2013-11-14T12:52:17-06:00 2013-06-30 020476956 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2012-07-01 020226774 SPEARE MEMORIAL HOSPITAL SPEA 6032382231 16 HOSPITAL ROAD PLYMOUTH NH 03264 MICHELLE MCEWEN 6035361120 2013-11-12 1 W JAY SIMMS P00435321 6036530044 2013-11-12 2012 2016-02-24 21:20:13Z MICHELLE MCEWEN 16 HOSPITAL ROAD PLYMOUTH NH 03264 61722054 0 X SPEAREHOSPITAL.COM X 1899 NH TO PROVIDE INPATIENT, OUTPATIENT AND PHYSICIAN HEALTH CARE SERVICES 15 12 454 75 0 0 250331 870980 55734614 57976992 471707 754004 311738 263714 56768390 59865690 328000 228000 0 0 21926043 22543915 0 0 121820 31231672 30003704 53485715 52775619 3282675 7090071 65430916 75507185 27993419 31554594 37437497 43952591 X TO MAINTAIN A HOSPITAL AND OTHER SUCH INSTITUTIONS WITHIN THE STATE OF NEW HAMPSHIRE, WITH FACILITIES THAT INCLUDE MEDICAL SERVICES TO PROVIDE FOR THE DIAGNOSIS AND TREATMENT OF PATIENTS THAT MAY REQUIRE INPATIENT, OUTPATIENT, EMERGENCY CARE AND OTHER PURSUITS DESIGNED TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. SMH DOES NOT DISCRIMINATE RELATIVE TO RACE, RELIGION OR NATIONAL ORIGIN, ABILITY TO PAY AND WILL ASSURE THAT ALL PATIENTS RECEIVE THE SAME LEVEL OF CARE THROUGH QUALITY ASSESSMENT MONITORING AND IMPROVEMENT ACTIVITIES. 0 0 47608254 228000 57976992 SMH IS A 25-BED ACUTE-CARE HOSPITAL THAT PROVIDES INPATIENT AND OUTPATIENT SERVICES TO THE SURROUNDING COMMUNITY. 47608254 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 51 0 1 454 1 0 0 0 0 0 1 1 0 0 0 0 X 15 12 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 NH X X FINANCE DIRECTOR 6032382160 SMH 16 HOSPITAL ROAD PLYMOUTH NH 03264 MICHELLE MCEWEN 40.00 X X 283302 0 48128 CLINT HUTCHINS 1.00 X X 0 0 0 STANLEY LEE FREEMAN 1.00 X X 0 0 0 ELDWIN WIXSON 1.00 X 0 0 0 NANCY PUGLISI 1.00 X X 0 0 0 STEVE TAKSAR 1.00 X X 0 0 0 QUENTIN BLAINE 1.00 X 0 0 0 SAM BRICKLEY II 1.00 X 0 0 0 WILLIAM LARSEN 1.00 X X 0 0 0 ALISON RITZ 1.00 X 0 0 0 JILL DUNCAN 1.00 X 0 0 0 MARILYN SANDERSON 1.00 X 0 0 0 LINDA CRAWFORD MD 1.00 X 0 0 0 DANA MERRITHEW MD 1.00 X 0 0 0 ROBERT MALONEY 1.00 X 0 0 0 RICHARD F WERKOWSKI 40.00 X 149571 0 23751 MICHAEL P GIOVAN MD 40.00 X 407883 0 67128 JOSEPH CASEY MD 40.00 X 363118 0 56248 VICTOR GENNARO MD 40.00 X 408483 0 65446 STEVE F DANOSI MD 40.00 X 452390 0 72332 TIMOTHY R LYONS MD 40.00 X 317196 0 35488 2381943 0 368521 7 0 1 0 0 300 739949 130731 870980 NET PATIENT REVENUE 624100 57093338 57093338 OTHER OPERATING REVENU 900099 883654 883654 57976992 551969 551969 48706 45000 3706 3706 3706 1984781 4676 1303846 483576 680935 -478900 202035 202035 47861 300 23942 23919 23919 CAFETERIA INCOME 722210 136348 136348 PHARMACY INCOME 446110 99741 99741 236089 59865690 57976992 0 1017718 228000 228000 495400 495400 16555341 14125662 2379370 50309 1345291 1145316 195896 4079 2789500 2343308 437846 8346 1358383 1129401 224960 4022 25271 25271 83114 83114 88536 88536 98531 98531 4635454 4564595 17283 53576 1254436 1188369 66067 113371 94254 17820 1297 900 900 690325 690325 2942504 2942504 BAD DEBT 6663107 6663107 PURCHASED SERVICES 5090309 4906742 183567 PHYSICIAN FEES & WAGES 4697461 4697461 COST OF DRUGS 2174087 2174087 1446298 615692 830415 191 52775619 47608254 5045545 121820 7777432 12652016 4454001 1470060 7260625 7717508 2440850 2534011 758600 864005 453318 455790 47212795 22794862 24988466 24417933 13678453 16406439 1609825 6603676 1014765 999011 994581 1386736 65430916 75507185 2655504 2176809 16098028 20979190 659554 230652 8580333 8167943 27993419 31554594 X 36885858 43101817 285507 288948 266132 561826 37437497 43952591 65430916 75507185 X 7090071 1064476 284898 -1924350 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11723 11723 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: SPEARE MEMORIAL HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF SPEARE MEMORIAL HOSPITAL AND THE OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSE. SPEARE MEMORIAL HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITES. 270198 6 270204 271045 7 -854 270198 248354 25000 5 2314 271045 223344 25000 10 248354 137808 40000 45536 223344 0.98500 0.01500 1 0 646258 646258 28420933 11305880 17115053 922885 495366 427519 16972996 10993616 5979380 249723 249723 24417933 BOND FUNDS 6603676 F 6603676 OTHER CURRENT LIABILITIES 2464766 EST. THIRD-PARTY PAYER SETTLEMENTS 4230015 INVESTMENT IN SUB-BOULDER 1473162 8167943 52015377 1064476 -8636461 -7571985 59587362 88536 189792 278328 59865690 45795977 0 45795977 88536 6891107 6979643 52775620 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUND IS USED TO SUPPORT OPERATIONS OF THE HOSPITAL. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -6,663,107. LOSS ON EARLY EXTINGUISHMENT OF BOND -1,973,354. PART XI, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE 228,000. BAD DEBT EXPENSE ON MSHC RECEIVABLE 6,792. RENTAL EXPENSES -45,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE 228,000. BAD DEBT EXPENSE 6,663,107. GOLF TOURNAMENT 48161 300 47861 25 9104 4902 9911 48161 300 47861 25 9104 4902 9911 23942 23919 1 1 1 X 125.000000000000 1 X 225.000000000000 1 1 0 1 1 1781754 1091185 690569 0.01310 4526829 5757105 -1230276 0.00000 6308583 6848290 -539707 0.01310 202099 202099 0.00380 11500 11500 0.00020 334729 334729 0.00630 272485 272485 0.00520 820813 820813 0.01550 7129396 6848290 281106 0.02860 1 2992673 95766 16846659 17093670 -247011 X 1 1 1 PLYMOUTH REGIONAL REHABILITATION SERVICES PHYSICAL THERAPY, OCCUPATIONAL THERAPY & MEDICAL FITNESS 0.50000 1 1 SPEARE MEMORIAL HOSPITAL

16 HOSPITAL ROAD PLYMOUTH NH 03264

X X X X Y 1 1 X X X X X X X X X X 11 1 0 1 X X X X X X X X X X 1 0 1 1 1 100.000000000000 1 X X X X X X X 1 1 X X X X 1 X 1 X X X X 1 X 0 0 PART III, LINE 4: SMH HAS NO APPROPRIATE FOOTNOTE IN THE APPLICABLE AUDITED FINANCIAL STATEMENT. SMH HAS USED A RATIO OF COSTS TO CHARGES OF 48% IN DETERMINING THE COST OF BAD DEBT EXPENSE. PART III, LINE 8: 100% OF THE SHORTFALL FROM MEDICARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT. THE SOURCE USED TO DETERMINE THIS AMOUNT IS THE MEDICARE CHARGES LESS THE MEDICARE PAYMENTS MADE TO SPEARE MEMORIAL HOSPITAL. SERVICES THAT INCUR SUCH COSTS ARE PROVIDED BY THE HOSPITAL TO PROMOTE THE WELL-BEING OF THE COMMUNITY. THE SERVICES ARE RENDERED IN CONJUNCTION WITH THE HOSPITAL'S CHARITABLE TAX EXEMPT PURPOSE. TREATING THE SHORTFALL AS A COMMUNITY BENEFIT RELIEVES THE BURDEN ON LOCAL SOCIAL SERVICES AND GOVERNMENT SUPPORTED PROGRAMS. PART III, LINE 9B: SPEARE MEMORIAL HOSPITAL HAS BOTH A COLLECTIONS POLICY, AND A CHARITY CARE POLICY THAT DESCRIBES CHARITY ELIGIBILITY AND THE STEPS TO BE COMPLETED BEFORE A PATIENT'S ACCOUNT IS WRITTEN OFF TO BAD DEBT. Y PART V, SECTION B, LINE 1J: SPEARE MEMORIAL HOSPITAL CONDUCTED A COMMUNITY WIDE PUBLIC PRESENTATION OF THE NEEDS ASSESSMENT REPORT IN OCTOBER 2011. PART VI, LINE 2: INFORMATION GATHERING THROUGH SURVEYS, FOCUS GROUPS, COMMUNITY REPRESENTATION, PUBLIC FORUMS, INPUT FROM HEALTH CARE PROVIDERS, INDUSTRY LEADERS, OUTSIDE CONSULTANTS,AND ANALYSIS OF INTERNAL DATA AND EXTERNAL DATA PROVIDED BY HOSPITAL ASSOCIATIONS, PAYERS, ETC. PART VI, LINE 3: PATIENTS ARE EDUCATED AT TIME OF REGISTRATION OR THROUGH EDUCATIONAL MATERIALS THAT ARE DISTRIBUTED THROUGH THE HOSPITAL'S WEBSITE OR BY COMMUNITY OUTREACH. SPEARE MEMORIAL HOSPITAL IS A MEMBER OF A STATE-WID COMMUNITY HEALTH NETWORK THAT PROVIDES ASSISTANCE, SUPPORT,AND EDUCATION RELATING TO ELIGIBILITY ASSISTANCE. PART VI, LINE 4: SPEARE MEMORIAL HOSPITAL IS LOCATED IN THE MOUNTAIN AND LAKES REGION OF NEW HAMPSHIRE AND PRIMARLY SERVES CONSTITUENTS IN GRAFTON COUNTY. GRAFTON COUNTY POPULATION SIZE IS APPROXIMATELY 86,000 WITHIN ITS 40 DISTINCT MUNICIPALITIES. ITS SERVICE AREA INCLUDES 17 TOWNS WITH AN APPROXIMATE TOTAL POPULATION OF 30,000. PART VI, LINE 5: SPEARE MEMORIAL HOSPITAL PROVIDES PRESCRIPTION MEDICATION ASSISTANCE, PRIMARY-CARE CLINCS, MULTIPLE SUPPORT GROUPS, COMMUNITY EDUCATION PROGRAMS, SCHOOL DENTAL PROGRAM, ETC. AND HAS AFFLIATIONS AND PARTNERSHIPS WITH MANY COMMUNITY ORGANIZATIONS; AN OPEN MEDICAL STAFF AND COMMUNITY BOARD. OPERATING FUNDS ARE USED FOR ONGOING CAPITAL EXPENDITURES. REPORTS FILED WITH STATES PART VI, LINE 7 NH 1 MID-STATE HEALTH CENTER 101 BOULDER POINT DRIVE NO 1 PLYMOUTH NH 03264 020487172 501 (C)(3) 228000 FMV COMMUNITY BENEFIT GRANT 1 X X X X X 0 0 0 0 0 0 0 0 0 MICHELLE MCEWEN 283302 0 0 0 0 0 29754 0 18374 0 331430 0 0 0 RICHARD F WERKOWSKI 149571 0 0 0 0 0 19340 0 4411 0 173322 0 0 0 MICHAEL P GIOVAN MD 407883 0 0 0 0 0 49748 0 17380 0 475011 0 0 0 JOSEPH CASEY MD 363118 0 0 0 0 0 38868 0 17380 0 419366 0 0 0 VICTOR GENNARO MD 408483 0 0 0 0 0 49556 0 15890 0 473929 0 0 0 STEVE F DANOSI MD 452390 0 0 0 0 0 57144 0 15188 0 524722 0 0 0 TIMOTHY R LYONS MD 317196 0 0 0 0 0 18368 0 17120 0 352684 0 0 0 A NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY 020279866 2012-12-07 21100000 TO PAY OFF AND PROVIDE ADVANCED REFUNDING FOR 2010 AND 2004 BONDS 0 0 0 A 16323208 21100000 12612773 209815 4566977 1 1 0 1 A 0 0 0 0 0 0 0 A 1 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 THE COMMUNITY RELATIONS DIRECTOR IS THE SPOUSE OF A BOARD MEMBER. FORM 990, PART VI, SECTION A, LINE 3 THE REHABILITATION DEPARTMENT IS NOW MANAGED BY ORTHOPEDIC HEALTH SERVICES. INC. FORM 990, PART VI, SECTION A, LINE 6 THE PROVISIONS OF SMH GOVERNING DOCUMENTS PROVIDE THE BOARD OF DIRECTORS AND IS COMPRISED OF ASSOCIATION MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE ASSOCIATION MEMBERS ELECT THE BOARD MEMBERS FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE HOSPITAL CFO AND THE PRESIDENT/CEO AND THE FINANCE COMMITTEE. THE TAX FORM 990 IS MADE AVAILABLE FOR REVIEW TO THE BOARD OF DIRECTORS. THE FORM 990 IS THEN SIGNED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL COMPLIANCE FORM COMPLETED BY EACH MEMBER OF THE BOARD FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION FOR THE CEO IS DETERMINED VIA A COMPENSATION COMMITTEE, COMPENSATION SURVEY OR STUDY, COMPARISON OF OTHER ORGANIZATIONS 990 INFORMATION, BOARD APPROVAL AND WRITTEN EMPLOYMENT CONTACT. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: BAD DEBT EXPENSE ON MSHC RECEIVABLE -6,792. RENTAL EXPENSE 55,796. LOSS ON EARLY EXTINGUISHMENT OF BOND -1,973,354. SPEARE MEMORIAL AT BOULDER POINT BOULDER POINT DR PLYMOUTH NH 03264 263888977 REAL ESTATE NH 501(C)(3) LINE 9 SPEARE MEMORIAL HOSPITAL 0 SPEARE HEALTH VENTURE 16 HOSPITAL ROAD PLYMOUTH NH 03264 020366565 HEALTHCARE SERVICES NH C 5160 239746 1.00000 0 SPEARE HEALTH NETWORK LLC 16 HOSPITAL ROAD PLYMOUTH NH 03264 043372339 PHYSICIAN/HOSPITAL ORGANIZATION NH C 57 21145 0.50000 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 SPEARE MEMORIAL AT BOULDER POINT-LEASES ALL OF ITS SPACE TO SMH K 502582 ACTUAL SPEARE HEALTH VENTURE D 244355 FAIR MARKET VALUE SPEARE MEMORIAL AT BOULDER POINT D 2040520 FAIR MARKET VALUE SPEARE MEMORIAL AT BOULDER POINT Q 8266 ACTUAL