2015-11-15T21:11:09-06:00 2014-12-31 990 2014-01-01 581425000 ADVENTIST HEALTH SYSTEM GEORGIA INC ADVE 7066027800 1035 RED BUD ROAD CALHOUN GA 30701 LYNN C ADDISCOTT ASSISTANT SECRETARY 4079751492 2015-11-15 2014 2016-03-07 17:11:31Z GORDON HOSPITAL PETER WEBER 1035 RED BUD ROAD CALHOUN GA 30701 107817935 0 1071 X WWW.GORDONHOSPITAL.COM X 1981 GA THE PROVISION OF MEDICAL CARE TO THE COMMUNITY THROUGH THE OPERATION OF A 69 BED HOSPITAL. 12 5 1060 75 94588 -10244 101722 66048 98298735 106110999 1676741 1205283 860897 363543 100938095 107745873 120208 128464 0 0 50501286 57871464 0 0 0 40374726 44566822 90996220 102566750 9941875 5179123 158977723 167329643 47553130 50994236 111424593 116335407 ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION AND ALL OF ITS SUBSIDIARY ORGANIZATIONS WERE ESTABLISHED BY THE SEVENTH-DAY ADVENTIST CHURCH TO BRING A MINISTRY OF HEALING AND HEALTH TO THE COMMUNITIES SERVED. OUR MISSION IS TO EXTEND THE HEALING MINISTRY OF CHRIST. 0 0 94870815 128464 106379954 OPERATION OF A 69-BED ACUTE CARE HOSPITAL. THERE WERE 4,032 PATIENT ADMISSIONS DURING THE CURRENT YEAR RESULTING IN 15,630 PATIENT DAYS, AND 71,024 OUTPATIENT VISITS. 94870815 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 121 0 1 1060 1 1 1 0 0 0 0 0 0 0 0 0 X 12 5 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 X CORY REEVES 7066027800 1035 RED BUD ROAD CALHOUN GA 30701 X PETER WEBER CEO/DIR/SECRETARY 50.00 0.00 X X 0 628640 131766 RICHARD REINER CHAIRMAN/DIRECTOR 0.20 50.00 X 0 1629916 134368 BRENT BOX MD DIRECTOR 51.60 0.00 X 370877 0 44214 JEFF BROWN DIRECTOR 0.20 0.00 X 845 0 0 STEVEN FEHLENBERG DIRECTOR (END 12/14) 0.20 0.00 X 774 0 0 JOE JOYAVE MD DIRECTOR (END 12/14) 1.00 0.00 X 4993 0 0 LAVERNE KEIZER MD DIRECTOR (END 12/14) 0.90 0.00 X 4849 0 0 DAVID LANCE DIRECTOR 0.20 0.00 X 993 0 0 PAUL LEBLANC MD DIRECTOR 41.80 0.00 X 246484 0 31532 DEBRA MOYER DIRECTOR 0.20 0.00 X 993 0 0 MAX PARROTT MD DIRECTOR 52.80 0.00 X 298982 0 15289 EDWARD WRIGHT VICE CHAIR/DIRECTOR 0.20 0.00 X 934 950 0 CORY REEVES CFO 50.00 0.00 X 0 269426 52512 AMELIA D JORDON CNO 50.00 0.00 X 0 216714 36571 BRANDON NUDD COO (BEG 5/14) 50.00 0.00 X 0 197789 50126 STEPHEN KING MD PHYSICIAN 41.60 0.00 X 765445 0 42588 DANIEL AHN MD PHYSICIAN 41.60 0.00 X 629025 0 41741 ANDREW HESTER MD PHYSICIAN 41.60 0.00 X 585663 0 38498 CYNTHIA BROWN MD PHYSICIAN 52.10 0.00 X 440373 0 42869 LORIE HUGHES MD PHYSICIAN 41.60 0.00 X 405726 0 33406 CARLENE JAMERSON FORMER CEO 0.00 50.00 X 0 694564 34559 SAM HUENERGARDT FORMER COO 0.00 50.00 X 0 366211 52042 3756956 4004210 782081 61 1 1 0 BRASFIELD & GORRIE LLC 1990 VAUGHN ROAD SUITE 100 KENNESAW GA 301440000 CONSTRUCTION SERVICES 6144262 PT SOLUTIONS HOLDINGS LLC PO BOX 242278 MONTGOMERY AL 361242037 PHYSICAL THERAPY SERVICES 1941836 MEDICAL SERVICES INC PO BOX 22266 CHATTANOOGA TN 37422 BILLING SERVICE 976179 CALHOUN ANESTHESIA PC PO BOX 128 CALHOUN GA 30703 ANESTHESIOLOGY SERVICES 789673 SIEMENS MEDICAL SOLUTIONS 51 VALLEY STEAM PARKWAY MALVERN PA 19355 SERVICE CONTRACT 439640 21 57348 8700 66048 NET PATIENT REVENUE 900099 105152970 105118430 34540 COUNTY SUBSIDY-EMS 621910 293730 293730 CAFETERIA REVENUE 900099 283248 283248 MEDICAL OFFICE BUILDING 531120 277988 277988 SATISFACTION OF PROGRAM RESTRICTI 900099 38547 38547 64516 4468 60048 106110999 938825 938825 233520 105000 0 72062 233520 32938 266458 266458 EHR REVENUE 900099 363543 363543 363543 107745873 106379954 94588 1205283 X 128464 128464 2605303 2605303 41143007 41143007 1215714 1181811 33903 9923020 9635998 287022 2984420 2901030 83390 79132 79132 24302 24302 10975043 8997498 1977545 634476 634476 2448878 1576018 872860 3130205 2727872 402333 3445604 3445604 400881 400881 63675 63675 1236793 1236793 5725238 5725238 1141225 1117461 23764 MEDICAL SUPPLIES 11225966 11225966 REPAIRS & MAINTENANCE 2502756 2502756 GA NET REVENUE TAX 1137544 1137544 PURCHASED SERVICES 69348 69348 325756 187755 138001 102566750 94870815 7695935 0 5451 5650 85231279 81093050 15026031 13922389 1488384 1588314 1860481 1572325 117163811 54529178 51098208 62634633 174349 97871 4093540 6415411 158977723 167329643 6951434 12209271 84635 85678 40517061 38699287 47553130 50994236 X 111384346 116315834 40247 19573 111424593 116335407 158977723 167329643 X 5179123 -277 -268032 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9064 9064 0 PART II-B, LINE 1: MEMBER DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION AND THE GEORGIA HOSPITAL ASSOCIATION THAT REPRESENT LOBBYING ACTIVITIES CONDUCTED BY THESE TWO ASSOCIATIONS. 3290654 3290654 49536859 21124488 28412371 46285194 32765021 13520173 18051104 639669 17411435 62634633 PAYABLE TO THIRD PARTIES 4810476 CREDIT BALANCES IN A/R 569765 INTERCO. ALLOC. OF TE BOND PROCEEDS 32738874 DUE TO RELATED 483159 OTHER CURRENT LIABILITIES 97013 38699287 X PART X, LINE 2: THE FILING ORGANIZATION IS A SUBSIDIARY ORGANIZATION WITHIN ADVENTIST HEALTH SYSTEM (AHS). THE CONSOLIDATED FINANCIAL STATEMENTS OF AHS CONTAIN THE FOLLOWING FIN 48 FOOTNOTE: PLEASE NOTE THAT DOLLAR AMOUNTS ARE IN THOUSANDS. HEALTHCARE CORPORATION AND ITS AFFILIATED ORGANIZATIONS, OTHER THAN NORTH AMERICAN HEALTH SERVICES, INC. AND ITS SUBSIDIARY (NAHS), ARE EXEMPT FROM STATE AND FEDERAL INCOME TAXES. ACCORDINGLY, HEALTHCARE CORPORATION AND ITS TAX-EXEMPT AFFILIATES ARE NOT SUBJECT TO FEDERAL, STATE OR LOCAL INCOME TAXES EXCEPT FOR ANY NET UNRELATED BUSINESS TAXABLE INCOME. NAHS IS A WHOLLY OWNED, FOR-PROFIT SUBSIDIARY OF HEALTHCARE CORPORATION. NAHS AND ITS SUBSIDIARY ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. NAHS FILES A CONSOLIDATED FEDERAL INCOME TAX RETURN AND, WHERE APPROPRIATE, CONSOLIDATED STATE INCOME TAX RETURNS. ALL TAXABLE INCOME WAS FULLY OFFSET BY NET OPERATING LOSS CARRYFORWARDS FOR FEDERAL INCOME TAX PURPOSES; AS SUCH, THERE IS NO PROVISION FOR CURRENT FEDERAL OR STATE INCOME TAX FOR THE YEARS ENDED DECEMBER 31, 2014 AND 2013. NAHS ALSO HAS TEMPORARY DEDUCTIBLE DIFFERENCES OF APPROXIMATELY $63,600 AND $65,000 AT DECEMBER 31, 2014 AND 2013, RESPECTIVELY, PRIMARILY AS A RESULT OF NET OPERATING LOSS CARRYFORWARDS. AT DECEMBER 31, 2014, NAHS HAD NET OPERATING LOSS CARRYFORWARDS OF APPROXIMATELY $63,400, EXPIRING BEGINNING IN 2020 THROUGH 2026. DEFERRED TAXES HAVE BEEN PROVIDED FOR THESE AMOUNTS, RESULTING IN A NET DEFERRED TAX ASSET OF APPROXIMATELY $24,200 AND $24,700 AT DECEMBER 31, 2014 AND 2013, RESPECTIVELY. A FULL VALUATION ALLOWANCE HAS BEEN PROVIDED AT DECEMBER 31, 2014 AND 2013 TO OFFSET THE DEFERRED TAX ASSET SINCE HEALTHCARE CORPORATION HAS DETERMINED THAT IT IS MORE LIKELY THAN NOT THAT THE BENEFIT OF THE NET OPERATING LOSS CARRYFORWARDS WILL NOT BE REALIZED IN FUTURE YEARS. THE INCOME TAXES TOPIC OF THE ASC (ASC 740) PRESCRIBES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAX POSITIONS RECOGNIZED IN FINANCIAL STATEMENTS. ASC 740 PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN, OR EXPECTED TO BE TAKEN, IN A TAX RETURN. THERE WERE NO MATERIAL UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2014 AND 2013. 1 1 X 1 X 0 1 1 0 1 1 7363593 7363593 0.07180 16467297 11875202 4592095 0.04480 23830890 11875202 11955688 0.11660 971817 971817 0.00950 971817 971817 0.00950 24802707 11875202 12927505 0.12610 1 10588421 2161986 23087607 19586311 3501296 X 1 1 1 1 GORDON HOSPITAL 1035 RED BUD ROAD CALHOUN GA 30701 WWW.GORDONHOSPITAL.COM 064-334 X X X ADVENTIST HEALTH SYSTEM GEORGIA INC 1 0 0 1 X X X X X X X X 13 1 0 0 1 X SEE STATEMENT X X 1 14 1 SEE STATEMENT 0 0 1 X 200.000000000000 X X X 1 1 X X X X 1 X X X X X X X X 1 X 0 X X X X 1 X 0 0 ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 5: ADVENTIST HEALTH SYSTEM GEORGIA, INC., DBA GORDON HOSPITAL (GH OR THE HOSPITAL), SERVES GORDON COUNTY RESIDENTS IN NORTHWEST GEORGIA. GH IS A 69-BED COMMUNITY HOSPITAL LOCATED IN CALHOUN, GEORGIA AND IS THE ONLY HOSPITAL LOCATED WITHIN GORDON COUNTY. THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES ALL ZIP CODES WITHIN GORDON COUNTY. THE POPULATION OF GORDON COUNTY IS APPROXIMATELY 55,500 WITH AN AVERAGE PER CAPITA INCOME OF APPROXIMATELY $28,000. IN CONDUCTING ITS 2013 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA), GH SOLICITED INPUT FROM NUMEROUS STAKEHOLDERS FROM THROUGHOUT GORDON COUNTY IN AN EFFORT TO GAIN A THOROUGH UNDERSTANDING OF THE UNIQUE HEALTH NEEDS IN ITS SERVICE AREA. PRIMARY DATA WAS GATHERED THROUGH INTERVIEWS AND SURVEYS. INTERVIEWS WERE CONDUCTED WITH MULTIPLE STAKEHOLDER GROUPS, INCLUDING MEMBERS OF THE GENERAL PUBLIC, RESIDENTS IN FAIRMOUNT GEORGIA, A MEDICALLY UNDERSERVED AREA, SENIOR CITIZENS, SCHOOL NURSES AND INDIVIDUALS UTILIZING THE LOCAL VOLUNTARY ACTION CENTER'S COMMUNITY KITCHEN. THE GENERAL PUBLIC INTERVIEWS WERE CONDUCTED AT SEVERAL RETAIL LOCATIONS WITHIN THE HOSPITAL'S PRIMARY SERVICE AREA WITH THE INTENT TO SOLICIT INPUT FROM ALL SEGMENTS OF THE POPULATION, INCLUDING YOUNG AND OLD AS WELL AS A WIDE RANGE OF ETHNIC AND ECONOMIC GROUPS. ONE OF THE INTERVIEW LOCATIONS WAS IN THE FAIRMOUNT COMMUNITY (A MEDICALLY UNDERSERVED AREA AS NOTED ABOVE). AS A PART OF ITS EFFORTS TO ENSURE BROAD COMMUNITY-BASED INPUT INTO THE CHNA PROCESS, THE HOSPITAL ESTABLISHED A COMMUNITY HEALTH NEEDS ASSESSMENT COMMITTEE (CHNAC). THE CHNAC WAS INTENDED TO REPRESENT THE NEEDS OF THE GENERAL COMMUNITY, WITH A PARTICULAR FOCUS ON INCLUDING REPRESENTATIVES OF THE MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS. COMMITTEE MEMBERS INCLUDED BOTH INTERNAL AND COMMUNITY STAKEHOLDERS. EACH MEMBER BROUGHT A UNIQUE PERSPECTIVE OF THE COMMUNITY, AVAILABLE SERVICES AND EXPERTISE IN THEIR FIELD. COMMUNITY MEMBERS OF THE CHNAC REPRESENTED THE FOLLOWING ORGANIZATIONS: - THE GORDON HOSPITAL AUTHORITY; - THE LOCAL CHAMBER OF COMMERCE; AND - THE GORDON COUNTY HEALTH DEPARTMENT. ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 7D: THE HOSPITAL HAS ADOPTED A POLICY THAT ADDRESSES THE PUBLIC POSTING REQUIREMENTS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT. UNDER THIS POLICY, THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT MUST BE POSTED ON THE HOSPITAL'S WEBSITE BY THE END OF THE YEAR IN WHICH IT IS CONDUCTED. THE HOSPITAL WILL MAKE A COPY OF ITS COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AVAILABLE UPON REQUEST. THE HOSPITAL WILL ALSO MAKE A PAPER COPY OF THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AVAILABLE FOR PUBLIC INSPECTION AT THE HOSPITAL FACILITY. ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 11: PRIORITY 1: CANCER CANCER (INCLUDING ALL TYPES) RANKED NUMBER 1 IN OUR COMMUNITY SURVEY IN GORDON COUNTY. THE STATE OF GEORGIA'S AGE ADJUSTED CANCER DEATHS/100,000 IS 181.8 VS. THE U.S. NATIONAL AVERAGE AT 178.4. THE HEALTHY PEOPLE 2020 GOAL IS 160.6. ALTHOUGH THE LATEST CDC SHOWED THAT GORDON COUNTY'S CANCER RATES HAVE STABILIZED, THEY ARE NOT MEETING MEET THE HP2020 GOALS. THEREFORE, THE NEEDS ASSESSMENT COMMITTEE BELIEVED CANCER TO BE A HIGH PRIORITY FOR OUR COMMUNITY.HOSPITAL INTERVENTIONS INCLUDE: - FREE CANCER SCREENING EVENTS FOR MELANOMA, PROSTATE CANCER, ETC. - CANCER EDUCATION PROGRAM WITH A SPECIAL FOCUS ON UNDERSERVED POPULATIONS - PARTNERSHIP WITH THE HEALTH DEPARTMENT TO OFFER LOW-COST MAMMOGRAMS - PARTNERSHIPS WITH THE NORTHWEST GEORGIA CANCER COALITION AND THE AMERICAN CANCER SOCIETY- THE HOSPITAL'S NEW HARRIS RADIATION THERAPY CENTER.PRIORITY 2: ACCESS TO HEALTH CARETHE SECOND PRIORITY IDENTIFIED BY COMMUNITY FEEDBACK IS THE LACK OF HEALTH CARE AVAILABILITY IN ZIP CODE 30139, WHICH IS THE COMMUNITY OF FAIRMOUNT IN GORDON COUNTY. RECENTLY, A PRIVATELY OWNED CLINIC SHUT ITS DOORS FOR FINANCIAL REASONS AND THE COMMUNITY WAS LEFT WITH NO MEDICAL COVERAGE. THIS AREA IS COMPOSED LARGELY OF SENIORS WHO HAVE LITTLE TO NO PUBLIC TRANSPORTATION, AND MOST PHYSICIANS ARE LOCATED 25-30 MINUTES AWAY. THE NEEDS ASSESSMENT COMMITTEE SAW A NEED TO BRING HEALTH CARE ACCESS TO THAT AREA OF OUR COUNTY. HOSPITAL INTERVENTIONS INCLUDE:- OPEN AN AFFORDABLE PRIMARY CARE CLINIC IN FAIRMOUNT.PRIORITY 3: HEART DISEASE AND STROKE THE THIRD PRIORITY IDENTIFIED BY THE NEEDS ASSESSMENT COMMITTEE WAS HEART DISEASE AND STROKE. CARDIOVASCULAR DISEASE IS THE NUMBER ONE KILLER IN THE STATE OF GEORGIA. FOR GEORGIA, THE AGE-ADJUSTED DEATH RATE PER 100,000 IS 49.7. IT IS 42.2 NATIONALLY, AND THE HEALTHY PEOPLE 2020 GOAL IS 33.8. THIS RANKED VERY HIGH IN OUR SURVEY DATA, AS WELL AS WITHIN OUR LOCAL INDUSTRY SECTOR (MANUFACTURING, HEAVY AND LIGHT INDUSTRY, AND FLOORING PLANTS). EMPLOYEE HEALTH NURSES AT THE VARIOUS PLANTS WERE MORE CONCERNED WITH EMPLOYEES HAVING HEART ATTACKS THAN WITH GETTING HURT ON THE JOB. BY CHOOSING THIS PRIORITY AND FOCUSING ON HEALTHY EATING, WE HOPE TO REDUCE THE INCIDENCE OF OBESITY AND DIABETES FOR OUR COUNTY AS WELL.HOSPITAL INTERVENTIONS INCLUDE:- FREE MONTHLY BLOOD PRESSURE SCREENINGS THROUGHOUT THE COMMUNITY AT LOCATIONS SUCH AS WALMART.- CREATION HEALTH EDUCATIONAL PROGRAMS BASED ON THE TENTS OF CHOICE, REST, ENVIRONMENT, ACTIVITY, TRUST, INTERPERSONAL RELATIONSHIPS, OUTLOOK AND NUTRITION - EDUCATION OF 200 FIFTH-GRADERS IN GORDON COUNTY ON HEALTHY EATING, THE NEED FOR PHYSICAL ACTIVITY, AND THE DANGERS OF TOBACCO - HOST A WEEKLY CREATION HEALTH FARMERS MARKET DURING THE SUMMER. PRIORITY 4: RESPIRATORY DISEASE AND SMOKING THE FINAL PRIORITY THAT THE NEEDS ASSESSMENT COMMITTEE CHOSE IS RESPIRATORY DISEASE AND SMOKING. FROM OUR INTERVIEWS, WE HAVE SEEN AN INCREASE IN TEEN SMOKING, WHICH IN TURNS LEADS TO HIGHER INCIDENCES OF RESPIRATORY DISEASES. THIS PRIORITY EMERGED IN BOTH OUR COMMUNITY SURVEY AS WELL AS OUR INTERNAL DATA. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, GEORGIA'S PERCENTAGE OF SMOKERS IS 17.6%. THE HEALTHY PEOPLE GOAL IS 12%. THE COMMITTEE FELT LIKE THESE TWO ITEMS WERE INTERTWINED AND COULD BE ADDRESSED TOGETHER.HOSPITAL INTERVENTIONS INCLUDE: - INCREASED ENROLLMENT IN FREE BREATHE FREE TOBACCO CESSATION PROGRAM - EDUCATION OF 200 FIFTH-GRADERS ABOUT THE DANGERS OF TOBACCO- PROVIDE LUNG DISEASE/COPD SEMINARS FOR LOW-INCOME POPULATIONS IN GORDON COUNTY - HEALTH EDUCATION IN COOPERATION WITH THE HEALTH DEPARTMENT EDUCATION- EDUCATIONAL PROGRAMS AT THE BOYS AND GIRLS CLUB- SUPPORT OF FAMILY INTERVENTION SPECIALISTS, A COMMUNITY GROUP THAT TALKS TO TEENS ABOUT THE DANGERS OF SMOKING.PRIORITIES CONSIDERED BUT NOT SELECTED SUBSTANCE ABUSE (DRUGS) RANKED HIGH IN OUR COMMUNITY SURVEYS. THE HOSPITAL SUPPORTS EXISTING COMMUNITY PROGRAMS INCLUDING THE DRUGS DON'T WORK PROGRAM, RED RIBBON WEEK, FAMILY INTERVENTION SPECIALISTS, AND DRUG TAKE BACK PROGRAM. WE DO NOT OFFER DRUG REHABILITATION SERVICES BUT CAN HELP COMMUNITY PARTNERS WORK UPSTREAM TO PREVENT OR DECREASE ADDICTIONS.MATERNAL, INFANT AND CHILD HEALTH AND UNPROTECTED SEXUAL ACTIVITY RANKED HIGH IN OUR SURVEY. COMMUNITY PROGRAMS ARE OFFERED THROUGH THE BOYS AND GIRLS CLUB, THE TEEN HEALTH TASK FORCE, AND FAMILY INTERVENTION SPECIALISTS. THE HOSPITAL WORKS WITH THE HEALTHY FAMILIES PROGRAM AFTER A CHILD IS BORN. THIS ISSUE OF UNPROTECTED SEXUAL ACTIVITY IS NOT WITHIN THE HOSPITAL'S AREAS OF EXPERTISE; THE HEALTH DEPARTMENT HANDLES THIS ISSUE. ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 22D: IN DETERMINING THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO FINANCIAL ASSISTANCE POLICY-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE, THE HOSPITAL USED THE FOLLOWING METHODOLOGY IN 2014:THE HOSPITAL IDENTIFIED ALL COMMERCIAL PAYORS THAT HAD ANY ACTIVITY WITH THE HOSPITAL DURING THE TAXABLE YEAR. FOR THOSE IDENTIFIED COMMERCIAL PAYORS, AN AVERAGE OF THE NEGOTIATED COMMERCIAL INSURANCE RATES WAS DETERMINED. THE AVERAGE OF ALL OF THE NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE IDENTIFIED COMMERCIAL PAYORS DETERMINED THE MAXIMUM AMOUNT THAT COULD BE CHARGED TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART V, SECTION B, LINE 7A URL FOR HOSPITAL'S CHNA: WWW.GORDONHOSPITAL.COM/ABOUT-US/COMMUNITY-BENEFIT PART V, SECTION B, LINE 10A URL FOR THE HOSPITAL FACILITY'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY: WWW.GORDONHOSPITAL.COM/ABOUT-US/COMMUNITY-BENEFIT PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 16A WEBSITE: WWW.GORDONHOSPITAL.COM/PATIENTS-VISITORS/AFTER-MY-STAY/FINANCIAL-ASSISTANCE ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 16B WEBSITE: WWW.GORDONHOSPITAL.COM/PATIENTS-VISITORS/AFTER-MY-STAY/FINANCIAL-ASSISTANCE ADVENTIST HEALTH SYSTEM GEORGIA, INC. PART V, SECTION B, LINE 16C WEBSITE: WWW.GORDONHOSPITAL.COM/PATIENTS-VISITORS/AFTER-MY-STAY/FINANCIAL-ASSISTANCE 13 GORDON HOSPITAL INTERNAL & FAMILY MEDICI 400 TIMMS RD CALHOUN GA 30701 PHYSICIAN CLINIC - FAMILY PRACTICE GORDON HOSPITAL OWASA FAMILY MEDICINE 109 HOSPITAL COURT CALHOUN GA 30701 PHYSICIAN CLINIC - FAMILY PRACTICE GORDON HOME CARE 104 HOSPITAL COURT CALHOUN GA 30701 HOME HEALTH SERVICES NORTH GEORGIA ORTHOPEDIC & SPORTS MEDICI 106 HOSPITAL COURT CALHOUN GA 30701 PHYSICIAN CLINIC - ORTHOPEDIC AMBULANCE SERVICE 101 PROFESSIONAL COURT CALHOUN GA 30701 AMBULANCE SERVICE GORDON ADULT & PEDIATRIC MEDICAL ASSOC 815 CURTIS PARKWAY SE CALHOUN GA 30701 PHYSICIAN CLINIC - INTERNAL & PEDIATRIC GORDON URGENT CARE - CALHOUN 100 HOSPITAL COURT CALHOUN GA 30701 PHYSICIAN CLINIC - FAMILY PRACTICE GORDON HEALTH DEPOT 824 GI MADDOX PARKWAY CHATSWORTH GA 30705 PHYSICIAN CLINIC - FAMILY PRACTICE GORDON HOSPITAL ADAIRSVILLE FAMILY MEDIC 6000 JOE FRANK HARRIS PKWY NW ADAIRSVILLE GA 30103 PHYSICIAN CLINIC - FAMILY PRACTICE NORTHWEST GEORGIA OB GYN 110 HOSPITAL COURT CALHOUN GA 30701 PHYSICIAN CLINIC - OB GYN CHATSWORTH CLINIC 1289 GI MADDOX PARKWAY CHATSWORTH GA 30705 PHYSICIAN CLINIC - FAMILY PRACTICE GORDON HOSPITAL FAIRMOUNT FAMILY MEDICIN 2712 HWY 411 FAIRMOUNT GA 30139 PHYSICIAN CLINIC - FAMILY PRACTICE NORTH GEORGIA CANCER CENTER 100 WILLOWBROOK WAY CALHOUN GA 30701 PHYSICIAN CLINIC PART I, LINE 6A: THE FILING ORGANIZATION IS A WHOLLY OWNED SUBSIDIARY OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). AHSSHC SERVES AS A PARENT ORGANIZATION TO 24 TAX-EXEMPT 501(C)(3) HOSPITAL ORGANIZATIONS THAT OPERATE 44 HOSPITALS IN TEN STATES WITHIN THE U.S. THE SYSTEM OF ORGANIZATIONS UNDER THE CONTROL AND OWNERSHIP OF AHSSHC IS KNOWN AS "ADVENTIST HEALTH SYSTEM" (AHS).ALL HOSPITAL ORGANIZATIONS WITHIN AHS COLLECT, CALCULATE, AND REPORT THE COMMUNITY BENEFITS THEY PROVIDE TO THE COMMUNITIES THEY SERVE. AHS ORGANIZATIONS EXIST SOLELY TO IMPROVE AND ENHANCE THE LOCAL COMMUNITIES THEY SERVE. AHS HAS A SYSTEM-WIDE COMMUNITY BENEFITS ACCOUNTING POLICY THAT PROVIDES GUIDELINES FOR ITS HEALTH CARE PROVIDER ORGANIZATIONS TO CAPTURE AND REPORT THE COSTS OF SERVICES PROVIDED TO THE UNDERPRIVILEGED AND TO THE BROADER COMMUNITY. ON AN ANNUAL BASIS, THE COMMUNITY BENEFITS OF ALL AHS ORGANIZATIONS ARE CONSOLIDATED AND REPORTED IN THE AHS ANNUAL REPORT DOCUMENT PREPARED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (EIN 59-2170012). PART I, LINE 7: THE AMOUNTS OF COSTS REPORTED IN THE TABLE IN LINE 7 OF PART I OF SCHEDULE H WERE DETERMINED BY UTILIZING A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, CONTAINED IN THE SCHEDULE H INSTRUCTIONS. PART III, LINE 2: THE AMOUNT OF BAD DEBT EXPENSE, REPORTED ON LINE 2 OF SECTION A OF PART III IS RECORDED IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15. DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS ARE RECORDED AS ADJUSTMENTS TO REVENUE, NOT BAD DEBT EXPENSE. PART III, LINE 3: METHODOLOGY FOR DETERMINING THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE THAT MAY REPRESENT PATIENTS WHO COULD HAVE QUALIFIED UNDER THE FILING ORGANIZATION'S FINANCIAL ASSISTANCE POLICY:SELF-PAY PATIENTS MAY APPLY FOR FINANCIAL ASSISTANCE BY COMPLETING A FINANCIAL ASSISTANCE APPLICATION FORM (FAA FORM). IF AN INDIVIDUAL DOES NOT SUBMIT A COMPLETE FAA FORM WITHIN 240 DAYS AFTER THE FIRST BILLING STATEMENT IS SENT TO THE INDIVIDUAL, AN INDIVIDUAL MAY BE CONSIDERED FOR PRESUMPTIVE ELIGIBILITY BASED UPON A SCORING TOOL THAT IS DESIGNED TO CLASSIFY PATIENTS INTO GROUPS OF VARYING ECONOMIC MEANS. THE SCORING TOOL USES ALGORITHMS THAT INCORPORATE DATA FROM CREDIT BUREAUS, DEMOGRAPHIC DATABASES, AND HOSPITAL SPECIFIC DATA TO INFER AND CLASSIFY PATIENTS INTO RESPECTIVE ECONOMIC MEANS CATEGORIES. INDIVIDUALS WHO EARN A CERTAIN SCORE ON THE SCORING TOOL ARE CONSIDERED TO QUALIFY AS NON-STATE CHARITY PATIENTS. AN AMOUNT UP TO $1,000 OF SUCH A PATIENT'S BILL IS WRITTEN OFF AS BAD DEBT EXPENSE, WHILE THE REMAINING PORTION OF THE PATIENT'S BILL IS CONSIDERED TO BE NON-STATE CHARITY. THE AMOUNT WRITTEN OFF AS BAD DEBT EXPENSE FOR THOSE PATIENTS WHO POTENTIALLY QUALIFY AS NON-STATE CHARITY USING THE SCORING TOOL IS THE AMOUNT SHOWN ON LINE 3 OF SECTION A OF PART III. RATIONALE FOR INCLUDING CERTAIN BAD DEBTS IN COMMUNITY BENEFIT:THE FILING ORGANIZATION IS DEDICATED TO THE VIEW THAT MEDICALLY NECESSARY HEALTH CARE FOR EMERGENCY AND NON-ELECTIVE PATIENTS SHOULD BE ACCESSIBLE TO ALL, REGARDLESS OF AGE, GENDER, GEOGRAPHIC LOCATION, CULTURAL BACKGROUND, PHYSICIAN MOBILITY, OR ABILITY TO PAY. THE FILING ORGANIZATION TREATS EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF THEIR ABILITY TO PAY OR THE AVAILABILITY OF THIRD-PARTY COVERAGE. BY PROVIDING HEALTH CARE TO ALL WHO REQUIRE EMERGENCY OR NON-ELECTIVE CARE IN A NON-DISCRIMINATORY MANNER, THE FILING ORGANIZATION IS PROVIDING HEALTH CARE TO THE BROAD COMMUNITY IT SERVES.AS A 501(C)(3) HOSPITAL ORGANIZATION, THE FILING ORGANIZATION MAINTAINS A 24/7 EMERGENCY ROOM PROVIDING CARE TO ALL WHOM PRESENT. WHEN A PATIENT'S ARRIVAL AND/OR ADMISSION TO THE FACILITY BEGINS WITHIN THE EMERGENCY DEPARTMENT, TRIAGE AND MEDICAL SCREENING ARE ALWAYS COMPLETED PRIOR TO REGISTRATION STAFF PROCEEDING WITH THE DETERMINATION OF A PATIENT'S SOURCE OF PAYMENT. IF THE PATIENT REQUIRES ADMISSION AND CONTINUED NON-ELECTIVE CARE, THE FILING ORGANIZATION PROVIDES THE NECESSARY CARE REGARDLESS OF THE PATIENT'S ABILITY TO PAY. THE FILING ORGANIZATION'S OPERATION OF A 24/7 EMERGENCY DEPARTMENT THAT ACCEPTS ALL INDIVIDUALS IN NEED OF CARE PROMOTES THE HEALTH OF THE COMMUNITY THROUGH THE PROVISION OF CARE TO ALL WHOM PRESENT. CURRENT INTERNAL REVENUE SERVICE GUIDANCE THAT TAX-EXEMPT HOSPITALS MAINTAIN SUCH EMERGENCY ROOMS WAS ESTABLISHED TO ENSURE THAT EMERGENCY CARE WOULD BE PROVIDED TO ALL WITHOUT DISCRIMINATION. THE TREATMENT OF ALL AT THE FILING ORGANIZATION'S EMERGENCY DEPARTMENT IS A COMMUNITY BENEFIT. UNDER THE FILING ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, EVERY EFFORT IS MADE TO OBTAIN A PATIENT'S NECESSARY FINANCIAL INFORMATION TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE. HOWEVER, NOT ALL PATIENTS WILL COOPERATE WITH SUCH EFFORTS AND A FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION CANNOT BE MADE BASED UPON INFORMATION SUPPLIED BY THE INDIVIDUAL. IN THIS CASE, A PATIENT'S PORTION OF A BILL THAT REMAINS UNPAID FOR A CERTAIN STIPULATED TIME PERIOD IS WHOLLY OR PARTIALLY CLASSIFIED AS BAD DEBT. BAD DEBTS ASSOCIATED WITH PATIENTS WHO HAVE RECEIVED CARE THROUGH THE FILING ORGANIZATION'S EMERGENCY DEPARTMENT SHOULD BE CONSIDERED TO BE COMMUNITY BENEFIT AS CHARITABLE HOSPITALS EXIST TO PROVIDE SUCH CARE IN PURSUIT OF THEIR PURPOSE OF MEETING THE NEED FOR EMERGENCY MEDICAL CARE SERVICES AVAILABLE TO ALL IN THE COMMUNITY. PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS:THE FINANCIAL INFORMATION OF THE FILING ORGANIZATION IS INCLUDED IN A CONSOLIDATED AUDITED FINANCIAL STATEMENT FOR THE CURRENT YEAR.THE APPLICABLE FOOTNOTE FROM THE ATTACHED CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ADDRESSES ACCOUNTS RECEIVABLE, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS, AND THE PROVISION FOR BAD DEBTS CAN BE FOUND ON PAGES 7 AND 8. PLEASE NOTE THAT DOLLAR AMOUNTS ON THE ATTACHED CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE IN THOUSANDS. PART III, LINE 8: COSTING METHODOLOGY:MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST-TO-CHARGE RATIO. PART III, LINE 9B: THE HOSPITAL FILING ORGANIZATION'S COLLECTION PRACTICES ARE IN CONFORMITY WITH THE REQUIREMENTS SET FORTH IN THE 2012 PROPOSED REGULATIONS REGARDING THE REQUIREMENTS OF INTERNAL REVENUE CODE SECTION 501(R)(4) - (R)(6). NO EXTRAORDINARY COLLECTION ACTIONS (ECA'S) ARE INITIATED BY THE HOSPITAL FILING ORGANIZATION IN THE 120-DAY PERIOD FOLLOWING THE DATE AFTER THE FIRST BILLING STATEMENT IS SENT TO THE INDIVIDUAL (OR, IF LATER, THE SPECIFIED DEADLINE GIVEN IN A WRITTEN NOTICE OF ACTIONS THAT MAY BE TAKEN, AS DESCRIBED BELOW). INDIVIDUALS ARE PROVIDED WITH AT LEAST ONE WRITTEN NOTICE (NOTICE OF ACTIONS THAT MAY BE TAKEN) THAT INFORMS THE INDIVIDUAL THAT THE HOSPITAL FILING ORGANIZATION MAY TAKE ACTIONS TO REPORT ADVERSE INFORMATION TO CREDIT REPORTING AGENCIES/BUREAUS IF THE INDIVIDUAL DOES NOT SUBMIT A FINANCIAL ASSISTANCE APPLICATION FORM (FAA FORM) OR PAY THE AMOUNT DUE BY A SPECIFIED DEADLINE. THE SPECIFIED DEADLINE IS NOT EARLIER THAT 120 DAYS AFTER THE FIRST BILLING STATEMENT IS SENT TO THE INDIVIDUAL AND IS AT LEAST 30 DAYS AFTER THE NOTICE IS PROVIDED. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FAA FORM DURING THE 240-DAY PERIOD FOLLOWING THE DATE ON WHICH THE FIRST BILLING STATEMENT WAS SENT TO THE INDIVIDUAL, THE HOSPITAL FILING ORGANIZATION SUSPENDS ANY REPORTING TO CONSUMER CREDIT REPORTING AGENCIES/BUREAUS AND PROVIDES A WRITTEN NOTICE TO THE INDIVIDUAL DESCRIBING WHAT ADDITIONAL INFORMATION OR DOCUMENTATION IS NEEDED TO COMPETE THE FAA FORM. THIS WRITTEN NOTICE INCLUDES A COPY OF THE HOSPITAL FILING ORGANIZATION'S PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY (PLS) AND INFORMS THE INDIVIDUAL THAT THE HOSPITAL FILING ORGANIZATION MAY ENGAGE IN ADVERSE REPORTING TO CONSUMER CREDIT REPORTING AGENCIES/BUREAUS IF THE FAA FORM IS NOT COMPLETED BY A SPECIFIED DEADLINE WHICH IS NO EARLIER THAN THE 240-DAY PERIOD FOLLOWING THE DATE ON WHICH THE FIRST BILLING STATEMENT WAS SENT TO THE INDIVIDUAL OR, IF LATER, 30 DAYS AFTER THE WRITTEN NOTICE IS PROVIDED. IF AN INDIVIDUAL SUBMITS A COMPETE FAA FORM WITHIN THE 240-DAY PERIOD AFTER THE FIRST BILLING STATEMENT IS SENT, THE HOSPITAL FILING ORGANIZATION WILL SUSPEND ANY ADVERSE REPORTING TO CONSUMER CREDIT REPORTING AGENCIES/BUREAUS UNTIL A FINANCIAL ASSISTANCE POLICY ELIGIBILITY DETERMINATION CAN BE MADE. SUPPLEMENTAL SCHEDULE TO SCHEDULE H, PART III, SECTION B RECONCILIATION OF SCHEDULE H REPORTED MEDICARE SURPLUS/(SHORTFALL) TO UNREIMBURSED MEDICARE COSTS ASSOCIATED WITH THE PROVISION OF SERVICESTO ALL MEDICARE BENEFICIARIES:THE MEDICARE REVENUE AND ALLOWABLE COSTS OF CARE REPORTED IN SECTION B OF PART III OF SCHEDULE H ARE BASED UPON THE AMOUNTS REPORTED IN THE FILING ORGANIZATION'S MEDICARE COST REPORT IN ACCORDANCE WITH THE IRS INSTRUCTIONS FOR SCHEDULE H. ON AN ANNUAL BASIS, THE FILING ORGANIZATION ALSO DETERMINES ITS TOTAL UNREIMBURSED COSTS ASSOCIATED WITH PROVIDING SERVICES TO ALL MEDICARE PATIENTS. UNREIMBURSED COSTS ARE REPORTED AS A COMMUNITY BENEFIT TO THE ELDERLY AND ARE INCLUDED IN THE CONSOLIDATED ADVENTIST HEALTH SYSTEM (AHS OR THE COMPANY) COMMUNITY BENEFITS REPORT CONTAINED IN THE AHS ANNUAL REPORT DOCUMENT. THE PRIMARY RECONCILING ITEMS BETWEEN THE MEDICARE SURPLUS/(SHORTFALL) SHOWN ON LINE 7 OF SECTION B OF PART III OF SCHEDULE H AND THE FILING ORGANIZATION'S UNREIMBURSED COSTS OF SERVICES PROVIDED TO MEDICARE PATIENTS AS REPORTED IN THE AHS COMMUNITY BENEFIT REPORT ARE AS FOLLOWS:- MEDICARE SURPLUS/(SHORTFALL) SHOWN ON LINE 7 OF SECTION B OF SCHEDULE H: $ 3,501,296- DIFFERENCE IN COSTING METHODOLOGY: (9,556,630)- UNREIMBURSED COSTS INCURRED FOR SERVICES PROVIDED TO MEDICARE PATIENTS THAT ARE NOT INCLUDED IN THE ORGANIZATION'S MEDICARE COST REPORT: (2,335,668) -------------TOTAL SURPLUS/(SHORTFALL) COSTS OF SERVING ALL MEDICARE PATIENTS PER THE FILING ORGANIZATION'S COMMUNITY BENEFIT REPORTING: $(8,391,002)AS INDICATED ABOVE, THE PRIMARY DIFFERENCES BETWEEN THE MEDICARE SURPLUS/(SHORTFALL) REPORTED ON SCHEDULE H, PART III, SECTION B, LINE 7 AND THE FILING ORGANIZATION'S PORTION OF THE COMPANY'S ANNUAL COMMUNITY BENEFIT STATEMENT IS DUE TO A DIFFERENCE IN THE COSTING METHODOLOGY AND DIFFERENCES IN THE POPULATION OF MEDICARE PATIENTS WITHIN THE CALCULATION. THE COST METHODOLOGY UTILIZED IN CALCULATING ANY MEDICARE SURPLUS/(SHORTFALL) FOR PURPOSES OF THE ANNUAL COMMUNITY BENEFIT REPORTING IS BASED UPON THE COST-TO-CHARGE RATIO OUTLINED IN WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. THE SAME COST-TO-CHARGE RATIO IS USED TO DETERMINE THE COSTS ASSOCIATED WITH SERVICES PROVIDED TO CHARITY CARE PATIENTS AND MEDICAID PATIENTS AS REPORTED IN SCHEDULE H, PART I, LINE 7. IN ADDITION, THE MEDICARE COST REPORT EXCLUDES SERVICES PROVIDED TO MEDICARE PATIENTS FOR PHYSICIAN SERVICES, SERVICES PROVIDED TO PATIENTS ENROLLED IN MEDICARE HMOS, AND CERTAIN SERVICES PROVIDED BY OUTPATIENT DEPARTMENTS OF THE FILING ORGANIZATION THAT ARE REIMBURSED ON A FEE SCHEDULE. THE COMPANY'S OWN COMMUNITY BENEFIT STATEMENT CAPTURES THE UNREIMBURSED COST OF PROVIDING SERVICES TO ALL MEDICARE BENEFICIARIES THROUGHOUT THE ORGANIZATION. PART VI, LINE 2: AS REPORTED IN SCHEDULE H, PART V, SECTION B, LINES 1-8, THE HOSPITAL CONDUCTED ITS INITIAL COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) DURING 2013. ITS INITIAL CHNA WAS ADOPTED BY ITS GOVERNING BOARD BY DECEMBER 31, 2013, THE END OF THE HOSPITAL'S TAXABLE YEAR IN WHICH IT CONDUCTED THE CHNA. THE HOSPITAL'S INITIAL CHNA COMPLIED WITH THE GUIDANCE SET FORTH BY THE IRS IN PROPOSED REGULATION SECTION 1.501(R)-3. IN ADDITION TO THE CHNA DISCUSSED ABOVE, A VARIETY OF PRACTICES AND PROCESSES ARE IN PLACE TO ENSURE THAT THE FILING ORGANIZATION IS RESPONSIVE TO THE HEALTH NEEDS OF ITS COMMUNITY.SUCH PRACTICES AND PROCESSES INVOLVE THE FOLLOWING:1. A HOSPITAL OPERATING/COMMUNITY BOARD COMPOSED OF INDIVIDUALS BROADLY REPRESENTATIVE OF THE COMMUNITY, COMMUNITY LEADERS, AND THOSE WITH SPECIALIZED MEDICAL TRAINING AND EXPERTISE;2. POST-DISCHARGE PATIENT FOLLOW-UP RELATED TO THE ON-GOING CARE AND TREATMENT OF PATIENTS WHO SUFFER FROM CHRONIC DISEASES; 3. SPONSORSHIP AND PARTICIPATION IN COMMUNITY HEALTH AND WELLNESS ACTIVITIES THAT REACH A BROAD SPECTRUM OF THE FILING ORGANIZATION'S COMMUNITY; AND 4. COLLABORATION WITH OTHER LOCAL COMMUNITY GROUPS TO ADDRESS THE HEALTH CARE NEEDS OF THE FILING ORGANIZATION'S COMMUNITY. PART VI, LINE 3: THE FINANCIAL ASSISTANCE POLICY (FAP) OF THE FILING ORGANIZATION'S HOSPITAL FACILITY IS TRANSPARENT AND AVAILABLE TO ALL INDIVIDUALS SERVED AT ANY POINT IN THE CARE CONTINUUM. THE FAP, THE FINANCIAL ASSISTANCE APPLICATION FORM (FAA FORM), THE PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY (PLS), AND CONTACT INFORMATION FOR THE HOSPITAL FACILITY'S FINANCIAL COUNSELORS ARE PROMINENTLY AND CONSPICUOUSLY POSTED ON THE FILING ORGANIZATION'S HOSPITAL FACILITY'S WEBSITE. SIGNAGE IS DISPLAYED IN THE FILING ORGANIZATION'S HOSPITAL FACILITY AT ALL POINTS OF ADMISSION AND REGISTRATION, INCLUDING THE EMERGENCY DEPARTMENT. THE SIGNAGE CONTAINS THE HOSPITAL FACILITY'S WEBSITE ADDRESS WHERE THE FAP AND THE FAA FORM CAN BE ACCESSED AND THE TELEPHONE NUMBER AND PHYSICAL LOCATION THAT INDIVIDUALS CAN CALL OR VISIT WITH ANY QUESTIONS ABOUT THE FAP OR THE APPLICATION PROCESS. PAPER COPIES OF THE HOSPITAL FACILITY'S FAP, FAA FORM AND PLS ARE AVAILABLE UPON REQUEST AND WITHOUT CHARGE, BOTH IN PUBLIC LOCATIONS IN THE HOSPITAL FACILITY AND BY MAIL. THE FILING ORGANIZATION'S HOSPITAL FACILITY'S FINANCIAL COUNSELORS SEEK TO PROVIDE PERSONAL FINANCIAL COUNSELING TO ALL INDIVIDUALS ADMITTED TO THE HOSPITAL FACILITY WHO ARE CLASSIFIED AS SELF-PAY DURING THE COURSE OF THEIR HOSPITAL STAY OR AT TIME OF DISCHARGE TO EXPLAIN THE FAP AND FAA FORM AND TO PROVIDE INFORMATION CONCERNING OTHER SOURCES OF ASSISTANCE THAT MAY BE AVAILABLE, SUCH AS MEDICAID. A COPY OF THE HOSPITAL FACILITY'S PLS AND FAA FORM IS DISTRIBUTED TO EVERY INDIVIDUAL BEFORE DISCHARGE FROM THE HOSPITAL FACILITY. ADDITIONALLY, A COPY OF THE PLS IS INCLUDED WITH AT LEAST THREE BILLING STATEMENTS THAT ARE SENT TO THE INDIVIDUAL DURING THE 120-DAY PERIOD AFTER THE FIRST BILLING STATEMENT IS SENT. INDIVIDUALS ARE INFORMED ABOUT THE HOSPITAL FACILITY'S FAP IN ALL ORAL COMMUNICATIONS REGARDING THE AMOUNT DUE FOR THE INDIVIDUAL'S CARE. PART VI, LINE 4: ADVENTIST HEALTH SYSTEM GEORGIA, INC., D/B/A GORDON HOSPITAL (THE HOSPITAL), IS A 69-BED COMMUNITY HOSPITAL THAT SERVES THE RESIDENTS OF CALHOUN, GORDON COUNTY AND SURROUNDING AREAS IN GEORGIA. THE HOSPITAL'S PRIMARY MARKET HAS A POPULATION OF APPROXIAMTELY 55,500, WITH AN ESTIMATED 6,600 OVER THE AGE OF 65. GORDON HOSPITAL PROVIDES THE FOLLOWING SERVICES TO ITS COMMUNITY: A 24-HOUR EMERGENCY CENTER, AMBULANCE SERVICE, REHABILITATION SERVICES, INTENSIVE AND PROGRESSIVE CARE UNITS, CANCER RESOURCE CENTER, RADIOLOGY, INTERVENTIONAL RADIOLOGY, LAB, CARDIOPULMONARY, SLEEP DISORDERS CENTER, NEW BEGINNINGS MATERNITY CENTER, URGENT CARE CENTERS, ORTHOPEDIC SURGERY, OPTHALMOLOGY SURGERY, AND PASTORAL CARE. IN 2009, THE HOSPITAL OPENED A NEW DIAGNOSTIC CARDIAC CATHETERIZATION LAB. THE HOSPITAL IS THE ONLY HOSPITAL IN NORTHWEST GEORGIA TO BE AN ACCREDITED BREAST IMAGING CENTER OF EXCELLENCE. IN NOVEMBER 2012, THE HOSPITAL OPENED A RADIATION ONCOLOGY CENTER THAT FOR THE FIRST TIME PROVIDES THIS SERVICE WITHIN THE COMMUNITY. APPROXIMATELY 4 UNRELATED HOSPITALS ARE EACH ABOUT 20 MILES AWAY FROM GORDON HOSPITAL. THE WEIGHTED AVERAGE HOUSEHOLD INCOME, BASED ON POPULATION, IN THE PRIMARY MARKET IS APPROXIMATELY $41,390. HIGH SCHOOL GRADUATES ACCOUNT FOR APPROXIMATELY 74% OF GORDON COUNTY, WITH AN ESTIMATED 12% HAVING A BACHELOR'S DEGREE OR HIGHER. IT IS ESTIMATED THAT 16% OF THE INDIVIDUALS RESIDING IN GORDON COUNTY LIVE BELOW THE POVERTY LEVEL AND THE UNEMPLOYMENT RATE IS ABOUT 11.5%.APPROXIMATELY 59% OF THE HOSPITAL'S PATIENTS DURING 2014 WERE COVERED BY MEDICARE AND MEDICAID. MEDICARE PATIENTS COMPRISE ABOUT 44% OF THE HOSPITAL'S PATIENTS. APPROXIMATELY 15% OF THE HOSPITAL'S PATIENTS ARE COVERED BY THE MEDICAID PROGRAM, 11% REPRESENTING SELF-PAY, WITH THE REMAINING 30% IN COMMERCIAL PAYORS. APPROXIMATELY 66% OF THE HOSPITAL'S IN-PATIENTS ARE ADMITTED THROUGH THE HOSPITAL'S EMERGENCY DEPARTMENT. PART VI, LINE 5: THE PROVISION OF COMMUNITY BENEFIT IS CENTRAL TO GORDON HOSPITAL'S MISSION OF SERVICE AND COMPASSION. RESTORING AND PROMOTING THE HEALTH AND QUALITY OF LIFE OF THOSE IN THE COMMUNITIES SERVED BY THE HOSPITAL IS A FUNCTION OF "EXTENDING THE HEALING MINISTRY OF CHRIST" AND EMBODIES THE HOSPITAL'S COMMITMENT TO ITS VALUES AND PRINCIPLES. THE HOSPITAL COMMITS SUBSTANTIAL RESOURCES TO PROVIDE A BROAD RANGE OF SERVICES TO BOTH THE UNDERPRIVILEGED AS WELL AS THE BROADER COMMUNITY. IN ADDITION TO THE COMMUNITY BENEFIT INFORMATION PROVIDED IN PARTS I, II AND III OF THIS SCHEDULE H, THE HOSPITAL CAPTURES AND REPORTS THE BENEFITS PROVIDED TO ITS COMMUNITY THROUGH FAITH-BASED CARE. EXAMPLES OF SUCH BENEFITS INCLUDE THE COST ASSOCIATED WITH CHAPLAINCY CARE PROGRAMS AND MISSION PEER REVIEWS AND MISSION CONFERENCES. DURING THE CURRENT YEAR, HOSPITAL PROVIDED $142,587 OF BENEFIT WITH RESPECT TO THE FAITH-BASED AND SPIRITUAL NEEDS OF THE COMMUNITY IN CONJUNCTION WITH ITS OPERATION OF A COMMUNITY HOSPITAL. THE HOSPITAL ALSO PROVIDES BENEFITS TO ITS COMMUNITY'S INFRASTRUCTURE BY INVESTING IN CAPITAL IMPROVEMENTS TO ENSURE THAT FACILITIES AND TECHNOLOGY PROVIDE THE BEST POSSIBLE CARE TO THE COMMUNITY. DURING THE CURRENT YEAR, THE HOSPITAL EXPENDED $17,605,875 IN NEW CAPITAL IMPROVEMENTS. AS A FAITH-BASED MISSION-DRIVEN COMMUNITY HOSPITAL, THE HOSPITAL IS CONTINUALLY INVOLVED IN MONITORING ITS COMMUNITY, IDENTIFYING UNMET HEALTH CARE NEEDS AND DEVELOPING SOLUTIONS AND PROGRAMS TO ADDRESS THOSE NEEDS. IN ACCORDANCE WITH ITS CONSERVATIVE APPROACH TO FISCAL RESPONSIBILITY, SURPLUS FUNDS OF THE HOSPITAL ARE CONTINUALLY BEING INVESTED IN RESOURCES THAT IMPROVE THE AVAILABILITY AND QUALITY OF DELIVERY OF HEALTH CARE SERVICES AND PROGRAMS TO ITS COMMUNITY. PART VI, LINE 6: GORDON HOSPITAL IS A PART OF A FAITH-BASED HEALTHCARE SYSTEM OF ORGANIZATIONS WHOSE PARENT IS ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). THE SYSTEM IS KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). AHSSHC IS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). AHSSHC AND ITS SUBSIDIARY ORGANIZATIONS OPERATE 44 HOSPITALS IN 10 STATES THROUGHOUT THE U.S., PRIMARILY IN THE SOUTHEASTERN PORTION OF THE U.S. AHSSHC AND ITS SUBSIDIARIES ALSO OPERATE 16 NURSING HOME FACILITIES AND OTHER ANCILLARY HEALTH CARE PROVIDER FACILITIES, SUCH AS AMBULATORY SURGERY CENTERS AND DIAGNOSTIC IMAGING CENTERS. AS THE PARENT ORGANIZATION OF THE AHS SYSTEM, AHSSHC PROVIDES EXECUTIVE LEADERSHIP AND OTHER PROFESSIONAL SUPPORT SERVICES TO ITS SUBSIDIARY ORGANIZATIONS. PROFESSIONAL SUPPORT SERVICES INCLUDE AMONG OTHERS CORPORATE COMPLIANCE, LEGAL, HUMAN RESOURCES, REIMBURSEMENT, RISK MANAGEMENT, AND TAX AS WELL AS TREASURY FUNCTIONS. THE PROVISION OF THESE EXECUTIVE AND SUPPORT SERVICES ON A CENTRALIZED BASIS BY AHSSHC PROVIDES AN APPROPRIATE BALANCE BETWEEN PROVIDING EACH AHS SUBSIDIARY HOSPITAL ORGANIZATION WITH MISSION-DRIVEN CONSISTENT LEADERSHIP AND SUPPORT WHILE ALLOWING THE HOSPITAL ORGANIZATION TO FOCUS ITS RESOURCES ON MEETING THE SPECIFIC HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES. THE READER OF THIS FORM 990 SHOULD KEEP IN MIND THAT THIS REPORTING ENTITY MAY DIFFER IN CERTAIN AREAS FROM THAT OF A STAND-ALONE HOSPITAL ORGANIZATION DUE TO ITS INCLUSION IN A LARGER SYSTEM OF HEALTHCARE ORGANIZATIONS. AS A PART OF A SYSTEM OF HOSPITAL AND OTHER HEALTH CARE ORGANIZATIONS, THE FILING ORGANIZATION BENEFITS FROM REDUCED COSTS DUE TO SYSTEM EFFICIENCIES, SUCH AS LARGE GROUP PURCHASING DISCOUNTS, AND THE AVAILABILITY OF INTERNAL RESOURCES SUCH AS INTERNAL LEGAL COUNSEL. EACH AHS SUBSIDIARY PAYS A MANAGEMENT FEE TO AHSSHC FOR THE INTERNAL SERVICES PROVIDED BY AHSSHC. AS A RESULT, MANAGEMENT FEE EXPENSE REPORTED BY A AHS SUBSIDIARY ORGANIZATION MAY APPEAR GREATER IN RELATION TO MANAGEMENT FEE EXPENSE THAT MAY BE REPORTED BY A SINGLE STAND-ALONE HOSPITAL. THE SINGLE STAND-ALONE HOSPITAL WOULD LIKELY REPORT COSTS ASSOCIATED WITH MANAGEMENT AND OTHER PROFESSIONAL SERVICES ON VARIOUS EXPENSE LINE ITEMS IN ITS STATEMENT OF REVENUE AND EXPENSE AS OPPOSED TO REPORTING SUCH COSTS IN ONE OVERALL MANAGEMENT FEE EXPENSE. AS THE REPORTING OF THE FORM 990 IS DONE ON AN ENTITY BY ENTITY BASIS, THERE IS NO SINGLE FORM 990 THAT CAPTURES THE PROGRAMS AND OPERATIONS OF AHS AS A WHOLE. THE READER IS DIRECTED TO VISIT THE WEB-SITE OF AHS AT WWW.ADVENTISTHEALTHSYSTEM.COM TO LEARN MORE ABOUT THE MISSION AND OPERATIONS OF AHS AND TO ACCESS AHS'S ANNUAL REPORT THAT CONTAINS FINANCIAL DATA AS WELL AS COMMUNITY BENEFIT REPORTING FOR THE ENTIRE SYSTEM. PART VI, LINE 7: THE ANNUAL COMMUNITY BENEFIT REPORT CONTAINED IN THE ANNUAL REPORT PREPARED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC) ON BEHALF OF THE ENTIRE AHS SYSTEM OF HEALTHCARE ORGANIZATION IS NOT FILED WITH ANY STATE AGENCIES. 1 SUNSYSTEM DEVELOPMENT CORPORATION DBA GORDON HOSPITAL FOUNDATION 1035 RED BUD ROAD CALHOUN GA 30701 592219301 501(C)(3) 99389 COST GENERAL ADMINISTRATIVE SUPPORT PROVISION OF GENERAL ADMINISTRATIVE SUPPORT NORTHWEST GEORGIA REGIONAL CANCER COALITION 96 E CALLAHAN STREET SUITE 479-01 ROME GA 30161 020657616 501(C)(3) 10000 GENERAL SUPPORT 2 0 PART I, LINE 2: GRANTS ARE GENERALLY MADE ONLY TO RELATED ORGANIZATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3), OR TO OTHER LOCAL CHARITABLE COMMUNITY ORGANIZATIONS, OR TO OTHER 501(C)(3) ORGANIZATIONS THAT ARE A PART OF THE GROUP EXEMPTION RULING ISSUED TO THE GENERAL CONFERENCE OF SEVENTH-DAY ADVENTISTS. ACCORDINGLY, THE FILING ORGANIZATION HAS NOT ESTABLISHED SPECIFIC PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE UNITED STATES AS THE FILING ORGANIZATION DOES NOT HAVE A GRANT MAKING PROGRAM THAT WOULD NECESSITATE SUCH PROCEDURES. X X X X 1 1 0 1 0 0 0 1 0 0 0 PETER WEBER CEO/DIR/SECRETARY 0 418131 0 120789 0 89720 0 73894 0 57872 0 760406 0 47035 RICHARD REINER CHAIRMAN/DIRECTOR 0 939818 0 320728 0 369370 0 14105 0 120263 0 1764284 0 0 BRENT BOX MD DIRECTOR 342518 0 18562 0 9797 0 14105 0 30109 0 415091 0 0 0 PAUL LEBLANC MD DIRECTOR 207600 0 30922 0 7962 0 13174 0 18358 0 278016 0 0 0 MAX PARROTT MD DIRECTOR 285849 0 9191 0 3942 0 14105 0 1184 0 314271 0 0 0 CORY REEVES CFO 0 221693 0 34001 0 13732 0 23587 0 28925 0 321938 0 0 AMELIA D JORDON CNO 0 169983 0 30755 0 15976 0 6802 0 29769 0 253285 0 0 BRANDON NUDD COO (BEG 5/14) 0 147418 0 16948 0 33423 0 6205 0 43921 0 247915 0 0 STEPHEN KING MD PHYSICIAN 756840 0 0 0 8605 0 14105 0 28483 0 808033 0 0 0 DANIEL AHN MD PHYSICIAN 392822 0 217372 0 18831 0 14105 0 27636 0 670766 0 0 0 ANDREW HESTER MD PHYSICIAN 578373 0 0 0 7290 0 8905 0 29593 0 624161 0 0 0 CYNTHIA BROWN MD PHYSICIAN 408694 0 24358 0 7321 0 14105 0 28764 0 483242 0 0 0 LORIE HUGHES MD PHYSICIAN 400224 0 0 0 5502 0 14105 0 19301 0 439132 0 0 0 CARLENE JAMERSON FORMER CEO 0 376012 0 110869 0 207683 0 14105 0 20454 0 729123 0 35172 SAM HUENERGARDT FORMER COO 0 257319 0 57462 0 51430 0 16732 0 35310 0 418253 0 14577 PART I, LINE 1A THE FILING ORGANIZATION IS A PART OF THE SYSTEM OF HEALTHCARE ORGANIZATIONS KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). MEMBERS OF THE FILING ORGANIZATION'S EXECUTIVE MANAGEMENT TEAM THAT HOLD THE POSITION OF VICE-PRESIDENT OR ABOVE ARE COMPENSATED BY AND ON THE PAYROLL OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC), THE PARENT ORGANIZATION OF AHS. AHSSHC IS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). THE FILING ORGANIZATION REIMBURSES AHSSHC FOR THE SALARY AND BENEFIT COST OF THOSE EXECUTIVES ON THE PAYROLL OF AHSSHC THAT PROVIDE SERVICES AND ARE ON THE MANAGEMENT TEAM OF THE FILING ORGANIZATION. TRAVEL FOR COMPANIONS: AHSSHC HAS A CORPORATE EXECUTIVE POLICY THAT PROVIDES A BENEFIT TO ALLOW FOR A TRAVELING AHSSHC EXECUTIVE TO HAVE HIS OR HER SPOUSE ACCOMPANY THE EXECUTIVE ON CERTAIN BUSINESS TRIPS EACH YEAR. TYPICALLY, REIMBURSEMENT IS ONLY PROVIDED TO VICE PRESIDENTS AND ABOVE AND IS USUALLY LIMITED TO ONE BUSINESS TRIP PER YEAR BEYOND THE ANNUAL AHS PRESIDENT'S COUNCIL BUSINESS MEETING AND OTHER MEETINGS WHERE THE SPOUSE IS SPECIFICALLY INVITED. THE AHSSHC CORPORATE EXECUTIVE SPOUSAL TRAVEL POLICY WAS ORIGINALLY APPROVED AND REVIEWED BY THE AHSSHC BOARD COMPENSATION COMMITTEE, AN INDEPENDENT BODY OF THE AHSSHC BOARD OF DIRECTORS. ALL SPOUSAL TRAVEL COSTS REIMBURSED TO THE EXECUTIVE ARE CONSIDERED TAXABLE COMPENSATION TO THE EXECUTIVE. TAX INDEMNIFICATION AND GROSS-UP PAYMENTS: AHS HAS A SYSTEM-WIDE POLICY ADDRESSING GROSS-UP PAYMENTS PROVIDED IN CONNECTION WITH EMPLOYER-PROVIDED BENEFITS/OTHER TAXABLE ITEMS. UNDER THE POLICY, CERTAIN TAXABLE BUSINESS-RELATED REIMBURSEMENTS (I.E. TAXABLE BUSINESS-RELATED MOVING EXPENSES, TAXABLE ITEMS PROVIDED IN CONNECTION WITH EMPLOYMENT) PROVIDED TO ANY EMPLOYEE MAY BE GROSSED-UP AT A 25% RATE UPON APPROVAL OF THE FILING ORGANIZATION'S CEO AND CFO. ADDITIONALLY, EMPLOYEES AT THE DIRECTOR LEVEL AND ABOVE ARE ELIGIBLE FOR GROSS-UP PAYMENTS ON GIFTS RECEIVED FOR BOARD OF DIRECTOR SERVICES. DISCRETIONARY SPENDING ACCOUNT: A NOMINAL DISCRETIONARY SPENDING AMOUNT WAS PROVIDED IN THE CURRENT YEAR TO ALL ELIGIBLE EXECUTIVES WHO ATTEND THE ANNUAL AHS PRESIDENT'S COUNCIL BUSINESS MEETING ($500 PER EXECUTIVE) OR THE ANNUAL AHS CFO CONFERENCE, OR CMO/CNO BUSINESS MEETING ($300 PER EXECUTIVE). OTHER DISCRETIONARY SPENDING ACCOUNTS MAY BE PROVIDED IN CONNECTION WITH OTHER AHS SPONSORED CONFERENCES BUT TYPICALLY DO NOT EXCEED $200 PER PARTICIPANT. WITH RESPECT TO THE AHS PRESIDENT'S COUNCIL MEETING, ELIGIBLE EXECUTIVES MAY INCLUDE AHSSHC VICE PRESIDENTS AND ABOVE AND ALL AHSSHC SUBSIDIARY ORGANIZATION CEOS AND REGIONAL CFOS. THE PAYMENT PROVIDED TO EACH EXECUTIVE WAS CONSIDERED TAXABLE COMPENSATION TO THE EXECUTIVE. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE: AHSSHC HAS A CORPORATE EXECUTIVE POLICY THAT ADDRESSES ASSISTANCE TO EXECUTIVES WHO HAVE BEEN RELOCATED BY THE COMPANY DURING THE YEAR. RELOCATION ASSISTANCE PROVIDED TO EXECUTIVES MAY INCLUDE RELOCATION ALLOWANCES TO ASSIST WITH DUPLICATE HOUSING EXPENSES. RELOCATION ASSISTANCE IS ADMINISTERED PER AHSSHC POLICY BY AN EXTERNAL RELOCATION COMPANY. ANY TAXABLE REIMBURSEMENTS MADE TO EXECUTIVES IN CONNECTION WITH RELOCATION ASSISTANCE ARE TREATED AS WAGES TO THE EXECUTIVE AND ARE SUBJECT TO ALL PAYROLL WITHHOLDING AND REPORTING REQUIREMENTS. PART I, LINE 3 THE INDIVIDUAL WHO SERVES AS THE CEO OF THE FILING ORGANIZATION IS COMPENSATED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC) FOR THAT INDIVIDUAL'S ROLE IN SERVING AS THE CEO. COMPENSATION AND BENEFITS PROVIDED TO THIS INDIVIDUAL ARE DETERMINED PURSUANT TO POLICIES, PROCEDURES, AND PROCESSES OF AHSSHC THAT ARE DESIGNED TO ENSURE COMPLIANCE WITH THE INTERMEDIATE SANCTIONS LAWS AS SET FORTH IN IRC SECTION 4958. AHSSHC HAS TAKEN STEPS TO ENSURE THAT PROCESSES ARE IN PLACE TO SATISFY THE REBUTTABLE PRESUMPTION OF REASONABLENESS STANDARD AS SET FORTH IN TREASURY REGULATION 53.4958-6 WITH RESPECT TO ITS ACTIVE EXECUTIVE-LEVEL POSITIONS. THE AHSSHC BOARD COMPENSATION COMMITTEE (THE COMMITTEE) SERVES AS THE GOVERNING BODY FOR ALL EXECUTIVE COMPENSATION MATTERS. THE COMMITTEE IS COMPOSED OF CERTAIN MEMBERS OF THE BOARD OF DIRECTORS (THE BOARD) OF AHSSHC. VOTING MEMBERS OF THE COMMITTEE INCLUDE ONLY INDIVIDUALS WHO SERVE ON THE BOARD AS INDEPENDENT REPRESENTATIVES OF THE COMMUNITY, WHO HOLD NO EMPLOYMENT POSITIONS WITH AHSSHC AND WHO DO NOT HAVE RELATIONSHIPS WITH ANY OF THE INDIVIDUALS WHOSE COMPENSATION IS UNDER THEIR REVIEW THAT IMPACTS THEIR BEST INDEPENDENT JUDGMENT AS FIDUCIARIES OF AHSSHC. THE COMMITTEE'S ROLE IS TO REVIEW AND APPROVE ALL COMPONENTS OF THE EXECUTIVE COMPENSATION PLAN OF AHSSHC. AS AN INDEPENDENT GOVERNING BODY WITH RESPECT TO EXECUTIVE COMPENSATION, IT SHOULD BE NOTED THAT THE COMMITTEE WILL OFTEN CONFER IN EXECUTIVE SESSIONS ON MATTERS OF COMPENSATION POLICY AND POLICY CHANGES. IN SUCH EXECUTIVE SESSIONS, NO MEMBERS OF MANAGEMENT OF AHSSHC ARE PRESENT. THE COMMITTEE IS ADVISED BY AN INDEPENDENT THIRD PARTY COMPENSATION ADVISOR. THIS ADVISOR PREPARES ALL THE BENCHMARK STUDIES FOR THE COMMITTEE. COMPENSATION LEVELS ARE BENCHMARKED WITH A NATIONAL PEER GROUP OF OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS AND HOSPITALS OF SIMILAR SIZE AND COMPLEXITY TO AHS AND EACH OF ITS AFFILIATED ENTITIES. THE FOLLOWING PRINCIPLES GUIDE THE ESTABLISHMENT OF INDIVIDUAL EXECUTIVE COMPENSATION: - THE SALARY OF THE PRESIDENT/CEO OF AHS WILL NOT EXCEED THE 40TH PERCENTILE OF COMPARABLE SALARIES PAID BY SIMILARLY SITUATED ORGANIZATIONS; AND - OTHER EXECUTIVE SALARIES SHALL BE ESTABLISHED USING MARKET MEDIANS. THE COMPENSATION PHILOSOPHY, POLICIES, AND PRACTICES OF AHSSHC ARE CONSISTENT WITH THE ORGANIZATION'S FAITH-BASED MISSION AND CONFORM TO APPLICABLE LAWS, REGULATIONS, AND BUSINESS PRACTICES. AS A FAITH-BASED ORGANIZATION SPONSORED BY THE SEVENTH-DAY ADVENTIST CHURCH (THE CHURCH), AHSSHC'S PHILOSOPHY AND PRINCIPLES WITH RESPECT TO ITS EXECUTIVE COMPENSATION PRACTICES REFLECT THE CONSERVATIVE APPROACH OF THE CHURCH'S MISSION OF SERVICE AND WERE DEVELOPED IN COUNSEL WITH THE CHURCH'S LEADERSHIP. PART I, LINE 4B AS DISCUSSED IN LINE 1A ABOVE, EXECUTIVES ON THE FILING ORGANIZATION'S MANAGEMENT TEAM THAT HOLD THE POSITION OF VICE-PRESIDENT OR ABOVE ARE COMPENSATED BY AND ON THE PAYROLL OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC), THE PARENT ORGANIZATION OF A HEALTHCARE SYSTEM KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). IN RECOGNITION OF THE CONTRIBUTION THAT EACH EXECUTIVE MAKES TO THE SUCCESS OF AHS, AHS PROVIDES TO ELIGIBLE EXECUTIVES PARTICIPATION IN THE AHS EXECUTIVE FLEX BENEFIT PROGRAM (THE PLAN). THE PURPOSE OF THE PLAN IS TO OFFER ELIGIBLE EXECUTIVES AN OPPORTUNITY TO ELECT FROM AMONG A VARIETY OF SUPPLEMENTAL BENEFITS, INCLUDING DEFERRED COMPENSATION BENEFITS TAXABLE UNDER INTERNAL REVENUE CODE (IRC) SECTION 457(F), TO INDIVIDUALLY TAILOR A BENEFITS PROGRAM APPROPRIATE TO EACH EXECUTIVE'S NEEDS. THE PLAN PROVIDES ELIGIBLE PARTICIPANTS A PRE-DETERMINED BENEFITS ALLOWANCE CREDIT THAT IS EQUAL TO A PERCENTAGE OF THE EXECUTIVE'S BASE PAY FROM WHICH IS DEDUCTED THE COST OF MANDATORY AND ELECTIVE EMPLOYEE BENEFITS. THE PRE-DETERMINED BENEFITS ALLOWANCE CREDIT PERCENTAGE IS APPROVED BY THE AHSSHC BOARD COMPENSATION COMMITTEE, AN INDEPENDENT COMMITTEE OF THE BOARD OF DIRECTORS OF AHSSHC. ANY FUNDS THAT REMAIN AFTER THE COST OF MANDATORY AND ELECTIVE BENEFITS ARE SUBTRACTED FROM THE ANNUAL PRE-DETERMINED BENEFITS ALLOWANCE ARE CONTRIBUTED, AT THE EMPLOYEE'S OPTION, TO EITHER AN IRC 457(F) DEFERRED COMPENSATION ACCOUNT OR TO AN IRC 457(B) ELIGIBLE DEFERRED COMPENSATION PLAN. UPON ATTAINMENT OF AGE 65, ALL PREVIOUS 457(F) DEFERRED AMOUNTS ARE PAID IMMEDIATELY TO THE PARTICIPANT AND ANY FUTURE EMPLOYER CONTRIBUTIONS ARE MADE QUARTERLY FROM THE PLAN DIRECTLY TO THE PARTICIPANT. THE PLAN DOCUMENTS DEFINE AN EMPLOYEE WHO IS ELIGIBLE TO PARTICIPATE IN THE PLAN TO GENERALLY INCLUDE THE CHIEF EXECUTIVE OFFICERS OF AHS ENTITIES AND VICE PRESIDENTS OF ALL AHS ENTITIES WHOSE BASE SALARY IS AT LEAST $224,000. THE PLAN PROVIDES FOR A CLASS YEAR VESTING SCHEDULE (2 YEARS FOR EACH CLASS YEAR) WITH RESPECT TO AMOUNTS ACCUMULATED IN THE EXECUTIVE'S 457(F) DEFERRED COMPENSATION ACCOUNT. DISTRIBUTIONS COULD ALSO BE MADE FROM THE EXECUTIVE'S 457(F) DEFERRED COMPENSATION ACCOUNT UPON ATTAINMENT OF AGE 65 OR UPON AN INVOLUNTARY SEPARATION. THE ACCOUNT IS FORFEITED BY THE EXECUTIVE UPON A VOLUNTARY SEPARATION. IN ADDITION TO THE PLAN, AHS HAS INSTITUTED A DEFINED BENEFIT, NON-TAX-QUALIFIED DEFERRED COMPENSATION PLAN FOR CERTAIN EXECUTIVES WHO HAVE PROVIDED LENGTHY SERVICE TO AHS AND/OR TO OTHER SEVENTH-DAY ADVENTIST CHURCH HOSPITALS OR HEALTH CARE INSTITUTIONS. PARTICIPATION IN THE PLAN IS OFFERED TO AHS EXECUTIVES ON A PRORATA SCHEDULE BEGINNING WITH 20 YEARS OF SERVICE AS AN EMPLOYEE OF AHS AND/OR ANOTHER HOSPITAL OR HEALTH CARE INSTITUTION CONTROLLED BY THE SEVENTH-DAY ADVENTIST CHURCH AND WHO SATISFY CERTAIN OTHER QUALIFYING CRITERIA. THIS SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) WAS DESIGNED TO PROVIDE ELIGIBLE EXECUTIVES WITH THE ECONOMIC EQUIVALENT OF AN ANNUAL INCOME BEGINNING AT NORMAL RETIREMENT AGE EQUAL TO 60% OF THE AVERAGE OF THE PARTICIPANT'S THREE, FIVE OR SEVEN HIGHEST YEARS OF BASE SALARY FROM AHS ACTIVE EMPLOYMENT INCLUSIVE OF INCOME FROM ALL OTHER SEVENTH-DAY ADVENTIST CHURCH HEALTHCARE EMPLOYER-FINANCED RETIREMENT INCOME SOURCES AND INVESTMENT INCOME EARNED ON THOSE CONTRIBUTIONS THROUGH SOCIAL SECURITY NORMAL RETIREMENT AGE AS DEFINED IN THE PLAN. THE NUMBER OF YEARS INCLUDED IN HIGHEST AVERAGE COMPENSATION IS DETERMINED BY THE INDIVIDUAL'S YEAR OF ENTRY TO THE SERP AND BY THE INDIVIDUAL'S YEAR OF ENTRY TO THE AHS EXECUTIVE FLEX BENEFIT PROGRAM. FLEX PLAN FLEX PLAN/ SERP 457(B) CY CY EMPLOYER CY CONTRIB./ DISTRIBUTIONS CONTRIB. DISTRIBUTIONS* PAYMENT ------------------------------------------------------- RICHARD REINER $ 197,083 $ 179,583 $122,669 $ 0 PETER WEBER $ 59,789 $ 63,480 $ 5,908 $ 0 CORY REEVES $ 9,482 $ 0 $ 0 $ 0 CARLENE JAMERSON $ 55,786 $ 38,286 $117,202 $ 0 SAM HUENERGARDT $ 20,127 $ 17,955 $ 0 $ 0 *INCLUDING INVESTMENT EARNINGS PART I, LINE 6 THE FILING ORGANIZATION'S PHYSICIAN COMPENSATION FORMULA IS DESIGNED TO RESULT IN TOTAL COMPENSATION THAT WOULD BE REASONABLE FOR EACH PHYSICIAN. THE FILING ORGANIZATION UTILIZES NATIONAL SURVEY PRODUCTIVITY, COST, AND COMPENSATION DATA IN FORMULATING ALL ASPECTS OF THE COMPENSATION PLAN. PHYSICIAN COMPENSATION CONTRACTUAL AGREEMENTS INCLUDE A CEILING OR REASONABLE MAXIMUM ON THE AMOUNT A PHYSICIAN MAY EARN. THE FILING ORGANIZATION'S EMPLOYED PHYSICIANS ENTER INTO A WRITTEN AGREEMENT THAT REQUIRES THE PHYSICIANS TO PROVIDE MEDICAL CARE TO INDIVIDUALS WHO ARE REFERRED BY THE FILING ORGANIZATION. THE FILING ORGANIZATION'S COMPENSATION ARRANGEMENT DOES NOT USE A METHOD OF COMPENSATION THAT IS BASED UPON A PERCENTAGE OF THE ORGANIZATION'S NET INCOME. UNDER THE COMPENSATION ARRANGEMENT, PHYSICIAN BASE SALARY, INCLUDING ANY ADDITIONAL COMPENSATION BASED ON A PERCENTAGE OF THE PRACTICE/LOCATION NET REVENUE, IS DOCUMENTED AS BEING WITHIN A RANGE OF FAIR MARKET VALUE. JUDY FEHLENBERG SPOUSE OF BOARD MEMBER 24254 EMPLOYEE COMPENSATION 0 NORTHWEST GEORGIA SURGICAL ASSOCIATES PC 33% OWNED BY BOARD MEMBER FAMILY MEMBER 396000 CONTRACTED ON-CALL SERVICES 0 CALHOUN ANESTHESIA PC 33% OWNED BY BOARD MEMBER 789673 PROFESSIONAL SERVICE AGREEMENT 0 JEMGLEN LLLP 50% OWNED BY BOARD MEMBER 256534 LEASE AGREEMENT 0 NORTHWEST GEORGIA MEDICAL PARK LLC 45% OWNED BY BOARD MEMBERS 611204 LEASE AGREEMENT 0 FORM 990, PART VI, SECTION A, LINE 2 BRENT BOX AND MAX PARROTT - BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 ADVENTIST HEALTH SYSTEM GEORGIA, INC. (THE FILING ORGANIZATION) HAS ONE MEMBER. THE SOLE MEMBER OF THE FILING ORGANIZATION IS ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION. ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC) IS A FLORIDA, NOT-FOR-PROFIT CORPORATION THAT IS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). THERE ARE NO OTHER CLASSES OF MEMBERSHIP IN THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER OF THE FILING ORGANIZATION IS AHSSHC. THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION ARE APPOINTED BY THE SOLE MEMBER, AHSSHC, WHO HAS THE RIGHT TO ELECT, APPOINT OR REMOVE ANY MEMBER OF THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B AHSSHC, AS THE SOLE MEMBER OF THE FILING ORGANIZATION, HAS CERTAIN RESERVED POWERS AS SET FORTH IN THE BYLAWS OF THE FILING ORGANIZATION. THESE RESERVED POWERS INCLUDE THE FOLLOWING: A) TO APPROVE AND DISAPPROVE THE EXECUTIVE AND/OR ADMINISTRATIVE LEADERSHIP OF THE FILING ORGANIZATION, AND THEIR SALARIES; B) TO ADOPT, AMEND, RESTATE, AND REPEAL THE ARTICLES OF INCORPORATION OR BYLAWS OF THE FILING ORGANIZATION, AND THE MEDICAL STAFF BYLAWS; C) TO SET LIMITS AND TERMS FOR THE BORROWING OF FUNDS; D) TO APPROVE OR DISAPPROVE MAJOR BUILDING PROGRAMS AND/OR PURCHASE OR SALE OF PERSONAL PROPERTY OR REAL PROPERTY EQUAL TO OR IN EXCESS OF ONE MILLION DOLLARS; E) TO APPROVE OR DISAPPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS OF THE FILING ORGANIZATION; F) TO DIRECT THE PLACEMENT OF FUNDS AND CAPITAL OF THE FILING ORGANIZATION; G) TO ESTABLISH GENERAL GUIDING POLICIES, TO IMPLEMENT QUALITY ASSESSMENT, IMPROVEMENT AND UTILIZATION REVIEW PROGRAMS; H) TO APPROVE THE APPOINTMENT OF AN AUDITING FIRM AND ELECTION OF THE FISCAL YEAR FOR THE FILING ORGANIZATION; AND I) TO ESTABLISH A PROCESS FOR ADDRESSING PATIENT GRIEVANCES. FORM 990, PART VI, SECTION B, LINE 11 THE FILING ORGANIZATION'S CURRENT YEAR FORM 990 WAS REVIEWED BY THE BOARD CHAIRMAN, BOARD FINANCE COMMITTEE CHAIR, CEO AND BY THE CFO PRIOR TO ITS FILING WITH THE IRS. THE REVIEW CONDUCTED BY THE BOARD CHAIRMAN, BOARD FINANCE COMMITTEE CHAIR, CEO AND THE CFO DID NOT INCLUDE THE REVIEW OF ANY SUPPORTING WORKPAPERS THAT WERE USED IN PREPARATION OF THE CURRENT YEAR FORM 990, BUT DID INCLUDE A REVIEW OF THE ENTIRE FORM 990 AND ALL SUPPORTING SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY OF THE FILING ORGANIZATION APPLIES TO MEMBERS OF ITS BOARD OF DIRECTORS AND ITS PRINCIPAL OFFICERS (TO BE KNOWN AS INTERESTED PERSONS). IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTERESTS, ANY MEMBER OF THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION OR ANY PRINCIPAL OFFICER OF THE FILING ORGANIZATION (I.E. INTERESTED PERSONS) MUST DISCLOSE THE EXISTENCE OF ANY FINANCIAL INTEREST WITH THE FILING ORGANIZATION AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS CONCERNING THE FINANCIAL INTEREST/ARRANGEMENT TO THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION OR TO ANY MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS THAT IS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. SUBSEQUENT TO ANY DISCLOSURE OF ANY FINANCIAL INTEREST/ARRANGEMENT AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE RELEVANT BOARD MEMBER OR PRINCIPAL OFFICER, THE REMAINING MEMBERS OF THE BOARD OF DIRECTORS OR COMMITTEE WITH BOARD DELEGATED POWERS SHALL DISCUSS, ANALYZE, AND VOTE UPON THE POTENTIAL FINANCIAL INTEREST/ARRANGEMENT TO DETERMINE IF A CONFLICT OF INTEREST EXISTS. ACCORDING TO THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY, AN INTERESTED PERSON MAY MAKE A PRESENTATION TO THE BOARD OF DIRECTORS (OR COMMITTEE WITH BOARD DELEGATED POWERS), BUT AFTER SUCH PRESENTATION, SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN A CONFLICT OF INTEREST. EACH INTERESTED PERSON, AS DEFINED UNDER THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY, SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTERESTS POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE FILING ORGANIZATION IS A CHARITABLE ORGANIZATION THAT MUST PRIMARILY ENGAGE IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS EXEMPT PURPOSES. THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY ALSO REQUIRES THAT PERIODIC REVIEWS SHALL BE CONDUCTED TO ENSURE THAT THE FILING ORGANIZATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES. FORM 990, PART VI, SECTION B, LINE 15 THE FILING ORGANIZATION'S CEO, OTHER OFFICERS AND KEY EMPLOYEES ARE NOT COMPENSATED BY THE FILING ORGANIZATION. SUCH INDIVIDUALS ARE COMPENSATED BY THE RELATED TOP-TIER PARENT ORGANIZATION OF THE FILING ORGANIZATION. PLEASE SEE THE DISCUSSION CONCERNING THE PROCESS FOLLOWED BY THE RELATED TOP-TIER PARENT ORGANIZATION IN DETERMINING EXECUTIVE COMPENSATION IN OUR RESPONSE TO SCHEDULE J, LINE 3. FORM 990, PART VI, SECTION C, LINE 19 THE FILING ORGANIZATION IS A PART OF THE SYSTEM OF HEALTHCARE ORGANIZATIONS KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). EACH YEAR, AHS PUBLISHES AN ANNUAL REPORT DOCUMENT THAT INCLUDES A FINANCIAL REPORT FOR THE RELEVANT YEAR AS WELL AS A COMMUNITY BENEFIT REPORT. THE FINANCIAL REPORT AND COMMUNITY BENEFIT REPORT ARE PRESENTED ON A CONSOLIDATED BASIS AND REPRESENT ALL OF THE ACTIVITIES, RESULTS OF OPERATIONS, AND FINANCIAL POSITION AT YEAR-END OF THE ENTIRE AHS SYSTEM. IN ADDITION, THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS OF AHS AND OF THE AHS "OBLIGATED GROUP" ARE FILED ANNUALLY WITH THE MUNICIPAL SECURITIES RULEMAKING BOARD (MSRB). THE "OBLIGATED GROUP" IS A GROUP OF AHSSHC SUBSIDIARIES THAT ARE JOINTLY AND SEVERALLY LIABLE UNDER A MASTER TRUST INDENTURE THAT SECURES DEBT PRIMARILY ISSUED ON A TAX-EXEMPT BASIS. UNAUDITED QUARTERLY FINANCIAL STATEMENTS PREPARED IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP) ARE ALSO FILED WITH MSRB FOR AHS ON A CONSOLIDATED BASIS AND FOR THE GROUPING OF AHS SUBSIDIARIES COMPRISING THE "OBLIGATED GROUP". THE FILING ORGANIZATION DOES NOT GENERALLY MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. PART VII, SECTION A FOR THOSE BOARD OF DIRECTOR MEMBERS WHO DEVOTE LESS THAN FULL-TIME TO THE FILING ORGANIZATION (BASED UPON THE AVERAGE NUMBER OF HOURS PER WEEK SHOWN IN COLUMN (B) ON PAGE 7 OF THE RETURN) THE COMPENSATION AMOUNTS SHOWN IN COLUMNS (E) AND (F) ON PAGE 7 WERE PROVIDED IN CONJUNCTION WITH THAT PERSON'S RESPONSIBILITIES AND ROLES IN SERVING IN AN EXECUTIVE LEADERSHIP POSITION WITHIN ADVENTIST HEALTH SYSTEM. FORM 990, PART IX, LINE 11G PAYMENTS TO HEALTHCARE PROFESSIONALS : PROGRAM SERVICE EXPENSES 1,584,621. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,584,621. PROFESSIONAL FEES : PROGRAM SERVICE EXPENSES 5,223,123. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,223,123. PURCHASED MEDICAL SERVICES : PROGRAM SERVICE EXPENSES 1,316,466. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,316,466. ENVIRONMENTAL SERVICES : PROGRAM SERVICE EXPENSES 702,344. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 702,344. RECRUITING : PROGRAM SERVICE EXPENSES 27,435. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 27,435. TRANSCRIPTION SERVICES : PROGRAM SERVICE EXPENSES 143,509. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 143,509. AHS MANAGEMENT FEES : PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 899,152. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 899,152. BILLING & COLLECTION SERVICES : PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 857,955. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 857,955. EHR MANAGEMENT FEES : PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 220,438. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 220,438. FORM 990, PART XI, LINE 9: TEMPORARILY RESTRICTED NET GIFTS 443,250. TRANSFER TO TAX-EXEMPT PARENT -739,132. ALLOCATION FROM TAX-EXEMPT PARENT WITH RESPECT TO DEBT 119,522. TRANSFER TO TAX-EXEMPT RELATED ORGANIZATION -91,671. ROUNDING -1. PART X, LINE 2 THE AMOUNTS SHOWN ON LINE 2 OF PART X OF THIS RETURN INCLUDE THE FILING ORGANIZATION'S INTEREST IN A CENTRAL INVESTMENT POOL MAINTAINED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION, THE FILING ORGANIZATION'S TOP-TIER PARENT. THE INVESTMENTS IN THE CENTRAL INVESTMENT POOL ARE RECORDED AT MARKET VALUE. ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL 60440 651219504 OPERATION OF HOSPITAL & RELATED SERVICES IL 501(C)(3) LINE 3 ADVENTIST HLTH SYSTEMSUNBELT INC 1 ADVENTIST CARE CENTERS - COURTLAND INC 730 COURTLAND STREET ORLANDO FL 32804 205774723 OPERATION OF HOME FOR THE AGED/HLTHCARE DELIVERY FL 501(C)(3) LINE 9 SUNBELT HLTH CARE CENTERS INC 1 ADVENTIST GLENOAKS HOSPITAL 701 WINTHROP AVENUE GLENDALE HEIGHTS IL 60139 363208390 OPERATION OF HOSPITAL & RELATED SERVICES IL 501(C)(3) LINE 3 ADVENTIST HLTH SYSTEMSUNBELT INC 1 ADVENTIST HLTH MID-AMERICA INC 9100 W 74TH STREET SHAWNEE MISSION KS 66204 521347407 HLTHCARE RELATED SERVICES KS 501(C)(3) LINE 11A, I ADVENTIST HLTH SYSTEMSUNBELT INC 1 ADVENTIST HLTH PARTNERS INC 1000 REMINGTON BLVD STE 200 BOLINGBROOK IL 60440 364138353 OPERATE OUT-PATIENT PHYSICIAN CLINICS IL 501(C)(3) LINE 3 AHS MIDWEST MANAGEMENT INC 1 ADVENTIST HLTH SYSTEM SUNBELT HLTHCARE CORP 900 HOPE WAY ALTAMONTE SPRINGS FL 32714 592170012 MANAGEMENT SERVICES FL 501(C)(3) LINE 11A, I N/A 0 ADVENTIST HLTH SYSTEM GEORGIA INC 1035 RED BUD ROAD CALHOUN GA 30701 581425000 OPERATION OF HOSPITAL & RELATED SERVICES GA 501(C)(3) LINE 3 ADVENTIST HLTH SYSTEM SUNBELT HLTHCARE CORP 1 ADVENTIST HLTH SYSTEMSUNBELT INC 900 HOPE WAY ALTAMONTE SPRINGS FL 32714 591479658 OPERATION OF HOSPITAL & RELATED SERVICES FL 501(C)(3) LINE 3 ADVENTIST HLTH SYSTEM SUNBELT HLTHCARE CORP 1 ADVENTIST HLTH SYSTEMTEXAS INC 11801 S FREEWAY BURLESON TX 36028 742578952 LEASING PERSONNEL TO AFFILIATED HOSPITAL TX 501(C)(3) LINE 11C, III-FI ADVENTIST HLTH SYSTEM SUNBELT HLTHCARE CORP 1 ADVENTIST HINSDALE HOSPITAL 120 NORTH OAK STREET HINSDALE IL 60521 362276984 OPERATION OF HOSPITAL & RELATED SERVICES IL 501(C)(3) LINE 3 ADVENTIST HLTH SYSTEMSUNBELT INC 1 ADVENTIST UNIVERSITY OF HEALTH SCIENCES INC (630 YEAR END) 671 LAKE WINYAH DRIVE ORLANDO FL 32803 593069793 EDUCATION/OPERATION OF SCHOOL FL 501(C)(3) LINE 2 ADVENTIST HLTH SYSTEMSUNBELT INC 1 AHS MIDWEST MANAGEMENT INC 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