2013-05-14T12:11:10-05:00 2012-09-30 410746749 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2011-10-01 430662495 HANNIBAL REGIONAL HOSPITAL HANN 5732481300 6000 HOSPITAL DRIVE PO BOX 551 HANNIBAL MO 63401 ROGER DIX 5732481300 2013-05-14 1 JEFF PARKER P00970069 3149254300 2011 2016-02-25 16:41:14Z C TODD AHRENS 6000 HOSPITAL DRIVE PO BOX 551 HANNIBAL MO 63401 123794546 0 X WWW.HRHONLINE.ORG X 1987 MO HOSPITAL OPERATES A FULL SERVICE ACUTE CARE FACILITY 8 7 1079 250 0 0 608133 543122 108459190 119603490 432915 969819 2583243 2368056 112083481 123484487 30792 86652 0 0 64975831 67282982 0 0 363428 45445301 48810102 110451924 116179736 1631557 7304751 121818390 131068696 54767600 55335893 67050790 75732803 YOUR HEALTH IS OUR MISSION 0 0 98354113 121056662 THE SYSTEM OPERATES A FULL SERVICE 91 BED ACUTE CARE HOSPITAL FACILITY IN HANNIBAL, MISSOURI AS ITS PRIMARY SERVICE ACTIVITY. 17,830 TOTAL INPATIENT DAYS WERE PROVIDED DURING THE COURSE OF THE YEAR. THE HOSPITAL PROVIDES SERVICES TO PATIENTS THAT MEET THE HOSPITAL'S CHARITY CARE POLICY AS WELL AS SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. THE TOTAL COST OF UNCOMPENSATED CARE WAS, CHARITY CARE - $3,191,272 AND STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS - $631,455. 98354113 1 1 0 1 0 1 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 112 0 1 1079 1 0 0 0 0 0 0 0 0 0 0 X 8 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X ROGER DIX 5732481300 6000 HOSPITAL DRIVE HANNIBAL MO 63401 JACK WHITAKER 1.00 X X 0 0 0 ROBERT GILSTRAP 1.00 X X 1370 0 0 JERRY TROWER 1.00 X X 1159 0 0 TIMOTHY A REUSCHEL 1.00 X X 0 0 0 TOM LENNON 1.00 X X 737 0 0 PAUL EWERT 1.00 X X 0 0 0 CAROLYN SHAW 1.00 X 0 0 0 GENE SCHOLES JR 1.00 X 0 0 0 JENNIFER VALUCK MD 1.00 X 0 0 0 ROBERT M CHRISCINSKE 1.00 X X 0 0 0 GORDON SPILKER 1.00 X X 0 0 0 JIM HUMPHREYS 1.00 X X 0 0 0 PRANAV PARIKH MD 1.00 X X 0 0 0 JEFFRY EVANS MD 1.00 X 0 0 0 PAT BENSON 1.00 X 0 0 0 JILL JANES MD 1.00 X 0 0 0 DARREN SMITH 1.00 X 0 0 0 TOM WOOTEN 1.00 X 0 0 0 SANDRA AHLUM MD 1.00 X 0 0 0 RALPH EAGAN 1.00 X 0 0 0 RANDY PARK 1.00 X 0 0 0 JOHN GROSSMEIER 40.00 X 545817 0 88518 ROGER DIX 40.00 X 302221 0 46946 C TODD AHRENS 40.00 X 238360 0 49712 DAVID HEVEL 40.00 X 151866 0 25720 JULIE LEVERENZ 40.00 X 160264 0 35667 SHARON NUNLEY 40.00 X 181715 0 38036 SARAH BRADSHAW 40.00 X 184206 0 30721 G DOUG RUBLE 40.00 X 157789 0 24823 JEFF EVANS 40.00 X 160960 0 29432 SUZANNE KOEHLER 40.00 X 172712 0 32885 LYNN OLSON 40.00 X 18830 0 0 DEAN AKERSON 40.00 X 309125 0 671 RICHARD DRAPER 40.00 X 729072 0 48048 MARK SHIMA 40.00 X 754076 0 5181 RICHARD VALUCK 40.00 X 545239 0 7761 LUVELL GLANTON 40.00 X 576609 0 2305 PERVEZ ALVI 40.00 X 552720 0 2280 ANNE DELONAIS-TURNER 40.00 X 418708 0 2996 MARK BELCHER 40.00 X 443241 0 6484 6606796 0 478186 67 1 1 0 MISSOURI HOSPITAL PLAN 4700 COUNTRY CLUB DRIVE JEFFERSON CITY MO 65102 INSURANCE PROVIDER 1201217 BANC OF AMERICA LEASING & CAPITAL 2059 NORTHLAKE PARKWAY TUCKER GA 30384 LEASING COMPANY 1187031 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 LOCUM PHYSICIANS 1019287 EMERCON EMERGENCY MEDICAL 8021 CORNELL AVE ST LOUIS MO 63130 LOCUM PHYSICIANS 445800 FMH CORESOURCE PO BOX 25946 OVERLAND PARK KS 66225 INSURANCE PROVIDER 402668 25 543122 543122 NET PATIENT SERVICE RE 621110 119603490 119603490 119603490 956219 956219 283075 30282 252793 252793 252793 274795 18582 278757 1020 -3962 17562 13600 17562 -3962 CHILDREN'S DEVELOPMENT 624410 760447 760447 CAFETERIA 722210 572443 572443 CONTRACTED SERVICES 621110 511685 511685 270688 163478 107210 2115263 123484487 121056662 0 1884703 86652 86652 2583865 384638 1965098 234129 48260957 39730569 8490341 40047 3442218 2820847 602809 18562 9734623 7957819 1721825 54979 3261319 2672536 571116 17667 139313 139313 119641 119641 12425 10193 2232 244615 244615 11313742 9281159 2032583 1504571 1234266 270305 661517 542671 118846 106628 87472 19156 1310350 1074938 235412 7408060 7408060 788919 647185 141734 BAD DEBT EXPENSE 9229171 9229171 HEALTHCARE PURCHASED SE 4357184 4357184 EQUIPMENT RENTAL 2874985 2358476 516509 PHARMACY DRUGS 2594506 2594506 6144475 5631156 515275 -1956 116179736 98354113 17462195 363428 7660293 15259185 15073541 15290528 98750 42500 1450730 1208898 2403874 2302730 586866 538825 129729709 74304661 57788916 55425048 30337121 34312519 300000 0 6118299 6688463 121818390 131068696 11516738 14249860 25026012 23036676 8951150 7369297 9273700 10680060 54767600 55335893 X 63854864 72252697 3195926 3480106 67050790 75732803 121818390 131068696 X 7304751 1377262 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 12425 0 0 0 12425 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING ACTIVITY PROVIDED THROUGH MEMBERSHIP IN THE MISSOURI HOSPITAL ASSOCIATION 1 2804 0 38860 0 0 2693370 2693370 68263932 35351666 32912266 51700166 38952995 12747171 7072241 7072241 55425048 BOND ISSUE COST 253539 RECEIVABLE FROM HANNIBAL REGIONAL HOSPITAL FOUNDATION 3441246 INVESTMENT IN JOINT VENTURES 314268 SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN 2679410 6688463 MINIMUM PENSION LIABILITY 8000650 SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN LIABILITY 2679410 10680060 123484487 116179736 7304751 3214499 -1837237 1377262 8682013 124577569 3214499 -2121417 1093082 123484487 0 123484487 116179736 0 116179736 0 116179736 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501 OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE HOSPITAL APPLIES THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS IN ACCORDANCE WITH THE INCOME TAX STANDARD. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE HOSPITAL'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE HOSPITAL IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE HOSPITAL IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. THE TAX RETURNS FOR THE FISCAL YEARS 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN MINIMUM PENSION LIABILITY -2,121,417. PEARL LOWRIE FUND NET ACTIVITY 2,804. TEMP. RESTRICTED NET ASSETS RELEASED FOR CAPITAL EXPENDITURES -543,122. NET CONTRIBUTION REVENUE FROM FOUNDATION 824,498. TOTAL TO SCHEDULE D, PART XI, LINE 8: -1,837,237. PART XII, LINE 2D - OTHER ADJUSTMENTS: MINIMUM PENSION LIABILITY EXPENSE -2,121,417. 1 1 1 X 0 1 1 1 0 1 1 8963280 6958470 2004810 0.01730 9749807 6958471 2791336 0.02400 18713087 13916941 4796146 0.04130 1259716 290537 969179 0.00830 327783 327783 0.00280 12474402 4328522 8145880 0.07010 21209 21209 0.00020 14083110 4619059 9464051 0.08140 32796197 18536000 14260197 0.12270 2384720 940316 1444404 0.01240 391578 391578 0.00340 2776298 940316 1835982 0.01580 1 9229171 5537503 32587604 35847007 -3259403 X 1 1 1 HANNIBAL MEDICAL SUPPLY DME COMPANY 0.33000 0.33000 2 HANNIBAL MOBILE DIAGNOSTICS MOBILE IMAGING/RADIOLOGY SERVICES 0.50000 0.50000 1 1 HANNIBAL REGIONAL HOSPITAL

6000 HOSPITAL DRIVE HANNIBAL MO 63401

X X X HANNIBAL REGIONAL HOSPITAL 1 1 X X X X X X X X X 1 0 0 X X 1 1 1 200.000000000000 0 1 X X 1 1 X 1 0 1 X 0 0 PART I, LINE 3C: THE CRITERIA UTILIZED TO DETERMINE ELIGIBILITY FOR CHARITY CARE IS BASED ON THE ABILITY TO PAY. A PERSON IS ELIGIBLE FOR CHARITY CARE IF THEY MEET ANY OF THE FOLLOWING CRITERIA; THEIR INSURANCE IS INADEQUATE, THEY ARE UNINSURED, PATIENTS WITH A FAMILY INCOME AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINE, PATIENTS WITH A SPENDABLE INCOME THAT IS LESS THAN 5% OF THE BALANCE OWED TO THE HOSPITAL, THERE IS LESS THAN $2,000 IN TOTAL ASSETS AVAILABLE TO PAY HOSPITAL EXPENSES (EXCEPTIONS HOME EQUITY, AUTO EQUITY, LIFE INSURANCE EQUITY). PART I, LINE 6A: PART I, LINE 6A: THE MISSOURI HOSPITAL ASSOCIATION HAS INCLUDED HANNIBAL REGIONAL HOSPITAL IN THEIR ANNUAL COMMUNITY BENEFIT REPORT. PART III, LINE 4: THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HOSPITAL BILLS THIRD-PARTY PAYORS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. AT SEPTEMBER 30, 2012 AND 2011, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS WAS APPROXIMATELY $5,444,000 AND $4,022,000, RESPECTIVELY. PART III, LINE 8: THE HOSPITAL'S COST ACCOUNTING SYSTEM IS UTILIZED IN DETERMINING THE ORGANIZATRIONS COMMUNITY BENEFIT. PART III, LINE 9B: WHEN CHARITY CONSIDERATION IS REQUESTED ALL COLLECTION EFFORTS ARE HALTED UNTIL A DETERMINATION ON ELIGIBILITY IS MADE. COLLECTION EFFORTS ARE RESUMED ONLY IF THE INDIVIDUAL DOES NOT MEET ONE OF THE CHARITY CRITERIA. HANNIBAL REGIONAL HOSPITAL PART V, SECTION B, LINE 19D: ELIGIBILITY FOR CHARITY CARE IS BASED ON THE INDIVIDUALS ABILITY TO PAY. A PERSON IS ELIGIBLE FOR CHARITY CARE IF THEY MEET ANY OF THE FOLLOWING CRITERIA: THEY ARE UNINSURED, THEY HAVE INADEQUATE INSURANCE, INCOME LESS THAN 200% OF THE FEDERAL POVERTY GUIDELINES, SPENDABLE INCOME LESS THAN 5% OF THE BALANCE OWED OR LESS THAN $2,000 IN ASSETS AVAILABLE TO PAY HEALTHCARE EXPENSES. PART VI, LINE 2: THE ORGANIZATION RECEIVES ANNUAL UPDATES ON THE HEALTH STATUS OF ITS POPULATION FROM THE STATE THAT INCLUDE MORTALITY AND DISEASE STATUS. THE ORGANIZATION ALSO MONITORS NATIONAL DATA ON TRENDS AND DISEASE STATUS. PART VI, LINE 3: THE ORGANIZATION MAINTAINS EDUCATIONAL PROGRAMS TO KEEP STAFF APPRISED OF ALL POTENTIAL PROGRAMS THAT MIGHT ASSIST PATIENTS IN PAYING THEIR HOSPITAL CLAIM. STAFF MEMBERS ARE ENCOURAGED TO UTILIZE THIS KNOWLEDGE TO RECONCILE ALL OUTSTANDING BALANCES. PART VI, LINE 4: HANNIBAL, MARION COUNTY ARE RURAL COMMUNITES OF APPROXIMATELY 30,000 POPULATION. ALSO SERVED ARE SEVEN OTHER RURAL COUNTIES IN NORTHEAST MISSOURI. PART VI, LINE 5: SEE STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS ON FORM 990, PART III, LINE 4A. 1 AMERICAN CANCER SOCIETY 3145 HIGHWAY 61 HANNIBAL MO 63401 131788491 501(C)(3) 8214 2012 HOPE CONTRIBUTION AND THE 2012 PINK RIBBON GOLF TOURNAMENT MHA CENTER FOR EDUCATION PO BOX 60 JEFFERSON CITY MO 65102 430898947 501(C)(3) 78438 MCE HEALTH IMPR., RESEARCH AND SCHOLARSHIP FUND, MHA SPECIAL PROJECTS, MISSOURI CENTER FOR PATIENTS SAFETY CONTRIBUTION, MISSOURI POISON CENTER CONTRIBUTION. 2 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: POLICY GA 1-112 CORPORATE CITIZENSHIP GUIDES THE ORGANIZATION IN CONTRIBUTING TO OTHER ORGANIZATIONS. ALL ACTIVITIES WHICH CONSTITUTE A CHARITABLE CONTRIBUTION ARE DOCUMENTED ON THE CHARITABLE CONTRIBUTION FORM. X 1 1 X X X X 0 1 0 0 0 1 0 0 0 JOHN GROSSMEIER 432265 0 29882 0 83670 0 83670 0 4848 0 634335 0 0 0 ROGER DIX 234664 0 12803 0 54754 0 46946 0 0 0 349167 0 0 0 C TODD AHRENS 225630 0 12730 0 0 0 45827 0 3885 0 288072 0 0 0 DAVID HEVEL 121657 0 5818 0 24391 0 23720 0 2000 0 177586 0 0 0 JULIE LEVERENZ 146411 0 8111 0 5742 0 30282 0 5385 0 195931 0 0 0 SHARON NUNLEY 160087 0 9111 0 12517 0 32188 0 5848 0 219751 0 0 0 SARAH BRADSHAW 141997 0 6968 0 35241 0 28409 0 2312 0 214927 0 0 0 G DOUG RUBLE 124053 0 6678 0 27058 0 23375 0 1448 0 182612 0 0 0 JEFF EVANS 147399 0 7937 0 5624 0 28047 0 1385 0 190392 0 0 0 SUZANNE KOEHLER 164912 0 7800 0 0 0 31500 0 1385 0 205597 0 0 0 DEAN AKERSON 188486 0 0 0 120639 0 0 0 671 0 309796 0 0 0 RICHARD DRAPER 466779 0 32194 0 230099 0 42200 0 5848 0 777120 0 0 0 MARK SHIMA 750326 0 0 0 3750 0 0 0 5181 0 759257 0 0 0 RICHARD VALUCK 545239 0 0 0 0 0 0 0 7761 0 553000 0 0 0 LUVELL GLANTON 430335 0 136274 0 10000 0 0 0 2305 0 578914 0 0 0 PERVEZ ALVI 543720 0 0 0 9000 0 0 0 2280 0 555000 0 0 0 ANNE DELONAIS-TURNER 415708 0 0 0 3000 0 0 0 2996 0 421704 0 0 0 MARK BELCHER 443241 0 0 0 0 0 0 0 6484 0 449725 0 0 0 PART I, LINE 1A COMPANION TRAVEL EXPENSES : ROBERT GILSTRAP $1,370; JERRY TROWER $1,159; TOM LENNON $737 PART I, LINE 1B ALL EXPENSES WERE APPROVED THROUGH THE NORMAL CHECK REQUEST AND EXPENSE REPORT PROCESS WHICH REQUIRES TWO SIGNATURES. CEO EXPENSES ARE APPROVED BY A BOARD MEMBER AND VALIDATED BY THE CONTROLLER, ALL BOARD MEMBER EXPENSES ARE APPROVED BY THE CEO AND VALIDATED BY THE CONTROLLER, AND ALL OFFICER AND KEY EMPLOYEE EXPENSES ARE APPROVED BY THE CEO AND VALIDATED BY THE CONTROLLER OR ANOTHER OFFICER. PART I, LINE 4B JOHN GROSSMEIER, SERP, $83,670 ROGER DIX, SERP, $54,754 DAVID HEVEL, SERP, $24,391 C. TODD AHRENS, SERP, $0 SHARON NUNLEY, SERP, $12,517 RICHARD DRAPER, SERP, $198,599 JULIE LEVERNZ, SERP, $0 G. DOUG RUBLE, SERP, $22,332 SARAH BRADSHAW, SERP, $28,409 PART I, LINE 6 DR. GLANTON RECEIVES 50% OF ALL PAIN MEDICINE PHYSICIAN SERVICE NET COLLECTIONS GENERATED AS A RESULT OF PROFESSIONAL SERVICES COLLECTED IN EXCESS OF ONE HUNDRED THOUSAND DOLLARS EACH YEAR. TOTAL SALARY PLUS BONUS NOT TO EXCEED THE NINETIETH PERCENTILE OF THE PRIOR YEAR'S RANGE AS REPORTED FOR THE SOUTHERN REGION BY THE MEDICAL GROUP MANAGEMENT ASSOCIATION. THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE CITY OF HANNIBAL MISSOURI 531320446 410632AT0 2006-04-01 24064011 HOSPITAL REFUNDING REVENUE BONDS 0 0 0 THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE CITY OF HANNIBAL MISSOURI 531320446 410632BJ1 2010-07-29 7588694 HOSPITAL REFUNDING OF ER ADDITION BONDS 0 0 0 7314381 24064011 23868280 195731 2022 1 0 1 1 1301648 7588694 7743162 120532 2020 1 0 0 1 0 1 1 1 0 1 0 1 1 1 0 1 1 0 0 1 SOCIETE GENERALE 14.800000000000 1 0 0 0 0 0 0 0 0 X SCHEDULE K, PART II, LINE 14, ISSUANCE A PURPOSE OF 2006 REFUNDING BOND ISSUANCE THE HEALTH FACILITIES REFUNDING REVENUE BONDS SERIES 2006 BOND ISSUANCE WAS ISSUED TO REFUND THE REMAINING OUTSTANDING 1996 REVENUE BONDS. SCHEDULE K, PART II, LINE 14, ISSUANCE B PURPOSE OF 2010 REFUNDING BOND ISSUANCE THE HEALTH FACILITIES REFUNDING REVENUE BONDS SERIES 2010 BOND ISSUANCE WAS ISSUED TO REFUND THE REMAINING OUTSTANDING 2007 REVENUE BONDS. PERVEZ ALVI PHYSICIAN RELOCATION X 60000 30000 0 1 1 ANNE DELONAIS PHYSICIAN RELOCATION X 20000 0 1 1 LUVELL GLANTON PHYSICIAN RELOCATION X 40000 0 1 1 MARK SHIMA PHYSICIAN RELOCATION X 25000 12500 0 1 1 42500 FORM 990, PART VI, SECTION B, LINE 11 THE PREPARED FORM 990 WILL BE FORWARDED TO EACH MEMBER OF THE BOARD OF DIRECTORS, AS WELL AS THE OFFICERS OF THE CORPORATION APPROXIMATELY ONE WEEK PRIOR TO A REGULAR BOARD MEETING AT WHICH THE PREPARED FORM 990 WILL BE ON THE AGENDA. THE CHIEF FINANCIAL OFFICER WILL PRESENT THE PREPARED FORM 990 TO THE BOARD OF DIRECTORS AND ENTERTAIN QUESTIONS FROM DIRECTORS AND OFFICERS. THE CHIEF EXECUTIVE OFFICER AND GENERAL COUNSEL FOR THE CORPORATION WILL ALSO BE PRESENT TO ASSIST WITH QUESTIONS FOR THE DIRECTORS AND OFFICERS. THIS PROCEDURE WILL BE COMPLETED PRIOR TO THE FILING OF THE PREPARED FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A POLICY TITLED BUSINESS ETHICS AND CONFLICT OF INTEREST WHICH REQUIRES THAT ALL DIRECTORS, OFFICERS, AND EMPLOYEES OF THE HOSPITAL ALWAYS ACT IN THE BEST INTEREST OF THE HOSPITAL WITHOUT CONFLICTS OF INTEREST. ANNUALLY EACH MEMBER OF THE BOARD OF DIRECTORS, EACH OFFICER OF THE ORGANIZATION, AND CERTAIN OTHER MANAGERS RECEIVE A COPY OF THE POLICY AND ARE REQUIRED TO COMPLETE A CONFIDENTIALITY AGREEMENT AND A CONFLICT OF INTEREST QUESTIONNAIRE WHEREBY THE INDIVIDUAL ANSWERS QUESTIONS REGARDING FAMILY MEMBERS, SUBSTANTIAL BUSINESS OR INVESTMENT HOLDINGS, AND OTHER TRANSACTIONS OR AFFILIATIONS WITH BUSINESSES OR OTHER ORGANIZATIONS THAT MIGHT AFFECT THEIR RELATIONSHIP WITH THE HOSPITAL. AS PART OF THE CONFLICTS OF INTEREST QUESTIONNAIRE THE INDIVIDUAL IS ASKED TO ACKNOWLEDGE THAT THEY HAVE RECEIVED AND READ A COPY OF THE POLICY, AGREE TO COMPLY WITH THE POLICY, ACKNOWLEDGE THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION, WHICH MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH OUR TAX EXEMPT PURPOSES IN ORDER TO MAINTAIN OUR TAX EXEMPT STATUS, AGREE TO REPORT PROMPTLY TO THE BOARD OF DIRECTORS ANY CHANGES IN THEIR ANSWERS TO THE QUESTIONS OR ANY CHANGE IN CIRCUMSTANCE THAT MIGHT DEVELOP PRIOR TO THE COMPLETION OF THEIR NEXT ANNUAL QUESTIONNAIRE. WITH RESPECT TO DIRECTORS OF THE ORGANIZATION, THEY ALSO ACKNOWLEDGE THAT NONE OF THE CONDITIONS OF THE POLICY WHICH WOULD MAKE THEM INELIGIBLE TO REMAIN ON THE BOARD EXIST AT THE TIME THEY SIGN THE ACKNOWLEDGMENT AND THAT THEY WOULD REPORT ANY CONDITIONS WHICH BECOME APPLICABLE IMMEDIATELY TO THE CHAIRPERSON OF THE BOARD OF DIRECTORS. ON AN ANNUAL BASIS THESE DOCUMENTS ARE SENT BY THE SECRETARY OF THE HOSPITAL TO EACH INTERESTED PERSON AND TO THOSE EMPLOYEES OF THE HOSPITAL THAT THE BOARD DETERMINES. THE DOCUMENT IS COMPLETED BY THE INDIVIDUAL AND RETURNED TO THE SECRETARY OF THE BOARD THROUGH GENERAL COUNSEL, WHO ANNUALLY ANALYZES ANY DISCLOSED CONFLICT OF INTEREST OR ANY OTHER FACT THAT MIGHT MAKE THE INDIVIDUAL NOT INDEPENDENT FOR IRS TAX EXEMPT PURPOSES. THE SECRETARY THEN SUBMITS TO THE BOARD OF DIRECTORS A CONFIDENTIAL REPORT CONCERNING ANY INTEREST OF EMPLOYEES OF THE HOSPITAL DISCLOSED BY SUCH QUESTIONNAIRE, ANY INTEREST OF DIRECTORS AND OFFICERS WHO ARE NOT EMPLOYEES OF THE HOSPITAL, AND WHAT ACTIONS THE PRESIDENT OF THE ORGANIZATION MAY TAKE AS A RESULT OF ANY CONFLICTS DISCLOSED BY SUCH INDIVIDUALS. AN INDIVIDUAL IS INELIGIBLE TO SERVE ON THE BOARD OF DIRECTORS FOR ANY OF THE FOLLOWING REASONS AS TAKEN FROM HANNIBAL REGIONAL HOSPITAL BOARD OF DIRECTORS POLICY B-VII: A. FAILURE TO ADHERE COMPLETELY TO DISCLOSURE REQUIREMENTS; B. THE INDIVIDUAL IS AN OWNER, PARTNER, EMPLOYEE, BOARD MEMBER OR INVESTOR IN A DIRECT COMPETITOR OF THE HOSPITAL, OR ANY ENTITY AFFILIATED WITH THE HOSPITAL. AN OWNERSHIP OR INVESTMENT INTEREST IN A DIRECT COMPETITOR OF THE HOSPITAL, OR ANY ENTITY AFFILIATED WITH THE HOSPITAL, OF FIVE (5) PERCENT OR LESS WILL NOT MAKE INDIVIDUAL INELIGIBLE TO SERVE ON THE BOARD OF DIRECTORS; C. THE INDIVIDUAL IS AN EMPLOYEE OF THE HOSPITAL, OR ANY ENTITY AFFILIATED WITH THE HOSPITAL, OR A FAMILY MEMBER IS A MEMBER OF THE MANAGEMENT TEAM OF THE HOSPITAL, OR ANY ENTITY AFFILIATED WITH THE HOSPITAL; D. THE INDIVIDUAL RECEIVES DIRECT COMPENSATORY BENEFIT FOR ONGOING SERVICES PROVIDED TO THE HOSPITAL, OR ANY ENTITY AFFILIATED WITH THE HOSPITAL (SERVING AS A "DE FACTO EMPLOYEE"); E. THE INDIVIDUAL IS AN OWNER, PARTNER, EMPLOYEE, BOARD MEMBER OR INVESTOR OR OTHER VENDOR WHO RECEIVES A SUBSTANTIAL AMOUNT OF REVENUE FROM THE HOSPITAL, OR ANY ENTITY AFFILIATED WITH THE HOSPITAL - THE GREATER OF $200,000.00 OR 2% OF THE ANNUAL REVENUES OF THAT VENDOR IN THE PRECEDING OR CURRENT YEAR. F. THE INDIVIDUAL IS AN OWNER, PARTNER, EMPLOYEE, BOARD MEMBER OR INVESTOR OF AN ENTITY WHO HAS CONTRACTED WITH HOSPITAL FOR THE EXCLUSIVE PROVISION OF ANY MEDICAL SERVICES WITHIN THE HOSPITAL, OR ITS AFFILIATES. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS HAS DELEGATED TO THE COMPENSATION COMMITTEE, PURSUANT TO A CHARTER ADOPTED BY THE BOARD OF DIRECTORS, THE RESPONSIBILITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS IN ADMINISTERING COMPENSATION PLANS AND IN MAKING DECISIONS ON THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER AND THOSE EXECUTIVES WHO REPORT DIRECTLY TO THE CHIEF EXECUTIVE OFFICER WHO QUALIFY AS "DISQUALIFIED PERSONS" WITHIN THE MEANING OF SECTION 4958 OF THE INTERNAL REVENUE CODE. THE COMMITTEE THEN REPORTS ITS ACTIONS TO THE BOARD OF DIRECTORS. THE COMMITTEE IS COMPOSED SOLEY OF INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE SCOPE OF THE COMMITTEE INCLUDES, BUT IS NOT LIMITED TO, REVIEWING AND APPROVING THE ANNUAL BASE SALARY LEVELS, ANNUAL INCENTIVE OPPORTUNITY LEVELS, EXECUTIVE PERQUISITES, EMPLOYMENT AGREEMENTS, BENEFITS AND SUPPLEMENTAL BENEFITS. FORM 990, PART VI, SECTION C, LINE 19 THE ARTICLES OF INCORPORATION AND AMENDMENTS THERETO ARE AVAILABLE ON THE MISSOURI SECRETARY OF STATE'S WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,214,499. CHANGE IN MINIMUM PENSION LIABILITY -2,121,417. PEARL LOWRIE FUND NET ACTIVITY 2,804. TEMP. RESTRICTED NET ASSETS RELEASED FOR CAPITAL EXPENDITURES -543,122. NET CONTRIBUTION REVENUE FROM FOUNDATION 824,498. TOTAL TO FORM 990, PART XI, LINE 5: 1,377,262. FORM 990, PART XI, LINE 2C THE ORGANIZATION'S POLICY REGARDING OVERSIGHT OF AUDIT IS CONSISTENT WITH THE PRIOR YEAR. FORM 990, PART VI, SECTION A IN ITS CONTINUING EFFORT TO BETTER SERVE THE RESIDENTS OF THE HANNIBAL, MISSOURI REGION, A SEPARATE ENTITY AND BOARD WAS PREVIOUSLY CREATED FOR THE HANNIBAL REGIONAL HEALTHCARE SYSTEM (HRHS) TO PROVIDE THE NECESSARY OVERSIGHT AND TO BEGIN TO FOSTER IDEAS TO EXPAND THE SERVICE OFFERINGS OF NOT ONLY THE HOSPITAL, BUT THE ENTIRE SYSTEM. THE HOSPITAL AND HRHS BOARDS MEET AND VOTE SEPARATELY ON THEIR RESPECTIVE ISSUES AND SEVERAL MEMBERS ARE ON BOTH BOARDS TO PROVIDE CONTINUITY AND TO BETTER SHARE IDEAS. THE HRHS BOARD ELECTS THE MEMBERS OF THE HOSPITAL BOARD. LANAC 6000 HOSPITAL DRIVE HANNIBAL MO 63401 431822503 REAL ESTATE MO 0 0 HANNIBAL REGIONAL HOSPITAL HANNIBAL REGIONAL HOSPITAL FOUNDATION 175 SHINN LANE HANNIBAL MO 63401 431658744 FUNDRAISING MO 501(C)(3) LINE 11A, TYPE 1 0 HANNIBAL MOBILE DIAGNOSTICS PO BOX 1254 HANNIBAL MO 63401 300234397 IMAGING MO N/A RELATED 20874 32368 0 0 0.50000 HANNIBAL REGIONAL PHYSICIAN HOSPITAL ORGANIZATION INC 6500 HOSPITAL DRIVE HANNIBAL MO 64301 431706291 PHYSICIAN HOSPITAL ORGANIZATION MO C -23687 116843 0.50000 0 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 HANNIBAL REGIONAL HOSPITAL FOUNDATION C 543122 COST INCURRED HANNIBAL REGIONAL HOSPITAL FOUNDATION N 303462 COST INCURRED HANNIBAL REGIONAL HOSPITAL FOUNDATION O 162612 COST INCURRED