2015-11-13T14:55:18-06:00 2014-12-31 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2014-01-01 636001820 JACKSON HOSPITAL AND CLINIC INC JACK 3342938000 1725 PINE STREET NO 1200 MONTGOMERY AL 36106 JOE B RILEY PRESIDENT / CEO 3342938000 2015-11-13 1 AMY BIBBY P00445891 8282542254 2014 2016-04-25 22:37:26Z JOE B RILEY 1725 PINE STREET NO 1200 MONTGOMERY AL 36106 196167950 0 X WWW.JACKSON.ORG X 1946 AL COMMUNITY NOT-FOR-PROFIT 344 BED HOSPITAL SERVING MONTGOMERY AND ALABAMA RIVER REGION 11 9 1754 49 317202 277897 182781 140954 187916415 188998563 3422874 2510670 4314565 4517763 195836635 196167950 115306 37466 0 0 71345311 76094698 0 0 107643 117754466 118807964 189215083 194940128 6621552 1227822 232769121 229344065 130874941 123160570 101894180 106183495 X TO PROVIDE SUPERIOR HEALTHCARE IN A SAFE, COMPASSIONATE ENVIRONMENT WHILE FULFILLING OUR CHARITABLE OBLIGATION AS A NOT-FOR-PROFIT ORGANIZATION. 0 0 159365865 37466 191418964 JACKSON HOSPITAL OPERATES A GENERAL ACUTE CARE HOSPITAL THAT PROVIDES CERTAIN TERTIARY SERVICES SUCH AS NEUROLOGY AND NEUROSURGERY, CARDIOLOGY (INCLUDING CARDIAC CATHERIZATION AND CARDIOVASCULAR SURGERY) AND ONCOLOGY. JACKSON HOSPITAL IS LICENSED FOR 344 BEDS THAT INCLUDE 30 INTENSIVE CARE BEDS AND 22 OBSTETRIC BEDS. PLEASE SEE SCHEDULE O FOR A CONTINUATION OF OUR PROGRAM SERVICE ACCOMPLISHMENTS.THE INPATIENT ANCILLARY AND SUPPORT SERVICES OFFERED BY JACKSON HOSPITAL ARE AS FOLLOWS; ACUTE DIALYSIS, BLOOD BANK, CARDIAC CATHETERIZATION LABORATORY, NUCLEAR MEDICINE, NURSERY (LEVEL II), PHARMACY, PHYSICAL THERAPY, POST ANESTHESIA CARE, RESPIRATORY CARE, ELECTRO CARDIOLOGY, INTENSIVE CARE, LABOR AND DELIVERY, MRI, CARDIOVASCULAR SURGERY, CARDIOVASCULAR LABORATORY, CLINICAL AND ANATOMICAL LABORATORY, COMPUTERIZED TOMOGRAPHY, CORONARY CARE, DIAGNOSTIC RADIOLOGY, SURGICAL FACILITIES AND ULTRASOUND. THE OUTPATIENT ANCILLARY AND SUPPORT SERVICES OFFERED BY JACKSON HOSPITAL ARE AS FOLLOWS; BLOOD BANK, CARDIAC CATHETERIZATION LABORATORY, EMERGENCY DEPARTMENT, ENDOSCOPY, LITHOTRIPSY, DIABETES TREATMENT CENTER, PAIN MANAGEMENT, PHYSICAL THERAPY, RESPIRATORY CARE, SLEEP LAB, ELECTRO CARDIOLOGY, MRI, CARDIOVASCULAR LABORATORY, CLINICAL LABORATORY, COMPUTERIZED TOMOGRAPHY, DIAGNOSTIC RADIOLOGY, AMBULATORY SURGERY, ULTRASOUND AND WOUND CARE CENTER. FOR THE 12 MONTHS ENDING DECEMBER 31, 2014, JACKSON HOSPITAL HAD 12,662 ADMISSIONS, 60,864 PATIENT DAYS, 1,279 DELIVERIES, 18,841 OUTPATIENT SURGERIES,43,272 EMERGENCY DEPARTMENT VISITS, 579,629 OUTPATIENT LABORATORY TESTS, 2,217 CATHETERIZATIONS AND 103,453 OUTPATIENT RADIOLOGY PROCEDURES. 159365865 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 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 1 1 0 0 1 47 0 1 1754 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X PAUL PEIFFER 3342938819 1725 PINE STREET SUITE 1200 MONTGOMERY AL 36106 X W KEN UPCHURCH CHAIRMAN 1.00 X X 0 0 0 PATRICK G RYAN MD VICE CHARIMAN 1.00 X X 0 0 0 RANDALL G COOK MD SECRETARY 1.00 X X 27500 0 0 KYLE KYSER BOARD MEMBER 1.00 X 0 0 0 KEITH KARST BOARD MEMBER 1.00 X 0 0 0 GLENN YATES MD BOARD MEMBER 1.00 X 0 0 0 GEORGE W THOMPSON III BOARD MEMBER 1.00 X 0 0 0 WILBUR HUFMAN BOARD MEMBER 1.00 X 0 0 0 STEVE BARRINGTON MD BOARD MEMBER 1.00 X 0 0 0 CHARLOTTE MUSSAFER BOARD MEMBER 1.00 X 0 0 0 RENE' A LLERA MD BOARD MEMBER 1.00 X 0 0 0 JOE RILEY PRESIDENT/CEO 40.00 X 562928 0 8514 MICHAEL JAMES VICE PRESIDENT COO 40.00 X 215770 0 18068 PETE VERRECCHIA PAST VP CFO 40.00 X 119226 0 0 PAUL PEIFFER VICE PRESIDENT CFO AS OF MARCH 40.00 X 203483 0 21769 JANET MCQUEEN VICE PRESIDENT MARKETING 40.00 X 160649 0 27410 SHARON GOODISON VICE PRESIDENT PATIENT CARE 40.00 X 185498 0 24568 MICHAEL RITZUS VICE PRESIDENT PHYSICIAN SERVICES 40.00 X 150192 0 5910 LARRY SHERBETT AVP FINANCE 40.00 X 177723 0 21210 PETER VANDERVOORT AVP SUPPORT SERVICES 40.00 X 151319 0 21850 BRIAN RICHARDSON MD PHYSICIAN 40.00 X 1213077 0 39410 BRIAN SELLERS MD PHYSICIAN 40.00 X 693198 0 42785 JAMES MRACEK MD PHYSICIAN 40.00 X 397838 0 8514 BRIAN GARY MD PHYSICIAN 40.00 X 393556 0 26014 REZA SEIRAFI MD PHYSICIAN 40.00 X 379115 0 8514 5031072 0 274536 56 0 1 0 LIFESOUTH COMMUNITY BLOOD CENTERS INC PO BOX 830469 BIRMINGHAM AL 352830469 BLOOD PRODUCTS 1897158 MONTGOMERY ANESTHESIA ASSOCIATES PC PO BOX 230725 MONTGOMERY AL 231230725 ANESTHESIA SERVICES 1596000 JACKSON NURSE PROFESSIONALS LLC PO BOX 404118 ATLANTA GA 303844118 STAFFING NURSING 1369861 PHYSIOTHERAPY ASSOCIATES 1215 MULBERRY STREET MONTGOMERY AL 36106 PHYSICAL THERAPY 987713 DIVERSIFIED CLINICAL SERVICES PO BOX 636981 CINCINNATI OH 452636981 WOUND CARE TREATMENT 939363 39 140954 140954 NET PATIENT SERVICE 621400 184523066 184461167 61899 ANCILLIARY SERVICES 900099 1729150 1729150 SURGERY CENTER REVENUES 621400 1416815 1416815 IMAGING CENTER REVENUES 621400 1201314 1201314 HOME HEALTH SERVICES 621610 128218 128218 188998563 2510670 2510670 2482300 0 2482300 2482300 2482300 CAFETERIA 722210 1378951 1378951 JOINT VENTURE 900099 255303 255303 COFFEE SHOP 722210 188611 188611 212598 212598 2035463 196167950 191418964 317202 4290830 X 37466 37466 1040618 260155 780463 66542 66542 62385522 49452733 12845106 87683 2649694 2077399 568623 3672 5692499 4463003 1221608 7888 4259823 3339764 914156 5903 189848 189848 252709 252709 25599078 20768319 4830759 468335 468335 11130974 4293076 6836196 1702 2793691 2793691 4231280 4231280 227962 183703 43464 795 4888250 4888250 11275789 11275789 1555998 1555998 UBIT 91630 91630 SUPPLIES 40320910 36739743 3581167 BAD DEBT EXPENSE 15727584 15727584 RECRUITMENT 48621 48621 5305 5061 244 194940128 159365865 35466620 107643 5318166 7902584 7457261 7335966 31258571 32652902 5930248 6204772 891011 1185750 211387650 110015767 104241954 101371883 72043894 62610634 3723532 8832221 1904484 1247353 232769121 229344065 16647780 19184054 1540021 1540021 98465000 96095000 1500000 950000 12722140 5391495 130874941 123160570 X 101894180 106183495 101894180 106183495 232769121 229344065 X 1227822 279555 2781938 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 10682 0 0 10682 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE ALABAMA HOSPITAL ASSOCIATION. EACH YEAR, A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TOWARDS LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR 2014, AMOUNTS OF MEMBERSHIP DUES ALLOCATED TO THESE EXPENDITURES WERE APPROXIMATELY $ 7,000 FOR AHA AND $ 3,000 FOR ALABAMA HOSPITAL ASSOCIATION. 1644606 5140921 6785527 92031818 44383635 47648183 1305481 614001 691480 109977541 65018131 44959410 1287283 1287283 101371883 ACCRUED INTEREST 1596568 PENSION LIABILITY 761047 UNAMORTIZED BOND PREMIUM 1907821 NOTES PAYABLE BBVA COMPASS 1126059 5391495 X PART X, LINE 2: THE ORGANIZATION FILES A CONSOLIDATED FINANCIAL STATEMENT WITH ITS SUBSIDIARIES. THE FOLLOWING FOOTNOTE REFERENCES ENTITIES WHOSE ACTIVITY IS NOT REPORTED ON THE FORM 990 FOR JACKSON HOSPITAL AND CLINIC, INC. "THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(A) OF THE INTERNAL REVENUE CODE AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3); ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. AS A LIMITED LIABILITY COMPANY, THE SURGERY CENTER AND IMAGING CENTER'S TAXABLE INCOME OR LOSS IS ALLOCATED TO THE MEMBERS AND IS INCLUDED IN THE CALCULATION OF THEIR TAXABLE INCOME. ACCORDINGLY, THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR INCOME TAXES. THE COMPANY DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF DECEMBER 31, 2014 AND 2013. YEARS ENDING ON OR AFTER DECEMBER 31, 2011, REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES." 1 1 1 X 0 1 1 1 0 0 7361025 7361025 0.04110 22754073 19231052 3523021 0.01970 30115098 19231052 10884046 0.06080 15000 15000 0.00010 8413115 5938674 2474441 0.01380 39766 39766 0.00020 8467881 5938674 2529207 0.01410 38582979 25169726 13413253 0.07490 1 3496862 2500000 59003624 55766814 3236810 X 1 1 1 JACKSON IMAGING CENTER LLC RADIOLOGY PROCEDURES 0.67000 0.33000 2 JACKSON SURGERY CENTER LLC OUTPATIENT SURGERY 0.54580 0.45420 1 1 JACKSON HOSPITAL AND CLINIC 1725 PINE STREET MONTGOMERY AL 361061117 X X X DISPROPORTIONATE SHARE HOSPITAL JACKSON HOSPITAL & CLINIC 1 0 0 1 X X X X X X X 13 1 0 0 1 X HTTP://WWW.JACKSON.ORG/PDFS/CHNA.PDF X 1 13 1 HTTP://WWW.JACKSON.ORG/PDFS/CHNA.PDF 0 0 1 X 100.000000000000 X X X 1 1 X X 1 X X X 1 0 1 X 0 0 JACKSON HOSPITAL & CLINIC PART V, SECTION B, LINE 5: TWENTY IN-PERSON INTERVIEWS WERE CONDUCTED FROM MAY 15-16, 2013. INTERVIEWS REQUIRED APPROXIMATELY 30 MINUTES TO COMPLETE. INTERVIEWERS FOLLOWED THE SAME PROCESS FOR EACH INTERVIEW, WHICH INCLUDED DOCUMENTING THE INTERVIEWEE'S EXPERTISE AND EXPERIENCE RELATED TO THE COMMUNITY. ADDITIONALLY, THE FOLLOWING COMMUNITY-FOCUSED QUESTIONS WERE USED AS THE BASIS FOR DISCUSSION: - INTERVIEWEE'S NAME - INTERVIEWEE'S TITLE - INTERVIEWEE'S ORGANIZATION - OVERVIEW INFORMATION ABOUT THE INTERVIEWEE'S ORGANIZATION - WHAT ARE THE TOP HEALTH STRENGTHS OF THE COMMUNITY? - WHAT ARE THE TOP HEALTH CONCERNS OF THE COMMUNITY? - WHAT ARE THE HEALTH ASSETS AND RESOURCES AVAILABLE IN THE COMMUNITY? - WHAT ARE THE HEALTH ASSETS OR RESOURCES THAT THE COMMUNITY LACKS? - WHAT ARE THE BARRIERS TO OBTAINING HEALTH SERVICES IN THE COMMUNITY? - WHAT IS THE SINGLE MOST IMPORTANT THING THAT COULD BE DONE TO IMPROVE THE HEALTH IN THE COMMUNITY? - WHAT OTHER INFORMATION CAN BE PROVIDED ABOUT THE COMMUNITY THAT HAS NOT ALREADY BEEN DISCUSSED? JACKSON HOSPITAL & CLINIC PART V, SECTION B, LINE 11: 1 CARDIOVASCULAR DISEASE-HEART DISEASE IS THE LEADING CAUSE OF DEATH IN AUTAUGA, ELMORE AND MONTGOMERY COUNTIES.-STROKE IS THE THIRD LEADING CAUSE OF DEATH IN MONTGOMERY.-MORTALITY RATES FROM ESSENTIAL HYPERTENSION ARE HIGHER IN AUTAUGA, ELMORE AND MONTGOMERY COUNTIES COMPARED TO ALABAMA AND THE UNITED STATES.-HEART CONDITIONS ARE AMONG THE MOST COMMON REASONS FOR DISCHARGE AT JACKSON HOSPITAL.-HYPERTENSION (HIGH BLOOD PRESSURE) IS THE TOP REASON FOR BEING SEEN AT THE JACKSON CLINIC, ACCOUNTING FOR 28 PERCENT OF ALL VISITS.HOW WE ARE HELPINGJACKSON HOSPITAL HAS BEEN RECOGNIZED AS AN ADVANCED PRIMARY STROKE CENTER BY THE JOINT COMMISSION. THIS DESIGNATION IS GIVEN TO HOSPITALS THAT HAVE DEMONSTRATED THAT THEIR PROGRAM MEETS CRITICAL ELEMENTS OF PERFORMANCE TO ACHIEVE LONG-TERM SUCCESS IN IMPROVING OUTCOMES FOR STROKE PATIENTS. JACKSON HOSPITAL DISTRIBUTES STROKE AWARENESS CARDS THROUGH AREA WALGREENS LOCATIONS AND PROVIDES PUBLIC EDUCATION THROUGHOUT THE YEAR. WE ARE ALSO INCREASING HEALTH FAIR INVOLVEMENT AND COMMUNITY HEALTH SCREENINGS THROUGH OUR WELLNESS WORKS PROGRAM AND ARE IMPLEMENTING A LOW-COST HEART AND STROKE SCREENING PROGRAM FOR INDIVIDUALS AT RISK.2 DIABETES-THE DIABETES MORTALITY RATE IN MONTGOMERY IS SUBSTANTIALLY HIGHER THAN THE STATE AND NATIONAL RATES.-DIABETES-RELATED CONDITIONS ACCOUNT FOR 12.8 PERCENT OF ALL VISITS TO THE JACKSON CLINIC.-ADULTS IN THE MONTGOMERY REGION ARE MORE LIKELY TO REPORT DIAGNOSED DIABETES THAN ADULTS IN THE REST OF THE U.S.HOW WE ARE HELPINGJACKSON HOSPITAL OFFERS FREE WEEKLY DIABETES EDUCATION COURSES. WE HAVE ALSO ADDED ANOTHER ENDOCRINOLOGY SPECIALIST, A. BAHADIR ERGIN, MD, WHO JOINED THE JACKSON CLINIC IN JULY. THIS WILL HELP MEET THE HIGH DEMAND FOR THESE SERVICES.3 ACCESS TO HEALTHCARE-THE LACK OF PHYSICIANS ACCEPTING MEDICAID AND MEDICARE PATIENTS IS A SERIOUS HEALTH CONCERN.-THE AGING PHYSICIAN POPULATION WAS A MAJOR CONCERN FOR THE COMMUNITY.-A LACK OF ACCESS TO PREVENTION AND SCREENING RESOURCES WAS A CONCERN.HOW WE ARE HELPING-HEALTH SERVICES, INC., RECEIVED A GRANT THROUGH THE HEALTH RESOURCES AND SERVICES ADMINISTRATION TO PROVIDE OUTREACH AND ENROLLMENT SERVICES FOR UNINSURED INDIVIDUALS FOR THE AFFORDABLE INSURANCE MARKETPLACE. THE ORGANIZATION PLANS TO WORK WITH AREA HOSPITALS, INCLUDING JACKSON HOSPITAL, TO INCREASE ACCESS AND AWARENESS OF THIS SERVICE.-JACKSON HOSPITAL HAS RECRUITED MORE THAN A DOZEN NEW PHYSICIANS TO THE AREA OVER THE PAST 18 MONTHS.4 MENTAL HEALTH-SUICIDE IS THE EIGHTH LEADING CAUSE OF DEATH IN AUTAUGA, WITH A RATE SUBSTANTIALLY HIGHER THAN THAT OF ALABAMA AND THE UNITED STATES.-THE LACK OF RESOURCES AND SERVICES FOR THESE PATIENTS WAS A CONCERN.-REDUCING STIGMA AND RAISING COMMUNITY AWARENESS WAS A PRIORITY.HOW WE ARE HELPING-JACKSON HOSPITAL WILL START AN INITIATIVE FOR DEPRESSION SCREENING AT INTAKE IN KIOSKS THROUGH CARE COORDINATION SERVICES.-WE ARE ALSO PARTNERING WITH LOCAL PROVIDERS TO PROVIDE PUBLIC EDUCATION ABOUT MENTAL HEALTH ISSUES AND THE COMMUNITY RESOURCES AVAILABLE.5 OBESITYOBESITY WAS A MAJOR CONCERN. POOR NUTRITIONAL HABITS AND LACK OF EXERCISE WERE DISCUSSED AS THE PRIMARY CAUSES.HOW WE ARE HELPING-JACKSON HOSPITAL DIETITIANS OFFER NUTRITIONAL COUNSELING AT HEALTH FAIRS AND COMMUNITY EVENTS. THEY FOCUS ON HEALTHY EATING FOR WEIGHT AND DISEASE MANAGEMENT.-JACKSON HOSPITAL HAS ALSO PARTNERED WITH EAT SOUTH TO OFFER EDUCATION ABOUT HEALTHY EATING AND SUSTAINABLE FOOD PRODUCTION THROUGH COMMUNITY HEALTH FAIRS.-JACKSON IS A FOUNDING MEMBER OF THE MONTGOMERY AREA COMMUNITY WELLNESS COALITION. THE COALITION HOSTS SEMINARS AND PRESENTATIONS FOR HEALTH PROFESSIONALS IN THE COMMUNITY, DISCUSSING CHRONIC DISEASE AND RISK FACTORS.-JACKSON HOSPITAL IS STRIVING TO INCREASE THE NUMBER OF EMPLOYEES AT A HEALTHY WEIGHT BY CREATING AN EMPLOYEE WELLNESS COMMITTEE.-THE HOSPITAL ENCOURAGES PARTICIPATION IN THE SCALE BACK ALABAMA INITIATIVE AND HAS RECENTLY ADDED SIGNS FOR AN INDOOR WALKING PATH. THE HOSPITAL CAFETERIA OFFERS BARCODES SO PEOPLE DINING CAN USE THEIR SMARTPHONES TO SCAN AND DETERMINE THE NUTRITIONAL VALUE OF FOODS THEY ARE EATING.6 SEXUALLY TRANSMITTED INFECTIONSIN MONTGOMERY, CHLAMYDIA, GONORRHEA, SYPHILIS, HIV AND AIDS INCIDENCE RATES ARE ALL SUBSTANTIALLY HIGHER THAN IN ALABAMA.HOW WE ARE HELPINGJACKSON HOSPITAL WAS THE HOST SITE FOR A REGIONAL INFECTIOUS DISEASE CONFERENCE IN APRIL 2014. THE COLLABORATIVE EFFORT WITH THE ALABAMA DEPARTMENT OF HEALTH AND THE MEDICAL AIDS OUTREACH PROGRAM PROVIDED INFORMATION ABOUT SEXUALLY TRANSMITTED INFECTIONS. JACKSON HOSPITAL & CLINIC PART V, SECTION B, LINE 16I: PATIENTS ARE INTERVIEWED FOR SELF PAY ADMISSIONS. 3 JACKSON CLINIC FAMILY MEDICINE CENTER 1111 OLIVE STREET MONTGOMERY AL 36106 FAMILY MEDICINE/OUTPATIENT JACKSON SURGERY CENTER 1725 PARK PLACE MONTGOMERY AL 36106 OUTPATIENT SURGERY JACKSON IMAGING CENTER 1825 PARK PLACE MONTGOMERY AL 36106 MEDICAL IMAGING PART I, LINE 3C: ALL SELF-PAY PATIENTS RECEIVE A 73% DISCOUNT SO THAT THEY ARE ONLY BILLED FOR 27% OF TOTAL CHARGES. PART I, LINE 7G: JACKSON HOSPITAL HAS ONE HEALTH PROGRAM THAT OPERATED AT A LOSS FOR THE BENEFIT OF THE COMMUNITY. THE DEPARTMENT, INCLUDED ON PART I, LINE 7(G) IS: EMERGENCY ROOM - $2,474,441 PART I, LN 7 COL(F): THE AMOUNT LISTED ON FORM 990, PART IX, LINE 25 CONTAINS A BAD DEBT EXPENSE OF $ 15,727,584 THAT HAS BEEN REMOVED FOR PURPOSES OF CALCULATING PERCENT OF TOTAL EXPENSE ON PART I, LINE 7, COLUMN (F). PART III, LINE 4: WORKSHEET 2 OF THE 2014 SCHEDULE H INSTRUCTIONS WAS USED TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE BAD DEBT EXPENSE AT COST FOR PURPOSES OF PART III, LINE 2.RECEIVABLES FROM PATIENTS, INSURANCE COMPANIES, AND THIRD-PARTY CONTRACTUAL AGENCIES ARE RECORDED AT REGULAR PATIENT SERVICE CHARGE RATES. A MAJORITY OF THE COMPANY'S PATIENTS ARE INSURED BY CERTAIN THIRD PARTY INSURERS (PRINCIPALLY BLUE CROSS, MEDICARE, AND MEDICAID) BASED ON CONTRACTUAL AGREEMENTS WHICH GENERALLY RESULT IN THE COMPANY COLLECTING LESS THAN THE ESTABLISHED CHARGE RATES. FINAL DETERMINATION OF PAYMENTS UNDER THESE AGREEMENTS IS SUBJECT TO REVIEW BY APPROPRIATE AUTHORITIES. ADEQUATE ALLOWANCES ARE PROVIDED FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS AND OTHER UNCERTAINTIES. CREDIT LOSSES HAVE HISTORICALLY BEEN WITHIN MANAGEMENT'S EXPECTATIONS. DOUBTFUL ACCOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE AFTER ADEQUATE COLLECTION EFFORT IS EXHAUSTED AND RECORDED AS RECOVERIES OF BAD DEBTS IF SUBSEQUENTLY COLLECTED. PART III, LINE 8: THE ORGANIZATION USED ITS MEDICARE COST REPORT TO CALCULATE ALLOWABLE COSTS OF CARE RELATED TO MEDICARE FOR PURPOSES OF PART III, LINE 6. PART III, LINE 9B: THE ORGANIZATION QUALIFIES PATIENTS FOR ITS CHARITY CARE POLICY AT TIME OF DISCHARGE. DISCOUNTS ON SELF-PAY PATIENTS ARE APPLIED USING A NON-FINANCIAL MEASURE, SO ACCOUNTS IN BAD DEBTS ARE NOT LIKELY ELIGIBILE FOR FURTHER FINANCIAL ASSISTANCE AFTER HAVING THEIR FINAL BILLS ISSUED. THE HOSPITAL PRIMARILY USES A THIRD-PARTY TO HANDLE BAD DEBT COLLECTIONS, AND ROUTINELY REEVALUATES ITS BAD DEBT ACCOUNTS TO DETERMINE PATIENTS THAT QUALIFY UNDER THE ORGANIZATION'S CHARITY CARE POLICY. PART VI, LINE 2: JACKSON HOSPITAL IS A COMMUNITY NOT-FOR-PROFIT HOSPITAL SERVING MONTGOMERY AND THE ALABAMA RIVER REGION LICENSED FOR 344 BEDS. OUR COMPREHENSIVE HEALTHCARE SERVICES INCLUDE CARDIAC, CANCER, NEUROSCIENCES, ORTHOPEDICS AND WOMEN'S AND CHILDREN'S CARE, ALONG WITH 24 HOUR EMERGENCY SERVIES. IT RANKS AMONG THE LARGEST HOSPITALS IN ALABAMA AND IS WIDELY RECOGNIZED FOR PROVIDING EXCELLENCE IN CARE. EVEN WITH OUR LEADING TECHNOLOGY AND FACILITIES, WE REMAIN TRUE TO OUR MISSION OF PROVIDING SUPERIOR PERSONAL HEALTHCARE IN A SAFE, COMPASSIONATE ENVIRONMENT WHILE FULFILLING OUR COMMITMENT AS A CHARITABLE ORGANIZATION PART VI, LINE 3: THE HOSPITAL PROVIDES SIGNAGE IN AND AROUND THE EMERGENCY ROOM STATING THE CONTACT INFORMATION FOR FINANCIAL ASSISTANCE REPRESENTATIVES. "YOU MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THE TERMS AND CONDITIONS THE HOSPITAL OFFERS TO QUALIFIED PATIENTS. FOR ADDITIONAL INFORMATION, CONTACT THE HOSPITAL FINANCIAL ASSISTANCE REPRESENTATIVE AT 334-293-6970."IN ADDITION, A REPRESENTATIVE VISITS EACH SELF-PAY INPATIENT, AND AN APPLICATION FORM FOR ASSISTANCE IS COMPLETED AT THAT TIME. EACH PRIVATE PAY PATIENT IS INTERVIEWED TO DETERMINE QUALIFICATION BASED ON NATIONAL POVERTY GUIDELINES FOR FINANCIAL ASSISTANCE. BASED ON THIS DETERMINATION, A DECISION IS MADE AS TO ELIGIBILTY FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: JACKSON HOSPITAL'S PRIMARY SERVICE AREA IS COMPRISED OF MONTGOMERY, ELMORE, AND AUTAUGA COUNTIES, LOCATED IN THE EASTERN CENTRAL PART OF THE STATE OF ALABAMA. THE SECONDARY SERVICE AREA IS COMPRISED OF BULLOCK, BUTLER, CRENSHAW, DALLAS, LOWNDES, MACON, AND PIKE COUNTRIES. JACKSON HOSPITAL IS ADJACENT TO I-85 AND NEAR THE INTERSECTION OF I-65 AND I-85, PROVIDING FOR EASY ACCESS FROM THE PRIMARY AND SECONDARY SERVICE AREAS. MAJOR PRIMARY SERVICE AREA EMPLOYERS ARE MAXWELL AIR FORCE BASE, STATE OF ALABAMA, HYUNDAI MOTOR MANUFACTURING ALABAMA, ALFA INSURANCE COMPANIES, ALABAMA STATE UNIVERSITY, AUBURN UNIVERSITY MONTGOMERY AND CITY OF MONTGOMERY. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES, INDEPENDENT CONTRACTORS, NOR A FAMILY MEMBER OF AN EMPLOYEE OF THE ORGANIZATION. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY TO MOST OF ITS DEPARTMENTS. IN ADDITION, SURPLUS FUNDS ARE REINVESTED IN THE HOSPITAL THROUGH THE PURCHASE OF TECHNOLOGY, PROPERTY, AND PLANT EQUIPMENT. PART VI, LINE 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X 1 1 X X X X 1 0 0 0 0 1 0 0 0 JOE RILEY PRESIDENT/CEO 434600 0 127500 0 828 0 0 0 8514 0 571442 0 0 0 MICHAEL JAMES VICE PRESIDENT COO 200000 0 15500 0 270 0 12000 0 6068 0 233838 0 0 0 PAUL PEIFFER VICE PRESIDENT CFO AS OF MARCH 192709 0 10000 0 774 0 17218 0 4551 0 225252 0 0 0 JANET MCQUEEN VICE PRESIDENT MARKETING 142800 0 17136 0 713 0 23000 0 4410 0 188059 0 0 0 SHARON GOODISON VICE PRESIDENT PATIENT CARE 150000 0 34875 0 623 0 18500 0 6068 0 210066 0 0 0 MICHAEL RITZUS VICE PRESIDENT PHYSICIAN SERVICES 140205 0 9900 0 87 0 1500 0 4410 0 156102 0 0 0 LARRY SHERBETT AVP FINANCE 177154 0 0 0 569 0 16800 0 4410 0 198933 0 0 0 PETER VANDERVOORT AVP SUPPORT SERVICES 151319 0 0 0 0 0 21850 0 0 0 173169 0 0 0 BRIAN RICHARDSON MD PHYSICIAN 546369 0 666384 0 324 0 35000 0 4410 0 1252487 0 0 0 BRIAN SELLERS MD PHYSICIAN 495000 0 197838 0 360 0 34271 0 8514 0 735983 0 0 0 JAMES MRACEK MD PHYSICIAN 330398 0 67170 0 270 0 0 0 8514 0 406352 0 0 0 BRIAN GARY MD PHYSICIAN 373958 0 19245 0 353 0 17500 0 8514 0 419570 0 0 0 REZA SEIRAFI MD PHYSICIAN 309022 0 69473 0 620 0 0 0 8514 0 387629 0 0 0 PART I, LINE 1A THE HOSPITAL PROVIDED INITIAL DUES AND MONTHLY DUES FOR A COUNTRY CLUB MEMBERSHIP FOR THE PRESIDENT/CEO. PART I, LINE 4A CFO PETE VERRECCHIA LEFT THE ORGANIZATION ON JANUARY 6, 2014. HE RECEIVED 3 MONTHS OF SEVERANCE PAYMENTS DURING 2014. THIS AMOUNT IS REFLECTED ON PART II COLUMN B (III). PART I, LINE 6 EXECUTIVE BONUS CALCULATIONS INCLUDE A METRIC FOR NET EARNINGS. A THE MEDICAL CLINIC BOARD OF THE CITY OF MONTGOMERY 630881546 013058CG9 2006-12-05 113221823 REFUNDING, CAPITAL ACQUISITION 0 0 0 A 14480000 115784596 7263706 1260470 6203213 2007 0 1 1 1 A 1 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 1 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: THE MEDICAL CLINIC BOARD OF THE CITY OF MONTGOMERY DATE THE REBATE COMPUTATION WAS PERFORMED: 01/28/2015 MONTGOMERY ANESTHESIA COMPANY OWNED BY BOARD MEMBER RENE A. LLERA 1596000 PAYMENT STIPEND TO ANESTHESIA GROUP 0 EDITH JAMES FAMILY MEMBER OF OFFICER MICHAEL JAMES, COO 66542 COMPENSATION 0 FORM 990, PART III, LINE 4A CASH AND IN-KIND DONATIONS - JACKSON HOSPITAL BELIEVES IN GIVING BACK TO THE COMMUNITY. IN THE PAST YEAR, THE HOSPITAL DONATED FUNDS AND SERVICES TO THE FOLLOWING ORGANIZATIONS: -AMERICAN CANCER SOCIETY -AUBURN UNIVERSITY SCHOOL OF NURSING -ENVISION 20/20 -FIVE POINTS OF LIFE FOUNDATION, INC -HOSPICE OF MONTGOMERY -LEADERSHIP MONTGOMERY -MONTGOMERY AREA BUSINESS COMMITTEE FOR THE ARTS -MONTGOMERY AREA CHAMBER OF COMMERCE -RIVER REGION MEDICAL ALLIANCE -MONTGOMERY LIONS CLUB -FAMILY SUNSHINE CENTER -AFA CHAPTER 102 -HALO -NATIONAL FALLEN FIRE FIGHTERS FOUNDATION -CAMP WHEEZEAWAY -PSIF -SPINA BIFIDA ASSOCIATION OF ALABAMA -ARTHRITIS FOUNDATION -MONTGOMERY CORPORATE CHALLENGE -CAMELLIA BOWL -MONTGOMERY AREA COMMITTEE OF 100 -FELLOWSHIP OF CHRISTIAN ATHLETES -MONTGOMERY BAPTIST ASSOCIATION FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS FOUR CLASSES OF MEMBERS: ACTIVE MEMBERS, SENIOR ACTIVE MEMBERS, ASSOCIATE MEMBERS, AND COMMUNITY MEMBERS. ACTIVE MEMBERS - TO QUALIFY AS AN ACTIVE MEMBER, AN APPLICANT MUST: BE ACTIVE IN THE PRACTICE OF MEDICINE, BE A MEMBER OF THE ACTIVE MEDICAL STAFF OF THE HOSPITAL, HAVE SERVED AS AN ASSOCIATE MEMBER FOR NOT LESS THAN THREE YEARS, HAVE DEMONSTRATED INTEREST IN AND ADHERENCE TO THE OBJECTIVES OF THE ORGANIZATION, AND BE IN COMPLIANCE WITH ALL OTHER PROVISIONS FROM TIME TO TIME ADOPTED BY THE BOARD RELATING TO MEMBERSHIP. SENIOR ACTIVE MEMBERS - ACTIVE MEMBERS THAT HAVE RETIRED FROM ACTIVE PRACTICE BUT EXPRESS A DESIRE TO CONTINUE TO PARTICIPATE IN THE OBJECTIVES OF THE ORGANIZATION. ASSOCIATE MEMBERS - TO QUALIFY AS AN ASSOCIATE MEMBER, AN APPLICANT MUST: BE ACTIVE IN THE PRACTICE OF MEDICINE, HAVE SERVED AS A MEMBER OF THE MEDICAL STAFF OF THE HOSPITAL FOR NOT LESS THAN TWO YEARS, HAVE DEMONSTRATED INTEREST IN AND ADHERENCE TO THE OBJECTIVES OF THE ORGANIZATION, AND BE IN COMPLIANCE WITH ALL OTHER PROVISIONS FROM TIME TO TIME ADOPTED BY THE BOARD RELATING TO MEMBERSHIP. COMMUNITY MEMBERS - A COMMUNITY MEMBER MUST BE A CITIZEN OF THE UNITED STATES OF NOT LESS THAN 21 YEARS OF AGE AND A PERMANENT RESIDENT OF MONTGOMERY COUNTY, ALABAMA, OR ANY OTHER COUNTY WITHIN THE STATE WHICH IS WITHIN THE SERVICE AREA OF THE HOSPITAL AND SHALL POSSESS SUCH ADDITIONAL QUALIFICATIONS AS SHALL BE SET FORTH FROM TIME TO TIME BY THE BOARD. FORM 990, PART VI, SECTION A, LINE 7A ACTIVE MEMBERS HAVE THE EXCLUSIVE RIGHT TO VOTE ON THE APPROVAL OF THE ADMISSION OF ANY PERSON AS AN ACTIVE OR ASSOCIATE MEMBER OF THE NON-PROFIT CORPORATION. COMMUNITY MEMBERS ARE PERMITTED TO PARTICIPATE IN THE ELECTION OF THE MEMBERS OF THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B ALL VOTING RIGHTS OF MEMBERS ACCRUING TO MEMBERS GENERALLY, UNDER THE ALABAMA NONPROFIT CORPORATION ACT OR UNDER THE RESTATED ARTICLES OF INCORPORATION, ARE RESERVED TO THE ACTIVE MEMBERS, EXCEPT FOR THE PARTICIPATION OF COMMUNITY MEMBERS IN THE ELECTION OF MEMBERS OF THE BOARD OF TRUSTEES AND EXCEPT IN THOSE INSTANCES WHERE THE BOARD OF TRUSTEES, IN ITS DISCRETION, DESIRES TO REFER A PARTICULAR MATTER TO THE MEMBERSHIP AS A WHOLE OR TO ANY RESTRICTED CLASS OR CLASSES FOR CONSIDERATION AND ADVICE AS PROVIDED HEREIN, PROVIDED, HOWEVER, THAT NO CLASS OF MEMBERS OTHER THAN ACTIVE MEMBERS SHALL, BY SUCH PROCEDURE, BE GIVEN THE RIGHT TO VOTE ON ANY MATTER REQUIRING THE VOTE OR APPROVAL OF MEMBERS GENERALLY UNDER THE ALABAMA NONPROFIT CORPORATION ACT OR THE VOTE OF ACTIVE MEMBERS UNDER THE RESTATED ARTICLES OF INCORPORATION. THE MATTERS UPON WHICH THE ACTIVE MEMBERS SHALL HAVE THE EXCLUSIVE RIGHT TO VOTE ARE THOSE MATTERS GENERALLY RESERVED TO MEMBERS IN THE ALABAMA NONPROFIT CORPORATION ACT AS IT MAY EXIST FROM TIME TO TIME, INCLUDING, WITHOUT LIMITATION, THE FOLLOWING: - THE LIQUIDATION, DISSOLUTION, OR REORGANIZATION OF THE CORPORATION, - THE SALE, EXCHANGE, OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTIES OF THE CORPORATION, BUT NOT THE POWER TO MORTGAGE OR CONVEY SUCH PROPERTY SOLELY FOR THE PURPOSE OF SECURING ANY INDEBTEDNESS OR OTHER OBLIGATIONS OF THE CORPORATION, WHICH THE BOARD OF TRUSTEES, ACTING ALONE, SHALL HAVE AND EXERCISE, - THE APPROVAL OF THE AMENDMENT OF THE RESTATED ARTICLES OF INCORPORATION, - THE APPROVAL OF THE ADMISSION OF ANY PERSON AS AN ACTIVE OR ASSOCIATE MEMBER OF THE CORPORATION. SUCH MATTERS SHALL BE SUBMITTED FOR VOTE OF THE ACTIVE MEMBERS UPON RECOMMENDATION OF THE BOARD OF TRUSTEES. NO ACTION UPON ANY SUCH MATTERS SHALL BE TAKEN BY THE ACTIVE MEMBERS (OR ANY OTHER MEMBER ENTITLED TO VOTE) WITHOUT NOTICE OF SUCH PURPOSE BEING GIVEN PRIOR TO THE MEETING, OTHER THAN THE ELECTION OF THE BOARD OF TRUSTEES WHICH SHALL OCCUR AT EACH ANNUAL MEETING WITHOUT REQUIREMENT OF FURTHER NOTICE. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY HOSPITAL MANAGEMENT. THE RETURN WAS PROVIDED TO THE BOARD FOR REVIEW PRIOR TO FILING WITH THE IRS. THE BOARD REVIEWED THE FORM 990 AT A SUBSEQUENT BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION UPDATES ITS CONFLICT OF INTEREST POLICY ANNUALLY FOR KEY HOSPITAL EMPLOYEES AND BOARD MEMBERS TO PROVIDE INFORMATION ON ANY POTENTIAL CONFLICTS OF INTEREST. THE UPDATES OF THE POLICY FORMS ARE REVIEWED BY HOSPITAL ADMINISTRATION. IN THE EVENT OF A POTENTIAL CONFLICT OF INTEREST, A BOARD MEMBER WILL ABSTAIN FROM VOTING ON MATTERS PERTAINING TO THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 AN OUTSIDE INDEPENDENT CONSULTING FIRM REVIEWS THE COMPENSATION OF OFFICERS EVERY TWO YEARS TO ENSURE COMPENSATION IS COMPARABLE TO THE MARKET. THE HOSPITAL EXECUTIVE COMMITTEE REVIEWS THE RECOMMENDATIONS OF THE OUTSIDE CONSULTING COMPANY AND APPROVES THE COMPENSATION AND ANY CHANGES TO THE COMPENSATION OF OFFICERS. THE EXECUTIVE COMMITEE IS COMPOSED OF MEMBERS OF THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. PLEASE SEE PART VI, LINE 20. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. PLEASE SEE PART VI, LINE 20. FORM 990, PART VII, SECTION A, LINE 1A: BOARD MEMBER COMPENSATION: THE COMPENSATION PAID TO BOARD MEMBER RANDALL G. COOK, MD IS FOR HIS SERVICES AS A MEDICAL DIRECTOR OF THE HOSPITAL, NOT FOR HIS POSITION AS A BOARD MEMBER. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,717,039. MANAGEMENT AND GENERAL EXPENSES 10,546. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,727,585. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 16,099,347. MANAGEMENT AND GENERAL EXPENSES 4,047,538. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 20,146,885. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,951,933. MANAGEMENT AND GENERAL EXPENSES 474,567. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,426,500. BILLING SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 298,108. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 298,108. FORM 990, PART XI, LINE 9: MINIMUM PENSION LIABILITY ADJUSTMENT 2,781,938. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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