2014-02-06T07:59:37-06:00 2013-09-30 020476956 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2012-10-01 020276210 UPPER CONNECTICUT VALLEY HOSPITAL UPPE 6032374971 CORLISS LANE COLEBROOK NH 03576 JAMES TIBBETTS 6032374971 2014-01-31 1 JAMES N GODFREY CPA P00913422 6036530044 2014-01-31 2012 2015-11-30 17:44:51Z GREG PLACY CORLISS LANE COLEBROOK NH 03576 15244521 0 X WWW.UCVH.ORG X 1969 NH TO PROVIDE HEALTH CARE SERVICES. 11 9 165 20 0 0 54407 56697 14031660 13921381 344058 395132 421752 848125 14851877 15221335 85000 50000 0 0 7918126 8215712 0 0 4830 7271882 7855155 15275008 16120867 -423131 -899532 17882185 19408317 4758783 5700013 13123402 13708304 UPPER CONNECTIBUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURUAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 0 0 12786868 50000 14732657 UPPER CONNECTICUT VALLEY HOSPTIAL PROVIDED HOSPITAL CARE AND INPATIENTS AND OUTPATIENTS SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2012 WAS $679,363. 12786868 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 40 0 1 165 1 0 0 0 0 0 0 0 0 0 0 X 11 9 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X THE ORGANIZATION 6032374971 UCVH CORLISS LANE COLEBROOK NH 03576 E HARLAN CONNARY 1.00 X X 0 0 0 BRUCE BEAN 1.00 X 0 0 0 ODETTE CRAWFORD 1.00 X X 0 0 0 JAMES TIBBETTS 1.00 X X 0 0 0 GREG PLACY 1.00 X X 0 0 0 PALMER LEWIS 1.00 X 0 0 0 PETER MORAN 1.00 X 0 0 0 ERIC STOHL 1.00 X 0 0 0 SALLY WENTZELL 1.00 X 0 0 0 EDWARD LAVERTY PA-C 53.00 X 187001 0 29283 CHARLES WHITE 40.00 X X 133995 0 19394 CHARANJIT VEDI 29.50 X 335012 0 0 JOHN EPPOLIOTO 47.70 X 276860 0 11513 JOSEPH KIEMAN 31.10 X 212700 0 31714 ROBERT SOUCY 52.20 X 205445 0 24852 KIMBERLEE DALEY 47.50 X 128335 0 18986 1479348 0 135742 7 0 1 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 REHAB PERSONNEL & SERVICES 576720 VISTA STAFFING SOLUTIONS FILE 50834 LOS ANGELES CA 50834 PROVIDES LOCUMS PHYSICIANS FOR HOSPITALI 426508 RN NETWORK PO BOX 9740888 DALLAS TX 75266 LOCUMS RN NURSING STAFF 141100 VIRTUAL RADIOLOGIC CORP 25983 NETWORK PLACE CHICAGO IL 60673 RADIOLOGICAL SERVICES 111324 4 48113 8584 56697 NET PATIENT REVENUE 621990 13921381 13921381 13921381 39149 39149 379169 0 23186 379169 -23186 355983 355983 MEANINGFUL USE REVENUE 900099 400063 400063 OTHER REVENUE 900099 217710 217710 SCHOOL NURSING 900099 176700 176700 53652 16803 36849 848125 15221335 14732657 0 431981 50000 50000 59142 59142 6535417 5583743 951674 54177 45911 8266 1176165 1001339 174826 390811 331182 59629 74125 74125 56807 56807 24765 21471 3294 1244630 1188109 56521 245621 170607 75014 637053 537449 99604 108785 65972 42813 2823 2823 589713 589713 114184 114184 PURCHASED SERVICES 2158642 1345064 813578 PROVISION FOR BAD DEBT 1258768 1258768 MEDICAID ENHANCEMENT TA 657353 657353 REPAIRS AND MAINTENANCE 220251 215012 5239 461635 382528 74277 4830 16120867 12786868 3329169 4830 652544 331548 3077268 3401509 1455924 2012004 288789 295772 121176 226509 10931650 6758572 4099446 4173078 7021043 7480449 704068 358769 461927 1128679 17882185 19408317 1213582 1806337 15476 173973 1561549 1244193 1968176 2475510 4758783 5700013 X 12521395 13185384 532822 449850 69185 73070 13123402 13708304 17882185 19408317 X -899532 225665 1258769 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3060 3060 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: UPPER CONNECTICUT VALLEY HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THIS ORGANIZATION IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF UCVH AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT DIRECLTY PERFORM ANY LOBBYING ACTIVITIES. 161056 18320 9173 170203 129746 31310 161056 127616 2130 129746 112258 15358 127616 111704 554 112258 0.42930 0.57070 0 0 9700 9700 4161476 2114886 2046590 231555 117830 113725 6407277 4525856 1881421 121642 121642 4173078 OTHER RECEIVABLES 1083000 DEPOSITS & OTHER 45679 1128679 DUE TO THIRD PARTY PAYERS 2464484 CAPITAL LEASE 11026 2475510 15440659 225665 225665 15214994 6341 6341 15221335 14857268 0 14857268 1263599 1263599 16120867 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INVESTMENTS ARE TO BE HELD IN PERPETUITY. THE INCOME FROM THE INVESTMENTS IS EXPENDABLE TO SUPPORT THE HOSPITAL'S HEALTH CARE SERVICES. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 4,830. NET ASSETS RELEASED FOR CAP EXPENDITURES 1,511. PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 4,830. PROVISION FOR BAD DEBTS 1,258,768. ROUNDING 1. 1 1 1 X 1 X 1 1 0 1 1 624977 270626 354351 0.02380 1877514 1499688 377826 0.02540 2502491 1770314 732177 0.04920 4373175 2825303 1547872 0.10410 171493 171493 0.01150 636913 285571 351342 0.02360 50862 50862 0.00340 5232443 3110874 2121569 0.14260 7734934 4881188 2853746 0.19180 1405 1405 0.00010 4686 4686 0.00030 9111 9111 0.00060 67016 67016 0.00450 9260 9260 0.00060 91478 91478 0.00610 1 624517 19985 8545212 8761601 -216389 X 1 1 1 NORTHERN NEW HAMPSHIRE HEALTH CARE COLLABORATIVE LLC OF 3 COSS COUNTY HOSPITALS 1 1 UPPER CONNECTICUT VALLEY HOSPITAL

181 CORLISS LANE COLEBROOK NH 03576

X X X X UPPER CONNECTICUT VALLEY HOSPITAL 1 1 X X X X X X X X X 10 1 0 1 X X 1 0 1 1 125.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X 1 X 0 X X X 1 X 0 0 PART I, LINE 7: PART I, LINES 7A-C; THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES.PART I, LINES 7E-I; THE HOSPITAL DETERMINES COST BY COMBINING DIRECT EXPENSES IDENTIFIED BY ITS ACCOUNTING SYSTEM WITH AN ESTIMATED OVERHEAD ALLOCATION. PART I, LINE 7G: SPECIALTY CARE PROVIDERS, LET NO WOMAN BE OVERLOOKED PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1258768. PART II: THE COMMUNITY BUILDING ACTIVITIES UNDERTAKEN BY UCVH CONSIST OF SUPPORTING LOCAL GOVERNMENT AND OTHER HEALTH CARE PROVIDERS, COORDINATION OF DISASTER DRILLS, EMERGENCY PREPAREDNESS AND ALSO SUPPORT OF OTHER LOCAL ORGANIZATIONS WITHIN THE COMMUNITY. IN ADDITION, IN AN EFFORT TO PROVIDE THE NECESSARY HEALTH CARE SERVICES FOR THE POPULATION WITHIN A REASONABLE DRIVING DISTANCE, UCVH HAS ENTERED INTO A COLLABORATION WITH THE OTHER TWO COOS COUNTY HOSPITALS TO PROVIDE NECESSARY SPECIALTY SERVICES FOR THE UCVH SERVICE AREA. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNT. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICE PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, INCLUDING BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR ONLY PART OF THE BILL, THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL HAS ESTIMATED ITS COST OF BAD DEBT USING COST-TO-CHARGE METHODOLOGY IN ACCRODANCE WITH WORKSHEET 2 OF THE FORM 990 SCHEDULE H INSTRUCTIONS. PART III, LINE 8: AS UCVH OPERATES AT A LOSS FROM MEDICARE, THE SHORTFALL COULD BE TREATED AS COMMUNITY BENEFIT AS THERE ARE NO OTHER FUNDS AVAILABLE TO SUBSIDIZE THE LOSS. UCVH USES CCR TO DETERMINE COST, REVENUE RECEIVED IS NET PATIENT REVENUE, DSH FUNDS ARE INCLUDED AS PAYMENTS. PART III, LINE 9B: IF KNOWN TO QUALIFY FOR CHARITY OR FINANCIAL ASSISTANCE, THEY ARE GIVEN THE ASSISTANCE NEEDED. PART VI, LINE 2: IN 2013, UCVH PARTNERED WITH INDIAN STREAM HEALTH CENTER (ISHC), A FEDERALLY QUALIFIED HEALTH CENTER, TO GATHER INFORMATION REGARDING THE HEALTH CARE NEEDS OF THE COMMUNITY. THIS WAS DONE USING PAPER & INTERNET SURVEYS, AND FOCUS GROUP INTERVIEWS. THIS DATA, AND OTHER PERTINENT INFORMATION, WAS COLLECTED AND REVIEWED BY THE UCVH BOARD OF DIRECTORS WHO PRIORITIZED THE AREAS OF NEED. THE COMMUNITY NEEDS THAT FALL WITHIN THE SCOPE OF UCVH WILL BE ADDRESSED BY THE UCVH STRATEGIC PLAN. A COMMUNITY HEALTH NEEDS ASSESSMENT HAS BEEN COMPILED FROM THIS RESEARCH AND HAS BEEN APPROVED BY THE UCVH BOARD OF DIRECTORS. PART VI, LINE 3: UCVH HAS A FULL TIME PATIENT FINANCIAL COUNSELOR WHO IS RESPONSIBLE FOR WORKING WITH PATIENTS AND ANY WHO MAY BE BILLED FOR THEIR CARE TO DETERMINE THEIR ELIGIBILITY, ON A CASE BY CASE BASIS, FOR ANY GOVERNMENT PROGRAMS, SUCH AS MEDICAID OR THE UCVH FINANCIAL ASSISTANCE PROGRAM. ALL STAFF AT UCVH, PARTICULARLY REGISTRATION STAFF WHO WILL BE THE FIRST ONES TO NOTICE IF A PATIENT DOES NOT HAVE INSURANCE, ARE TRAINED TO REFER THE PATIENT TO THE FINANCIAL COUNSELOR. IN ADDITION, BROCHURES ARE AVAILABLE, AS IS CONTACT INFORMATION ON THE WEBSITE. PART VI, LINE 4: UCVH IS THE SMALLEST CRITICAL ACCESS HOSPITAL IN NEW HAMPSHIRE THAT SERVES THE LARGEST GEOGRAPHIC SERVICE AREA (OVER 850 SQUARE MILES) INCLUDING COMMUNITIES IN THE STATES OF NEW HAMPSHIRE, VERMONT, AND MAINE. ACCORDING TO THE NEW HAMPSHIRE STATE HEALTH PROFILE, OUR RESIDENTS ARE THE MOST FRAGILE OF ALL CITIZENS IN NEW HAMPSHIRE AS IT RELATES TO HEALTH OUTCOMES AND ECONOMIC CONDITIONS. UCVH IS DEPENDENT OF PUBLIC FUNDING AND DISPROPORTIONATE SHARE FUNDING TO SUBSIDIZE THE CARE PROVIDED TO THE PATIENTS WE SERVE. REPORTS FILED WITH STATES PART VI, LINE 7 NH 0 AMBULANCE SERVICES INDIAN STREAM HEALTH CENTER INC 2 CORLISS LN RR2 BOX 25 COLEBROOK NH 03576 200999212 501(C)3 50000 FMV MEDICAL SERVICESMEDICAL SERVICES X 0 1 X X X 0 0 0 0 0 0 0 0 0 EDWARD LAVERTY PA-C 183948 0 3053 0 0 0 3331 0 25952 0 216284 0 0 0 CHARLES WHITE 133942 0 53 0 0 0 0 0 19394 0 153389 0 0 0 CHARANJIT VEDI 334959 0 53 0 0 0 0 0 0 0 335012 0 0 0 JOHN EPPOLIOTO 265807 0 11053 0 0 0 0 0 11513 0 288373 0 0 0 JOSEPH KIEMAN 212647 0 53 0 0 0 4091 0 27623 0 244414 0 0 0 ROBERT SOUCY 205392 0 53 0 0 0 4251 0 20601 0 230297 0 0 0 PART I, LINE 1A RENT WAS PAID FOR THE LODGING OF DR. VEDI- A PER DIEM PHYSICIAN. FORM 990, PART VI, SECTION A, LINE 3 NORTHERN NEW HAMPSHIRE COLLABORATIVE, LLC PROVIDES MANAGEMENT SERVICES TO THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PROVIDED TO THE FINANCE COMMITTEE FOR REVIEW AND APPROVAL BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS, AMD KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST DOCUMENT. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL CAO'S COMPENSATION AND BENEFIT PACKAGE IS REVIEWED PERIODICALLY BY COMMUNITY BOARD MEMBERS WHO GOVERN THE NON-PROFIT ORGANZATION AS UNPAID, INDEPENDENT VOLUNTEERS. THE PERIODIC REVIEW INCLUDES COMPARABILITY DATA, AND THE DELIBERATION AND DECISION-MAKING IS SUBSTANTIATED BY WRITTEN MINUTES. FORM 990, PART VI, SECTION C, LINE 18 UVCH MAKES ITS 990 AVAILABLE UPON REQUEST AND ON THE GUIDESTAR WEBSITE FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: BAD DEBT EXPENSE 1,258,769. WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 020222242 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 MARY HITCHCOCK MEMORIAL HOSPITAL 1 MEDICAL CENTER DRIVE LEBANON NH 03756 020222140 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 DARTMOUTH-HITCHCOCK CLINIC 1 MEDICAL CENTER DRIVE LEBANON NH 03756 222519596 MEDICAL CLINIC NH 501C(3) 509(A)(2) 0 NORTHERN NH HEALTHCARE COLLABORATIVE LLC 455617105 HEALTHCARE COLLABORATIVE NH RELATED 0 1 0.33330 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 NORTHERN NH HEALTHCARE LLC M 226078 NEW ENGLAND ALLIANCE FOR HEALTH M 147455 ANDROSCOGGIN VALLEY HOSPITAL M 681759 WEEKS MEDICAL CENTER M 52434