2013-05-08T15:41:38-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-07-01 314446959 SHELTERING ARMS HOSPITAL FOUNDATION SHEL 7405935551 55 HOSPITAL DRIVE ATHENS OH 45701 KEN DICKEN 7405935551 2013-05-02 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-25 16:41:14Z O'BLENESS MEMORIAL HOSPITAL O'BLENESS MEMORIAL FOUNDATION GREG LONG 55 HOSPITAL DRIVE ATHENS OH 45701 83584329 0 X WWW.OBLENESS.ORG X 1948 OH TO PROVIDE SUPERIOR HEALTHCARE AT A COST THAT REPRESENTS VALUE TO THE COMMUNITY. 11 9 585 237 8683216 -3347514 462880 123132 73137198 80159827 241702 584777 -1968224 1462087 71873556 82329823 0 0 0 0 31301742 36462389 0 0 0 37457827 43594333 68759569 80056722 3113987 2273101 74721530 74008787 44149330 41235556 30572200 32773231 TO PROVIDE SUPERIOR HEALTHCARE AT A COST THAT REPRESENTS VALUE TO THE COMMUNITY. 0 0 71504421 0 72848474 PATIENT CARE PROVIDED INCLUDED 8,418 INPATIENT DAYS OF CARE TO 2,914 ACUTE PATIENTS; 28,276 EMERGENCY ROOM VISITS; 91,119 OTHER OUTPATIENT VISITS; 1,876 INPATIENT AND OUTPATIENT SURGERIES; AND 691 BIRTHS. PROCEDURES AND TESTS PERFORMED INCLUDED 889,267 LAB TESTS; 26,531 X-RAYS; 3,201 MAMMOGRAPHIES; 2,553 ULTRASOUNDS; 1,351 NUCLEAR MEDICINE SCANS; 7,009 CT SCANS; 286 CARDIOVASCULAR CATHETERIZATIONS; 18,149 PHYSICAL THERAPY MODALITIES; 73,514 CARDIOPULMONARY PROCEDURES; 2,187 MRIS; AND 10,227 EKGS. THE HOSPITAL ALSO SPONSORED OR PARTICIPATED IN VARIOUS FAIRS OR HEALTH SCREENINGS THROUGHOUT THE COMMUNITY AND SURROUNDING AREAS. CHARGES FOREGONE FOR CHARITY AMOUNTED TO $11,914,261. 71504421 1 1 0 1 0 0 0 0 0 1 1 0 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 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 90 0 1 585 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 OH X KEN DICKEN 7405935551 55 HOSPITAL DRIVE ATHENS OH 45701 GREG LONG 40.00 X X 0 0 0 DOUGLAS BOLON PHD 2.00 X X 0 0 0 DON COOLEY 2.00 X X 0 0 0 MICHAEL BERNSTEIN 2.00 X 0 0 0 SUSAN QUINN OD 2.00 X X 0 0 0 JACQUELINE LEGG 2.00 X X 0 0 0 CANDY KEMMERER 2.00 X 0 0 0 GERALD A MOLLICA 2.00 X 0 0 0 BRENDA NOFTZ 2.00 X 0 0 0 DAWN SAMMONS 2.00 X 0 0 0 JOHN YANES 40.00 X X 0 0 0 LARRY THORNHILL 40.00 X X 0 0 0 BOB NORRIS 2.00 X X 0 0 0 KEN DICKEN 40.00 X 0 0 0 DERRICK REEDUS 40.00 X 561911 0 24128 STENNETH ADAMS 40.00 X 377826 0 22102 MARK ROTHSTEIN 40.00 X 392393 0 18528 NEAL NESBIT 40.00 X 419850 0 13973 JASON REED 40.00 X 1317245 0 26910 3069225 0 105641 21 0 1 0 OHIOHEALTH HOSPITAL MANAGEMENT SERVICES 3535 OLENTANGY RIVER ROAD COLUMBUS OH 43214 MANAGEMENT 1319051 BRICKER & ECKLER LLP 100 SOUTH THIRD STREET COLUMBUS OH 432154291 LEGAL SERVICES 543828 OLOGIE LLC 447 EAST MAIN STREET COLUMBUS OH 43215 MARKETING 286096 ACCESS HEALTH ATHENS LLC 7450 HUNTINGTON PARK DRIVE SUITE 1 COLUMBUS OH 43235 HEALTHCARE 273654 DAWSON HEALTHCARE 3650 OLENTANGY RIVER ROAD SUITE 45 COLUMBUS OH 43214 HEALTHCARE STAFFING SOLUTION 158735 6 123132 123132 PATIENT SERVICES 622110 79931491 71754053 8177438 SCORP INVESTMENTS 621500 161136 161136 RENT FROM AFFILIATE 631110 67200 67200 80159827 248320 248320 1331233 1241009 90224 90224 90224 349954 0 13497 349954 -13497 336457 336457 CAFETERIA 722210 399908 399908 AMA CONTRACTED SVCS 900099 289502 289502 PHARMACY 561000 162503 162503 519950 464810 55140 1371863 82329823 72848474 8683216 675001 27066754 24251811 2814943 1405419 1259255 146164 6116638 5480508 636130 1873578 1678726 194852 771181 771181 257544 257544 14076266 12612335 1463931 454583 407307 47276 14095249 12629343 1465906 23865 21383 2482 434200 389043 45157 153809 137813 15996 28135 25209 2926 2118413 1898098 220315 2441253 2187362 253891 2016520 1806802 209718 BAD DEBTS EXPENSE 6565420 6565420 MEMBERSHIP DUES 120504 120504 CONTRACTED LABOR 37391 33502 3889 80056722 71504421 8552301 0 17753513 11293554 3690328 8720400 9706500 8098990 188525 291885 752993 799178 1289115 2422067 80951048 49486893 30687112 31464155 755893 1166120 9897551 9752438 74721530 74008787 5923382 3196277 27937083 27407500 798941 848555 9489924 9783224 44149330 41235556 X 29801418 32110934 160914 52429 609868 609868 30572200 32773231 74721530 74008787 X 2273101 -72068 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1584 1584 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENSES RELATE TO THE PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION WHICH IS USED FOR LOBBYING. 770777 -108483 662294 786504 -15727 770777 801779 -15275 786504 663242 138537 801779 0.07920 0.92080 0 0 2389777 2389777 33085636 16550965 16534671 41248631 30922521 10326110 4227004 2013407 2213597 31464155 BOND ISSUE COSTS 955723 COST REPORT SETTLEMENT RECEIVABLE 205361 OTHER CURRENT ASSETS 8058854 OTHER NONCURRENT ASSETS 532500 9752438 LEASED PROPERTY DEPOSITS 3748813 ACCRUED WAGES 3289451 OTHER ACCRUED LIABILITIES 1756077 OTHER LIABILITIES 988883 9783224 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENTS ARE INTENDED FOR THE SUPPORT OF THE ORGANIZATION'S HEALTHCARE ACTIVITIES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: O'BLENESS MEMORIAL HOSPITAL AND THE APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES, INC. ARE EXEMPT FROM FEDERAL TAXES UNDER SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ATHENS MEDICAL LABORATORY ASSOCIATES, INC., ATHENS SURGERY CENTER, LTD., ATHENS MEDICAL ASSOCIATES, LLC, AND O'BLENESS MEMORIAL PAIN MANAGEMENT CLINIC, LLC ARE FOR-PROFIT SUBSIDIARIES SUBJECT TO FEDERAL INCOME TAXES. FEDERAL INCOME TAX EXPENSE IS NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF JUNE 30, 2012, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO JUNE 30, 2009. 1 1 X 1 X 1 X 1 1 1 0 0 5456758 1858726 3598032 0.04900 14850425 6616686 8233739 0.11200 20307183 8475412 11831771 0.16100 4816 290 4526 0.00010 924557 846593 77964 0.00110 929373 846883 82490 0.00120 21236556 9322295 11914261 0.16220 1 15400 0 15400 0.00020 1 15400 15400 0.00020 1 6565420 196963 15834298 14718718 1115580 X 1 1 1 ATHENS SURGERY CENTER LTD OUTPATIENT SURGERY 0.59790 0.04120 0.36090 1 1 O'BLENESS MEMORIAL HOSPITAL

55 HOSPITAL DRIVE ATHENS OH 45701

X X X X O'BLENESS MEMORIAL HOSPITAL 1 1 1 150.000000000000 1 200.000000000000 1 X X X X 1 0 1 0 1 X 0 0 1 ATHENS MEDICAL ASSOCIATES LLC

55 HOSPITAL DRIVE ATHENS OH 45701

PHYSICIAN SERVICES PART I, LINE 3C: THE HOSPITAL HAS MORE THAN ONE POLICY CONCERNING FREE OR DISCOUNTED CARE. O'BLENESS MEMORIAL HOSPITAL WILL OFFER AND PROVIDE FREE CARE TO ANY PATIENT WHO MEETS THE ELIGIBILITY REQUIREMENT FOR FREE CARE UNDER THE OCAP OR HCAP FINANCIAL ASSISTANCE POLICIES. THE FOLLOWING STEPS WILL BE USED TO DETERMINE ELIGIBILITY FOR FREE CARE UNDER OCAP (O'BLENESS CARE ASSURANCE PROGRAM): 1. A RECIPIENT OF THE OHIO MEDICAID PROGRAM IS NOT ELIGIBLE. (OAC RULE 5 10 1 :3-2-07.17) 2. IF THE PATIENT IS COVERED UNDER A THIRD-PARTY INSURER OR A GOVERNMENTAL PROGRAM, THE THIRD PARTY WILL BE BILLED AND ANY PAYMENT RECEIVED WILL BE APPLIED TO THE ACCOUNT FIRST. ANY BALANCE ON THE ACCOUNT WILL BE CONSIDERED FOR THE OCAP WRITE-OFF. 3. OCAP ASSISTANCE WILL BE APPROVED ONLY WHEN SERVICES ARE PROVIDED BY O'BLENESS MEMORIAL HOSPITAL. THESE SERVICES ALSO INCLUDE ANESTHESIA PROFESSIONAL FEES, PHYSICIAN INTERPRETATION FEES FOR CARDIOPULMONARY SERVICES, AND SERVICE PROVIDED IN THE O'BLENESS FAMILY PRACTICE CLINIC.4. FAMILY INCOME IS BETWEEN 100 TO 150% OF THE FEDERAL POVERTY GUIDELINES. FAMILY: FAMILY SHALL BE DEFINED AS THE PATIENT, THE PATIENT'S SPOUSE, AND ALL OF THE PATIENT'S CHILDREN, NATURAL AND ADOPTIVE UNDER THE AGE OF EIGHTEEN WHO LIVE AT HOME. IF THE PATIENT IS UNDER THE AGE OF EIGHTEEN THE FAMILY SHALL INCLUDE THE PATIENT, THE PATIENT'S NATURAL OR ADOPTIVE PARENT(S) AND THE PARENT(S) CHILDREN, NATURAL OR ADOPTIVE UNDER THE AGE OF EIGHTEEN WHO LIVE IN THE HOME. IF THE PATIENT IS A CHILD OF A MINOR PARENT WHO STILL RESIDES IN THE HOME OF THE PATIENT'S GRANDPARENTS, THE FAMILY SHALL INCLUDE ONLY THE PARENT(S) OF ANY OF THE PARENT(S) NATURAL OR ADOPTIVE CHILDREN WHO RESIDE IN THE HOME. INCOME: INCOME SHALL BE DEFINED AS THE TOTAL SALARIES, WAGES AND CASH RECEIPTS BEFORE TAXES: RECEIPTS THAT REFLECT REASONABLE DEDUCTION FOR BUSINESS EXPENSES SHALL BE COUNTED FOR BOTH FARM AND NON-FARM SELF-EMPLOYMENT. THE FOLLOWING STEPS WILL BE USED TO DETERMINE ELIGIBILITY FOR FREE CARE UNDER HCAP (HOSPITAL CARE ASSURANCE PROGRAM): 1. A COMPLETED APPLICATION WILL BE OBTAINED FROM ALL PATIENTS SEEKING FREE CARE UNDER HCAP. 2. A PATIENT MUST BE A RESIDENT OF THE STATE OF OHIO TO BE ELIGIBLE FOR HCAP. 3. O'BLENESS MEMORIAL HOSPITAL WILL DEFINE INCOME REQUIREMENTS USING THE FEDERAL POVERTY GUIDELINES AS INDICATED YEARLY. 4. O'BLENESS MEMORIAL HOSPITAL WILL DEFINE A FAMILY AS INDICATED IN BALDWIN'S OHIO ADMINISTRATIVE CODE CHAPTER 5101:3-2-0717. 5. THE INCOME PROVIDED BY THE APPLICANT WILL BE VERIFIED VIA SWORN SIGNATURE. 6. A RECIPIENT OF THE OHIO MEDICAID PROGRAM IS NOT ELIGIBLE (OAC RULE: 5101:3-2-0717) IF A PATIENT HAS INSURANCE COVERAGE, O'BLENESS MEMORIAL HOSPITAL WILL FIRST BILL THE INSURANCE AND RECEIVE A PAYMENT OF A DENIAL BEFORE THE HCAP APPLICATION IS PROCESSED. PART I, LINE 7: THE COST OF CHARITY CARE, UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS WAS ESTIMATED USING A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. COSTING METHODOLOGY USED TO DETERMINE THE COST OF COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS: THE HOSPITAL USES THE COMPUTER SOFTWARE CBISA TO TRACK OUR PROGRAMS THAT HAPPEN IN THE COMMUNITY OR AT THE HOSPITAL FOR THE COMMUNITY. THE COMPUTER TRACKS DIRECT EXPENSES ASSOCIATED WITH THE PROGRAMS AS WELL AS ANY OFFSETTING REVENUE THAT WILL DECREASE THE COMMUNITY BENEFIT. THE SYSTEM ACCOUNTS FOR UTILITIES USED IF THE ACTIVITY OCCURS AT THE FACILITY (HOSPITAL). THE SYSTEM ALSO ACCOUNTS FOR ANY SUPPLIES USED AND WAGES OF ANY EMPLOYEE THAT IS PRESENT AT THE ACTIVITY. A HOSPITAL WIDE WAGE AVERAGE IS USED IN DETERMINING THE AMOUNT OF SALARY TO USE IN THE DIRECT EXPENSES. 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 $ 6565420. PART II: THE COMMUNITY BUILDING ACTIVITY INCLUDES A SPONSORSHIP OF A LOCAL BASEBALL TEAM. THIS SPONSORSHIP HELPS ADVISE THE HOSPITAL AS WELL AS PROMOTE WELLNESS AND THE IMPORTANCE OF AN ACTIVE LIFESYLE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLES ARE CARRIED AT THE ORIGINAL CHARGE LESS AN ESTIMATE MADE FOR DOUBTFUL OR UNCOLLECTIBLE ACCOUNTS. THE ALLOWANCE IS BASED UPON A REVIEW OF THE OUTSTANDING BALANCES AGED BY FINANCIAL CLASS. MANAGEMENT USES COLLECTION PERCENTAGES BASED UPON HISTORICAL COLLECTION EXPERIENCE TO DETERMINE COLLECTABILITY. MANAGEMENT ALSO REVIEWS TROUBLED, AGED ACCOUNTS TO DETERMINE COLLECTION POTENTIAL. PATIENT ACCOUNTS RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO BAD DEBT EXPENSE WHEN RECEIVED. INTEREST IS NOT CHARGED ON PATIENT ACCOUNTS RECEIVABLE.FINANCIAL STATEMENT FOOTNOTE: ACCOUNTS RECEIVABLE ARE STATED NET OF CONTRACTUAL ALLOWANCES AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS DETERMINED UTILIZING A NUMBER OF FACTORS INCLUDING ACCOUNT AGING AND FINANCIAL CLASS INFORMATION AS WELL AS RECENT AND HISTORICAL COLLECTION ACTIVITY.THE BAD DEBT WAS DETERMINED BASED ON FORM 990, PART IX. THE ESTIMATED AMOUNT OF THE ORGANIZATIONS BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATIONS FINANCIAL ASSISTANCE POLICY IS ESTIMATED AT 3% OF BAD DEBT. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING METHODOLOGY REQUIRED FOR THE MEDICARE COST REPORT (COST TO CHARGE RATIO). PART III, LINE 9B: PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE ASKED TO FILL OUT THE PAPERWORK ASSOCIATED WITH THE PROGRAMS WE HAVE AVAILABLE TO PATIENTS WITH LOW INCOME. WE DO NOT HAVE A COLLECTIONS PROCESS FOR CHARITY CARE PATIENTS AND THE FULL AMOUNT IS WRITTEN OFF TO THE ASSOCIATED PROGRAM. THIS DOES NOT APPLY TO PATIENTS THAT DO NOT QUALIFY FOR EITHER OF THE PROGRAMS. IF IT IS DETERMINED THAT THE PATIENT IS CAPABLE OF PAYING FOR THEIR MEDICAL CARE, THEN AT THAT POINT THEY ARE BILLED AT A DISCOUNTED RATE FOR THE SERVICES PROVIDED. IF THEY FAIL TO PAY AT THE DISCOUNTED RATE THEN COLLECTION PRACTICES ENSUE. O'BLENESS MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: THE MAXIMUM AMOUNTS CHARGED TO FINANCIAL ASSISTANCE POLICY ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY IS $0 FOR PATIENTS WHO FALL WITHIN 150% OF THE FPG AND 50% OF CHARGEMASTER RATES FOR PATIENTS WHO FALL WITHIN 200% OF THE FPG. PART VI, LINE 2: THE HOSPITAL IS CURRENTLY ACTIVELY INVOLVED IN CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT TO BEST SERVE THE NEEDS OF THE PATIENTS AND BE IN COMPLIANCE WITH FUTURE HEALTHCARE LEGISLATION. PART VI, LINE 3: THE HOSPITAL INFORMS PATIENTS OF THEIR ELIGIBILITY FOR ASSISTANCE IN DIFFERENT WAYS. THERE IS A SIGN IN THE ADMITTING AREA THAT DIRECTS THEIR ATTENTION TO THE FACT THAT THERE IS AVAILABLE CARE AT A REDUCED FEE OR FREE OF CHARGE. ON EACH DATA MAILER THAT IS SENT OUT TO PATIENTS, THERE IS A SECTION THAT INFORMS THEM OF THE AVAILABILITY OF THIS CARE. ANY PATIENT THAT COMES IN WITHOUT INSURANCE OR PROOF OF INSURANCE IS SUPPLIED A SELF-PAY PACKET. IN THIS PACKET IS AN OUTLINE ON HOW TO OBTAIN FREE OR DISCOUNTED CARE; THE PACKET ALSO DETAILS THE PARAMETERS OF EACH PROGRAM. IF ANY OF OUR EMPLOYEES ARE ASKED IN ADMISSIONS OR DURING THEIR CARE IF THERE ARE ANY OPTIONS AVAILABLE FOR PAYMENT OF THEIR CARE, THE EMPLOYEES WILL DESCRIBE TO THE PATIENTS THE PROGRAMS AVAILABLE OR PROVIDE THEM WITH MATERIALS ON HOW TO APPLY AND BE ACCEPTED INTO THE FREE OR DISCOUNTED CARE PROGRAMS. PART VI, LINE 4: O'BLENESS MEMORIAL HOSPITAL IS A COMMUNITY HOSPITAL IN A RURAL AREA OF APPALACHIA. OUR PRIMARY SERVICE AREA INCLUDES THE COMMUNITIES WITHIN ATHENS COUNTY, OHIO, WHICH HAS BEEN IDENTIFIED BY THE APPALACHIAN REGIONAL COMMISSION AS AN ARC-DESIGNATED DISTRESSED COUNTY. ACCORDING TO THE UNITED STATES CENSUS BUREAU, THE POPULATION OF ATHENS COUNTY IN 2012 WAS 64,304. THE MEDIAN INCOME OF $33,546 IS NOT TRULY REPRESENTATIVE OF THE POPULATION, AS THE COMMUNITY INCLUDES A MAJOR UNIVERSITY. ATHENS COUNTY HAS THE HIGHEST POVERTY LEVEL OF ANY COUNTY IN OHIO, AS 31.5% OF THE COMMUNITY RESIDENTS HAVE INCOMES AT OR BELOW THE FEDERAL POVERTY GUIDELINE. UNINSURED INDIVIDUALS IN ATHENS COUNTY REPRESENT 21% OF THE POPULATION. THE HOSPITAL'S PATIENT POPULATION INCLUDES 8.8% WHO ARE UNINSURED AND 23.18% WHO ARE MEDICAID RECIPIENTS. LOCATED WITHIN O'BLENESS' PRIMARY SERVICE AREA OF ATHENS COUNTY IS ONE ADDITIONAL HOSPITAL, DOCTORS HOSPITAL OF NELSONVILLE AFFILIATED WITH OHIOHEALTH BASED IN COLUMBUS, OHIO. PORTIONS OF THE PATIENT POPULATION ARE ALSO SERVED BY EIGHT OTHER HOSPITALS IN WASHINGTON, GALLIA, JACKSON, HOCKING, FAIRFIELD AND ROSS COUNTIES IN OHIO AND WOOD COUNTY IN WEST VIRGINIA, AS WELL AS THREE MAJOR HEALTH SYSTEMS WITH MULTIPLE FACILITIES IN FRANKLIN COUNTY, OHIO. TWO TOWNSHIPS IN ATHENS COUNTY HAVE BEEN DESIGNATED AS MEDICALLY UNDERSERVED AREAS/POPULATIONS BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: LODI AND TRIMBLE. PART VI, LINE 5: AT O'BLENESS MEMORIAL HOSPITAL IT IS OUR GOAL TO GIVE ACCESS TO ANY PERSON IN OUR COMMUNITY TO MODERN DAY HEALTHCARE AT A COST EFFECTIVE PRICE. AS THE ONLY HOSPITAL IN ATHENS, WE STRIVE TO GIVE HELP WHERE HELP IS NEEDED. TO FURTHER OUR COMMITMENT TO THE COMMUNITY AND OUR EXEMPT PURPOSE WE ENGAGE IN MANY ACTIVITIES. OUR BOARD IS COMPILED OF PEOPLE WHO RESIDE IN OUR COMMUNITY WITHOUT A CONFLICT OF INTEREST WITH THE HOSPITAL. WE BELIEVE THE MORE DIVERSE THE BOARD THE BETTER THEY WILL BE ABLE TO IDENTIFY THE NEEDS OF THE COMMUNITY. THE MAJORITY OF THE BOARD HAS NO CONNECTION TO THE ORGANIZATION NOR ARE CONTRACTED WITH THE HOSPITAL. THEY PROVIDE THEIR CONSULT AND GUIDANCE OUT OF THE PURE DESIRE TO SEE THEIR COMMUNITY BE AFFORDED THE SAME QUALITY OF CARE AS BIGGER MARKETS. WE EXTEND MEDICAL PRIVILEGES TO QUALIFIED PHYSICIANS THAT HAVE A DESIRE TO PRACTICE WITHIN OUR FACILITIES. WE CONTINUE TO SEARCH FOR PROGRAMS AND ACTIVITIES THAT WILL BE NEW TO THE COMMUNITY IN ORDER TO GIVE THE POPULATION VARIETY AND HEALTH ORIENTED ALTERNATIVES. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT THAT IS VITAL IN KEEPING UP WITH AN EVER EVOLVING MEDICAL WORLD. IT IS ALSO USED TO FUND ACTIVITIES INSIDE AND OUTSIDE OF THE HOSPITAL THAT INVOLVES THE COMMUNITY ON VARIOUS LEVELS WHETHER IT BE A HEALTH FAIR OR AN INTERACTIVE EXERCISE PROGRAM. WE HAVE MANY VOLUNTEERS FROM THE COMMUNITY THAT ARE INSTRUMENTAL IN CARRYING OUT VARIOUS ACTIVITIES. PART VI, LINE 6: THE O'BLENESS HEALTH SYSTEM IS DESIGNED TO OFFER THE MOST COMPREHENSIVE MEDICAL ATTENTION TO A MAINLY CENTRALIZED LOCATION TO THE COMMUNITY IN WHICH WE LIVE. THE AFFILIATES OF THE SYSTEM WORK TOGETHER IN A COLLABORATIVE EFFORT TO INCREASE THE EFFICIENCY AND COST OF HEALTHCARE TO THE PATIENT. THE O'BLENESS MEMORIAL HOSPITAL IS THE MAIN COMPONENT OF THE HEALTH SYSTEM. AT THE HOSPITAL WE OFFER A VARIETY OF INPATIENT AND OUTPATIENT SERVICES. THE EMERGENCY DEPARTMENT IS OPERATIONAL 24 HOURS A DAY 7 DAYS A WEEK. WE OFFER CARE TO ANYONE REGARDLESS OF ABILITY TO PAY. WE ARE THE ONLY FULLY FUNCTIONAL HOSPITAL IN THE COMMUNITY. IT IS OUR GOAL NOT TO EXCLUDE ANYONE FROM OUR COMMUNITY THAT IS IN NEED OF CARE. THE ATHENS MEDICAL LAB (AML) IS AN AFFILIATE OF THE SYSTEM THAT IS A MEDICAL REFERENCE LAB THAT OFFERS CONVENIENCE AND COST EFFICIENCY FOR THE PATIENT. THIS ALLOWS US TO KEEP PATIENTS CLOSE TO HOME AND SPEED UP RESULT TIME. THE ATHENS MEDICAL ASSOCIATES (AMA) IS A MULTI-PHYSICIAN PRACTICE THAT OFFERS A VARIETY OF SERVICES TO PATIENTS. AMA IS COMPRISED OF A MULTIFACETED OB/GYN PRACTICE, AN ORTHOPEDIC SURGEON, AND A FAMILY PRACTICE CLINIC THAT SERVICE NUMEROUS MEMBERS OF THE COMMUNITY. THERE IS ALSO APPALACHIAN COMMUNITY VISITING NURSES ASSOCIATION, HOSPICE AND HEALTH SERVICES (ACVNAHHS). THIS AFFILIATE PROVIDES HOSPICE SERVICES TO NOT ONLY ATHENS COUNTY BUT SURROUNDING COUNTIES. THEY ARE ALSO PROVIDERS OF VISITING NURSES THAT SERVE OUR CLIENTS OUT OF THE COMFORT OF THEIR OWN HOME. 0 0 0 0 0 0 0 0 0 DERRICK REEDUS 430000 0 0 0 131911 0 7500 0 16628 0 586039 0 0 0 STENNETH ADAMS 315000 0 0 0 62826 0 7500 0 14602 0 399928 0 0 0 MARK ROTHSTEIN 332304 0 0 0 60089 0 7500 0 11028 0 410921 0 0 0 NEAL NESBIT 390000 0 0 0 29850 0 7500 0 6473 0 433823 0 0 0 JASON REED 650000 0 647893 0 19352 0 7500 0 19410 0 1344155 0 0 0 PART I, LINE 3 THE CEO IS COMPENSATED THROUGH AN UNRELATED MANAGEMENT COMPANY, OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC. THE CONTRACT WITH THE MANAGEMENT COMPANY IS REVIEWED AND APPROVED BY THE BOARD. THE COMPENSATION FOR THE CEO IS REVIEWED AND APPROVED BY THE MANAGEMENT COMPANY. COUNTY OF ATHENS OHIO 316400063 047075BA3 2003-08-21 31263724 BOND REFUNDING, HOSPITAL CONSTRUCTION & RENOVATION 0 0 0 31263724 2493855 625274 2005 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 JASON REED PHYSICIAN EDUCATION LOAN X 170000 56667 0 1 1 DAWN SAMMONS PHYSICIAN EDUCATION LOAN X 250000 42000 0 1 1 STENNETH ADAMS PHYSICIAN EDUCATION LOAN X 50000 20192 0 1 1 MARK ROTHSTEIN PHYSICIAN EDUCATION LOAN X 50000 33333 0 1 1 DERRICK REEDUS PHYSICIAN EDUCATION LOAN X 178624 139693 0 1 1 291885 FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIP BETWEEN MICHAEL BERNSTEIN (BOARD MEMBER), LARRY THORNHILL (OFFICER AND BOARD MEMBER), GREG LONG (OFFICER AND BOARD MEMBER). CANDY KEMMERER (BOARD MEMBER) IS AN EMPLOYEE OF HOCKING VALLEY BANK WITH WHOM WE HAVE ACCOUNTS. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION ENTERED INTO A MANAGEMENT AGREEMENT WITH OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC, AN OHIO NONPROFIT LIMITED LIABILITY COMPANY, EFFECTIVE AUGUST 1, 2010 FOR A FIVE YEAR TERM. OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC IS A WHOLLY OWNED SUBSIDIARY OF OHIOHEALTH CORPORATION, AN OHIO NONPROFIT CORPORATION THAT IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE IRS. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER REVIEWS THE FORM 990 THROUGHOUT THE PREPARATION PROCESS AND ALSO CONDUCTS A FINAL REVIEW BEFORE PRESENTATION TO THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS AND DIRECTORS ANNUALLY DISCLOSE INTERESTS THAT COULD GIVE RISE TO CONFLICT THROUGH AN ANNUAL QUESTIONNAIRE. ADDITIONALLY, CONFLICTS THAT ARISE THROUGHOUT THE YEAR ARE TO BE DISCLOSED AS SOON AS POSSIBLE. CONFLICTS ARE ADDRESSED BY IMPOSING RESTRICTIONS SUCH AS PROHIBITIONS AGAINST PARTICIPATING IN GOVERNING BODY'S DELIBERATIONS, AND MAKING DECISIONS RELATIVE TO TRANSACTIONS RELATED TO THE CONFLICT, ANY TIME THE CONFLICT ITSELF CANNOT BE REVERSED. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION OF THE EXECUTIVE DIRECTOR IS DETERMINED BASED ON COMPARABILITY DATA, CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION AND BY A COMPENSATION COMMITTEE WITH THE FULL BOARD'S APPROVAL. THE EXECUTIVE IS PAID THROUGH OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC. THE LAST COMPENSATION REVIEW WAS COMPLETED IN 2012. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023, 990 AND 990-T ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -427,526. REDUCTION IN PLEDGE RECEIVABLE VALUE -101,016. CAPITAL CONTRIBUTION FROM AFFILIATE 608,918. S-CORPORATION INCOME TAXABLE ON RETURN NOT ON BOOKS -161,136. PAIN MANAGEMENT INCOME ON RETURN NOT ON BOOKS 8,692. TOTAL TO FORM 990, PART XI, LINE 5: -72,068. FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR. FORM 990, PART I, LINE 6 O'BLENESS HAD 237 VOLUNTEERS SERVE DURING THE 2012 FISCAL YEAR. TOTAL WAGES ACCORDING TO THE BUREAU OF LABOR STATISTICS IS $496,416 (BASED ON NON-FARM LABOR PLUS BENEFITS). FORM 990, PART VII THE OFFICERS OF THE ORGANIZATION ARE CONTRACTED THROUGH OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC WHICH IS A MANAGEMENT COMPANY THAT THE ORGANIZATION HAS A FIVE YEAR AGREEMENT. THIS MANAGEMENT COMPANY IS UNRELATED TO THE ORGANIZATION. 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