2014-05-08T13:11:23-07:00 2013-09-30 990 2012-10-01 042126583 ATHOL MEMORIAL HOSPITAL INCORPORATED ATHO 9782493511 2033 Main Street Athol MA 01331 Robert Crosby 9786306157 2014-04-25 2012 2015-11-30 17:44:51Z Robert Crosby Heywood Hospital 242 Green Street Gardner MA 01440 21390846 0 X www.atholhospital.org X 1918 MA Our vision is to be one of the best independent community hospitals in America. Our mission is to be our communities' trusted choice for exceptional patient-centered care. 21 19 279 93 0 0 439362 605945 20349585 20306415 119050 79416 416990 388482 21324987 21380258 0 0 0 0 10987459 10501285 0 0 0 12730074 10646598 23717533 21147883 -2392546 232375 8058828 9065130 8972699 7014892 -913871 2050238 Our mission is to be our communities' trusted choice for exceptional patient-centered care. 0 0 19169740 0 20306415 Athol Memorial Hospital is a critical access hospital (CAH) serving the nine towns of North Quabbin Region. The areas relatively small population is dispersed over a large geographic area. Inherent in the Hospital mission of providing healthcare services are efforts to help improve the health and lives of our community. This intent is the framework for our community benefits activities. 0 0 0 19169740 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 48 0 1 279 1 0 0 0 0 0 0 0 0 0 0 X 21 19 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X Heywood Hospital Robert Crosby 9786306157 242 Green Street Gardner MA 01440 X Kenneth Pierce 0 X 0 0 0 Glenn Hunt 0 X 0 0 0 Rebecca Bialecki MD 0 X 0 0 0 Cheney Castine 0 X 0 0 0 Tina Sbrega 0 X 0 0 0 Roy Lake MD 0 X 0 0 0 John Skrzypczak MD 0 X 0 0 0 Donald Mruk MD 0 X 0 0 0 Mohsen Noreldin MD 0 X 26580 0 0 Doug Starrett 0 X 0 0 0 Daniel Asquino 0 X 0 0 0 Winfield Brown 0 40 X X 0 526138 50699 Robert Chauvin 0 X 0 0 0 Laura Chen MD 0 X 0 0 0 Joyce Fletcher 0 X 0 0 0 John Flick 0 X 0 0 0 James Garrison 0 X 0 0 0 John Kerney 0 X 0 0 0 Michele Parker MD 0 X 0 0 0 JoAnne Parks 0 X 0 0 0 James Meehan 40 0 X 33400 0 3247 Paul Dabrody 40 X X 248547 0 0 Robert Crosby 0 40 X 0 268605 48958 Lucille Songer 40 0 X 95684 0 20568 Steven Penka 40 0 X X 101883 0 15469 Michael Grimmer 0 40 X 0 228187 43961 Haytham Mohamed 40 0 X 431879 0 26146 Mark Wu 40 0 X 345380 0 12291 1283353 1022930 221339 4 1 1 0 St Vincent Physician Services 123 Summer Street Worcester MA 01608 ER & Hospitalist Physicians 1289078 Healthcare Provider Advocates PO Box 2117 Amherst MA 01004 Patient Accounts Manager & Consulting 512706 Labcorp of America Holdings PO Box 12140 Burlington NC 27216 Lab Services 449122 Navix Diagnostics PO Box 347203 Pittsburg PA 15251 Nuclear Medicine Consulting 194116 LocumTenenscom PO Box 405547 Atlanta GA 30353 Anesthesia Coverage 158682 6 0 0 20670 0 402322 182953 1200 605945 Ancillary OP Services 622110 17443417 17443417 0 0 Ancillary IP & Routine Services 622110 2765617 2765617 0 0 MRI/PET Scan Income 622110 89452 89452 0 0 CPR Classes 622110 7929 7929 0 0 0 0 0 0 20306415 81127 0 0 81127 0 0 0 0 0 0 0 0 270886 0 0 0 270886 0 270886 0 0 270886 0 250 0 1961 0 -1711 -1711 0 0 -1711 2268 20670 8627 -6359 0 -6359 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722212 71793 0 0 71793 Medical Record Copies 561499 13547 0 0 13547 Rebates 900099 4418 0 0 4418 34197 0 0 34197 123955 21380258 20306415 0 467898 0 0 0 0 0 0 0 0 138264 95064 43200 0 0 0 0 0 8520745 8208656 312089 0 0 0 0 0 1203100 1139047 64053 0 639176 605869 33307 0 0 0 0 0 71411 0 71411 0 5078 0 5078 0 0 0 0 0 0 0 0 0 0 0 1028199 947267 80932 0 13846 12292 1554 0 2768000 2460630 307370 0 37010 0 37010 0 0 0 0 0 581677 581677 0 0 23338 13588 9750 0 0 0 0 0 8980 8980 0 0 19598 19598 0 0 0 0 0 0 781188 778261 2927 0 195913 163966 31947 0 Professional Fees 1780456 849771 930685 0 Free Care 1374961 1374961 0 0 Physician Fees 1143494 1143494 0 0 Provisions for Bad Debt 557203 476755 80448 0 256246 289864 -33618 0 21147883 19169740 1978143 0 514085 819734 0 0 0 0 2131811 2209386 0 0 0 0 0 0 424187 162626 109942 27205 17514726 13439530 3809455 4075196 0 0 1069348 1770983 0 0 0 0 0 0 8058828 9065130 4112296 4113052 0 0 0 74282 0 0 0 0 0 0 737415 984621 0 0 4122988 1842937 8972699 7014892 X -2582242 491051 239635 94938 1428736 1464249 -913871 2050238 8058828 9065130 X 232375 0 0 0 0 2731734 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1428736 15816 1091 0 -113554 0 1559197 968215 359388 137402 0 36269 0 1428736 1039129 0 -28328 0 42586 0 968215 992383 0 46746 0 0 0 1039129 1013033 0 -20650 0 0 0 992383 0 0.9391 0.0609 0 0 0 71990 71990 0 8359992 5567656 2792336 0 0 0 0 0 8280713 7871874 408839 0 802031 0 802031 4075196 Donor restricted investments 1770983 F 1770983 Estimated Third Party Settlements 1842937 1842937 X SchD_P05_S00_L04 Schedule D, Part V, Line 4 The organization's endowment includes both donor restricted endowment funds and funds designated by the Boad of Directors to function as endowments. As required by GAAP, net assets associated with endowment funds, including funds designated by the Board of Directors to function as endowments, are classified and reported based on the existence or absence of donor-imposed restrictions. The organization has interpreted state law as requiring realized and unrealized gains of premanently restricted net assets to be retained in a temporarily restricted net asset classification until appropriated by the Organization's Board of Directors and expended. State law allows the Board to appropriate as much of the net appreciation of premanently restrictednet assets as is prudent considering the Organization's long and short term needs, present and anticipated financial requirements, expected total return on investments, price-level trends, and general economic conditions. SchD_P10_S00_L02 Schedule D, Part X, Line 2 Heywood Healthcare, Heywood Hospital, Athol Hospital and HMGI have been determined to be not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code"), and the Realty Corp has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Code. All of the entities are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Any income not substantially related to these Organizations' exempt purposes may be considered unrelated business income under IRC section 511 and, as such, be subject to tax at normal corporate rates. In accordance with GAAP, the Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years 2009 through the current year remain open for examination by federal and state taxing authorities. Golf Tournament 22938 20670 2268 1330 50 5460 1474 0 313 0 0 22938 20670 2268 1330 50 5460 1474 0 313 8627 -6359 1 1 1 X 1 X 600 1 1 1 0 1 1 0 0 538505 352213 186292 0.0091 0 0 4863726 3807757 1055969 0.0515 0 0 0 0 0 0 0 0 5402231 4159970 1242261 0.0606 0 0 121730 2268 119462 0.0058 0 0 0 0 0 0.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4896 0 4896 0.0002 0 0 126626 2268 124358 0.0060 0 0 5528857 4162238 1366619 0.0666 1 143408 5292 3790307 5441078 -1650771 X 1 1 1 1 Athol Memorial Hospital

2033 Main Street Athol MA 01331

www.atholhospital.org X X X X Athol Memorial Hospital 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X 1 0 1 1 200 1 600 1 X X X X X X X 1 1 X 1 X 0 1 X 0 1 SchH_P01_S00_L06b Schedule H, Part I, Line 6b The Organization makes its annual Community Benefit Report available to the public by transmitting the report electronically to the Attorney General's Community Benefit office which then makes it public on their website. SchH_P01_S00_L07 Schedule H, Part I, Line 7 The costing methodology used to calculate the amounts reported in the table in Part I, for lines 7a through 7c were based on the cost to charge ratio derived from the supplied Worksheet 2 in the IRS Sch H instructions. The costs for lines 7e through 7i were actual costs incurred. SchH_P03_S0A_L02 Schedule H, Part III, Section A, Line 2 The cost methodology used for line 2 was based on the cost to charge ratio derived from the supplied Worksheet 2 in the IRS sch H instructions. SchH_P03_S0A_L03 Schedule H, Part III, Section A, Line 3 The methodology used for line 3 was to take the percent of financial assistance applications that were denied due to inadequate documentation divided by the total applications received for FY13. This amounted to be approximately 3.69% which was applied against the number on line 2. It is our belief that $5,292 in bad debt should be included as community benefits. As a not for profit, patient care is provided to all, regardless of ability to pay for that care. Making quality patient care available to all in our community, regardless of their economic means, qualifies bad debt as a community benefit. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 The footnote on bad debt in the organization's audited financial statements can be found on page 8, allowance for doubtful accounts. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The allowable costs on line 6 were obtained from our FY 2013 Medicare Cost Report, worksheet D schedules. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b Standard Collection Policies and Procedures for Athol Memorial Hospital are as follows: 1. AMH provides patients with information about financial assistance programs available through the Commonwealth of MA, which may cover all or some of their unpaid hospital bill. For those patients that request assistance, the hospital will assist in eligibility screening for and applying for an available public assistance program. These programs include, but are not limited to MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start and the Health Safety Net. When applicable the hospital will also assist patients in applying for coverage of services as a medical hardship based on the patient's documented family income, current and prior insurance coverage and allowable medical expenses. 2. Financial assistance is intended to assist low income patients who do not otherwise have the ability to pay for their healthcare services. Such assistance takes into account each individual's ability to contribute to the cost of his or her care. AMH will work with those patients that are uninsured or underinsured to assist with applying for available financial assistance programs that may cover all or some of their unpaid hospital bills. This assistance is provided for both residents and non-residents of MA, however there may not be coverage in a state public assistance program for medical services received at a MA hospital by a non resident of MA. 3. An initial itemized bill is sent to the party responsible for the patient's personal financial obligations. 4. AMH uses a 4 week billing cycle. Account statements are issued every 28 days following the initial bill. 5. Issuance of subsequent billings, telephone calls, pre-collection letters and other personal contract notices will follow the initial bill as necessary to constitute a genuine effort to contact the party responsible for the obligation. 6. Document alternative efforts to locate the party responsible for the obligation or the correct address on billing returned by the postal service as incorrect address or undeliverable. 7. Documentation of continuous collection action undertaken on a regular, frequent basis will be maintained via paper or electronic media. 8. Documentation of collection efforts will be maintained until audit is complete. SchH_P05_S0B_L03 Schedule H, Part V, Section B, Line 3 The 2011-2012 Community Health Needs Assessment was completed through compilation of area data available from the US Census, Massachusetts Department of Public Health and other related sources within the State. The Assessment includes a community survey intended to calculate the community's perception of health, barriers to care and unmet needs in the North Quabbin area. Focus groups were held to further investigate, including parents, youth, educators, veterans, elders and health care providers. Community-based health related agencies who provided consultation and input included Athol Board of Health, Tobacco Control Alliance, Northeast Quabbin District Dept of Veteran's Services, Franklin County Dept of Veteran's Services, Montachusett's Veteran's Outreach, Community Center of Franklin County, Community Action, Valuing Our Children, Orange Elementary Schools, RC Mahar Regional School, Athol-Royalston Regional School District, MOC Community Partnership, Athol Council on Aging, Franklin County Home Care, Communities That Care Coalition, Community Coalition for Teens and Dial Self. SchH_P05_S0B_L14 Schedule H, Part V, Section B, Line 14 Signage is posted throughout the ER, Admissions and Waiting Rooms regarding financial assistance available through the Hospital and are directed to contact the Financial Counselors. SchH_P05_S0B_L16 Schedule H, Part V, Section B, Line 16 AMH follows its standard collection practices to attempt to resolve balances of Uninsured Patients. 1. An itemized bill is sent to the patient or guarantor. If initial bill is returned as undeliverable, a Financial Counselor will attempt to contact the patient or Guarantor by telephone to obtain current mailing address. If unsuccessful, the account will be referred to an outside Collection Agency for skip tracing and additional collection action. 2. Financial Counselor attempts to contact patient or guarantor either by telephone or written correspondence to establish third party liability, if any. 3. Verbal or written information is given about MassHealth, HSN and other governmental assistance programs and where to apply for assistance. AMH mails the patient or guarantor two additional statements and two pre-collection letters. Subsequent attempts to reach the patient by telephone are made at the pre-collection stage. AMH maintains electronic notes on the patient's account of mail returned as undeliverable and alternative attempts to contact the patient. AMH will request documentation of collection activity from its outside Collection Agencies for accounts referred to skip tracing prior to the normal 120 day ERBD write off requirements. AMH will send a final notice by certified mail for accounts of $1,000 or more where there have been no prior notices returned as incorrect address or undeliverable. AMH's patient billing system operates on a 4 week cycle. After an initial itemized invoice, account statements are generated every 28 days. Patient Account Representatives or Financial Counselors will review Accounts Receivable reports to identify any account not receiving a statement to ensure there is no gap in continuous collection activity of 120 days or greater. SchH_P05_S0B_L22 Schedule H, Part V, Section B, Line 22 All patients are charged the same amount for services regardless of ability to pay or insurance coverage. Insurance companies pay for patients they cover at negotiated rates with the Hospital, these rates are usually less than the gross charge. All uninsured, underinsured or self pay patients are directed to Financial Counselors to determine if they are eligible for government assistance, check for medical hardships, or if they have access to health insurance or are eligible for a discount. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Athol Hospital assesses the health needs of the communities it serves in a variety of ways in addition to the CHNA. The Patient and Family Advisory Council which meets quarterly includes a minimum of 8 patients from Athol and surrounding towns, including Orange, Royalston, Philipston, Petersham, New Salem, Wendell, Warwick and Erving, and two hospital representatives. This council, comprised of former patients and their families, provides general input on community needs, as well asinput on hospital-specific services and opportunities for improvement. In addition, the hospital works closely throughout the year with area social service agencies obtaining input on community health needs including, the Athol Board of Health, Council on Aging, Athol Senior Center, North Quabbin Community Coalition and their Substance Abuse Prevention Taskforce, Erving Board of Health, Erving Senior Center, Royalston Board of Health, Phillipston Board of Health, Athol Area YMCA, Community Health Center of Franklin County, Children's Health and Wellness Taskforce, Tobacco Control Alliance, Montachusetts Veterans Outreach, Athol-Royalston Regional School District, Orange Public Schools and direct community outreach to Athol and surrounding towns, The hospital solicits feedback from social service and nursing staff, as well as physicians regarding patient feedback. The hospital also provides space for/and facilitates support groups which provide feedback on community interests and needs. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Athol Memorial Hospital has financial counselors to assist patients to apply for MassHealth, Commonwealth Care, Healthy Start, Children's Medical Security, EAEDC, the Massachusetts Health Safety Net program, Medical Hardship and any other available financial assistance. Financial counseling staff will assist with the application process as well as address billing concerns and provide pre and post service payment assistance. It is the patient or their guarantor's responsibility to provide all necessary information and documentation to determine eligibility for all financial assistance programs and payment plans. 1. Upon admission to the hospital Emergency Room, AMH Registration staff will, as soon as is reasonably possible, make every effort to obtain the financial information necessary to determine responsibility for payment of the bill from the patient or Guarantor. a. If hospital staff is not able to obtain sufficient information to determine financial responsibility at the time of Emergency Room service, a hospital Financial Counselor will attempt to reach the patient or guarantor via telephone and/or written correspondence sent via the US Postal System. b. In the event that the patient has deceased, the hospital Financial Counselor will make reasonable efforts to reach the guarantor, patient's designated Health Care Proxy, or designated Next of Kin in order to obtain financial information necessary to determine responsibility for payment of the hospital bill. 2. Upon admission to the hospital as an Inpatient, AMH Registration staff will make every reasonable effort to obtain the financial information necessary to determine responsibility for payment of the Hospital bill from the patient or guarantor. a. If the patient or guarantor is unable to provide the information needed at the time of admission as an Inpatient, the Patient Financial Advocate and Social Service Staff, with the patient's consent, will make reasonable efforts to contact the relatives, friends, guarantor, and the patient for additional information while the patient is in the Hospital. b. If sufficient patient financial information has not been obtained to assess the ability of the patient or guarantor to pay for services prior to the date of discharge, the Patient Financial Advocate will make reasonable efforts to obtain the necessary information at the time of the patient's discharge. c. If sufficient patient financial information has not been obtained to assess the ability of the patient or guarantor to pay for services at time of discharge, a Financial Counselor will attempt to reach the patient or guarantor by telephone calls and/or written correspondence sent via the US Postal System. d. In the event that the patient has deceased, the hospital Financial Counselor will make reasonable efforts to reach the guarantor, patient's designated Health Care Proxy, or designated Next of Kin in order to obtain financial information necessary to determine responsibility for payment of the bill. 3. When a patient present at AMH for Urgent Outpatient Services hospital Registration staff, will as soon as possible, make every effort to obtain the financial information necessary to determine responsibility for payment of the bill from the patient or guarantor. a. If hospital registration staff is not able to obtain sufficient informaiton to determine financial responsibility at the time of Urgent Outpatient service, a hospital Financial Counselor will attempt to reach the patient or Guarantor via telephone and/or written correspondence via US Postal System. 4. When a patient presents at AMH for an elective or scheduled Outpatient Service, the patient or guarantor must provide hospital registration staff or staff of the receiving department with sufficient information to determine responsibility for payment of the bill. a. If the patient or guarantor is unable to provide sufficient information to determine responsibility for payment of the bill, AMH may choose to defer elective or scheduled Outpatient Services, with consent from the ordering physician, nurse practitioner, or physician assistant, until the patient or guarantor is able to provide necessary financial information. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Athol Memorial Hospital, an acute care, not-for-profit community hospital, was founded to provide Inpatient, Outpatient, Emergency Care and Home Care Services for residents of Worcester and Franklin counties. The mission of the Community Benefits Program is to encourage healthy lifestyles through outreach, education and support to the communities we serve (Athol, Erving, New Salem, Orange, Petersham, Philipston, Royalston, Warwick and Wendell). This underlying principle of encouraging health lives guides our existing Community Benefits activities and will be carried forward as we formalize our Community Benefits Plan. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Athol Hospital works closely with the community to promote health in areas identified by the 2012 Community Health Needs Assessment (CHNA) through a variety of means. Direct outreach is provided to community members including seniors, shut-ins, and school-aged children through our Community Health Nurse(CHN). The CHN provides a variety of services as needed through local area Health Boards including Athol, Phillipston, Erving and Royalston and through direct services provided at community member homes, senior centers and community health events. Services provided include, but are not limited to, education, blood pressure monitoring, influenza inoculation, prevention efforts for diabetes, behavior health and substance abuse, navigation/access to insurance and community agency assistance and direct care for other chronic conditions. This directly addresses community members with barriers to accessing healthcare as identified in the 2012 CHNA, with barriers including distance and lack of transportation to services, difficulty navigating insurance systems, and management of chronic diseases in adults and children. The hospital also works closely with the Children's Health and Wellness Taskforce addressing poverty-related health issues in children as indicated in the 2012 CHNA including asthma, behavioral health and nutrition, and with the Franklin Hampshire North Quabbin Opiate Prevention Taskforce addressing the highest local priority indicated in the 2012 CHNA - drug abuse in youth and adults. In collaboration with local service agencies, the hospital provides Lifeline systems to 131 subscribers at reduced cost including elderly, disabled, and those with socioeconomic and rural transportation challenges, addressing a significant barrier to care as indicated in the 2012 CHNA. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 Community Benefit Plans are determined by the Administrative Team of the affiliated healthcare organization, with input from community health-focused staff at member hospitals including Community Health Nurse, Social Workers, Emergency Department staff, Community Relations, CHNA, local educational institutions and area social service agencies. Each hospital focuses on community health activities specific to the community health needs identified in the CHNA related to its determined service area. Each hospital then carries out Community Benefit Plan addressing the health needs of their target areas as determined in the CHNA. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 Athol Memorial Hospital files an annual Community Benefit Report to the Attorney General's Community Benefit Office in Massachusetts. X X X X X 0 0 0 0 0 0 0 1 0 Haytham Mohamed 431879 0 0 0 0 0 0 0 26146 0 458025 0 0 0 Mark Wu 274997 0 70383 0 0 0 0 0 12291 0 357671 0 0 0 Winfield Brown 0 383569 0 133569 0 9000 0 19261 0 31438 0 576837 0 0 Robert Crosby 0 225978 0 41469 0 1158 0 21255 0 27703 0 317563 0 0 Steven Penka 76883 0 25000 0 0 0 0 0 15469 0 117352 0 0 0 Michael Grimmer 0 190066 0 25621 0 12500 0 17000 0 26961 0 272148 0 0 SchJ_P01_S00_L07 Schedule J, Part I, Line 7 Dr. Mark Wu has an employment contract with Athol Hospital for a Physician Bonus Award. This Contract states "In each year, your bonus will be calculated based upon Employer receiving net receipts in excess of the Physician Base Salary. In Addition, the Employer will be entitled to recoup up to $30,000 in Personal Insurance Benefits prior to the processing of the Bonus Award. After the Base Salary and the above mentioned Personal Insurance Benefits, the incentive will be split 40% for Hospital and 60% for Physician". For the period of January 1, 2012 through December 31, 2012 Dr. Wu earned $70,383.31 for a bonus incentive. Out of this amount, $40,000 was paid in Fiscal Year 2012 and $30,383.31 was paid in Fiscal Year 2013, with the entire amount being paid in calendar year 2012. SchJ_P02_S00_L00 Schedule J, Part II Steven Penka was the former CEO of Athol Memorial Hospital. He terminated on July 16, 2012. F990_P06_S0A_L03 Form 990, Part VI, Section A, Line 3 Athol's CFO, Dean Flemming, terminated on October 14, 2011. In October, Athol utilized the services of Healthcare Provider Advocates for an interim CFO, Paul Dabrody. Paul worked with Athol from Oct 2011 through December 2012. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The Accountant for Athol prepares the form 990 and provides it to the Sr. Accountant and Controller for review. The form is then sent to the CFO for final review. Once approved and signed, the 990 is placed on the Hospital Cyber Board for the Board of Trustees' review. The 990 is then approved by the Board and submitted by the Accounting Department. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The Board of Trustees review the organization's Conflict of Interest policy annually in order to ensure that the organization's Board of Trustees, Officers and Employees are regularly and consistently monitoring and enforcing it. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Salaries are determined by the Board of Directors considering comparable salary information for Officers of other entities of similar size and level of activity. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The organization makes the governing documents, conflict of interest policy and financial statements available to the public by providing completed copies to the Executive Assistant, who provides copies upon request. F990_P07_S0A_L01a Form 990, Part VII, Section A, Line 1a Steven Penka, former CEO of Athol, terminated on July 16,2012. James Meehan was elected as the Interim CEO starting in July 2012 and terminating on December 31, 2012 when Heywood Hospital became affiliated with Athol Hospital. AMH utilized the services of Healthcare Provider Advocates for an interim CFO, Paul Dabrody. The amount listed is what was paid to the company for his services. Paul worked with Athol from October 2011 through October 2012. F990_P11_S00_L09 Form 990, Part XI, Line 9 The amount that makes up the other changes in net assets or fund balance is from inter-corporate transfers from related organizations to support the operations of the Hospital. Heywood Healthcare Inc 242 Green Street Gardner MA 01440 222720658 Parent Corp MA 501(c)(3) 7 N/A 0 Heywood Healthcare Charitable Foundation Inc 242 Green Street Gardner MA 01440 222720562 Inactive MA 501(c)(3) 7 Heywood Healthcare Inc 0 Henry Heywood Memorial Hospital 242 Green Street Gardner MA 01440 042103581 Hospital MA 501(c)(3) 3 Heywood Healthcare Inc 0 Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 Physicians Offices MA 501(c)(3) 9 Heywood Healthcare Inc 0 Henry Heywood Realty Corp 242 Green Street Gardner MA 01440 043327447 Property Holding Corp MA 501(c)(2) Heywood Healthcare Inc 0 HHMH Aid Association 242 Green Street Gardner MA 01440 042198019 raise funds for hospital MA 501(c)(3) 9 N/A 0 AMH Auxillary 2033 Main Street Athol MA 01331 042126583 raise funds for hospital MA 501(c)(3) 9 N/A 0 Winchendon Health Foundation 87 Central Street Winchendon MA 01475 042113276 Support Organization MA 501(c)(3) PF N/A 0 Heywood Physicians Hospital Organization 242 Green Street Gardner MA 01440 043153119 Managed Care Contract MA 501(c)(3) 9 N/A 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 1 Athol Memorial Hospital submitted form 8868 on January 29, 2014 for an extension to file until May 15, 2014. We received notice# CP211A dated March 31, 2014 approving the form 8868.