2014-08-12T12:50:41-05:00 2013-09-30 440160260 BKD LLP 1201 WALNUT SUITE 1700 KANSAS CITY MO 64106 990 2012-10-01 060250773 THE WILLIAM W BACKUS HOSPITAL WILL 8608898331 326 WASHINGTON STREET NORWICH CT 06360 DANIEL E LOHR 8608898331 2014-08-12 MICHAEL J ENGLE P00482834 8162216300 2012 2015-11-30 17:44:51Z DANIEL E LOHR 326 WASHINGTON STREET NORWICH CT 06360 332093794 0 X WWW.BACKUSHOSPITAL.ORG X 1891 CT BACKUS HOSPITAL DELIVERS AND COORDINATES A CONTINUUM OF HIGH-QUALITY HEALTH CARE THAT IS SENSITIVE TO THE NEEDS OF INDIVIDUALS IN EASTERN CONNECTICUT. 15 10 2133 465 2234756 219181 1179014 1225848 285997171 279344487 4525194 6336590 1628784 2501468 293330163 289408393 752684 130303 0 0 146148497 144190562 0 0 437085 115188670 113205414 262089851 257526279 31240312 31882114 393284501 477063817 195088980 151234531 198195521 325829286 X THE WILLIAM W BACKUS HOSPITAL DELIVERS AND COORDINATES A CONTINUUM OF HIGH QUALITY HEALTH CARE THAT IS SENSITIVE TO THE NEEDS OF INDIVIDUALS IN EASTERN CONNECTICUT. THE HOSPITAL IS COMMITTED TO BEING RESPONSIVE AND ACCOUNTABLE TO THOSE FOR WHOSE BENEFIT IT EXISTS, AND TO IMPROVING THE HEALTH OF ITS COMMUNITIES. 0 0 209142811 130303 278231478 IN FISCAL YEAR 2013, BACKUS HOSPITAL HAD 10,573 ADMISSIONS, 78,884 EMERGENCY DEPARTMENT VISITS, AND 460,916 OUTPATIENT VISITS. THE HOSPITAL DELIVERED 860 BABIES AND 6,323 SAME DAY SURGICAL PROCEDURES. BACKUS PERFORMED 128,607 OUTPATIENT IMAGING EXAMS, 7,132 MRI EXAMINATIONS, 7,973 PSYCHIATRIC CLINICAL VISITS AND 7,992 PSYCHIATRIC PARTIAL HOSPITAL VISITS. 209142811 1 0 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 1 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 204 0 1 2133 1 1 1 0 0 0 0 1 1 0 0 0 0 X 15 10 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 X X DANIEL LOHR 8608898331 326 WASHINGTON STREET NORWICH CT 06360 DAVID WHITEHEAD 40.00 7.00 X X 1054517 0 39768 JOHN BILDA 2.00 1.00 X 0 0 0 STEPHEN BRIGGS 2.00 1.00 X 0 0 0 ELIZABETH CONWAY 6.00 1.00 X X 0 0 0 KARIN EDWARDS 2.00 1.00 X 0 0 0 NANCY GENTES 2.00 1.00 X 0 0 0 ANTHONY JOYCE 6.00 1.00 X X 0 0 0 PETER MANERI 2.00 1.00 X 0 0 0 PAUL MAXFIELD 2.00 1.00 X 0 0 0 DEBORAH MONAHAN 6.00 1.00 X X 0 0 0 LYNNE QUINTAL-HILL 2.00 1.00 X 0 0 0 ROBERT RAMSDELL 6.00 1.00 X X 0 0 0 DONNA ROMITO 2.00 1.00 X 0 0 0 DENNIS SLATER 2.00 1.00 X 0 0 0 MARK TRAMONTOZZI 2.00 1.00 X 0 0 0 DANIEL LOHR 40.00 9.00 X 713794 0 39768 PETER SHEA 40.00 X 636111 0 39184 SERGIO CASILLAS 40.00 X 495341 0 39184 ROBERT SIDMAN 40.00 X 422418 0 39415 MARK TOUSIGNANT 40.00 X 514535 0 39184 FRED FENTON 40.00 X 341303 0 46915 RICHARD GOULDING 40.00 X 358979 0 39184 4536998 0 322602 167 0 1 0 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 MEDICAL SERVICES 3137705 NAVIN HAFTY & ASSOC 1900 WEST PARK DRIVE STE 180 WESTBOROUGH MA 01581 CONSULTING 2548871 YALE NEW HAVEN HOSPITAL 20 YORK STREET NEW HAVEN CT 06504 MEDICAL SERVICES 1945762 EXECUTIVE HEALTH RESOURCES PO BOX 822688 PHILADELPHIA PA 19182 CONSULTING 1106719 DAVITA INC PO BOX 8500-1607 PHILADELPHIA PA 19178 MEDICAL SERVICES 498533 36 101867 3500 586588 533893 3894 1225848 INPATIENT 900099 118361330 118361330 OUTPATIENT 900099 103455748 103455748 EMERGENCY DEPT 900099 52725675 52725675 EHR REVENUE 900099 2611725 2611725 LAB COURIER SERVICE 621500 2190009 2190009 279344487 3582788 3582788 879099 1241059 -361960 -361960 -361960 43451957 337151 40559506 475800 2892451 -138649 2753802 2753802 30320 101867 43976 -13656 -13656 515308 365060 150248 150248 CAFETERIA 722320 1225242 1225242 CHILD CARE 624410 379847 379847 PURCHASE DISCOUNTS 900099 218906 218906 902841 858094 44747 2726836 289408393 278231478 2234756 7716311 117803 117803 12500 12500 2034773 577237 1457536 115218074 100571289 14537332 109453 7678569 6680355 992071 6143 10827673 9420076 1398935 8662 8431473 7335382 1089349 6742 1475968 1475968 346185 346185 51325 51325 109002 109002 16509418 13411828 3097590 132453 110611 21842 5140225 3913243 1218057 8925 3596627 492509 3104118 5261549 452531 4809018 210558 77355 133203 14710 2085 12625 3170525 3170525 14971813 7108267 7863546 5126318 4531196 595122 MEDICAL EXPENSES 34713650 34713650 BAD DEBT 8725735 8723935 1800 MAINT/SERVICE CONTRACTS 4894477 3710464 1184013 LAB EXPENSES 4113229 4113229 4641647 3067266 1299063 275318 257526279 209142811 47946383 437085 3816199 1643564 103907072 130996812 31723 29416 32015340 31013657 74517 53821 3602936 3778841 5066915 2941851 299682104 160938198 91354486 138743906 147043829 158491234 12632 12632 6358852 9358083 393284501 477063817 23583670 21300221 59265000 62005476 1126557 1527930 111113753 66400904 195088980 151234531 X 187548862 314456228 2890743 3305592 7755916 8067466 198195521 325829286 393284501 477063817 X 31882114 5113161 -393191 91031681 X 0 1 X 1 0 X 0 0 0 0 0 1 51325 0 0 0 51325 0 5396859 159637 4511 5551985 5396859 5226 5226 5396859 5320786 5000 76505 5432 5396859 4841631 358064 505259 378271 5897 5320786 3871631 970000 142089 135254 6835 4841631 1.00000 0 0 5011878 5011878 10381267 117921709 35489934 92813042 63741714 51595691 12146023 102548384 73852573 28695811 77152 77152 138743906 DUE TO 3RD PARTIES 17467823 EMPLOYEE RELATED OBLIGATIONS 21820825 SELF-INSURED PROF LIABILITY 14348700 CAPITAL LEASE OBLIGATIONS 6103598 OTHER LIABILITIES 6659958 66400904 295396450 5113161 5113161 290283289 393191 -1268087 -874896 289408393 258797835 1423684 1423684 257374151 152128 152128 257526279 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE PERMANENTLY RESTRICTED ENDOWMENT FUNDS ARE MEANT TO PROVIDE LONG TERM SUPPORT FOR CAPITAL AND OPERATING PROGRAMS FOR THE HOSPITAL IN ACCORDANCE WITH THE DONOR'S WISHES. PART XI, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY INCOME-156,999 K-1 PASSTHROUGH-(1,402) LOSS ON FIXED ASSETS-(138,649) RENTAL EXPENSES-(1,241,059) GOLF TOURNAMENT EXPENSES-(43,976) PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES-1,241,059 GOLF TOURNAMENT EXPENSES-43,976 LOSS ON FIXED ASSETS-138,649 PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES-152,128 SCHEDULE D PART X LINE 2: ASC 740-10, UNCERTAIN TAX POSITIONS, PRECRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN.THIS INTERPRETATION ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, AND DISCLOSURE REQUIREMENTS FOR UNCERTAIN TAX POSITION.MANAGEMENT HAS EVALUATED THE IMPLICATIONS OF ASC 740-10 AND DETERMINED THAT ITS IMPACT ON THE FINANCIAL STATEMENTS IS NOT SIGNIFICANT. GOLF TOURNAMENT 91435 69035 22400 12420 11200 3082 1791 SEDER GOLF TOURNAMENT 40752 32832 7920 13254 765 750 714 132187 101867 30320 12420 24454 3847 750 2505 43976 -13656 1 1 1 X 250.000000000000 1 X 1 1 0 1 1 3145248 525427 2619821 0.01050 58661230 40262278 18398952 0.07400 61806478 40787705 21018773 0.08450 78 37619 850994 14110 836884 0.00340 15 848 174283 5000 169283 0.00070 19841 3935738 3935738 0.01580 27352 27352 0.00010 15 120 87248 87248 0.00040 108 58428 5075615 19110 5056505 0.02040 108 58428 66882093 40806815 26075278 0.10490 7 39641 39641 0.00020 2 1126 1126 0.00000 2 1319 1319 0.00000 3 5117 5117 0.00000 1 7 691 691 0.00000 1 560 560 0.00000 16 7 48454 48454 0.00020 0 3352286 2556613 50291272 68283759 -17992487 X 1 1 1 1 THE WILLIAM W BACKUS HOSPITAL

326 WASHINGTON STREET NORWICH CT 06360

X X X THE WILLIAM W BACKUS 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 X 0 0 1 1 250.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X 1 0 X X X X 1 X 0 0 10 BACKUS OUTPATIENT CARE CENTER

111 SALEM TURNPIKE NORWICH CT 06360

OUTPATIENT SERVICES MEDICAL OFFICE BUILDING

330 WASHINGTON STREET NORWICH CT 06360

RADIATION THERAPY/LAB COLCHESTER BACKUS HEALTH CENTER

163 BROADWAY COLCHESTER CT 06415

RADIOLOGY/LAB/PRIMARY CARE MONTVILLE BACKUS HEALTH CARE

80 NORWICH/NEW LONDON TURNPIKE UNCASVILLE CT 06382

RADIOLOGY/LAB/PRIMARY CARE LEDYARD BACKUS HEALTH CENTER

743 COLONEL LEDYARD HIGHWAY LEDYARD CT 06339

LAB/PRIMARY CARE JEWETT CITY PATIENT SERVICE CENTER

70 MAIN STREET JEWETT CITY CT 06351

LAB INFECTIOUS DISEASE CLINIC

107 LAFAYETTE STREET NORWICH CT 06360

CLINIC NORTH STONINGTON BACKUS HEALTH CENTER

82 NORWICH-WESTERLY ROAD NORTH STONINGTON CT 06359

PRIMARY CARE NORWICHTOWN BACKUS PATIENT SERVICE CTR

55 TOWN STREET NORWICH CT 06360

LAB PLAINFIELD EMERGENCY CENTER

582 NORWICH ROAD PLAINFIELD CT 06374

LAB/RADIOLOGY/EMERGENCY SERVICES 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 $ 8725735. PART III, LINE 4: SEE PAGES 13&14 OF THE AUDITED FINANCIAL STATEMENTS. LINE 3-COST METHODOLOGY EQUALS RCC FROM 2013 OHCA FILING. PORTION OF BAD DEBT CONSIDERED COMMUNITY BENEFIT IS BASED ON THE COST OF THE ACCOUNTS RETURNED FROM THE COLLECTION AGENCY AS UNCOLLECTIBLE. PART III, LINE 8: THE MEDICARE SHORTFALL WAS NOT INCLUDED IN THE COMMUNITY BENEFIT COST. THE COSTING METHODOLOGY CONSISTED OF INFORMATION FROM THE HOSPITAL'S COST ACCOUNTING SYSTEM AS WELL AS COSTS FROM THE MEDICARE COST REPORT PART III, LINE 9B: IN THE SELF-PAY POLICY, SECTION IIB, STATES THAT THE MEDICAL BUREAU OF ECONOMICS (MBE) RECEIVES A WEEKLY LIST OF PATIENTS WHO WERE SENT FINANCIAL ASSISTANCE APPLICATIONS FROM BACKUS STAFF. THIS INFORMATION IS FROM THE PATIENT ACCOUNTS OR FINANCIAL COUNCELING DEPARTMENTS. MBE'S COLLECTION ACTIVITY ON THESE PATIENTS IS HAULTED UNTIL IT HAS BEEN DETERMINED IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S POLICY,BY THE HOSPITAL FINANCIAL COUNCELING UNIT. COLLECTION ACTION IS ONLY RESUMED ONCE IT IS DETERMINED THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 3: IN THE MOST RECENT CHNA, WILLIAM W. BACKUS HOSPITAL CONTRACTED WITH HOLLERAN, AN INDEPENDENT RESEARCH AND CONSULTING FIRM LOCATED IN LANCASTER, PENNSYLVANIA. A SAMPLE OF 461 INDIVIDUALS WHO RESIDE WITHIN EASTERN CONNECTICUT WERE INTERVIEWED BY TELEPHONE TO ASSESS THEIR HEALTH BEHAVIORS, PREVENTATIVE PRACTICES, AND ACCESS TO HEALTH CARE. INDIVIDUALS WERE RANDOMLY SELECTED FOR PARTICIPATION BASED ON A STATISTICALLY VALID SAMPLING FRAME DEVELOPED BY HOLLERAN. THE SAMPLING FRAME REPRESENTED 24 ZIP CODES WITHIN THE HOSPITAL'S SERVICE AREA. INTERVIEWS WERE CONDUCTED BY HOLLERAN'S TELE-RESEARCH CENTER BETWEEN THE DATES OF JULY 24, 2012 AND SEPTEMBER 6, 2012. INTERVIEWERS CONTACTED RESPONDENTS VIA LAND-LINE TELEPHONE NUMBERS GENERATED FROM A RANDOM CALL LIST. EACH INTERVIEW LASTED APPROXIMATELY 12 - 15 MINUTES DEPENDING ON THE CRITERIA MET AND WAS COMPLETELY CONFIDENTIAL. ONLY RESPONDENTS WHO WERE AT LEAST 18 YEARS OF AGE AND LIVED IN A PRIVATE RESIDENCE WERE INCLUDED. THE SURVEY WAS ADAPTED FROM THE CENTER FOR DISEASE CONTROL AND PREVENTION'S BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS). BRFSS IS THE LARGEST TELEPHONE HEALTH SURVEY IN THE WORLD. IT IS USED NATIONALLY TO IDENTIFY NEW HEALTH PROBLEMS, MONITOR CURRENT PROBLEMS AND GOALS, AND ESTABLISH AND EVALUATE HEALTH PROGRAMS AND POLICIES. THE SURVEY TOOL CONSISTED OF APPROXIMATELY 100 FACTORS SELECTED FROM THE 2010 AND 2011 BRFSS TOOLS. THE FACTORS WERE CHOSEN BY WILLIAM W. BACKUS HOSPITAL, IN CONSULTATION WITH HOLLERAN AND ADDRESSED 27 HEALTH-RELATED TOPICS RANGING FROM GENERAL HEALTH STATUS TO CHILD HUMAN PAPILLOMA VIRUS. IN ADDITION, BRFSS RESULTS FOR CONNECTICUT AND THE UNITED STATES ARE INCLUDED WHEN AVAILABLE TO INDICATE HOW THE HEALTH STATUS OF WILLIAM W. BACKUS HOSPITALS SERVICE AREA COMPARES ON A STATE AND NATIONAL LEVEL.THE SUMMARY REPORT IS AVAILABLE AT: HTTP://BACKUSHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/05/CHNA-FINAL-REPORT.PDF THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 5C: THE CHNA REPORT WAS MADE WIDELY AVAILABLE TO THE PUBLIC. INFORMATION ABOUT THE CHNA AND ITS MAJOR FINDINGS AND IMPLEMENTATION STRATEGY APPEARED IN HEALTHY CONNECTIONS AND THE HOSPITELL. BACKUS HOSPITAL PUBLISHES HEALTHY CONNECTIONS EACH MONTH AS A COMMUNITY SERVICE TO THE RESIDENTS OF EASTERN CONNECTICUT. INFORMATION IN HEALTHY CONNECTIONS COMES FROM A WIDE RANGE OF MEDICAL RESOURCES. THE HOSPITELL IS A WEEKLY NEWSLETTER FOR BACKUS EMPLOYEES, VOLUNTEERS, PATIENTS, AND COMMUNITY MEMBERS. IT IS KEEPS READERS UPDATED ON HOSPITAL NEWS AND CAN BE FOUND IN PRINTED FORM IN THE HOSPITAL AND ITS OFFSITE LOCATIONS AND IT CAN ALSO BE FOUND ONLINE AT THE HOSPITAL'S WEBSITE. THE ENTIRE NEEDS ASSESSMENT IS MADE AVAILABLE TO THE PUBLIC VIA THE HOSPITALS WEBSITE AND CAN BE FOUND AT WWW.BACKUSHOSPITAL.ORG/HEALTHSURVEY. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 7: BY FOCUSING EFFORTS THE CROSS-CUTTING ISSUES OF ACCESS TO CARE, PREVENTATIVE HEALTH (INCLUDING CHRONIC AND INFECTIOUS DISEASE, RESPIRATORY HEALTH, AND OBESITY), AND MENTAL HEALTH (INCLUDING SUBSTANCE ABUSE), THE BACKUS HEALTH SYSTEM WILL TAKE A COMPREHENSIVE APPROACH TO ADDRESSING EIGHT OF THE NINE MOST URGENT NEEDS IN THE COMMUNITIES IT SERVES. AS WITH ALL BACKUS HEALTH SYSTEM PROGRAMS, IT WILL CONTINUE TO MONITOR COMMUNITY NEEDS AND ADJUST PROGRAMMING AND SERVICES ACCORDINGLY.BACKUS RECOGNIZES THAT THERE ARE NUMEROUS PARTNERS IN THE COMMUNITY THAT CAN HELP TO IMPROVE THE IDENTIFIED HEALTH NEEDS. IN SOME CASES, PARTNERS ARE BETTER SUITED TO LEAD THE INITIATIVE TO IMPACT CERTAIN HEALTH NEEDS. SUCH IS THE CASE WITH THE BUILT ENVIRONMENT. BACKUS HEALTH SYSTEM WILL SUPPORT ONGOING AND NEW EFFORTS TO IMPROVE THE COMMUNITY'S PHYSICAL ENVIRONMENT AND INFRASTRUCTURE TO IMPROVE SAFETY, THE TRANSPORTATION SYSTEM, AND CREATE MORE OPPORTUNITIES FOR PHYSICAL ACTIVITY, BUT SEES ITS PRIMARY ROLE AS ALLOCATING RESOURCES TO ADDRESS DIRECT HEALTH NEEDS FOR THE COMMUNITY. NEEDS ASSESSMENT PART V SECTION B IN 2012, BACKUS COMMISSIONED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED BY HOLLERAN, A PROFESSIONAL RESEARCH FIRM. THE ASSESMENT CONSISTED OF 461 TELEPHONE INTERVIEWS WHICH WERE CONDUCTED THROUGHOUT THE HOSPITAL'S SERVICE REGION (BOTH NEW LONDON AND WINDOM COUNTIES). THE ASSESSMENT ALSO INCLUDED A DETAIED ANALYSIS OF SECONDARY DATA SOURCES, AS WELL AS KEY INFORMANT INTERVIEWS AND THREE FOCUS GROUPS. THE NEEDS ASSESSMENT WAS PRESENTED AND DISTRIBUTED, AND CAN BE ACCESSED AT WWW.BACKUSHOSPITAL.ORG/HEATLHSURVEY. THE SUMMARY REPORT IS AVAILABLE AT: HTTP://BACKUSHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/05/CHNA-FINAL-REPORT.PDF PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI LINE 3 NOTIFICATION ABOUT CHARITABLE CARE AND ASSISTANCE PROGRAMS IS AVAILABLE AT ALL REGRISTRATION AREAS, ON AND OFF THE MAIN HOSPITAL CAMPUS, IN WAITING AREAS, IN THE PATIENT HANDBOOK, ON OUR WEBSITE, ON PROMINENTLY PLACED SIGNS (IN ENGLISH AND IN SPANISH). ADDITIONALLY, CARE MANAGEMENT SOCIAL WORKERS MEET WITH PARENTS, FAMILY, CLERGY, AND OTHERS AS APPROPRIATE TO DISCUSS ASSISTANCE PROGRAMS AND SERVICES THAT MAY BE AVAILABLE. IN ADDITION TO THE COMPLETE FINANCIAL ASSISTANCE POLICY AND APPLICATION FOR FINANCIAL ASSISTANCE, HERE IS THE INFORMATION INCLUDED ON THE HOSPITAL WEBSITE:FINANCIAL ASSISTANCEBACKUS HOSPITAL PROVIDES FINANCIAL ASSISTANCE PROGRAMS FOR CERTAIN QUALIFIED PATIENTS WHO ARE UNABLE TO PAY ALL OR PART OF THEIR BILL FOR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES RENDERED AT THE HOSPITAL.IF YOU ARE COPING WITH A FINANCIAL HARDSHIP, AND ARE FACING DEBTS OWED TO BACKUS HOSPITAL, FINANCIAL ASSISTANCE MAY BE AVAILABLE TO YOU.INCOME VERIFICATIONBACKUS REQUESTS INCOME INFORMATION FROM THE APPLICANT. VERIFICATION OF REPORTED INCOME SHOULD BE INCLUDED WITHIN THE APPLICATION PACKAGE.APPROPRIATE VERIFICATION SOURCES INCLUDE: MOST RECENT FEDERAL TAX RETURN AND W-2 MOST RECENT 3 PAYROLL CHECKS COPIES OF UNEMPLOYMENT CHECKS COPIES OF ANY PENSION, ALIMONY, CHILD SUPPORT OR OTHER SOURCES OF INCOME COPIES OF SOCIAL SECURITY EARNINGS, IF ANY ANY OTHER PERTINENT INFORMATIONIF THE APPLICANT HAS NO INCOME A STATEMENT DETAILING THE CURRENT METHOD OF SUPPORT WILL BE ACCEPTED. PROOF OF INCOME OR EARNINGS IS REQUIRED WITH APPLICATION OR THE APPLICATION WILL NOT BE CONSIDERED.FINANCIAL ASSISTANCE OPTIONSTHE LEVEL OF FINANCIAL ASSISTANCE THAT YOU MAY BE ELIGIBLE TO RECEIVE WILL BE BASED UPON THE CRITERIA DEFINED IN THE FINANCIAL ASSISTANCE POLICY.THE WILLIAM W. BACKUS HOSPITAL CONSIDERS FINANCIAL ASSISTANCE AWARDS ON A CASE-BY-CASE BASIS. PLEASE CONTACT US IF YOU HAVE QUESTIONS REGARDING ELIGIBILITY.FINANCIALLY INDIGENTFINANCIALLY INDIGENT IS DEFINED AS AN INDIVIDUAL WHOSE TOTAL GROSS ANNUAL INCOME IS LESS THAN OR EQUAL TO 250% OF THE FEDERAL POVERTY GUIDELINES (FPG).PATIENTS AT OR BELOW 250% FPG ARE ELIGIBLE FOR A 100% DISCOUNT OFF OF THEIR OUTSTANDING BALANCES. INDIVIDUALS ABOVE 250% UP TO 400% FPG ARE ELIGIBLE FOR A DISCOUNT BASED ON THEIR TOTAL GROSS ANNUAL INCOME.MEDICALLY INDIGENTBACKUS HOSPITAL CONSIDERS AN INDIVIDUAL TO BE MEDICALLY INDIGENT IF THEIR TOTAL ANNUAL GROSS INCOME IS ABOVE 400% FPG AND THEIR OUTSTANDING MEDICAL OBLIGATIONS ARE GREATER THAN 50% OF THEIR TOTAL ANNUAL GROSS INCOME.THESE INDIVIDUALS MAY BE ELIGIBLE FOR A DISCOUNT SEPARATE FROM TRADITIONAL FINANCIAL ASSISTANCE. PLEASE REFER TO THE FINANCIAL ASSISTANCE POLICY FOR DETAILS REGARDING ELIGIBILITY AND THE DISCOUNT SCHEDULE.MEDICALLY INDIGENT IS DEFINED BY THE IRS AS: PERSONS WHOM THE ORGANIZATION HAS DETERMINED ARE UNABLE TO PAY SOME OR ALL OF THEIR MEDICAL BILLS BECAUSE THEIR MEDICAL BILLS EXCEED A CERTAIN PERCENTAGE OF THEIR FAMILY OR HOUSEHOLD INCOME OR ASSETS (FOR EXAMPLE, DUE TO CATASTROPHIC COSTS OR CONDITIONS), EVEN THOUGH THEY HAVE INCOME OR ASSETS THAT OTHERWISE EXCEED THE GENERALLY APPLICABLE ELIGIBILITY REQUIREMENTS FOR FREE OR DISCOUNTED CARE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY.BACKUS HOSPITAL TREATS EACH APPLICATION INDIVIDUALLY. IF YOU HAVE ANY QUESTIONS ABOUT YOUR SPECIFIC SITUATION, PLEASE CONTACT OUR CUSTOMER SERVICE REPRESENTATIVES AT 860-889-8331, EXT. 2917, MONDAY THROUGH FRIDAY FROM 7:30 AM TO 4 PM.FINANCIAL ASSISTANCE LETTERTHE WILLIAM W. BACKUS HOSPITAL PROVIDES FINANCIAL ASSISTANCE FOR CERTAIN QUALIFIED PATIENTS WHO ARE UNABLE TO PAY ALL OR PART OF THEIR BILL FOR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES RENDERED AT THE HOSPITAL.IF YOU ARE COPING WITH A FINANCIAL HARDSHIP AND ARE FACING DEBTS OWED TO THE WILLIAM W. BACKUS HOSPITAL, FINANCIAL ASSISTANCE SUCH AS FREE CARE OR A SLIDING SCALE DISCOUNT MAY BE AVAILABLE TO YOU. THE FINANCIAL COUNSELING PROCESS WILL INDICATE WHAT OPTIONS EXIST TO ASSIST YOU WITH YOUR OUTSTANDING BALANCE.FINANCIAL ASSISTANCE APPLIES TO BACKUS HOSPITAL BILLS ONLY. IT DOES NOT APPLY TO RADIOLOGISTS, PATHOLOGISTS, ANESTHESIOLOGISTS OR OTHER PROFESSIONAL SERVICES INVOLVED IN YOUR CARE THAT ARE BILLED SEPARATELY.FREQUENTLY ASKED QUESTIONS 1. DOES THE HOSPITAL HAVE A FINANCIAL ASSISTANCE POLICY?THE WILLIAM W. BACKUS HOSPITAL DOES HAVE A WRITTEN FINANCIAL ASSISTANCE POLICY THAT DEFINES THE DISCOUNT STRUCTURE AND PROGRAMS AVAILABLE TO QUALIFYING PATIENTS.THE WILLIAM W. BACKUS HOSPITAL BASES ALL FINANCIAL ASSISTANCE ON THE MOST CURRENT FEDERAL POVERTY GUIDELINES (FPG), WHICH ARE BASED ON THE GROSS INCOME AND HOUSEHOLD SIZE.BACKUS GRANTS 100% CHARITY CARE TO THOSE APPLICANTS WHOSE GROSS HOUSEHOLD INCOME IS AT OR BELOW 250% FPG. A SLIDING DISCOUNT IS AVAILABLE TO THOSE PATIENTS WHO HAVE GROSS INCOME UP TO 400% FPG.CURRENTLY, THE FEDERAL GOVERNMENT DEFINES 100% OF POVERTY AS AN INDIVIDUAL EARNING A GROSS INCOME OF $11,670 PER YEAR. THE WILLIAM W. BACKUS HOSPITAL FINANCIAL ASSISTANCE POLICY GRANTS 100% CHARITY CARE TO A FAMILY OF ONE EARNING UP TO $29,175 PER YEAR, OR 250% FPG. INCOME THRESHOLDS INCREASE RELATIVE TO HOUSEHOLD SIZE. A DISCOUNT IS AVAILABLE FOR APPLICANTS EARNING UP TO 400% FPG.2. WHAT SERVICES DOES THE FINANCIAL ASSISTANCE POLICY COVER?THE WILLIAM W. BACKUS HOSPITALS FINANCIAL ASSISTANCE POLICY COVERS SERVICES RENDERED AT THE WILLIAM W. BACKUS HOSPITAL, INCLUDING INPATIENT, EMERGENCY, AND OUTPATIENT PROCEDURES.FINANCIAL ASSISTANCE MAY NOT BE GRANTED FOR SOME PROCEDURES, SUCH AS ELECTIVE PROCEDURES OR SOME SPECIAL SITUATIONS, SUCH AS THAT OF AN INDIVIDUAL WHO IS ELIGIBLE FOR INSURANCE BUT HAS REFUSED TO APPLY OR FUNDS ARE AVAILABLE THROUGH ANOTHER SOURCE FOR PAYMENT (I.E. SETTLEMENTS, STATE FUNDED PROGRAMS).FINANCIAL ASSISTANCE APPLIES TO BACKUS HOSPITAL BILLS ONLY. IT DOES NOT APPLY TO RADIOLOGISTS, PATHOLOGISTS, ANESTHESIOLOGISTS OR OTHER PROFESSIONAL SERVICES INVOLVED IN YOUR CARE THAT ARE BILLED SEPARATELY.3. DOES THE HOSPITAL PROVIDE PERSONNEL TO HELP WITH APPLICATIONS AND TO ANSWER QUESTIONS?THE WILLIAM W. BACKUS HOSPITAL EMPLOYS FINANCIAL COUNSELORS TO HELP PATIENTS APPLY FOR FINANCIAL ASSISTANCE, MEDICAID, AND OTHER STATE HEALTH PROGRAMS.THE HOSPITAL ALSO HAS RESOURCES TO HELP WITH APPLICATIONS FOR STATE NUTRITIONAL ASSISTANCE PROGRAMS (SNAP) AND PHARMACY ASSISTANCE PROGRAMS. FINANCIAL COUNSELORS CAN HELP TO DETERMINE APPROPRIATE REFERRALS TO THESE RESOURCES.THE WILLIAM W. BACKUS HOSPITAL PROVIDES LANGUAGE TRANSLATION VIA CYRACOM AND MARTTI LANGUAGE LINES.4. DOES THE HOSPITAL COMMUNICATE THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THE COMMUNITY?THE WILLIAM W. BACKUS HOSPITAL BELIEVES IT IS IMPORTANT TO COMMUNICATE THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THE COMMUNITIES IT SERVES. THEREFORE, A NOTICE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE IS INCLUDED WITH THE PAPER BILL SENT TO THE PATIENT'S HOME, IS POSTED IN ALL MAIN REGISTRATION AREAS, IS AVAILABLE ON THE HOSPITAL'S WEBSITE, AND UPON REQUEST OF HOSPITAL STAFF OR REPRESENTATIVES.5. DOES THE HOSPITAL EVER DENY CARE BASED ON INABILITY TO PAY?THE WILLIAM W. BACKUS HOSPITAL WILL NEVER DELAY OR DENY EMERGENCY CARE OR NECESSARY SERVICES DUE TO AN INABILITY TO PAY.6. DOES THE HOSPITAL HAVE A PROGRAM FOR PATIENTS WHO DONT QUALIFY FOR TRADITIONAL FINANCIAL ASSISTANCE BUT INCUR CATASTROPHIC MEDICAL DEBTS?THE HOSPITAL HAS A WRITTEN POLICY THAT COVERS CATASTROPHIC FINANCIAL ASSISTANCE FOR THE MEDICALLY INDIGENT. THE POLICY IS INCLUDED IN THE FINANCIAL ASSISTANCE POLICY, IS AVAILABLE ON THE WEBSITE, AND UPON REQUEST. COMMUNITY INFORMATION PART VI 4 THE WILLIAM W. BACKUS HOSPITAL IS LOCATED IN NORWICH, 45 MINUTES SOUTHEAST OF HARTFORD. IN THE PAST DECADE, THE REGION HAS UNDERGONE MAJOR ECONOMIC CHANGES, DUE TO THE OPERATION OF TWO NATIVE-AMERICAN OWNED ENTERTAINMENT VENUES BRINGING THOUSANDS OF VISITORS INTO THE REGION EACH DAY. THE CASINOS ARE THE LARGEST EMPLOYERS, AND ARE EXPERIENCING LAYOFFS AND CUTBACKS AS THE ECONOMY CONTINUES TO DECLINE. THE HOSPITAL'S PRIMARY SERVICE AREA HAS AN ESTIMATED POPULATION OF ABOUT 134,111. THE SECONDARY SERVICE AREA CONSISTS OF LARGER COMMUNITIES, SUCH AS NEW LONDON AND GROTON, AND SMALLER LOWER-DENSITY RURAL COMMUNITIES. THE TOTAL POPULATION OF THE SECONDARY SERVICE AREA IS ABOUT 136,881. THE SERVICE AREAS CONTAIN MUNICIPALITIES IN THE NEW LONDON AND WINDHAM COUNTIES.A DETAILED ANALYSIS OF THE COMMUNITIES WHICH BACKUS SERVES CAN BE FOUND WITHIN THE COMMUNITY HEALTH NEEDS ASSESSMENT, IN BOTH THE SECONDARY DATA PROFILE AND THE FINAL REPORT, LINKED BELOW:SECONDARY DATA PROFILE, BEGINNING ON PAGE 4:HTTP://BACKUSHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/05/SECONDARY-DATA-PROFILE-WILLIAM-W-BACKUS-HOSPITAL-2012-CHNA-2012-10-24-REV.PDFFINAL REPORT, BEGINNING ON PAGE 3:HTTP://BACKUSHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/05/CHNA-FINAL-REPORT.PDF PROMOTION OF COMMUNITY HEALTH PART VI 5 A) THE HOSPITAL IS GOVERNED BY A VOLUNTEER COMMUNITY BOARD OF DIRECTORS/TRUSTEES. THESE INDIVIDUALS REPRESENT AN ARRAY OF PROFESSIONS AND BACKGROUNDS. B) THE HOSPITAL HAS 110 CORPORATORS VOLUNTEER MEMBERS CHOSEN FROM ALL THE COMMUNITIES IN OUR PRIMARY AND SECONDARY SERVICE AREAS. IN ADDITION TO THEIR OFFICIAL CAPACITY AS NOMINATORS OF BOARD MEMBERS, THE CORPORATORS SERVE AS THE HOSPITAL'S EYES AND EARS THROUGHOUT ITS SERVICE AREA. C) THE HOSPITAL OWNS AND OPERATES A MOBILE HEALTH RESOURCE CENTER- A 40-FOOT VAN AND A SMALLER CAREVAN THAT TRAVELS TO VARIOUS LOCATIONS IN EASTERN CONNECTICUT OFFERING HEALTH EDUCATION, COUNSELING, AND SCREENINGS. THE VANS MAKE REGULARLY SCHEDULED STOPS AT SENIOR CITIZEN CENTERS, SOUP KITCHENS, ELDERLY HOUSING COMPLEXES, AND HOMELESS SHELTERS. NOT-FOR PROFIT GROUPS ARE ENCOURAGED TO REQUEST THE VANS AND THEIR SERVICES AT THEIR FUNCTIONS OR OFFICES. D) THE HOSPITAL PROVIDES INDIVIDUALS WHO DO NOT IDENTIFY AS HAVING A PRIMARY MEDICAL HOME WITH A FOLLOW UP VISIT POST DISCHARGE TO LINK THESE INDIVIDUALS WITH A PRIMARY CARE PHYSICIAN IN THE COMMUNITY. THIS IS FACILITATED THROUGH THE MY HEALTH DIRECT PROGRAM, A WEB-BASED TOOL THAT ALLOWS HOSPITAL STAFF TO ACCESS BLOCKED APPOINTMENTS FOR PHYSICIANS IN THE COMMUNITY. FROM 10/1/12 TO 9/30/13 THE HOSPITAL LINKED 1042 INDIVIDUALS WITH PRIMARY AND PREVENTIVE CARE. E) THE HOSPITAL PROVIDES FREE COMMUNITY PROSTATE SCREENINGS, DIABETES EDUCATION, BACKPACK SAFETY, HIV EDUCATION/TESTING, BLOOD PRESSURE TESTS, SKIN CANCER SCREENINGS, NUTRITION EDUCATION, AND MANY OTHER SERVICES. F) THE HOSPITAL PROVIDES A COMPREHENSIVE MEDICAL LIBRARY, WHICH IS OPEN TO ALL STAFF. THE LIBRARY HAS SUBSCRIPTIONS TO HUNDREDS OF MAJOR SCIENTIFIC AND CLINICAL JOURNALS, AS WELL AS AN ON-STAFF LIBRARIAN TO HELP WITH SPECIFIC REQUESTS. G) THE HOSPITAL PROVIDES FREE WEBSITE ACCESS TO COMPLETE AND CURRENT MEDICAL INFORMATION TO ANSWER CLINICAL QUESTIONS, THROUGH UPTODATE.COM, A PEER-REVIEWED ONLINE MEDICAL REFERENCE. UPTODATE COVERS MORE THAN 7,400 TOPICS IN 13 MEDICAL SPECIALTIES AND INCLUDES MORE THAN 76,000 PAGES OF TEXT, GRAPHICS, LINKS TO MEDICAL ABSTRACTS, MORE THAN 254,000 REFERENCES, AND A DRUG DATABASE. H) THE HOSPITAL PROVIDES FREE MEDICATION CARDS TO HELP PATIENTS KEEP TRACK OF THEIR CURRENT MEDICATIONS, AND ITS PHARMACISTS OFFER FREE REGULAR EDUCATION REVIEWS TO CHECK FOR POSSIBLE INTERACTIONS AND EXPIRED MEDICATION. I) THE HOSPITAL OFFERS FREE WIRELESS INTERNET (WI-FI) USE THROUGHOUT THE CAMPUS, AND PROVIDES FREE COMPUTER USE TO VISITORS. J) THE HOSPITAL PUBLISHES A MONTHLY HEALTH MAGAZINE. THE PUBLICATION CONTAINS INFORMATION ABOUT HEALTH ISSUES AND TRENDS, A CALENDAR OF FREE HEALTHCARE EDUCATION AND SCREENINGS, AND CONTACT INFORMATION FOR HEALTHCARE PROVIDERS. 44,000 COPIES ARE DISTRIBUTED MONTHLY. AFFILIATED HEALTH CARE SYSTEM PART VI 6 ON AUGUST 1, 2013 (THE ACQUISITION DATE), HARTFORD HEALTH CARE (HHC) BECAME THE SOLE CORPORATE MEMBER OF BACKUS CORPORATION AND A FULL CORPORATE AFFILIATION WAS COMPLETED. ALL ASSETS AND LIABILITIES WERE REVALUED TO FAIR VALUES AS OF AUGUST 1, 2013. THE HOSPITAL IS CONSOLIDATED IN HHCS FINANCIALS FOR THE PERIOD AUGUST 1, 2013 TO SEPTEMBER 30, 2013. STATE FILING OF COMMUNITY BENEFIT REPORT PART VI 7 THE HOSPITAL FILES A COMMUNITY BENEFIT REPORT WITH THE CONNECTICUT OFFICE OF THE HEALTH ADVOCATE, OHCA. FACILITY REPORTING GROUPS PART VI 8 PLEASE SEE THE ANSWERS TO PART VI QUESTION 1. 1 CHAMBER OF COMMERCE OF SE CT 914 HARTFORD TPKE WATERFORD CT 06385 060475490 501C6 12459 SPONSORSHIPSPONSORSHIP DR MARTIN LUTHER KING SCHOLARSHIP TRUST FUND PO BOX 1308 NEW LONDON CT 06320 066107846 501C3 10000 SPONSORSHIP CENTER FOR HOSPICE CARE 227 DURHAM STREET NORWICH CT 06360 222667260 501C3 8500 SPONSORSHIP NORWICH HUMAN SERVICES UNION STREET NORWICH CT 06360 10000 SPONSORSHIP BROADWAY KIDS 12 PENNSYLVANIA AVE NIANTIC CT 06357 5500 SPONSORSHIP 2 3 SCHOLARSHIP 5 12500 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: DONATIONS MADE FOR LOCAL EVENTS, SUCH AS SPONSORSHIPS ARE TYPICALLY ATTENDED BY HOSPITAL EMPLOYEES. FIVE SCHOLARSHIPS IN THE AMOUNT OF $2500 EACH ARE AWARDED TO STUDENTS WHO WILL ATTEND SCHOOL EITHER FOR NURSING OR IN THE MEDICAL FIELD. THE APPLICANTS ARE REVIEWED BY THE SCHOLARSHIP COMMITTEE OF THE AUXILIARY AND WINNERS ARE BASED ON ACADEMICS AS WELL AS COMMUNITY SERVICE. X X X X X 0 1 0 0 0 0 0 1 0 DAVID WHITEHEAD 664686 0 0 0 389831 0 22000 0 17768 0 1094285 0 0 0 DANIEL LOHR 454036 0 0 0 259758 0 22000 0 17768 0 753562 0 0 0 PETER SHEA 454686 0 0 0 181425 0 14500 0 24684 0 675295 0 0 0 SERGIO CASILLAS 495341 0 0 0 0 0 14500 0 24684 0 534525 0 0 0 ROBERT SIDMAN 304139 0 101279 0 17000 0 14500 0 24915 0 461833 0 0 0 MARK TOUSIGNANT 393232 0 121303 0 0 0 14500 0 24684 0 553719 0 0 0 FRED FENTON 243823 0 78680 0 18800 0 22000 0 24915 0 388218 0 0 0 RICHARD GOULDING 274634 0 82845 0 1500 0 14500 0 24684 0 398163 0 0 0 PART I, LINE 3 PART I, LINE 4B DAVID WHITEHEAD, DANIEL LOHR AND PETER SHEA PARTICIPATE IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THERE WERE NO ACCRUALS OR CONTRIBUTIONS THAT WERE MADE TO THE PLAN DURING THE REPORTING PERIOD.THEY DID RECEIVE DISBURSEMENTS OF $377,527, $233,170 AMD $180,651, RESPECTIVELY. PART I, LINE 7 BASE COMPENSATION FOR EXECUTIVES IS APPROVED BASED ON CRITERIA LISTED IN PART 1 LINE 3, HOWEVER A PORTION OF THAT IS HELD BACK AND SUBSEQUENTLY DISTRIBUTED BASED ON EVALUATION OF THE INDIVIDUALS PERFORMANCE AND ACCOMPLISHMENT OF THE GOALS SET AT THE BEGINNING OF THE YEAR BY AN INDEPENDENT COMPENSATION COMMITTEE. PHYSICIANS BONUSES ARE BASED ON MEETING PREESTABLISHED GOALS. A STATE OF CT HEALTH & EDUCATIONAL FACILITIES 060806186 20774LSV3 2005-08-10 28992719 ADVANCED REFUND OF SERIES D, FINANCE FACILITY MASTER PLAN 0 0 0 B STATE OF CT HEALTH & EDUCATIONAL FACILITIES 060806186 20774UC86 2008-07-02 30168922 CONSTRUCTION, RENOVATION AND IMPROVEMENTS TO THE FACILITY 0 0 0 A 3535000 28992719 755086 16750062 369723 583673 10514252 19923 2008 0 1 1 1 B 2850000 30168922 30100000 68922 2008 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 1 B 1 1 1 UBS AG 29.900000000000 0 0 0 0 1 A 1 B 1 DAVID WHITEHEAD DANIEL LOHR AND PE OFFICERS OF BOTH WWBH AND CONNCARE INC 3394691 REIMBURSEMENTS PAID BY CONNCARE TO WWBH, PERFORMANCE OF SERVICES BY WWBH FOR CONNCARE, LEASED PROPERTY 0 DAVID WHITEHEAD AND DANIEL LOHR OFFICERS OF BOTH WWBH AND OMNI HOME HEALTH 132000 MANAGEMENT FEES PAID BY OMNI TO WWBH 0 DAVID WHITEHEAD AND DANIEL LOHR OFFICERS OF BOTH WWBH AND WWB INC 9308319 REIMBURSEMENTS PAID BY WWB TO WWBH 0 FORM 990, PART VI, SECTION A, LINE 2 DAVID WHITEHEAD AND DANIEL LOHR HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER. THEY SERVE AS AN OFFICER OR DIRECTOR FOR CONNCARE INC, WWB CORPORATION, AND BACKUS HOME HEALTH WHICH ARE RELATED FOR PROFIT COMPANIES. FORM 990, PART VI, SECTION A, LINE 4 EFFECTIVE AUGUST 1, 2013, HARTFORD HEALTHCARE CORPORATION BECAME THE SOLE CORPORATE MEMBER OF BACKUS CORPORATION. FORM 990, PART VI, SECTION A, LINE 6 BACKUS CORPORATION, A NOT-FOR-PROFIT 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF THE WILLIAM W BACKUS HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A BACKUS CORPORATION, BEING THE SOLE MEMBER OF THE WILLIAM W BACKUS HOSPITAL, HAS THE RIGHT TO ELECT ALL THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B IN ADDITION TO ANY OTHER RIGHTS AND POWERS WHICH THE MEMBER MAY HAVE UNDER LAW,THE MEMBER SHALL HAVE THE RIGHT AND POWER TO (A)APPROVE THE STRATEGIC PLAN AND THE CONSOLIDATION OR CLOSURE OF SIGNIFICANT LINES OF BUSINESS, PROGRAMS OR SERVICES (B)TO EFFECTUATE THE TRANSFER OF FUNDS TO ANOTHER AFFILIATED CORPORATION (C)TO EFFECTUATE THE HOSPITALS PAYMENT TO OR RECEIPT OF PAYMENT FROM THE CORPORATION (D)TO APPROVE THE ACQUISITION OR LEASE OF ANY EQUIPMENT AND ANY PROJECT OR CONSTRUCTION CONTRACT THAT ENTAILS AN EXPENDITURE BY THE HOSPITAL IN EXCESS OF, OR WITH A VALUE OVER, $400,000 IN ANY FISCAL YEAR AND THAT IS NOT ALREADY INCORPORATED IN AN APPROVED BUDGET (E) TO APPROVE ANY PROJECTS THAT WOULD REQUIRE A CERTIFICATE OF NEED (CON) OR FOR WHICH A CON DETERMINATION WILL BE SUBMITTED TO THE OFFICE OF HEALTH CARE ACCESS (F)TO APPROVE THE REORGANIZATION, MERGER, CONSOLIDATION OR DISSOLUTION OF THE HOSPITAL OR THE AFFILIATION OF THE HOSPITAL WITH ANOTHER HOSPITAL OR HEALTH DELIVERY SYSTEM, OR THE CREATION OR ACQUISITION OF ANY SUBSIDIARY OR AFFILIATE OF THE HOSPITAL (G)TO APPROVE THE HOSPITALS ANNUAL OPERATING BUDGET (H)TO APPROVE PLANS FOR THE BORROWING OF ANY SUM IN EXCESS OF $400,000 WHICH HAS A STATED TERM GREATER THAN ONE YEAR OR WHICH IS SECURED BY A MORTGAGE OF ALL OR ANY PORTION OF THE HOSPITALS REAL PROPERTY OR BY A SECURITY INTEREST IN THE HOSPITALS ASSTS OR REVENUES (I)TO APPROVE AMENDMENTS TO THE CERTIFICATE OF INCORPORATION OR BYLAWS FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED BY THE ACCOUNTING STAFF AND THEN REVIEWED BY AN INDEPENDENT ACCOUNTING FIRM. THE 990 IS THEN REVIEWED BY THE CFO AND ANY QUESTIONS ADDRESSED. THE FINAL 990 IS THEN PROVIDED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C ALL TRUSTEES, OFFICERS AND KEY EMPLOYEES OF THE HOSPITAL SHALL COMPLETE AND SIGN A DISCLOSURE STATEMENT. THE STATEMENT WILL INCLUDE AN ITEMIZATION AND DESCRIPTION OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST AND ALL MATERIAL FACTS RELATED THERETO FOR SUCH INDIVIDUAL BY VIRTUE OF HIS OR HER ACTIVITIES OR THE ACTIVITIES OF RELATED PERSONS. DISCLOSURE STATEMENTS SHALL BE RETURNED TO THE CORPORATE COMPLIANCE OFFICER WHO, UNDER THE DIRECTION OF THE CHAIR AND THE PRESIDENT, SHALL EXERCISE GOOD FAITH AND JUDGEMENT AS TO WHETHER A CONFLICT EXISTS. THE CHAIR AND THE PRESIDENT SHALL BE RESPONSIBLE FOR MONITORING TRANSACTIONS OR ARRANGEMENTS IN WHICH A TRUSTEE, OFFICER OR KEY EMPLOYEE MAY HAVE A CONFLICT OF INTEREST AND FOR ASSURING THAT INDIVIDUAL SERVES THE HOSPITAL'S BEST INTEREST. THE COMPLAINCE OFFICER, THE CHAIR AND/OR PRESIDENT MAY CONSULT WITH ANY TRUSTEE, OFFICER, OR KEY EMPLOYEE TO OBTAIN INFORMATION NECESSARY FOR AN ORDINARILY PRUDENT PERSON TO MAKE A JUDGEMENT AS TO WHETHER A CONFLICT EXISTS AND REQUESTS SHALL BE COMPLIED WITH. IF AN ACTUAL OR POTENTIAL CONFLICT ARISES, THE COMPLIANCE OFFICER SHALL BE PROMPTLY NOTIFIED IN WRITING. TRUSTEES, OFFICERS, AND KEY EMPLOYEES WHO HAVE DECLARED OR HAVE BEEN DEEMED TO HAVE A CONFLICT OF INTEREST MUST REFRAIN FROM CONSIDERATION OF PROPOSED TRANSACTIONS OR ARRANGEMENTS, UNLESS FOR SPECIAL REASON THE BOARD OF TRUSTEES REQUESTS INFORMATION OR INTERPRETATIONS. FORM 990, PART VI, SECTION B, LINE 15 A PERFORMANCE REVIEW COMMITTEE CONSISTING OF INDEPENDENT BOARD MEMBERS REVIEWS THE PERFORMANCE OF THE SENIOR MANAGMENT TEAM. COMPENSATION IS BASED ON THE RESULTS OF THESE REVIEWS. THE COMMITTEE ALSO TAKES INTO CONSIDERATION INFORMATION FROM COMPENSATION SURVEYS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. PLEASE CONTACT DANIEL LOHR AT 326 WASHINGTON STREET, NORWICH, CT 06360 ABOUT INSPECTING THE ORGANIZATION'S DOCUMENTS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: K-1 PASSTHROUGH 1,402. TRANSFER TO AFFILIATES -2,794,559. INCREASE IN ASSETS HELD IN TRUST 156,434. CHANGE IN PENSION FUNDING 41,885,288. FAIR VALUE ADJUSTMENT 51,783,116. BACKUS HEALTH CARE INC 326 WASHINGTON STREET NORWICH CT 06360 222481794 SUPPORT CT 501C3 11A BACKUS CORP 1 BACKUS CORPORATION 326 WASHINGTON STREET NORWICH CT 06360 222757608 SUPPORT CT 501C3 11B N/A 0 HARTFORD HOSPITAL 80 SEYMOUR STREET HARTFORD CT 06102 060646668 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 WINDHAM COMMUNITY MEMORIAL HOSPITAL 112 MANSFIELD AVE WILLIMANTIC CT 06226 060646966 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 MIDSTATE MEDICAL CENTER 435 LEWIS AVENUE MERIDAN CT 06451 060646715 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 WINDHAM HOSPITAL FOUNDATION INC 112 MANSFIELD AVE WILLIMANTIC CT 06226 562546632 SUPPORTING ORGANIZATION CT 501C3 11A WINDHAM COMMUNITY MEMORIAL HOSPITAL 1 HARTFORD HOSPITAL AUXILIARY CO HARTFORD HOSPITAL 80 SEYMOUR STREET HARTFORD CT 06115 066040747 FUNDRAISING CT 501C3 11C HARTFORD HOSPITAL 1 CONNECTICUT HEALTH SYSTEM INC 80 SEYMOUR STREET HARTFORD CT 06102 222779421 COORDINATION 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