2013-10-15T12:59:39-05:00 2012-12-31 454051133 FREED MAXICK CPAS PC 800 LIBERTY BLDG 420 MAIN ST BUFFALO NY 142023508 990 2012-01-01 150346515 ALICE HYDE MEDICAL CENTER ALIC 5184833000 133 PARK STREET MALONE NY 12953 DOUGLAS DIVELLO 5184833000 2013-10-07 1 MARY MADONIA P00405803 7168472651 2012 2016-03-07 17:11:31Z DOUGLAS DIVELLO 133 PARK STREET MALONE NY 12953 70231628 0 X WWW.ALICEHYDE.COM X 1905 NY TO SERVE THE COMMUNITY THROUGH ACUTE, LONG TERM AND PRIMARY HEALTHCARE. 12 11 731 842 0 0 679381 2372179 65478952 67247947 -36587 101036 1241898 -59353 67363644 69661809 0 0 0 0 42510371 42464846 7500 0 93982 26655328 26314357 69173199 68779203 -1809555 882606 40880625 39770508 18689138 16620003 22191487 23150505 ALICE HYDE MEDICAL CENTER WILL DISTINGUISH ITSELF AS A TRUSTED AND RESPECTED HEALTH CARE LEADER AND PROVIDER OF CHOICE, EXCEEDING EXPECTATIONS THROUGH SERVICE EXCELLENCE. 0 0 57793274 67247947 PATIENT CARE, GENERAL MEDICAL/SURGICAL HOSPITAL, PROVIDED INPATIENT SERVICES FOR 3,005 PEOPLE, OUTPATIENT SERVICES FOR 838,456 VISITS, AND PROVIDED 27,061 DAYS OF SKILLED NURSING FACILITY CARE. 57793274 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 27 0 731 1 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NY X SANDRA MACDONALD CONTROLLER 5184833000 133 PARK STREET MALONE NY 12953 ANJNI BHAGAT MD 10.00 X 46008 0 0 WILLIAM BOND REV 10.00 X 0 0 0 DANIEL CLARK 10.00 X X 0 0 0 WAYNE DUSO 10.00 X 0 0 0 JERRY GRIFFIN 10.00 X 0 0 0 BRYAN J HUGHES 10.00 X 0 0 0 DEAN JOHNSTON 10.00 X X 0 0 0 BENSON KELLY MD 10.00 X 0 0 0 CRAIG LAVIGNE 10.00 X X 0 0 0 THOMAS LEITZ 10.00 X 0 0 0 BRIAN MONETTE 10.00 X X 0 0 0 SHARON NOREAULT 10.00 X 0 0 0 JOHN JOHNSON 40.00 X 251426 0 10652 D CHRIS FRAUENHOFER 40.00 X 196227 0 8278 LEONARDO DISHMAN MD 40.00 X 185870 0 5558 DOUG DIVELLO 40.00 X 106648 0 1903 JOHN AUFDENGARTEN 40.00 X 174964 0 395 DRAGOS MACELARU MD 40.00 X 786703 0 9570 MARCO BERARD MD 40.00 X 776992 0 8400 RAHUL GUPTA MD 40.00 X 399199 0 5077 NIKALESH REDDY MD 40.00 X 355912 0 3011 MYRNA SANCHEZ MD 40.00 X 280964 0 6970 3560913 0 59814 35 0 1 0 RLPS II 1910 HARRINGTON DRIVE LANCASTER PA 17601 ARCHITECT 1347690 APOGEE MEDICAL MANAGEMENT 2525 E CAMELBACK ROAD PHOENIX AZ 85016 HOSPITALIST PROFESSIONAL 931214 MEMS PC 484 TEMPLE HILL ROAD NEW WINDSOR NY 12553 EMERGENCY PROFESSIONAL 924343 FLETCHER ALLEN HEALTHCARE PO BOX 1870 BURLINGTON VT 054021870 UROLOGY & CARDIOLOGY PROFESSIONALS 574005 WEATHERBY LOCUMS 6440 MILLROC DRIVE SALT LAKE CITY UT 84121 LOCUMS SERVICES 491317 5 50825 2174275 147079 2372179 PATIENT CARE 622000 67247947 67247947 67247947 33141 33141 203579 268492 -64913 -64913 -64913 353039 285144 67895 67895 67895 21743 50825 16183 5560 5560 69661809 67247947 0 41683 941921 941921 33147462 28466228 4608449 72785 1005235 864030 139021 2184 4918833 4212809 695106 10918 2451395 2121917 324383 5095 2386336 2052249 334087 367016 367016 196845 196845 33117 33117 3000 3000 88103 75769 12334 212668 182894 29774 1249630 1074682 174948 94160 80978 13182 377617 324751 52866 3022401 2599265 423136 721870 620808 101062 MEDICAL SUPPLIES & IMPL 7189827 6183251 1006576 DIRECT EXPENSES 4918428 4229848 688580 PHARMACEUTICALS 3251587 2796365 455222 UTILITIES 1474349 1267940 206409 727403 639490 87913 68779203 57793274 10891947 93982 46408 1162831 10612866 9210679 1010379 1190757 812837 617856 1008806 566612 64855968 41241318 23304091 23614650 3057252 2366366 1027986 1040757 40880625 39770508 11088840 9504770 2752835 2759082 4847463 4356151 18689138 16620003 X 21391821 22332059 615720 634500 183946 183946 22191487 23150505 40880625 39770508 882606 76412 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 33117 33117 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION RETAINS AN OUTSIDE LOBBYIST FOR CONTACT WITH STATE AND FEDERAL ELECTED OFFICIALS REGARDING HEALTH CARE ISSUES AND GRANT FUNDING OPPORTUNITIES. 183946 183946 183946 183946 183946 183946 183946 183946 183946 183946 1.00000 0 0 364054 364054 34636287 22381308 12254979 27595105 18860010 8735095 2260522 2260522 23614650 X 69754404 76412 16183 92595 69661809 0 69661809 68795386 16183 16183 68779203 0 68779203 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE MEDICAL CENTER IS A NOT-FOR-PROFIT ORGANIZATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE), AND ACCORDINGLY, IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN REFLECTED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE MEDICAL CENTER ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH U.S. GAAP, WHICH REQUIRES THE RECOGNITION AND MEASUREMENT OF UNCERTAIN INCOME TAX POSITIONS THAT THE MEDICAL CENTER HAS TAKEN OR EXPECTS TO TAKE IN THE MEDICAL CENTER'S TAX RETURN. THE MEDICAL CENTER HAS NOT RECORDED ANY AMOUNTS RELATING TO UNCERTAIN TAX POSITIONS. IN ADDITION, THE MEDICAL CENTER IS NO LONGER SUBJECT TO FEDERAL AND NYS INCOME TAX EXAMINATION FOR YEARS PRIOR TO 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES NETTED AGAINST REVENUE 16,183. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES NETTED AGAINST REVENUE 16,183. GOLF BENEFIT 33758 28850 4908 8103 131 2636 GALA 38810 21975 16835 3122 800 1391 72568 50825 21743 8103 3253 800 4027 16183 5560 1 1 1 X 1 X 1 1 1 0 1 1 155 943014 902604 40410 0.00060 15106219 12031392 3074827 0.04470 0 0 155 16049233 12933996 3115237 0.04530 2337 83878 27757 56121 0.00080 0 0 0 0 0 0 37181 0 37181 0.00050 2337 121059 27757 93302 0.00130 2492 16170292 12961753 3208539 0.04660 1 2336277 1173367 11479258 12340156 -860898 X 1 1 1 1 ALICE HYDE MEDICAL CENTER

133 PARK STREET MALONE NY 12953

ALICEHYDE.COM X X X ALICE HYDE MEDICAL CENTER 1 1 1 300.000000000000 0 1 X X X X X 1 1 X X X X X 1 X X 1 X X X X X X 1 X 0 0 1 ALICE HYDE NURSING HOME

133 PARK STREET MALONE NY 12953

SKILLED NURSING FACILITY PART I, LINE 7: UTILIZED IRS WORKSHEETS FOR SCHEDULE H AND RATIO OF COST TO CHARGES. PART I, L7 COL(F): BAD DEBT WAS NOT INCLUDED IN CALCULATIONS IN SCHEDULE H, PART I, LINE 7. PART III, LINE 4: THE MEDICAL CENTER RECOGNIZES PATIENT SERVICE REVENUE ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY PAYOR COVERAGE ON THE BASIS OF CONTRACTUAL RATES FOR THE SERVICES RENDERED. FOR UNINSURED PATIENTS THAT DO NOT QUALITY FOR CHARITY CARE, THE MEDICAL CENTER RECOGNIZES REVENUE ON THE BASIS OF ITS STANDARD RATES FOR SERVICES PROVIDED (OR ON THE BASIS OF DISCOUNTED RATES, IF NEGOTIATED OR PROVIDED BY POLICY). BASED UPON HISTORICAL EXPERIENCE, A SIGNIFICANT PORTION OF THE MEDICAL CENTERS UNINSURED PATIENTS WILL BE UNABLE OR UNWILLING TO PAY FOR THE SERVICES PROVIDED. THUS, THE MEDICAL CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED. PART III, LINE 8: THE MEDICARE BENEFICIARIES WHO ALICE HYDE PROVIDES SERVICES TO ARE PART OF OUR COMMUNITY OF MALONE, NEW YORK, AND THEREFORE, SHOULD BE TREATED AS COMMUNITY BENEFIT. THE SOURCE FOR THE COST METHODOLOGY IS THE 2012 MEDICARE COST REPORT. PART III, LINE 9B: THE CENTER PROVIDE CARE TO CLIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. THE CENTERS POLICY IS NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE; THEREFORE THESE AMOUNTS ARE NOT REPORTED IN NET OPERATING REVENUES OR IN PROVISIONS FOR DOUBTFUL ACCOUNTS. THE ESTIMATED COST OF PROVIDING UNCOMPENSATED CARE TO PATIENTS WAS APPROXIMATELY $1,000,000 FOR THE YEAR ENDED DECEMBER 31, 2012 ($731,000- 2011), AS MEASURED UTILIZING A CALCULATED RATIO OF COSTS TO CHARGES. ALICE HYDE MEDICAL CENTER PART V, SECTION B, LINE 11: ANY PATIENT WIHOUT INSURANCE IS GIVEN A DISCOUNT EQUAL TO THE LOWEST NEGOCIATED COMMERICAL INSURANCE RATE. FORM 990, SCHEDULE H, PART VI, LINE 3 THE ALICE HYDE MEDICAL CENTER (AHMC) BELIEVES THAT FEAR OF A MEDICAL BILL SHOULD NOT PRECLUDE A RESIDENT OF ITS COMMUNITY FROM SEEKING OR OBTAINING ESSENTIAL HEALTH CARE SERVICES. TO HELP THOSE WHO ARE UNINSURED, AHMC PARTNERS WTIH VARIOUS ORGANIZATIONS, INCLUDING THE FRANKLIN COUNTY DEPARTMENT OF SOCIAL SERVICES, PUBLIC HEALTH, FIDELIS, AND EXCELLUS, TO ENSURE ACCURATE INFORMATION AND RESOURCES ARE AVAILABLE THROUGHOUT THE COMMUNITY, INCLUDING A FACILITATED ENROLLMENT PROGRAM FOR ITS UNINSURED PATIENTS. THIS PROGRAM ASSISTS INDIVIDUALS IN APPLYING FOR STATE SPONSORED HEALTH INSUANCE INCLUDING MEDICAID, CHILD HEALTH PLUS AND FAMILY HEALTH PLUS. THE GOAL OF THIS INITATIVE IS TO PROVIDE A CONVENIENT LOCATION FOR PATIENTS AND COMMUNITY MEMBERS TO ACCESS THE PROGRAM AND TO PROVIDE ASSISTANCE IN COMPLETING HEALTH INSURANCE APPLICATIONS. THESE GOALS ARE MET THROUGH A PARTNERSHIP BETWEEN AHMC AND UPPER HUDSON PRIMARY CARE CONSORTIUM. AHMC HAS AN EMPLOYEE DEDICATED TO FINANCIAL COUNSELING AND ASSISTANCE. FORM 990, SCHEDULE H, PART VI, LINE 4 ALICE HYDE MEDICAL CENTER (AHMC) PRIMARILY SERVES TOWNS, VILLAGES, AND THE NATIVE AMERICAN RESERVATION IN FRANKLIN COUNTY. AHMC'S PRIMARY SERVICE AREA COVERS THE FOLLOWING TOWNS (BY ZIP CODE) - MALONE (12953), NORTH BANGOR (12966), CHATEAUGAY (12920), CONSTABLE (12926), BRUSHTON (12916), MOIRA(12957), BURKE (12917), FORT COVINGTON (12937), HOGANSBURG (13655), SAINT REGIS FALLS (12980),BOMBAY (12914), OWLS HEAD (12969), DICKINSON CENTER (12930). THE SECONDARY SERVICE AREAS SERVED BY AHMC INCLUDE CHURUBUSCO (12923), ELLENBURG CENTER (12934), NORTH LAWRENCE (12967), LYON MOUNTAIN (12955), NICHOLVILLE (12965). IN ADDITION, AHMC PROVIDES SERVICES TO THE INMATE POPULATION FOR THE FRANKLIN COUNTY JAIL AND THE CLINTON, FRANKLIN, UPSTATE, BAREHILL, CHATEAUGAY, ALTONA AND ADIRONDACK CORRECTIONAL FACILITIES. FORM 990, SCHEDULE H, PART VI, LINE 7 NEW YORK STATE X 0 0 X X X 0 0 0 0 0 0 0 0 0 JOHN JOHNSON 249846 0 0 0 1580 0 8322 0 2330 0 262078 0 0 0 D CHRIS FRAUENHOFER 196227 0 0 0 0 0 7663 0 615 0 204505 0 0 0 LEONARDO DISHMAN MD 185870 0 0 0 0 0 5558 0 0 0 191428 0 0 0 JOHN AUFDENGARTEN 174964 0 0 0 0 0 0 0 395 0 175359 0 0 0 DRAGOS MACELARU MD 536703 0 250000 0 0 0 7500 0 2070 0 796273 0 0 0 MARCO BERARD MD 526992 0 250000 0 0 0 7500 0 900 0 785392 0 0 0 RAHUL GUPTA MD 399199 0 0 0 0 0 5077 0 0 0 404276 0 0 0 NIKALESH REDDY MD 355912 0 0 0 0 0 2513 0 498 0 358923 0 0 0 MYRNA SANCHEZ MD 280964 0 0 0 0 0 5590 0 1380 0 287934 0 0 0 PART I, LINE 1B AS PART OF THE PRESIDENT'S COMPENSATION PACKAGE CONSIDERED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS, THE ALICE HYDE MEDICAL CENTER (AHMC) PROVIDED FOR THE CONTINUED FORGIVENESS OF CERTAIN OBLIGATIONS UNDER A NOTE EXECUTED BY THE PRESIDENT ON JULY 27, 2004 CONTEMPORANEOUS WITH THE TRANSFER OF A CERTAIN LIFE INSURANCE POLICY AND FOR TAX INDEMNIFICATION AND GROSS UP PAYMENTS RELATED THERETO. THE PRESIDENT'S RIGHT TO SUCH ADDITIONAL COMPENSATION IS SPECIFICALLY CONDITIONED ON HIS CONTINUTED PERFORMANCE OF SUBSTANTIAL SERVICES IN ACCORDANCE WITH THE PRESIDENT'S EMPLOYMENT AGREEMENT, AS AMENDED. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY AN INDEPENDENT OUTSIDE ACCOUNTING FIRM. IT IS PROVIDED TO THE FULL BOARD OF DIRECTORS FOR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS MONITORED AND ENFORCED BY THE BOARD OF DIRECTORS. SPECIFICALLY, THE POLICY REQUIRES A DISCLOSURE OF ANY POTENTIAL CONFLICT TO THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS THEN REFERS THE POTENTIAL CONFLICT TO THE AUDIT AND COMPLIANCE COMMITTEE TO REVIEW THE MATTER. THE AUDIT AND COMPLIANCE COMMITTEE REVIEWS THE PROPOSED TRANSACTION OR ARRANGEMENT TO DETERMINE IF REASONABLE ATLTERNATIVES TO THE PROPOSED TRANSACTION EXIST. BASED ON REVIEW, THE AUDIT AND COMPLIANCE COMMITTEE SHALL APPROVE OR DISAPPROVE THE TRANSACTION. ALL FINDINGS AND ACTIONS TAKEN BY THE AUDIT AND COMPLIANCE COMMITTEE ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED MEETING OF THE BOARD OF DIRECTORS. IN ADDITION, THE AUDIT AND COMPLIANCE COMMITTEE AND THE ORGANIZATION COMPLIANCE OFFICER IS RESPONSIBLE FOR REVIEWING AND RETAINING ANNUAL DISCLOSURE STATEMENTS COMPLETED BY EACH DIRECTOR, OFFICER, COMMITTEE MEMBER AND KEY EMPLOYEE. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMING THE BEGINNING OF THE YEAR PRESIDENT/CEO'S COMPENSATION WAS ESTABLISHED AT CONTRACT RENEWAL IN 2012. THE PROCESS IS AS FOLLOWS: THE BOARD OF DIRECTORS REVIEWED IN DEPTH THE RECOMMENDATION OF THE PRESIDENT/CEO EVALUATION AND COMPENSATION COMMITTEE ("COMPENSATION COMMITTEE") RELATING TO THE EXTENSION OF THE EMPLOYMENT CONTRACT OF THE CURRENT PRESIDENT/CEO AND UNANIMOUSLY APPROVED SUCH EXTENSION. THE PRESIDENT/CEO WAS NOT PRESENT AT THIS MEETING OR ANY OTHER MEETING AT WHICH HIS COMPENSATION WAS CONSIDERED. AS PART OF ITS REVIEW AND DISCUSSION, THE FULL BOARD OF DIRECTORS DISCUSSED THE DATA PREVIOUSLY REVIEWED BY THE COMPENSATION COMMITTEE. THIS DATA INCLUDED, BUT WAS NOT LIMITED TO, COMPARABILITY DATA COMPILED BY YAFFEE AND COMPANY, INC. AS PROVIDED TO AHMC BY THE IROQUOIS HOSPITAL ASSOCIAITON FOR THE YEAR 2012. SPECIFICALLY, THE COMPENSATION COMMITTEE REVIEWED THE DATA AND REPORTED RESULTS OF THIS REVIEW TO THE BOARD OF DIRECTORS, CONCERNING BASE SALARY AND TOTAL COMPENSATION FOR ALL THE OFFICERS AT FACILITIES LOCATED WITHIN THE RANGE FOR SIMILARY SITUATED OFFICERS. THE COMPENSATION COMMITTEE ALSO REVIEWD DATA COMPILED BY THE IROQUOIS HEALTHCARE ASSOCIATION/ROCHESTER REGIONAL HOSPITAL ASSOCIATION WESTERN NEW YORK HOSPITAL ASSOCIATION FOR 2012 RELATING TO COMPARABLE CEO INCENTIVE PLANS, LIFE INSURANCE (BASIC AND SUPPLEMENTAL), LONG TERM DISABILITY PLANS, SUPPLEMENTAL/EXECUTIVE RETIREMENT PLANS, CONTRACT LENGTH INFORMATION, SEVERANCE PAY INFORMATION AND PREREQUISITES SUMMARY. IT WAS FINALLY DETERMINED THAT THE PRESIDENT/CEO'S PROPOSED CONTRACT EXTENSION WAS REASONABLE AND COMPARABLE IN LIGHT OF THE AFOREMENTIONED INFORMATION. THE PROCESS FOR DETERMINING THE PRESIDENT/CEO AT THE END OF THE YEAR'S COMPENSATION WAS SIMILIAR. THE PROCESS FOR DETERMINING THE COMPENSATION FOR KEY EMPLOYEES OF THE ORGANIZATION INCLUDES A REVIEW OF EXECUTIVE COMPENSATION SURVEYS. THIS REVIEW IS COMPLETED BY THE HUMAN RESOURCES DIRECTOR AND THE PRESIDENT/CEO. COMPENSATION IS DETERMINED BASED ON THE SPECIFIC RESPONSIBILIES DELEGATED TO THE POSITION HELD BY THE KEY EMPLOYEE. FORM 990, PART VI, SECTION C, LINE 18 THE COMPLETED FORMS 1023, 990, AND 5500 FOR THE MEDICAL CENTER ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, THE CONFLICT OF INTEREST POLICY, AND THE FINANCIAL STATEMENTS FOR THE MEDICAL CENTER ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 2C THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR TO THE PROCESS THAT THE ORGANIZATION HAS IN PLACE FOR THE OVERSIGHT OF THE AUDIT OR THE SELECTION OF AN INDEPENDENT ACCOUNTANT.