2014-08-12T08:20:20-05:00 2013-09-30 061533253 SASLOW LUFKIN & BUGGY LLP 175 POWDER FOREST DRIVE SIMSBURY CT 06089 990 2012-10-01 060646559 BRISTOL HOSPITAL INC BRIS 8605853000 BREWSTER RD BRISTOL CT 06011 GEORGE W EIGHMY 8605853000 2014-08-07 1 RICHARD BUGGY P00512316 8606789200 2012 2015-11-30 17:44:51Z KURT BARWIS BREWSTER RD BRISTOL CT 06011 131994532 0 X WWW.BRISTOLHOSPITAL.ORG X 1920 CT TO ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. WE WILL PROVIDE SAFE, QUALITY CARE AND SERVICES TO OUR PATIENTS THROUGH OUR CONTINUUM OF SERVICES AND HEALTH PROMOTION. WE WILL COLLABORATE WITH HEALTH PROFESSIONAL AND OTHER ORGANIZATIONS AS ADVOCATES FOR OUR COMMUNITY. WE WILL PROVIDE THE OPPORTUNITY FOR GROWTH TO OUR MEDICAL STAFF AND EMPLOYEES IN AN ENVIRONMENT WHERE EACH INDIVIDUAL IS RESPECTED AND VALUED. 16 13 1392 253 348034 -298192 1338407 1114855 131079119 129286883 477499 288256 3914160 1225255 136809185 131915249 0 0 0 0 69542815 68831487 0 0 0 64943488 60872187 134486303 129703674 2322882 2211575 112654038 113932754 102022703 87460483 10631335 26472271 X BRISTOL HOSPITAL IS COMMITTED TO PROVIDING THE BEST PATIENT EXPERIENCE IN THE REGION. OUR 134-BED, FULL-SERVICE HEALTH CARE INSTITUTION PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT CARE FOR THE GREATER BRISTOL, CONNECTICUT AREA. 0 0 107191204 129494663 AS A SHORT-TERM ACUTE CARE COMMUNITY HOSPITAL, BRISTOL HOSPITAL PROVIDES A BROAD SPECTRUM OF HEALTHCARE SERVICES TO ANY INDIVIDUAL REGARDLESS OF THE INDIVIDUAL'S ABILITY TO PAY. THE HOSPITAL PROVIDED $5,306,456 IN CHARITY CARE DURING THE OPERATING YEAR. THE HOSPITAL ALSO PROVIDES EDUCATION AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE ACTIVITIES TYPICALLY REACH ABOUT 1,600 INDIVIDUALS PER QUARTER. THESE ACTIVITIES INCLUDE: WELLNESS CENTER - SPECIAL CENTER FOR EDUCATIONAL OUTREACH PROGRAMMING SERVING HUNDREDS OF INDIVIDUALS PER MONTH. - COMMUNITY HEALTH SCREENINGS - ONGOING FREE AND REDUCED PRICE SCREENINGS FOR MAMMOGRAMS, BLOOD PRESSURE, CHOLESTEROL, PROSTATE CANCER, SKIN CANCER AND A FLU CLINIC PROVIDING FREE FLU SHOTS IN THE FALL. - SPEAKERS BUREAU - A COMMUNITY SERVICE WHERE THE HOSPITAL PROVIDES SPEAKERS ON A VARIETY OF TOPICS TO SERVE THE COMMUNITY'S EDUCATIONAL NEEDS. - PERIODIC COMMUNITY SERVICE PROJECTS - THE HOSPITAL HAS SPONSORED TWO MAJOR OUTREACH EFFORTS, ONE TO PROMOTE EARLY DETECTION OF BREAST CANCER AND ONE TARGETED TO PREVENT COLON CANCER. BOTH PROGRAMS HAVE INCREASED THE COMMUNITY'S COMPLIANCE WITH THE RECOMMENDED CANCER SCREENINGS AND HAVE BEEN RECOGNIZED WITH STATE, REGIONAL AND NATIONAL AWARDS. 107191204 1 1 0 1 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 0 0 0 1 82 0 1 1392 1 1 1 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 CT X GEORGE EIGHMY 8605853000 BREWSTER ROAD BRISTOL CT 06011 KENNETH BENOIT MD 2.00 2.00 X 0 0 0 MARK BLUM 2.00 2.00 X X 0 0 0 BALA SHANMUGAM MD 2.00 40.00 X 0 290714 0 JOHN J LEONE JR 2.00 2.00 X X 0 0 0 GLENN HEISER 2.00 2.00 X 0 0 0 KURT BARWIS 60.00 2.00 X X 590898 0 157758 JOHN LODOVICO JR 2.00 2.00 X 0 0 0 MARIE O'BRIEN 2.00 2.00 X X 0 0 0 DOUGLAS DEVNEW 2.00 2.00 X 0 0 0 KAREN GUADAGNINI MD 2.00 40.00 X 18680 94245 3280 MARY ANN CORDEAU PHD RN 2.00 2.00 X 0 0 0 FAWAD KAZI MD 2.00 2.00 X 0 0 0 THOMAS MONAHAN 2.00 2.00 X 0 0 0 ELLEN SOLEK 2.00 2.00 X 0 0 0 VALERIE VITALE MD 2.00 2.00 X 0 0 0 SHARON ADLER 2.00 2.00 X 0 0 0 GEORGE EIGHMY 40.00 X 273791 0 17692 LEONARD BANCO MD 40.00 X 335550 0 16478 JEANINE RECKDENWALD 40.00 X 207901 0 19183 DAVE RACKLIFFE 40.00 X 169453 0 19213 SHEILA KEMPF PHD 40.00 X 282250 0 19791 EVA WICKWIRE 40.00 2.00 X 164030 0 8122 PAUL SMITH 40.00 X 164280 0 0 RUSSELL TUVERSON MD 40.00 X 164030 0 1637 MARIA SIMMONE 40.00 X 138288 0 8372 LYNNE RAMER 40.00 X 133659 0 15370 MARIE MARCIANO 40.00 X 131304 0 8467 2774114 384959 295363 56 0 1 0 MAYO COLLABORATIVE SERVICES INC 200 SW 1ST STREET ROCHESTER MN 55905 LAB SERVICES 1478217 IPC THE HOSPITALIST COMPANY INC PO BOX 844929 LOS ANGELES CA 90084 MEDICAL SERVICES 734164 ACG NORTH AMERICA INC 120 HALCYON DRIVE BRISTOL CT 06010 GENERAL CONTRACTORS 530056 US FOODS INC 222 OTROBANDO AVENUE YANTIC CT 06389 FOOD SERVICE 457128 TOTAL LAUNDRY COLLABORATIVE LLC 114 WOODLAND STREET HARTFORD CT 06105 LAUNDRY SERVICES 445298 34 1114855 20819 1114855 PATIENT SERVICE REVENUE 622110 126808091 126390608 417483 MISC. PROGRAM AND HEALTHCARE REVE 621990 1689750 1689750 OCCUPATIONAL HEALTH REVENUE 621990 789042 789042 129286883 288208 288208 271852 0 271852 271852 271852 79331 79283 48 48 48 JOINT VENTURES 900099 555814 625263 -69449 CAFETERIA 722210 397589 397589 953403 131915249 129494663 348034 957697 3261594 3261594 51842571 42692315 9150256 3108585 2486868 621717 6627425 5301940 1325485 3991312 3193050 798262 807090 7353 799737 171312 171312 1019025 1019025 1227954 55493 1172461 13337492 12834198 503294 2853887 197347 2656540 2617643 2224997 392646 185783 137169 48614 1461258 1461258 6328212 6328212 2134447 1707558 426889 MEDICAL SERVICES FEES 13999619 13906859 92760 DRUGS 7381245 7376353 4892 REPAIR & MAINTENENCE 1857021 1811792 45229 COLLECTION FEES 1168027 1168027 4322172 3281390 1040782 129703674 107191204 22512470 0 9376449 12810191 96452 96526 16562143 16887452 1592222 1445186 2242612 2321980 150523259 111762978 37764529 38760281 13893883 13766654 13377950 14260744 7642154 7150033 10105644 6433707 112654038 113932754 29017801 29340577 630235 765934 24261420 23842748 297961 290136 1957753 2828131 45857533 30392957 102022703 87460483 X -376115 15896282 4079847 3555410 6927603 7020579 10631335 26472271 112654038 113932754 X 2211575 518644 13110717 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 1770 0 1 75557 77327 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE CONNECTICUT HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. $21,557 REPRESENTS THE PORTION OF THE DUES PAID TO THESE ASSOCIATIONS WHICH WERE USED FOR LOBBYING PURPOSES. THE HOSPITAL ENGAGED CAMILLIERE, CLOUD & KENNEDY, A CONNECTICUT LOBBYING AND BUSINESS DEVELOPMENT FIRM, FOR CONSULTING SERVICES IN THE AMOUNT OF $54,000. 18397107 2199827 3054472 17542462 13347087 2000000 4675975 1625979 18397083 13491685 40613 185211 13347087 12626745 1587194 722254 13491685 13867227 570728 -523731 1287479 12626745 0.39710 0.40020 0.20270 0 0 1595276 1595276 58597130 40403545 18193585 1006331 753488 252843 83654370 68455263 15199107 5670152 2150682 3519470 38760281 FUNDS HELD FOR MALPRACTICE SELF-INSURANCE 6934622 F ASSETS HELD IN TRUST BY OTHERS 3220623 F FUNDS HELD UNDER BOND INDENTURE 2506471 F DONOR RESTRICTED INVESTMENTS 1154124 F DEBT SERVICE FUND 444904 C 14260744 INVESTMENTS IN JOINT VENTURES 969890 C INTEREST IN NET ASSETS OF FOUNDATION 6180143 F 7150033 OTHER RECEIVABLES 2653347 DUE FROM AFFILIATES 1022462 ESTIMATED SETTLEMENTS WITH THIRD-PARTY PAYERS 2757898 6433707 ACCRUED POSTRETIREMENT BENEFIT LIABILITY 5310964 LINE OF CREDIT 3125000 ASSET RETIREMENT OBLIGATIONS 604800 ACCRUED PENSION LIABILITY 18682813 OTHER LIABILITIES 2669380 30392957 X 131894430 0 131894430 20819 20819 131915249 129703674 0 129703674 0 129703674 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF MULTIPLE FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES, SUCH AS CAPITAL EXPENDITURES, OPERATING EXPENSES, AND OTHER SPECIFIED DONOR AND BOARD RESTRICTED USES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740, "INCOME TAXES" WHICH PROVIDES A FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS IN THEIR FINANCIAL STATEMENTS. THE HOSPITAL MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS AS SEPTEMBER 30, 2013 AND 2012. IT IS THE HOSPITAL'S POLICY TO RECORD PENALTIES AND INTEREST ASSOCIATED WITH UNCERTAIN TAX PROVISIONS AS A COMPONENT OF OPERATING EXPENSES. AS OF SEPTEMBER 30, 2013 AND 2012, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. THE HOSPITAL'S PRIOR THREE TAX YEARS ARE OPEN AND SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: NONCASH VACCINE CONTRIBUTIONS 20,819. 1 1 1 X 250.000000000000 1 X 800.000000000000 1 1 1 0 0 4434661 3492477 942184 0.00730 23074764 18000260 5074504 0.03910 27509425 21492737 6016688 0.04640 151340 0 151340 0.00120 151340 151340 0.00120 27660765 21492737 6168028 0.04760 1 1383762 345941 47894414 55176420 -7282006 X 1 1 1 BRISTOL MSO LLC RADIOLOGY SERVICES 0.50000 0.00000 0.00000 2 MEDWORKS LLC REHAB & OCCUPATIONAL HEALTH 0.50000 0.00000 0.00000 3 CT OCCUPATIONAL MEDICAL PARTNERS OCCUPATIONAL HEALTH 0.33000 0.00000 0.00000 4 MEDCONN COLLECTION AGENCY COLLECTION SERVICES 0.25000 0.00000 0.00000 5 TOTAL LAUNDRY COLLABORATIVE LLC LAUNDRY SERVICES 0.14110 0.00000 0.00000 6 CENTRAL CT ENDOSCOPY CENTER MEDICAL SERVICES 0.06500 0.00000 0.00000 7 HEALTH CT LLC MEDICAL SERVICES 0.05400 0.00000 0.00000 1 1 BRISTOL HOSPITAL INC

BREWSTER ROAD BRISTOL CT 06010

X X X X BRISTOL HOSPITAL INC 1 1 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 1 250.000000000000 1 800.000000000000 1 X X X X 1 1 X X X X X 1 X X X 1 X X X X X X X 1 X 0 0 12 BRISTOL BEHAVIORAL HEALTH SERVICES

10 N MAIN STREET SUITE 210 BRISTOL CT 06010

BEHAVIORAL HEALTH BRISTOL HOSPITAL CENTER FOR DIABETES

102 NORTH STREET BRISTOL CT 06010

DIABETES MEDICAL CARE AND EDUCATION BRISTOL HOSPITAL COUNSELING CENTER

440-C NORTH MAIN STREET BRISTOL CT 06010

THERAPY AND COUNSELING BRISTOL HOSPITAL WELLNESS CENTER

842 CLARK AVENUE BRISTOL CT 06010

MEDICAL AND FITNESS SERVICES BRISTOL RADIOLOGY CENTER

25 COLLINS ROAD BRISTOL CT 06010

MAMMOGRAPHY AND MRI MED HELP

539 FARMINGTON AVENUE BRISTOL CT 06010

URGENT CARE MEDWORKS LLC

375 CEDAR STREET NEWINGTON CT 06111

OCCUPATIONAL HEALTH SERVICES PARENT & CHILD CENTER - BRISTOL HOSPITA

9 PROSPECT STREET BRISTOL CT 06010

CHILDREN AND FAMILY SERVICES REHAB DYNAMICS

975 FARMINGTON AVENUE BRISTOL CT 06010

PHYSICAL THERAPY AND SPORTS MEDICINE BRISTOL HOSPITAL LABORATORY

641 FARMINGTON AVENUE BRISTOL CT 06010

LABORATORY SERVICES BRISTOL HOSPITAL LABORATORY

27 MAIN STREET TERRYVILLE CT 06786

LABORATORY SERVICES BRISTOL HOSPITAL WIC PROGRAM

450 MAIN STREET NEW BRITAIN CT 06051

NUTRITION FOR WOMEN AND CHILDREN PART I, LINE 3C: THERE IS AN APPROVED SLIDING SCALE FOR DISCOUNTS BASED ON INCOME LEVELS AND FAMILY SIZE. PART III, LINE 4: USE OF ESTIMATES - THE PREPARATION OF FINANCIAL STATEMENTS IN CONFORMITY WITH GAAP REQUIRES MANAGEMENT TO MAKE ESTIMATES AND ASSUMPTIONS THAT IMPACT THE REPORTED AMOUNTS OF ASSETS AND LIABILITIES AND DISCLOSURE OF CONTINGENT ASSETS AND LIABILITIES AT THE DATE OF THE FINANCIAL STATEMENTS. ESTIMATES ALSO IMPACT THE REPORTED AMOUNTS OF REVENUES AND EXPENSES DURING THE REPORTING PERIOD. ACTUAL RESULTS COULD DIFFER FROM THOSE ESTIMATES. THE HOSPITAL'S SIGNIFICANT ESTIMATES RELATE TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ALLOWANCES ON PATIENT ACCOUNTS RECEIVABLE, VALUATION OF INVESTMENTS, ESTIMATED SETTLEMENTS DUE TO THIRD-PARTY PAYERS, RESERVES FOR SELF-INSURANCE LIABILITIES AND THE PENSION AND OTHER POSTRETIREMENT EMPLOYEE BENEFIT PLAN LIABILITY ASSUMPTIONS.PART III, LINE 3: THE METHODOLOGY USED IN DETERMINING THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY ASSUMES, BASED ON PAST EXPERIENCE AND PATIENT DEMOGRAPHICS, THAT 25% OF BAD DEBT ACCOUNTS ARE FROM INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR FINANCIAL ASSISTANCE OR MEDICAID, HAD THEY FOLLOWED THROUGH PROPERLY WITH THE APPLICATION PROCESS. THIS AMOUNT SHOULD BE INCLUDED AS COMMUNITY BENEFIT. PART III, LINE 8: THE CALCULATED MEDICARE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE IT REPRESENTS UNREIMBURSED COSTS FOR PATIENT SERVICES. THESE UNREIMBURSED COSTS ARE BRISTOL HOSPITAL EXPENSES THAT ULTIMATELY BENEFIT THE COMMUNITY BRISTOL HOSPITAL SERVICES. PART III, LINE 9B: IT IS THE POLICY OF BRISTOL HOSPITAL TO PROVIDE EVERY PATIENT FROM THE COMMUNITY WE SERVE WITH MEDICALLY NECESSARY HEALTH SERVICES REGARDLESS OF THEIR ABILITY TO PAY. THE POLICY SETS SPECIFIC GUIDLINES FOR THE COLLECTION OF PATIENT PAYMENTS AND ESTABLISHES A HIERARCHY FOR PAYMENT METHODS THAT ARE BOTH FRIENDLY TO THE PATIENT AND BENEFICIAL TO THE HOSPITAL. PATIENTS WHO ARE UNABLE TO PAY THEIR LIABILITY ARE REFERRED TO A FINANCIAL COUNSELOR WHO WILL ASSESS THE PATIENT'S ELIGIBILITY FOR CHARITY CARE OR ALTERNATIVE FUNDING SOURCES. FUNDING SOURCES INCLUDE CHARITY CARE, OUTSIDE FINANCING, HOSPITAL PAYMENT PLANS, FEDERAL, STATE AND LOCAL PROGRAMS AND THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. BRISTOL HOSPITAL, INC. PART V, SECTION B, LINE 3: COMMUNITY ENGAGEMENT AND FEEDBACK WERE AN INTEGRAL PART OF THE CHNA PROCESS. BRISTOL HOSPITAL SOUGHT COMMUNITY INPUT THROUGH THE INCLUSION OF COMMUNITY LEADERS IN THE PRIORITIZATION AND IMPLEMENTATION PLANNING PROCESS. PUBLIC HEALTH AND HEALTH CARE PROFESSIONALS SHARED KNOWLEDGE AND EXPERTISE ABOUT HEALTH ISSUES, AND LEADERS AND REPRESENTATIVES OF NON-PROFIT AND COMMUNITY-BASED ORGANIZATIONS PROVIDED INSIGHT ON THE COMMUNITY, INCLUDING THE MEDICALLY UNDERSERVED, LOW INCOME, AND MINORITY POPULATIONS. FOR A COMPLETE LIST OF PARTICIPANTS, PLEASE SEE THE COMMUNITY HEALTH NEEDS ASSESSMENT - FINAL SUMMARY REPORT, AVAILABLE ON THE BRISTOL HOSPITAL WEBSITE. BRISTOL HOSPITAL, INC. PART V, SECTION B, LINE 11: THERE IS AN APPROVED SLIDING SCALE FOR DISCOUNTS BASED ON INCOME LEVELS AND FAMILY SIZE. BRISTOL HOSPITAL, INC. PART V, SECTION B, LINE 12H: BRISTOL HOSPITAL RECOGNIZES THAT THE BURDEN OF HEALTH CARE COSTS ON INDIVIDUALS IS A NATIONAL CRISIS. DECADES OF HOSPITAL PRICING, DISTORTED BY THE UNIQUE BILLING REQUIREMENTS IMPOSED BY PRIVATE AND GOVERNMENTAL PAYERS AND REGULATIONS, HAS RESULTED IN A CHARGE STRUCTURE WHICH UNFAIRLY BURDENS THE INDIVIDUALS AND FAMILIES WITHOUT OR WITH LIMITED INSURANCE. BRISTOL HOSPITAL WISHES TO CORRECT THIS UNFAIRNESS BY ENSURING THAT ALL UNINSURED PATIENTS' CHARGES ARE LIMITED AND CAPPED AT MEDICARE PAYMENT LEVELS. THIS DISCOUNTED LEVEL IS DEFINED AS THE RATIO OF MEDICARE CHARGE TO PAYMENTS AND IS LISTED ON THE MOST RECENT OHCA FILING. THE MOST CURRENT DISCOUNT IS 71%. WHEN A PATIENT HAS NO INSURANCE, THEIR BILL WILL BE IMMEDIATELY REDUCED BY THAT PERCENTAGE DISCOUNT, USING THE CHARITY CARE UNINSURED ALLOWANCE CODE. PATIENTS WHO HAVE BALANCES DUE AFTER INSURANCE AND REQUIRE FINANCIAL ASSISTANCE IN PAYING THOSE BILLS, WILL BE ENTITLED TO A CHARITY CARE PATIENT ASSISTANCE DISCOUNT BASED ON THEIR INCOME AND FAMILY SIZE, USING THE APPROVED SLIDING FINANCIAL ASSISTANCE SCALE. THE STATE OF CONNECTICUT HAS SET RECOMMENDED LEVELS OF CHARITY CARE DISCOUNTS WHICH STIPULATES THAT FOR FAMILIES AT OR BELOW 200% OF FEDERAL POVERTY LEVELS SHOULD BE DISCOUNTED TO COST, AND THAT FOR FAMILIES BETWEEN 200 AND 400% SHOULD BE DISCOUNTED TO THE COMMERCIAL AND/OR MEDICARE RATE. THE BRISTOL HOSPITAL SLIDING SCALE HAS GREATER DISCOUNTS APPLIED AT LOWER LEVELS OF THE FEDERAL POVERTY INCOME LEVELS. PART VI, LINE 2: THE HOSPITAL'S ASSESSMENT OF THE HEALTH CARE NEEDS OF THE COMMUNITY IS A DYNAMIC PROCESS THAT INVOLVES ALL LEVELS OF HOSPITAL ADMINISTRATION, STAFF, THE BOARD OF DIRECTORS, AND MEDICAL STAFF. VARIOUS COMMITTEES AND GROUPS AT THE HOSPITAL MEET PERIODICALLY TO DISCUSS THE NEEDS OF THE COMMUNITY, AS WELL AS THE RESOURCES AND SERVICES AVAILABLE AT THE HOSPITAL AND OTHER AGENCIES IN THE AREA. THE HOSPITAL IS REPRESENTED AT VARIOUS COMMUNITY ORGANIZATIONS AND GROUPS INVOLVED WITH ASSESSMENT OF COMMUNITY NEEDS. HOSPITAL RESOURCES ARE FREQUENTLY CALLED UPON TO PARTICIPATE IN PROGRAMS AND PROJECTS TO ADDRESS THOSE NEEDS. PART VI, LINE 3: AT BRISTOL HOSPITAL, PATIENTS ARE NOTIFIED OF THEIR ABILITY TO DISCUSS FINANCIAL ASSISTANCE OPTIONS INCLUDING CHARITY CARE IN ALL OF THEIR BILLING STATEMENTS. THE HOSPITAL ENCOURAGES PATIENTS TO FIND OUT THEIR ELIGIBILITY FOR ASSISTANCE AND PROVIDES FINANCIAL COUNSELORS TO ASSIST PATIENTS IN APPLYING FOR CHARITY CARE. PATIENTS CAN CONTACT THE FINANCIAL ASSISTANCE DEPARTMENT WITHIN THE HOSPITAL AT 860-585-3878. THIS SUPPORT ALSO INCLUDES A REPRESENTATIVE THROUGH THE STATE OF CONNECTICUT (REPRESENTATIVE PAID BY BRISTOL HOSPITAL) TO ENSURE THAT ALL ASPECTS OF ASSISTANCE ARE PROVIDED FOR EACH PATIENT. THE FINANCIAL ASSISTANCE DEPARTMENT ALSO DISCUSSES GOVERNMENT BENEFITS THAT THEY MAY BE ELIGIBLE FOR. CONTACT INFORMATION FOR OUR FINANCIAL COUNSELOR IS ALSO INCLUDED ON THE HOSPITAL WEBSITE FOR PATIENTS TO REFERENCE. PART VI, LINE 4: THE HOSPITAL SERVES THE GREATER BRISTOL AREA. BRISTOL IS A SUBURBAN CITY LOCATED IN HARTFORD COUNTY, CONNECTICUT, 20 MILES SOUTHWEST OF HARTFORD. BRISTOL HAS A TOTAL AREA OF 26.8 SQUARE MILES AND A POPULATION OF APPROX 62,000. 84.2% OF THE PEOPLE SPEAK ENGLISH AND 4.8% OF PEOPLE SPEAK SPANISH. 54.6% OF PEOPLE ARE MARRIED, AND 92.2% OF RESIDENTS WERE BORN IN THE UNITED STATES.COMMUNITY INFORMATION:THE PRIMARY SERVICE AREA (PSA) FOR OUR HOSPITAL INCLUDES:BRISTOL (ZIP CODE 06010,06011)- 2011 CENSUS 62,078BURLINGTON (ZIP CODE 06013)- 2011 CENSUS- 10,011PLAINVILLE (ZIP CODE 06062)- 2011 CENSUS 17,767PLYMOUTH (ZIP CODE 06781,06782,06786)- 2011 CENSUS 12,605THE TOTAL POPULATION FROM THE 2011 CENSUS FOR OUR PSA IS- 102,461IN 2010, THE LATEST DATE DATA IS AVAILABLE, ,THE FOLLOWING INFORMATION WAS PROVIDED FOR THE FOLLOWING COMMUNITIES: BRISTOL:MEDIAN HOUSEHOLD INCOME: $57,781FAMILIES BELOW POVERTY LEVEL- 5.6%INDIVIDUALS BELOW POVERTY LEVEL- 7.7%RACE: WHITE- 87.6%, BLACK OR AFRICAN AMERICAN- 3.6%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 1.8%, OTHER RACE- 3.9%BURLINGTON: MEDIAN HOUSEHOLD INCOME: $116,419 FAMILIES BELOW POVERTY LEVEL- 1.2% INDIVIDUALS BELOW POVERTY LEVEL- 1.9% RACE: WHITE- 98%, BLACK OR AFRICAN AMERICAN- 0.2%,AMERICAN INDIAN OR ALASKA NATIVE- 0.1%, ASIAN- 1.2%PLAINVILLE: MEDIAN HOUSEHOLD INCOME: $62,440 FAMILIES BELOW POVERTY LEVEL- 4.1% INDIVIDUALS BELOW POVERTY LEVEL- 5.0% RACE: WHITE- 93.1%, BLACK OR AFRICAN AMERICAN- 2.5%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 1.3%, OTHER RACE- 0.6% PLYMOUTH: MEDIAN HOUSEHOLD INCOME: $70,132 FAMILIES BELOW POVERTY LEVEL- 2.9% INDIVIDUALS BELOW POVERTY LEVEL- 5.6% RACE: WHITE- 96.7%, BLACK OR AFRICAN AMERICAN- 0.5%, AMERICAN INDIAN OR ALASKA NATIVE- 0.3%, ASIAN- 0.6%, OTHER RACE- 0.7% THE SECONDARY SERVICE AREA (SSA) FOR OUR HOSPITAL INCLUDES:FARMINGTON (ZIP CODE 06085,06087)- 2011 CENSUS 6,058SOUTHINGTON (ZIP CODE 06489)- 2011 CENSUS 33,560WOLCOTT (ZIP CODE 06716)- 2011 CENSUS 17,458THOMASTON (ZIP CODE 06787)- 2011 CENSUS 8,512HARWINTON (ZIP CODE 06791)- 2011 CENSUS 5,938THE TOTAL POPULATION FROM THE 2011 CENSUS FOR OUR SSA IS- 71,526BOTH THE PSA (PRIMARY SERVICE AREA) AND SSA (SECONDARY SERVICE AREA) ARE PRIMARILY SUBURBAN AND RURAL AREAS BUT ALSO INCLUDE SOME URBAN AREAS AS WELL. SOME OF THE MAJOR HEALTH PROBLEMS PREVALENT IN OUR PSA ARE ASSOCIATED WITH BEHAVIORAL HEALTH, CHEMICAL DEPENDENCY, OBESITY, AND PULMONARY DISEASE. PART VI, LINE 5: BRISTOL HOSPITAL TAKES GREAT PRIDE IN SERVING THE COMMUNITY. AS PART OF ITS MISSION, BRISTOL HOSPITAL INCORPORATES A BROAD ARRAY OF COMMUNITY OUTREACH AND WELLNESS ACTIVITIES, DELIVERING EDUCATIONAL MATERIAL AND COUNSELING, OFFERING FREE OR LOW COST HEALTH SCREENINGS AND HOSTING PATIENT AND FAMILY SUPPORT GROUPS. WE UNDERSTAND THE IMPORTANCE AND VALUE OF EMPHASIZING GOOD HEALTH, FITNESS, SAFETY AND THE PROMOTION OF EARLY DETECTION OF ILLNESS OR DISEASE. THEREFORE, ALL OF OUR OUTREACH EFFORTS REFLECT OUR STRONG DESIRE TO IMPROVE THE QUALITY OF LIFE FOR ALL WHO LIVE AND WORK IN THE COMMUNITIES WE SERVE. BRISTOL HOSPITAL PROVIDES FINANCIAL SUPPORT AND ACCESS TO APPROPRIATE CLINICAL CARE FOR SEVERAL LIFE-SAVING INITIATIVES, INCLUDING THE BRISTOL COMMUNITY BREAST HEALTH PROJECT AND THE COLON CANCER AWARENESS PROJECT OF GREATER BRISTOL, WHICH ALLOW US TO OFFER FREE BREAST, AND COLORECTAL CANCER SCREENINGS TO THOSE WHO, DUE TO INSURANCE OR INCOME FACTORS, MIGHT NOT OTHERWISE HAVE ACCESS TO THESE VALUABLE DIAGNOSTIC SCREENING SERVICES. THE EYE CARE PROJECT OF GREATER BRISTOL PROVIDES VITAL ACCESS TO SERVICES FOR THOSE SUFFERING FROM VISION IMPAIRMENT.AT BRISTOL HOSPITAL WE UNDERSTAND THE IMPORTANCE OF OUR ROLE AS AN EXEMPT HEALTHCARE PROVIDER TO THE COMMUNITY WE SERVICE. OUR LEADERSHIP TEAM IS COMMITTED TO PROVIDING OUTSTANDING PATIENT CARE AND PROMOTING THE HEALTH OF THE COMMUNITY. BRISTOL HOSPITAL ATTEMPTS TO PROMOTE OUR FREE AND NON-REVENUE GENERATING PROGRAMS IN A VARIETY OF WAYS. THREE TIMES A YEAR, THE HOSPITAL MAILS A "PATHWAYS TO YOUR HEALTH" CATALOG. THE CATALOG CONTAINS A LISTING OF PROGRAMS AVAILABLE TO THE GREATER BRISTOL COMMUNITY. THIS CATALOG IS MAILED TO OVER 60,000 RESIDENTS AND PROVIDES INFORMATION ON FREE HEALTH SCREENINGS, SUPPORT GROUPS, HEALTH EDUCATION, WELLNESS PROGRAMS, ETC. THE CATALOG IS ALSO INCLUDED ON OUR HOSPITAL WEBSITE TO PROVIDE INCREASED ACCESS TO PATIENTS. THE PATHWAYS CATALOG IS DELIVERED AND DISPLAYED IN EACH DEPARTMENT WITHIN THE HOSPITAL AND IS FREE FOR ALL PATIENTS TO TAKE. PROGRAMS ARE ALSO LISTED ON OUR WEBSITE UNDER AN "EVENTS" SECTION WHERE PATIENTS CAN REGISTER FOR FREE, DIRECTLY ONLINE. WE ALSO PROMOTE OUR PROGRAMS MONTHLY IN THE BRISTOL PRESS, BRISTOL OBSERVER, HARTFORD COURANT AND PLYMOUTH CONNECTION. WE SUBSCRIBE TO AN "ON-HOLD" SYSTEM FOR OUR PHONES WHICH ALLOWS US TO RECORD MESSAGES FOR PATIENTS WHEN THEY CALL THE HOSPITAL. MANY OF THESE MESSAGES ARE ABOUT FREE PROGRAMS AND SERVICES, HEALTH EDUCATION FACTS AND SERVICES TO THE COMMUNITY. REPORTS FILED WITH STATES PART VI, LINE 7 CT X X 1 0 X X X X X 0 1 0 0 0 1 0 0 1 1 BALA SHANMUGAM MD 0 290714 0 0 0 0 0 0 0 0 0 290714 0 0 KURT BARWIS 458938 0 120000 0 11960 0 140300 0 17458 0 748656 0 0 0 GEORGE EIGHMY 234402 0 39389 0 0 0 458 0 17234 0 291483 0 0 0 LEONARD BANCO MD 285780 0 49770 0 0 0 2450 0 14028 0 352028 0 0 0 JEANINE RECKDENWALD 179035 0 28866 0 0 0 1842 0 17341 0 227084 0 0 0 DAVE RACKLIFFE 148260 0 21193 0 0 0 1527 0 17686 0 188666 0 0 0 SHEILA KEMPF PHD 243495 0 38755 0 0 0 2450 0 17341 0 302041 0 0 0 EVA WICKWIRE 140120 0 23910 0 0 0 1360 0 6762 0 172152 0 0 0 PAUL SMITH 153000 0 0 0 11280 0 0 0 0 0 164280 0 0 0 RUSSELL TUVERSON MD 164030 0 0 0 0 0 1637 0 0 0 165667 0 0 0 PART I, LINE 1A THE HOSPITAL PAID $7,315 IN GOLF CLUB MEMBERSHIP FEES FOR THE HOSPITAL'S PRESIDENT, AS THE CLUB DID NOT HAVE A CORPORATE MEMBERSHIP CATEGORY. THE HOSPITAL PAID $11,280 HOUSING ALLOWANCE FOR PAUL SMITH, DIRECTOR OF FACILITIES AND ENGINEERING. PART I, LINE 4B KURT BARWIS, PRESIDENT, PARTICIPATES IN THE HOSPITAL'S 457(F) DEFINED CONTRIBUTION PLAN. PART I, LINE 6 THE COMPENSATION OF THE HOSPITAL'S PRESIDENT, CFO, AND KEY EMPLOYEES IS BASED IN PART ON THE NET EARNINGS OF THE HOSPITAL. PART I, LINE 8 AMOUNTS WERE PAID TO KURT BARWIS PURSUANT TO A CONTRACT THAT WAS SUBJECT TO THE INITIAL CONTRACT EXCEPTION DESCRIBED IN REGS. SECTION 53.4958-4(A)(3). THE ORGANIZATION FOLLOWED THE REBUTTABLE PRESUMPTION PROCEDURE DESCRIBED IN REGS. SECTION 53.4958-6(C). MORRIS LAVIERO PURCHASE BUILDING X 350000 290136 0 1 1 290136 X 1 20819 REPORT FROM DHHS 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 A COMPLETED 990 IS PROVIDED TO EACH BOARD MEMBER BEFORE IT IS FILED. THIS PROVIDES AN OPPORTUNITY FOR MEMBERS TO ASK QUESTIONS AND FOLLOW UP WITH THE FINANCE TEAM REGARDING ANY ISSUES OR CONCERNS. THE 990 IS ALSO REVIEWED INTERNALLY BY MEMBERS OF THE FINANCE AND MANAGEMENT TEAMS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL APPLICABLE PARTIES ARE REQUIRED TO RECEIVE AND SIGN A STATEMENT ACKNOWLEDGING THAT THEY HAVE READ, UNDERSTOOD AND AGREE TO COMPLY WITH THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMPENSATION COMMITTEE IS AUTHORIZED UNDER THE BRISTOL HOSPITAL AND HEALTH CARE GROUP BYLAWS AND IS RESPONSIBLE FOR (1) DETERMINING THE OVERALL TOTAL COMPENSATION STRATEGY FOR ALL CORPORATE OFFICERS, (2) APPROVING ALL COMPENSATION AND BENEFITS DECISIONS FOR CORPORATE OFFICERS, AND (3) REPORTING SUCH ACTIONS TO THE FULL BRISTOL HOSPITAL AND HEALTH CARE GROUP BOARD ON AN ANNUAL BASIS. IN ADDITION, THE EXECUTIVE COMPENSATION COMMITTEE EXPRESSLY DETERMINES THE REASONABLENESS OF TOTAL COMPENSATION AND BENEFITS FOR ALL CORPORATE OFFICERS AND ASSURES THAT ALL OFFICER COMPENSATION DECISIONS ARE MADE AFTER THOROUGH CONSIDERATION OF AND COMPARISON TO THE MARKET PRACTICES OF OTHER SIMILARLY SITUATED NOT-FOR-PROFIT HEALTHCARE EXECUTIVES IN COMPARABLE ORGANIZATIONS. THE EXECUTIVE COMPENSATION COMMITTEE CONSISTS OF BOARD MEMBERS WHO DO NOT HAVE MATERIAL FINANCIAL INTERESTS THAT COULD BE AFFECTED BY THE OFFICER COMPENSATION DECISIONS MADE BY THE COMMITTEE. THE COMPARABILITY DATA USED TO ASSIST THE EXECUTIVE COMPENSATION COMMITTEE IN ITS COMPENSATION DELIBERATIONS ARE COMPILED BY AN INDEPENDENT, NATIONAL COMPENSATION CONSULTING FIRM THAT IS RETAINED BY AND REPORTS DIRECTLY TO THE EXECUTIVE COMPENSATION COMMITTEE. THE DATA COLLECTED BY THE CONSULTANT CONSISTS OF MARKET INFORMATION FOR EXECUTIVES IN FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS. THE DELIBERATIONS AND DECISIONS OF THE EXECUTIVE COMPENSATION COMMITTEE ARE CONTEMPORANEOUSLY DOCUMENTED, REVIEWED AND APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE AND PROVIDED TO THE BOARD ON AN ANNUAL BASIS. THE LAST COMPENSATION REVIEW FOR THE CEO, OTHER OFFICERS AND KEY EMPLOYEES OCCURRED ON NOVEMBER 19, 2012. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: INCREASE IN PERMANENTLY RESTRICTED NET ASSETS 116,976. TRANSFER TO BRISTOL HOSPITAL MULTISPECIALTY GROUP -472,971. PENSION CHANGES OTHER THAN NET PERIODIC BENEFIT COSTS 12,746,301. CHANGES IN POSTRETIREMENT HEALTH & WELFARE BENEFITS 1,933,951. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 1,695,168. NONCASH VACCINE CONTRIBUTIONS -20,819. TRANSFER TO BRISTOL HEALTH CARE, INC. -1,414,373. TRANSFER TO BRISTOL HOSPITAL DEVELOPMENT FOUNDATION -1,473,516. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESSES OF OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. 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