2013-02-11T16:16:51-06:00 2012-06-30 621046406 JOHNSON HICKEY & MURCHISON PC 651 E 4TH ST STE 200 CHATTANOOGA TN 37403 990 2011-07-01 620790132 CUMBERLAND MEDICAL CENTER CUMB 9314849511 421 SOUTH MAIN STREET CROSSVILLE TN 38555 LARRY E MOORE 9314849511 2013-02-11 JOEL D SUSMAN P00577620 4237560052 2011 2016-02-25 16:41:14Z LARRY E MOORE 421 SOUTH MAIN STREET CROSSVILLE TN 38555 107770650 0 X WWW.CMCHEALTHCARE.ORG X 1967 TN THE MISSION IS TO MAKE AVAILABLE QUALITY HEALTH CARE ON A REGIONAL LEVEL TO THOSE IN NEED OF ITS SERVICE THROUGH DEDICATION, PROFESSIONALISM AND FINANCIAL STABILITY. 11 9 1237 141 0 0 57015 161654 99138073 106710289 505750 338109 2865995 429889 102566833 107639941 0 0 0 0 50663822 51592457 0 0 0 52586294 54007621 103250116 105600078 -683283 2039863 121038135 124330508 51252518 52937183 69785617 71393325 X THE MISSION IS TO MAKE AVAILABLE QUALITY HEALTH CARE ON A REGIONAL LEVEL TO THOSE IN NEED OF ITS SERVICE THROUGH DEDICATION, PROFESSIONALISM AND FINANCIAL STABILITY. 0 0 8485689 18387245 INPATIENT ROUTINE CARE SERVICES TO INCLUDE NURSING, MEALS, HOUSEKEEPING, ETC. FOR 20,937 ROUTINE INPATIENT DAYS. 7022880 29948429 CUMBERLAND MEDICAL CENTER PERFORMED 4,366 SURGICAL PROCEDURES. 4887867 18682487 CUMBERLAND MEDICAL CENTERS DISPENSED 781,319 PHARMACY DOSES. 72668821 40002302 ALL OTHER ROUTINE AND NECESSARY EXPENSES TO PROVIDE HEALTHCARE SERVICES IN AN ACUTE CARE HOSPITAL WITH 145 ROUTINE BEDS, 12 INTENSIVE CARE UNIT BEDS, 14 NURSERY BEDS, AND 12 REHABILITATION UNIT BEDS. 72668821 40002302 93065257 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 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 0 1 66 0 1 1237 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 TN X LARRY MOORE CFO 9314849511 421 S MAIN STREET CROSSVILLE TN 38555 EDWARD ANDERSON 40.00 X X 60668 0 0 REYNALDO OLAECHEA 40.00 X 175011 0 15099 BETH PETTY MD 0.00 X 0 0 0 COSBY A STONE 0.00 X X 0 0 0 JW BROWN 0.00 X X 0 0 0 JAMES BARNAWELL MD 0.00 X X 0 0 0 SALLY OGLESBY 0.00 X 0 0 0 LARRY REED MD 0.00 X 0 0 0 ROBERT COUCH 0.00 X X 0 0 0 ROY HOWARD 0.00 X 0 0 0 ROBERT HARRISON 0.00 X 0 0 0 BARRY S WAGNER MD 40.00 X 241412 0 1271 LARRY MOORE 40.00 X 223932 0 20162 ALEXANDER C PIERCE 40.00 X 324491 0 34146 SIVALINGAM KANAGASEGAR MD 40.00 X 289255 0 22126 ROHITASH MEHTA 40.00 X 284720 0 0 ROBIN BRAD BAUER 40.00 X 280832 0 2167 WESLEY CHAD HALFORD 40.00 X 282105 0 26589 2162426 0 121560 30 0 1 0 CUMBERLAND ANESTHESIA GROUP LLC PO BOX 88544 MILWAUKEE WI 53288 CONTRACT ANESTHESIA 1200000 DR JOHN MILLIGAN 61 FLAMINGO DRIVE CORSSVILLE TN 38555 PROFESSIONAL LIABILITY INS./PHYSICIANS G 441454 MILLER & MARTIN PLLC 832 GEORGIA AVENUE CHATTANOOGA TN 37402 ATTORNEYS 406158 MOBILE TECH SVC 201 NORTH WHITE 1 ATHENS TN 37303 MOBILE PET/CT 390900 JAMES BARNWELL MD 421 SOUTH MAIN STREET CROSSVILLE TN 38555 PATHOLOGY 277200 5 60554 101100 161654 NET PATIENT SERVICE RE 621990 106710289 106710289 106710289 457824 457824 10994 130709 -119715 -119715 -119715 MISCELLANEOUS REVENUE 621990 429889 429889 429889 107639941 107020463 0 457824 683777 553859 129918 40250384 32602811 7647573 339884 275306 64578 7407643 6000191 1407452 2910769 2357723 553046 1791303 1450955 340348 216865 175661 41204 44200 44200 6731242 6731242 1020237 1020237 481927 481927 113522 113522 3942998 3193828 749170 133708 108303 25405 433 351 82 2364250 2364250 5470582 5470582 2697821 2697821 MEDICAL SUPPLIES AND DR 12455142 12455142 BAD DEBTS 8528535 8528535 TAX & LICENSES 4013826 3251199 762627 OTHER EXPENSES 2756576 2215400 541176 1244454 972212 272242 105600078 93065257 12534821 0 17012796 22024303 10178068 3527767 12718785 15869091 42842 1882 1719057 1735459 1327383 1086211 145493415 68597975 75224116 76895440 520918 805510 2294170 2384845 121038135 124330508 5629251 8081655 41140000 40138718 4483267 4716810 51252518 52937183 X 69603063 71231631 182554 161694 69785617 71393325 121038135 124330508 X 2039863 -432155 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2674819 2674819 85122820 27447646 57675174 56412032 40241251 16170781 1283744 909078 374666 76895440 SWAP AGREEMENT LIABILITY 4372713 CMC CAPITAL LEASE LIABILITY 321462 CMC MOB SECURITY DEPOSITS 22635 4716810 107639941 105600078 2039863 -432155 -432155 1607708 108072096 432155 432155 107639941 0 107639941 105600078 0 105600078 0 105600078 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE MEDICAL CENTER IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE MEDICAL CENTER BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE MEDICAL CENTER'S FORMS 990, "RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX", FOR THE YEARS ENDING 2009, 2010, 2011 ARE SUBJECT TO EXAMINATION BY THE IRS, GENERALLY FOR 3 YEARS AFTER THEY WERE FILED. PART XII, LINE 2D - OTHER ADJUSTMENTS: UNREALIZED LOSS ON SWAP AGREEMENT 389,357. UNREALIZED LOSSES ON OTHER THAN TRADING SECURITIES 42,798. 1 1 1 X 1 X 1 1 1 0 0 879194 879194 0.00910 12877466 6707021 6170445 0.06360 13756660 6707021 7049639 0.07270 412654 412654 0.00430 6124850 3487276 2637574 0.02720 26754 26754 0.00030 6564258 3487276 3076982 0.03180 20320918 10194297 10126621 0.10450 1 3117770 558081 39569172 36561484 3007688 X 1 1 1 CST COMM HEALTH LLC HEALTHCARE SERVICES/CARDIAC CATH 1.00000 1 1 CUMBERLAND MEDICAL CENTER INC

421 S MAIN ST CROSSVILLE TN 38555

X X X HOSPITAL CUMBERLAND MEDICAL CENTER 1 1 1 150.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X 1 X X 1 X X X X X X 1 0 0 10 CMC HOME CARE

79 S MAIN ST CROSSVILLE TN 38555

HOME HEALTH AGENCY CUMBERLAND PHYSICAL REHAB UNIT

421 S MAIN ST CROSSVILLE TN 38555

INPATIENT REHABILITATION FACILITY CUMBERLAND PHYSICIANS GROUP

133 HAYES ST CROSSVILLE TN 38555

GEN. AND SPECIALTY PHYSICIANS CMC WELLNESS COMPLEX

130 WOODMERE MALL CROSSVILLE TN 38555

WELLNESS AND DIABETES MANAGEMENT CUMBERLAND MEDICAL CENTER AT FFG

130 STONEHENGE DR CROSSVILLE TN 38555

WELLNESS, PHYSICAL THERAPY, & MAMMOGRAPHY CMC OUTPATIENT IMAGING CENTER

28 HAYES ST CROSSVILLE TN 38555

MEDICAL IMAGING AND PET SCAN CMC MEDICAL EQUIPMENT SERVICES

591 S MAIN ST CROSSVILLE TN 38555

MEDICAL EQUIPMENT AND OXYGEN CMC CANCER CENTER

421 S MAIN ST CROSSVILLE TN 38555

ONCOLOGY RADIATION THERAPY CMC OCCUPATIONAL MEDICINE

44 HAYES ST SUITE 202 CROSSVILLE TN 38555

WORK RELATED CARE AND EXAMS CMC WOUND CENTER

421 S MAIN ST CROSSVILLE TN 38555

WOUND AND HYPERBARIC TREATMENT PART I, LINE 7: LINE 7E - COMMUNITY HEALTH IMPROVEMENT AND BENEFIT OPERATIONSTHE COST OF $412,654 FOR COMMUNITY HEALTH IMPROVEMENT AND BENEFIT OPERATIONS WAS PROVIDED BY VARIOUS OPERATIONS INCLUDING:BLOOD PRESSURE CHECKS AND VARIOUS VOLUNTEER SERVICES AT THE SENIOR CITIZEN CENTERSERVICES PROVIDED TO THE BREAD OF LIFE MISSION CLINICRELAY FOR LIFE AND HEART WALKCOLON CANCER SCREENING AND CONSULTATIONGRIEF AND CPAP SUPPORT GROUPSPROVIDING COMMUNITY HEALTH FAIRSPROVIDING MEDICAL EDUCATION SEMINARS PART I, LINE 7G: SUBSIZIDED HEALTH SERVICESTHE SUBSIDY OF $2,637,574 IS THE DIFFERENCE BETWEEN THE COST OF SERVICES PROVIDED IN THE HOSPITAL'S PHYSICIAN OFFICES, WOUND CARE CENTER, AND SENIOR PERSPECTIVES AND THE PAYMENTS RECEIVED FOR THOSE SERVICES. THE PHYSICIAN OFFICES INCLUDE FAMILY, INTERNAL MEDICINE, OB/GYN, SURGEONS, AND OTHER SPECIALTY PHYSICIANS. ALTHOUGH PATIENTS WITH MEDICARE OR COMMERCIAL INSURANCE COVERAGE ARE PROVIDED SERVICES, THESE PHYSICIAN OFFICES WERE ESTABLISHED TO PROVIDE SERVICES FOR PATIENTS WITHOUT INSURANCE COVERAGE OR WITH TENNCARE/MEDICAID. THE COST OF PROVIDING THESE SERVICES EXCEEDED THE PAYMENTS RECEIVED BY $2,512,062 DURING THE REPORTING PERIOD.THE WOUND CARE CENTER PROVIDES HYPERBARIC AND WOUND TREATMENT SERVICES. THE COST OF PROVIDING THESE SERVICES EXCEEDED THE PAYMENTS RECEIVED BY $95,269 DURING THE REPORTING PERIOD.SENIOR PERSPECTIVES PROVIDES BEHAVIORAL HEALTH SERVICES TO SENIOR CITIZENS. THE COST OF PROVIDING THESE SERVICES EXCEEDED THE PAYMENTS RECEIVED BY $30,243 DURING THE REPORTING PERIOD. 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 $ 8528535. PART III, LINE 4: THE MEDICAL CENTER MAINTAINS ALLOWANCES FOR DOUBTFUL ACCOUNTS FOR ESTIMATED LOSSES RESULTING FROM THE INABILITY OF ITS PATIENTS TO MAKE PAYMENTS. MANAGEMENT CONSIDERS THE FOLLOWING FACTORS WHEN DETERMINING THE COLLECTIBILITY OF PATIENT ACCOUNTS: PAYOR CREDIT-WORTHINESS, PAST TRANSACTION HISTORY WITH THE PAYOR, CURRENT ECONOMIC INDUSTRY TRENDS, AND CHANGES IN PAYOR PAYMENT TERMS. IF THE FINANCIAL CONDITION OF THE MEDICAL CENTER'S PAYORS OR PATIENTS WERE TO DETERIORATE, ADVERSELY AFFECTING THEIR ABILITY TO MAKE PAYMENTS, ADDITIONAL ALLOWWANCES WOULD BE REQUIRED. BASED ON MANAGEMENT'S ASSESSMENT, THE MEDICAL CENTER PROVIDES FOR ESTIMATED UNCOLLECTABLE AMOUNTS THROUGH A CHARGE TO EARNINGS AND A CREDIT TO AN ALLOWANCE. BALANCES THAT REMAIN OUTSTANDING AFTER THE MEDICAL CENTER HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE.THE ESTIMATED AMOUNT OF THE MEDICAL CENTER'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS 17.9% OF THE TOTAL BAD DEBT EXPENSE. THIS IS BASED ON THE PERCENT OF THE POPULATION IN CUMBERLAND COUNTY IN 2010 THAT IS LIVING IN POVERTY (SOURCE HTTP://WWW.ERS.USDA.GOV/DATA-PRODUCTS/COUNTY-LEVEL-DATA-SETS/POVERTY.ASPX). SINCE THE MEDICAL CENTER PROVIDES FINANCIAL ASSISTANCE TO THOSE WHO EXCEED THE FEDERAL POVERTY LEVEL BY 150 - 200%, THIS PERCENT IS A CONSERVATIVE ESTIMATE. PART III, LINE 8: CUMBERLAND MEDICAL CENTER IS AN ACUTE CARE MEDICAL/SURGICAL FACILITY WHICH SERVES A LARGE TENNCARE AND MEDICARE POPULATION. WITH THIS DEMOGRAPHIC COMES THE REALIZATION OF LOW REIMBURSEMENT, BAD DEBT, AND MEDICARE SHORTFALLS. IN OUR AREA OF THE COUNTRY AND ESPECIALLY OUR AREA OF THE STATE, IT IS PART OF PROVIDING HEALTHCARE TO OUR PATIENTS. WE CONSIDER A LARGE PART OF WHAT WE "WRITE-OFF" EACH YEAR AND THE MONEY THAT WE WILL NEVER SEE AS INCOME TO OUR BOTTOM LINE AS A BENEFIT THAT WE GIVE BACK TO OUR COMMUNNITY. IT IS A SERVICE THAT WE ARE PROVIDING TO THOSE WHO CANNOT PROVIDE FOR THEMSELVES. OUR MISSION STATES THAT WE WILL MAKE AVAILABLE QUALITY HEALTH CARE ON A REGIONAL LEVEL TO THOSE IN NEED OF ITS SERVICES THROUGH DEDICATION, PROFESSIONALISM, AND FINANCIAL STABILITY. WHILE IT IS OUR FIDUCIARY RESPONSIBILITY TO MANAGE OUR FACILITY, IT IS OUR FIRST CONCERN TO CARE FOR THE PATIENT'S HEALTH AND WELL BEING. THE DIFFERENCE BETWEEN THOSE IN A COMMUNITY LIKE OURS WHEN ABSORBED BY THE HOSPITAL IS MOST DEFINATELY BENEFITTING THE COMMUNITY. X X X 0 0 0 1 0 1 0 0 0 REYNALDO OLAECHEA 175011 0 0 0 0 0 13276 0 1823 0 190110 0 0 0 BARRY S WAGNER MD 241412 0 0 0 0 0 0 0 1271 0 242683 0 0 0 LARRY MOORE 223932 0 0 0 0 0 17833 0 2329 0 244094 0 0 0 ALEXANDER C PIERCE 324491 0 0 0 0 0 31534 0 2612 0 358637 0 0 0 SIVALINGAM KANAGASEGAR MD 289255 0 0 0 0 0 19810 0 2316 0 311381 0 0 0 ROHITASH MEHTA 284720 0 0 0 0 0 0 0 0 0 284720 0 0 0 ROBIN BRAD BAUER 280832 0 0 0 0 0 0 0 2167 0 282999 0 0 0 WESLEY CHAD HALFORD 282105 0 0 0 0 0 21468 0 5121 0 308694 0 0 0 PART I, LINE 5 COMPENSATION CONTINGENT UPON REVENUES OF ORGANIZATION: LISTED EMPLOYED PHYSICIANS RECEIVE AN INCENTIVE BONUS EQUAL TO A PERCENTAGE OF CASH COLLECTIONS FROM THEIR OWN PRACTICE GREATER THAN THE PHYSICIAN'S ANNUAL SALARY. PART I, LINE 6 PAID COMPENSATION CONTINGENT ON THE NET EARNINGS OF THE ORGANIZATION: THE PRESIDENT/CEO AND OTHER OFFICERS RECEIVE AN INCENTIVE BONUS BASED ON VARIOUS CRITERIA, INCLUDING A COMPARISON OF ACTUAL NET EARNINGS TO BUDGETED NET EARNINGS. HEALTH & ED FAC BD OF THE CITY OF CROSSVILLE TN REV REFUND BONDS SER 2012 581799575 2012-05-01 40017750 PAYOFF PREVIOUSLY ISSUED BONDS 0 0 0 39967221 40017750 50529 2012 1 0 1 1 0 0 0 0 1 0 1 1 REGIONS BANK 5.000000000000 1 0 0 0 1 FORM 990, PART VI, SECTION B, LINE 11 MANAGEMENT AND THE BOARD OF DIRECTORS WILL REVIEW THE 990 BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C CUMBERLAND MEDICAL CENTER'S CONFLICT OF INTEREST STATEMENT IS DISCUSSED AND REVIEWED WITH POTENTIAL APPLICANTS FOR EMPLOYMENT DURING THE INTERVIEW PROCESS, WITH NEW EMPLOYEES DURING A NEW EMPLOYEE ORIENTATION AS WELL AS DURING DEPARTMENTAL ORIENTATION AND ANNUALLY FOR ALL EMPLOYEES DURING EACH EMPLOYEE'S ANNUAL PERFORMANCE REVIEW. IF NO CONFLICT OF INTEREST IS IDENTIFIED, IT IS NOTED ON THE CONFLICT OF INTEREST STATEMENT, SIGNED BY THE EMPLOYEE, AND PLACED IN THE EMPLOYEE'S FILE. IF A CONFLICT OF INTEREST IS IDENTIFIED, AFTER DISCUSSION AND REVIEW BY A CORPORATE OFFICER AND/OR OTHER ADDITIONAL INPUT AS NECESSARY, APPROPRIATE ACTION IS TAKEN UP TO AND INCLUDING TERMINATION OF EMPLOYMENT WITH CUMBERLAND MEDICAL CENTER OR THE OTHER EMPLOYER THAT IS CAUSING THE CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE CEO REVIEW COMMITTEE AND THE EXECUTIVE COMPENSATION COMMITTEE REVIEW THE PERFORMANCE AND SALARY OF THE CEO ANNUALLY. THE COMMITTEES ARE APPOINTED ANNUALLY BY THE CHAIRMAN OF THE BOARD OF DIRECTORS. TENNESSEE HOSPITAL ASSOCIATION SALARY SURVEY INFORMATION IS PROVIDED FOR REVIEW. DUE TO BUDGET CONSTRAINTS, NO WAGE INCREASE WAS PROVIDED DURING THE YEAR. THE PRESIDENT/CEO REVIEWS THE PERFORMANCE AND SALARY OF THE OFFICERS. TENNESSEE HOSPITAL ASSOCIATION SALARY SURVEY INFORMATION IS PROVIDED FOR REVIEW. DUE TO BUDGET CONSTRAINTS, NO WAGE INCREASES FOR OFFICERS WERE PROVIDED DURING THE YEAR. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -432,155. THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWS THE AUDITED FINANCIAL STATEMENTS ON AN ANNUAL BASIS. CST COMMUNITY HEALTH LLC 421 S MAIN ST CROSSVILLE TN 38555 621730751 HEALTHCARE TN N/A RELATED 88399 529917 0 1 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 CST COMMUNITY HEALTH LLC R 80000 CASH EXCHANGED