2013-05-14T16:28:12-05:00 2012-06-30 621517792 PERSHING YOAKLEY & ASSOCIATES P C ONE CHEROKEE MILLS 2220 SUTHERLAND KNOXVILLE TN 379192363 990 2011-07-01 581966795 DEKALB MEDICAL CENTER INC DEKA 4045011000 2701 NORTH DECATUR ROAD DECATUR GA 30033 JOHN KATSIANIS 4045011000 2013-05-14 1 SUSAN P CLARK CPAFHFMA P00017549 8656730844 2011 2016-02-24 21:20:13Z JOHN SHELTON 2701 NORTH DECATUR ROAD DECATUR GA 30033 452936183 0 X WWW.DEKALBMEDICAL.ORG X 1991 GA TO IMPROVE PATIENTS' LIVES THROUGH THE DELIVERY OF EXCELLENT HEALTH AND WELLNESS SERVICES. 7 5 4326 240 62768 -56517 1192414 3340510 413438521 443625483 6038682 5960679 2195151 8941 422864768 452935613 0 1777045 0 0 194620044 204971666 0 0 0 227304366 253340341 421924410 460089052 940358 -7153439 404221357 379429709 245325559 256486577 158895798 122943132 AT DEKALB MEDICAL CENTER, INC. ("DMC"), OUR MISSION IS TO IMPROVE LIVES THROUGH THE DELIVERY OF EXCELLENT HEALTH AND WELLNESS SERVICES IN PARTNERSHIP WITH OUR PHYSICIANS. 0 0 255551735 1777045 329333881 DEKALB MEDICAL AT NORTH DECATUR - 22,067 PATIENTS DISCHARGED (INCLUDES NICU AND EXCLUDES BABIES) FROM THE HOSPITAL FOR A TOTAL OF 107,796 DISCHARGED DAYS. THERE WERE 181,745 VISITS TO THE HOSPITAL DURING THE YEAR. 68579339 89181943 DEKALB MEDICAL AT HILLANDALE - 5,068 PATIENTS DISCHARGED FROM THE HOSPITAL FOR A TOTAL OF 21,197 DISCHARGED DAYS. THERE WERE 93,862 VISITS TO THE HOSPITAL DURING THE YEAR. 36469945 25118600 DEKALB MEDICAL PHYSICIAN NETWORK - 130,930 PATIENTS WERE TREATED IN THE PHYSICIANS OFFICES DURING THE FISCAL YEAR. 360601019 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 1 510 0 1 4326 1 1 1 0 0 0 0 0 0 0 0 0 X 7 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 GA X JOHN KATSIANIS 4045015025 2701 NORTH DECATUR ROAD DECATUR GA 30033 ERIC P NORWOOD 40.00 X X 963071 0 51741 JOHN A SHELTON JR 40.00 X X 289772 0 13820 OLIVER LEE 1.00 X 0 0 0 DAVID JOLLAY 1.00 X 0 0 0 ROBERT WILSON 1.00 X 0 0 0 CHARLES CLIFTON MD 1.00 X 0 0 0 ROBIN DRETLER MD 40.00 X 19997 0 0 DOMINIQUE SMITH MD 1.00 X 9165 0 0 DIANE P HARDEN 40.00 X 440291 0 45670 CATHLEEN WHEATLEY 40.00 X 451713 0 21962 JAN GANNON 40.00 X 337181 0 19192 JOSEPH FOWLER 40.00 X 201059 0 10508 CHERYL IVERSON 40.00 X 199414 0 38372 THOMAS CRAWFORD 40.00 X 223010 0 41905 CHARLES BARCLAY MD 40.00 X 312754 0 24387 STEPHEN THOMAS MD 40.00 X 335407 0 21922 MARK TROCINO 40.00 X 252619 0 14203 JAMES FORSTNER 40.00 X 204230 0 26658 SUSAN HARRIS 40.00 X 190846 0 27601 JOEL SCHUESSLER 40.00 X 158687 0 13977 DAVID HOLLADAY MD 40.00 X 962222 0 23957 RAYMOND LAWHEAD MD 40.00 X 545945 0 19987 SHAINUL BHATIA MD 40.00 X 389713 0 41628 AUGSTINE CONDUAH MD 40.00 X 516796 0 29412 RODERICK STEVENSON MD 40.00 X 253709 0 14771 7257601 0 501673 97 0 1 0 DEKALB ANESTHESIA ASSOCIATES PA 21717 WEST PARK COURT SUITE A STONE MOUNTAIN GA 30087 ANESTHESIOLOGY SRVCS 3733295 SODEXO INC & AFFILIATES PO BOX 536922 ATLANTA GA 30353 MANAGEMENT SERVICES 3502010 MEADOWS AND OHLY LLC 275 SCIENTIFIC DRIVE SUITE 275 NORCROSS GA 30092 MANAGEMENT SERVICES 3198833 BRASFIELD AND GORRIE PO BOX 11407 BIRMINGHAM AL 35246 CONSTRUCTION SRVCS 2160531 METRO VASCULAR PC 2675 N DECATUR ROAD SUITE 210 DECATUR GA 30033 SURGICAL SERVICES 1076169 42 2539336 127108 674066 3340510 NET PATIENT REV N DECA 621990 328046984 328046984 NET PATIENT REV HILLAN 621990 89181943 89181943 NET PATIENT REV PRIMAR 621110 25118616 25118616 WELLNESS CENTER 713940 804119 804119 RADIOLOGY SCHOOL 900099 117792 117792 356029 225317 62768 67944 443625483 5521209 5521209 8941 0 8941 8941 8941 440040 0 570 440040 -570 439470 439470 452935613 443503712 62768 6028623 1777045 1777045 175651919 143770104 31881815 6157672 5040020 1117652 10367998 8621161 1746837 12794077 10460572 2333505 810319 810319 316383 1732 314651 465847 465847 28192472 17643968 10548504 1947611 584 1947027 77725883 75523617 2202266 8136763 751032 7385731 21601143 8955551 12645592 166316 58441 107875 315740 96566 219174 112137 112137 20868738 757050 20111688 3055170 428822 2626348 BAD DEBT 72305001 72305001 REPAIRS AND MAINTENANCE 9826253 9006490 819763 MEDICARE PROVIDER TAX 4645312 4645312 MEMBERSHIP, DUES & SUBS 1033470 218326 815144 1815783 539625 1276158 460089052 360601019 99488033 0 13485455 12249518 7621947 7165490 62572601 58112119 5860483 5921091 2749509 1743794 410304538 281378942 137742124 128925596 168590597 160126020 1063206 1413807 4535435 3772274 404221357 379429709 43330734 38057988 191970095 189316202 10024730 29112387 245325559 256486577 X 158345967 122404058 549831 539074 158895798 122943132 404221357 379429709 X -7153439 -28799227 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 35655 35655 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: DUES PAID TO GEORGIA HOSPITAL ASSOCIATION WERE $98,913. OF THIS AMOUNT, $23,739 OR APPROXIMATELY 24%, WENT FOR LOBBYING. DUES PAID TO AMERICAN HOSPITAL ASSOCIATION WERE $48,439. OF THIS AMOUNT, $11,916 OR APPROXIMATELY 24.6%, WENT FOR LOBBYING. 549831 826617 837374 539074 585490 672897 708556 549831 1999808 7300 -1277654 143964 585490 2836621 261659 -1045126 53346 1999808 1.00000 0 0 403305 403305 229231586 133418070 95813516 172313148 142500045 29813103 8356499 5460827 2895672 128925596 SELF INSURANCE RESERVES 3982046 ACCRUED PENSION COSTS 18485795 ASSET RETIREMENT OBLIGATION 4931327 FAIR VALUE OF INTEREST RATE SWAPS 1713219 29112387 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TO PURCHASE EQUIPMENT, GRANT FUNDS FOR THE CANCER CENTER, PURCHASE SAFETY EQUIPMENT FOR THE EMERGENCY RESPONSE UNIT, AND FUND THE WELLNESS ON WHEELS PROGRAM. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: PER THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS FOR DEKALB REGIONAL HEALTH SYSTEM, INC. AND SUBSIDIARIES: THE SYSTEM, DEKALB MEDICAL CENTER,INC., DEKALB MEDICAL CENTER FOUNDATION, INC., AND DECATUR HEALTH RESOURCES, INC. ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) AS ORGANIZATIONS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED, AS WELL AS STATE INCOME TAX. VENTURES IS A TAXABLE ENTITY AND FILES A CORPORATE TAX RETURN. WITH RESPECT TO ITS FOR-PROFIT ENTITY, AS WELL AS ANY UNRELATED BUSINESS INCOME GENERATED AT THE TAX-EXEMPT ENTITIES, THE SYSTEM RECORDS INCOME TAXES USING THE ASSET AND LIABILITY METHOD UNDER WITH DEFERRED TAX ASSETS AND LIABILITIES ARE DETERMINED BASED ON THE DIFFERENCES BETWEEN THE FINANCIAL ACCOUNTING AND TAX BASES OF ASSETS AND LIABILITIES. DEFERRED TAX ASSETS OR LIABILITIES AT THE END OF EACH PERIOD ARE DETERMINED USING THE CURRENTLY ENACTED TAX RATE EXPECTED TO APPLY TO TAXABLE INCOME IN THE PERIOD THAT THE DEFERRED TAX ASSET OR LIABILITY IS EXPECTED TO BE REALIZED OR TO BE SETTLED. ALL SUCH INCOME TAX ACCOUNTING IS IMMATERIAL TO THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM APPLIES ASC 740, INCOME TAXES, WHICH PROVIDES GUIDANCE ON WHEN TAX POSITIONS ARE RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS AND HOW THE VALUES OF THESE POSITIONS ARE DETERMINED. THERE IS CURRENTLY NO IMPACT ON THE SYSTEM'S CONSOLIDATED FINANCIAL STATEMENTS AS A RESULT OF THE APPLICATION OF ASC 740. 1 1 X 1 X 1 X 1 1 1 0 1 1 11283505 11283505 0.02910 64203823 41379596 22824227 0.05890 75487328 41379596 34107732 0.08800 11584 57461 57461 0.00010 2336 416924 416924 0.00110 1460 72860 72860 0.00020 3 4317 11799 -7482 0.00000 3857 194988 194988 0.00050 19240 746550 11799 734751 0.00190 19240 76233878 41391395 34842483 0.08990 1 24152982 0 94557395 83855313 10702082 X 1 0 2 1 DEKALB MEDICAL AT NORTH DECATUR

2701 NORTH DECATUR ROAD DECATUR GA 30033

X X X 2 DEKALB MEDICAL AT HILLANDALE

2801 DEKALB MEDICAL PARKWAY LITHONIA GA 30058

X X X DEKALB MEDICAL CENTER AT NORTH DECATUR 1 0 1 1 200.000000000000 1 250.000000000000 1 X X X X X X X 1 1 X X 1 0 1 X 0 1 DEKALB MEDICAL CENTER AT HILLANDALE 2 0 1 1 200.000000000000 1 250.000000000000 1 X X X X X X X 1 1 X X 1 0 1 X 0 1 3 DEKALB MEDICAL PRIMARY CARE

2701 NORTH DECATUR ROAD DECATUR GA 30033

PRIMARY CARE DEKALB MEDICAL SPECIALTY CARE

2701 NORTH DECATUR ROAD DECATUR GA 30033

SPECIALIST CARE DEKALB MEDICAL OCCUPATIONAL MEDICINE GRO

2701 NORTH DECATUR ROAD DECATUR GA 30033

OCCUPATIONAL MEDICINE PART I, LINE 3C: THE ORGANIZATION USES FEDERAL POVERTY GUIDELINES. PART I, LINE 7: A COST-TO-CHARGE RATIO, DERIVED FROM THE SCHEDULE H APPLICABLE WORKSHEETS, INCLUDING WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, WAS USED TO DETERMINE CHARITY CARE. ACTUAL EXPENSE DATA IS ACCUMULATED WITHIN THE GENERAL LEDGER WHICH ADDRESSES ALL PATIENT SEGMENTS INCLUDING INPATIENT, OUTPATIENT, EMERGENCY ROOM, COMMERCIAL INSURANCE, GOVERNMENT INSURANCE, UNINSURED AND SELF-PAY. THE TOTAL OPERATING EXPENSE WAS DIVIDED BY PATIENT REVENUES TO CALCULATE AN OVERALL RATIO THAT WAS THEN APPLIED TO INDIGENT AND CHARITY CARE CHARGES TO ARRIVE AT COST. PART I, LINE 7G: BEHAVIORAL HEALTH SERVICES ARE OFFERED BY DEKALB MEDICAL CENTER. 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 $ 72305002. PART III, LINE 4: PER THE DEKALB REGIONAL HEALTH SYSTEM, INC. AND SUBSIDIARIES CONSOLIDATED FINANCIAL STATEMENTS: "THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT ROUTINELY ASSESSES, IN THE NORMAL COURSE OF BUSINESS, THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON ITS ASSESSMENT OF THESE AND OTHER FACTORS BY PAYOR CATEGORY, AND ADJUSTS THE ALLOWANCE AND RELATED PROVISION ACCORDINGLY. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, MANAGEMENT ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A RELATED PROVISION, IF NECESSARY, FOR PAYORS WITH KNOWN FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, WHICH INCLUDES PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL (PATIENT APPORTIONMENT), MANAGEMENT RECORDS A PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICES ON THE BASIS OF PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE SYSTEM'S SELF-PAY WRITE-OFFS INCREASED $15,393,000 DURING 2012 FROM $46,803,000 IN FISCAL YEAR 2011 TO $62,196,000 IN FISCAL YEAR 2012. THE INCREASE WAS A RESULT OF DECREASES IN THE NUMBER OF PATIENTS QUALIFYING FOR CHARITY CARE IN FISCAL YEAR 2012. THE SYSTEM HAS NOT CHANGED ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING FISCAL YEARS 2012 OR 2011. AS IT RELATES TO THIRD-PARTY PAYORS, THE SYSTEM DOES NOT MAINTAIN A MATERIAL ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS, NOR DOES IT HAVE SIGNIFICANT WRITE-OFFS." PART III, LINE 9B: THE CURRENT BILLING AND COLLECTION POLICY DOES NOT CONTAIN PROVISIONS FOR COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE BUT THE FAP OR "CHARITY POLICY" DOES AS IT OUTLINES THE COMPLETE WRITE OFF OR SLIDING SCALE AMOUNTS THE INDIVIDUAL WILL BE RESPONSIBLE FOR. DEKALB MEDICAL CENTER AT NORTH DECATUR PART V, SECTION B, LINE 13G: AVAILABILITY OF FAP APPLICATION IS DISCUSSED DURING THE FINANCIAL COUNSELING PROCESS. DEKALB MEDICAL CENTER AT HILLANDALE PART V, SECTION B, LINE 13G: AVAILABILITY OF FAP APPLICATION DISCUSSED DURING THE FINANCIAL COUNSELING PROCESS DEKALB MEDICAL CENTER AT NORTH DECATUR PART V, SECTION B, LINE 19D: DEKALB'S FAP REQUIRES A COMPLETE WRITE OFF OR ADJUSTMENT OF TOTAL CHARGES OR A PORTION OF CHARGES IF PATIENT IS FAP ELIGIBLE AND IS BASED ON FEDERAL POVERTY GUIDELINES (FPG). DEKALB MEDICAL CENTER AT HILLANDALE PART V, SECTION B, LINE 19D: DEKALB'S FAP REQUIRES A COMPLETE WRITE OFF OR ADJUSTMENT OF TOTAL CHARGES OR A PORTION OF CHARGES IF PATIENT IS FAP ELIGIBLE AND IS BASED ON FEDERAL POVERTY GUIDELINES (FPG). DEKALB MEDICAL CENTER AT NORTH DECATUR PART V, SECTION B, LINE 21: THE HOSPITAL CURRENTLY UTILIZES AN AUTOMATIC BILL PROCEDURE WHICH PREPARES THE FIRST BILL AT GROSS CHARGES. DISCOUNTS AND WRITE-OFFS ARE APPLIED AFTER THE FIRST BILL. IN TAX YEAR ENDING 06/30/2012, THE FACILITY BILLED ALL FAP ELIGIBLE PATIENTS AT GROSS BUT COLLECTED LESS THAN GROSS BASED ON FAP AND FPG. DEKALB MEDICAL CENTER AT HILLANDALE PART V, SECTION B, LINE 21: THE HOSPITAL CURRENTLY UTILIZES AN AUTOMATIC BILL PROCEDURE WHICH PREPARES THE FIRST BILL AT GROSS CHARGES. DISCOUNTS AND WRITE-OFFS ARE APPLIED AFTER THE FIRST BILL. IN TAX YEAR ENDING 06/30/2012, THE FACILITY BILLED ALL FAP ELIGIBLE PATIENTS AT GROSS BUT COLLECTED LESS THAN GROSS BASED ON FAP AND FPG. PART VI, LINE 2: EVERY FIVE YEARS, WE PARTNER WITH THE DEKALB BOARD OF HEALTH TO ASSESS LOCAL RISK FACTORS AND MEASURE THE SUCCESS OF OUR HEALTHCARE INITIATIVES. THE COMMUNITY "HEALTH REPORT" INCLUDES AN EVALUATION OF DISEASE PREVALENCE AND COMPARISON AGAINST NATIONAL AVERAGES THAT HELPS US ENGINEER SERVICES TO ELIMINATE HEALTH DISPARITIES BASED ON ETHNICITY, INCOME, EDUCATION AND OTHER FACTORS. AMONG THE OPPORTUNITIES IDENTIFIED FOR PREVENTION AND COMMUNITY ACTION IN DEKALB AND SURROUNDING COUNTIES WERE THE FOLLOWING: *80% OF REFUGEES IN GEORGIA LIVE IN DEKALB COUNTY AND SPEAK MORE THAN 64 DIFFERENT LANGUAGES. *72% OF ALL HOSPITALIZATIONS ARE CAUSED BY HEART DISEASE. *PREGNANCY AND CHILDBIRTH COMPLICATIONS ARE THE 2ND LEADING CAUSE OF HOSPITALIZATION. *STROKE, HEART DISEASE AND CANCER WERE THE LEADING CAUSES FOR DEATH IN ADULTS AGED 65 AND OVER. PART VI, LINE 3: PATIENTS PROVIDED CARE BY THE HOSPITAL MEET WITH A FINANCIAL COUNSELOR AFTER THEIR CARE IS RENDERED. ELEGIBILITY CRITERIA FOR VARIOUS FINANCIAL ASSISTANCE PROGRAMS IS REVIEWED WITH THE PATIENT INCLUDING CHARITY, MEDICAID, OR OTHER FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS. BILLING STATEMENTS RECEIVED BY A PATIENT ADVISE THEM TO CONTACT THE FINANCIAL COUNSELING DEPARTMENT ABOUT THESE PROGRAMS. PART VI, LINE 4: DEKALB REGIONAL HEALTH SYSTEM SERVES THE POPULATION OF DEKALB COUNTY, GA (54% AFRICAN AMERICAN, 35% WHITE, 4% ASIAN) AS WELL AS ROCKDALE AND GWINNETT COUNTIES. THE MEDIAN INCOME OF DEKALB COUNTY IS APPROXIMATELY $51,700 AND ABOUT 17% OF THE COUNTY RESIDENTS LIVE BELOW THE POVERTY LEVEL. APPROXIMATELY 9% OF THE POPULATION IS OVER AGE 65 AND 24% OF THE POPULATION IS UNDER AGE 18. PART VI, LINE 5: UNDERSTANDING THAT A HEALTH COMMUNITY IS ABOUT MORE THAN JUST THE ABSENCE OF DEATH AND DISEASE, WE ALSO CONTRIBUTE TO THE ECONOMIC VITALITY AND CREATION OF QUALITY JOBS RIGHT HERE AT HOME. NAMED THE 2010 CORPORATION OF THE YEAR BY THE DEKALB COUNTY CHAMBER OF COMMERCE FOR OUR ROLE AS AN ACTIVE CORPORATE CITIZEN AND PROPONENT OF DIVERSITY, THE FOLLOWING PROGRAMS HAVE HELPED BUILD THE HEALTH OF OUR COMMUNITY: 1) WE HELP REDUCE TEEN PREGNANCY AND SEXUALLY TRANSMITTED DISEASE BY PROVIDING FREE PREVENTION EDUCATION THROUGH OUR PUBERTY ROCKS PROGRAM FOR PRE-TEENS; 2) WE SUPPORT 100 BLACK MEN OF DEKALB IN THE EFFORT TO PROVIDE HIGHER EDUCATION TO AT-RISK YOUTH; 3) WE PARTNER WITH THE PHYSICIANS'S CARE CLINIC TO PROVIDE NEARLY 2,000 LOW OR NO COST PATIENT VISITS A YEAR INCLUDING LAB WORK AND PRESCRIPTION MEDICATIONS TO AREA LOW-INCOME AND UNINSURED RESIDENTS; 4) WE SPONSOR A FREE ANNUAL CANCER SCREENING DAY ON TWO OF OUR HOSPITAL CAMPUSES; 5) WE HAVE RECENT HEALTHY WORKPLACE INIATIVES INCLUDE SMOKE-FREE BUILDINGS INSIDE AND OUT, A NO-NICOTINE HIRING POLICY AND ADOPTION OF HEALTHY FOOD OPTIONS IN HOSPITAL CAFETERIAS; 6) WE COLLECT AND DONATE SURPLUS MEDICAL SUPPLIES TO MEDSHARE INTERNATIONAL IN SUPPORT OF HEALTH INITIATIVES IN LESS FORTUNATE COUNTRIES; 7) WE HAVE AN OPEN MEDICAL STAFF THAT ATTRACTS UNLIMITED, HIGHLY TRAINED MEDICAL TALENT TO SERVE THE AREA; 8) WE ARE A MAJOR SPONSOR OF THE LEADERSHIP DEKALB INITIATIVE TO PROMOTE COMMUNITY CONNECTIVITY AND ACTION PLANS FOR ECONOMIC DEVELOPMENT, SUSTAINABILITY AND IMPROVEMENT OF THE QUALITY OF LIFE IN DEKALB COUNTY; 9) DEKALB MEDICAL PROVIDES FURTHER ENRICHMENT AND EMPLOYMENT OPPORTUNITIES BY CHAMPIONING WORKPLACE SUCCESS FOR YOUTH AND ADULTS WITH DISABILITIES. PARTNERING WITH THE NATIONALLY RECOGNIZED TOMMY NOBIS CENTER, DEKALB MEDICAL CONTRACTS WITH THE CENTER, DEKALB MEDICAL CONTRACTS WITH THE CENTER TO PROVIDE SWITCHBOARD OPERATORS FOR THE HEALTH SYSTEM; 9) WE PARTNER WITH DEKALB COUNTY HIGH SCHOOLS TO PROVIDE MENTALLY AND PHYSICALLY CHALLENGED STUDENTS WITH VOCATIONAL TRAINING AND REAL-LIFE WORK EXPERIENCE IN THE HEALTHCARE INDUSTRY. THE STUDENTS, WHO RECEIVE SCHOOL CREDIT, SERVE AS VOLUNTEERS IN OUR CAFETERIA, LAUNDRY ROOM AND MOTHER-BABY UNITS; 10) WE PARTICIPATE IN NUMEROUS CAREER DAYS, ENCOURAGING THE SCIENCE AND MATH EDUCATION THAT'S NEEDED TO PROVIDE COMPETENT HEALTH WORKERS OF THE FUTURE; 11) WE SUPPORT A DEKALB WORKFORCE DEVELOPMENT PARTNERSHIP THAT PROVIDES TRAINING PROGRAMS, EDUCATION AND A CLINICAL SITE FOR PATIENT CARE TECHNICIAN CERTIFICATION; AND 12) WE MAINTAIN A PARTNERSHIP WITH GEORGIA PERIMETER COLLEGE AND MERCER UNIVERSITY TO PROVIDE CLINICAL ROTATIONS, PRECEPTORSHIPS, EDUCATION AND INSTRUCTION TO GEORGIA'S FUTURE NURSES. PART VI, LINE 6: DEKALB REGIONAL HEALTH SYSTEM, INC. IS THE PARENT ENTITY WHICH PROVIDES SUPPORT TO DEKALB MEDICAL CENTER, INC., DECATUR HEALTH RESOURCES, INC. AND DEKALB MEDICAL CENTER FOUNDATION, INC. DEKALB MEDICAL CENTER, INC. OPERATES TWO ACUTE CARE HOSPITALS AND A PHYSICIAN PRACTICE NETWORK TO PROVIDE HEALTHCARE SERVICES TO THE RESIDENTS OF DEKALB COUNTY, GEORGIA AND SURROUNDING COUNTIES. DECATUR HEALTH RESOURCES PROVIDES LONG-TERM ACUTE CARE HOSPITAL SERVICES TO PATIENTS WHO NEED ADDITIONAL TIME TO RECOVER FROM SERIOUS ILLNESS. DEKALB MEDICAL CENTER FOUNDATIONS'S MISSION IS TO STRENGTHEN THE LINK BETWEEN DEKALB REGIONAL HEALTH SYSTEM AND THE COMMUNITY IT SERVICES THROUGH COMMUNICATION, EDUCATION, SERVICE AND PHILANTHROPY. REPORTS FILED WITH STATES PART VI, LINE 7 GA 1 DEKALB REGIONAL HEALTH SYSTEM INC 2701 NORTH DECATUR DECATUR GA 30033 582034980 501(C)(3) 1777045 INTERCOMPANY TRANSFER - GENERAL SUPPORT 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION HAS GUIDELINES IN PLACE THAT ARE USED IN REVIEWING THE ELIGIBILITY OF GRANTEES. SCHOLARSHIP FUNDS ARE REMITTED TO THE EDUCATIONAL INSTITUTIONS DIRECTLY. FOR OTHER GRANTS, VARIOUS PROCEDURES ARE IN PLACE DEPENDING ON GRANT TYPE, INCLUDING REQUIREMENTS TO SUBMIT APPLICATIONS FOR REVIEW AND APPROVAL. ALL GRANTS REQUIRE WRITTEN DOCUMENTATION AND APPROPRIATE LEVELS OF APPROVAL. 1 X X X X X 1 0 0 0 0 0 0 0 0 ERIC P NORWOOD 431548 0 232630 0 298893 0 11025 0 40716 0 1014812 0 0 0 JOHN A SHELTON JR 134762 0 104900 0 50110 0 6264 0 7556 0 303592 0 0 0 DIANE P HARDEN 320507 0 89442 0 30342 0 32425 0 13245 0 485961 0 0 0 CATHLEEN WHEATLEY 279032 0 150043 0 22638 0 15925 0 6037 0 473675 0 0 0 JAN GANNON 101629 0 92804 0 142748 0 10609 0 8583 0 356373 0 0 0 JOSEPH FOWLER 3300 0 3539 0 194220 0 0 0 10508 0 211567 0 0 0 CHERYL IVERSON 163622 0 13474 0 22318 0 14179 0 24193 0 237786 0 0 0 THOMAS CRAWFORD 139296 0 61628 0 22086 0 35563 0 6342 0 264915 0 0 0 CHARLES BARCLAY MD 246125 0 21092 0 45537 0 18375 0 6012 0 337141 0 0 0 STEPHEN THOMAS MD 300019 0 19609 0 15779 0 7552 0 14370 0 357329 0 0 0 MARK TROCINO 211162 0 19005 0 22452 0 8530 0 5673 0 266822 0 0 0 JAMES FORSTNER 172059 0 15553 0 16618 0 25736 0 922 0 230888 0 0 0 SUSAN HARRIS 171706 0 7418 0 11722 0 15226 0 12375 0 218447 0 0 0 JOEL SCHUESSLER 139397 0 13230 0 6060 0 5276 0 8701 0 172664 0 0 0 DAVID HOLLADAY MD 938662 0 318 0 23242 0 13797 0 10160 0 986179 0 0 0 RAYMOND LAWHEAD MD 521977 0 0 0 23968 0 13628 0 6359 0 565932 0 0 0 SHAINUL BHATIA MD 275018 0 91380 0 23315 0 34875 0 6753 0 431341 0 0 0 AUGSTINE CONDUAH MD 500997 0 500 0 15299 0 8575 0 20837 0 546208 0 0 0 RODERICK STEVENSON MD 115384 0 61797 0 76528 0 8100 0 6671 0 268480 0 0 0 PART I, LINE 4A THE INDIVIDUALS BELOW RECEIVED SEVERANCE PAYMENTS TOTALING THE FOLLOWING: ERIC NORWOOD $153,462 JOSEPH FOWLER $171,600 JAN GANNON $101,629 THE DEKALB COUNTY HOSPITAL AUTHORITY 586011209 24047CCC0 2003-12-10 28325646 REFUND 2003A SERIES 0 0 0 THE DEKALB COUNTY HOSPITAL AUTHORITY 586011209 24047CDH8 2010-05-03 180623920 REFUND SERIES 2010 0 0 0 28325646 2691072 177160 2003 1 0 1 1 180623920 14114456 3168280 19992698 2011 1 0 1 1 0 0 0 0 0.00840 0.00000 0.00840 1 0 0 0 0 0.00840 0.00000 0.00840 1 1 0 0 0 0 0 0 0 0 0 0 0 DEKALB ANESTHESIA ASSOCIATES PROVIDER OF MEDICAL SERVICES TO DMC. 3067440 CHARLES CLIFTON, M.D., MEMBER OF THE DMC BOARD OF DIRECTORS, IS AN OWNER OF DEKALB ANESTHESIA ASSOCIATES. 0 FORM 990, PART VI, SECTION A, LINE 6 DEKALB REGIONAL HEALTH SYSTEM, INC. IS THE SOLE MEMBER OF DEKALB MEDICAL CENTER, INC. FORM 990, PART VI, SECTION A, LINE 7A EACH BOARD OF DIRECTORS MEMBER NOMINATED TO THE DEKALB MEDICAL CENTER, INC. BOARD IS SUBJECT TO APPROVAL BY THE BOARD OF DIRECTORS OF DEKALB REGIONAL HEALTH SYSTEM, INC. IN ACCORDANCE WITH THE DEKALB MEDICAL CENTER BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B DEKALB REGIONAL HEALTH SYSTEM, INC. MUST APPROVE CAPITAL EXPENDITURES IN EXCESS OF $2,000,000, ACQUISITIONS, REORGANIZATIONS, MERGERS AND/OR CONSOLIDATIONS, BUDGETS AND ANY REVISIONS AND REVISIONS OF THE ARTICLES OF INCORPORATION FOR DEKALB MEDICAL CENTER, INC. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS PREPARED BY AN UNRELATED, INDEPENDENT ACCOUNTING FIRM AND SUBMITTED TO THE FINANCE COMMITTEE OF THE DEKALB REGIONAL HEALTH SYSTEM, INC. BOARD OF DIRECTORS FOR REVIEW PRIOR TO FILING. A COPY OF FORM 990 IS ALSO PROVIDED TO THE DEKALB MEDICAL CENTER, INC. BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ALL OFFICERS, DIRECTORS, AND INDIVIDUALS IN MANAGEMENT LEVEL POSITIONS TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT ANNUALLY. THESE CONFLICT OF INTEREST DISCLOSURES ARE REVIEWED TO ASSURE COMPLIANCE WITH THE POLICY. ADDITIONALLY, BOARD MEMBERS ARE ASKED TO RECUSE THEMSELVES ON ANY MATTERS OF INTEREST BEFORE THE BOARD IN WHICH A CONFLICT OF INTEREST MAY EXIST. ANY RECUSAL IS DOCUMENTED WITHIN THE MINUTES OF THE BOARD OR COMMITTEE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE OF THE DEKALB REGIONAL HEALTH SYSTEM, INC. BOARD OF DIRECTORS REVIEWS AND APPROVES THE COMPENSATION OF THE CEO AND OTHER OFFICERS. THE COMMITTEE RELYS ON COMPENSATION DATA SUPPLIED BY AN INDEPENDENT CONSULTANT IN DETERMINING THE APPROPRIATE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL OFFICERS ARE COMPENSATED BY DEKALB MEDICAL CENTER, INC., A RELATED ENTITY. COMPENSATION IS REVIEWED AND APPROVED BY THE COMPENSATION COMMITTEE OF THE DEKALB REGIONAL HEALTH SYSTEM, INC. BOARD OF DIRECTORS. THE COMMITTEE UTILIZES AN INDEPENDENT CONSULTANT TO ASSIST IN SETTING COMPENSATION LEVELS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -3,118,240. PRIOR PERIOD ADJUSTMENTS: -916. MINIMUM PENSION LIABILITY -25,680,071. TOTAL TO FORM 990, PART XI, LINE 5: -28,799,227. NETWORK MEDICAL PROVIDERS 2701 NORTH DECATUR ROAD DECATUR GA 30033 582121470 PHYSICIAN SERVICES GA 0 0 DEKALB MEDICAL CENTER INC DEKALB MEDICAL SPECIALTY CARE GROUP LLC 2701 NORTH DECATUR ROAD DECATUR GA 30033 263454941 PHYSICIAN SERVICES GA 0 0 DEKALB MEDICAL CENTER INC DEKALB MEDICAL PRIMARY CARE GROUP LLC 2701 NORTH DECATUR ROAD DECATUR GA 30033 263454827 PHYSICIAN SERVICES GA 0 0 DEKALB MEDICAL CENTER INC DEKALB MEDICAL OCCUPATIONAL MEDICINE GROUP LLC 2701 NORTH DECATUR ROAD DECATUR GA 30033 263455069 PHYSICIAN SERVICES GA 0 0 DEKALB MEDICAL CENTER INC DEKALB MEDICAL HOSPITALISTS 2701 NORTH DECATUR ROAD DECATUR GA 30033 582639633 PHYSICIAN SERVICES GA 0 0 DEKALB MEDICAL CENTER INC DECATUR NETWORK MEDICAL PROVIDER 2701 NORTH DECATUR ROAD DECATUR GA 30033 586300825 PHYSICIAN SERVICES GA 0 0 DEKALB MEDICAL CENTER INC DEKALB MEDICAL CENTER FOUNDATION INC 2701 NORTH DECATUR ROAD DECATUR GA 30033 581924605 FUNDRAISING ON BEHALF OF DMC GA 501(C)(3) LINE 11B, II DEKALB REGIONAL HEALTH SYSTEM INC 0 DEKALB REGIONAL HEALTH SYSTEM 2701 NORTH DECATUR ROAD DECATUR GA 30033 582034958 SUPPORT DMC, INC. GA 501(C)(3) LINE 3 N/A 0 DECATUR HEALTH RESOURCES INC 450 NORTH CANDLER STREET DECATUR GA 30030 582081599 LONG TERM ACUTE CARE GA 501(C)(3) LINE 11C, III-FI DEKALB REGIONAL HEALTH SYSTEM INC 0 DRHS VENTURES INC 2701 NORTH DECATUR ROAD DECATUR GA 30033 201864828 JOINT VENTURE GA N/A C DEKALB PHYSICIAN HOSPITAL ORGANIZATION INC 250 E PONCE LEON AVENUE DECATUR GA 30033 582110792 PHYSICIANS SERVICES GA DEKALB MEDICAL CENTER INC C 899537 615997 0.50000 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0