2014-11-14T15:27:51-06:00 2013-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2013-01-01 150533577 SAMARITAN MEDICAL CENTER SAMA 3157855702 830 WASHINGTON STREET WATERTOWN NY 13601 SEAN MILLS CFO 3157855702 2014-11-04 1 JOSEPH J SCHLEGEL P00301329 3154463600 2013 2015-11-30 17:44:51Z SEAN MILLS 830 WASHINGTON STREET WATERTOWN NY 13601 204663713 0 X WWW.SAMARITANHEALTH.COM X 1881 NY SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 19 17 1916 185 0 0 2946399 2341867 192654193 199441080 156823 264368 1834857 2616398 197592272 204663713 0 0 0 0 107399088 111540486 0 0 282649 85736379 86332314 193135467 197872800 4456805 6790913 207881444 205390346 119258858 104734085 88622586 100656261 X SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 0 0 167848698 202145893 PROVIDE CARE FOR 10,820 INPATIENT DISCHARGES IN ADDITION, SAMARITAN MEDICAL CENTER PROVIDED FOR 150,890 OUTPATIENT VISITS, 51,833 EMERGENCY ROOM VISITS, AND 96,535 FAMILY HEALTH CLINIC VISITS. 167848698 1 1 0 0 0 0 0 0 0 1 1 1 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 0 0 0 0 0 0 0 0 1 0 0 0 1 126 0 1 1916 1 0 0 0 0 0 0 0 0 0 0 X 19 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X SEAN MILLS 3157796686 104 PADDOCK STREET WATERTOWN NY 13601 DAVID FLINT TRUSTEE 40.00 X 296962 0 37366 DAVID RECHLIN TRUSTEE 1.00 X 155000 0 7809 JACK RUSH TRUSTEE 1.00 X 187617 0 29331 ALFRED CALLIGARIS CHAIRMAN OF FINANCE 1.00 X X 0 0 0 PAUL CARR TRUSTEE 1.00 X 0 0 0 BRUCE DINES TRUSTEE 1.00 X 0 0 0 REV FRED GARRY VICE CHAIRMAN 1.00 X X 0 0 0 KATHLEEN GEBO TRUSTEE 1.00 X 0 0 0 COL MATTHEW MATTNER TRUSTEE 1.00 X 0 0 0 CYRIL MOUAIKEL TRUSTEE 1.00 X 0 0 0 MELANIE PARKER-GUERTSEN SECRETARY 1.00 X X 0 0 0 RONALD PERCIACCANTE TRUSTEE 1.00 X 0 0 0 MARY PERRINE TRUSTEE 1.00 X 0 0 0 CATHERINE BURNS QUENCER TRUSTEE 1.00 X 0 0 0 JOAN TREADWELL WOODS TRUSTEE 1.00 X 0 0 0 JAN TURCOTTE TRUSTEE 1.00 X 0 0 0 DANIEL VILLA TRUSTEE 1.00 X 0 0 0 PETER WALTON TRUSTEE 1.00 X 0 0 0 RENEE WATERBURY TRUSTEE 1.00 X 0 0 0 LISA WEBER CHAIR 1.00 X X 0 0 0 MARTIN YENAWINE TRUSTEE 1.00 X 0 0 0 THOMAS H CARMAN PRESIDENT & CEO 40.00 4.00 X 567210 0 102304 PAUL KRAEGER TREASURER 1.00 3.50 X 155682 0 21628 SEAN MILLS CFO 40.00 3.50 X 56824 0 4392 MICHAEL SHORT CIO 40.00 X 208935 0 24959 MARIO VICTORIA CMO 40.00 1.00 X 364879 0 37362 BRIAN O'HEARN VP PATIENT CARE/CNO 40.00 X 205269 0 18469 ANTHONY JOSEPH VP LONG TERM CARE 40.00 1.00 X 179737 0 18736 ALEJANDRO RODRIGUEZ UROLOGIST 40.00 X 565377 0 23615 JOSEPH WETTERHAHN FAMILY PRACTICE MD 40.00 X 461949 0 37373 MOONJOHN KIM INTERVENTIONAL RADIOLOGIST 40.00 X 544997 0 37372 SHAHANDEH HAGHIR PATHOLOGIST 40.00 X 424902 0 32383 YILIN ZHANG PATHOLOGIST 40.00 X 398900 0 20112 4774240 0 453211 106 0 1 0 PURCELL-LECESSE 75 THRUWAY PARK DRIVE WEST HENRIETTA NY 14586 CONTRACTOR SERVICE 9844450 JEFFERSON ANESTHESIOLOGIST PO BOX 837 WATERTOWN NY 13601 ANESTHESIOLOGY SERVICES 2306254 HAYNER HOYT CORPORATION 625 ERIE BLVD WEST SYRACUSE NY 13204 CONTRACTOR SERVICE 1916940 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 PURCHASED SERVICE 1598710 NORTH COUNTRY EMERGENCY MEDICAL CONSULTA 830 WASHINGTON ST WATERTOWN NY 13601 PURCHASED SERVICE 571909 34 280794 1099215 961858 2341867 PATIENT SERVICE REVENUE 623000 199441080 199441080 199441080 226256 226256 175953 0 175953 175953 175953 26762 11350 0 0 26762 11350 38112 38112 SOLD SERVICES 541900 1562982 1562982 CAFETERIA 722210 766624 766624 110839 110839 2440445 204663713 202145893 0 175953 2680471 714085 1966386 82850268 72197663 10618939 33666 8374867 7167435 1207432 11048325 9418284 1586612 43429 6586555 5636950 949605 1013422 10200 1003222 182926 176026 6900 17770618 14931619 2793628 45371 253271 587 251232 1452 1826335 425283 1360118 40934 2566208 2046796 511699 7713 3973965 3192346 781619 170970 105713 60876 4381 164450 50970 107419 6061 627160 570966 56194 235340 3739 231601 11448189 10380923 1067266 1839782 1172055 667727 SUPPLIES 24476986 24162670 283690 30626 PROVISION FOR BAD DEBT 9462572 9462572 EQUIP REPAIR & MAINT 6038534 4200385 1838149 OTHER EXPENSES 2709485 425356 2222013 62116 1572101 1572101 197872800 167848698 29741453 282649 5153 5684 28526776 31370909 25542253 28806482 2156236 2081965 2738914 2587049 256006798 143044781 123297111 112962017 2135074 2341360 10657834 18162004 12822093 7072876 207881444 205390346 32026707 29223310 51874135 50164974 35358016 25345801 119258858 104734085 X 85711713 98604838 2036402 1176952 874471 874471 88622586 100656261 207881444 205390346 X 6790913 62689 5180073 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2910899 657922 -1517398 2051423 9761548 147073 -6997722 2910899 9720908 1183545 -1142905 9761548 1686419 8606970 -572481 9720908 1772796 1137000 -1223377 1686419 0.42600 0.57400 0 0 1124952 1124952 123598897 37028233 86570664 3333240 2173504 1159736 127756182 103843044 23913138 193527 193527 112962017 CSV OF OFFICERS LIFE INSURANCE 424882 F INVESTMENT IN NEWELL ST., LLC 90000 C DUE FROM AFFILIATES 14009355 C GOODWILL INVESTMENT 110750 C ED PHYSICIAN CALL 1209835 C LOC FEE - SERIES B 7655 C FINANCING COSTS - SERIES B 510209 C INTEREST RATE SWAP -1105540 F FINANCING COSTS - KEY BANK 151398 C MEDICAL MALPRACTICE LT INS RECOVERY 2753460 C 18162004 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 6689553 RETIREMENT PLAN OBLIGATIONS 18656248 25345801 X PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SUPPORT SAMARITAN MEDICAL CENTER AND RELATED FACILITIES IN PROVIDING HEALTH CARE SERVICES TO THE PUBLIC. PART X, LINE 2: SAMARITAN QUALIFIES AS A TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2013 AND 2012, SAMARITAN DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2010 THROUGH 2013. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 1 X 1 X 1 1 1 0 1 1 1656453 362980 1293473 0.00650 25486861 19089865 6396996 0.03230 27143314 19452845 7690469 0.03880 162823 162823 0.00080 1021909 51743 970166 0.00490 9271027 6494124 2776903 0.01400 10455759 6545867 3909892 0.01970 37599073 25998712 11600361 0.05850 1 3922813 51756992 61433411 -9676419 X 1 1 1 1 SAMARITAN MEDICAL CENTER 830 WASHINGTON STREET WATERTOWN NY 13601 X X SAMARITAN MEDICAL CENTER 1 1 X X X X X X X X 13 1 1 1 X SAMARITANHEALTH.COM X NCNYHEALTHCOMPASS.ORG X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X 1 0 1 0 X X 1 X 0 0 SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 3: THE GOAL OF THE COMMUNITY HEALTH SURVEY WAS TO ENGAGE RESIDENTS OF THE THREE-COUNTY REGION (JEFFERSON, LEWIS, ST. LAWRENCE COUNTIES) AND GAUGE THEIR PERCEPTIONS OF HEALTH NEEDS IN THE COMMUNITY. ULTIMATELY, THE SURVEY WAS DESIGNED TO INFORM THE REGIONAL CHA/CHIP PROCESS UNDERTAKEN THROUGH A COLLABORATION BETWEEN PUBLIC HEALTH AGENCIES, HOSPITALS AND COMMUNITY-BASED ORGANIZATIONS. THE INSTRUMENT WAS MODELED AFTER A SURVEY DISTRIBUTED WITHIN ST. LAWRENCE COUNTY FOR THE PURPOSE OF ASSESSING HEALTH NEEDS WITHIN THAT REGION. A VAST RANGE OF HEALTH RELATED TOPICS WERE COVERED, INCLUDING SPECIFIC DISEASES AND CONDITIONS, HEALTH RISKS, ACCESS TO CARE, PREVENTION, AND COMMUNITY HEALTH NEEDS. THE SURVEY WAS OPEN TO COMMUNITY RESIDENTS FROM JUNE 1ST THROUGH JULY 1ST, 2013. THE INSTRUMENT WAS DISTRIBUTED USING AN ONLINE SURVEY TOOL (SURVEY MONKEY). RESPONDENTS ACCESSED THE SURVEY BY FOLLOWING A WEB LINK. INFORMATION ABOUT THE SURVEY WAS SENT TO REGIONAL HEALTH ORGANIZATIONS/AGENCIES AND THEIR AFFILIATES, VARIOUS NEWS OUTLETS, SOCIAL MEDIA OUTLETS, AND PRIVATE MEDICAL PRACTICES (ALONG WITH RESPECTIVE PATIENT PORTALS). FLYERS WERE ALSO CREATED AND POSTED AT VARIOUS COMMUNITY SITES (E.G. CLINICS AND HOSPITALS). THE PRELIMINARY FINDINGS OF THIS REPORT WERE SHARED WITH THE NORTH COUNTRY HEALTH COMPASS PARTNERS DURING MONTHLY MEETINGS HELD SINCE APRIL 2013. PRELIMINARY DATA WAS ALSO SHARED AS FOLLOWS: IN AN ONLINE SURVEY TOOL TO ENGAGE STAKEHOLDERS IN THE SELECTION OF PREVENTION AGENDA PRIORITIES AND GOALS, WHICH WAS OPEN FROM JULY 29, 2013 TO AUGUST 15, 2013; AT THE "PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 9, 2013; AT THE "PREVENT CHRONIC DISEASES" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 9, 2013; IN A MEETING WITH THE SOLE REGIONAL PEDIATRIC DENTIST TO BRAINSTORM STRATEGIES TO ADDRESS ORAL HEALTH ISSUES AFFECTING CHILDREN ON SEPTEMBER 13, 2013; AT THE "PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 16, 2013; AND IN A MEETING WITH THE FDRHPO PROVIDER EXECUTIVE COMMITTEE (PEC), COMPRISED OF PHYSICIANS WITHIN THE REGION, ON SEPTEMBER 25, 2013 SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 4: SAMARITAN MEDICAL CENTER AS WELL AS CANTON-POTSDAM HOSPITAL, CARTHAGE AREA HOSPITAL, CLAXTON-HEPBURN MEDICAL CENTER, CLIFTON-FINE HOSPITAL, GOUVERNEUR HOSPITAL, LEWIS COUNTY GENERAL HOSPITAL, MASSENA MEMORIAL HOSPITAL, RIVER HOSPITAL SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 7: THE GOAL OF THE COMMUNITY HEALTH SURVEY WAS TO ENGAGE RESIDENTS OF THE THREE-COUNTY REGION (JEFFERSON, LEWIS, ST. LAWRENCE COUNTIES) AND GAUGE THEIR PERCEPTIONS OF HEALTH NEEDS IN THE COMMUNITY. ULTIMATELY, THE SURVEY WAS DESIGNED TO INFORM THE REGIONAL CHA/CHIP PROCESS UNDERTAKEN THROUGH A COLLABORATION BETWEEN PUBLIC HEALTH AGENCIES, HOSPITALS AND COMMUNITY-BASED ORGANIZATIONS. THE INSTRUMENT WAS MODELED AFTER A SURVEY DISTRIBUTED WITHIN ST. LAWRENCE COUNTY FOR THE PURPOSE OF ASSESSING HEALTH NEEDS WITHIN THAT REGION. A VAST RANGE OF HEALTH RELATED TOPICS WERE COVERED, INCLUDING SPECIFIC DISEASES AND CONDITIONS, HEALTH RISKS, ACCESS TO CARE, PREVENTION, AND COMMUNITY HEALTH NEEDS. THE SURVEY WAS OPEN TO COMMUNITY RESIDENTS FROM JUNE 1ST THROUGH JULY 1ST, 2013. THE INSTRUMENT WAS DISTRIBUTED USING AN ONLINE SURVEY TOOL (SURVEY MONKEY). RESPONDENTS ACCESSED THE SURVEY BY FOLLOWING A WEB LINK. INFORMATION ABOUT THE SURVEY WAS SENT TO REGIONAL HEALTH ORGANIZATIONS/AGENCIES AND THEIR AFFILIATES, VARIOUS NEWS OUTLETS, SOCIAL MEDIA OUTLETS, AND PRIVATE MEDICAL PRACTICES (ALONG WITH RESPECTIVE PATIENT PORTALS). FLYERS WERE ALSO CREATED AND POSTED AT VARIOUS COMMUNITY SITES (E.G. CLINICS AND HOSPITALS). THE PRELIMINARY FINDINGS OF THIS REPORT WERE SHARED WITH THE NORTH COUNTRY HEALTH COMPASS PARTNERS DURING MONTHLY MEETINGS HELD SINCE APRIL 2013. PRELIMINARY DATA WAS ALSO SHARED AS FOLLOWS: IN AN ONLINE SURVEY TOOL TO ENGAGE STAKEHOLDERS IN THE SELECTION OF PREVENTION AGENDA PRIORITIES AND GOALS, WHICH WAS OPEN FROM JULY 29, 2013 TO AUGUST 15, 2013; AT THE "PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 9, 2013; AT THE "PREVENT CHRONIC DISEASES" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 9, 2013; IN A MEETING WITH THE SOLE REGIONAL PEDIATRIC DENTIST TO BRAINSTORM STRATEGIES TO ADDRESS ORAL HEALTH ISSUES AFFECTING CHILDREN ON SEPTEMBER 13, 2013; AT THE "PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN" AD HOC WORK GROUP SESSION WHICH WAS HELD ON SEPTEMBER 16, 2013; AND IN A MEETING WITH THE FDRHPO PROVIDER EXECUTIVE COMMITTEE (PEC), COMPRISED OF PHYSICIANS WITHIN THE REGION, ON SEPTEMBER 25, 2013 SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 20D: WE USED A PERCENTAGE OF GROSS CHARGES. 8 SAMARITAN FAMILY HEALTH - CLAYTON 909 STRAWBERRY LANE CLAYTON NY 13624 PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - PLAZA 1575 WASHINGTON STREET WATERTOWN NY 13601 PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - UROLOGY 19324 US ROUTE 11 WATERTOWN NY 13601 OUTPATIENT UROLOGY CLINIC SAMARITAN FAMILY HEALTH - LACONA 3 DEMOTT STREET LACONA NY 13083 PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - WBI 428 WASHINGTON STREET WATERTOWN NY 13601 OUTPATIENT IMAGING CLINIC SAMARITAN OUTPATIENT BEHAVIOR HEALTH 165 COLEMAN STREET WATERTOWN NY 13601 OUTPATIENT PSYCHIATRIC CLINIC SAMARITAN FAMILY HEALTH - LERAY 26908 INDEPENDENCE WAY EVAN MILLS NY 13637 PRIMARY CARE CLINIC/URGENT CARE CAPE VINCENT CLINIC 782 E BROADWAY CAPE VINCENT NY 13618 PRIMARY CARE CLINIC PART I, LINE 6A: SAMARITAN COMPLETES AND FILES THE COMMUNITY SERVICE PLAN ANNUALLY. A FULL REPORT IS COMPLETED AND SUBMITTED EVERY THREE YEARS, WITH UPDATES SUBMITTED EACH OF THE OTHER TWO YEARS. THE REPORTS ARE AVAILABLE TO THE PUBLIC VIA SAMARITAN'S WEBSITE (WWW.SAMARITANHEALTH.COM) OR BY CONTACTING THE SAMARITAN MARKETING OFFICE. PART I, LINE 7: THE RATIO OF COST TO CHARGES METHODOLOGY WAS UTILIZED IN COMPUTING ALL EXPENSES REPORTED ON LINES 7A. THROUGH 7G. THE WORKSHEET (#1 THROUGH #6) TEMPLATES IN THE INSTRUCTIONS FOR SCHEDULE H WERE FOLLOWED TO COMPUTE COSTS REPORTED. PART I, LINE 7G: THE COSTS REPORTED ON THIS LINE REPRESENT THE NET EXPENSE FOR THE OUTPATIENT PRIMARY CARE CLINICS OPERATED BY SAMARITAN MEDICAL CENTER. THE "NET" EXPENSE WAS COMPUTED UTILIZING WORKSHEET 6 OF THE SCHEDULE H FORM. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, SAMARITAN MEDICAL CENTER (SMC), SAMARITAN MEDICAL PRACTICE, P.C. (SMP) AND SAMARITAN KEEP NURSING HOME, INC. (SKH) ANALYZE PAST PAYMENT HISTORY AND IDENTIFY TRENDS FOR EACH MAJOR PAYOR SOURCE OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH PATIENTS WHO HAVE THIRD-PARTY COVERAGE, SMC, SMP AND SKH ANALYZE CONTRACTUALLY DUE AMOUNTS AND PROVIDE AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS AND FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, SMC, SMP AND SKH ALSO ANALYZE AMOUNTS DUE AND PROVIDE AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE BASED ON PAST EXPERIENCE, INCLUDING CONSIDERATION OF CURRENT BUSINESS AND ECONOMIC CONDITIONS. WHEN SMC, SMP AND SKH ESTABLISH THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BOTH TAKE INTO CONSIDERATION THE FACT THAT MANY SELF-PAY 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 AMOUNT OF BAD DEBT AT COST REPORTED ON LINE #2 WAS CALCULATED BY APPLYING THE OVERALL HOSPITAL RCC (COMPUTED USING WORKSHEET #2) TO THE PROVISION FOR BAD DEBT EXPENSE AS REPORTED IN OUR 2013 AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS REPORTED WERE TAKEN DIRECTLY FROM THE 2013 MEDICARE COST REPORT FILED WITH NATIONAL GOVERNMENT SERVICES. THE METHODOLOGY IS BASED ON APPLYING FACILITY RATIO OF COST TO CHARGES TO THE MEDICARE (PROGRAM) CHARGES, AS PROVIDED BY NATIONAL GOVERNMENT SERVICES IN THE PS&R REPORT.THE MEDICARE SHORTFALL REPORTED SHOULD BE TREATED AS COMMUNITY BENEFIT EXPENSE. SAMARITAN MEDICAL CENTER PROVIDES MEDICAL SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE COVERAGE. THE OVERALL (INPATIENT AND OUTPATIENT) MEDICARE PAYOR MIX FOR 2013 WAS APPROXIMATELY 36%. PART III, LINE 9B: IF CHARITY CARE ASSISTANCE IS GRANTED, PATIENT ACCOUNTS THAT HAVE BEEN REFERRED TO A COLLECTION AGENCY WITHIN 60 DAYS OF APPLICATION DATE ARE ELIGIBLE FOR CHARITY CARE DISCOUNT. ANY BILL AMOUNT REMAINING AFTER APPLICATION OF THE CHARITY CARE DISCOUNT IS THE RESPONSIBILITY OF THE PATIENT. THE PATIENT WILL BE ASSISTED BY THE HOSPITAL IN MAKING SHORT TERM ARRANGEMENT TO SATISFY ANY REMAINING BALANCE ON THE ACCOUNT. PART VI, LINE 2: SAMARITAN MEDICAL CENTER PARTICIPATED WITH COMMUNITY PARTNERS FROM JEFFERSON AND LEWIS COUNTY TO ASSESS THE COMMUNITY HEALTH NEEDS, IDENTIFY PREVENTION AGENDA PRIORITIES, DEFINE GOALS, OBJECTIVES AND WORK PLANS TO MEET THESE COMMUNITY HEALTH NEEDS. THESE PARTNERS INCLUDE FORT DRUM, JEFFERSON COUNTY PUBLIC HEALTH, LEWIS COUNTY PUBLIC HEALTH, CARTHAGE AREA HOSPITAL, LEWIS COUNTY GENERAL HOSPITAL, RIVER HOSPITAL, NORTH COUNTRY CHILDREN'S CLINIC, NORTHERN NEW YORK RURAL HEALTHCARE ALLIANCE, INC., FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION.SAMARITAN CONTINUES TO WORK WITH ITS PARTNERS, MEETING REGULARLY (AT MINIMUM, QUARTERLY AND AS FREQUENTLY AS MONTHLY) TO ASSESS THE EFFECTIVENESS OF OUR COLLABORATIVE ACTIVITIES.FINALLY, IN TERMS OF PRIORITIZING HEALTH ISSUES, THE RECOMMENDATIONS OF LOCAL, REGIONAL, STATE, AND NATIONAL HEALTH EXPERTS WERE REVIEWED AND CONSIDERED IN THE PROCESS OF IDENTIFYING PRIORITY ISSUES. THE PLANNING COMMITTEE SELECTED THE FINAL HEALTH PRIORITIES AS THEY RELATED TO THE NYS DOH PREVENTION AGENDA AND BY USING COMMUNITIES WORKING TOGETHER FOR A HEALTHIER NEW YORK. PART VI, LINE 3: THE CHARITY CARE PROGRAM CAN BE COMMUNICATED TO PATIENTS BY ANY SAMARITAN STAFF MEMBER; AS OUR CHARITY CARE PROGRAM IS AN EDUCATION TOPIC IN NEW EMPLOYEE ORIENTATION AND IS PART OF OUR ANNUAL MANDATORY EDUCATION REQUIREMENT. ADDITIONALLY, EACH PATIENT IS PROVIDED WITH A FINANCIAL ASSISTANCE APPLICATION AND RETURN ENVELOPE INCLUDED IN THE SAMARITAN PATIENT HANDBOOK. OUR GOVERNMENT INSURANCE LIAISON RECEIVES REFERRALS FROM PATIENT & FAMILY SERVICES REGARDING PATIENTS THAT MIGHT NEED ASSISTANCE OR EDUCATION REGARDING FEDERAL, STATE OR OTHER GOVERNMENT PROGRAMS. ADDITIONALLY, SHE ATTEMPTS TO CONTACT ALL SELF PAY ADMISSIONS. SAMARITAN PROVIDES SPACE FOR A NYS FACILITATED ENROLLER TO MEET WITH INDIVIDUALS INTERESTED IN APPLYING FOR NYS PROGRAMS. PART VI, LINE 4: SAMARITAN MEDICAL CENTER IS A 294 BED ACUTE CARE HOSPITAL SERVING SEVERAL COMMUNITIES IN UPSTATE NEW YORK. THE HOSPITAL IS LOCATED IN WATERTOWN, NEW YORK IN JEFFERSON COUNTY, WHICH LIES WITHIN A FEDERALLY DESIGNATED HPSA. THE POPULATION SERVED BY SAMARITAN MEDICAL CENTER PRIMARILY INCLUDES JEFFERSON COUNTY AND PORTIONS OF LEWIS, NORTHERN OSWEGO AND ST. LAWRENCE COUNTIES.SAMARITAN PROVIDES A FULL ARRAY OF INPATIENT AND OUTPATIENT HOSPITAL SERVICES, INCLUDING INPATIENT MEDICAL/SURGICAL, CRITICAL CARE, PEDIATRIC, MATERNITY, AND MENTAL HEALTH SERVICES AND AN EMERGENCY SERVICES DEPARTMENT.THE U.S. CENSUS REPORT LISTS THE 2009 ESTIMATED TOTAL POPULATION OF JEFFERSON COUNTY AT 118,719. THIS REPRESENTS A 6.2% GROWTH FROM THE 2000 CENSUS OF 111,738. THE INCREASE IN TOTAL POPULATION IS LARGELY DUE TO THE EXPANSION OF MILITARY PERSONNEL AT FORT DRUM. FORT DRUM DOES NOT OPERATE A HOSPITAL ON THE ARMY BASE, NOR DO THEY STAFF MEDICAL SPECIALISTS IN THEIR OUTPATIENT HEALTH CENTER.THE PERCENTAGE OF JEFFERSON COUNTY TOTAL POPULATION BELOW THE POVERTY LEVEL HAS GRADUALLY INCREASED FROM 11% IN 1990 TO 13.5% IN 2002 TO 14.6% IN 2008. MEDIAN HOUSEHOLD INCOME FOR 2008 FALLS SHORT OF STATEWIDE MEDIAN HOUSEHOLD INCOME BY APPROXIMATELY 20%. UNEMPLOYMENT IN JEFFERSON COUNTY IS APPROXIMATELY 8% - 9%. THE JEFFERSON COUNTY POPULATION CONTINUES TO BE PREDOMINANTLY CAUCASIAN, ALTHOUGH THERE ARE AN INCREASING NUMBER OF PERSONS OF OTHER RACE AND, IN PARTICULAR, HISPANIC, OR AFRICAN AMERICAN IN ORIGIN.THE CURRENT OVERALL (INPATIENT AND OUTPATIENT) PAYOR MIX EXPERIENCED AT SAMARITAN MEDICAL CENTER IS AS FOLLOWS:MEDICARE 36%, MEDICAID 13%, BLUE CROSS 18%, COMMERCIAL 10%, TRICARE 18%, NO FAULT 1%, WORKMEN'S COMPENSATION 1%, AND SELF PAY 3%. PART VI, LINE 5: SINCE 2006, SAMARITAN HAS RECRUITED AND RETAINED MORE THAN 80 PHYSICIANS TO THE AREA. PHASE III OF THE FACILITY MASTER PLAN BEGAN IN 2011 WHICH PROVIDES FOR RENOVATION OF THE EXISTING MAIN BUILDING. THIS RENOVATION AND RECONFIGURATION PROJECT WILL CONTRIBUTE DIRECTLY TO PROMOTING INCREASED OUTPATIENT SERVICES BY CONSOLIDATING HEALTHCARE SERVICES AND ENHANCE OUTPATIENT AND AMBULATORY CARE AT LEVELS THAT ARE BOTH EFFICIENT AND ACCESSIBLE.SAMARITAN MEDICAL CENTER EXPANDED SERVICES IN 2012 TO INCLUDE A ROBOTICALLY ASSISTED SURGICAL PROGRAM, SPINE CENTER OF EXCELLENCE AND NEUROSURGERY. PREVIOUSLY, THESE SERVICES WERE ONLY ACCESSIBLE TO COMMUNITY MEMBERS AT OUTSIDE REFERRAL CENTERS IN SYRACUSE AND BEYOND. PART VI, LINE 7, REPORTS FILED WITH STATES NY X X X X X 0 1 0 0 0 0 0 0 0 DAVID FLINT TRUSTEE 286052 0 0 0 10910 0 20097 0 17269 0 334328 0 0 0 DAVID RECHLIN TRUSTEE 130000 0 0 0 25000 0 7800 0 9 0 162809 0 0 0 JACK RUSH TRUSTEE 142374 0 0 0 45243 0 12062 0 17269 0 216948 0 0 0 THOMAS H CARMAN PRESIDENT & CEO 459993 0 85217 0 22000 0 80299 0 22005 0 669514 0 0 0 PAUL KRAEGER TREASURER 142153 0 0 0 13529 0 11372 0 10256 0 177310 0 0 0 MICHAEL SHORT CIO 180133 0 19802 0 9000 0 12734 0 12225 0 233894 0 0 0 MARIO VICTORIA CMO 314995 0 34134 0 15750 0 20093 0 17269 0 402241 0 0 0 BRIAN O'HEARN VP PATIENT CARE/CNO 195000 0 0 0 10269 0 1200 0 17269 0 223738 0 0 0 ANTHONY JOSEPH VP LONG TERM CARE 162669 0 6033 0 11035 0 1467 0 17269 0 198473 0 0 0 ALEJANDRO RODRIGUEZ UROLOGIST 540377 0 25000 0 0 0 6346 0 17269 0 588992 0 0 0 JOSEPH WETTERHAHN FAMILY PRACTICE MD 284502 0 0 0 177447 0 20104 0 17269 0 499322 0 0 0 MOONJOHN KIM INTERVENTIONAL RADIOLOGIST 534997 0 0 0 10000 0 20103 0 17269 0 582369 0 0 0 SHAHANDEH HAGHIR PATHOLOGIST 415002 0 0 0 9900 0 20092 0 12291 0 457285 0 0 0 YILIN ZHANG PATHOLOGIST 390500 0 0 0 8400 0 20091 0 21 0 419012 0 0 0 PART I, LINE 4B PART I, LINE 4B: THOMAS H. CARMAN RECEIVED CONTRIBUTIONS TO AN IRC 457(F) PLAN OF $65,299 DURING 2013. A DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DD5 2009-04-09 31660000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE 0 0 0 B DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DE3 2009-04-09 23945000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE, REFUND 1998 SERIESA 0 0 0 A 30000000 31660000 883291 1623236 27750175 3169880 2010 0 0 0 1 B 23945000 737831 1388843 18830508 4463480 2010 1 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 1 0 0 0 0 B 0 0 0 0 1 0 0 0 0 A 0 B 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FORM 990 AND ACCOMPANYING SCHEDULES WERE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD PRIOR TO FILING. FORM 990 WAS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL DISCLOSURE STATEMENTS ARE REQUIRED BY ALL BOARD MEMBERS AND KEY PERSONS. WE HAVE BEEN AT 100% COMPLIANCE WITH THIS REQUIREMENT EACH YEAR. RESPONSES ARE REVIEWED INITIALLY BY THE CEO AND CHIEF COMPLIANCE OFFICER FOR ACCURACY AND COMPLETENESS. THIS INFORMATION IS THEN PUT INTO A FULL REPORT TO THE BOARD OF TRUSTEES FOR REVIEW AND CONSIDERATION IN UPCOMING DECISION MAKING. BOARD MEMBERS AND KEY PERSONS AFFIRM THEIR UNDERSTANDING OF THEIR DUTY TO REPORT ANY ADDITIONAL OR NEW POTENTIAL CONFLICTS THROUGHOUT THE YEAR. BOARD MEMBERS WITH A CONFLICT ARE PROHIBITED FROM PARTICIPATION IN VOTING AND DECISION MAKING IN RELATED TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES AN EXTERNAL CONSULTANT TO ANALYZE AND ESTABLISH COMPENSATION AND BENEFITS FOR ALL EXECUTIVE POSITIONS. AN EVALUATION IS PERFORMED ANNUALLY. THE ANALYSIS INCLUDES A REVIEW OF MARKET DATA BASED ON REGION, FACILITY SIZE, AND RESPECTIVE RESPONSIBILITIES. THIS INFORMATION IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR REVIEW AND SUBSEQUENTLY PRESENTED TO THE FULL BOARD OF TRUSTEES FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE FILED AS PART OF THE ANNUAL FORM 990 AND ANNUAL NYS DEPARTMENT OF HEALTH INSTITUTIONAL COST REPORT, AND ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: PENSION AND POSTRETIREMENT LIABILITY 14,561,020. VALUE OF INTEREST RATE SWAP 829,372. FORFEITURE OF GRANTS -174,973. EQUITY TRANSFERS TO AFFILIATES -10,035,346. FORM 990 PART XII LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SAMARITAN KEEP NURSING HOME 133 PRATT STREET WATERTOWN NY 13601 160969838 SKILLED NURSING FACILITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 THE SAMARITAN MEDICAL CENTER FDN OF NORTHERN NEW YORK INC 830 WASHINGTON STREET WATERTOWN NY 13601 161490523 PROVIDES FUND FOR SAMARITAN MEDICAL CENTER AND AFFLIATES NY 501(C)3 LINE 7 SCH A SAMARITAN MEDICAL CENTER 0 EDWARD J NOBLE HOSPITAL- SAMARITAN 104 PADDOCK STREET SUITE 104 WATERTOWN NY 13601 237227989 HOSPITAL NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON STREET WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN SENIOR VILLAGE INC 22691 CAMPUS DRIVE WATERTOWN NY 13601 454913668 SENIOR CITIZEN COMMUNITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 0 1 1 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0