2013-10-23T11:47:13-05:00 2012-12-31 264298079 EFP ROTENBERG LLP 280 KENNETH DRIVE ROCHESTER NY 14623 990 2012-01-01 160743068 LAKESIDE MEMORIAL HOSPITAL INC LAKE 5853956095 156 WEST AVENUE BROCKPORT NY 14420 JAMES CUMMINGS 5853956095 2013-10-23 1 WILLIAM MCDONALD P01600766 5854278900 2013-10-21 2012 2016-02-24 21:20:13Z JAMES CUMMINGS 156 WEST AVENUE BROCKPORT NY 14420 40943025 0 X WWW.LAKESIDEHEALTH.COM X 1939 NY TO PROVIDE A FULL RANGE OF HOSPITAL/MEDICAL SERVICES TO THE GENERAL PUBLIC. 12 10 542 138 -166611 -460805 0 2485 35126804 32425950 60617 73097 5546752 6085638 40734173 38587170 0 0 0 0 23912327 21232491 0 0 0 20694344 20932294 44606671 42164785 -3872498 -3577615 22578748 19178983 23019321 22360813 -440573 -3181830 LAKESIDE HEALTH SYSTEM IS TO BE THE CENTER OF OUR HEALTHCARE COMMUNITY AND TO PROVIDE THE HIGHEST LEVEL OF QUALITY, COMPASSIONATE, COST-EFFECTIVE CARE. THE SERVICES WE PROVIDE TO OUR CUSTOMERS ARE ROOTED IN AN INTEGRATED DELIVERY SYSTEM. 0 0 24748339 23037257 PATIENT HEALTH CARE INCLUDES SERVICES SUCH AS MEDICAL AND SURGICAL PROCEDURES, OBSTETRICS, INTENSIVE CARE, NEWBORN NURSERY, DELIVERY ROOM, RECOVERY ROOM, EMERGENCY ROOM, AND URGENT CARE CENTER. 12227788 10808650 OTHER PROFESSIONAL SERVICES INCLUDED LABORATORY COSTS, RADIOLOGY, INTRAVENOUS THERAPY, RESPIRATORY THERAPY, PHYSICAL THERAPY, AND ELECTROCARDIOLOGY COST INCURRED FOR PATIENT SERVICE 36976127 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 230 0 1 542 1 1 1 0 0 0 0 0 0 0 X 12 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 NY X X LEON GOSSIN 5853956095 156 WEST AVENUE BROCKPORT NY 14420 PATRICIA HAYLES 8.00 X X 0 0 0 NANCY PLEWS 8.00 X X 0 0 0 GERARD WENZKE 8.00 X X 0 0 0 KATHLEEN PETERSON 8.00 X 0 0 0 NORMAN KNIGHT 8.00 X 0 0 0 MARK MAXIM 8.00 X X 0 0 0 DAVID NEWMAN MD 8.00 X 0 0 0 MICHAEL RAFF OD 8.00 X 0 0 0 DANIEL RICHARDSON 8.00 X 0 0 0 THOMAS RICHARDSON 8.00 X 0 0 0 JOHN RISOLO MD 8.00 X 0 0 0 DR JAMES SZALADOS 2.00 X 0 0 0 HUGH COLLINS 40.00 X 117382 0 23456 JIM CUMMINGS 40.00 X 123127 0 15595 HARRIS SILVERMD 40.00 X 504055 0 100811 TIMOTHY HAGY 40.00 X 249673 0 49935 ERIK PETERSON 40.00 X 438977 0 87795 JASON MCCLUNG MD 40.00 X 397745 0 79549 JACK DAVIDOFF 40.00 X 247541 0 49508 BRIDGETT REED 40.00 X 57482 0 11497 JAMES WISSLER 40.00 X 72045 0 14409 2208027 0 432555 7 1 1 0 URMC - ORTHO 4901 LAC DE VILLE BLVD ROCHESTER NY 14618 MEDICAL 620769 LAKESIDE ANESTHESIA PLLC 3205 MT READ BLVD ROCHESTER NY 14616 ANESTHESIOLOGY 490563 PRONEXUS 171 SULLYS TRAIL SUITE 201 PITTSFORD NY 14534 ACCOUNTING 229692 BETH PLATT & ASSOC 2100 PENFIELD RD WALWORTH NY 14568 MEDICAL BILLING/COLLECTION 189895 4 2485 2485 NET PATIENT SERVICE RE 621990 32425950 32425950 32425950 7605 7605 791710 499397 292313 292313 292313 866329 800837 65492 65492 65492 889010 1055621 -166611 -166611 PHYSICIAN PRACTICE 621110 3106233 3106233 MEANINGFUL USE INCOME 900099 1419957 1419957 SHARED SERVICES 900099 1061526 1061526 372220 372220 5959936 38587170 33845907 -166611 4905389 279561 279561 16970950 14670748 2300202 524720 444963 79757 2271811 1926495 345316 1185449 1005261 180188 165355 165355 80250 80250 7167 6137 1030 282441 282441 90556 82600 7956 320790 274683 46107 1887516 1646167 241349 398856 358486 40370 CONTRACTED SERVICES 8622167 8021101 601066 SUPPLIES 4863325 4590415 272910 BAD DEBT 2252028 2252028 LOSS ON IMPAIRMENT 1134956 987412 147544 826887 709631 117256 42164785 36976127 5188658 0 626739 696025 1048795 104018 4385332 4068879 947642 872243 669458 1507922 37383372 27843294 11664600 9540078 802654 2433528 2389818 22578748 19178983 6441922 6861373 7496373 6682678 9081026 8816762 23019321 22360813 X -1110248 -3866919 367253 382943 302422 302146 -440573 -3181830 22578748 19178983 X -3577615 -136 836494 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 9747 9747 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: AS MEMBERS OF 3 ASSOCIATIONS (AHA - AMERICAN HOSPITAL ASSOCIATION, HANYS-THE HEALTHCARE ASSOCIATION OF NEW YORK STATE & RRHA/SEAGATE ALLIANCE) A PORTION OF THE DUES (TOTAL REFLECTED ABOVE) ARE PAID AS PART OF MEMBERSHIP AND REPRESENT AMOUNTS DESIGNATED FOR LOBBYING ACTIVITIES. THESE ASSOCIATE ORGANIZATIONS OF WHICH WE ARE MEMBERS HANDLE THE DIRECT LOBBYING/ADVOCACY ACTIVITIES ON BEHALF OF THEIR MEMBERS. 51707 51707 19672339 14760056 4912283 17659326 13083238 4576088 9540078 BENEFICIAL INTEREST IN NET ASSETS OF LAKESIDE FOUNDATION, INC. 685089 DUE FROM RELATED PARTIES 1441521 OTHER ASSETS 263208 2389818 ACCRUED PENSION COSTS 7150939 ACCRUED POSTRETIREMENT BENEFITS 706337 DUE TO THIRD PARTY PAYERS 959486 8816762 X 37098450 -1488720 -1488720 38587170 0 38587170 39912757 0 39912757 2252028 2252028 42164785 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. HOWEVER, INCOME FROM CERTAIN ACTIVITIES NOT DIRECTLY RELATED TO THE HOSPITAL'S TAX-EXEMPT PURPOSES IS SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME. IN ACCORDANCE WITH ASC 740-10-50, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, THE HOSPITAL RECOGNIZES THE TAX BENEFITS FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES. MANAGEMENT BELIEVES THAT THE HOSPITAL IS CURRENTLY OPERATING IN COMPLIANCE WITH THE APPLICABLE REQUIREMENTS OF THE INTERNAL REVENUE CODE. THEREFORE, NO LIABILITY FOR UNRECOGNIZED TAX BENEFITS HAS BEEN INCLUDED ON THE HOSPITALS FINANCIAL STATEMENTS. THE EXEMPT HOSPITAL'S INFORMATIONAL RETURNS ARE SUBJECT TO AUDIT BY VARIOUS TAXING AUTHORITIES AND ITS OPEN AUDIT PERIODS ARE 2009 THROUGH 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: GROSS RENTS -791,710. RENTAL EXPENSE 499,397. COST OF GOODS SOLD 1,055,621. BAD DEBT EXPENSE -2,252,028. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,252,028. 1 1 1 X 1 X 1 1 1 0 1 1 190317 0 190317 0.00450 5468286 4617739 850547 0.02020 5658603 4617739 1040864 0.02470 5658603 4617739 1040864 0.02470 1 1118435 653629 3455360 4371838 -916478 X 1 1 1 1 LAKESIDE MEMORIAL HOSPITAL

156 WEST AVE BROCKPORT NY 14420

X X X LAKESIDE MEMORIAL HOSPITAL INC 1 1 1 200.000000000000 1 300.000000000000 1 X X X X 1 1 X X 1 1 X X X X 1 X 0 0 PART III, LINE 4: COST TO CHARGE RATIO FROM COST REPORT APPLIED BY PATIENT TYPE. BAD DEBT INCLUDED IN COMMUNITY BENEFIT BECAUSE MANY MORE PEOPLE WOULD QUALIFY IF THEY APPLIED, BUT THEY DID NOT GO THROUGH THE PROCESS. THIS IS LIKELY THE CASE WITH MOST OF BAD DEBT. PART III, LINE 8: COST PER CMS 2552-96 PER WKST D SERIES. PART III, LINE 9B: LAKESIDE MEMORIAL HOSPITAL WORKS WITH PATIENTS TO ESTABLISH A REASONABLE PAYMENT PLAN PRIOR TO ANY COLLECTION REFERRALS. PATIENTS WHO DO NOT FULFILL THEIR PAYMENT OBLIGATIONS WITHIN SPECIFIED TIME PERIODS WILL BE REFERRED TO A COLLECTION AGENCY FOR FURTHER COLLECTION ACTIVITY. LAKESIDE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 10: FAMILY SIZE AND EARNINGS BROKEN OUT MONTHLY AND YEARLY DETERMINES WHETHER FREE CARE WILL BE GIVEN. LAKESIDE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 11: FAMILY SIZE AND EARNINGS BROKEN OUT MONTHLY AND YEARLY DETERMINES THE PERCENTAGE OF CHARITY CARE TO BE PROVIDED. LAKESIDE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 20D: CHARITY CARE ASSISTANCE IS DETERMINED BY ASSESSING ANNUAL HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE IN THE HOME AND COMPARING IT TO THE FEDERAL POVERTY GUIDELINES FOR THE SAME SIZE HOUSEHOLD. THOSE PATIENTS WHO DO NOT FALL WITHIN THE POVERTY GUIDELINE WILL BE REQUIRED TO SUBMIT ADDITIONAL INFORMATION REDARGING INCOME, LIQUID ASSETS, AND EXPENSES. THE PROGRAM IS GENERALLY DESIGNED SO THAT PATIENTS ARE NOT EXPECTED TO EXPEND MORE THAN 20% OF THEIR INCOME OR 10% OF ASSETS FOR QUALIFYING HEALTHCARE OBLIGATIONS. PATIENTS WHO HAVE EXHAUSTED THEIR INSURANCE BENEFITS AND/OR EXCEED FINANCIAL ELIGIBILITY CRITERIA BUT FACE EXTRAORDINARY MEDICAL COSTS WILL BE TREATED ON A CASE-BY-CASE BASIS. PART VI, LINE 2: COMMUNITY PERCEPTION SURVEY, INTERVIEW LOCAL PHYSICIANS TO DETERMINE PATIENT SPECIALTY NEEDS. PART VI, LINE 3: GIVEN BROCHURE, SIGNS IN PATIENT REGISTRATION AREA, MEDICAID LIAISON USED BY CASE MANAGEMENT/SOCIAL WORK STAFF. PART VI, LINE 4: RURAL, COLLEGE STUDENTS, MIDDLE CLASS AND UNINSURED POPULATION. PART VI, LINE 6: LAKESIDE MEMORIAL HOSPITAL SERVES AS A HOSPITAL, LAKESIDE BEIKIRCH CARE CENTER IS A NURSING HOME WITH REHABILITATION SERVICES, LAKESIDE FOUNDATION RAISES MONEY FOR THE ENTITIES OF THE HEALTH SYSTEM, AND LAKESIDE CHILD CARE PROVIDES DAY CARE SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X X X 0 0 0 0 0 0 0 0 0 HARRIS SILVERMD 504055 0 0 0 0 0 0 0 100811 0 604866 0 0 0 TIMOTHY HAGY 249673 0 0 0 0 0 0 0 49935 0 299608 0 0 0 ERIK PETERSON 399977 0 0 0 39000 0 0 0 87795 0 526772 0 0 0 JASON MCCLUNG MD 378129 0 0 0 19616 0 0 0 79549 0 477294 0 0 0 JACK DAVIDOFF 247541 0 0 0 0 0 0 0 49508 0 297049 0 0 0 BRIDGETT REED 57482 0 0 0 0 0 0 0 11497 0 68979 0 0 0 JAMES WISSLER 72045 0 0 0 0 0 0 0 14409 0 86454 0 0 0 JOHN RISOLO MD DIRECTOR 21604 RENTS SPACE FROM ORGANIZATION 0 DAVID NEWMAN MD DIRECTOR 8580 PROVIDES BILLING SERVICES FOR ONE OF THE PHYSICIAN PRACTICES, ON CALL COVERAGE THROUGH CONTRACT, AND ED-PHYSICIAN SALARY 0 JAMES SZALADOS MD DIRECTOR 27450 MEDICAL DIRECTOR SALARY 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 IS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. THE FORM 990 IS PREPARED IN CONJUNCTION WITH ACCOUNTING FIRM AND MANAGEMENT. FORM 990, PART VI, SECTION B, LINE 12C EACH MEMBER SIGNS A STATEMENT THAT LISTS CONFLICTS AND THAT THEY HAVE REVIEWED CONFLICT OF INTEREST POLICY. AT ANNUAL BOARD MEETING ALL CONFLICTS ARE DISCUSSED WITH THE GROUP. FORM 990, PART VI, SECTION B, LINE 15A MARKET SURVEYS ARE UTILIZED TO ASSESS COMPETITIVE SALARY LEVELS FOR EXECUTIVE LEADERSHIP POSITIONS. WITH THIS SURVEY INFORMATION FOR THE ROCHESTER REGION AS A BASIS, IT IS LAKESIDE'S POLICY TO PAY SALARIES FOR ALL EXECUTIVE POSITIONS WHICH ARE COMPETITIVE FOR THE POSITION, WHICH ARE CONSISTENT WITH OUR ORGANIZATION'S SIZE AND WHICH ACCOUNT FOR THE OCCUPANT'S EXPERIENCE AND PERFORMANCE. COMPENSATION IS REVIEWED BY THE BOARD ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF LAKESIDE FOUNDATION 97,912. PENSION & POSTRETIREMENT CHANGES OTHER THAN NET PERIODIC BENEFIT COST -24,726. RENTAL EXPENSES 499,397. COST OF GOOD SOLD 1,055,621. GROSS RENTS -791,710. FORM 990, PART XI, LINE 2C NO CHANGE FROM PRIOR YEAR. LAKESIDE HEALTH SYSTEM INC 156 WEST AVENUE BROCKPORT NY 14420 161396374 TO PROVIDE MANAGEMENT SERVICES TO RELATED ENTITIES NY 501(C)(3) SECTION 509(A)(3) 1 LAKESIDEBEIKIRCH CARE CENTER INC 170 WEST AVENUE BROCKPORT NY 14420 222998029 OPERATION OF NURSING HOME NY 501(C)(3) SECTION 509(A)(2) 1 LAKESIDE FOUNDATION INC 156 WEST AVENUE BROCKPORT NY 14420 161374547 TO PROVIDE FINANCIAL SUPPORT TO RELATED ENTITIES NY 501(C)(3) 170(B)(1)(A) (VI) 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 LAKESIDEBEIKIRCH CARE CENTER INC Q 1323476 ACTUAL AMOUNTS INCURRED LAKESIDE FOUNDATION INC Q 116410 ACTUAL AMOUNTS INCURRED