2015-11-16T08:53:05-06:00 2014-12-31 990 2014-01-01 560928089 FORSYTH MEMORIAL HOSPITAL FORS 3367182803 2085 FRONTIS PLAZA BLVD WINSTON SALEM NC 27103 FRED HARGETT EVP & CFO 3367182803 2015-11-16 2014 2016-02-25 16:41:14Z NOVANT HEALTH FORSYTH MEDICAL CENTER DENISE MIHAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM NC 27103 1137028290 0 X WWW.NOVANTHEALTH.ORG X 1968 NC SEE SCHEDULE O 17 14 7792 846 387350 77115 2469354 4298738 1004595686 1050066874 465186 -192327 67719651 82287326 1075249877 1136460611 639957 807960 0 0 444745702 455928431 0 0 0 550050833 604755786 995436492 1061492177 79813385 74968434 1060812977 1133278673 54559584 60201980 1006253393 1073076693 X SEE SCHEDULE O 0 0 863351155 807960 1124767038 FORSYTH MEMORIAL HOSPITAL, INC. (FMH), KERNERSVILLE MEDICAL CENTER (KMC), AND CLEMMONS MEDICAL CENTER (CMC) CARRY OUT THE PURPOSE OF THE FORSYTH COUNTY BOARD OF COMMISSIONERS BY ADVANCING AND SUPPORTING THE PROMOTION OF THE HEALTH OF THE INHABITANTS OF FORSYTH COUNTY AND THE KERNERSVILLE AREA OF NC. FMH, KMC, AND CMC MAINTAIN AN OPEN DOOR POLICY, ACCEPTING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. FMH HAS 921 LICENSED BEDS. DURING 2014 THERE WERE 225,044 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 6 DAYS, AN AVERAGE DAILY CENSUS OF 617, AND 40,240 DISCHARGES. THERE WERE 24,624 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 1,021,842 OUTPATIENT ENCOUNTERS AND 89,309 EMERGENCY DEPARTMENT VISITS. (CONTINUED ON SCHEDULE O) 863351155 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 1 0 0 1 0 0 1 0 0 1 1 1 1 0 0 1 2 0 1 7792 1 1 1 0 0 0 0 1 1 0 0 0 0 X 17 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 NC X X KAREN DAUGHERTY 3367182803 2085 FRONTIS PLAZA BLVD WINSTON SALEM NC 27103 X BAREFOOT SAMUEL TRUSTEE 2.00 X 0 0 0 CARROLL JOE TRUSTEE 2.00 X 0 0 0 EARNHARDT HAROLD TRUSTEE 2.00 X 0 0 0 EDWARDS JOEL TRUSTEE 2.00 X 527528 0 75061 ELY JOSEPH VICE CHAIR 2.00 X X 0 0 0 FORIEST BRYANT TRUSTEE 2.00 X 0 0 0 GREEN GARY SEC/TREAS 2.00 X X 0 0 0 HAULSEE HADA DE VARONA CHAIR 2.00 X X 0 0 0 HAUSER CHARLES TRUSTEE 2.00 X 0 0 0 HICKMAN TOMMY TRUSTEE 2.00 X 0 0 0 JOHNSON JOIA TRUSTEE 2.00 X 0 0 0 LAMBE CLARENCE TRUSTEE 2.00 X 0 0 0 MCNEIL-MILLER KAREN TRUSTEE 2.00 X 0 0 0 POLLARD III HAROLD TRUSTEE 2.00 X 0 0 0 POLONSKY SHERRY TRUSTEE 2.00 X 0 0 0 WOLFE III JOHN TRUSTEE 2.00 X 0 0 0 ALLEN JOANNE PRESIDENT KMC 60.00 X 250663 0 61210 LINDSAY JEFFERY FMR PRES FMC/ COO WS MKT 60.00 X 1226070 0 83818 MIHAL DENISE PRES FMC/ COO WS MKT 60.00 X 872519 0 76136 MORRIS JOHN ASST SEC 2.00 X 0 322754 76309 GREGORY CHERE SVP WOMEN'S SERVICES 60.00 X 16207 406750 107677 JARRETT-PULLIAM KIMBERLY CNO 60.00 X 261748 0 45401 LARSON KIP FORMER VP & SR MED DIR SPECIALTY SERV 60.00 X 436120 0 69406 NYCUM LAWRENCE SVP MEDICAL AFFAIRS 60.00 X 628222 0 120689 SANZ SEAN SVP & COO NHFMC 60.00 X 294938 0 91000 WALLEY BRUCE FORMER SVP MEDICAL AFFAIRS 60.00 X 675341 0 56619 CHEN FRANKLIN ONCOLOGIST 40.00 X 731217 0 95952 CHRYSSON NICK ONCOLOGIST 40.00 X 844637 0 102481 COLLINS TIMOTHY ONCOLOGIST 40.00 X 700346 0 93632 GROTE THOMAS ONCOLOGIST 40.00 X 862750 0 77016 PASCHOLD EUGENE ONCOLOGIST 40.00 X 723941 0 91334 MCGEE LAWRENCE FORMER ASST SEC 0.00 X 0 348935 0 9052247 1078439 1323741 391 1 1 0 CROTHALL HEALTH CARE INC 955 CHESTERBROOK BLVD S300 WAYNE PA 19087 FACILITY SERVICES 11437741 LABORATORY CORPORATION OF AMERICA HOLDIN PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 9860429 MORRISON MANAGEMENT SPECIALIST PO BOX 102289 ATLANTA GA 30368 FOOD MANAGEMENT SERVICES 9256419 CROSS COUNTRY STAFFING PO BOX 404674 ATLANTA GA 30384 STAFFING SERVICES 5568353 SALEM CHEST SPECIALISTS 3001 LYNDHURST AVENUE WINSTON SALEM NC 27103 HEALTH SERVICES 4918188 81 2574510 1476688 247540 7666 4298738 NET PATIENT REVENUE 622110 1050066874 1050066874 1050066874 313809 313809 2477824 0 2477824 2477824 2477824 61543 567679 -506136 -506136 -506136 PHARMACY 446110 65506353 65129457 376896 MISCELLANEOUS REVENUE 621999 8546980 8536526 10454 CAFETERIA MEALS 722514 3437629 3437629 2318540 1034181 1284359 79809502 1136460611 1124767038 387350 7007485 724877 724877 83083 83083 5869024 5869024 114696 114696 357846152 342422983 15423169 14320067 13702872 617195 53473143 51168451 2304692 24305349 23257788 1047561 2418787 2418787 600 600 3292 3292 89702274 75103059 14599215 2774016 2654456 119560 5958407 5701600 256807 8191740 7838676 353064 28978913 27729922 1248991 1084035 1037313 46722 326346 312280 14066 20204825 19333997 870828 22289184 21328520 960664 2111127 2020137 90990 CORPORATE ALLOCATION 150609616 150609616 DRUGS 101089993 101089993 UBI TAXES 32287 32287 MEDICAL SUPPLIES 98361164 98361164 70619180 69479984 1139196 1061492177 863351155 198141022 0 2589293 648893 111373192 122188230 87500 20 7887194 8389746 18536721 19779811 957274 365167 446743889 272156317 176162050 174587572 31015047 31015047 712204706 776304187 1060812977 1133278673 52210666 57773208 162314 265686 2186604 2163086 54559584 60201980 X 1006253393 1073076693 1006253393 1073076693 1060812977 1133278673 X 74968434 -8145134 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 53200 53200 0 PART II-B, LINE 1I, LOBBYING ACTIVITIES: DUES PAID TO CERTAIN ORGANIZATIONS WHICH INCLUDE A PORTION RELATED TO LOBBYING ACTIVITIES. 6278279 6278279 101427192 13152321 88274871 9803011 6128903 3674108 296347072 241449735 54897337 32888335 11425358 21462977 174587572 DUE FROM AFFILIATE 776303645 STATE INCOME TAX RECEIVABLE 542 776304187 1049 CAPITAL LEASE PAYABLE 57863 THIRD PARTY PAYMENT ADJUSTMENTS 2104174 2163086 X PART X, LINE 2: PART X, LINE 2: LIABILITY UNDER FIN 48 (ASC 740) FOOTNOTE THE AUDIT FOR NOVANT HEALTH AND ITS AFFILIATES IS PREPARED ON A CONSOLIDATED BASIS. THE COMPANY IS REQUIRED TO EVALUATE UNCERTAIN TAX POSITIONS. THIS EVALUATION INCLUDES A QUANTIFICATION OF TAX RISK IN AREAS SUCH AS UNRELATED BUSINESS TAXABLE INCOME AND THE TAXATION OF OUR FOR-PROFIT SUBSIDIARIES. THIS EVALUATION DID NOT HAVE A MATERIAL EFFECT ON THE COMPANY'S CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS FOR THE YEARS ENDED DECEMBER 31, 2014 AND 2013. 1 1 X 1 X 300.000000000000 0 0 1 1 0 1 1 42518772 0 42518772 0.04180 128331873 102421273 25910600 0.02550 0 0 0 0.00000 170850645 102421273 68429372 0.06730 1041060 44942 996118 0.00100 3670893 881411 2789482 0.00270 44427407 30447572 13979835 0.01370 2094840 967233 1127607 0.00110 634049 0 634049 0.00060 51868249 32341158 19527091 0.01910 222718894 134762431 87956463 0.08640 0 0 0 0.00000 93796 0 93796 0.00010 77217 0 77217 0.00010 0 0 0 0.00000 3000 0 3000 0.00000 0 0 0 0.00000 0 0 0 0.00000 23000 0 23000 0.00000 0 0 0 0.00000 197013 0 197013 0.00020 1 44187769 0 173442148 176174729 -2732581 X 1 0 3 1 FMH DBA NH FORSYTH MEDICAL CENTER 3333 SILAS CREEK PARKWAY WINSTON SALEM NC 27103 WWW.NOVANTHEALTH.ORG H0209 X X X 2 FMH DBA NH KERNERSVILLE MEDICAL CENTER 1750 KERNERSVILLE MEDICAL PARKWAY KERNERSVILLE NC 27284 WWW.NOVANTHEALTH.ORG H0209 X X X 3 FMH DBA NH CLEMMONS MEDICAL CENTER 6915 VILLAGE MEDICAL CIRCLE CLEMMONS NC 27012 WWW.NOVANTHEALTH.ORG H0209 X X NH FORSYTH MEDICAL CENTER 1 0 0 1 X X X X X X 13 1 0 0 1 X WWW.NOVANTHEALTH.ORG 1 13 1 WWW.NOVANTHEALTH.ORG 0 0 1 X 300.000000000000 X X X X 0 1 X X X 1 X X X X X X X X 1 X 0 X X X X 1 X 0 0 NH KERNERSVILLE MEDICAL CENTER 2 0 0 1 X X X X X X 13 1 0 0 1 X WWW.NOVANTHEALTH.ORG 1 13 1 WWW.NOVANTHEALTH.ORG 0 0 1 X 300.000000000000 X X X X 0 1 X X X 1 X X X X X X X X 1 X 0 X X X X 1 X 0 0 NH CLEMMONS MEDICAL CENTER 3 0 0 1 X X X X X X 13 1 0 0 1 X WWW.NOVANTHEALTH.ORG 1 13 1 WWW.NOVANTHEALTH.ORG 0 0 1 X 300.000000000000 X X X X 0 1 X X X 1 X X X X X X X X 1 X 0 X X X X 1 X 0 0 NH FORSYTH MEDICAL CENTER PART V, SECTION B, LINE 5: WHILE CONDUCTING THE CHNA, THE HOSPITAL FACILITY(IES) SOLICITED INPUT FROM, AND CONSULTED WITH, A VARIETY OF COMMUNITY REPRESENTATIVES INCLUDING, BUT NOT LIMITED TO, REPRESENTATIVES OF CITY AND COUNTY GOVERNMENT INCLUDING HEALTH DEPARTMENTS, COMMUNITY-BASED ORGANIZATIONS, FOUNDATIONS, CHURCHES, COLLEGES/UNIVERSITIES, COMMUNITY COALITIONS AND OTHER SOCIAL SERVICE AGENCIES. THE SCOPE OF EXPERTISE WAS BROAD AND INCLUDED SUCH AREAS AS PUBLIC HEALTH, MINORITY POPULATIONS, HEALTH DISPARITIES, AND SOCIAL SERVICES. THE ORGANIZATION IS A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. WHERE POSSIBLE, WE HAVE LEVERAGED THE RESOURCES OF THE ORGANIZATION TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NH KERNERSVILLE MEDICAL CENTER PART V, SECTION B, LINE 5: WHILE CONDUCTING THE CHNA, THE HOSPITAL FACILITY(IES) SOLICITED INPUT FROM, AND CONSULTED WITH, A VARIETY OF COMMUNITY REPRESENTATIVES INCLUDING, BUT NOT LIMITED TO, REPRESENTATIVES OF CITY AND COUNTY GOVERNMENT INCLUDING HEALTH DEPARTMENTS, COMMUNITY-BASED ORGANIZATIONS, FOUNDATIONS, CHURCHES, COLLEGES/UNIVERSITIES, COMMUNITY COALITIONS AND OTHER SOCIAL SERVICE AGENCIES. THE SCOPE OF EXPERTISE WAS BROAD AND INCLUDED SUCH AREAS AS PUBLIC HEALTH, MINORITY POPULATIONS, HEALTH DISPARITIES, AND SOCIAL SERVICES. THE ORGANIZATION IS A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. WHERE POSSIBLE, WE HAVE LEVERAGED THE RESOURCES OF THE ORGANIZATION TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NH CLEMMONS MEDICAL CENTER PART V, SECTION B, LINE 5: WHILE CONDUCTING THE CHNA, THE HOSPITAL FACILITY(IES) SOLICITED INPUT FROM, AND CONSULTED WITH, A VARIETY OF COMMUNITY REPRESENTATIVES INCLUDING, BUT NOT LIMITED TO, REPRESENTATIVES OF CITY AND COUNTY GOVERNMENT INCLUDING HEALTH DEPARTMENTS, COMMUNITY-BASED ORGANIZATIONS, FOUNDATIONS, CHURCHES, COLLEGES/UNIVERSITIES, COMMUNITY COALITIONS AND OTHER SOCIAL SERVICE AGENCIES. THE SCOPE OF EXPERTISE WAS BROAD AND INCLUDED SUCH AREAS AS PUBLIC HEALTH, MINORITY POPULATIONS, HEALTH DISPARITIES, AND SOCIAL SERVICES. THE ORGANIZATION IS A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. WHERE POSSIBLE, WE HAVE LEVERAGED THE RESOURCES OF THE ORGANIZATION TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NH FORSYTH MEDICAL CENTER PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY(IES) IS/ARE A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. THE FACILITY'S CHNA IDENTIFIED MULTIPLE NEEDS FOR THE COMMUNITY SERVED. THE NEEDS IDENTIFIED WERE REVIEWED AND PRIORITIZED BY THE CHNA RESOURCE GROUP AND SUBSEQUENTLY BY THE ORGANIZATION'S BOARD AND THE NOVANT HEALTH EXECUTIVE TEAM. THEY EVALUATED EACH DOCUMENTED NEED AND ITS INTERSECTION WITH THE ORGANIZATION'S VISION, COMMITMENTS, AND KEY STRENGTHS BEFORE FURTHER PRIORITIZING THE HEALTH NEEDS AND AGREEING UPON THE TOP HEALTH PRIORITIES TO BE ADDRESSED. WHERE POSSIBLE, WE HAVE LEVERAGED THE SYSTEM'S STRENGTHS AND RESOURCES TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NOVANT HEALTH AND EACH OF ITS HOSPITAL FACILITIES HAVE ADOPTED AND EXECUTED AN IMPLEMENTATION STRATEGY THAT ADDRESSES THE PRIORITIZED COMMUNITY HEALTH NEEDS FROM THE CHNAS. THE IMPLEMENTATION STRATEGIES OUTLINE THE PLAN THAT THE HOSPITAL FACILITY(IES) WILL UNDERTAKE TO MEET THOSE HEALTH NEEDS IN EACH OF ITS COMMUNITIES. CERTAIN NEEDS THAT WERE IDENTIFIED BY THE CHNA HAVE NOT BEEN ADDRESSED. IT WAS DETERMINED THAT THERE ARE OTHER RESOURCES IN THE COMMUNITY THAT CAN MORE APPROPRIATELY ADDRESS THESE NEEDS BASED ON SCOPE OF SERVICES AND SKILL SET. FOR MORE DETAILED INFORMATION, REFER TO THE PUBLICLY AVAILABLE IMPLEMENTATION PLAN AVAILABLE ON THE WEBSITE; REFER TO THE URL GIVEN PREVIOUSLY FOR THE POSTING OF THE PLAN. NH KERNERSVILLE MEDICAL CENTER PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY(IES) IS/ARE A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. THE FACILITY'S CHNA IDENTIFIED MULTIPLE NEEDS FOR THE COMMUNITY SERVED. THE NEEDS IDENTIFIED WERE REVIEWED AND PRIORITIZED BY THE CHNA RESOURCE GROUP AND SUBSEQUENTLY BY THE ORGANIZATION'S BOARD AND THE NOVANT HEALTH EXECUTIVE TEAM. THEY EVALUATED EACH DOCUMENTED NEED AND ITS INTERSECTION WITH THE ORGANIZATION'S VISION, COMMITMENTS, AND KEY STRENGTHS BEFORE FURTHER PRIORITIZING THE HEALTH NEEDS AND AGREEING UPON THE TOP HEALTH PRIORITIES TO BE ADDRESSED. WHERE POSSIBLE, WE HAVE LEVERAGED THE SYSTEM'S STRENGTHS AND RESOURCES TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NOVANT HEALTH AND EACH OF ITS HOSPITAL FACILITIES HAVE ADOPTED AND EXECUTED AN IMPLEMENTATION STRATEGY THAT ADDRESSES THE PRIORITIZED COMMUNITY HEALTH NEEDS FROM THE CHNAS. THE IMPLEMENTATION STRATEGIES OUTLINE THE PLAN THAT THE HOSPITAL FACILITY(IES) WILL UNDERTAKE TO MEET THOSE HEALTH NEEDS IN EACH OF ITS COMMUNITIES. CERTAIN NEEDS THAT WERE IDENTIFIED BY THE CHNA HAVE NOT BEEN ADDRESSED. IT WAS DETERMINED THAT THERE ARE OTHER RESOURCES IN THE COMMUNITY THAT CAN MORE APPROPRIATELY ADDRESS THESE NEEDS BASED ON SCOPE OF SERVICES AND SKILL SET. FOR MORE DETAILED INFORMATION, REFER TO THE PUBLICLY AVAILABLE IMPLEMENTATION PLAN AVAILABLE ON THE WEBSITE; REFER TO THE URL GIVEN PREVIOUSLY FOR THE POSTING OF THE PLAN. NH CLEMMONS MEDICAL CENTER PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY(IES) IS/ARE A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. THE FACILITY'S CHNA IDENTIFIED MULTIPLE NEEDS FOR THE COMMUNITY SERVED. THE NEEDS IDENTIFIED WERE REVIEWED AND PRIORITIZED BY THE CHNA RESOURCE GROUP AND SUBSEQUENTLY BY THE ORGANIZATION'S BOARD AND THE NOVANT HEALTH EXECUTIVE TEAM. THEY EVALUATED EACH DOCUMENTED NEED AND ITS INTERSECTION WITH THE ORGANIZATION'S VISION, COMMITMENTS, AND KEY STRENGTHS BEFORE FURTHER PRIORITIZING THE HEALTH NEEDS AND AGREEING UPON THE TOP HEALTH PRIORITIES TO BE ADDRESSED. WHERE POSSIBLE, WE HAVE LEVERAGED THE SYSTEM'S STRENGTHS AND RESOURCES TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NOVANT HEALTH AND EACH OF ITS HOSPITAL FACILITIES HAVE ADOPTED AND EXECUTED AN IMPLEMENTATION STRATEGY THAT ADDRESSES THE PRIORITIZED COMMUNITY HEALTH NEEDS FROM THE CHNAS. THE IMPLEMENTATION STRATEGIES OUTLINE THE PLAN THAT THE HOSPITAL FACILITY(IES) WILL UNDERTAKE TO MEET THOSE HEALTH NEEDS IN EACH OF ITS COMMUNITIES. CERTAIN NEEDS THAT WERE IDENTIFIED BY THE CHNA HAVE NOT BEEN ADDRESSED. IT WAS DETERMINED THAT THERE ARE OTHER RESOURCES IN THE COMMUNITY THAT CAN MORE APPROPRIATELY ADDRESS THESE NEEDS BASED ON SCOPE OF SERVICES AND SKILL SET. FOR MORE DETAILED INFORMATION, REFER TO THE PUBLICLY AVAILABLE IMPLEMENTATION PLAN AVAILABLE ON THE WEBSITE; REFER TO THE URL GIVEN PREVIOUSLY FOR THE POSTING OF THE PLAN. NH FORSYTH MEDICAL CENTER PART V, SECTION B, LINE 13H: OTHER ELIGIBILITY CRITERIA EXPLAINED IN THE NOVANT HEALTH FAP INCLUDE THE FOLLOWING: FREE CARE IS ONLY APPLICABLE TO MEDICALLY NECESSARY SERVICES; PROVIDER BASED PHYSICIAN CLINICS REQUIRE THAT PATIENTS MUST HAVE BEEN TREATED BY A NOVANT HEALTH MEDICAL GROUP PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS THREE YEARS; PATIENTS MUST BE UNABLE TO ACCESS ENTITLEMENT PROGRAMS; PATIENTS WITH SPECIAL CIRCUMSTANCES SUCH AS BANKRUPTCY MAY ALSO BE ELIGIBLE FOR CHARITY CARE. NH KERNERSVILLE MEDICAL CENTER PART V, SECTION B, LINE 13H: OTHER ELIGIBILITY CRITERIA EXPLAINED IN THE NOVANT HEALTH FAP INCLUDE THE FOLLOWING: FREE CARE IS ONLY APPLICABLE TO MEDICALLY NECESSARY SERVICES; PROVIDER BASED PHYSICIAN CLINICS REQUIRE THAT PATIENTS MUST HAVE BEEN TREATED BY A NOVANT HEALTH MEDICAL GROUP PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS THREE YEARS; PATIENTS MUST BE UNABLE TO ACCESS ENTITLEMENT PROGRAMS; PATIENTS WITH SPECIAL CIRCUMSTANCES SUCH AS BANKRUPTCY MAY ALSO BE ELIGIBLE FOR CHARITY CARE. NH CLEMMONS MEDICAL CENTER PART V, SECTION B, LINE 13H: OTHER ELIGIBILITY CRITERIA EXPLAINED IN THE NOVANT HEALTH FAP INCLUDE THE FOLLOWING: FREE CARE IS ONLY APPLICABLE TO MEDICALLY NECESSARY SERVICES; PROVIDER BASED PHYSICIAN CLINICS REQUIRE THAT PATIENTS MUST HAVE BEEN TREATED BY A NOVANT HEALTH MEDICAL GROUP PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS THREE YEARS; PATIENTS MUST BE UNABLE TO ACCESS ENTITLEMENT PROGRAMS; PATIENTS WITH SPECIAL CIRCUMSTANCES SUCH AS BANKRUPTCY MAY ALSO BE ELIGIBLE FOR CHARITY CARE. NH FORSYTH MEDICAL CENTERPART V, LINE 16A, FAP WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH KERNERSVILLE MEDICAL CENTERPART V, LINE 16A, FAP WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH CLEMMONS MEDICAL CENTERPART V, LINE 16A, FAP WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH FORSYTH MEDICAL CENTERPART V, LINE 16B, FAP APPLICATION WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH KERNERSVILLE MEDICAL CENTERPART V, LINE 16B, FAP APPLICATION WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH CLEMMONS MEDICAL CENTERPART V, LINE 16B, FAP APPLICATION WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH FORSYTH MEDICAL CENTERPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH KERNERSVILLE MEDICAL CENTERPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXNH CLEMMONS MEDICAL CENTERPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/ FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPX NH FORSYTH MEDICAL CENTER PART V, SECTION B, LINE 22D: AFTER APPLICATION AND APPROVAL, ALL FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENTS RECEIVE 100% FREE CARE AND THEREFORE ARE NOT CHARGED FOR CARE AND DO NOT RECEIVE BILLS ONCE FAP ELIGIBILITY HAS BEEN ESTABLISHED. ALL PATIENTS DO RECEIVE INFORMATIONAL STATEMENTS WHICH INCLUDE TOTAL CHARGES LESS ANY NON-FINANCIAL ASSISTANCE POLICY ADJUSTMENTS. NH KERNERSVILLE MEDICAL CENTER PART V, SECTION B, LINE 22D: AFTER APPLICATION AND APPROVAL, ALL FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENTS RECEIVE 100% FREE CARE AND THEREFORE ARE NOT CHARGED FOR CARE AND DO NOT RECEIVE BILLS ONCE FAP ELIGIBILITY HAS BEEN ESTABLISHED. ALL PATIENTS DO RECEIVE INFORMATIONAL STATEMENTS WHICH INCLUDE TOTAL CHARGES LESS ANY NON-FINANCIAL ASSISTANCE POLICY ADJUSTMENTS. NH CLEMMONS MEDICAL CENTER PART V, SECTION B, LINE 22D: AFTER APPLICATION AND APPROVAL, ALL FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENTS RECEIVE 100% FREE CARE AND THEREFORE ARE NOT CHARGED FOR CARE AND DO NOT RECEIVE BILLS ONCE FAP ELIGIBILITY HAS BEEN ESTABLISHED. ALL PATIENTS DO RECEIVE INFORMATIONAL STATEMENTS WHICH INCLUDE TOTAL CHARGES LESS ANY NON-FINANCIAL ASSISTANCE POLICY ADJUSTMENTS. 60 NH ARCADIA FAMILY MEDICINE 12208 NC HWY 150 NORTH WINSTONSALEM NC 27127 PHYSICIAN CLINIC NH BREAST CENTER 2025 FRONTIS PLAZA BLVDSTE 123 WINSTONSALEM NC 27103 IMAGING CENTER NH BREAST CENTER 2025 FRONTIS PLAZA BLVDSTE 119 300 WINSTONSALEM NC 27103 IMAGING CENTER NH CARDIOLOGY CLEMMONS 7114 VILLAGE MEDICAL CIRCLE CLEMMONS NC 27012 PHYSICIAN CLINIC NH CHAIR CITY FAMILY MEDICINE 903 RANDOLPH ST THOMASVILLE NC 27360 PHYSICIAN CLINIC NH CLEMMONS FAMILY MEDICINE 6301 STADIUM DRIVE CLEMMONS NC 27012 PHYSICIAN CLINIC NH DAVIE MEDICAL ASSOCIATES 485 VALLEY ROAD MOCKSVILLE NC 27028 PHYSICIAN CLINIC NH FORSYTH ENDOCRINE CONSULTANTS 755 HIGHLAND OAKS DRSTE 201 WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH FORSYTH FAMILY MEDICINE 400 JONESTOWN ROAD WINSTONSALEM NC 27104 PHYSICIAN CLINIC NH FORSYTH INTERNAL MEDICINE 1381 WESTGATE CENTER DRIVE WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH FORSYTH NEUROLOGY 2025 FRONTIS PLAZA BLVDSTE 120 WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH GATEWAY FAMILY MEDICINE 390 SALEM AVENUE WINSTONSALEM NC 27101 PHYSICIAN CLINIC NH HAWTHORNE OUTPATIENT SURGERY 1999 S HAWTHORNE ROAD WINSTONSALEM NC 27103 AMBULATORY SURGERY CENTER NH HILLSDALE MEDICAL ASSOCIATES 121 MEDICAL DRIVE ADVANCE NC 27006 PHYSICIAN CLINIC NH IMAGING KERNERSVILLE 445 PINEVIEW DRIVE SUITE 100 KERNERSVILLE NC 27284 IMAGING CENTER NH IMAGING MAPLEWOOD 3155 MAPLEWOOD AVENUE WINSTONSALEM NC 27103 IMAGING CENTER NH INFECTIOUS DISEASE SPECIALISTS 1381 WESTGATE CENTER DRIVE WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH INPATIENT CARE SPECIALISTS KVILLE 1750 KERNERSVILLE MEDICAL PKWY KERNERSVILLE NC 27284 PHYSICIAN CLINIC NH KERNERSVILLE FAMILY MEDICINE 291 BROAD STREET WINSTONSALEM NC 27284 PHYSICIAN CLINIC NH LEWISVILLE FAMILY MEDICINE 1225 LEWISVILLE-CLEMMONS ROAD LEWISVILLE NC 27023 PHYSICIAN CLINIC NH LEXINGTON PRIMARY CARE 110 WEST MEDICAL PARK DRIVE LEXINGTON NC 27292 PHYSICIAN CLINIC NH MAPLEWOOD FAMILY MEDICINE ROBINHOOD MEDICAL PLAZA BLDG 100 WINSTONSALEM NC 27106 PHYSICIAN CLINIC NH MEADOWLARK PEDIATRICS 5110 ROBINHOOD VILLAGE DR SUITE C-1 WINSTONSALEM NC 27106 PHYSICIAN CLINIC NH MOUNTAINVIEW MEDICAL 216 MOORE ROAD KING NC 27021 PHYSICIAN CLINIC NH NEW GARDEN MEDICAL ASSOCIATES 1941 NEW GARDEN RD STES 212 216 GREENSBORO NC 27410 PHYSICIAN CLINIC NH NORTH POINT MEDICAL ASSOCIATES 1995 BETHABARA ROAD WINSTONSALEM NC 27106 PHYSICIAN CLINIC NH NORTHWEST FAMILY MEDICINE 7607 NC HIGHWAY 68 N STE B OAK RIDGE NC 27310 PHYSICIAN CLINIC NH ONCOLOGY SPECIALISTS 276 OLD MOCKSVILLE RDSTE 800 STATESVILLE NC 28625 PHYSICIAN CLINIC NH ONCOLOGY SPECIALISTS 865 WESTLAKE DRIVE STE 200 MOUNT AIRY NC 27030 PHYSICIAN CLINIC NH ONCOLOGY SPECIALISTS 1010 BETHESDA COURT WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH ONCOLOGY SPECIALISTS 1370 PIEDMONT DRIVE STE 202 LEXINGTON NC 27295 PHYSICIAN CLINIC NH ONCOLOGY SPECIALISTS 1710 KERNERSVILLE MED PKWY STE 116 KERNERSVILLE NC 27284 PHYSICIAN CLINIC NH PFAFFTOWN FAMILY MEDICINE 4611 YADKINVILLE ROAD PFAFFTOWN NC 27040 PHYSICIAN CLINIC NH PHARMACY 105 VEST MILL CIRCLE WINSTONSALEM NC 27103 PHARMACY NH PHARMACY 212 MOORE ROAD KING NC 27021 PHARMACY NH PHARMACY 291 BROAD STREET KERNERSVILLE NC 27284 PHARMACY NH PHARMACY 100 ROBINHOOD MEDICAL PLAZA WINSTONSALEM NC 27106 PHARMACY NH PHARMACY 1381 WESTGATE CENTER DRIVE WINSTONSALEM NC 27103 PHARMACY NH PHARMACY 1010 BETHESDA COURT WINSTONSALEM NC 27103 PHARMACY NH PHARMACY 255 CHARLOIS BLVD WINSTONSALEM NC 27103 PHARMACY NH PILOT MOUNTAIN MEDICAL CARE 207 MEDICAL STREET PILOT MOUNTAIN NC 27041 PHYSICIAN CLINIC NH PINEVIEW FAMILY MEDICINE 490 PINEVIEW DRIVE KERNERSVILLE NC 27284 PHYSICIAN CLINIC NH PREMIER MEDICAL ASSOCIATES 3333 BROOKVIEW HILLS BLVD STE 203204 WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH PSYCHIATRIC MEDICINE 175 KIMEL PARK DR STE 100 WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH RHEUMATOLOGY AND ARTHRITIS 1995 BETHABARA ROAD WINSTONSALEM NC 27106 PHYSICIAN CLINIC NH SALEM FAMILY MEDICINE 105 VEST MILL CIRCLE WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH SURRY MEDICAL ASSOCIATES 865 WESTLAKE DRIVE MOUNT AIRY NC 27030 PHYSICIAN CLINIC NH THOMASVILLE MEDICAL ASSOCIATES 309 PINEYWOOD ROAD THOMASVILLE NC 27360 PHYSICIAN CLINIC NH TRIAD ENDOCRINE 500 PINEVIEW DR SUITE 101 KERNERSVILLE NC 27284 PHYSICIAN CLINIC NH UROLOGY PARTNERS 2010 BALDWIN LANE WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH UROLOGY PARTNERS 1710 KERNERSVILLE MED PKWY STE 201 KERNERSVILLE NC 27284 PHYSICIAN CLINIC NH WEST FORSYTH INTERNAL MED & PED 105 STADIUM OAKS DRIVE CLEMMONS NC 27012 PHYSICIAN CLINIC NH WINSTON-SALEM CARDIOLOGY 445 PINEVIEW DRIVE SUITE 220 WINSTONSALEM NC 27284 PHYSICIAN CLINIC NH WINSTON-SALEM CARDIOLOGY 186 KIMEL PARK DRIVE WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH WINSTON-SALEM CARDIOLOGY 1710 KERNERSVILLE MED PKWY STE 205 KERNERSVILLE NC 27284 PHYSICIAN CLINIC NH WINSTON-SALEM HEALTH CARE 250 CHARLOIS BLVD WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH WINSTON-SALEM HEALTH CARE 175 KIMEL PARK DR STE 250 WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH WINSTON-SALEM HEALTH CARE PSYCH 280 CHARLOIS BLVD 3RD FLOOR WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH WOUND CARE & HYPERBARIC MEDICINE 1901 S HAWTHORNE RDSTE 220 WINSTONSALEM NC 27103 PHYSICIAN CLINIC NH YADKIN MEDICAL ASSOCIATES 305 EAST LEE AVENUE YADKINVILLE NC 27055 PHYSICIAN CLINIC PART I, LINE 3C: OTHER CRITERIA BESIDES INCOME AND FPG USED IN DETERMINING ELIGIBILITY FOR FREE CARE INCLUDE: (1) RESIDENCY - PATIENTS MUST RESIDE WITHIN THE SERVICE AREA OF THE HOSPITAL; (2) THE KIND OF SERVICE PROVIDED - ONLY MEDICALLY NECESSARY SERVICES ARE COVERED; (3) PATIENT STATUS - IN PROVIDER BASED PHYSICIAN CLINICS, PATIENTS MUST HAVE BEEN TREATED BY A NOVANT HEALTH MEDICAL GROUP PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS THREE YEARS; AND (4) ACCESS TO HEALTH CARE COVERAGE - PATIENTS MUST BE UNABLE TO ACCESS EMPLOYER SPONSORED HEALTH PLANS OR ENTITLEMENT PROGRAMS. LASTLY, THE PATIENT MUST BE WITHOUT SUBSTANTIAL LIQUID ASSETS (I.E. CASH-ON-HAND). ASSETS SUCH AS HOUSES, CARS, PENALIZED RETIREMENT SAVINGS FUNDS, ETC. ARE NOT CONSIDERED LIQUID ASSETS. SUBSTANTIAL ASSETS ARE DEFINED AS ENOUGH CASH-ON-HAND TO COVER THE MEDICAL EXPENSES WITHOUT PLACING A HARDSHIP ON THE PATIENT. PATIENTS WITH SPECIAL CIRCUMSTANCES SUCH AS BANKRUPTCY MAY ALSO BE ELIGIBLE FOR CHARITY CARE; DETERMINATION IS MADE ON A CASE BY CASE BASIS UNDER THESE CIRCUMSTANCES. PART I, LINE 6A: THE ORGANIZATION IS A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. THE COMMUNITY BENEFIT REPORT IS PREPARED BY A RELATED ORGANIZATION. NOVANT HEALTH, INC. IS THE NOVANT HEALTH PARENT COMPANY AND PRODUCES A COMMUNITY BENEFIT REPORT REPRESENTING THE HEALTH SYSTEM AS A WHOLE. THE REPORT CAN BE FOUND AT HTTP://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMPANY-INFORMATION/FINANCIAL -PROFILE/COMMUNITY-BENEFIT-REPORT.ASPX. PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. PART I, LINE 7: COSTS REPORTED IN THE TABLE FOR CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AMOUNTS ARE CALCULATED USING AN ENTITY SPECIFIC COST TO CHARGE RATIO BASED ON WORKSHEET 2 (CCR). PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT REMOVED FROM TOTAL EXPENSES (DENOMINATOR) WAS $44,187,769. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION IS A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. NOVANT HEALTH'S COMMUNITY BUILDING ACTIVITIES IMPACTS THE HEALTH OF OUR COMMUNITY THROUGH PARTNERSHIPS WITH LOCAL AGENCIES DEDICATED TO IMPROVING THE LIVES OF ALL INDIVIDUALS. OUTREACH INCLUDES PROVIDING SUPPORT FOR ORGANIZATIONS SUCH AS HABITAT FOR HUMANITY AND LOCAL CHAMBERS OF COMMERCE, ASSISTING WITH COMMUNITY/COUNTY COALITIONS, PROVIDING EDUCATIONAL SEMINARS AND TRAINING FOR COMMUNITY WORKFORCES, AND SUPPORTING COMMUNITY AGENCIES SUCH AS ROTARY, LIONS CLUBS AND MORE. THROUGH EACH OF THESE PARTNER AGENCIES, NOVANT HEALTH ADDRESSES THE UNDERLYING ISSUES IMPACTING THE HEALTH OF OUR COMMUNITIES AND ENSURES THAT OUR COMMUNITIES GROW FOR YEARS TO COME. PART III, LINE 2: THE ALLOWANCE FOR BAD DEBT IS DETERMINED BASED ON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, BUSINESS AND ECONOMIC CONDITIONS, THE AGE OF THE ACCOUNTS, TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTHCARE COVERAGE AND OTHER COLLECTION INDICATORS. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE (AT COST) ON LINE 2 IS CALCULATED USING THE SAME METHODOLOGY AS CHARITY CARE AND OTHER COMMUNITY BENEFITS USING AN ENTITY SPECIFIC COST TO CHARGE RATIO (CCR). FOOTNOTE 2 (ACCOUNTS RECEIVABLE) ON PAGE 7 OF THE AUDITED FINANCIAL STATEMENTS DESCRIBES THE BAD DEBT EXPENSE. PART III, LINE 8: THE METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT AS REFLECTED IN THE AMOUNT REPORTED IN PART III, LINE 6 IS DETERMINED BY FOLLOWING THE MEDICARE PRINCIPLES OF ALLOWABLE COSTS. COST FOR THE OVERHEAD DEPARTMENTS ARE STEPPED DOWN TO THE REMAINING COST CENTERS BASED ON STATISTICS FOR EACH OVERHEAD COST CENTER. ONCE THE STEP-DOWN PROCESS IS COMPLETE, A RATIO OF COST TO CHARGES IS DEVELOPED FOR EACH COST CENTER. THE CCR IS THEN APPLIED TO THE MEDICARE REVENUE BY COST CENTER AND TOTALED. IT SHOULD BE NOTED THAT THE MEDICARE COST REPORTS DO NOT ADDRESS ANY MANAGED CARE MEDICARE REVENUES, COSTS, OR RELATED SHORTFALL. THE TOTAL REVENUES REPORTED AS RECEIVED FROM MEDICARE IN LINE 5 OF SECTION B ARE ONLY REPRESENTATIVE OF MEDICARE FEE FOR SERVICE PAYMENTS RECEIVED. THE ALLOWABLE COSTS ON LINE 6 ARE SIGNIFICANTLY LOWER THAN THE ACTUAL EXPENDITURES. AS SUCH, THE SHORTFALL IS UNDERESTIMATED. EVERY HOSPITAL TREATS MEDICARE PATIENTS. SOME HOSPITALS ARE LOCATED IN HIGH MEDICARE POPULATION AREAS; OTHERS PROVIDE SERVICES DISPROPORTIONATELY USED BY MEDICARE PATIENTS. MEDICARE RATES AND NUMBERS OF MEDICARE PATIENTS ARE NOT NEGOTIATED. AS REIMBURSEMENT RATES DECLINE RELATIVE TO COSTS OF CARE, HOSPITALS CONTINUE TO SERVE THE MEDICARE POPULATION. WITHOUT THIS SERVICE THESE PATIENTS WOULD BECOME AN OBLIGATION ON THE GOVERNMENT. ANY UNREIMBURSED COSTS OF THIS CARE ARE A COMMUNITY BENEFIT PROVIDED BY THE HOSPITAL TO THE COMMUNITY AND GOVERNMENT. PART III, LINE 9B: THE ORGANIZATION'S BILLING AND COLLECTIONS POLICY DOES EXPLAIN ACTIONS AGAINST PATIENTS WHO HAVE OUTSTANDING DELINQUENT AMOUNTS, BUT THE POLICY DOES NOT CONTAIN PROVISIONS FOR COLLECTION PRACTICES AGAINST PATIENTS WHO ARE ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY (FAP) BECAUSE FAP ELIGIBLE PATIENTS RECEIVE 100% FREE CARE AND THEREFORE DO NOT RECEIVE BILLS ONCE FAP ELIGIBILITY HAS BEEN ESTABLISHED. PART VI, LINE 2: PART VI, LINE 2: NEEDS ASSESSMENTTHE ORGANIZATION IS PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM, WHICH HAS A COMMUNITY BENEFIT COMMITTEE. THE COMMUNITY BENEFIT COMMITTEE IS RESPONSIBLE FOR ASSISTING THE HOSPITALS WITHIN THE SYSTEM PREPARE THEIR COMMUNITY HEALTH NEEDS ASSESSMENTS (CHNA) INCLUDING THE CHNAS REPORTED IN PART V, SECTION B. THE COMMUNITY BENEFIT COMMITTEE IS MADE OF INDIVIDUALS REPRESENTING CORPORATE-WIDE DEPARTMENTS, SUCH AS COMMUNITY RELATIONS, LEGAL, TAX, INTERNAL AUDIT, MARKETING/COMMUNICATIONS, AS WELL AS INDIVIDUALS FROM VARIOUS DEPARTMENTS OF HOSPITAL OPERATIONS AND THE SYSTEM'S HOSPITAL FOUNDATIONS. EACH HOSPITAL, WITH THE ASSISTANCE OF THE COMMUNITY BENEFIT COMMITTEE, IDENTIFIES ORGANIZATIONS AND RESOURCES WITHIN ITS COMMUNITY THAT CONTRIBUTE TO THE PROCESS. THESE ORGANIZATIONS AND RESOURCES INCLUDE LOCAL HEALTH DEPARTMENTS, UNITED WAY, UNIVERSITIES, PUBLIC HEALTH DEPARTMENTS, ETC. COMMUNITY HEALTH ASSESSMENTS PREPARED BY OTHER ORGANIZATIONS IN THE COMMUNITY ARE USED IN COMBINATION WITH INTERNAL HOSPITAL DATA AND INFORMATION COLLECTED FROM LOCAL AGENCIES TO PREPARE THE HOSPITAL'S CHNA. IN ADDITION TO ADDRESSING NEEDS IDENTIFIED THROUGH THE CHNA, EACH HOSPITAL MAY RESPOND TO REQUESTS FOR SPECIFIC COMMUNITY BENEFIT ACTIVITIES OR PROGRAMS FROM PUBLIC AGENCIES OR COMMUNITY GROUPS. PART VI, LINE 3: PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCETHE ORGANIZATION IS PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS A NOT-FOR-PROFIT ORGANIZATION, NOVANT HEALTH IS COMMITTED TO PROVIDING OUTSTANDING HEALTHCARE TO ALL MEMBERS OF OUR COMMUNITIES, REGARDLESS OF THEIR ABILITY TO PAY. OUR ACUTE CARE FACILITIES PROVIDE CARE IN 35 COUNTIES ACROSS FOUR STATES. ADDITIONALLY, OUR PHYSICIANS AND ACUTE CARE FACILITIES OFFER CARE TO NATIONAL AND INTERNATIONAL MISSION PATIENTS. OUR FINANCIAL COUNSELING TEAMS ARE CONSTANTLY WORKING WITH THE PATIENTS WITHIN OUR COMMUNITIES TO UNDERSTAND THEIR NEEDS AND ENSURE THAT OUR POLICIES AND PROCESSES ADDRESS THESE NEEDS. WE ALSO MAINTAIN CONTRACTS WITH MEDICAID ELIGIBILITY VENDORS. THESE TEAMS OFFER ADDITIONAL SUPPORT IN PROCESSING AND ASSESSING HOW WE SERVE THE FINANCIAL NEEDS OF OUR PATIENTS. BASED ON THE ASSESSMENTS OF OUR COMMUNITIES, NOVANT HEALTH HAS DEVELOPED FINANCIAL ASSISTANCE POLICIES AND PROGRAMS THAT ADDRESS THE FINANCIAL NEEDS OF OUR PATIENTS. WE PRIDE OURSELVES ON THE TRANSPARENCY OF OUR PROGRAMS AND THE EDUCATION WE OFFER OUR PATIENTS AROUND OUR FINANCIAL ASSISTANCE POLICIES. OUR PROGRAMS ARE DOCUMENTED ON OUR WEBSITE, ALONG WITH CONTACT INFORMATION FOR OUR FINANCIAL COUNSELORS. ADDITIONALLY, OUR PROGRAMS ARE DOCUMENTED ON PATIENT FLYERS THROUGHOUT THE NOVANT HEALTH AFFILIATED FACILITIES AND PHYSICIAN OFFICES. OUR PATIENT ACCESS SPECIALISTS, FINANCIAL COUNSELORS AND BUSINESS OFFICE TEAMS WORK WITH ALL ELIGIBLE PATIENTS TO EDUCATE THEM ON THE VARIOUS OPTIONS AVAILABLE VIA OUR FINANCIAL ASSISTANCE PROGRAMS OR GOVERNMENT SPONSORED CARE. THEY ALSO REFERENCE OUR FINANCIAL ASSISTANCE POLICY IN ALL CONVERSATIONS RELATED TO PATIENTS BILLS. FINALLY, WE WORK WITH LOCAL AREA FREE HEALTH CLINICS AND OTHER CHARITABLE ORGANIZATIONS TO PROVIDE CONTINUATION OF CARE FOR THEIR PATIENTS. IN ADDITION TO OUR FINANCIAL COUNSELING PROCESSES USED TO IDENTIFY CHARITY CARE PATIENTS, OUR COLLECTIONS PROCESSES WITHIN OUR BUSINESS OFFICES ALSO HELP IDENTIFY PATIENTS WHO ARE ALREADY ELIGIBLE FOR CHARITY OR WHO MAY BE ELIGIBLE BASED ON THEIR STATUS WITHIN THE FEDERAL POVERTY GUIDELINES ("FPG"). WE UTILIZE PREVIOUSLY SUBMITTED PATIENT DOCUMENTATION AND CREDIT AGENCY REPORTED FPG FOR DETERMINATION. SUPPORTING DOCUMENTS ARE VALID 6 MONTHS FROM THE DATE OF SUBMISSION. OUR POLICIES ARE CONSIDERED FLUID AND ARE UPDATED FREQUENTLY BASED ON LOCAL AND NATIONAL MARKET STANDARDS AND NATIONAL ECONOMIC CONDITIONS. ANY UPDATES TO OUR POLICIES REQUIRE MULTI-LEVEL LEADERSHIP APPROVAL AND ARE ULTIMATELY APPROVED BY THE NOVANT HEALTH EXECUTIVE TEAM AND/OR THE NOVANT HEALTH BOARD OF DIRECTORS. PART VI, LINE 4: PART VI, LINE 4: COMMUNITY INFORMATIONTHE FORSYTH MEMORIAL HOSPITAL, INC. FORM 990 INCLUDES THE OPERATIONS OF THREE HOSPITALS. FORSYTH MEMORIAL HOSPITAL, INC. DBA NOVANT HEALTH FORSYTH MEDICAL CENTER, AS NOVANT HEALTH KERNERSVILLE MEDICAL CENTER AND AS NOVANT HEALTH CLEMMONS MEDICAL CENTERTHE ORGANIZATION DEFINES ITS COMMUNITY BY ITS PRIMARY SERVICE AREA, WHICH IS FORSYTH COUNTY, NORTH CAROLINA. THIS IS AN URBAN AREA.THERE ARE FOUR NONPROFIT ACUTE CARE HOSPITALS IN THE COMMUNITY, THREE OF WHICH ARE THE ORGANIZATION AND ONE OF WHICH IS PART OF THE NOVANT HEALTH SYSTEM. THERE IS ALSO ONE ACADEMIC, TEACHING HOSPITAL. ACCORDING TO SG2 DATA, THE SPECIFIC POPULATION GROUPS (ETHNIC AND CULTURAL) ARE AS FOLLOWS: WHITE NON-HISPANIC (236,234) 59.27%; BLACK NON-HISPANIC (97,658) 24.50%; HISPANIC (50,985) 12.79%; ASIAN AND PACIFIC ISLAND (9,761) 2.45%; OTHERS (3,938) .99%; FOR A TOTAL POPULATION OF 398,576. ACCORDING TO US CENSUS BUREAU DATA, THE MEDIAN HOUSEHOLD INCOME LEVEL WAS $45,724.ACCORDING TO SG2 DATA, THE AGE BREAKDOWN IS AS FOLLOWS: 0-17 YEARS (92,040) 23.68%; 18-64 YEARS (239,642) 61.64%; 65+ YEARS (57,057) 14.68%. PART VI, LINE 5: PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTHTHE ORGANIZATION FURTHERS ITS EXEMPT PURPOSES BY DOING THE FOLLOWING:1. ADOPTING A CHARITY CARE POLICY, WHICH PROVIDES FREE CARE TO INDIVIDUALS WHOSE INCOME IS AT OR BELOW 300% OF THE FEDERAL POVERTY LEVEL;2. REMAINING CERTIFIED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES TO PROVIDE SERVICES TO ALL BENEFICIARIES OF MEDICARE, MEDICAID, AND OTHER GOVERNMENT PAYMENT PROGRAMS, AND PROVIDING SERVICES IN A NONDISCRIMINATORY MANNER TO SUCH BENEFICIARIES;3. OPERATING A FULL-TIME EMERGENCY ROOM WHICH IS OPEN TO AND ACCEPTS ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY;4. MAINTAINING AN OPEN MEDICAL STAFF, SUBJECT TO EXCLUSIVE CONTRACTS FOR HOSPITAL-BASED SERVICES SUCH AS ANESTHESIOLOGY, RADIOLOGY, PATHOLOGY, HOSPITALIST, AND EMERGENCY DEPARTMENT SERVICES, TO THE EXTENT AN EXCLUSIVE CONTRACT FOR THOSE SERVICES IS REQUIRED TO OBTAIN PROPER STAFFING COVERAGE OR TO PERMIT A MORE EFFICIENT DELIVERY OF THOSE SERVICES WITHIN THE HOSPITAL FACILITY;5. MAINTAINING A GOVERNING BOARD CONSISTING PRIMARILY OF A BROAD CROSS-SECTION OF LEADERS IN THE COMMUNITY;6. ADOPTING AND APPLYING A CONFLICT OF INTEREST POLICY, WHICH APPLIES TO THE GOVERNING BOARD AND ORGANIZATION OFFICERS;7. PROVIDING HEALTH EDUCATION LECTURES AND WORKSHOPS;8. PROVIDING HEALTH FAIRS, EDUCATION ON SPECIFIC DISEASES OR CONDITIONS, AND HEALTH PROMOTION AND WELLNESS PROGRAMS TO THE COMMUNITIES IT SERVES;9. PROVIDING SUPPORT GROUPS AND SELF HELP PROGRAMS TO THE COMMUNITIES IT SERVES;10. PROVIDING COMMUNITY-BASED CLINICAL SERVICES, INCLUDING WITHOUT LIMITATION, HEALTH SCREENINGS AND CLINICS FOR UNINSURED OR UNDERINSURED PERSONS TO THE COMMUNITIES IT SERVES;11. PROVIDING HEALTHCARE SUPPORT SERVICES, INCLUDING WITHOUT LIMITATION, INFORMATION AND REFERRAL TO COMMUNITY SERVICES, CASE MANAGEMENT OF UNDERINSURED AND UNINSURED PERSONS, TELEPHONE INFORMATION SERVICES AND ASSISTANCE TO ENROLL IN PUBLIC PROGRAMS, SUCH AS STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP) AND MEDICAID TO THE COMMUNITIES IT SERVES;12. PROVIDING SUBSIDIZED HEALTH SERVICES AND CLINICAL PROGRAMS TO THE COMMUNITIES IT SERVES;13. PROVIDING CASH AND IN-KIND CONTRIBUTIONS TO NONPROFIT COMMUNITY HEALTHCARE ORGANIZATIONS IN THE COMMUNITIES IT SERVES; AND14. GENERALLY PROMOTING THE HEALTH, WELLNESS, AND WELFARE OF THE COMMUNITIES IT SERVES BY PROVIDING QUALITY HEALTHCARE SERVICES AT REASONABLE COST.FOR SPECIFIC EXAMPLES OF THIS ORGANIZATION'S COMMUNITY BENEFIT ACTIVITIES, WHICH FURTHER THE ORGANIZATION'S EXEMPT PURPOSES (AND THOSE OF ALL HOSPITALS AND HEALTHCARE FACILITIES IN THE SAME HEALTHCARE SYSTEM), PLEASE SEE THE NOVANT HEALTH COMMUNITY BENEFIT REPORT, LOCATED AT HTTP://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMPANY-INFORMATION/FINANCIAL -PROFILE/COMMUNITY-BENEFIT-REPORT.ASPX.PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. PART VI, LINE 6: PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEMTHE ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, A NOT-FOR-PROFIT INTEGRATED GROUP OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS AND OTHER HEALTHCARE SERVICE PROVIDERS. NOVANT HEALTH IS RANKED AS ONE OF OUR NATION'S TOP 20 INTEGRATED HEALTHCARE SYSTEMS - CARING FOR PATIENTS AND COMMUNITIES IN GEORGIA, NORTH CAROLINA, SOUTH CAROLINA, AND VIRGINIA. EACH HOSPITAL PROVIDES SUBSTANTIAL COMMUNITY BENEFIT TO THE COMMUNITY IT SERVES, AS REPORTED INDIVIDUALLY ON EACH HOSPITAL'S FORM 990, SCHEDULE H. THE COMMUNITY BENEFIT OF THE SYSTEM AS A WHOLE IS DOCUMENTED IN A SYSTEM-WIDE COMMUNITY BENEFIT REPORT, LOCATED AT HTTP://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMPANY-INFORMATION/FINANCIAL -PROFILE/COMMUNITY-BENEFIT-REPORT.ASPX. PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. THERE ARE SIGNIFICANT COMMUNITY BENEFIT ACTIVITIES WITHIN NOVANT HEALTH WHICH MAY NOT BE REPORTABLE ON A SCHEDULE H BECAUSE THEY ARE NOT CONDUCTED BY AN ENTITY WHICH OWNS OR OPERATES A HOSPITAL.IN ADDITION TO HOSPITALS, NOVANT HEALTH INCLUDES A PHYSICIAN ORGANIZATION WITH PRACTICES IN GEORGIA, NORTH CAROLINA, SOUTH CAROLINA, AND VIRGINIA AND FIVE HOSPITAL FOUNDATIONS WHICH SUPPORT AND ENHANCE THE ACTIVITIES IN THOSE HOSPITALS' COMMUNITIES. FURTHER, NOVANT HEALTH INCLUDES AMBULATORY SURGERY CENTERS, IMAGING CENTERS, REHABILITATION CENTERS, AND OTHER OUTPATIENT FACILITIES; ALL DEDICATED TO PROMOTING THE HEALTH OF THEIR RESPECTIVE COMMUNITIES. PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORT NOVANT HEALTH, INC. FILES A SYSTEM-WIDE COMMUNITY BENEFIT REPORT PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES WITH THE NORTH CAROLINA MEDICAL CARE COMMISSION AS PART OF THE DOCUMENTATION REQUIRED FOR THE ISSUANCE OF TAX EXEMPT BOND FINANCING. 1 AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75231 135613797 501(C)(3) 122000 COMMUNITY OUTREACH ARTS COUNCIL 206 N SPRUCE ST SUITE 3 WINSTONSALEM NC 27101 560526856 501(C)(3) 35000 COMMUNITY OUTREACH CRISIS CONTROL MINISTRY 200 E TENTH STREET WINSTONSALEM NC 27101 237348168 501(C)(3) 10000 COMMUNITY OUTREACH FORSYTH FUTURES 301 N MAIN STREET SUITE 1700 WINSTONSALEM NC 27101 561092807 501(C)(3) 25000 COMMUNITY OUTREACH JUVENILE DIABETES FOUNDATION 216 WEST MARKET STREET SUITE B GREENSBORO NC 27401 231907729 501(C)(3) 15000 COMMUNITY OUTREACH SUSAN G KOMEN BREAST CANCER FOUNDATION 1106 BURKE STREET WINSTONSALEM NC 27101 752891104 501(C)(3) 15000 COMMUNITY OUTREACH MARCH OF DIMES 410 BROOKSTOWN AVE WINSTONSALEM NC 27101 131846366 501(C)(3) 10000 COMMUNITY OUTREACH OLD HICKORY COUNCIL 6600 SILAS CREEK PARKWAY WINSTONSALEM NC 27106 560529985 501(C)(3) 13000 COMMUNITY OUTREACH SENIOR SERVICES INC 2895 SHOREFAIR DRIVE NW WINSTONSALEM NC 27105 561085968 501(C)(3) 27500 COMMUNITY OUTREACH UNITED WAY OF FORSYTH COUNTY 301 N MAIN STREET SUITE 1700 WINSTONSALEM NC 27101 237357234 501(C)(3) 40000 COMMUNITY OUTREACH WS ALLIANCE 100 N MAIN STREET SUITE 2550 WINSTONSALEM NC 27101 311726654 501(C)(6) 35000 COMMUNITY OUTREACH WS STATE UNIVERSITY FOUNDATION 601 S MARTIN LUTHER KING JR DRIVE SUITE 304 WINSTONSALEM NC 27110 560989620 501(C)(3) 100000 COMMUNITY OUTREACH JUNIOR LEAGUE OF WINSTON-SALEM 390 S LIBERTY ST 100 WINSTONSALEM NC 27101 566047957 501(C)(3) 12500 COMMUNITY OUTREACH CHAMBER OF COMMERCE OF WINSTON-SALEM 411 W 4TH STREE SUITE 211 WINSTONSALEM NC 27101 560459820 501(C)(6) 25500 COMMUNITY OUTREACH CHAMBER OF COMMERCE OF KERNERSVILLE 136 E MOUNTAIN ST KERNERSVILLE NC 27284 560934946 501(C)(6) 7766 COMMUNITY OUTREACH WINSTON-SALEM SYMPHONY ASSOCIATION 201 N BROAD STREET SUITE 200 WINSTONSALEM NC 27105 560692826 501(C)(3) 55000 COMMUNITY OUTREACH SCIWORKS 400 W HANES MILL ROAD WINSTONSALEM NC 27105 560815746 501(C)(3) 15000 COMMUNITY OUTREACH DAVIE COUNTY ECONOMIC DEVELOPMENT 135 SOUTH SALISBURY STREET MOCKSVILLE NC 27028 561932514 501(C)(3) 15000 COMMUNITY OUTREACH JUNIOR LEAGUE OF GREENSBORO 3101 W FRIENDLY AVENUE GREENSBORO NC 27408 560685368 501(C)(3) 8000 COMMUNITY OUTREACH SCEPTOR PAIN FOUNDATION 145 KIMEL PARK DRIVE SUTIE 300 WINSTONSALEM NC 27103 020723571 501(C)(3) 50000 COMMUNITY OUTREACH 17 3 DISCOUNTED PRESCRIPTION DRUG PROGRAM 1086 83083 FMV PRESCRIPTION DRUG ASSISTANCE PART I, LINE 2 : PROCEDURES FOR MONITORING THE USE OF THE GRANT FUNDS THE FILING ORGANIZATION IS PART OF THE INTEGRATED HEALTHCARE SYSTEM OPERATED BY NOVANT HEALTH, INC. ("NOVANT HEALTH"), THE PARENT ORGANIZATION. NOVANT HEALTH'S BYLAWS AUTHORIZE IT TO ESTABLISH CERTAIN POLICIES FOR ALL OF ITS SUBSIDIARIES WITHIN THE SYSTEM. NOVANT HEALTH HAS ESTABLISHED A SYSTEM-WIDE CORPORATE POLICY WITH STANDARDIZED GUIDELINES THAT ARE TO BE USED IN REVIEWING THE ELIGIBILITY AND SELECTION OF GRANTEES RECEIVING CERTAIN EXEMPT PURPOSE FUNDS. THE FILING ORGANIZATION MAINTAINS DOCUMENTATION OF THE ELIGIBILITY AND SELECTION CRITERIA AND RECORDS OF THE AMOUNTS ARE MAINTAINED VIA THE GENERAL LEDGER. FUNDS ARE GENERALLY NOT TRACKED AFTER BEING GRANTED, AS THE ORIGINAL ELIGIBILITY AND SELECTION CRITERIA HAVE ALREADY BEEN MET. X X X X X X 1 1 0 1 0 0 0 0 0 0 0 EDWARDS JOEL TRUSTEE 491797 0 0 0 35731 0 56100 0 18961 0 602589 0 7500 0 ALLEN JOANNE PRESIDENT KMC 179815 0 57330 0 13518 0 45527 0 15683 0 311873 0 0 0 LINDSAY JEFFERY FMR PRES FMC/ COO WS MKT 709856 0 382813 0 133401 0 58100 0 25718 0 1309888 0 7500 0 MIHAL DENISE PRES FMC/ COO WS MKT 536038 0 235258 0 101223 0 57100 0 19036 0 948655 0 0 0 MORRIS JOHN ASST SEC 0 245757 0 60571 0 16426 0 55603 0 20706 0 399063 0 0 GREGORY CHERE SVP WOMEN'S SERVICES 15543 331653 0 48870 664 26227 0 84610 424 22643 16631 514003 0 0 JARRETT-PULLIAM KIMBERLY CNO 236515 0 0 0 25233 0 32260 0 13141 0 307149 0 0 0 LARSON KIP FORMER VP & SR MED DIR SPECIALTY SER 226721 0 194367 0 15032 0 47956 0 21450 0 505526 0 0 0 NYCUM LAWRENCE SVP MEDICAL AFFAIRS 355215 0 241467 0 31540 0 85651 0 35038 0 748911 0 0 0 SANZ SEAN SVP & COO NHFMC 249982 0 27000 0 17956 0 63467 0 27533 0 385938 0 0 0 WALLEY BRUCE FORMER SVP MEDICAL AFFAIRS 359448 0 248798 0 67095 0 46630 0 9989 0 731960 0 0 0 CHEN FRANKLIN ONCOLOGIST 340573 0 389945 0 699 0 57524 0 38428 0 827169 0 0 0 CHRYSSON NICK ONCOLOGIST 655047 0 158596 0 30994 0 63600 0 38881 0 947118 0 0 0 COLLINS TIMOTHY ONCOLOGIST 401530 0 275267 0 23549 0 58090 0 35542 0 793978 0 0 0 GROTE THOMAS ONCOLOGIST 444096 0 391318 0 27336 0 48114 0 28902 0 939766 0 0 0 PASCHOLD EUGENE ONCOLOGIST 442488 0 252637 0 28816 0 57526 0 33808 0 815275 0 0 0 MCGEE LAWRENCE FORMER ASST SEC 0 0 0 257268 0 91667 0 0 0 0 0 348935 0 7500 PART I, LINE 1A FRINGE OR EXPENSE EXPLANATION FIRST-CLASS OR CHARTER TRAVEL: FIRST-CLASS OR CHARTER TRAVEL IS NOT A COVERED TRAVEL EXPENSE FOR EXECUTIVES; THEY ARE LIMITED TO BUSINESS OR COACH CLASS FARES FOR COMMERCIAL FLIGHTS. HOWEVER, CHARTER TRAVEL IS AVAILABLE TO CERTAIN EXECUTIVES, BOARD MEMBERS, AND APPROVED BUSINESS PERSONNEL IN LIMITED CIRCUMSTANCES MEETING APPLICABLE POLICY CRITERIA. TRAVEL FOR COMPANIONS: COMPANIONS ARE ALLOWED ON CERTAIN CHARTER FLIGHTS PAID FOR BY THE ORGANIZATION. IN THAT CASE, THE VALUE OF THE COMPANION'S FLIGHT IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. TAX INDEMNIFICATION AND GROSS-UP PAYMENTS: EXECUTIVES WHO USE FUNDS MADE AVAILABLE THROUGH THEIR DISCRETIONARY SPENDING ACCOUNT UNDER THE EXECUTIVE PERQUISITE PLAN (THE "PLAN") TO PAY PREMIUMS ON CASH VALUE LIFE INSURANCE POLICIES MAY RECEIVE ADDITIONAL COMPENSATION TO ADJUST FOR THE INCOME TAX LIABILITY ASSOCIATED WITH PAYING PREMIUMS FOR THIS INSURANCE. EXECUTIVES WHO RECEIVE TAXABLE RELOCATION INCOME MAY HAVE THE ADDITIONAL INCOME TAX OWED ON THE INCOME PAID BY THE ORGANIZATION. EXECUTIVES MAY RECEIVE AS SEVERANCE BENEFITS CASH PAYMENTS IN LIEU OF PREMIUMS PAID FOR COVERAGE OF CERTAIN BENEFITS THAT ENDED WITH THE EXECUTIVE'S TERMINATION. THE ORGANIZATION MAY PAY THE ADDITIONAL TAX OWED ON ACCOUNT OF THESE PAYMENTS. DISCRETIONARY SPENDING ACCOUNT: CERTAIN EXECUTIVES RECEIVE A DISCRETIONARY SPENDING ACCOUNT. THE DOLLAR AMOUNT IN THE ACCOUNT IS PRE-APPROVED BY THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE NOVANT HEALTH BOARD OF TRUSTEES. THE ACCOUNT CAN BE USED ONLY FOR AN APPROVED LIST OF EXPENDITURES. ALL OPTIONS OTHER THAN A DEFERRED, AT-RISK, COMPENSATION OPTION ARE CONSIDERED TAXABLE AND ARE INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE: WE PROVIDE TEMPORARY HOUSING ALLOWANCES IN CERTAIN EXECUTIVE RECRUITMENT AND RELOCATION PACKAGES. IN THE CASE THAT SUCH EXPENSE IS NOT REIMBURSABLE UNDER THE ACCOUNTABLE PLAN RULES, THE VALUE IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES: IN CASES WHERE CORPORATE MEMBERSHIPS ARE NOT AVAILABLE, A MEMBERSHIP MAY BE OBTAINED IN AN EXECUTIVE'S NAME WITH A "BUSINESS USE ONLY" RESTRICTION. PART I, LINE 3 THE FILING ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, AN INTEGRATED HEALTHCARE SYSTEM. NOVANT HEALTH, INC. IS THE PARENT ORGANIZATION AND USES THE PROCESS DESCRIBED IN PART VI, LINE 15A OF THIS RETURN TO ESTABLISH THE COMPENSATION OF THE TOP MANAGEMENT OFFICIAL OF THE FILING ORGANIZATION. THIS PROCESS ADHERES TO THE REQUIREMENTS SET FORTH TO SECURE THE REBUTTABLE PRESUMPTION OF REASONABLENESS AND INCLUDES A REVIEW AND APPROVAL BY INDEPENDENT AND DISINTERESTED MEMBERS OF A COMPENSATION COMMITTEE, CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, THE UTILIZATION OF THIRD-PARTY COMPARABILITY DATA SUCH AS PUBLISHED COMPENSATION SURVEYS, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. PART I, LINE 4B PART I, LINE 4A-C: SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SEVERANCE NONQUALIFIED EQUITY-BASED GREGORY, CHERE 0 52,500 0 NYCUM, LAWRENCE 0 28,125 0 SANZ, SEAN 0 25,550 0 PART III - OTHER ADDITIONAL INFORMATION DESCRIPTIONS OF SUPPLEMENTAL EXECUTIVE BENEFITS INCLUDED IN PART VII AND SCHEDULE J: EXECUTIVE ANNUAL INCENTIVE PLAN: AS PART OF THE REPORTED COMPENSATION AMOUNTS, THE REPORTING ORGANIZATION PROVIDES ANNUAL INCENTIVE COMPENSATION TO CERTAIN KEY EXECUTIVES UNDER AN EXECUTIVE ANNUAL INCENTIVE PLAN. THE INCENTIVE PLAN IS DESIGNED TO OFFER OPPORTUNITIES FOR ADDITIONAL COMPENSATION, BUT ONLY TO THE EXTENT THAT ELIGIBLE EXECUTIVES HAVE PROVIDED EXTRAORDINARY SERVICES AND ACHIEVED EXTRAORDINARY RESULTS THAT MEET OR EXCEED PREDETERMINED GOALS IN THE AREAS OF QUALITY, PATIENT SATISFACTION, EMPLOYEE SATISFACTION AND FINANCIAL VITALITY. THESE GOALS ARE ESTABLISHED AND APPROVED BY INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD). THESE GOALS ARE WEIGHTED EQUALLY. THE ADDITIONAL COMPENSATION CAN RANGE ANYWHERE FROM ZERO TO A MAXIMUM PERCENTAGE OF BASE SALARY THAT DIFFERS BY THE CLASS OF EXECUTIVE. IN ADDITION, THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD WHO OVERSEE THE INCENTIVE COMPENSATION PROGRAM APPLY TWO "CIRCUIT BREAKERS," WHICH ARE SUBSTANTIAL LEVELS OF ORGANIZATION-WIDE ACHIEVEMENT THAT MUST BE SATISFIED BEFORE ANY AWARDS ARE PAID TO ANY EXECUTIVE UNDER THE PROGRAM. THE INCENTIVE COMPENSATION AWARDS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(II) OF SCHEDULE J. THEY ARE REPORTED IN THE YEAR PAID. THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD REVIEW, APPROVE, AND OVERSEE ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS ANNUAL INCENTIVE PLAN. LONG-TERM INCENTIVE PLAN: THE REPORTING ORGANIZATION OFFERS A LONG-TERM INCENTIVE PLAN (THE "PLAN") TO CERTAIN KEY EXECUTIVES. THE PLAN TIES A KEY EXECUTIVE'S COMPENSATION TO THE ORGANIZATION'S LONG-TERM STRATEGIC PERFORMANCE, PROVIDES A RETENTION INCENTIVE FOR KEY EXECUTIVES, AND ALLOWS THE ORGANIZATION TO COMPETE IN THE MARKETPLACE FOR TOP LEADERSHIP TALENT. THE PLAN OPERATES ON THREE-YEAR PERFORMANCE CYCLES THAT BEGIN EACH YEAR. LONG-TERM STRATEGIC GOALS (IN THE PRINCIPAL AREAS OF QUALITY OF PATIENT CARE AND LONG-TERM FINANCIAL STRENGTH) ARE ESTABLISHED AND APPROVED FOR EACH CYCLE, IN ADVANCE, BY INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD). NOVANT HEALTH'S INTERNAL AUDIT DEPARTMENT REVIEWS THE METHODOLOGY AND PROCESS USED TO DETERMINE ACHIEVEMENT OF THE QUALITY METRICS. IN ADDITION, THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD WHO OVERSEE THE INCENTIVE COMPENSATION PROGRAM APPLY TWO "CIRCUIT BREAKERS," RELATING TO COMMUNITY HEALTH NEEDS ASSESSMENTS AND IMPLEMENTATION PLANS, AND FINANCIAL PERFORMANCE; AWARDS ARE PAYABLE FOR A PARTICULAR THREE-YEAR PERFORMANCE CYCLE ONLY IF THE CIRCUIT BREAKERS ARE MET FOR THE RESPECTIVE THREE-YEAR PERFORMANCE PERIOD. IF AN AWARD IS EARNED AT THE END OF A PERFORMANCE CYCLE, THEN THE INCENTIVE AWARD IS PAID OUT AND IS INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(II) OF SCHEDULE J. THEY ARE REPORTED IN THE YEAR PAID. THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THE PLAN. PART I, LINE 4A - SEVERANCE PLAN: ELIGIBLE EXECUTIVES MAY RECEIVE SEVERANCE PAY THAT IS BASED ON ANNUAL COMPENSATION FOR A SPECIFIED PERIOD OF TIME. THE SEVERANCE PAY WOULD BE PAID ONLY IN THE EVENT OF CERTAIN TYPES OF EMPLOYMENT TERMINATION, AND IS FURTHER CONTINGENT ON THE SATISFACTION OF OTHER CONDITIONS SUCH AS COMPLIANCE WITH A NON-COMPETITION COVENANT. ANY CURRENT YEAR PAYMENTS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(III) OF SCHEDULE J. THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS SEVERANCE PLAN. PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS: THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("SERP") IS INTENDED TO SUPPORT RETENTION OF KEY EXECUTIVES, AND TO OFFER COMPETITIVE TOTAL COMPENSATION. ELIGIBLE EXECUTIVES WILL BE NOMINATED BY THE CEO AND APPROVED BY THE COMMITTEE TO PARTICIPATE. GENERALLY, ANNUAL CONTRIBUTIONS TO THE PLAN OR PAYMENTS TO PARTICIPANTS WILL BE BASED ON A PERCENTAGE OF THE PARTICIPANT'S BASE SALARY AS OF JANUARY 1ST OF THE PREVIOUS PLAN YEAR AND ARE REPORTED IN COLUMN (C) OF SCHEDULE J. PRIOR TO MAKING THE CONTRIBUTIONS OR PAYMENTS, THE COMMITTEE WILL APPROVE THE AMOUNTS AS TO REASONABLENESS, WHEN COMBINED WITH ALL OTHER ANNUAL COMPENSATION. A 3 YEAR CLASS-YEAR VESTING PERIOD WILL APPLY UP TO AGE 62, WHEN ALL MONEY WOULD BE VESTED AND PAID OUT TO THE PARTICIPANT. OTHERWISE, VESTING WILL OCCUR ON JANUARY 1ST OF EACH YEAR FOR THE APPROPRIATE CLASS-YEAR VESTING PERIOD. THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS INCLUDING THE AMOUNTS AWARDED UNDER THE PLAN. CHERE GREGORY EMPLOYEE EMPLOYMENT RELATED X 63125 20 0 1 1 20 MARY E WALLEY FAMILY MEMBER OF BRUCE WALLEY, KEY EMPLOYEE 93255 COMPENSATION PAID BY THE FILING ORGANIZATION TO A FAMILY MEMBER OF THE INTERESTED PERSON. 0 X 1 5452 FMV 0 0 1 0 PART I, COLUMN (B): NUMBER OF CONTRIBUTIONS FORM 990, PI, L1: ORGANIZATION'S MISSION OR MOST SIGNIFICANT ACTIVITIES FORSYTH MEMORIAL HOSPITAL, INC. DOING BUSINESS AS NOVANT HEALTH FORSYTH MEDICAL CENTER ("NHFMC") IS AN INTEGRAL PART OF THE NOVANT HEALTH SYSTEM (COLLECTIVELY KNOWN AS "NOVANT HEALTH"), A NOT-FOR-PROFIT INTEGRATED GROUP OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS AND OTHER HEALTHCARE SERVICE PROVIDERS. NOVANT HEALTH CONSISTS OF MORE THAN 1,200 PHYSICIANS AND 26,000 EMPLOYEES WHO MAKE HEALTHCARE REMARKABLE AT NEARLY 500 LOCATIONS, INCLUDING 14 MEDICAL CENTERS AND HUNDREDS OF OUTPATIENT FACILITIES AND PHYSICIAN CLINICS. HEADQUARTERED IN WINSTON-SALEM, NC, NOVANT HEALTH IS COMMITTED TO MAKING HEALTHCARE REMARKABLE FOR PATIENTS AND COMMUNITIES, SERVING MORE THAN FOUR MILLION PATIENTS ANNUALLY. NOVANT HEALTH IS RANKED AS ONE OF THE NATION'S TOP 20 INTEGRATED DELIVERY NETWORKS BY IMS HEALTH. IN 2014, THE NOVANT HEALTH SYSTEM REPORTED $3.8 BILLION IN REVENUES. GENERAL INFORMATION NHFMC IS A TERTIARY HOSPITAL COMMITTED TO IMPROVING THE HEALTH OF OUR COMMUNITIES IN THE PIEDMONT TRIAD REGION OF NC, ONE PERSON AT A TIME. IT OFFERS A FULL CONTINUUM OF EMERGENCY, MEDICAL, SURGICAL, REHABILITATIVE AND BEHAVIORAL HEALTH SERVICES. CENTERS OF EXCELLENCE INCLUDE THE FOLLOWING: NOVANT HEALTH MAYA ANGELOU WOMEN'S HEALTH AND WELLNESS CENTER, NOVANT HEALTH HEART AND VASCULAR INSTITUTE, NOVANT HEALTH DERRICK L. DAVIS CANCER CENTER, NOVANT HEALTH STROKE AND NEUROSCIENCES SPECIALISTS, NOVANT HEALTH ORTHOPEDIC CENTER AND NOVANT HEALTH FORSYTH BEHAVIORAL HEALTH. IN ADDITION, NHFMC IS FOCUSED ON PROVIDING COMMUNITY SUPPORT, CONSISTENT QUALITY, EXCELLENT SERVICE AND A REMARKABLE WORK ENVIRONMENT FOR STAFF. IN ITS THIRD FULL YEAR OF OPERATION, NOVANT HEALTH FORSYTH MEDICAL CENTER AFFILIATE HOSPITAL, NOVANT HEALTH KERNERSVILLE MEDICAL CENTER IN KERNERSVILLE, NC, FOCUSED ON PROVIDING A REMARKABLE PATIENT EXPERIENCE VIA A FAST-ACCESS EMERGENCY DEPARTMENT, GENERAL, ORTHOPEDIC AND EYE SURGICAL SERVICES, CONSISTENT QUALITY, AND EXCELLENT SERVICE TO RESIDENTS IN THE KERNERSVILLE AREA, WESTERN GUILFORD AND ROCKINGHAM COUNTIES OF NC, AS WELL AS EASTERN STOKES AND FORSYTH COUNTIES OF NC. IN ADDITION, THE MEDICAL CENTER OPENED A BREAST HEALTH CENTER AND A CANCER CENTER IN 2014. NOVANT HEALTH FORSYTH MEDICAL CENTER'S AFFILIATE HOSPITAL, NOVANT HEALTH CLEMMONS MEDICAL CENTER IN CLEMMONS, NC FOCUSED ON PROVIDING A REMARKABLE PATIENT EXPERIENCE VIA A FAST-ACCESS EMERGENCY DEPARTMENT, GENERAL, ORTHOPEDIC, PODIATRIC AND EAR, NOSE AND THROAT SURGICAL SERVICES, CONSISTENT QUALITY, AND EXCELLENT SERVICE TO RESIDENTS IN WESTERN FORSYTH COUNTY, DAVIE COUNTY AND YADKIN COUNTY. IN ADDITION TO OUR QUALITY OF SERVICES AND COMPREHENSIVE CATEGORIES OF SERVICE, WE'RE VERY PROUD OF OUR PATIENT FINANCIAL ASSISTANCE PROGRAM. WE WORK WITH CUSTOMERS TO HELP QUALIFY THEM FOR PUBLIC ASSISTANCE, ESTABLISH A REASONABLE PAYMENT PLAN, DISCOUNT THEIR BILL OR PROVIDE THEM WITH FREE CHARITY CARE. NEW TECHNOLOGY & SERVICES DURING 2014, NHFMC EXPANDED ACCESS TO MEDICAL CARE AND PROVIDED ADDITIONAL RESOURCES TO HELP PATIENTS AND OUR LOCAL COMMUNITIES GET BETTER AND STAY HEALTHY. NOVANT HEALTH PATIENTS DISCHARGED FROM NHFMC EXPERIENCE A SIMPLER TRANSITION TO HOME FROM THE HOSPITAL DUE TO READY AT HOME. THE PROGRAM'S TEAM COORDINATES DETAILS AROUND A PATIENT'S DISCHARGE AND AT-HOME MEDICATIONS. IF PATIENTS NEED MEDICATIONS OR OTHER HEALTHCARE SUPPLIES, THE TEAM'S TRANSITION SPECIALISTS PROVIDE AFFORDABLE SOLUTIONS. SINCE DISCHARGE MEDICATIONS AND SUPPLIES ARE NOT INCLUDED IN THE HOSPITAL BILL, READY AT HOME HELPS MAKE SURE THEY ARE PROPERLY PROCESSED BY THE INSURER. NEARLY HALF OF ALL AMERICANS NEVER FILL THEIR PRESCRIPTIONS, FILL THEM BUT NEVER TAKE THE DRUG, OR DON'T TAKE THE FULL DOSE. READY AT HOME IS ADDRESSING THAT PROBLEM. A CONCURRENT ELECTRONIC HEALTH RECORD (EHR) INITIATIVE IS BEING UNDERTAKEN BY BOTH THE ACUTE AND AMBULATORY FACILITIES IN THE NOVANT HEALTH SYSTEM. IN JULY, 2013, NOVANT HEALTH MEDICAL GROUP FINALIZED THE IMPLEMENTATION OF THE EHR IN ALL PHYSICIAN PRACTICES ACROSS THE NOVANT HEALTH SYSTEM. MANY NOVANT HEALTH FACILITIES HAVE SUCCESSFULLY IMPLEMENTED THE EHR AND CLINICIANS CAN NOW SHARE PATIENTS' MEDICAL INFORMATION BETWEEN PHYSICIAN OFFICES, OUTPATIENT CENTERS AND HOSPITALS. THIS SHARING OF INFORMATION IMPROVES SAFETY AND COORDINATION OF CARE AND PROMOTES CONNECTIVITY AND COMMUNICATION BETWEEN HOSPITAL CAREGIVERS, SPECIALISTS AND PRIMARY CARE PROVIDERS. EMBARKING ON THE JOURNEY TO CREATE A SHARED EHR IS THE MOST SIGNIFICANT AND IMPORTANT INVESTMENT NOVANT HEALTH HAS EVER MADE FOR ITS PATIENTS, STAFF AND PHYSICIANS. AWARDS, RECOGNITIONS & RECERTIFICATIONS WE ARE PROUD OF THE ACHIEVEMENTS IN QUALITY THIS YEAR AS WE RANK WELL ABOVE STATE AVERAGES IN HEART ATTACK, HEART FAILURE AND PNEUMONIA CARE. IN ADDITION, NHFMC'S BREAST CANCER CENTER PROGRAM IS NATIONALLY CERTIFIED. THE CENTER'S STROKE AND NEUROSCIENCES INSTITUTE AND CARDIAC AND VASCULAR CENTER HEART FAILURE PROGRAM AND STROKE REHABILITATION PROGRAM ARE ALL NATIONALLY ACCREDITED AS WELL AS ITS TOTAL HIP AND KNEE JOINT REPLACEMENT PROGRAM. NHFMC IS AMONG 22 HOSPITALS NATIONWIDE TO EARN THE ADVANCED COMPREHENSIVE STROKE CENTER DESIGNATION FROM THE JOINT COMMISSION AND THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION. THE DESIGNATION WAS EARNED FOR HAVING ADVANCED CAPABILITIES AND EXPERTISE IN TREATING THE MOST COMPLEX STROKE CASES. NHFMC'S HEART FAILURE PROGRAM RECEIVED ADVANCED HEART FAILURE CERTIFICATION FOR EXCEPTIONAL EFFORTS TO IMPROVE HEART FAILURE PATIENT OUTCOMES AND THE AMERICAN COLLEGE OF SURGEONS NAMED NHFMC WITHIN ITS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM. THE NOVANT HEALTH MAYA ANGELOU WOMEN'S HEALTH AND WELLNESS CENTER WAS DESIGNATED A CENTER OF EXCELLENCE IN MINIMALLY INVASIVE GYNECOLOGIC SURGERY BY THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS. NHFMC HAS BEEN RECOGNIZED FOR ACHIEVING THE TOP 10 PERCENT OF HOSPITALS NATIONALLY FOR PATIENT SATISFACTION BASED ON HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS DATA. IN ADDITION, U.S. NEWS & WORLD REPORT RELEASED ITS 2013-2014 BEST HOSPITALS REPORT, RANKING NHFMC IN EIGHT SPECIALTIES: DIABETES & ENDOCRINOLOGY, GASTROENTEROLOGY & GI SURGERY, GERIATRICS, GYNECOLOGY, NEPHROLOGY, NEUROLOGY & NEUROSURGERY, ORTHOPEDICS AND PULMONOLOGY. OUR COMMITMENT TO EXCELLENCE IN PATIENT CARE, INCLUDING NURSING CARE, CONTINUED DURING THE YEAR. NHFMC IS AMONG ONLY 6.9 PERCENT OF HOSPITALS IN THE UNITED STATES TO BE DESIGNATED BY THE AMERICAN NURSES CREDENTIALING CENTER AS A MAGNET FACILITY, CONFIRMING THE EXCEPTIONAL QUALITY OF CARE THAT OUR NURSES PROVIDE. AT THE STATE LEVEL, TWO NURSES FROM NHFMC WERE SELECTED BY THE NORTH CAROLINA NURSES' ASSOCIATION TO BE AMONG THE "GREAT 100 NURSES." OVER THE PAST SEVERAL YEARS, NHFMC HAS ACHIEVED SIGNIFICANT PROGRESS IN THIS AREA BY PROVIDING SAFETY EDUCATION FOR ALL TEAM MEMBERS AND MAKING CHANGES IN AREAS WHERE THE FREQUENCY OF SERIOUS SAFETY EVENTS IS GREATER THAN ZERO. IN 2013, NHFMC IMPLEMENTED NEW BIOMETRIC TECHNOLOGY TO AID PATIENT SAFETY. THE RIGHTPATIENT BIOMETRIC PATIENT IDENTIFICATION SYSTEM IS NOW PART OF THE ADMISSION PROCESS AND USES IRIS RECOGNITION TO IDENTIFY PATIENTS. THIS TECHNOLOGY IMPROVES PATIENT SAFETY BY ACCURATELY IDENTIFYING PATIENTS AND LIMITING DUPLICATE MEDICAL RECORDS. IT ALSO HELPS TO ELIMINATE MEDICAL IDENTIFY THEFT AT THE POINT OF SERVICE. ACCREDITATION NHFMC HAS BEEN FULLY ACCREDITED BY THE JOINT COMMISSION, AN INDEPENDENT ORGANIZATION THAT EVALUATES A HEALTHCARE ORGANIZATION'S PERFORMANCE IN AREAS THAT MOST AFFECT PATIENT HEALTH AND SAFETY. IN 2014, NHFMC ALSO PASSED A SUCCESSFUL SURVEY BY THE JOINT COMMISSION TO ACHIEVE ACCREDITATION FOR ADVANCED PALLIATIVE CARE. THE ONSITE SURVEYOR CONGRATULATED STAFF FOR HAVING A "PHENOMENAL" PROGRAM THAT IS A NATIONAL LEADER IN TEAMWORK, BEST PRACTICES AND DATA UTILIZATION. NHKMC SUCCESSFULLY COMPLETED ITS SECOND JOINT COMMISSION ACCREDITATION SURVEY WITH OUTSTANDING RESULTS. COMMUNITY BENEFIT REPORT HTTP://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMPANY-INFORMATION/FINANCIAL -PROFILE/COMMUNITY-BENEFIT-REPORT.ASPX THE COMMUNITY BENEFIT REPORT PREPARED BY NOVANT HEALTH IS A SYSTEM-WIDE REPORT THAT INCLUDES QUALITATIVE AND QUANTITATIVE INFORMATION. PLEASE NOTE THAT THE NUMERIC DATA IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT, ITS COMMUNITY HEALTH NEEDS ASSESSMENT OR COMMUNITY BENEFIT IMPLEMENTATION STRATEGY. IN THIS REPORT, THE NOVANT HEALTH SYSTEM'S COMMUNITY BENEFIT WAS APPROXIMATELY $639,000,000, INCLUDING $135,000,000 IN CHARITY CARE FOR 2014. FORM 990, PART III, LINE 1: MISSION, VISION, AND VALUES MISSION: NOVANT HEALTH EXISTS TO IMPROVE THE HEALTH OF COMMUNITIES, ONE PERSON AT A TIME. VISION: WE, THE NOVANT HEALTH TEAM, WILL DELIVER THE MOST REMARKABLE PATIENT EXPERIENCE, IN EVERY DIMENSION, EVERY TIME. VALUES: - COMPASSION: WE TREAT OUR CUSTOMERS AND THEIR FAMILIES, STAFF AND OTHER HEALTHCARE PROVIDERS AS FAMILY MEMBERS BY SHOWING THEM KINDNESS, PATIENCE, EMPATHY AND RESPECT. - DIVERSITY AND INCLUSION: WE RECOGNIZE THAT EVERY PERSON IS DIFFERENT, EACH SHAPED BY UNIQUE LIFE EXPERIENCES. THIS ENABLES US TO BETTER UNDERSTAND ONE ANOTHER AND OUR CUSTOMERS. BY ENGAGING THE STRENGTHS AND TALENTS OF EACH TEAM MEMBER, WE ENSURE A STRONG ORGANIZATION CAPABLE OF PROVIDING REMARKABLE HEALTHCARE TO OUR PATIENTS, FAMILIES AND COMMUNITIES. - PERSONAL EXCELLENCE: WE STRIVE TO GROW PERSONALLY AND PROFESSIONALLY, AND WE APPROACH EACH SERVICE OPPORTUNITY WITH A POSITIVE, FLEXIBLE ATTITUDE. HONESTY AND PERSONAL INTEGRITY GUIDE ALL THAT WE DO. - TEAMWORK: THE NEEDS AND EXPECTATIONS OF ANY ONE CUSTOMER ARE GREATER THAN THAT WHICH ONE PERSON'S SERVICE EFFORTS CAN SATISFY. WE SUPPORT EACH OTHER SO THAT TOGETHER AS A TEAM, WE CAN BE SUCCESSFUL IN THE EYE OF THE CUSTOMER AS A QUALITY SERVICE PROVIDER. - COURAGE: WE ACT BOLDLY IN MAKING THE CHANGES NECESSARY TO ACHIEVE OUR MISSION, VISION AND PROMISE OF DELIVERING REMARKABLE HEALTHCARE. OUR PROMISE TO PATIENTS WE ARE MAKING YOUR HEALTHCARE EXPERIENCE REMARKABLE. WE WILL BRING YOU WORLD-CLASS CLINICIANS, CARE AND TECHNOLOGY - WHEN AND WHERE YOU NEED THEM. WE ARE REINVENTING THE HEALTHCARE EXPERIENCE TO BE SIMPLER, MORE CONVENIENT AND MORE AFFORDABLE, SO THAT YOU CAN FOCUS ON GETTING BETTER AND STAYING HEALTHY. FORM 990, PART I, LINE 6: THE NUMBER OF VOLUNTEERS REPORTED INCLUDES THOSE VOLUNTEERS SERVING AS BOARD MEMBERS. FORM 990, PART III, LINE 4A: PROGRAM SERVICE ACCOMPLISHMENTS KMC HAS 50 LICENSED BEDS. DURING 2014 THERE WERE 9,303 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 4 DAYS, AND AVERAGE DAILY CENSUS OF 25, AND 2,540 DISCHARGES. THERE WERE 3,070 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 40,267 OUTPATIENT ENCOUNTERS AND 31,034 EMERGENCY DEPARTMENT VISITS. DURING 2014 CMC HAD 928 OUTPATIENT SURGERIES, A TOTAL OF 12,920 OUTPATIENT ENCOUNTERS AND 11,640 EMERGENCY DEPARTMENT VISITS. FORM 990, PART VI, SECTION A, LINE 6 FORM 990, PART VI, SECTION A, LINE 6: CLASSES OF MEMBERS OR STOCKHOLDERS THE CORPORATION IS A NONPROFIT CORPORATION WITH MEMBERS (OR A MEMBER). FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION A, LINE 7A: ELECTION OF MEMBERS AND THEIR RIGHTS NOVANT HEALTH, INC. ELECTS ALL MEMBERS OF THE GOVERNING BODY OF FORSYTH MEMORIAL HOSPITAL,INC. FORM 990, PART VI, SECTION A, LINE 7B FORM 990, PART VI, SECTION A, LINE 7B: DECISIONS SUBJECT TO APPROVAL OF MEMBERS NOVANT HEALTH, INC. HAS CERTAIN RESERVED POWERS, SUCH AS APPROVAL OF AMENDMENTS TO THE ARTICLES AND BYLAWS OF THE CORPORATION, AND TO ADOPT CERTAIN POLICIES WHICH SHALL BE IMPLEMENTED BY THE CORPORATION BOARD. FORM 990, PART VI, SECTION B, LINE 11 FORM 990, PART VI, SECTION B, LINE 11: ORGANIZATION'S PROCESS TO REVIEW FORM 990 THE BOARD HAS DELEGATED REVIEW OF THE FORM 990 TO NOVANT HEALTH'S AUDIT AND COMPLIANCE COMMITTEE ("THE COMMITTEE"), WHICH OVERSEES TAX MATTERS FOR NOVANT HEALTH. THE COMMITTEE IS THE REVIEW BODY FOR ALL OF THE FORM 990S FILED FOR ORGANIZATIONS WITHIN THE NOVANT HEALTH SYSTEM. THE COMMITTEE MEETS BEFORE THE FORM 990S ARE FILED WITH THE IRS AND AFTER ALL BOARD MEMBERS HAVE RECEIVED A COPY OF THE FORM 990 AND A SUMMARY OF ITS CONTENTS. THE SENIOR DIRECTOR OF TAX AND LEGAL COUNSEL FOR NOVANT HEALTH ATTEND THE MEETING TO ANSWER ANY QUESTIONS AND ADDRESS ANY SIGNIFICANT DISCLOSURES WITHIN THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C FORM 990, PART VI, SECTION B, LINE 12C: MONITORING AND ENFORCEMENT OF COI THE ORGANIZATION'S TRUSTEE CONFLICT OF INTEREST POLICY APPLIES TO ALL TRUSTEES, PRINCIPAL OFFICERS OR MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS INCLUDING ANY APPLICABLE DISREGARDED ENTITIES. ALL TRUSTEES ARE SENT AN ANNUAL DISCLOSURE FORM. THE TRUSTEE ANNUAL DISCLOSURE FORMS ARE REVIEWED BY THE LEGAL DEPARTMENT. WITH RESPECT TO PARTICULAR TRANSACTIONS THAT COME BEFORE THE BOARD, THE CONFLICT OF INTEREST POLICY WOULD BE FOLLOWED. THE POTENTIAL CONFLICT OF INTEREST WOULD BE DISCLOSED BY THE BOARD MEMBER BEFORE A VOTE ON THE TRANSACTION AND THE REST OF THE BOARD WOULD DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF THE REST OF THE BOARD DETERMINED THAT A CONFLICT OF INTEREST EXISTED THEN THE BOARD MEMBER WITH THE CONFLICT OF INTEREST WOULD NOT PARTICIPATE IN THE DELIBERATIONS AND VOTE. FORM 990, PART VI, SECTION B, LINE 15B FORM 990, PART VI, SECTION B, LINE 15A: COMPENSATION PROCESS FOR TOP OFFICIAL THE FILING ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, AN INTEGRATED HEALTHCARE SYSTEM COLLECTIVELY REFERRED TO AS "NOVANT HEALTH." NOVANT HEALTH, INC. IS THE PARENT ORGANIZATION AND INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH, INC. BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS OF COMPENSATION AND BENEFITS FOR CERTAIN EXECUTIVES ("EXECUTIVES") SERVING AS THE TOP MANAGEMENT OFFICIAL(S) FOR NOVANT HEALTH ENTITIES. THE COMMITTEE WORKS WITH AN INDEPENDENT COMPENSATION CONSULTANT AND USES THIRD PARTY COMPARABILITY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS TO ENSURE THAT TOTAL COMPENSATION AND BENEFITS FOR EACH EXECUTIVE IS REASONABLE FOR THAT EXECUTIVE'S POSITION. THE COMMITTEE REVIEWS AND APPROVES EXECUTIVE COMPENSATION AND BENEFITS ANNUALLY, CONSISTENT WITH THE WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY OF NOVANT HEALTH, AND IN A MANNER THAT QUALIFIES FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, THEREBY ASSURING THAT TOTAL COMPENSATION AND BENEFITS PROVIDED TO EACH EXECUTIVE IS REASONABLE. FORM 990, PART VI, SECTION B, LINE 15B: COMPENSATION PROCESS FOR OFFICERS THE FILING ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, AN INTEGRATED HEALTHCARE SYSTEM COLLECTIVELY REFERRED TO AS "NOVANT HEALTH." NOVANT HEALTH, INC. IS THE PARENT ORGANIZATION AND INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH, INC. BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS OF COMPENSATION AND BENEFITS FOR CERTAIN LEADERS AND EXECUTIVES ("EXECUTIVES") SERVING AS OFFICERS OR KEY EMPLOYEES FOR NOVANT HEALTH ENTITIES. THE COMMITTEE WORKS WITH AN INDEPENDENT COMPENSATION CONSULTANT AND USES THIRD PARTY COMPARABILITY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS TO ENSURE THAT TOTAL COMPENSATION AND BENEFITS FOR EACH EXECUTIVE IS REASONABLE FOR THAT EXECUTIVE'S POSITION. THE COMMITTEE REVIEWS AND APPROVES EXECUTIVE COMPENSATION AND BENEFITS ANNUALLY, CONSISTENT WITH THE WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY OF NOVANT HEALTH, AND IN A MANNER THAT QUALIFIES FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, THEREBY ASSURING THAT TOTAL COMPENSATION AND BENEFITS PROVIDED TO EACH EXECUTIVE IS REASONABLE. FORM 990, PART VI, SECTION C, LINE 19 FORM 990, PART VI, SECTION C, LINE 19: GOVERNING DOCUMENTS DISCLOSURE THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS CONTAINING ALL ORGANIZATIONS IN THE NOVANT HEALTH SYSTEM ARE POSTED TO THE NOVANT HEALTH WEBSITE. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. FORM 990, PART VII, SECTION A, COLUMN B: RELATED ORGANIZATIONS THE ORGANIZATION EMPLOYS CERTAIN EXECUTIVES WHOSE ROLES ARE SUCH THAT THEY PROVIDE SERVICES TO NOT ONLY THE ORGANIZATION, BUT ALSO TO SOME OR ALL OF THE OTHER TAX-EXEMPT ORGANIZATIONS WITHIN THE NOVANT HEALTH HEALTHCARE SYSTEM. FOR EXAMPLE, MANY OF THESE EXECUTIVES' ROLES FOCUS ON PARTICULAR SERVICE LINES WHICH CROSS THE VARIOUS GEOGRAPHIC MARKETS OUR ORGANIZATIONS SERVE, THUS THE SERVICES PROVIDED BY THESE EXECUTIVES MAY BENEFIT AND BE RECEIVED BY MULTIPLE ORGANIZATIONS WITHIN THE SYSTEM. THE EXECUTIVES DO NOT ALLOCATE THEIR HOURS BETWEEN THE VARIOUS ORGANIZATIONS, BUT RATHER THEIR TIME SPENT ON SERVICES TO THE ORGANIZATION IS INCLUSIVE OF SERVICES TO ALL OF THE ORGANIZATIONS THEY SERVE WITHIN THE SYSTEM. FORM 990, PART XI, LINE 9: FMCF AND AUXILIARY OF FMC CONTRIBUTION: -2,574,510. MALPRACTICE INSURANCE: -3,817,958. AFFILIATE TRANSFERS: -1,752,670. ROUNDING: 4. 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