2013-11-15T11:04:00-06:00 2012-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2012-01-01 150533577 SAMARITAN MEDICAL CENTER SAMA 3157855702 830 WASHINGTON STREET WATERTOWN NY 13601 SEAN MILLS 3157855702 2013-11-12 1 JOSEPH J SCHLEGEL P00301329 3154463600 2012 2016-03-07 17:11:31Z SEAN MILLS 830 WASHINGTON STREET WATERTOWN NY 13601 197592272 0 X WWW.SAMARITANHEALTH.COM X 1881 NY SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 17 15 1897 186 0 0 1599400 2946399 193307441 192654193 50085 156823 1788275 1834857 196745201 197592272 0 0 0 0 98941568 107399088 0 0 287912 77990547 85736379 176932115 193135467 19813086 4456805 198607571 207881444 113262178 119258858 85345393 88622586 X SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 0 0 161577985 194562920 PROVIDE CARE FOR 10,734 INPATIENT DISCHARGES IN ADDITION, SAMARITAN MEDICAL CENTER PROVIDED FOR 108,579 OUTPATIENT VISITS, 52,854 EMERGENCY ROOM VISITS, AND 77,631 FAMILY HEALTH CLINIC VISITS. 161577985 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 1 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 1 111 0 1 1897 1 0 0 0 0 0 0 0 0 0 0 X 17 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X SEAN MILLS 3157796686 104 PADDOCK STREET WATERTOWN NY 13601 DAVID FLINT 1.00 X 278934 0 36098 JACK RUSH 1.00 X 171526 0 27960 ROBERT KIMBALL MD 1.00 X 28700 278211 7433 BRUCE DINES 1.00 X X 245 0 0 JAN TURCOTTE MD 1.00 X 0 27791 0 DANIEL VILLA 1.00 X 0 0 0 THOMAS HANLEY 1.00 X 0 0 0 REV FRED GARRY 1.00 X X 0 0 0 LISA WEBER 1.00 X X 0 0 0 MELANIE PARKER-GEURTSEN 1.00 X 0 0 0 RONALD PERCIACCANTE 1.00 X 0 0 0 MARY PERRINE 1.00 X 0 0 0 CATHERINE BURNS QUENCER 1.00 X 0 0 0 ALFRED CALLIGARIS 1.00 X 0 0 0 PAUL CARR 1.00 X 0 0 0 KATHLEEN GEBO 1.00 X 0 0 0 WENDY GRIMM 1.00 X 0 0 0 COL MARK THOMPSON 1.00 X 0 0 0 PETER WALTON 1.00 X 0 0 0 THOMAS H CARMAN 40.00 4.50 X 739873 0 97615 PAUL KRAEGER 40.00 4.00 X 490677 0 38858 MICHAEL SHORT 40.00 X 193181 0 25275 MARIO VICTORIA MD 40.00 X 320862 0 36310 RICHARD BROOKS 40.00 X 206458 0 26158 SIMON OUAKNINE 40.00 X 525904 0 36092 JOSEPH WETTERHAHN 40.00 X 454215 0 36090 MOONJOHN KIM 40.00 X 544997 0 31097 SHAHANDEH HAGHIR 40.00 X 425202 0 31406 YILIN ZHANG 40.00 X 399284 0 20024 4780058 306002 450416 86 0 1 0 PURCELL-LECESSE 75 THRUWAY PARK DRIVE WEST HENRIETTA NY 14586 CONTRACTOR SERVICE 41676628 HAYNER HOYT CORPORATION 625 ERIE BLVD WEST SYRACUSE NY 13204 CONTRACTOR SERVICE 10749173 JEFFERSON ANESTHESIOLOGIST PO BOX 837 WATERTOWN NY 13601 ANESTHESIOLOGY SERVICES 2541094 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 PURCHASED SERVICE 2104604 INTUITIVE SURGICAL PO BOX 39000 SAN FRANSICO CA 94139 PURCHASED SERVICE 1831419 73 310390 2488936 147073 2946399 PATIENT SERVICE REVENUE 623000 192654193 192654193 192654193 140311 140311 4383 4383 82953 0 82953 82953 82953 4500 7629 0 0 4500 7629 12129 12129 SOLD SERVICES 541900 992310 992310 CAFETERIA 722210 703347 703347 56247 56247 1751904 197592272 194562920 0 82953 X 2790833 543463 2247370 80320131 70162169 10104326 53636 8476088 7273990 1202098 9783984 8337020 1377774 69190 6028052 5173140 854912 607909 18695 588384 830 709203 695062 14141 241004 745 238236 2023 1853801 495484 1347337 10980 2216491 1773193 434032 9266 3635269 2939178 696091 181336 107740 67505 6091 193358 47899 138144 7315 653358 588610 64748 3304850 3000000 304850 10758270 8666436 2091834 1763047 1131078 631969 SUPPLIES 22317790 21978185 317943 21662 CONTRACTED SERVICES AND 20323316 13624603 6605935 92778 PROVISION FOR BAD DEBT 9815318 9815318 EQUIP REPAIR & MAINT 5599508 4338488 1261020 1562551 1562551 193135467 161577985 31269570 287912 4624 5153 38525340 28526776 29745918 25542253 1979598 2156236 2660952 2738914 254893704 131596593 100809988 123297111 1909989 2135074 11974215 10657834 10996947 12822093 198607571 207881444 25710514 32026707 53944423 51874135 33607241 35358016 113262178 119258858 X 75583845 85711713 8887077 2036402 874471 874471 85345393 88622586 198607571 207881444 X 4456805 146539 925106 -2251257 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9761548 147073 -6997722 2910899 9720908 1183545 -1142905 9761548 1686419 8606970 -572481 9720908 1772796 1137000 -1223377 1686419 1575443 240587 -43234 1772796 0.30040 0.69960 0 0 1124952 1124952 116346818 32741262 83605556 2546991 2057868 489123 121246600 96797463 24449137 13628343 13628343 123297111 CSV OF OFFICERS LIFE INSURANCE 424882 F INVESTMENT IN NEWELL ST., LLC 90000 C CWH NOTE RECEIVABLE 20945 C DUE FROM AFFILIATES 8502977 C GOODWILL INVESTMENT 110750 C ED PHYSICIAN CALL 825777 C LOC FEE - SERIES B 38170 C FINANCING COSTS - SERIES B 533141 C INTEREST RATE SWAP -1934913 F FINANCING COSTS - KEY BANK 158053 C MEDICAL MALPRACTICE LT INS RECOVERY 1888052 C 10657834 OTHER RECEIVABLES 12822093 12822093 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 4734461 RETIREMENT PLAN OBLIGATIONS 30623555 35358016 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SUPPORT SAMARITAN MEDICAL CENTER AND RELATED FACILITIES IN PROVIDING HEALTH CARE SERVICES TO THE PUBLIC. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: SAMARITAN QUALIFIES AS A TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2012 AND 2011, SAMARITAN DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2009 THROUGH 2012. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 1 X 1 X 1 1 1 0 1 1 1679700 342942 1336758 0.00690 23482900 14366215 9116685 0.04720 25162600 14709157 10453443 0.05410 901171 9719 891452 0.00460 7937029 4214867 3722162 0.01930 16433 16433 0.00010 8854633 4224586 4630047 0.02400 34017233 18933743 15083490 0.07810 1 4163282 44395365 53423772 -9028407 X 1 1 1 1 SAMARITAN MEDICAL CENTER

830 WASHINGTON STREET WATERTOWN NY 13601

X X SAMARITAN MEDICAL CENTER 1 1 1 200.000000000000 1 300.000000000000 1 X 1 0 1 0 1 X 0 0 8 SAMARITAN FAMILY HEALTH - CLAYTON

909 STRAWBERRY LANE CLAYTON NY 13624

PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - PLAZA

1575 WASHINGTON STREET WATERTOWN NY 13601

PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - UROLOGY

19324 US ROUTE 11 WATERTOWN NY 13601

OUTPATIENT UROLOGY CLINIC SAMARITAN FAMILY HEALTH - LACONA

3 DEMOTT STREET LACONA NY 13083

PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - WBI

428 WASHINGTON STREET WATERTOWN NY 13601

OUTPATIENT IMAGING CLINIC SAMARITAN OUTPATIENT BEHAVIOR HEALTH

165 COLEMAN STREET WATERTOWN NY 13601

OUTPATIENT PSYCHIATRIC CLINIC SAMARITAN FAMILY HEALTH - LERAY

26908 INDEPENDENCE WAY EVAN MILLS NY 13637

PRIMARY CARE CLINIC/URGENT CARE CAPE VINCENT CLINIC

782 E BROADWAY CAPE VINCENT NY 13618

PRIMARY CARE CLINIC PART I, LINE 6A: SAMARITAN COMPLETES AND FILES THE COMMUNITY SERVICE PLAN ANNUALLY. A FULL REPORT IS COMPLETED AND SUBMITTED EVERY THREE YEARS, WITH UPDATES SUBMITTED EACH OF THE OTHER TWO YEARS. THE REPORTS ARE AVAILABLE TO THE PUBLIC VIA SAMARITAN'S WEBSITE (WWW.SAMARITANHEALTH.COM) OR BY CONTACTING THE SAMARITAN MARKETING OFFICE. PART I, LINE 7: THE RATIO OF COST TO CHARGES METHODOLOGY WAS UTILIZED IN COMPUTING ALL EXPENSES REPORTED ON LINES 7A. THROUGH 7G. THE WORKSHEET (#1 THROUGH #6) TEMPLATES IN THE INSTRUCTIONS FOR SCHEDULE H WERE FOLLOWED TO COMPUTE COSTS REPORTED. PART I, LINE 7G: THE COSTS REPORTED ON THIS LINE REPRESENT THE NET EXPENSE FOR THE OUTPATIENT PRIMARY CARE CLINICS OPERATED BY SAMARITAN MEDICAL CENTER. THE "NET" EXPENSE WAS COMPUTED UTILIZING WORKSHEET 6 OF THE SCHEDULE H FORM. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, SAMARITAN MEDICAL CENTER (SMC), SAMARITAN MEDICAL PRACTICE, P.C. (SMP) AND SAMARITAN KEEP NURSING HOME, INC. (SKH) ANALYZE PAST PAYMENT HISTORY AND IDENTIFY TRENDS FOR EACH MAJOR PAYOR SOURCE OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH PATIENTS WHO HAVE THIRD-PARTY COVERAGE, SMC, SMP AND SKH ANALYZE CONTRACTUALLY DUE AMOUNTS AND PROVIDE AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS AND FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, SMC, SMP AND SKH ALSO ANALYZE AMOUNTS DUE AND PROVIDE AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE BASED ON PAST EXPERIENCE, INCLUDING CONSIDERATION OF CURRENT BUSINESS AND ECONOMIC CONDITIONS. WHEN SMC, SMP AND SKH ESTABLISH THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BOTH TAKE INTO CONSIDERATION THE FACT THAT MANY SELF-PAY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AMOUNT OF BAD DEBT AT COST REPORTED ON LINE #2 WAS CALCULATED BY APPLYING THE OVERALL HOSPITAL RCC (COMPUTED USING WORKSHEET #2) TO THE PROVISION FOR BAD DEBT EXPENSE AS REPORTED IN OUR 2012 AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS REPORTED WERE TAKEN DIRECTLY FROM THE 2012 MEDICARE COST REPORT FILED WITH NATIONAL GOVERNMENT SERVICES. THE METHODOLOGY IS BASED ON APPLYING FACILITY RATIO OF COST TO CHARGES TO THE MEDICARE (PROGRAM) CHARGES, AS PROVIDED BY NATIONAL GOVERNMENT SERVICES IN THE PS&R REPORT.THE MEDICARE SHORTFALL REPORTED SHOULD BE TREATED AS COMMUNITY BENEFIT EXPENSE. SAMARITAN MEDICAL CENTER PROVIDES MEDICAL SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE COVERAGE. THE OVERALL (INPATIENT AND OUTPATIENT) MEDICARE PAYOR MIX FOR 2012 WAS APPROXIMATELY 36%. PART III, LINE 9B: IF CHARITY CARE ASSISTANCE IS GRANTED, PATIENT ACCOUNTS THAT HAVE BEEN REFERRED TO A COLLECTION AGENCY WITHIN 60 DAYS OF APPLICATION DATE ARE ELIGIBLE FOR CHARITY CARE DISCOUNT. ANY BILL AMOUNT REMAINING AFTER APPLICATION OF THE CHARITY CARE DISCOUNT IS THE RESPONSIBILITY OF THE PATIENT. THE PATIENT WILL BE ASSISTED BY THE HOSPITAL IN MAKING SHORT TERM ARRANGEMENT TO SATISFY ANY REMAINING BALANCE ON THE ACCOUNT. SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 20D: WE USED A PERCENTAGE OF GROSS CHARGES. PART VI, LINE 2: SAMARITAN MEDICAL CENTER PARTICIPATED WITH COMMUNITY PARTNERS FROM JEFFERSON AND LEWIS COUNTY TO ASSESS THE COMMUNITY HEALTH NEEDS, IDENTIFY PREVENTION AGENDA PRIORITIES, DEFINE GOALS, OBJECTIVES AND WORK PLANS TO MEET THESE COMMUNITY HEALTH NEEDS. THESE PARTNERS INCLUDE FORT DRUM, JEFFERSON COUNTY PUBLIC HEALTH, LEWIS COUNTY PUBLIC HEALTH, CARTHAGE AREA HOSPITAL, LEWIS COUNTY GENERAL HOSPITAL, RIVER HOSPITAL, NORTH COUNTRY CHILDREN'S CLINIC, NORTHERN NEW YORK RURAL HEALTHCARE ALLIANCE, INC., FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION.SAMARITAN CONTINUES TO WORK WITH ITS PARTNERS, MEETING REGULARLY (AT MINIMUM, QUARTERLY AND AS FREQUENTLY AS MONTHLY) TO ASSESS THE EFFECTIVENESS OF OUR COLLABORATIVE ACTIVITIES.FINALLY, IN TERMS OF PRIORITIZING HEALTH ISSUES, THE RECOMMENDATIONS OF LOCAL, REGIONAL, STATE, AND NATIONAL HEALTH EXPERTS WERE REVIEWED AND CONSIDERED IN THE PROCESS OF IDENTIFYING PRIORITY ISSUES. THE PLANNING COMMITTEE SELECTED THE FINAL HEALTH PRIORITIES AS THEY RELATED TO THE NYS DOH PREVENTION AGENDA AND BY USING COMMUNITIES WORKING TOGETHER FOR A HEALTHIER NEW YORK. PART VI, LINE 3: THE CHARITY CARE PROGRAM CAN BE COMMUNICATED TO PATIENTS BY ANY SAMARITAN STAFF MEMBER; AS OUR CHARITY CARE PROGRAM IS AN EDUCATION TOPIC IN NEW EMPLOYEE ORIENTATION AND IS PART OF OUR ANNUAL MANDATORY EDUCATION REQUIREMENT. ADDITIONALLY, EACH PATIENT IS PROVIDED WITH A FINANCIAL ASSISTANCE APPLICATION AND RETURN ENVELOPE INCLUDED IN THE SAMARITAN PATIENT HANDBOOK. OUR GOVERNMENT INSURANCE LIAISON RECEIVES REFERRALS FROM PATIENT & FAMILY SERVICES REGARDING PATIENTS THAT MIGHT NEED ASSISTANCE OR EDUCATION REGARDING FEDERAL, STATE OR OTHER GOVERNMENT PROGRAMS. ADDITIONALLY, SHE ATTEMPTS TO CONTACT ALL SELF PAY ADMISSIONS. SAMARITAN PROVIDES SPACE FOR A NYS FACILITATED ENROLLER TO MEET WITH INDIVIDUALS INTERESTED IN APPLYING FOR NYS PROGRAMS. PART VI, LINE 4: SAMARITAN MEDICAL CENTER IS A 294 BED ACUTE CARE HOSPITAL SERVING SEVERAL COMMUNITIES IN UPSTATE NEW YORK. THE HOSPITAL IS LOCATED IN WATERTOWN, NEW YORK IN JEFFERSON COUNTY, WHICH LIES WITHIN A FEDERALLY DESIGNATED HPSA. THE POPULATION SERVED BY SAMARITAN MEDICAL CENTER PRIMARILY INCLUDES JEFFERSON COUNTY AND PORTIONS OF LEWIS, NORTHERN OSWEGO AND ST. LAWRENCE COUNTIES.SAMARITAN PROVIDES A FULL ARRAY OF INPATIENT AND OUTPATIENT HOSPITAL SERVICES, INCLUDING INPATIENT MEDICAL/SURGICAL, CRITICAL CARE, PEDIATRIC, MATERNITY, AND MENTAL HEALTH SERVICES AND AN EMERGENCY SERVICES DEPARTMENT.THE U.S. CENSUS REPORT LISTS THE 2009 ESTIMATED TOTAL POPULATION OF JEFFERSON COUNTY AT 118,719. THIS REPRESENTS A 6.2% GROWTH FROM THE 2000 CENSUS OF 111,738. THE INCREASE IN TOTAL POPULATION IS LARGELY DUE TO THE EXPANSION OF MILITARY PERSONNEL AT FORT DRUM. FORT DRUM DOES NOT OPERATE A HOSPITAL ON THE ARMY BASE, NOR DO THEY STAFF MEDICAL SPECIALISTS IN THEIR OUTPATIENT HEALTH CENTER.THE PERCENTAGE OF JEFFERSON COUNTY TOTAL POPULATION BELOW THE POVERTY LEVEL HAS GRADUALLY INCREASED FROM 11% IN 1990 TO 13.5% IN 2002 TO 14.6% IN 2008. MEDIAN HOUSEHOLD INCOME FOR 2008 FALLS SHORT OF STATEWIDE MEDIAN HOUSEHOLD INCOME BY APPROXIMATELY 20%. UNEMPLOYMENT IN JEFFERSON COUNTY IS APPROXIMATELY 8% - 9%. THE JEFFERSON COUNTY POPULATION CONTINUES TO BE PREDOMINANTLY CAUCASIAN, ALTHOUGH THERE ARE AN INCREASING NUMBER OF PERSONS OF OTHER RACE AND, IN PARTICULAR, HISPANIC, OR AFRICAN AMERICAN IN ORIGIN.THE CURRENT OVERALL (INPATIENT AND OUTPATIENT) PAYOR MIX EXPERIENCED AT SAMARITAN MEDICAL CENTER IS AS FOLLOWS:MEDICARE 36%, MEDICAID 13%, BLUE CROSS 18%, COMMERCIAL 10%, TRICARE 18%, NO FAULT 1%, WORKMEN'S COMPENSATION 1%, AND SELF PAY 3%. PART VI, LINE 5: SINCE 2006, SAMARITAN HAS RECRUITED AND RETAINED A TOTAL OF 79 PHYSICIANS TO THE AREA. PHASE III OF THE FACILITY MASTER PLAN BEGAN IN 2011 WHICH PROVIDES FOR RENOVATION OF THE EXISTING MAIN BUILDING. THIS RENOVATION AND RECONFIGURATION PROJECT WILL CONTRIBUTE DIRECTLY TO PROMOTING INCREASED OUTPATIENT SERVICES BY CONSOLIDATING HEALTHCARE SERVICES AND ENHANCE OUTPATIENT AND AMBULATORY CARE AT LEVELS THAT ARE BOTH EFFICIENT AND ACCESSIBLE.SAMARITAN MEDICAL CENTER EXPANDED SERVICES IN 2012 TO INCLUDE A ROBOTICALLY ASSISTED SURGICAL PROGRAM, SPINE CENTER OF EXCELLENCE AND NEUROSURGERY. PREVIOUSLY, THESE SERVICES WERE ONLY ACCESSIBLE TO COMMUNITY MEMBERS AT OUTSIDE REFERRAL CENTERS IN SYRACUSE AND BEYOND. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X X X X 0 1 0 0 0 0 0 0 0 DAVID FLINT 268324 0 0 0 10610 0 20001 0 16097 0 315032 0 0 0 JACK RUSH 140544 0 0 0 30982 0 11863 0 16097 0 199486 0 0 0 ROBERT KIMBALL MD 0 278211 0 0 28700 0 0 0 0 7433 28700 285644 0 0 THOMAS H CARMAN 438486 0 77350 0 224037 0 76928 0 20687 0 837488 0 0 0 PAUL KRAEGER 266347 0 38350 0 185980 0 30352 0 8506 0 529535 0 0 0 MICHAEL SHORT 170707 0 13939 0 8535 0 13804 0 11471 0 218456 0 0 0 MARIO VICTORIA MD 295279 0 10819 0 14764 0 20213 0 16097 0 357172 0 0 0 RICHARD BROOKS 179984 0 17475 0 8999 0 14748 0 11410 0 232616 0 0 0 SIMON OUAKNINE 385008 0 25000 0 115896 0 19995 0 16097 0 561996 0 0 0 JOSEPH WETTERHAHN 284502 0 0 0 169713 0 19993 0 16097 0 490305 0 0 0 MOONJOHN KIM 534997 0 0 0 10000 0 15000 0 16097 0 576094 0 0 0 SHAHANDEH HAGHIR 415002 0 0 0 10200 0 19996 0 11410 0 456608 0 0 0 YILIN ZHANG 390584 0 0 0 8700 0 20003 0 21 0 419308 0 0 0 PART I, LINE 4B PART I, LINE 4B: THOMAS H. CARMAN RECEIVED CONTRIBUTIONS TO AN IRC 457(F) PLAN OF $61,928 DURING 2012. PART I, LINE 4B: PAUL KRAEGER RECEIVED CONTRIBUTIONS TO AN IRC 457(F) PLAN OF $10,059 DURING 2012. PART I, LINE 4B: ROBERT KIMBALL RECEIVED DISTRIBUTIONS FROM ED CALL PAY PLAN OF $28,700 DURING 2012. A DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DD5 2009-04-09 31660000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE 0 0 0 B DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DE3 2009-04-09 23945000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE, REFUND 1998 SERIESA 0 0 0 A 30000000 31660000 1476106 1727382 148484 27750175 557853 2010 0 0 0 1 B 23945000 513766 1084656 504577 18830508 2213649 794844 2010 1 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 1 0 0 0 0 B 0 0 0 0 1 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FORM 990 AND ACCOMPANYING SCHEDULES WERE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD PRIOR TO FILING. FORM 990 WAS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL DISCLOSURE STATEMENTS ARE REQUIRED BY ALL BOARD MEMBERS AND KEY PERSONS. WE HAVE BEEN AT 100% COMPLIANCE WITH THIS REQUIREMENT EACH YEAR. RESPONSES ARE REVIEWED INITIALLY BY THE CEO AND CHIEF COMPLIANCE OFFICER FOR ACCURACY AND COMPLETENESS. THIS INFORMATION IS THEN PUT INTO A FULL REPORT TO THE BOARD OF TRUSTEES FOR REVIEW AND CONSIDERATION IN UPCOMING DECISION MAKING. BOARD MEMBERS AND KEY PERSONS AFFIRM THEIR UNDERSTANDING OF THEIR DUTY TO REPORT ANY ADDITIONAL OR NEW POTENTIAL CONFLICTS THROUGHOUT THE YEAR. BOARD MEMBERS WITH A CONFLICT ARE PROHIBITED FROM PARTICIPATION IN VOTING AND DECISION MAKING IN RELATED TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES AN EXTERNAL CONSULTANT TO ANALYZE AND ESTABLISH COMPENSATION AND BENEFITS FOR ALL EXECUTIVE POSITIONS. AN EVALUATION IS PERFORMED ANNUALLY. THE ANALYSIS INCLUDES A REVIEW OF MARKET DATA BASED ON REGION, FACILITY SIZE, AND RESPECTIVE RESPONSIBILITIES. THIS INFORMATION IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR REVIEW AND SUBSEQUENTLY PRESENTED TO THE FULL BOARD OF TRUSTEES FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE FILED AS PART OF THE ANNUAL FORM 990 AND ANNUAL NYS DEPARTMENT OF HEALTH INSTITUTIONAL COST REPORT, AND ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: PENSION AND POSTRETIREMENT LIABILITY -2,001,331. VALUE OF INTEREST RATE SWAP -249,926. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. SAMARITAN KEEP HOME 133 PRATT STREET WATERTOWN NY 13601 160969838 SKILLED NURSING FACILITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 THE SAMARITAN MEDICAL CENTER FDN OF NORTHERN NEW YORK INC 830 WASHINGTON STREET WATERTOWN NY 13601 161490523 PROVIDES FUND FOR SAMARITAN MEDICAL CENTER AND AFFLIATES NY 501(C)3 LINE 7 SCH A SAMARITAN MEDICAL CENTER 0 EJ NOBLE 104 PADDOCK STREET SUITE 104 WATERTOWN NY 13601 237227989 HOSPITAL NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON STREET WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN SENIOR VILLAGE INC 830 WASHINGTON STREET WATERTOWN NY 13601 454913668 SENIOR CITIZEN COMMUNITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 0 1 1 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0