2013-08-14T07:29:07-05:00 2012-09-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2011-10-01 570468486 WILLIAMSBURG REGIONAL HOSPITAL WILL 8433558888 PO DRAWER 568 KINGSTREE SC 29556 DAVID KLINE 8433558888 2013-08-12 1 JOHN NORMAN P01506766 7049985200 2011 2016-02-24 21:20:13Z DAVID KLINE PO DRAWER 568 KINGSTREE SC 29556 17405826 0 X WWW.WMBGRH.COM X 2002 SC OPERATION OF AN ACUTE CARE HOSPITAL. 10 9 266 10 0 0 105386 852456 14193961 16497274 0 0 608863 1784 14908210 17351514 0 0 0 0 7425764 9451365 0 0 0 7594967 8359346 15020731 17810711 -112521 -459197 6506682 6821728 7858526 8632769 -1351844 -1811041 WILLIAMSBURG REGIONAL HOSPITAL IS A NOT FOR PROFIT ACUTE CARE HOSPITAL WITH 25 LICENSED BEDS, PROVIDING EXCELLENCE IN PATIENT CARE IN AN ENVIRONMENT THAT IS RESPECTFUL OF OTHERS, ADAPTIVE TO CHANGE, ACCOUNTABLE FOR OUTCOMES, AND ATTENTIVE TO THE NEEDS OF THE COMMUNITY. 0 0 15343722 16497274 IN FISCAL YEAR 2012, THERE WERE 2,070 TOTAL ACUTE CARE PATIENT DAYS ALONG WITH SWING BED SERVICE PATIENT DAYS OF 2,069. OUTPATIENT VOLUMES WERE AS FOLLOWS : 11,037 ER VISITS, 25,399 PHYSICAL THERAPY PROCEDURES, 7,227 OCCUPATIONAL THERAPY PROCEDURES, 821 SPEECH THERAPY PROCEDURES, 47,451 RESPIRATORY PROCEDURES, 82,080 PHARMACY PRESCRIPTIONS, 49,325 LABORATORY PROCEDURES, AND 11,094 RADIOLOGY PROCEDURES, 216 SLEEP LAB VISITS. 15343722 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 69 0 1 266 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 SC X DONNA L KENYON CONTROLLER 8433550172 PO DRAWER 568 KINGSTREE SC 29556 JOHN MARTIN 1.00 X 0 0 0 JIM CHERRY 1.00 X 0 0 0 HARRY FLOYD MD 1.00 X 0 0 0 WILLIAM JENKINSON III 1.00 X 0 0 0 JAMES KIRBY 1.00 X 0 0 0 LEE MCCLARY 1.00 X 0 0 0 STANLEY PASLEY 1.00 X 0 0 0 FRANK TREFNY MD 1.00 X 0 0 0 JULIE FLOYD 1.00 X 0 0 0 STANLEY MYERS 1.00 X 0 0 0 MITCHELL D MONSOUR 40.00 X 132200 0 0 DAN HARRINGTON 40.00 X 58692 0 5082 SHERI SEIGLER 40.00 X 44734 0 1318 SHARON POSTON 40.00 X 105282 0 8381 DAVID KLINE 40.00 X 83870 0 6884 BAMBIE N FLOYD 40.00 X 44372 0 3394 DR TROY GAMBLE 40.00 X 112774 0 8461 MARK D FIELDER MD 21.00 X 190175 0 11463 TONNY HARMON 40.00 X 101678 0 8809 CATHERINE C POSTON 40.00 X 101773 0 8875 LIDIA M BURROUGHS 40.00 X 102634 0 8915 NAGASUMANTH VEMULA MD 40.00 X 257832 0 12567 1336016 0 84149 7 0 1 0 PEE DEE EMERGENCY PO BOX 246 MANNING SC 29102 ER PHYSICIANS 1215718 SLEEP MANAGEMENT LLC 6100 DUTCHMANS LN LOUISVILLE KY 40205 SLEEP LAB 198350 MCLEOD PHYSICIAN ASSOCIATES 901 E CHEVES ST FLORENCE SC 29506 PHYSICIAN SERVICES 172800 MERCATOR HEALTH ADVISORS PO BOX 16171 JACKSON MS 39236 CEO 132200 CLIFTONLARSONALLEN 101 NORTH TRYON STREET CHARLOTTE NC 28246 AUDITING SERVICES 122242 6 2166 606300 243990 852456 NET PATIENT REVENUE 621400 16244794 16244794 252480 252480 16497274 56096 54312 1784 1784 1784 17351514 16497274 0 1784 437192 437192 6787640 5944594 843046 58428 58428 1646623 1460281 186342 521482 462468 59014 17413 17413 3660927 3147568 513359 21172 629 20543 209745 64191 145554 694405 651971 42434 33071 32004 1067 9354 5526 3828 279547 279547 235129 235129 151132 151132 PATIENT SUPPLIES 1967320 1890625 76695 LICENSE AND PERMIT 404350 404350 REPAIRS AND MAINTENANCE 342892 273493 69399 332889 248944 83945 17810711 15343722 2466989 0 139062 147264 339057 0 3150506 3782513 409453 428312 78499 78546 11722433 9460975 2328909 2261458 15000 15000 46196 108635 6506682 6821728 3806155 4616514 2128441 1751039 1923930 2265216 7858526 8632769 X -1351844 -1811041 -1351844 -1811041 6506682 6821728 -459197 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 445790 445790 4003777 2805379 1198398 1456126 1427559 28567 5816740 5228037 588703 2261458 DUE TO THIRD PARTY 2243643 OTHER LIABILITIES 21573 2265216 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A TAX-EXEMPT ORGANIZATION AS DEFINED UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND AS SUCH IS EXEMPT FROM FEDERAL INCOME TAXES. IN ADDITION, THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES. THE HOSPITAL FILES AS A TAX-EXEMPT ORGANIZATION. SHOULD THIS STATUS BE CHALLENGED IN THE FUTURE, THE 2009, 2010, AND 2011 TAX YEARS ARE OPEN FOR EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. MANAGEMENT IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. 1 1 1 X 1 X 1 0 0 232155 232155 0.01810 1130127 1892934 -762807 0.00000 1362282 1892934 -530652 0.01810 1362282 1892934 -530652 0.01810 1 2262231 5887386 7436438 -1549052 X 1 1 1 SELECT LABORATORIES INDEPENDENT LAB OWNED BY MULTIPLE PHYSICIANS, ETC. 0.00008 1 1 WILLIAMSBURG REGIONAL HOSPITAL

500 NELSON BOULEVARD KINGSTREE SC 29556

X X WILLIAMSBURG REGIONAL HOSPITAL 1 1 1 200.000000000000 1 200.000000000000 1 1 1 X X 1 X X 1 X X X X 1 X 0 1 PART I, LINE 7: THE ORGANIZATION USED THE IRS WORKSHEETS TO CALCULATE THE AMOUNTS REPORTED ON SCHEDULE H. PART I, LINE 7G: N/A. NO SUBSIDIZED HEALTH SERVICES PROVIDED. PART I, L7 COL(F): THE ORGANIZATION DOES NOT HAVE A PROCESS FOR ESTIMATING THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY FINANCIAL ASSISTANCE POLICY. THE ORGANIZATION MAKES ITS BEST EFFORT TO DETERMINE FINANCIAL ASSISTANCE ELIGIBILITY WITH EVERY PATIENT. PART II: THIS CRITICAL ACCESS HOSPITAL HAS LIMITED COMMUNITY BUILDING ACTIVITES. PART III, LINE 8: THE HOSPITAL PROVIDES SERVICES TO PATIENTS REGARDLESS OF ABILITY TO PAY. AS A RESULT, THE HOSPITAL HAS INCURRED LOSSES BY SERVING MEDICARE PATIENTS. THE UNREIMBURSED SERVICES THE HOSPITAL PROVIDES TO THE COMMUNITY SHOULD BE CONSIDERED A COMMUNITY BENEFIT SINCE THE HEALTHCARE NEEDS OF THE COMMUNITY WOULD OTHERWISE BE UNMET. PART III, LINE 9B: IT IS THE POLICY OF WILLIAMSBURG REGIONAL HOSPITAL TO PRESERVE THE ASSETS OF THE HOSPITAL WHILE ACHIEVING THE GOAL OF ADMINISTERING MEDICAL CARE TO THOSE IN NEED, WITHOUT REGARD TO RACE, COLOR, ANCESTRY, NATIONAL ORIGIN, RELIGION, SEXUAL ORIENTATION, AGE, SEX, MARITAL OR DISABILITY STATUS. ALL WHO RECEIVE MEDICAL CARE AND ARE CAPABLE OF PAYING FOR ALL OR PART OF THE COST OF THESE SERVICES MUST DO SO. IT IS THE POLICY OF WILLIAMSBURG REGIONAL HOSPITAL TO COLLECT PAYMENT FOR SERVICES RENDERED OR PROVIDE FINANCIAL ASSISTANCE TO ALL PATIENTS WHO OWE OUTSTANDING PATIENT BALANCES. FINANCIAL COUNSELORS WILL SCREEN OR PRESCREEN ANY PATIENT OR RESPONSIBLE PARTY THAT IS UNEMPLOYED OR WHO INDICATES THAT FINANCIAL ASSISTANCE MAY BE NEEDED. WILLIAMSBURG REGIONAL HOSPITAL PART V, SECTION B, LINE 13G: CHARITY PROGRAM MENTIONED ON THE FIRST STATEMENT SENT OUT TO PATIENTS. WILLIAMSBURG REGIONAL HOSPITAL PART V, SECTION B, LINE 15E: REPORTING DEBT TO SET OFF PROGRAM TO THE STATE, WHEREBY INDIVIDUALS STATE TAX REFUNDS MAY BE CAPTURED AND APPLIED TO DEBT. WILLIAMSBURG REGIONAL HOSPITAL PART V, SECTION B, LINE 16E: RSI SENDS SET OFF FILE TO STATE EVERY YEAR. WILLIAMSBURG REGIONAL HOSPITAL PART V, SECTION B, LINE 19D: ALL SERVICES BILLED AT SAME RATE. WILLIAMSBURG REGIONAL HOSPITAL PART V, SECTION B, LINE 21: THE HOSPITAL BILLS SELF PAY PATIENTS AT THE NORMAL ESTABLISHED RATES. HOWEVER, IF THE PATIENTS COME IN TO SETTLE THE BILL, OFTEN TIMES THEY WILL BE GIVEN A DISCOUNT FOR PROMPT PAYMENT, ESPECIALLY IF THEY HAVE CASH IN HAND. PART VI, LINE 2: THIS IS A CRITICAL ACCESS HOSPITAL THAT PROVIDES MEDICAL SERVICES TO THE COMMUNITY. PART VI, LINE 3: PATIENT SERVICE CENTER. PART VI, LINE 4: THIS IS A CRITICAL ACCESS HOSPITAL THAT PROVIDES MEDICAL SERVICES TO THE COMMUNITY. PART VI, LINE 5: THIS IS A CRITICAL ACCESS HOSPITAL THAT PROVIDES MEDICAL SERVICES TO THE COMMUNITY. PART VI, LINE 6: N/A X X 0 0 0 0 0 0 0 0 0 MARK D FIELDER MD 190175 0 0 0 0 0 1879 0 9584 0 201638 0 0 0 NAGASUMANTH VEMULA MD 257832 0 0 0 0 0 2002 0 10565 0 270399 0 0 0 EXCHANGE BANK OF SC AN OFFICER OF THE HOSPITAL IS ALSO AN OFFICER OF EXCHANGE BANK OF SC JOHN MARTIN IS THE CHAIRMAN OF THE BOARD FOR THE FILING ORGANIZATION AND ALSO AN EXECUTIVE OF THE EXCHANGE BANK OF SC, WHICH HELD $128,447 FOR THE HOSPITAL AT SEPTEMBER 30, 2012. EXCHANGE BANK OF SC ALSO PROVIDED THE HOSPITAL WITH A NOTE PAYABLE DURING 2009. THE BALANCE OF THIS NOTE WAS $12,135 AS OF SEPTEMBER 30, 2012. 0 FORM 990, PART VI, SECTION B, LINE 11 FORM 990 TAX RETURN IS REVIEWED BY MANAGEMENT AND MADE AVAILABLE TO THE GOVERNING BODY BEFORE RETURNS FOR FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE DISCLOSED ANNUALLY. WHEN A CONFLICT ARISES, THE BOARD MEMBER IS EXCUSED FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF TRUSTEES AND THE HOSPITAL ATTORNEY DETERMINE THE SPECIFICS OF THE EMPLOYMENT CONTRACT WITH THE CEO OR TOP MANAGEMENT OFFICIAL. IN 2008, THE PROCESS INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. OTHER MANAGEMENT SALARIES ARE DETERMINED JOINTLY BY THE HUMAN RESOURCE DEPARTMENT AND THE CEO. 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. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE TAX YEAR. FORM 990, PART VII, DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS: OFFICERS LISTED ON PART VII WORK AN AVERAGE OF 40 HOURS PER WEEK. THEIR TIME IS SHARED BETWEEN THE FILING ORGANIZATION AND THE RELATED ENTITY LISTED ON SCHEDULE R. WILLIAMSBURG REGIONAL FOUNDATION INC PO DRAWER 568 KINGSTREE SC 29556 200161602 FUNDRAISING SC 501(C)3 509(A)3 N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0