2013-02-06T13:42:44-07:00 2012-06-30 990 2011-07-01 020222156 MEMORIAL HOSPITAL MEMO 6033565461 3073 White Mountain Highway North Conway NH 038605001 Roger Clapp 6033565461 2013-01-15 2011 2016-03-07 17:11:31Z Scott McKinnon President and CEO Same Address 3073 White Mountain Highway North Conway NH 03860 72775610 0 X http://www.thememorialhospital.org/ X 1910 NH Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire. 15 12 533 85 0 0 138066 173102 66202243 68927414 405020 565551 418877 575987 67164206 70242054 0 0 0 0 26637412 27563896 0 0 863221 36881732 40504315 63519144 68068211 3645062 2173843 68611842 71845152 23662522 25192746 44949320 46652406 X Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire. 1 0 57958318 0 69616690 Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington area of New Hampshire. Memorial Hospital is a 25 bed Critical Access Hospital and a 45 bed Intermediate Care Facility (Merriman House). The Hospital provides Med/Surg, ICU, ICF, Obstetrics, Radiology/Imaging, Oncology/Infusion, Cardiac Rehab, Wound Care, Specialty Care, ED and Primary Care. The Hospital had 4,729 Acute Inpatient Days, 15,337 ICF Inpatient Days and 12,584 ED Outpatient Visits in Fiscal Year 2012. 0 0 0 57958318 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 81 0 1 533 1 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Vera Schumann SVP-CFO 6033565461 3073 White Mtn Highway North Conway NH 038605001 Gene Bergoffen 1 X X 0 0 0 Bayard Kennett 1 X X 0 0 0 Phil Davies 1 X X 0 0 0 John Stratton 1 X X 0 0 0 Roger Clapp 1 X X 0 0 0 Daphne Wall 1 X 0 0 0 Melissa Myers 1 X 0 0 0 Janice Crawford 1 X 0 0 0 Barbara Hopkins 1 X 0 0 0 Thaire Bryant 1 X 0 0 0 Laura Jawitz 1 X 0 0 0 George Epstein 1 X 0 0 0 Scott McKinnon 40 X X 288054 0 34081 Raymond Rabideau 40 X X 1000 258729 27050 Allen Stam MD 40 X X 158070 0 23324 John Newton 40 X 317879 0 19384 David Riss MD 40 X 3000 408034 31899 Douglas Taylor MD 40 X 4000 484609 27050 Morice Dennery MD 40 X 0 555575 34400 Victor Lazaron MD 40 X 4000 419163 43500 Robert Tilney MD 40 X 3000 419181 32033 779003 2545291 272721 17 0 1 0 MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 Physician Services 8135142 Glen Builders Inc PO Box 1880 North Conway NH 03860 Building Contractor 358860 NORDX 102 Campus Drive Scarborough ME 04074 Lab Services 288344 Burgess Advertising & Marketing 1290 Congress St Portland ME 04102 Advertising & Marketing 222333 Navix Diagnostics PO Box 3698 Boston MA 02241 Nuclear Imaging Services 142476 5 0 0 40995 0 0 132107 0 173102 Hospital Services 622110 68927414 68927414 0 0 0 0 0 0 68927414 120609 0 0 120609 0 0 0 0 0 0 0 0 114732 0 228021 0 -113289 0 -113289 0 0 -113289 2724199 0 2279257 0 444942 0 444942 0 0 444942 26278 40995 26278 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Employee Prescriptions 446110 45622 45622 0 0 Cafeteria & Vending 722210 226182 226182 0 0 Community Health Staff Support 621300 153350 153350 0 0 264122 264122 0 0 689276 70242054 69616690 0 452262 0 0 0 0 0 0 0 0 1004497 219451 785046 0 0 0 0 0 18194121 14402543 3575091 216487 380277 301029 74723 4525 6626560 5242105 1305660 78795 1358441 1055913 286457 16071 0 0 0 0 146069 0 146069 0 102617 0 102617 0 0 0 0 0 0 0 28105 0 28105 0 10512004 10391181 120823 0 9012 0 9012 0 1374248 25043 844724 504481 259015 0 259015 0 0 0 0 0 3430688 2943151 461869 25668 116202 82307 33491 404 0 0 0 0 0 0 0 0 10901 10901 0 0 0 0 0 0 3585837 3127811 441236 16790 772734 0 772734 0 Medical Supplies 9083427 9083427 0 0 Bad Debt 6428589 6428589 0 0 Medicaid Enhancement Tax 2813347 2813347 0 0 Equipment Lease & Maintenance 1073022 1073022 0 0 758498 758498 0 0 68068211 57958318 9246672 863221 9680140 11668040 10086647 9569980 7676147 7338200 1895249 1906329 105102 23319 61863376 33289841 30897841 28573535 7599753 8348027 385565 366950 0 0 285398 4050772 68611842 71845152 3388295 4082435 19513257 19106647 760970 542664 1461000 23662522 25192746 X 44053700 45694398 282257 344645 613363 613363 44949320 46652406 68611842 71845152 X 2173843 -470757 X 0 1 1 X 0 X 6639144 0 100888 0 0 0 6740032 3575593 2400000 663551 0 0 0 6639144 3311669 0 263924 0 0 0 3575593 3205137 640000 -533468 0 0 0 3311669 0.89 0.09 0.02 0 0 0 598483 598483 0 43263018 21194315 22068703 0 0 0 0 0 16224442 10867594 5356848 0 1777433 1227932 549501 28573535 Est Third Party Settlement and Other Assets 4050772 4050772 0 Contigent Liabilities 1461000 1461000 SchD_P05_S00_L04 Schedule D, Part V, Line 4 The Endowment Fund contains permanently restricted funds with income available for general purposes. Also a portion of the earnings are to be used to assist patients with free care. The remainder of the fund is board designated. Annual Golf Tournament 67273 40995 26278 0 0 21006 0 0 5272 0 0 67273 40995 26278 0 0 21006 0 0 5272 26278 0 1 1 X 1 X 2.5 1 X 1 1 0 1 1 0 0 3425875 1660729 1765146 0.0287 0 0 7581943 6385023 1196920 0.0195 0 0 0 0 0 0 0 0 11007818 8045752 2962066 0.0482 0 0 305543 1500 304043 0.005 0 0 6000 0 6000 0.00001 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 311543 1500 310043 0.00501 0 0 11319361 8047252 3272109 0.05321 0 3433597 0 15654939 16890626 -1235687 X 1 1 1 1 Memorial Hospital

3073 White Mountain Highway North Conway NH 03860

X X X X Memorial Hospital 1 1 X X X X 10 1 0 1 X X X 1 1 1 250 1 400 1 X X X X X X X 1 1 X 1 1 1 X 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 Ratio of Patient Care Cost to Charges was used to calculate cost. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f The amount of Bad Debt excluded from the calculation was $6,390,466. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 FOOTNOTE 1-RECENT ACCOUNTING PRONOUNCEMENTS In July 2011, the FASB issued new guidance, Presentation and Disclosure of Patient Service Revenue, Provision for Bad Debts, and the Allowance for Doubtful Accounts. The guidance requires certain healthcare entities to present in certain circumstances the bad debt expense associated with patient service revenue as a deduction from patient service revenue (net of contractual allowances and discounts) rather than operating expense. The guidance is effective for fiscal years and interim periods within those fiscal years beginning after December 15, 2011, with early adoption permitted. The Hospital will adopt the presentation changes to the statement of operations in fiscal 2013. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The as filed Medicare cost report was used to extract cost for Part A and Part B hospital services. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b With the exception of insurance coverage the collection activity shall not be initiated or pursued for any amount approved under the Memorial Hospital Healthcare Assistance Program. SchH_P05_S0B_L03 Schedule H, Part V, Section B, Line 3 A community needs assessment survey was used to elicit community input and information. The Needs Assessment survey was distributed in the June 9, 2010 edition of the Conway Daily Sun and reached out to over 16,000 people in New Hampshire and Maine. An additional 2,000 copies were made available to and distributed by the members of the MWV community collaborative. In addition, the Gibson Center for Senior Services and the Mount Washington Valley Chamber of Commerce circulated the survey to their members. The survey resulted in 592 responses. SchH_P05_S0B_L11 Schedule H, Part V, Section B, Line 11 1) Documentation in the case of a civil union to determine household size. 2) Applicants that have Healthcare Savings Accounts must provide proof that the HSA has been spent down prior to applying for Healthcare Assistance. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 The MWV Community Healthcare Collaborative formed to cooperatively search for solutions to local health needs. In January 2010 they began a Community Needs Assessment. The Six Step Community Needs Assesssment Process developed by the Association of Community Health Improvement was utilized as the core framework for the project. The Assessment was completed in the fall of 2010. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Hospital utilizes several methods for communicating and educating patients regarding financial assistance with their hospital bills. At our registration and credit and collections offices it is visible to all with handouts. Our website includes information regarding the Healthcare Assistance Program. Hospital bills with a patient liability include information regarding the availability of financial assistance. Also the State Hospital Association website has links to various programs. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The hospital serves the northern part of Carroll County in New Hampshire and the western portion of Oxford County in Maine. The Mount Washington Valley is a four season destination resort area and serves the tourists that frequent the area. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 The Hospital files an annual report with the State of New Hampshire. X X X X X 0 0 0 1 0 1 0 0 0 Scott McKinnon 222648 0 55000 0 10406 0 7031 0 27050 0 322135 0 279036 0 John Newton 298750 0 20000 0 -871 0 0 0 19384 0 337263 0 387222 0 Raymond Rabideau 0 222019 0 30000 1000 6710 0 0 0 27050 1000 285779 4900 304106 Allen Stam MD 106882 0 0 0 51196 0 3866 0 19458 0 181402 0 214877 0 Morice Dennery MD 0 539075 0 0 0 16500 0 7350 0 27050 0 589975 0 482472 Douglas Taylor MD 0 462609 0 0 4000 22000 0 0 0 27050 4000 511659 4000 446149 Victor Lazaron MD 0 407663 0 0 4000 11500 0 16500 0 27050 4000 462713 4000 445250 Robert Tilney MD 0 397181 0 0 3000 22000 0 12575 0 19458 3000 451214 0 430064 David Riss MD 0 386034 0 0 3000 22000 0 12441 0 19458 3000 439933 3000 379276 SchJ_P01_S00_L05 Schedule J, Part I, Line 5 A portion of the CEO and CMO compensation was based on achieving certain organizational goals including financial goals related to meeting target operational margin. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 A portion of the CEO and CMO compensation was based partially on achieving certain organizational goals including financial goals related to meeting target operating margin. NH Health & Education Facilities Authority 020279866 644614QC6 2006-06-14 21069204 To Construct & Renovate Hospital Facility & Payoff Existing Debt 0 0 0 1848353 0 20955000 1725373 0 0 324775 0 0 20630225 0 0 2009 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 F990_P03_S00_L02 Form 990, Part III, Line 2 Memorial Hospital opened a Wound Care Clinic in FY 12 offering a new service to North Conway and surrounding area residents. F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 The sole member of The Memorial Hospital is the Memorial Development Foundation. F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b The sole member of The Memorial Development Foundation ratifies the appointments to the Board of Trustees of The Memorial Hospital F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The form 990 was provided to the Finance Committee and the full Board of Trustees. It was reviewed by the Finance Committee on January 15, 2013. It was then forwarded to the full Board of Trustees on January 16, 2013 for approval before the Executive Committee on February 6, 2013. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Confilct of Interest declaration forms are submitted annually in January by members of the Board of Trustees and are shared with the full board for information purposes and reviewed in depth by the Governance Committee. It is the members responsibility to notify the board should any conflict arise in between signing and of all members of the board to immediately raise any conflicts that they become aware of and the Board member with a conflict will recuse themselves from discussions and votes on the issue. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Compensation Committee of the board conducts the CEO evaluation and compensation process. The CEO's performance is reviewed against targets set for the year and his semi annual bonus determination. The CEO compensation is compared to the Sullivan Cotter and Associates information and periodically reviewed by our compensation consultant. No one with a conflict of interest relative to the hospital is involved in these discussions and minutes are recorded by the Secretary of the Board. Determining compensation for other officers and key employees included reference to professional association compensation data for comparable organizations and position scope. Compensation was reviewed and approved by the CEO and/or the Executive Committee of the Board of Trustees acting as the Compensation Committee. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Memorial Hospital will make copies of such documents available to the general public upon request. F990_P11_S00_L05 Form 990, Part XI, Line 5 Unrealized Gains on investments carried at Market Value. Memorial Development Foundation PO Box 5001 North Conway NH 03860 223160795 Coordinate healthcare NH 501(c)(3) 509(a)(3) Type 1 N/A VN & HCS of Northern Carroll Cty PO Box 432 North Conway NH 03860 020311473 Visiting Nurse & Hospice Services NH 501(c)(3) 9 N/A 0 White Mountain Community Health PO Box 2800 Conway NH 03818 020358715 Community Health Center NH 501(c)(3) 9 N/A 0 Carroll County Health & Home Care Services Inc PO Box 420 Chocorua NH 03817 237337000 Home Care Services NH 501(c)(3) 7 N/A 0 MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 020477066 Contract with Healthcare Professionals & Retail Pharmacy NH Memorial Hospital C 100 -18615 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 MWV Healthcare Assoc Inc o 8360207 White Mountain Community Health i 59004 White Mountain Community Health p 90324 White Mountain Community Health o 60800