2013-05-15T13:40:43-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-07-01 344451872 GALION COMMUNITY HOSPITAL GALI 4194684841 269 PORTLAND WAY SOUTH GALION OH 448332399 D ERIC DRAIME 4194684841 2013-05-10 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z D ERIC DRAIME 269 PORTLAND WAY SOUTH GALION OH 448332399 105402199 0 X WWW.AVITAHEALTH.ORG X 1954 OH TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. 19 16 969 333 0 0 303607 74329 79948220 103956113 -199634 27372 640704 1113511 80692897 105171325 2015339 1478865 0 0 34213739 29195042 0 0 0 41151372 68829414 77380450 99503321 3312447 5668004 74192103 75282573 47731086 51484311 26461017 23798262 TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. 0 0 42989577 1478865 67512794 GALION COMMUNITY HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL LOCATED WITHIN THE CITY OF GALION, OH. IT SERVES THE GREATER GALION AREA INCLUDING MUCH OF CRAWFORD COUNTY. THE FACILITY SERVES THE GENERAL PUBLIC AND IS OPEN SEVEN DAYS A WEEK, TWENTY-FOUR HOURS PER DAY. DURING THE FISCAL YEAR OF 2012, GALION HOSPITAL AND ITS AFFILIATES SERVED 1,977 INPATIENTS, 18,865 EMERGENCY VISITS, AND 75,101 OUTPATIENT VISITS. THESE WERE ALL SERVED REGARDLESS OF THE ABILITY TO PAY. GALION HOSPITAL IS AN INTRICATE PART OF THE COMMUNITY. IT IS ONE OF THE LARGEST EMPLOYERS IN THE COUNTY AT 529 FULL TIME EQUIVALENTS. 22438047 0 36541465 BCH ACQUISITION LLC (BUCYRUS COMMUNITY HOSPITAL) IS A 25 BED CRITICAL ACCESS HOSPITAL LOCATED WITHIN THE CITY OF BUCYRUS, OH. IT SERVES THE GREATER BUCYRUS AREA. THE FACILITY SERVES THE GENERAL PUBLIC AND IS OPEN SEVEN DAYS A WEEK, TWENTY-FOUR HOURS PER DAY. DURING THE FISCAL YEAR OF 2012, BUCYRUS HOSPITAL SERVED 1,078 INPATIENTS, 14,752 EMERGENCY VISITS, AND 32,824 OUTPATIENT VISITS. THESE WERE ALL SERVED REGARDLESS OF THE ABLIITY TO PAY. BCH ACQUISITION LLC IS AN INTRICATE PART OF THE COMMUNITY. IT IS ONE ON THE LARGEST EMPLOYERS IN THE COUNTY AT 213 FULL TIME EQUIVALENTS. 65427624 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 163 0 1 969 1 0 0 0 0 0 0 0 0 0 0 X 19 16 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 1 1 OH X D ERIC DRAIME 4194680501 269 PORTLAND WAY SOUTH GALION OH 44833 X DOUGLAS SCHILLING 1.90 X X 0 0 0 KYMBERLY FOX 1.90 X X 0 0 0 REX CRAMER 1.90 X X 0 0 0 LINDA CHAMBERS 1.90 X X 0 0 0 DONALD BARR 0.80 X 0 0 0 ALAN BASINGER 0.80 X 0 0 0 PHILLIP BROWN 0.80 X 0 0 0 SHERRI CLEVENGER 0.80 X 0 0 0 BOYD EPPERSON 0.80 X 0 0 0 ERIC GEYER 0.80 X 0 0 0 JANET HERMAN 0.80 X 0 0 0 KAY MCDONALD 0.80 X 0 0 0 MICHELE MCELLIGOTT 0.80 X 0 0 0 JASON MCMULLEN 0.80 X 0 0 0 MARK SCHNEIDER 0.80 X 0 0 0 JOSEPH SHADEED 0.80 X 0 0 0 CHARLES WALKER 0.80 X 0 0 0 DR JAMES KERBS 40.00 X 0 533717 165180 DR GRANT HOPE 40.00 X 84350 0 0 JERRY MORASKO 40.00 X 94437 162205 0 D ERIC DRAIME 40.00 X 56189 124439 0 ANDREW DANIELS 40.00 X 132067 0 0 JAMES GOUDY 40.00 X 540122 0 13903 JOHN HANNA 40.00 X 325712 0 16638 ERIC KUIVINEN 40.00 X 315321 0 3929 MARK WOOD 40.00 X 230544 0 28227 GOHAR GHAZARIAN 40.00 X 213773 0 40347 1992515 820361 268224 19 0 1 0 MID AMERICAN THERAPY 7652 EAGLE DRIVE FINDLAY OH 45840 PHYSICAL THERAPY 1378441 GALION ANESTHESIA SERVICES INC 4575 TOWNSHIP ROAD 126 CARDINGTON OH 43315 ANESTHESIA 1169033 CALFEE HALTER & GRISWOLD LLP 1400 KEYBANK CTR CLEVELAND OH 441142688 LEGAL SERVICES 394434 LABORATORY CORP OF AMERICA PO BOX 2140 BURLINGTON NC 272162140 LAB SERVICES 339233 PLANTE & MORAN PLLC PO BOX 353090 TOLEDO OH 436353090 ACCOUNTING SERVICES 213204 11 3705 70624 74329 NET PATIENT REVENUE 621110 103956113 103956113 103956113 239420 239420 116972 18826 98146 98146 98146 212048 -212048 -212048 -212048 CAFETERIA & CATERING 621110 511907 511907 REBATES 621110 161230 161230 VENDING MACHINE REV 621110 2010 2010 340218 340218 1015365 105171325 104054259 0 1042737 1468969 1468969 9896 9896 792504 792504 25927440 22816147 3111293 2475098 2178086 297012 24900193 24900193 517338 517338 245510 245510 4736660 4168261 568399 324003 285123 38880 18637435 16400943 2236492 4449135 3915239 533896 152454 134160 18294 862036 758592 103444 3420188 3009765 410423 1247169 1097509 149660 BAD DEBT EXPENSE 7737437 7737437 PHYSICIAN RECRUITING 1151713 1013507 138206 OHIO FRANCHISE TAX FEE 330202 330202 117941 103788 14153 99503321 65427624 34075697 0 3426191 7860414 13101357 12010402 103459 30185 356355 461516 586327 737713 956246 1288371 75942196 35845665 37812721 40096531 6434924 6549729 8091663 5691931 3322860 555781 74192103 75282573 6304965 8139769 29063249 27829864 12362872 15514678 47731086 51484311 X 25702870 23060750 482372 474512 275775 263000 26461017 23798262 74192103 75282573 X 5668004 -8330759 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 2386 2386 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: GALION COMMUNITY HOSPITAL PAYS DUES TO OHIO HOSPITAL ASSOCIATION. THE PORTION OF DUES RELATED TO LOBBYING ACTIVITIES WAS $2,386 WHICH IS 5.3% OF DUES. 623627 623627 43943184 17351123 26592061 28398188 17784865 10613323 2977197 709677 2267520 40096531 CERTIFICATES OF DEPOSIT 563723 F HELD BY TRUSTEE 3163051 F OTHER INVESTMENTS 1965157 F 5691931 FV OF INTEREST RATE SWAP AGMT 843474 ACCRUED PENSION 12053836 CAPITAL LEASES 1105369 INTEREST PAYABLE 639 ESTIMATED THIRD-PARTY PAYOR SETTLEMENT 1177443 INTERCOMPANY PAYABLE 1235 NOTE CAT SCANNER 332682 15514678 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE INTERNAL REVENUE SERVICE HAS RULED THAT GCH, CHA, NCOFCC, BCH, FOUNDATION, AND HOMECARE MATTERS ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AVITA AND GCH ACQUISITION SUB HAVE APPLIED WITH THE INTERNAL REVENUE SERVICE FOR TAX-EXEMPT ORGANIZATION STATUS AS DEFINED UNDER SECTION 501(C)(3), WHICH IS PENDING AS OF JUNE 30, 2012. ACCORDINGLY, NO PROVISION FOR FEDERAL INCOME TAXES HAS BEEN MADE IN THE CONSOLIDATED FINANCIAL STATEMENTS. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM 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 SYSTEM 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 SYSTEM 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 0 0 2535370 963594 1571776 0.01770 8365147 1808215 6556932 0.07380 10900517 2771809 8128708 0.09150 4 490 23114 23114 0.00030 4 490 23114 23114 0.00030 4 490 10923631 2771809 8151822 0.09180 0 3734872 186744 30723128 30795847 -72719 X 1 1 1 GALION COMMUNITY VASCULAR SERVICES LLC SERVICES FOR VASCULAR DIFFICULTIES 0.51000 0.00000 0.49000 2 GALION COMMUNITY PAIN MANAGEMENT LLC PAIN CLINIC 0.51000 0.00000 0.49000 2 1 GALION COMMUNITY HOSPITAL

269 PORTLAND WAY SOUTH GALION OH 44833

X X X X 2 BCH ACQUISITION LLC

269 PORTLAND WAY SOUTH GALION OH 44833

X X X X GALION COMMUNITY HOSPITAL 1 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 BCH ACQUISITION LLC 2 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 8 GCH SURGICAL SERVICES

1593 OLENTANGY ROAD GALION OH 44833

SURGERY GCH HEALTH SERVICES

270 PORTLAND WAY SOUTH GALION OH 44833

CARDIOLOGY GCH PHYSICIAN PRACTICES

385 N SELTZER STREET CRESTLINE OH 44827

PHYSICIAN GCH ORTHOPEDICS CENTER

955 HOSFORD ROAD GALION OH 44833

ORTHOPEDIC BUCYRUS COMMUNITY PHYSICIANS

120 W MAIN STREET NEW WASHINGTON OH 44854

PHYSICIAN BUCYRUS COMMUNITY PHYSICIANS

140 HILL STREET BUCYRUS OH 44820

PHYSICIAN BUCYRUS CARDIOLOGY

725 N SANDUSKY AVENUE BUCYRUS OH 44820

CARDIOLOGY GCH SPECIALTY CENTER

130 HILL STREET BUCYRUS OH 44820

OTOLARYNGOLOGY PART I, LINE 7: THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2 USED COSTING METHOD. PART I, LINE 7G: NOT APPLICABLE PART I, L7 COL(F): COLUMN F IS CALCULATED BASED ON THE TOTAL OF FORM 990, PART IX, LESS BAD DEBT EXPENSE ($7,737,437) REPORTED IN PART IX. PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL LOSS RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.BAD DEBT AT COST WAS CALCULATED USING A COST-TO-CHARGE RATIO. GALION COMMUNITY HOSPITAL DOES NOT BELIEVE BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT.ADDITIONAL BAD DEBT ATTRIBUTABLE TO PATIENTS IDENTIFIED UNDER CHARITY CARE WAS CALCULATED USING ACTUAL COSTS FROM SPECIFICALLY IDENTIFIED PATIENTS THAT WERE MISCLASSIFIED AS BAD DEBT ORIGINALLY. GALION COMMUNITY HOSPITAL AND BCH ACQUISITION LLC DOES NOT BELIEVE BAD DEBT IDENTIFIED UNDER CHARITY CARE SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. PART III, LINE 8: WE REPORT MEDICARE COSTS BY THE COST TO CHARGE METHOD. BECAUSE WE ARE A CRITICAL ACCESS HOSPITAL WE DO NOT HAVE A MEDICARE SHORTFALL. WE ARE REIMBURSED 1% ABOVE OUR COST. PART III, LINE 9B: EVEN IF THE HOSPITAL KNOWS A PATIENT QUALIFIES FOR FINANCIAL AID, IT IS NOT PROVIDED WITHOUT A SIGNED APPLICATION. GALION COMMUNITY HOSPITAL AND BCH ACQUISITION LLC DO MAKE AN EFFORT TO GET THE APPLICATION TO ALL PATIENTS. THE FINANCIAL COUNSELORS WILL TRY TO MAKE PHONE CONTACT WITH THOSE WHO ARE KNOWN TO QUALIFY TO ENCOURAGE COMPLETION OF THE FORMS. HOWEVER, THE PROCESS IS THE SAME FOR ALL PATIENTS. GALION COMMUNITY HOSPITAL AND BCH ACQUISITION LLC UTILIZES INTERNAL AND EXTERNAL COLLECTION EFFORTS (INCLUDING COLLECTION AGENCIES) FOR ALL PATIENTS. PART VI, LINE 2: COMMUNITY HEALTH SCREENINGS ARE CONDUCTED TO EVALUATE BLOOD PRESSURE, BLOOD SUGAR LEVELS, AND CHOLESTEROL. THE SCREENINGS ARE MONITORED TO DETERMINE THE TEACHING NEEDS OF THE COMMUNITY. GALION HOSPITAL ALSO DOES SCREENINGS FOR LOCAL BUSINESS AND COMMUNITY OUTREACH EVENTS. WE PARTICIPATE IN EVENTS SPONSORED BY THE CHAMBER OF COMMERCE AND THE CRAWFORD COUNTY FAIR. WE OFFER FREE DIABETES SUPPORT GROUPS AND PROSTATE CANCER SUPPORT GROUPS. GALION HOSPITAL ALSO MONITORS THE LOCAL HEALTH DEPARTMENT FOR ADVICE ON FLU TRENDS AND VACCINATION NEEDS. PART VI, LINE 3: EVERY BILL THAT IS SENT TO A PATIENT HAS INFORMATION ON THE REVERSE SIDE ABOUT HCAP AND THE CRITERIA FOR MEETING THE HCAP REQUIREMENTS. IT ALSO HAS THE GENERAL CHARITY POLICY AND INFORMS THE PATIENT OF AVAILABLE ASSISTANCE. THE PATIENT REPRESENTATIVE OR THE REGISTRATION PERSONNEL ARE ALL WELL VERSED IN THE REQUIREMENTS FOR HCAP AND CHARITY CARE. THEY WOULD BE HAPPY TO HELP ANY PATIENT TO FILL OUT THE FORMS AND REQUEST AID. THERE ARE ALSO SIGNS THROUGHOUT THE HOSPITAL THAT ADVISE THE PATIENT TO ASK ABOUT DISCOUNTS. PART VI, LINE 4: GALION AND BUCYRUS COMMUNITY HOSPITALS ARE BOTH LOCATED IN CRAWFORD COUNTY, OHIO. THE COUNTY HAS A TOTAL POPULATION OF 43,784. TWENTY-SIX PERCENT ARE UNDER THE AGE OF 19 AND ALMOST EIGHTEEN PERCENT ARE OVER THE AGE OF 65. THE LATEST STATISTICS FOR CRAWFORD COUNTY SHOW THE MEDIAN HOUSEHOLD INCOME AT $41,336. IT IS AN AREA HARD HIT BY THE RECESSION AND THE MOVEMENT OF JOBS OUT OF OHIO. UNEMPLOYMENT IS 6.8% FOR THE COUNTY. CRAWFORD COUNTY IS ONE OF THE LEADING COUNTIES IN THE STATE FOR PERSONS WITH DRUG ABUSE ISSUES. PART VI, LINE 5: GALION COMMUNITY HOSPITAL AND BCH ACQUISITION LLC BELIEVE THAT IT IS THEIR MISSION TO IMPROVE THE HEALTH OF THE COMMUNITY. TO THAT END, THERE ARE MANY PROFESSIONALS WHO VOLUNTEER THEIR TIME IN THE AREA TO WORK WITH LOCAL GROUPS TO SCREEN THE NEEDS OF THE COMMUNITY. GALION AND BUCYRUS ARE VERY ACTIVE IN THE AREA AND VERY PROACTIVE WITH PREVENTIVE DISEASE EDUCATION. VARIOUS HEALTH EDUCATION EVENTS ARE HELD EACH YEAR, INCLUDING WOMEN'S HEALTH CLINIC, PROSTATE CANCER SCREENING, MUSCULOSKELETAL EVALUATION, AND BLOOD PRESSURE SCREENINGS. PART VI, LINE 6: GALION COMMUNITY HOSPITAL AND BCH ACQUISITION LLC ARE PART OF A HEALTHCARE SYSTEM AND THEY DO EMPLOYEE PHYSICIANS THROUGH TWO PHYSICIAN GROUPS. COMMUNITY HEALTH ASSOCIATES AND NORTH CENTRAL OHIO FAMILY CARE CENTER. THESE ENTITIES ALL DELIVER CARE TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE PHYSICIAN OFFICES SEE MANY PATIENTS WHO ARE NOT ABLE TO PAY. THE HOSPITALS WILL ALWAYS TREAT A PATIENT FOR MEDICALLY NECESSARY SERVICES, REPORTS FILED WITH STATES PART VI, LINE 7 OH 1 COMMUNITY HEALTH ASSOCIATES INC 269 PORTLAND WAY SOUTH GALION OH 44833 341784017 501(C)(3) 1240341 CANCEL RELATED ORGANIZATION DEBT NORTH CRENTAL OHIO FAMILY CARE CENTER 269 PORTLAND WAY SOUTH GALION OH 44833 341807906 501(C)(3) 225796 CANCEL RELATED ORGANIZATION DEBT TUITION REIMBURSEMENT FOR GALION COMMUNITY HOSPITAL EMPLOYEES 2 9896 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAKES GRANTS TO RELATED EXEMPT ORGANIZATIONS TO FURTHER THEIR EXEMPT PURPOSES. SCHEDULE I, PART III: ALL GALION COMMUNITY HOSPITAL EMPLOYEES ARE ELIGIBLE FOR REIMBURSEMENT. APPLICATIONS ARE APPROVED BY HUMAN RESOURCES. TUITION INVOICES AND GRADES ARE MONITORED BY THE CONTROLLER TO MAKE SURE THE STUDENT MEETS CERTAIN CRITERIA TO RECEIVE THE FUNDS. X 1 1 X X X X 0 1 0 0 0 0 0 0 0 DR JAMES KERBS 0 504912 0 28805 0 0 0 160500 0 4680 0 698897 0 0 JERRY MORASKO 94437 135705 0 26500 0 0 0 0 0 0 94437 162205 0 0 D ERIC DRAIME 56189 102677 0 21762 0 0 0 0 0 0 56189 124439 0 0 JAMES GOUDY 506183 0 33939 0 0 0 13184 0 719 0 554025 0 0 0 JOHN HANNA 325712 0 0 0 0 0 16500 0 138 0 342350 0 0 0 ERIC KUIVINEN 315321 0 0 0 0 0 0 0 3929 0 319250 0 0 0 MARK WOOD 123434 0 107110 0 0 0 22000 0 6227 0 258771 0 0 0 GOHAR GHAZARIAN 156551 0 57222 0 0 0 33000 0 7347 0 254120 0 0 0 PART I, LINE 1A A MEMBERSHIP AT THE LOCAL COUNTRY CLUB IS PAID FOR THE CEO, JERRY MOROSKO. THIS BENEFIT HAS NOT BEEN TREATED AS TAXABLE COMPENSATION. PART I, LINE 4B JAMES KERBS PARTICIPATED IN A 457(F) PLAN. THE FOLLOWING AMOUNT WAS ASSOCIATED WITH THE RETIREMENT PLAN: 122,000. COUNTY OF CRAWFORD OH 346400345 NONEAVAIL 2010-12-29 27430000 SEE SCHEDULE O 0 0 0 30000 27431825 11180359 541437 27430 12635343 3047256 2013 1 0 0 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 1 FIFTH THIRD BANK 5.000000000000 0 0 0 0 0 SCHEDULE K, PART I DESCRIPTION OF PURPOSE REFUND ALL OUTSTANDING COUNTY OF CRAWFORD, OHIO ADJUSTABLE RATE HOSPITAL FACILITIES REVNUE REFUNDING AND IMPROVEMENT BONDS, SERIES 2003 (GALION COMMUNITY HOSPITAL PROJECT) DATED SEPTEMBER 30, 2003. REFUND ALL OUTSTANDING COUNTY OF CRAWFORD, OHIO ADJUSTABLE RATE HOSPITAL FACILITIES REVENUE BONDS, SERIES 2006 (GALION COMMUNITY HOSPITAL PROJECT). CONSRUCT AND EQUIP HOSPITAL FACILITIES. SCHEDULE K, PART II, LINE 6 PROCEEDS IN REFUNDING ESCROWS NO BOND PROCEEDS ARE CURRENTLY HELD IN A REFUNDING ESCROW. $11,180,359 OF PROCEEDS RECEIVED FROM THE SALE OF THE SERIES 2010 BONDS WERE USED TO REFUND THE SERIES 2003 AND SERIES 2006 BONDS PRIOR BONDS WITHIN 90 DAYS OF THE ISSUE DATE OF THE SERIES 2010 BONDS. SCHEDULE K, PART IV, LINE 6 EXCEPTION TO REBATE THE CURRENT REFUNDING PORTION OF THE SERIES 2010 BONDS QUALIFIED FOR THE 6-MONTH EXCEPTION OF TREAS. REG. 1.148-7(C). ERIC HOFF MEDICAL SCHOOL X 100833 25826 0 1 1 ROBERT DAWSON MEDICAL SCHOOL X 357553 4359 0 1 1 30185 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION SHALL, AT ALL TIMES, BE AVITA HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OR DIRECTORS SHALL HAVE THE APPROVAL OF THE BOARD OF DIRECTORS OF AVITA HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER HAS THE RIGHT TO APPROVE OR RATIFY DECISIONS OF THE ORGANIZATION'S GOVERNING BODY, SUCH AS APPEAL OF THE GOVERNING BODY'S ELECTION OR REMOVAL OF MEMBERS. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE SUB-COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND SENT TO THE EXECUTIVE COMMITTEE OF GALION COMMUNITY HOSPITAL'S BOARD FOR THEIR REVIEW PRIOR TO FILING. THE BOARD EXECUTIVE COMMITTEE APPROVES THE FORM 990 FOLLOWING REVIEW, AS AUTHORIZED BY THE FULL GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 12C BOTH GALION COMMUNITY HOSPITAL AND BCH ACQUISITION LLC HAVE A CONFLICT OF INTEREST POLICY THAT COVERS ALL BOARD OF DIRECTORS AND OFFICERS OF THE CORPORATION. CONFLICT OF INTEREST SURVEYS ARE REVIEWED BY BOARD CHAIRMAN AND THE CEO TO ENSURE COMPLIANCE. VARIOUS RESTRICTIONS ARE IMPOSED ON INDIVIDUALS WITH POTENTIAL CONFLICTS OF INTEREST (I.E. INABILITY TO VOTE) UNTIL DECISION HAS BEEN MADE ON POTENTIAL CONFLICT. FORM 990, PART VI, SECTION B, LINE 15A BOTH GALION COMMUNITY HOSPITAL'S AND BCH ACQUISITON LLC'S PROCESS FOR DETERMINING COMPENSATION CONSISTED OF BOARD EXECUTIVE COMMITTEE REVIEW OF OHIO HOSPITAL ASSOCIATION COMPENSATION SURVEYS, AND THE COMMITTEE DETERMINES EXECUTIVE COMPENSATION BASED ON THIS COMPARABILITY DATA. CONTEMPORANEOUS MINUTES ARE KEPT OF MEETINGS HELD BY THE EXECUTIVE COMMITTEE REGARDING DECISIONS AND DELIBERATIONS OF THIS PROCESS. THIS PROCESS WAS LAST COMPLETED IN JUNE OF 2012 FOR 2013 COMPENSATION. FORM 990, PART VI, SECTION C, LINE 18 FORM 990 AND FORM 1023 ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS ARE AVAILABLE TO THE PUBLIC. FORM 990, PART VII ESTIMATE OF OFFICERS' ALLOCATION OF HOURS WORKED FOR RELATED TAX-EXEMPT ENTITIES: AVITA HEALTH FOUNDATION: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 COMMUNITY HEALTH ASSOCIATES, INC.: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 -ANDREW DANIELS: .2 NORTH CENTRAL OHIO FAMILY CARE CENTER: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 -ANDREW DANIELS: .2 AVITA HEALTH SYSTEM: -JERRY MORASKO: .1 -D. ERIC DRAIME: .1 -ANDREW DANIELS: .1 CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -100,935. DONATED SERVICES AND USE OF FACILITIES: -37,990. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENTS -214,222. CHANGE IN PENSION COSTS -8,417,579. INCOME FROM RELATED EXEMPT ORGANIZATION 224,010. CONTROLLING INTEREST IN CRAWFORD COUNTY SHARED HEALTH SERVICES, INC. 1,061,362. BCH FOUNDATION UNRESTRICTED 1,734. INHERENT CONTRIBUTION FROM BUSINESS COMBINATION OF HOMECARE MATTERS -847,139. TOTAL TO FORM 990, PART XI, LINE 5: -8,330,759. FORM 990, PART XI, LINE 2C THE ORGANIZATION HAS A FINANCE COMMITTEE WHICH OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BCH ACQUISITION LLC 269 PORTLAND WAY SOUTH GALION OH 448332399 344451872 HEALTHCARE OH 36820016 20990524 GALION COMMUNITY HOSPITAL BCH PHYSICIAN CO 269 PORTLAND WAY SOUTH GALION OH 448332399 344451872 INACTIVE OH 0 0 GALION COMMUNITY HOSPITAL AVITA HEALTH FOUNDATION 269 PORTLAND WAY SOUTH GALION OH 44833 200934451 FUNDRAISING FOR GALION COMMUNITY HOSPITAL OH 501(C)(3) LINE 7 AVITA HEALTH SYSTEM 1 COMMUNITY HEALTH ASSOCIATES INC 955 BUCYRUS ROAD GALION OH 44833 341784017 PHYSICIAN OFFICE OH 501(C)(3) LINE 11A, I GALION COMMUNITY HOSPITAL 1 NORTH CENTRAL OHIO FAMILY CARE CENTER INC 269 PORTLAND WAY SOUTH GALION OH 44833 341807906 PHYSICIAN OFFICE OH 501(C)(3) LINE 11A, I GALION COMMUNITY HOSPITAL 1 AVITA HEALTH SYSTEM 269 PORTLAND WAY SOUTH GALION OH 44833 274385692 HEALTHCARE OH 501(C)(3) LINE 11A, I N/A 0 GCH AQUISITION SUB 269 PORTLAND WAY SOUTH GALION OH 44833 383821803 AQUISITION COMPANY OH 501(C)(3) LINE 9 GALION COMMUNITY HOSPITAL 1 CRAWFORD COUNTY SHARED HEALTH SERVICES INC 1220 NORTH MARKET STREET GALION OH 44833 341484014 HOME HEALTH & HOSPICE OH 501(C)(3) LINE 9 GALION COMMUNITY HOSPITAL 1 GALION COMMUNITY PAIN MANAGEMENT LLC 269 PORTLAND WAY SOUTH GALION OH 44833 300602607 HOSPITAL SUPPORT OH GALION COMMUNITY HOSPITAL RELATED 1328316 434013 0 0 0.51000 GALION COMMUNITY VASCULAR SERVICES LLC 269 PORTLAND WAY SOUTH GALION OH 44833 611613817 HOSPITAL SUPPORT OH GALION COMMUNITY HOSPITAL RELATED 1751738 550718 0 0 0.51000 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 COMMUNITY HEALTH ASSOCIATES INC R 3413196 ACCRUAL TRANSACTION COMMUNITY HEALTH ASSOCIATES INC R 570000 ACCRUAL TRANSACTION COMMUNITY HEALTH ASSOCIATES INC Q 3936529 ACCRUAL TRANSACTION COMMUNITY HEALTH ASSOCIATES INC P 802000 PAYROLL NORTH CENTRAL OHIO FAMILY CARE CENTER P 425687 PAYROLL NORTH CENTRAL OHIO FAMILY CARE CENTER R 179000 ACCRUAL TRANSACTION AVITA HEALTH SYSTEM L 24900193 MANAGEMENT FEE COMMUNITY HEALTH ASSOCIATES INC B 1240341 FORGIVENESS OF PAYABLE NORTH CENTRAL OHIO FAMILY CARE CENTER B 225796 FORGIVENESS OF PAYABLE