TO PROVIDING LEADERSHIP TO IMPROVE THE HEALTH OF THE COMMUNITY WE SERVE. 0 0 112286450 136763824 GRIFFIN HOSPITAL IS AN ACUTE CARE HOSPITAL PROVIDING MEDICAL CARE TO PATIENTS IN COMMUNITIES SERVED, INCLUDING SUBSIDIZED CARE, CHARITY CARE, AND EDUCATIONAL SERVICES TO HEALTH PROFESSIONALS TO HELP PREPARE THE NEXT GENERATION OF CAREGIVERS. 3748475 9697444 PROVIDE CANCER RELATED RADIOLOGY SERVICES TO THE COMMUNITY. 1100549 1542679 PROVIDE PSYCHIATRIC SERVICES TO THE COMMUNITY ON AN OUTPATIENT BASIS. 529679 1035195 PROVIDE HOSPICE SERVICES TO THE COMMUNITY. 529679 1035195 117665153 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 203 0 1 1471 1 1 1 0 0 0 0 0 0 0 0 0 X 19 13 0 0 0 0 0 1 0 1 1 0 0 0 1 1 1 1 1 1 1 1 1 CT X JAMES DOWNEY 2037327528 130 DIVISION STREET DERBY CT 06418 JOSEPH ANDREANA TRUSTEE 1.00 2.00 X 0 0 0 FREDERICK BROWNE MD TRUSTEE 1.00 42.00 X 0 151818 14862 KENNETH BALDYGA TRUSTEE 1.00 4.00 X 0 0 0 JOHN W BETKOWSKI III TRUSTEE 1.00 5.00 X 0 0 0 GREGORY BORIS DO TRUSTEE 1.00 1.00 X 0 0 0 PATRICK CHARMEL CEO/PRESIDENT 40.00 6.00 X X 490610 0 23884 DONNA DIGIANVITTORIO TRUSTEE 1.00 2.00 X 0 0 0 NANCY DINARDO TRUSTEE 1.00 3.00 X 0 0 0 KENNETH J DOBULER MD TRUSTEE/PHYSICIAN 40.00 1.00 X 240430 0 4219 DAVID J HENDRICKS MD TRUSTEE 1.00 2.00 X 0 0 0 JEAN CRUM JONES MPH RD TRUSTEE 1.00 3.00 X 0 0 0 THEMIS KLARIDES TRUSTEE 1.00 2.00 X 0 0 0 GEORGE S LOGAN TRUSTEE 1.00 4.00 X 0 0 0 FRANK M OSAK TRUSTEE 1.00 4.00 X 0 0 0 WM NEIL PEARSON MD TRUSTEE 1.00 2.00 X 39843 0 0 ROBERT G REISS TRUSTEE 1.00 3.00 X 0 0 0 GERALD T WEINER ESQ CHAIRMAN 1.00 5.00 X X 0 0 0 PHILLIP WHITE TRUSTEE 1.00 2.00 X 0 0 0 JOHN J ZAPRZALKA TRUSTEE 1.00 4.00 X 0 0 0 MARK O'NEILL CFO/VP FINANCE 40.00 X 284090 0 5538 MARGARET DEEGAN VP 40.00 X 216400 0 22065 TODD LIU VP 40.00 X 151609 0 19507 BARBARA STUMPO VP 40.00 X 206865 0 22127 KATHLEEN MARTIN VP 40.00 X 169166 0 22120 BENJAMIN ZIGUN PHYSICIAN 40.00 X 253876 0 19748 EDWARD HALSTEAD PHYSICIAN 40.00 X 233062 0 21929 MIHAELA BORAN PHYSICIAN 40.00 X 186526 0 20671 DEBORAH L HENNESSEY RN 40.00 X 141399 0 2546 GEORGE TOMAS DIRECTOR OF IT DEPARTMENT 40.00 X 154215 0 6144 KENNETH SCHWARTZ FORMER DIRECTOR 40.00 X 116977 0 26067 EDWARD BERNS FORMER OFFICER 40.00 X 161057 0 17712 SETH SHEPARD FORMER OFFICER 40.00 X 191146 0 17712 3237271 151818 266851 78 1 1 0 UNIDINE CORPORATION 75 REMITTANCE DRIVE CHICAGO IL 60675 DINING SERVICES 1760713 CONNECTICUT EMERGENCY MEDICINE PO BOX 271618 WEST HARTFORD CT 06127 MEDICAL SERVICES 1345203 QUEST DIAGNOSTICS 2025 COLLECTION CENTER CHICAGO IL 60693 LABORATORY SERVICES 828052 GRIFFIN PATHOLOGY CONSULTANTS 1140 FAIRFIELD AVENUE BRIDGEPORT CT 06605 MEDICAL SERVICES 550000 DAIKIN APPLIED 24827 NETWORK PLACE CHICAGO IL 60673 A/C REPAIRS 337816 23 1696835 607487 2304322 PATIENT SERVICE REVENUE 622110 144733465 141154314 3579151 STATE SUPPLEMENTAL REVENUE 900099 1899613 1899613 OTHER PROGRAM SERVICES 621500 823884 823884 TUITION/EDUCATION REVENUE 900099 404811 404811 147861773 330154 330154 332076 0 332076 332076 332076 60127 500 0 0 60127 500 60627 60627 CAFETERIA INCOME 900099 955105 955105 OTHER INCOME 900099 931437 878652 52245 540 ACO PROJECT 900099 246514 246514 52203 52203 2185259 153074211 145459991 3631396 1678502 2086961 304795 1782166 56038020 47923538 8114482 2908841 2446464 462377 11721936 9823406 1898530 4472312 3718837 753475 175864 175864 292721 292721 22288 22288 6917129 5791529 1125600 530845 530845 2975260 2342552 632708 1087335 332150 755185 3774354 2940132 834222 298459 79546 218913 2123882 2018275 105607 4440681 3450453 990228 798307 606959 191348 MEDICAL & DRUG SUPPLIES 24480232 24480232 STATE HOSPITAL TAX EXP 6283833 6283833 PHYSICIAN FEES 4610325 4005380 604945 GRANT EXPENSES 2039194 2039194 6897962 4830866 2067096 144976741 117665153 27311588 0 963 962 7522502 6771172 12651193 13268952 940022 938379 2653216 2650944 153063680 101440870 53137742 51622810 14345035 14161460 3760171 3450227 24084222 23068111 119095066 115933017 24399592 24726374 39289 157449 46239634 44033321 735000 2140557 64348110 74451699 135761625 145509400 X -26106535 -39254442 3519544 4067571 5920432 5610488 -16666559 -29576383 119095066 115933017 X 8097470 -566507 -20440787 X 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 22288 22288 0 PART II-B, LINE 1: THE GRIFFIN HOSPITAL PAID FOR MEMBERSHIP DUES TO THE CONNECTICUT HOSPITAL ASSOCIATION. FOR THE FISCAL YEAR ENDED 9/30/2015, $22,288 OF THE MEMBERSHIP DUES PAID WAS USED FOR LOBBYING ON ISSUES RELEVANT TO THE ORGANIZATION'S EXEMPT PURPOSE. 3626432 -40930 3585502 3409062 242728 25358 3626432 3249540 183001 23479 3409062 2932333 322207 5000 3249540 2953261 -1478 19450 2932333 0.59600 0.40400 1 0 4015091 4015091 72353793 38454107 33899686 74285053 61928958 12356095 2409743 1057805 1351938 51622810 OTHER RECEIVABLES 1093657 DUE FROM AFFILIATES 6476494 OTHER ASSETS & INSURANCE RECOVERABLE 5335406 INTEREST IN NET ASSETS OF AFFILIATES 8800729 INVESTMENT IN AFFILIATE 1361825 23068111 ACCRUED POSTRETIREMENT BENEFIT LIABILITY 9266609 PROFESSIONAL AND GENERAL LIABILITY LOSS RESERVES 3172632 ACCRUED PENSION LIABILITY 45060464 WORKERS COMPENSATION LOSS RESERVES 1827843 ACCRUED INTEREST PAYABLE 280977 CONDITIONAL ASSET RETIREMENT OBLIGATIONS 104600 INTEREST RATE SWAP AGREEMENTS 7643841 ESTIMATED THIRD-PARTY SETTLEMENTS 6818099 DUE TO AFFILIATES 276634 74451699 X 152548634 -494719 -494719 153043353 30858 30858 153074211 144976741 0 144976741 0 144976741 PART V, LINE 4: THE HOSPITAL'S ENDOWMENT FUNDS CONSIST OF DONOR RESTRICTED FUNDS TO BE INVESTED IN PERPETUITY TO PROVIDE A PERMANENT SOURCE OF INCOME. PART X, LINE 2: THE HOSPITAL AND GFP ARE NOT-FOR-PROFIT ORGANIZATIONS, EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL AND GFP ACCOUNT FOR UNCERTAINTY IN INCOME TAX POSITIONS BY APPLYING A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2015, THERE ARE NO UNCERTAIN TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE HOSPITAL AND GFP ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES THE HOSPITAL AND GFP ARE NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS PRIOR TO 2012. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED INVESTMENT INCOME 30,858. 1 1 1 X 250.000000000000 1 X 1 1 1 0 1 1 195 951441 0 951441 0.00700 16064 17927641 13033691 4893950 0.03600 117 118227 102186 16041 0.00000 16376 18997309 13135877 5861432 0.04300 15 117093 956856 114356 842500 0.00700 1 0 7284633 5948208 1336425 0.01000 3 37674 8225873 6066402 2159471 0.01600 1 0 1317442 1175510 141932 0.00100 3 589 81751 35842 45909 0.00000 23 155356 17866555 13340318 4526237 0.03400 23 171732 36863864 26476195 10387669 0.07700 1 543617 0 45706344 53132162 -7425818 X 1 1 1 1 GRIFFIN HOSPITAL 130 DIVISION STREET DERBY CT 06418 WWW.GRIFFINHEALTH.ORG X X X X GRIFFIN HOSPITAL 1 1 0 1 X X X X X X X 13 1 0 0 1 X WWW.GRIFFINHEALTH.ORG X WWW.CT.GOV/DPH/CWP/VIEW X X 1 13 1 WWW.GRIFFINHEALTH.ORG/ABOUT-GRIFFIN/COMMUNITY-BENEFIT-REPORT/CHNA 0 0 1 X 250.000000000000 400.000000000000 X X X X X 1 1 X X X X 1 X WWW.GRIFFINHEALTH.ORG/PATIENT-INFORMATION/BILLING-INSURANCE/UNINSURED X WWW.GRIFFINHEALTH.ORG/PORTALS/0/DOCUMENTS/FINANCIAL_ASSISTANCE_APPLICATION X WWW.GRIFFINHEALTH.ORG/PATIENT-INFORMATION/BILLING-INSURANCE X X X X X 1 0 X X X X 1 X 0 0 GRIFFIN HOSPITAL PART V, SECTION B, LINE 5: REGIONAL COOPERATION ON HEALTH ISSUES - REGIONAL COOPERATION, THE LEADERSHIP OF GRIFFIN HOSPITAL ON COMMUNITY HEALTH IMPROVEMENT AND THE EFFECTIVENESS OF EFFORTS WAS POSITIVELY NOTED IN FOCUS GROUPS, FORUMS AND SURVEYS. OF PARTICULAR NOTE WAS THE VALLEY COUNCIL OF HEALTH AND HUMAN SERVICE ORGANIZATIONS (VCHHSO) GRIFFIN HOSPITAL WAS A LEADER IN ESTABLISHING THE VALLEY COUNCIL OF HEALTH AND HUMAN SERVICE ORGANIZATIONS WHICH HAS BECOME A MODEL FOR OTHER COMMUNITIES. THE VALLEY COUNCIL IS A COOPERATIVE VENTURE FOUNDED OVER TWENTY YEARS AGO LINKING APPROXIMATELY 50 NON-PROFIT HEALTH & HUMAN SERVICE PROVIDERS THROUGHOUT THE VALLEY. ITS MISSION IS TO IDENTIFY, PLAN, IMPLEMENT, AND COORDINATE A COMPREHENSIVE SYSTEM OF HUMAN SERVICE DELIVERY AND TO ADVOCATE FOR COMMUNITY-WIDE AND CULTURALLY DIVERSE PLANNING APPROACHES IN THE LARGER VALLEY COMMUNITY. DECISION MAKERS FROM EACH OF THE ACTIVE MEMBERS MEET MONTHLY. THE COUNCIL'S OBJECTIVES ARE TO: 1. ENGAGE IN PERIODIC ASSESSMENT AND IDENTIFICATION OF LOCAL SERVICE NEEDS, INCLUDING CLIENT INPUT. 2. COLLABORATIVELY EVALUATE CURRENT SERVICES, IDENTIFY GAPS, AND STRATEGIZE ON HOW TO FILL GAPS IN SERVICES. 3. SERVE AS THE PRIMARY PLANNING AND COORDINATING BODY FOR THE REGIONS' SERVICE PROVISION SYSTEM. 4. PROVIDE A PLACE FOR SUPPORT AND NETWORKING AMONG THE VALLEY HUMAN SERVICES COMMUNITY. 5. ADVOCATE FOR THE NEEDS OF LOCAL RESIDENTS AND FOR RESOURCES TO MEET THOSE NEEDS ON A LOCAL, STATE, AND FEDERAL LEVEL. 6. SEEK TO DEVELOP PARTNERSHIPS WITH OTHER COMMUNITY SYSTEMS (I.E. SCHOOLS, BUSINESSES, STATE AND LOCAL GOVERNMENTS, PUBLIC SAFETY) TO ENHANCE SERVICE DELIVERY. GRIFFIN REMAINS AN ACTIVE MEMBER OF THE COUNCIL. NOT ONLY IS GRIFFIN HOSPITAL A CONTINUING MEMBER, THE VALLEY PARISH NURSE PROGRAM AND THE YALE-GRIFFIN PREVENTION RESEARCH CENTER ALSO ARE MEMBERS. THE COMMUNITY ADVISORY COUNCIL ENGAGED THE PATIENTS AND THE COMMUNITY TO GET MEANINGFUL FEEDBACK ABOUT THE HOSPITAL'S SERVICES. THROUGHOUT ITS HISTORY, GRIFFIN'S MOST INNOVATIVE PROGRAMS HAVE BEEN DEVELOPED USING INSIGHTS GLEANED FROM PATIENTS AND FAMILY MEMBER FOCUS GROUPS. THE COMMUNITY ADVISORY COUNCIL WAS A NATURAL NEXT STEP FOR GRIFFIN AS A WAY TO SOLICIT THE PATIENT'S PERSPECTIVE OF CARE, PROGRAMS AND SERVICES AND TO IDENTIFY COMMUNITY NEEDS ON AN ONGOING BASIS.THE VALLEY CARES TASKFORCE BETH PATTON COMERFORD, MS, YALE-GRIFFIN PREVENTION RESEARCH CENTER (TASKFORCE CO-CHAIR) MARY S. NESCOTT, MPH, BIRMINGHAM GROUP HEALTH SERVICES, INC. (TASKFORCE CO-CHAIR) HEIDI ZAVATONE-VETH, PHD, VALLEY COUNCIL FOR HEALTH & HUMAN SERVICES (VALLEY COUNCIL COORDINATOR) KAREN N. SPARGO, MA, MPH, NAUGATUCK VALLEY HEALTH DISTRICT JESSE REYNOLDS, MS, (CURRENTLY YALE UNIVERSITY) ANN HARRISON, THE WORKPLACE, INC. (CURRENTLY WORKFORCE ALLIANCE).THE MATERIAL IN THIS COMMUNITY HEALTH NEEDS ASSESSMENT WILL DOCUMENT GRIFFIN'S COMMITMENT TO THE SIX TOWN VALLEY COMMUNITIES THAT HAS BEEN ITS PRIMARY SERVICE AREA FOR OVER A CENTURY. MUCH OF THE RESEARCH REFERENCED AND USED IN THE CHNA HAS BEEN DONE OVER A TWO DECADE PERIOD OF TIME AND HAS BEEN A COLLABORATIVE EFFORT BETWEEN THE VALLEY COUNCIL OF HEALTH AND HUMAN SERVICE ORGANIZATIONS, GRIFFIN HOSPITAL AND THE YALE-GRIFFIN PREVENTION RESEARCH CENTER. GRIFFIN HOSPITAL PART V, SECTION B, LINE 6A: CHNA WAS NOT CONDUCTED WITH ANY OTHER HOSPITAL. GRIFFIN HOSPITAL PART V, SECTION B, LINE 7D: GUIDESTAR - WWW.GUIDESTAR.ORG/FINDOCUMENTS/2013 GRIFFIN HOSPITAL PART V, SECTION B, LINE 11: GRIFFIN'S CHNA IDENTIFIED OUR COMMUNITY NEEDS AS AWARENESS OF HEALTH AND HUMAN SERVICES, TRANSPORTATION, OBESITY, PRIMARY CARE ACCESS, COMMUNITY POPULATION BASED MEDICAL ISSUES, CLINICAL SERVICES, SUBSTANCE ABUSE, PRE-NATAL CARE AND REGIONAL COOPERATION ON HEALTH ISSUES. GRIFFIN PLANS TO ADDRESS PRIORITY AREAS WITH IMPLEMENTATION PLANS ON ALL BUT ONE OF THE SUGGESTED NEEDS. THERE WAS A PERCEPTION THAT PRE-NATAL CARE WAS LOW AND THAT AN INTERVENTION WAS NEEDED. RESEARCH, HOWEVER, REVEALED THAT PRENATAL CARE FOR MOTHERS-TO-BE IN THE VALLEY WAS SIGNIFICANTLY BETTER WHEN COMPARED TO THE STATE AND NEW HAVEN COUNTY AS REPORTED BY THE CONNECTICUT DEPARTMENT OF PUBLIC HEALTH. BASED ON THE ACTUAL DATA THERE IS NO ACTION REQUIRED RELATED TO PRE-NATAL CARE. THE INFORMATION WILL BE WIDELY SHARED WITH HEALTH AND HUMAN SERVICE ORGANIZATION AND OTHER COMMUNITY LEADERS TO ENSURE THAT THERE IS INCREASED KNOWLEDGE OF THE VALLEY DATA AS COMPARED TO NEW HAVEN COUNTY AND THE STATE OF CONNECTICUT. GRIFFIN HOSPITAL PART V, SECTION B, LINE 13B: INVESTMENT, IRA, CHECKING ACCT, REAL ESTATE GRIFFIN HOSPITAL PART V, SECTION B, LINE 16I: FINANCIAL ASSISTANCE INFORMATION FOR GRIFFIN HOSPITAL IS POSTED THROUGHOUT THE HOSPITAL'S MAIN REGISTRATION AREA AND IS ATTACHED TO THE BILLING INVOICES. GRIFFIN HOSPITAL PART V, SECTION B, LINE 22D: THE UNINSURED RATES ARE ESTABLISHED BASED ON THE AVERAGE PAYMENTS RECEIVED FROM OUR LARGEST PARTICIPATING HMO. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY GRIFFIN HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: WWW.GRIFFINHEALTH.ORG/PATIENT-INFORMATION/BILLING-INSURANCE/UNINSURED GRIFFIN HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: WWW.GRIFFINHEALTH.ORG/PORTALS/0/DOCUMENTS/FINANCIAL_ASSISTANCE_APPLICATION GRIFFIN HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: WWW.GRIFFINHEALTH.ORG/PATIENT-INFORMATION/BILLING-INSURANCE PART I, LINE 3C: GRIFFIN HOSPITAL CRITERIA FOR DETERMINING ELIGIBILITY FOR FREE CARE OR DISCOUNTED CARE INCLUDE ELIGIBILITY REQUIREMENTS ALL GUARANTORS WITH FAMILY INCOME EQUAL TO OR BELOW TWO HUNDRED PERCENT OF THE FEDERAL POVERTY STANDARD ADJUSTED FOR FAMILY SIZE SHALL BE DETERMINED TO BE INDIGENT PERSONS QUALIFYING FOR CHARITY SPONSORSHIP FOR THE FULL AMOUNT OF HOSPITAL CHARGES RELATED TO APPROPRIATE HOSPITAL-BASED MEDICAL SERVICES THAT ARE NOT COVERED BY PRIVATE OR PUBLIC THIRD-PARTY SPONSORSHIP. ALL GUARANTORS WITH FAMILY INCOME BETWEEN TWO HUNDRED ONE (250%) AND FOUR HUNDRED PERCENT (400%) OF THE FEDERAL POVERTY STANDARD ADJUSTED FOR FAMILY SIZE SHALL BE DETERMINED TO BE INDIGENT PERSONS QUALIFYING FOR DISCOUNTS FROM CHARGES RELATED TO APPROPRIATE HOSPITAL BASED MEDICAL SERVICES IN ACCORDANCE WITH THE SLIDING FEE SCHEDULE IN ATTACHMENT A AND POLICIES REGARDING INDIVIDUAL FINANCIAL CIRCUMSTANCES BASED ON THE BELOW CRITERIA: A. ELIGIBILITY SHALL BE BASED ON FINANCIAL NEED AT THE TIME OF APPLICATION BY COMPARING TOTAL FAMILY INCOME WITH THE CURRENT FEDERAL POVERTY GUIDELINES. IF A FAMILY'S TOTAL INCOME IS GREATER THAN 100% OF THE FEDERAL POVERTY GUIDELINE FAMILY ASSETS OTHER THAN EXEMPT ASSETS LISTED BELOW MAY BE CONSIDERED AS A SOURCE OF PAYMENT. B. EXEMPT ASSETS (BASED ON MEDICARE EXEMPTED ASSETS) LISTED BELOW SHOULD NOT BE ADDED TO FAMILY WORTH FOR CHARITY REVIEW: I. FAMILY PRINCIPAL RESIDENCE II. NECESSARY MOTOR VEHICLES REQUIRED FOR EMPLOYMENT, REQUIRED FOR ACCESS TO TREATMENT, OR MODIFIED FOR OPERATION OR TRANSPORT OF A DISABLED PERSON III. PERSONAL EFFECTS AND HOUSEHOLD GOODS IV. RESOURCES NECESSARY FOR SELF-SUPPORT. ALL RESOURCES OF BOTH SPOUSES ARE CONSIDERED TOGETHER. 3. CHARITY WILL BE ASSIGNED USING THE MOST RECENTLY PUBLISHED FEDERAL POVERTY STANDARDS AND EVALUATED ON THE ADJUSTED FAMILY INCOME AS EXPLAINED ABOVE FOR THOSE ABOVE 250% OF SUCH STANDARDS. 4. DOCUMENTATION WILL BE REQUESTED AND IN MOST CASES WILL BE REQUIRED TO ESTABLISH ELIGIBILITY FOR CHARITY CARE. IN THE EVENT THAT THE GUARANTOR IS NOT ABLE TO PROVIDE THE DOCUMENTATION DESCRIED ABOVE, THE HOSPITAL SHALL RELY UPON WRITTEN AND SIGNED STATEMENTS FORM THE GUARANTOR TO MAKE A FINAL DETERMINATION OF ELIGIBILITY FOR CLASSIFICATION AS AN INDIGENT PERSON. PART I, LINE 7: CHARITY CARE AND OTHER COMMUNITY BENEFITS TABLE WERE CALCULATED USING A COST ACCOUNTING SYSTEM OR COST TO CHARGE RATIO. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS AND ASSIGNS COST TO INDIVIDUAL SERVICES. PART I, LINE 6A: GRIFFIN HOSPITAL DID PREPARE A COMMUNITY BENEFIT REPORT FOR YEAR ENDING 2015. IT IS POSTED ON THE GRIFFIN HOSPITAL WEBSITE. PART I, LINE 6B: GRIFFIN HOSPITAL POSTS ITS COMMUNITY BENEFIT REPORT AND INFORMATION ON THE HOSPITAL WEBSITE GRIFFINHEALTH.ORG. PART III, LINE 4: GRIFFIN HOSPITAL AND SUBSIDIARY NOTES TO CONSOLIDATED FINANCIAL STATEMENTS SEPTEMBER 30, 2015NOTE 1 - SIGNIFICANT ACCOUNTING POLICIES AND ORGANIZATION - MEASURING CHARITY CARETHE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS FREE CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN IT'S ESTABLISHED AND CONTRACTUAL RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS FREE CARE, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE.A PATIENT IS CLASSIFIED AS A CHARITY PATIENT BY REFERENCE TO THE ESTABLISHED POLICIES OF THE HOSPITAL. ESSENTIALLY, THESE POLICIES DEFINE CHARITY SERVICES AS THOSE SERVICES FOR WHICH NO PAYMENT IS POSSIBLE. IN ASSESSING A PATIENT'S INABILITY TO PAY, THE HOSPITAL UTILIZES THE GENERALLY RECOGNIZED FEDERAL POVERTY INCOME LEVELS, BUT ALSO INCLUDES CERTAIN CASES WHERE INCURRED CHARGES ARE SIGNIFICANT WHEN COMPARED TO INCOMES AND ASSETS.SELF-PAY REVENUES ARE DERIVED PRIMARILY FROM PATIENTS WHO DO NOT HAVE ANY FORM OF HEALTH CARE COVERAGE. THE HOSPITAL EVALUATES THESE PATIENTS, AFTER THE PATIENT'S MEDICAL CONDITION IS DETERMINED TO BE STABLE, FOR THEIR ABILITY TO PAY BASED UPON FEDERAL AND STATE POVERTY GUIDELINES, QUALIFICATIONS FOR MEDICAID OR OTHER GOVERNMENTAL ASSISTANCE PROGRAMS, AS WELL AS THE HOSPITAL'S POLICY FOR CHARITY CARE. FOR THE YEARS ENDED SEPTEMBER 30, 2015 AND 2014, THE HOSPITAL ESTIMATES THAT ITS COSTS OF CARE PROVIDED UNDER ITS CHARITY CARE PROGRAMS APPROXIMATED $822,647 AND $1,020,814, RESPECTIVELY.THE HOSPITAL'S MANAGEMENT ESTIMATES ITS COSTS OF CARE PROVIDED UNDER ITS CHARITY CARE PROGRAMS UTILIZING A CALCULATED RATIO OF COSTS TO GROSS CHARGES MULTIPLIED BY THE HOSPITAL'S GROSS CHARITY CARE CHARGES PROVIDED. THE HOSPITAL'S GROSS CHARITY CARE CHARGES INCLUDE ONLY SERVICES PROVIDED TO PATIENTS WHO ARE UNABLE TO PAY AND QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. TO THE EXTENT THE HOSPITAL RECEIVES REIMBURSEMENT THROUGH THE VARIOUS GOVERNMENTAL ASSISTANCE PROGRAMS IN WHICH IT PARTICIPATES TO SUBSIDIZE ITS CARE OF INDIGENT PATIENTS, THE HOSPITAL DOES NOT INCLUDE THESE PATIENTS' CHARGES IN ITS COST OF CARE PROVIDED UNDER ITS CHARITY CARE PROGRAM. ADDITIONALLY, THE HOSPITAL DOES NOT REPORT A CHARITY CARE PATIENT'S CHARGES IN REVENUES OR IN THE PROVISION FOR DOUBTFUL ACCOUNTS AS IT IS THE HOSPITAL'S POLICY NOT TO PURSUE COLLECTION OF AMOUNTS RELATED TO THESE PATIENTS. PART III, LINE 8: GRIFFIN HOSPITAL BELIEVES THAT ALL OF THE $7.425 MILLION SHORTFALL SHOULD BE CONSIDERED AS COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY THE HOSPITAL IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITY. THIS YEAR MEDICARE ACCOUNTED FOR 5.5% OF HOSPITAL EXPENSES THE HOSPITAL PROVIDES CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVES THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. PART III, LINE 9B: GRIFFIN HOSPITAL HAS A WRITTEN POLICY ABOUT WHEN AND UNDER WHOSE AUTHORITY PATIENT DEBT IS ADVANCED FOR COLLECTION AND SHALL USE ITS BEST EFFORTS TO ENSURE THE PATIENT AMOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. GRIFFIN WILL ENSURE THAT PRACTICES TO BE USED BY THEIR OUTSIDE COLLECTION AGENCIES WILL CONFORM TO THE STANDARDS SET FORTH IN THIS POLICY AND SHALL OBTAIN WRITTEN COMMITMENTS FROM SUCH AGENCIES AT TIME OF BILLING. GRIFFIN WILL PROVIDE TO ALL LOW INCOME UNINSURED PATIENTS THE SAME INFORMATION CONCERNING SERVICES AND CHARGES PROVIDED TO ALL OTHER PATIENTS WHO RECEIVE CARE AT THE HOSPITAL FOR PATIENTS WHO HAVE AN APPLICATION PENDING DETERMINATION FOR EITHER GOVERNMENT SPONSORED COVERAGE OR FOR THE HOSPITAL OWN FINANCIAL ASSISTANCE PROGRAM GRIFFIN WILL NOT KNOWINGLY SEND THAT PATIENT BILL TO A COLLECTION AGENCY. IF A PATIENT DOES NOT MAINTAIN THE AGREED UPON PAYMENT SCHEDULE THE AMOUNT WILL BE FORWARDED TO AN OUTSIDE COLLECTION AGENCY AT THE FULL REMAINING BALANCE. IF IT IS LATER DETERMINED BY THE GRIFFIN HOSPITAL OR A COLLECTION AGENCY ACTING ON BEHALF OF GRIFFIN HOSPITAL THAT THE PATIENT FINANCIAL CONDITIONS HAVE CHANGED AND THE PATIENT WAS UNABLE TO PAY THE OUTSTANDING ACCOUNT BALANCES AN OVERRIDE MAY BE APPLIED BY THE BUSINESS SERVICES DIRECTOR. THE UNCOLLECTED DEBT WILL BE TRANSFERRED TO UNINSURED OR FREE CARE ASSISTANCE BY THE SUPERVISOR AFTER REVIEW. THE MEDICARE COSTS WERE OBTAINED FROM THE HOSPITAL'S INTERNAL COST ACCOUNTING SYSTEM. PART III, LINE 2: GRIFFIN HOSPITAL BAD DEBT EXPENSE IS DETERMINED USING UNCOLLECTED ACCOUNTS NET OF ANY BAD DEBT RECOVERY MULTIPLIED BY THE COST TO CHARGE RATIO. GRIFFIN HOSPITAL HAS A WRITTEN POLICY ABOUT WHEN AND UNDER WHOSE AUTHORITY PATIENT DEBT IS ADVANCED FOR COLLECTION AND SHALL USE ITS BEST EFFORTS TO ENSURE THAT THE PATIENT ACCOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. CHARITY APPROVAL WILL AFFECT ALL ACCOUNTS FOR WHICH THE APPROVED GUARANTOR IS RESPONSIBLE. THE APPROVED CHARITY PERCENTAGE WILL BE APPLIED TO ALL EXISTING ACCOUNTS WITH DEBIT BALANCES. ACCOUNTS MAY ALSO BE RETURNED FROM BAD DEBT STATUS IF FINANCIAL CIRCUMSTANCES WARRANT AND CHARITY MAY BE APPLIED. THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS FREE CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAT IT'S ESTABLISHED AND CONTRACTUAL RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS FREE CARE, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE. PART III, LINE 3: GRIFFIN HOSPITAL DOES NOT ATTRIBUTE ANY BAD DEBT TO COMMUNITY BENEFIT EXPENSE. UNCOLLECTED BALANCES ARE REVIEWED AT MANY STAGES TO DETERMINE IF THEY FALL UNDER UNINSURED OR FREE CARE ASSISTANCE. PART VI, LINE 2: GRIFFIN HAS A HISTORY OF COMMUNITY SERVICE AND SOCIAL RESPONSIBILITY DATING BACK TO ITS FOUNDING 100 YEARS AGO AND OF PROVIDING EDUCATIONAL, PREVENTION AND SCREENING PROGRAMS AND SERVICES. IN 1970, FUNDED BY A GRANT FROM THE KELLOGG FOUNDATION, GRIFFIN ESTABLISHED ONE OF THE FIRST HOSPITAL DEPARTMENTS OF COMMUNITY HEALTH IN THE COUNTRY TO FOCUS ON THE HEALTH AND SOCIAL NEEDS OF THE COMMUNITY IT SERVES. OVER THE PAST FIFTEEN YEARS, GRIFFIN'S REACH HAS BEEN EXPANDING INTO THE COMMUNITY. IN ADDITION TO PROVIDING HEALTH INFORMATION AND SERVICES TO THE PUBLIC AT THE HOSPITAL AND OTHER SATELLITE LOCATIONS, GRIFFIN TAKES THESE ACTIVITIES INTO THE COMMUNITIES WHERE PATIENTS LIVE AND WORK. BY OFFERING A VARIETY OF SUPPORT GROUPS, TRAINING SESSIONS, EDUCATIONAL PROGRAMS, AND OTHER COMMUNITY-BASED RESOURCES AND ACTIVITIES, AND COLLABORATING WITH OTHER NON-PROFIT ORGANIZATIONS AND GOVERNMENT ENTITIES, GRIFFIN HAS EXTENDED ITS MISSION FAR BEYOND THE HOSPITAL'S WALLS TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF PEOPLE OF ALL AGES. COMMUNITY LEADERSHIP RECOGNIZED THE NEED TO RESPOND TO THE CHANGING COMMUNITY DEMOGRAPHICS AND THE DIFFERENT SOCIOECONOMIC AND HEALTH NEEDS AND EXPECTATIONS OF THE MORE DIVERSE POPULATION. THREE MAJOR NEW STRUCTURES WERE CREATED. IN 1993, THE VALLEY COUNCIL OF HEALTH AND HUMAN SERVICE ORGANIZATION (VCHHSO) WERE FOUNDED. MORE THAN 55 ORGANIZATIONS THAT PROVIDE MOST OF THE HEALTH AND HUMAN SERVICES ARE MEMBERS. VCHHSO'S VISION IS A PROVIDER NETWORK THAT WORKS COLLABORATIVELY TO CREATE AN INTEGRATED HUMAN SERVICES DELIVERY SYSTEM THAT MEETS THE NEEDS OF ALL RESIDENTS. "HEALTHY VALLEY 2000", THE STATE'S FIRST HEALTHY COMMUNITY EFFORT, WAS LAUNCHED IN 1994. WITH FOUNDATION GRANT SUPPORT, THE NATIONAL CIVIC LEAGUE WAS ENGAGED TO GUIDE STAKEHOLDERS THROUGH THE PROCESS. THE VISION OF THE BROAD-BASED, VOLUNTEER INSPIRED AND MANAGED EFFORT WAS TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF THE COMMUNITY AND ITS RESIDENTS BY MAKING THE COMMUNITY A BETTER PLACE IN WHICH TO LIVE, WORK, SHOP, RAISE A FAMILY AND ENJOY LIFE. BASED ON RESEARCH, INCLUDING USE OF THE NATIONAL CIVIC LEAGUE INDEX, AN S.W.O.T ANALYSIS, AND BRAINSTORMING, 175 STAKEHOLDERS IDENTIFIED ARTS & RECREATION, COMMUNITY INVOLVEMENT, ECONOMIC DEVELOPMENT, EDUCATION AND HEALTH AS PRIORITIES. A TASK FORCE DEVELOPED A WORK PLAN FOR EACH OF THE PRIORITIES AND AN HONOR ROLE WAS DEVELOPED TO RECOGNIZE INITIATIVES UNDERTAKEN INDEPENDENTLY BY INDIVIDUALS OR ORGANIZATIONS RELATED TO THE IDENTIFIED PRIORITIES.THE PATIENT PROTECTION AND AFFORDABLE CARE ACT) REQUIRES NON-PROFIT HOSPITALS TO PERFORM A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) EVERY THREE YEARS AND TO ADOPT AN IMPLEMENTATION STRATEGY TO MEET OUTSTANDING COMMUNITY HEALTH NEEDS IDENTIFIED IN THE ASSESSMENT AS A CONDITION OF MAINTAINING THE INSTITUTION'S FEDERAL TAX EXEMPTION. GRIFFIN HOSPITAL'S FIRST CHNA WAS REQUIRED TO BE SUBMITTED NOT LATER THAN SEPTEMBER 30, 2013. IN PREPARING THE GRIFFIN HOSPITAL CHNA, THE HOSPITAL COLLABORATED WITH THE VALLEY COUNCIL OF HEALTH AND HUMAN SERVICE ORGANIZATIONS, THE LOWER NAUGATUCK VALLEY HEALTH DISTRICT, THE CONNECTICUT HOSPITAL ASSOCIATION AND THE CONNECTICUT ASSOCIATION OF DIRECTORS OF HEALTH AND NUMEROUS LOCAL COMMUNITY HEALTH AND HUMAN SERVICE ORGANIZATIONS THAT PARTICIPATED IN FOCUS GROUPS AND REVIEW OF THE CHNA DOCUMENT. GRIFFIN'S CHNA WAS SHARED WITH THE LOWER NAUGATUCK VALLEY HEALTH DISTRICT FOR USE IN PREPARING ITS COMMUNITY HEALTH IMPROVEMENT PLAN. PART VI, LINE 3: A FINANCIAL ASSISTANCE BROCHURE IS POSTED THROUGHOUT THE HOSPITAL (CHILDBIRTH AREA, ER AREA, AND CUSTOMER SERVICE AREA) IN ENGLISH AND SPANISH EXPLAINING THE FINANCIAL ASSISTANCE POLICY AND HOW TO CONTACT THE FINANCIAL COUNSELORS. THE FOLLOWING POLICY REPRESENTS GRIFFIN HOSPITAL'S PROCEDURES FOR THE UNINSURED PATIENT, FREE CARE ASSISTANCE, AND FREE BED FUNDS AVAILABLE FOR PATIENTS WHO DO NOT HAVE MEDICAL INSURANCE.1 - UNINSURED PATIENT PROCEDURETHE PATIENT IS REGISTERED BY THE ADMITTING REGISTRAR WHO WILL IDENTIFY THE PATIENT AS HAVING NO MEDICAL INSURANCE (SELF PAY).THE PATIENT WILL BE GIVEN A FINANCIAL ASSISTANCE PAMPHLET THAT WILL IDENTIFY ALL GRIFFIN HOSPITAL FREE CARE ASSISTANCE PROGRAMS. THE PAMPHLET ALSO INCLUDES HOSPITAL CONTACTS FOR PATIENTS SEEKING STATE WELFARE, SAGA (CITY WELFARE), OR OTHER STATE PROGRAMS.PATIENTS WHO REGISTER AS HAVING NO MEDICAL INSURANCE WITH ACCOUNT BALANCES OVER $3,000 WILL BE REFERRED TO THE HOSPITAL ELIGIBILITY WORKER. THE PATIENT WILL BE SEEN WITHIN 24 HOURS OF ADMISSION. IF THE ELIGIBILITY WORKER IS UNABLE TO FULFILL THIS REQUIREMENT DUE TO ABSENCE, THE FINANCIAL ADVISOR WILL TAKE THE NECESSARY STEPS TO FULFILL THIS REQUIREMENT. ALL ACCOUNTS UNDER $3,000 WILL BE REFERRED TO THE HOSPITAL FINANCIAL ADVISORS.THE HOSPITAL ELIGIBILITY WORKER WILL COMPLETE A FINANCIAL SCREENING FOR THOSE PATIENTS SEEKING TITLE 19 ELIGIBILITY AND FOR THE UNINSURED STATUS.THE HOSPITAL ELIGIBILITY WORKER WILL IDENTIFY PATIENTS MEETING THE STATE/SAGA AND HUSKY PROGRAM CRITERIA. FOR PATIENTS MEETING THE CRITERIA, THE APPLICATION PROCESS WILL BE COMPLETED AND ALL PAPERWORK FORWARDED TO THE APPROPRIATE STATE DEPARTMENT FOR PROCESSING.THE PATIENTS WHO DO NOT MEET THE CRITERIA FOR THE STATE/SAGA/HUSKY PROGRAMS WILL BE REFERRED TO THE HOSPITAL FINANCIAL ADVISOR.THE FINANCIAL ADVISOR WILL BEGIN A REVIEW TO DETERMINE IF THE PATIENT MEETS THE UNINSURED CRITERIA IDENTIFIED IN PUBLIC ACT 03-266. A LETTER WILL BE SENT TO THE PATIENT REQUESTING THAT PATIENT TO VERIFY THAT THEY DO NOT HAVE MEDICAL INSURANCE AS IDENTIFIED DURING THEIR HOSPITAL REGISTRATION PROCESS. THE LETTER WILL ALSO REQUEST ADDITIONAL PATIENT INFORMATION REGARDING THE PATIENT'S INCOME IF NECESSARY. THE CRITERIA THE PATIENT MUST MEET AS IDENTIFIED IN PUBLIC ACT 03-266 ARE AS FOLLOWS:PATIENT'S INCOME, BASED ON FAMILY SIZE, FALLS UNDER 250% OF THE POVERTY INCOME GUIDELINES (POVERTY INCOME GUIDELINE SCALE AVAILABLE UPON REQUEST)HOSPITAL HAS MADE A FULL DETERMINATION AS TO THE STATUS OF THE STATE/SAGA/HUSKY PROGRAMS (IF APPLICABLE)ALL GRIFFIN HOSPITAL FREE BED FUNDS HAVE BEEN REVIEWED AND DETERMINED NON-APPLICABLE FOR THE PATIENT IN REVIEWIF THE PATIENT RESPONDS TO THE LETTER SENT OUT BY THE FINANCIAL ADVISOR, THIS WILL BEGIN THE APPLICATION PROCESS FOR THE VERIFICATION OF THE UNINSURED PATIENT STATUS. THE FOLLOWING INFORMATION WILL NEED TO BE FINALIZED WITH THE PATIENT IN ORDER FOR THE UNINSURED DETERMINATION TO BE MADE:PROOF OF PATIENT INCOME AND FAMILY SIZEHOSPITAL HAS MADE A FINAL DETERMINATION AS TO THE STATUS OF THE STATE/SAGA/HUSKY PROGRAMS (IF APPLICABLE)VERIFICATION OF ALL FREE BED FUNDS BEING REVIEWED WITH THE PATIENTUPON DETERMINATION THAT A PATIENT MEETS THE OUTLINED CRITERIA, THE PATIENT WILL BE CLASSIFIED AS FOLLOWS:UNINSURED STATUS; THE PATIENTS ACCOUNT WILL BE TAKEN FROM TOTAL GROSS CHARGES AND REDUCED TO COST BY APPLYING FACTOR SUPPLIED ANNUALLY BY THE OFFICE OF HEALTH CARE ACCESSTHE PATIENT WILL BE INFORMED OF THIS DECISION AND WILL BE SENT A LETTER THAT WILL REFLECT THE BALANCE AT REDUCTION ON ALL APPLICABLE ACCOUNTSTHE PATIENT WILL BE ADVISED OF THE BALANCE THAT IS DUE AND PAYABLETHE FINANCIAL ADVISOR WILL CONTACT THE PATIENT TO ACCOMPLISH THE FOLLOWING:ATTEMPT PAYMENT ARRANGEMENT WITH THE PATIENT ON THE REMAINING BALANCEIF THE PATIENT IDENTIFIES TO THE FINANCIAL ADVISOR THAT THEY CANNOT AFFORD THE REMAINING BALANCE, AN APPLICATION FOR FREE CARE ASSISTANCE WILL BE COMPLETED IF A PATIENT APPLIES FOR FREE CARE ASSISTANCE, THE FINANCIAL ADVISOR WILL MAKE A DECISION ON FREE CARE ELIGIBILITY BASED ON THE PATIENT'S FAMILY SIZE AND INCOME. FREE CARE WILL BE OFFERED BASED ON THE GRIFFIN HOSPITAL FREE CARE ASSISTANCE SLIDING SCALE (SLIDING SCALE AVAILABLE UPON REQUEST).THE FINANCIAL ADVISOR WILL ADVISE THE PATIENT OF THE FREE CARE DETERMINATION THAT WILL BE APPLIED TO THE PATIENTS REMAINING BALANCE.THE FINANCIAL ADVISOR WILL COMPLETE ALL APPROPRIATE LOGS WITH THE DECISIONS AND AMOUNTS.2 - FREE CARE ASSISTANCEANY PATIENT REQUESTING FINANCIAL ASSISTANCE IN PAYING THEIR GRIFFIN HOSPITAL BILL CAN APPLY FOR THE FREE CARE ASSISTANCE PROGRAM BY CONTACTING THE HOSPITALS FINANCIAL ADVISORY STAFF.THE FINANCIAL ADVISOR WILL BE CONTACT BY THE PATIENT TO COMPLETE THE FREE CARE APPLICATION PROCESS.THE FINANCIAL ADVISOR WILL OBTAIN THE FOLLOWING INFORMATION FROM THE PATIENT IN ORDER TO COMPLETE THE FREE CARE APPLICATION:PATIENT W-2 FORM (TAX STATEMENT FROM PREVIOUS AND CURRENT YEAR)THREE CONSECUTIVE PAY STUBS FROM PATIENT'S CURRENT EMPLOYMENTDEPENDENT INFORMATION (FAMILY SIZE)ANY OR ALL BANK AND CHECKING ACCOUNT STATEMENTSTHE FINANCIAL ADVISOR WILL REFER TO THE GRIFFIN HOSPITAL SLIDING SCALE. THIS IS BASED ON THE FEDERAL POVERTY INCOME GUIDELINES (SLIDING SCALE AVAILABLE UPON REQUEST). THE FINANCIAL ADVISOR WILL MAKE A DETERMINATION OF FREE CARE ELIGIBILITY STATUS.IF THE PATIENT QUALIFIES FOR FREE CARE ASSISTANCE, THE APPLICABLE DISCOUNT PERCENTAGE WILL BE APPLIED TO THE PATIENTS ACCOUNT BALANCE.IF A PATIENT BALANCE REMAINS, THE FINANCIAL ADVISOR WILL PURSUE ONE OF THE FOLLOWING WITH THE PATIENT:REQUIRE PAYMENT IN FULLSET UP A MONTHLY PAYMENT ARRANGEMENTIF THE PATIENT DOES NOT MAINTAIN THE AGREED UPON PAYMENT SCHEDULE, THE ACCOUNT WILL BE FORWARDED TO AN OUTSIDE COLLECTION AGENCY AT THE FULL REMAINING BALANCE.IF A PATIENT DOES NOT QUALIFY FOR FREE CARE ASSISTANCE, THE FINANCIAL ADVISOR WILL ATTEMPT TO:OBTAIN PAYMENT IN FULLSET UP A MONTHLY PAYMENT ARRANGEMENTIF THE PATIENT DOES NOT MAINTAIN THE AGREED UPON PAYMENT SCHEDULE, THE ACCOUNT WILL BE FORWARDED TO AN OUTSIDE COLLECTION AGENCY AT THE FULL REMAINING BALANCE. IN SOME CASES, IT IS NECESSARY TO OVERRIDE THE POLICY GUIDELINES ON INCOME DUE TO SPECIAL CIRCUMSTANCE REQUIREMENTS, I.E., SOCIAL ADMITS, MAXED OUT DAYS, DECEASED PATIENTS. AN OVERRIDE CAN BE OBTAINED BY THE SUPERVISOR AND DIRECTOR OR CFO ALLOWING FOR CONSIDERATION OF ELIGIBILITY. THE COLLECTION SUPERVISOR WILL MAINTAIN ALL MONTHLY SPREADSHEETS THAT WILL IDENTIFY ALL FREE BED FUNDS, UNINSURED, AND FREE CARE ASSISTANCE ALLOCATED ON A MONTHLY BASIS.3 - FREE BED FUNDSTHE HOSPITAL HAS THE FOLLOWING FREE BED FUNDS AVAILABLE FOR PATIENTS WHO MEET THE FOLLOWING OUTLINED CRITERIA FOR EACH FUND:THE ENO FUND: THE APPLICANT MUST BE A WORTHY PROTESTANT WOMAN, 60 YEARS OF AGE OR OLDER, AND BE A RESIDENT OF ANSONIA, DERBY OR SEYMOUR.PINE TRUST: THE FUND IS AVAILABLE TO INDIGENT PATIENTS OF GRIFFIN HOSPITAL WHO RESIDE IN THE CITY OF ANSONIA.DN CLARK: THE FUND IS AVAILABLE TO SHELTON RESIDENTS.ALL FREE BED FUNDS GRANTED ARE PROCESSED THROUGH THE HOSPITAL'S FINANCIAL ADVISOR STAFF. PART VI, LINE 4: GRIFFIN HOSPITAL, LICENSED BY THE STATE OF CONNECTICUT FOR 160 BEDS AND 15 BASSINETS, IS A GENERAL ACUTE CARE HOSPITAL SERVING A PRIMARY SERVICE AREA (PSA) OF SIX TOWNS, ANSONIA, BEACON FALLS, DERBY, OXFORD, SEYMOUR AND SHELTON CONNECTICUT. THE SIX TOWN REGION HAS COME TO BE KNOWN AS THE LOWER NAUGATUCK VALLEY. THE SIX TOWNS WITH AN AREA OF A LITTLE MORE THAN 100 SQUARE MILES HAVE A COMBINED POPULATION OF OVER 107,000 BASED ON CURRENT ESTIMATES.THE VALLEY, GEOGRAPHICALLY LOCATED IN SOUTH CENTRAL CONNECTICUT, IS SURROUNDED BY THREE OF THE STATE'S LARGEST CITIES, NEW HAVEN, TO THE SOUTH, BRIDGEPORT, TO THE SOUTHWEST, AND WATERBURY TO THE NORTH EACH BETWEEN 9 AND 15 MILES FROM GRIFFIN HOSPITAL. THERE ARE TWO TERTIARY CARE HOSPITALS IN BRIDGEPORT AND WATERBURY AND WITH THE MERGER OF THE HOSPITAL OF ST. RAPHAEL WITH YALE NEW HAVEN HOSPITAL, ONE VERY LARGE HOSPITAL IN NEW HAVEN. YALE NEW HAVEN HOSPITAL IS NOW ONE OF THE TEN LARGEST HOSPITALS IN THE COUNTRY. EACH HAS VARYING DEGREES OF MARKET SHARE IN GRIFFIN'S PRIMARY SERVICE AREA TOWNS DEPENDING ON THE PROXIMITY TO THE THREE CITIES AND THE HOSPITALS LOCATED THERE. GRIFFIN'S LARGER GEOGRAPHIC REGION IS ONE OF THE MOST COMPETITIVE HOSPITAL MARKETS IN THE COUNTRY FOR BOTH PATIENTS AND STAFF.THE DEMOGRAPHICS IN TERMS OF POPULATION BY AGE GROUP MIRROR THOSE OF THE STATE OF CONNECTICUT. THE VALLEY'S AFRICAN AMERICAN POPULATION IS 4% COMPARED TO 10.1% FOR THE STATE AND THE HISPANIC POPULATION IS 6% COMPARED TO 13.4% FOR THE STATE. THE AFRICAN AMERICAN POPULATION IS CENTERED PRIMARILY IN ANSONIA (11.6%) AND THE HISPANIC POPULATION IS CENTERED PRIMARILY IN ANSONIA (16.7%) AND DERBY (14.2%). POPULATION BY ETHNIC BACKGROUND REMAINS PRIMARILY ITALIAN - 23%, POLISH/RUSSIAN/UKRAINIAN - 17% AND IRISH - 11%. THE AGE 65 AND OVER POPULATION IS 14% COMPARED TO THE STATE OF CONNECTICUT ALSO AT 14% IN 2010.MEDIAN HOUSEHOLD INCOME (2007-2011) IN ALL VALLEY TOWNS HAS BEEN INCREASING, BUT ANSONIA ($55,259) AND DERBY ($55,478) REMAIN ALMOST $15,000 BELOW THE STATE MEDIAN. THE REMAINING TOWNS, SEYMOUR ($65,036) BEACON FALLS ($70,228), SHELTON ($79,176) AND OXFORD ($95,710) WERE CLOSE TO OR CONSIDERABLY ABOVE THE CONNECTICUT MEDIAN ($68,055), AN INDICATION OF THE ECONOMIC DISPARITIES WITHIN THE VALLEY. THE NUMBER OF FOOD STAMP RECIPIENTS IN ANSONIA (2,998 - 16%) AND DERBY (1,612 - 12%) WERE HIGHER THAN THE CONNECTICUT RATE (10%). ALL OTHER TOWNS WERE CONSIDERABLY BELOW THE STATE RATE. THE OVERALL POVERTY RATE WAS THE HIGHEST IN THE VALLEY (YEAR 2009) IN DERBY (11.5%) AND ANSONIA (10.7%). ALL OTHER TOWNS WERE CONSIDERABLY BELOW THE STATE RATE (11.9%) WITH OXFORD THE LOWEST (2.1%). ANSONIA AND DERBY EXPERIENCED INSIGNIFICANT POPULATION DECLINES BETWEEN THE 2000 AND 2010 CENSUS. IN ALL OTHER TOWNS THE POPULATION GREW BETWEEN 4% AND 31% IN OXFORD WHICH WAS THE FASTEST GROWING TOWN IN THE STATE PERCENTAGE WISE. THE TOTAL VALLEY POPULATION IS PROJECTED TO BE 109,510 IN 2017 UP FROM THE CURRENT 107,000.UNDER 18 YEARS OLD: 23,701 (22%), ABOVE 65 YEARS OLD: 16,353 (15%), HISPANIC OR LATINO: 9,227 (9%),NON-HISPANIC WHITE: 88,855 (83%), NON-HISPANIC BLACK: 4,412 (4%),NON-HISPANIC ASIAN: 2,834 (3%), NON-HISPANIC OTHER: 1,638 (2%),BACHELOR'S DEGREE OR HIGHER: 20,565 (28%), NUMBER OF PEOPLE IN POVERTY: 5,831 (6%) PART VI, LINE 5: GRIFFIN HOSPITAL FURTHERS ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY THRU MANY PROGRAMS AND ASSOCIATIONS INCLUDING DEPARTMENT OF COMMUNITY OUTREACH AND PARISH NURSING GRIFFIN COORDINATE THE PROGRAM OUT OF ITS DEPARTMENT OF COMMUNITY OUTREACH AND PARISH NURSING. THE DEPARTMENT HAS FIVE EMPLOYEES WHO SUPPORT THE 75 VOLUNTEER PARISH NURSES AND 320 VOLUNTEERS WHO SERVE ON THE HEALTHCARE CABINETS OF THE CHURCHES.THE VALLEY PARISH NURSING PROGRAM (VPN) AT GRIFFIN HOSPITAL WILL CELEBRATE ITS 25TH YEAR WITH A CELEBRATION AT GRIFFIN HOSPITAL. IN HONOR OF THIS IMPRESSIVE MILESTONE, WE OFFER SOME OF THE PROGRAM'S GREATEST ACHIEVEMENTS IN IMPROVING THE HEALTH OF VALLEY COMMUNITIES.IN KEEPING WITH THE VALLEY PARISH NURSE PHILOSOPHY TO EMPOWER EACH AND EVERY PERSON TO CARE FOR HIS OR HER WHOLE BODY, MIND AND SPIRIT, THE VALLEY PARISH NURSES HAVE EMBARKED ON MANY NEW INITIATIVES IN ITS HISTORY. THE MOST NOTABLE ARE THE WOMEN & HEART DISEASE PROGRAM, CHILDHOOD IDENTIFICATION PROGRAM (CHIP), PUBLIC ACCESS DEFIBRILLATOR (PAD) PROGRAM, CHILDREN'S HEALTH & SAFETY FAIRS, FALLS PREVENTION PROGRAMS, AND BREAST WELLNESS OUTREACH.PERHAPS THE MOST INFLUENTIAL PROGRAM STARTED BY THE VALLEY PARISH NURSE PROGRAM IS ITS CPR INITIATIVE. BY BRINGING CPR TRAINING AND HELPING SET UP AUTOMATIC EXTERNAL DEFIBRILLATORS (AEDS) AT PLACES THROUGHOUT THE VALLEY, VPN HAS PLAYED A KEY ROLE IN INCREASING THE CARDIAC SURVIVAL RATE AT GRIFFIN HOSPITAL TO 26 PERCENT - THE NATIONAL SURVIVAL RATE IS 9%. SINCE THE INITIATIVE BEGAN, VALLEY PARISH NURSES HAVE ALSO RECEIVED MANY STORIES OF SURVIVAL RELATING TO CHOKING AND RECOGNIZING THE SIGNS OF HEART ATTACK AND CALLING 9-1-1.THE MOBILE HEALTH RESOURCE CENTER - THE MOBILE HEALTH RESOURCE CENTER FOCUSES ON PREVENTIVE HEALTH SERVICES AND PROVIDING HEALTH EDUCATION AND SCREENING SERVICES TO NEIGHBORHOODS, COMMUNITY EVENTS, HEALTH FAIRS, SHOPPING CENTERS AND BUSINESSES/COMPANIESCOMMUNITY OUTREACH SERVICES - IN FISCAL YEAR 2013, THE DEPARTMENT OF COMMUNITY OUTREACH AND THE VALLEY PARISH NURSE PROGRAM SERVED 39,054 PEOPLE. SERVICES INCLUDED 4,411 HEALTH SCREENING RECIPIENTS WHICH CONTRIBUTED TO 14,915 REFERRALS TO NEEDED SERVICES. IN ADDITION, 1,388 EDUCATIONAL PROGRAMS WERE PROVIDED ATTENDED BY 30,709 PEOPLE AND 3,540 PEOPLE WERE TRAINED IN CPR. THE PROGRAM ALSO PROVIDED AND PLACED AED'S (AUTOMATED EXTERNAL DEFIBRILLATORS) AT COMMUNITY SITES BRINGING THE TOTAL NUMBER OF AED'S PLACED AT COMMUNITY SITES TO 67. STARTING SIX YEARS AGO GRIFFIN HOSPITAL THROUGH ITS DEPARTMENT OF COMMUNITY OUTREACH AND PARISH NURSING, JOINED WITH ANSONIA COMMUNITY ACTION, THE NON-PROFIT AGENCY PROVIDING SERVICES TO THE AFRICAN AMERICAN COMMUNITY, FOR AN OUTREACH PROGRAM TO PROVIDE FREE CHOLESTEROL, DIABETES, AND HYPERTENSION SCREENING AND HEALTH EDUCATION FOR PEOPLE WHO ARE 60 AND OLDER. GREATER NAUGATUCK VALLEY SAFE KIDS CHAPTER - IN MARCH 2005 THE VALLEY PARISH NURSE PROGRAM ESTABLISHED THE GREATER NAUGATUCK VALLEY SAFE KIDS CHAPTER. GRIFFIN HOSPITAL, THE VALLEY PARISH NURSE PROGRAM, THE VALLEY N.A.A.C.P., THE CITY OF ANSONIA AND THE COMMUNITY FOUNDATION OF GREATER NEW HAVEN SPONSORED THE ANNUAL COMMUNITY HEALTH AND SAFETY CERTIFIED CPR TRAINING CENTER - GRIFFIN HOSPITAL HAS BEEN A CERTIFIED COMMUNITY AMERICAN HEART ASSOCIATION CPR TRAINING CENTER SINCE 2006GRIFFIN BREAST HEALTH INITIATIVE - THE PURPOSE OF THE GRIFFIN BREAST HEALTH INITIATIVE IS TO PROVIDE OUTREACH AND EDUCATION TO WOMEN, INCLUDING THE UNINSURED OR UNDERINSURED, ABOUT THE IMPORTANCE OF BREAST WELLNESS AND EARLY BREAST CANCER DETECTION AND PROVIDE SCREENING MAMMOGRAMS TO WOMEN WHO WOULD OTHERWISE NOT BE ABLE TO AFFORD ONE. VALLEY WOMEN'S HEALTH INITIATIVE - AED PLACEMENT AT PUBLIC SITES - THE GRIFFIN HOSPITAL VALLEY PARISH NURSE PROGRAM COORDINATED OBTAINING FUNDING FOR THE PURCHASE OF AUTOMATED EXTERNAL DEFIBRILLATORS (AEDS) AND HAS PLACED 65 AEDS AT PUBLIC NON-PROFIT PUBLIC ACCESS DEFIBRILLATOR SITES IN THE COMMUNITY. HOMELESS SHELTER FOOD BANK DONATIONS - PATIENT AND COMMUNITY SUPPORT GROUPS AND EDUCATIONAL MEETINGS - BY YOUR SIDE - CAREGIVER SUPPORT GROUPBEREAVEMENT SUPPORT GROUPBEREAVEMENT SUPPORT GROUP FOR PARENTSTHE WIDOW AND WIDOWER SUPPORT GROUP PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES CT X X X 0 0 0 0 0 0 0 0 0 FREDERICK BROWNE MD TRUSTEE 0 151818 0 0 0 0 0 7950 0 6912 0 166680 0 0 PATRICK CHARMEL CEO/PRESIDENT 443216 0 47394 0 0 0 7156 0 16728 0 514494 0 0 0 KENNETH J DOBULER MD TRUSTEE/PHYSICIAN 240430 0 0 0 0 0 4219 0 0 0 244649 0 0 0 MARK O'NEILL CFO/VP FINANCE 251548 0 32542 0 0 0 3558 0 1980 0 289628 0 0 0 MARGARET DEEGAN VP 189875 0 26525 0 0 0 4353 0 17712 0 238465 0 0 0 TODD LIU VP 136018 0 15591 0 0 0 1795 0 17712 0 171116 0 0 0 BARBARA STUMPO VP 182696 0 24169 0 0 0 4415 0 17712 0 228992 0 0 0 KATHLEEN MARTIN VP 147917 0 21249 0 0 0 4408 0 17712 0 191286 0 0 0 BENJAMIN ZIGUN PHYSICIAN 253876 0 0 0 0 0 2036 0 17712 0 273624 0 0 0 EDWARD HALSTEAD PHYSICIAN 233062 0 0 0 0 0 4217 0 17712 0 254991 0 0 0 MIHAELA BORAN PHYSICIAN 186526 0 0 0 0 0 2959 0 17712 0 207197 0 0 0 GEORGE TOMAS DIRECTOR OF IT DEPARTMENT 150562 0 3653 0 0 0 0 0 6144 0 160359 0 0 0 KENNETH SCHWARTZ FORMER DIRECTOR 97075 0 19902 0 0 0 9339 0 16728 0 143044 0 0 0 EDWARD BERNS FORMER OFFICER 141380 0 19677 0 0 0 0 0 17712 0 178769 0 0 0 SETH SHEPARD FORMER OFFICER 167203 0 23943 0 0 0 0 0 17712 0 208858 0 0 0 A CHEFA SERIES B 060806186 2005-02-01 24800000 CONSTRUCTION OF NEW WING 0 0 0 B CHEFA SERIES C & D 060806186 2007-05-01 23125000 CONSTRUCTION OF NEW CANCER CENTER 0 0 0 A 25769812 24573303 435721 760791 1996 1 0 1 1 B 22982209 1406958 234306 1133492 20207453 2010 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 1 1 WELLS FARGO 30.000000000000 0 0 0 0 0 A 1 B 1 GREGORY BORIS DO TRUSTEE 1345203 GRIFFIN HOSPITAL RETAINED THE SERVICES OF CONNECTICUT EMERGENCY MEDICINE SPECIALISTS TO OVERSEE THE EMERGENCY DEPARTMENT. GREGORY BORIS IS THE DIRECTOR OF THE EMERGENCY DEPARTMENT. 0 DAVID J HENDRICKS MD TRUSTEE 1345203 GRIFFIN HOSPITAL RETAINED THE SERVICES OF CONNECTICUT EMERGENCY MEDICINE SPECIALISTS TO OVERSEE THE EMERGENCY DEPARTMENT. DAVID J. HENDRICKS IS A CONSULTANT FOR CONNECTICUT EMERGENCY MEDICINE SPECIALISTS. 0 FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF TRUSTEES MAKES RECOMMENDATIONS TO THE INCORPORATORS OF THE HOSPITAL REGARDING NOMINATIONS OF MEMBERS OF THE COMMUNITY TO SERVE AS TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED BY MANAGEMENT PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR ALL MEMBERS OF THE HOSPITAL BOARD, OFFICERS, DIRECTORS, AND KEY EMPLOYEES RECEIVE, SIGN, AND SUBMIT A CONFLICT OF INTEREST DISCLOSURE. THE DISCLOSURES ARE REVIEWED BY THE HOSPITAL BOARD AND DOCUMENTED IN THE MINUTES. ANY DISCLOSURE OF A CONFLICT PREVENTS THE INDIVIDUAL FROM INVOLVEMENT WITH OR PARTICIPATION IN SUBJECT MATTER THAN MIGHT AFFECT THE DISCLOSED CONFLICT. ALL CONFLICTS ARE DISCLOSED AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF OFFICERS AND KEY EMPLOYEES ARE REVIEWED ANNUALLY BY THE COMPENSATION COMMITTEE WHICH IS A SUBCOMMITTEE OF THE HOSPITAL BOARD. THIS COMMITTEE SETS THE COMPENSATION FOR THE CEO BASED ON INDUSTRY DATA. COMPENSATION OF OTHER OFFICERS AND DIRECTORS IS SET BY THE CEO BASED ON INDUSTRY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS ARE FILED WITH THE OFFICE OF HEALTH CARE ACCESS AND ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: TRANSFERS BETWEEN AFFILIATES -6,299,917. MINIMUM PENSION LIABILITY ADJUSTMENT -12,041,404. CHANGE IN NET ASSETS OF AFFILIATE 691,232. CHANGE IN BENEFICIAL INTEREST IN TRUSTS -309,944. CHANGE IN FAIR VALUE OF INTEREST RATE SWAPS -2,480,754. FORM 990, PART XII, LINE 2C: THE BOARD OF TRUSTEES IS RESPONSIBLE FOR SELECTING AN INDEPENDENT AUDIT FIRM AND FOR OVERSEEING THE FINANCIAL STATEMENT PREPARATION PROCESS. THERE HAVE BEEN NO CHANGES IN THESE PROCEDURES SINCE THE PRIOR YEAR. GRIFFIN HEALTH SERVICES CORPORATION 130 DIVISION STREET DERBY CT 06418 222560257 HOLDING COMPANY CT 501(C)(3) LINE 11A, I N/A 0 GRIFFIN FACULTY PRACTICE PLAN INC 130 DIVISION STREET DERBY CT 06418 061463147 MEDICAL/EDUCATION CT 501(C)(3) LINE 9 GRIFFIN HOSPITAL 1 GRIFFIN HOSPITAL DEVELOPMENT FUND 130 DIVISION STREET DERBY CT 06418 222560254 FUNDRAISING CT 501(C)(3) LINE 11A, I GRIFFIN HEALTH SERVICES CORPORATION 0 PLANETREE INC 130 DIVISION STREET DERBY CT 06418 061505284 EDUCATION CT 501(C)(3) LINE 9 GRIFFIN HEALTH SERVICES CORPORATION 0 GH VENTURES INC 130 DIVISION STREET DERBY CT 06418 222560247 RENTAL REAL ESTATE CT N/A C 0 HEALTHCARE ALLIANCE INSURANCE CO LTD 171 ELGIN AVENUE GEORGETOWN GRAND CAYMAN CJ OFFSHORE CAPTIVE INSURANCE CJ N/A C 0 CT PRACTICE MANAGEMENT INC 130 DIVISION STREET DERBY CT 06418 061152819 INACTIVE CT N/A C 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 GRIFFIN FACULTY PRACTICE PLAN INC R 5649125