2013-06-05T07:42:40-05:00 2010-12-31 PLANTE & MORAN PLLC PO BOX 307 SOUTHFIELD MI 480370307 990 2010-01-01 381359247 CRITTENTON HOSPITAL MEDICAL CENTER CRIT 2486525000 1101 W UNIVERSITY DRIVE ROCHESTER MI 48307 FRANK SOTTILE MD 2486525785 2013-05-31 1 2483522500 2010 2016-03-07 17:11:31Z X FRANK SOTTILE MD 1101 W UNIVERSITY DRIVE ROCHESTER MI 48307 332290941 0 X WWW.CRITTENTON.COM X 1900 MI ENHANCING THE HEALTH STATUS OF THE INDIVIDUALS AND COMMUNITIES IT SERVES. 14 11 1952 393 8128763 0 500 130423 225651884 220468113 3111299 6310770 -5033997 901828 223729686 227811134 0 0 0 0 99731256 102099179 0 0 10759 128170280 135325047 227901536 237424226 -4171850 -9613092 314819430 331665503 160568429 158885108 154251001 172780395 CRITTENTON HOSPITAL MEDICAL CENTER IS DEDICATED TO ENHANCING THE HEALTH STATUS OF THE INDIVIDUALS AND COMMUNITIES WE SERVE IN PARTNERSHIP WITH OUR PHYSICIANS, EMPLOYEES, AND COMMUNITY MEMBERS. 0 0 203881086 212339350 SEE SCHEDULE O PART III, LINE 4 DESCRIPTION 203881086 1 1 0 1 0 0 0 0 1 1 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 256 0 1 1952 1 1 1 0 0 0 0 0 0 0 0 0 X 14 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 0 0 0 MI X TAMMIE SMITH 2486525444 1101 W UNIVERSITY DRIVE ROCHESTER MI 48307 BEVERLY ALLEN 1.00 X 0 0 0 LISA ASADOORIAN 1.00 X 0 0 0 BRYAN BARNETT 1.00 X 0 0 0 MICHAEL BROWE 1.00 X 0 0 0 PETER DESTEIGER 1.00 X 0 0 0 ROBERT GOMD 1.00 X 39422 0 0 KENNETH JOHNSON 1.00 X 0 0 0 KATHRIN KUDNER 1.00 X 0 0 0 ROBERT LENIHANII 1.00 X 0 0 0 FREDERICK MAIBAUERMD 1.00 X 65275 0 0 BRADFORD MERRELLIMD 1.00 X 0 0 0 F SCOTT MILLER 1.00 X 0 0 0 ROBERT SKANDALARIS 1.00 X 0 0 0 BRAD UPTON 1.00 X 0 0 0 JEFFREY JENNINGSMD 1.00 X X 50000 0 0 LYNN ORFGEN 40.00 X 523148 0 40457 AUDRIANNE MOCERI 40.00 X 61526 0 20954 CYNTHIA LONG 40.00 X 160325 0 12533 FRANK SOTTILE 40.00 X 398151 0 30559 GREGORY PARTAMIAN 40.00 X 251977 0 25768 KATHLEEN VANWAGONER 40.00 X 158304 0 24451 MICHELLE HORNBERGER 40.00 X 138115 0 22792 SAMER KAZZIHA MD 40.00 X 482778 0 25720 KEVIN K FLOREK DO 40.00 X 255106 0 21561 AMARBIR S KHAIRA MD 40.00 X 253685 0 0 NACIANCENO V WOO MD 40.00 X 199599 0 29114 SHERYL MAY 40.00 X 186821 0 10850 3224232 0 264759 74 0 1 0 BARTON MALOW CO 26500 AMERICAN DR SOUTHFIELD MI 48034 CONSTRUCTION MANAGEMENT 5935481 UNASOURCE SURGERY CENTERLLC 4550 INVESTMENT DR STE 100 TROY MI 48098 SURGICAL SERVICES 5310983 MCKESSON INFORMATION SOLUTIONS PO BOX 98347 CHICAGO IL 60693 INFORMATION TECHNOLOGY SERVICES 3187231 CARETECH SOLUTIONS INC PO BOX 674271 DETROIT MI 48267 INFORMATION TECHNOLOGY SERVICES 2717856 PATRIOT MEDICAL TECHNOLOGIES MSC-410672 PO BOX 415000 NASHVILLE TN 37241 BIOMEDICAL SERVICES 2172319 47 500 129923 130423 NET PATIENT SERVICE RE 900099 219165555 211036792 8128763 PROFESSIONAL FEES U-M 900099 510885 510885 INVESTMENT IN JOINT VE 900099 230804 230804 KARMANOS ONCOLOGY REVE 900099 167381 167381 CPR CLASSES 611600 100155 100155 293333 293333 220468113 2631377 2631377 107823217 170474 103845397 468901 3977820 -298427 3679393 3679393 29071 500 21724 7347 7347 221756 143785 77971 77971 MEDICAL STAFF FUNCTION 900099 231668 231668 TV RENTAL INCOME 900099 150841 150841 MISCELLANEOUS 900099 104954 104954 329047 329047 816510 227811134 212339350 8128763 7212598 2023757 2023757 79621463 74653511 4967952 4154263 3779548 374715 9878437 8926335 952102 6421259 5842061 579198 376058 376058 387289 387289 66361 11361 55000 61663 61663 38945723 34564175 4381548 2132803 35492 2097311 3734831 2445997 1286812 2022 7593108 7593108 5494384 2429184 3065200 173091 97886 75205 76273 15298 58706 2269 2460348 2460348 14709133 10368279 4336363 4491 900812 812767 88045 MEDICAL SUPPLIES 39523186 39089221 433965 BAD DEBT 12230791 12230791 QAAP EXPENSE 4936122 4936122 COLLECTION FEES 691484 691484 MEDICAL EQUIPMENT REPAI 369479 369479 462108 121747 338384 1977 237424226 203881086 33532381 10759 13628 12685 47602335 31655509 33941242 32721195 4129086 4338541 2329425 2436431 301114565 153270180 149448049 147844385 45429259 77599045 19273 28439 15804139 13541673 16102994 21487600 314819430 331665503 27560389 25921188 105285000 101980000 1000000 2223583 590185 147845 26132855 28612492 160568429 158885108 X 153286567 171936554 964434 843841 154251001 172780395 314819430 331665503 X -9613092 28142486 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 0 0 0 1 66361 66361 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: CRITTENTON HOSPITAL MEDICAL CENTER INDIRECTLY CONDUCTS LOBBYING ACTIVITIES THROUGHOUT THE YEAR. THE HOSPITAL HAS ENGAGED THE SERVICES OF A PROFESSIONAL LOBBYIST, WHO PERIODICALLY MEETS WITH FEDERAL, STATE, AND LOCAL LEGISLATORS TO DISCUSS ITEMS OF IMPORTANCE TO THE HOSPITAL AND HEALTH CARE INDUSTRY, AND ISSUES AFFECTING THE HEALTH CARE NEEDS OF THE COMMUNITY. THE EXPENDITURES LISTED IN PART II-B ARE FEES AND EXPENSE REIMBURSEMENTS PAID TO THE LOBBYIST DURING THE YEAR. ON RARE OCCASIONS, THE HOSPITAL ENCOURAGES ITS EMPLOYEES TO CONTACT LEGISLATORS TO CONSIDER CHANGES IN THE LAW THAT WOULD IMPROVE THE REGULATORY CLIMATE AFFECTING THE HEALTH CARE INDUSTRY AND ULTIMATELY, HEALTH CARE NEEDS OF THE COMMUNITY THE HOSPITAL SERVES. THE "GRASSROOT" LOBBYING IS INFREQUENT, AND INVOLVES NO SIGNIFICANT EXPENDITURES BY EITHER THE HOSPITAL OR ITS EMPLOYEES. NONE OF THIS ACTIVITY (DIRECT OR INDIRECT) INVOLVES POLITICAL CAMPAIGN ACTIVITY. 964434 167277 17908 295562 10216 843841 1026646 152319 19315 218961 14885 964434 1062921 168931 15719 203894 17031 1026646 1.00000 0 1 1 2565744 2565744 181747365 83861808 97885557 1640319 805959 834360 102255497 66686793 35568704 12905640 1915620 10990020 147844385 15000 ACCOUNTS RECEIVABLE AFFILIATES 112011 14010 MISCELLANEOUS ACCOUNTS RECEIVABLE 2200697 14300 ACCOUNTS RECEIVABLE POWERWORKS 58532 14165 INTEREST RECEIVABLE 152853 14030 CASH RESTRICTED BY BOND COVENANTS -1783186 14090 DEBT SECURITIES 4309396 8110-18140 DEBT ISSUANCE COST 853998 18160 LONG TERM ACCOUNTS RECEIVABLE 4306641 18170 ACCOUNTS RECEIVABLE KARMANOS 1581172 19010 ACCOUNTS RECEIVABLE SAAC 5838242 14400 DUE FROM THIRD PARTY 3857244 21487600 SELF FUNDED MALPRACTICE INS CLAIMS LIABILITY 3348275 POST RETIREMENT HEALTH INS LIABILITY 579986 PENSION LIABILITY 24684231 28612492 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS ARE USED FOR THE GIFT SHOP, THE AUXILLIARY AND THE HOSPITAL FOR GRANTS, SCHOLARSHIPS AND OTHER EXPENSES. CENTRAL AMERICA/CARIBBEAN PROGRAM SERVICES INSURANCE 18517663 0 0 0 0 0 0 18517663 0 18517663 0 0 1 0 0 0 HANDBAG AND JEWELRY SALE 10354 10354 5907 $6 SALE 6754 6754 4165 14 12463 500 11963 11652 29571 500 29071 21724 21724 7347 1 1 X 1 X 1 X 1 1 0 1 1 0 0 1043308 0 1043308 0.00460 1 484 17552362 13481904 4070458 0.01810 0 0 0 0 1 484 18595670 13481904 5113766 0.02270 2630 37576 436323 0 436323 0.00190 249 1021 6167964 2485640 3682324 0.01640 4 2996 22877127 21340938 1536189 0.00680 1 50 72800 0 72800 0.00030 76 11762 88416 0 88416 0.00040 2960 53405 29642630 23826578 5816052 0.02580 2961 53889 48238300 37308482 10929818 0.04850 0 0 0 0 0 0 0 0 17 3640 6101 0 6101 0.00000 0 0 0 0 22 1020 21956 0 21956 0.00010 74 1134 39285 0 39285 0.00020 1 110 350 0 350 0.00000 0 0 0 0 0 0 0 0 114 5904 67692 67692 0.00030 0 12230791 3903056 69541050 81467966 -11926916 X 1 0 1 USC LLC SURGICAL CENTER 0.28700 0.71300 1 1 CRITTENTON HOSPITAL MEDICAL CENTER

1101 W UNIVERSITY ROCHESTER MI 48307

X X X X CRITTENTON HOSPITAL MEDICAL CENTER 1 1 USC LLC

4800 INVESTMENT DRIVE STE 370 TROY MI 48098

SURGICAL CENTER PART I, LINE 7: A COST TO CHARGE RATIO WAS USED FROM WORKSHEET 2 TO CALCULATE THE NUMBERS; RATIO OF PATIENT CARE COST TO CHARGES PART I, L7 COL(F): THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THE REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE HOSPITAL FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES. PART II: COMMUNITY HEALTH LEADERSHIP AND OTHER SENIOR LEADERS ACTIVELY PARTICIPATE ON A BROAD RANGE OF COMMUNITY COALITIONS SUCH AS THE OLDER PERSON'S COMMISSION, ROCHESTER COMMUNITY SCHOOLS, ROCHESTER/AUBURN HILLS COMMUNITY COALITION, OAKLAND COUNTY OBESITY COALITION, REGION 2 NORTH, OAKLAND COUNTY MEDICAL CONTROL AUTHORITY, MICHIGAN DEPT OF COMMUNITY HEALTH, CROSSROADS PREGNANCY CENTER AND OTHERS. THIS PROVIDES ONGOING KNOWLEDGE OF VARYING COMMUNITY NEEDS AND ADJUSTS AS ECONOMIC, ENVIRONMENTAL, AND HEALTHCARE CHANGES OCCUR IN CRITTENTON'S KEY COMMUNITIES.THE VARIOUS PROGRAMS THAT CHMC OFFERS TO THE COMMUNITY HELP TO ENHANCE THE HEALTH STATUS BY EDUCATION, EARLY DETECTION, SCREENING, AND ACCESSIBILITY TO RESOURCES. WE RECEIVE MULTIPLY STORIES EVERY YEAR STATING THAT IF THEY HAD NOT HAD ATTENDED ONE OF OUR SCREENINGS THEN THEY MAY NOT HAVE PURSUED FURTHER MEDICAL CARE OR TREATMENT. THE SCREENING OR EDUCATION IS WHAT INCREASED THEIR AWARENESS AND ENCOURAGED THEM TO SEEK CARE AND THAT SCREENING OR ACTIVITY IS WHAT HELPED TO ENHANCE THEIR HEALTH. PART III, LINE 4: THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THE REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE HOSPITAL FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES. THE BAD DEBT REPORTED ON LINE 3 WAS DETERMINED USING THE COST TO CHARGE RATIO. PART VI, LINE 2: THE ALLOCATION OF CRITTENTON'S RESOURCES TO IMPROVE THE HEALTH STATUS AND QUALITY OF LIFE OF COMMUNITY RESIDENTS ARE BASED ON COMMUNITY NEEDS THAT ARE IDENTIFIED BOTH THROUGH THE STRATEGIC PLANNING PROCESS AND THROUGH A YEARLY COMPREHENSIVE REVIEW OF COUNTY, STATE AND FEDERAL HEALTHCARE DATA BY CRITTENTON'S COMMUNITY HEALTH AND EDUCATION DEPARTMENT. COMMUNITY NEEDS INFORMATION IS GATHERED FROM BOTH THE CDC'S NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION BEHAVIORAL RISK FACTOR SURVEILLLANCE SYSTEMS AND THROUGH THE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH. FOR EXAMPLE, IN 2008 THE NEED FOR A SCHOOL NURSE PROGRAM WAS IDENTIFIED WITH THE ROCHESTER COMMUNITY SCHOOLS. CRITTENTON'S COMMUNITY HEALTH AND EDUCATION DEPARTMENT DEVELOPED AND IMPLEMENTED THE PROGRAM WHICH NOW SERVES 14,000 STUDENTS AND MANAGES 450 MEDICAL MANAGEMENT PROGRAMS. IN 2009 AND AGAIN IN 2010, PARTICIPATION WITH THE ROCHESTER/AUBURN HILLS COALITION RESULTED IN CRITTENTON'S SPONSORING RACHEL'S CHALLENGE, A PROGRAM WHICH PROVIDES SUICIDE PREVENTION AND INTERVENTION AND IMPROVED PEER TO PEER CONFLICT MANAGEMENT SKILLS FOR AREA YOUTH. PART VI, LINE 3: CRITTENTON HOSPITAL MEDICAL CENTER DOES A NUMBER OF THINGS IN ORDER TO EDUCATE AND/OR ASSIST A PATIENT IN RECEIVING OUTSIDE ASSISTANCE, INCLUDING THE FOLLOWING:1. SIGNAGE IS POSTED AT REGISTRATION POINTS AROUND THE HOSPITAL REGARDING ASSISTANCE AVAILABLE TO PAY FOR SERVICES AS WELL AS OUR UNCOMPENSATED SERVICES PROGRAM, HANDOUTS ARE GIVEN TO THE PATIENTS AND THE PROGRAM IS OUTLINED ON THE BACK OF EVERY STATEMENT THAT IS SENT TO THE PATIENT.2. FINANCIAL COUNSELORS ARE ON SITE THAT ARE CONTACTED EVERY TIME A PATIENT WITHOUT INSURANCE COMES INTO THE EMERGENCY ROOM OR IS ADMITTED TO THE HOSPITAL. IN THE PAST 12 MONTHS THE FINANCIAL COUNSELORS HAVE ASSISTED OVER 600 PATIENTS IN QUALIFYING FOR COUNTY, STATE, FEDERAL, OR HOSPITAL ASSISTANCE PROGRAMS.3. TAKE PART AND ASSIST PATIENTS IN QUALIFYING FOR THE COUNTY INDIGENT HOSPITALIZATION PROGRAM WHICH IS RUN DIRECTLY THROUGH THE HOSPITAL AND PLACES VIRTUALLY NO BURDEN OF ANY TYPE ON THE PATIENT IN ORDER TO BE QUALIFIED.4. ALL MANAGERS THAT DEAL WITH THE PUBLIC ARE DIRECTLY INFORMED OF OUR UNCOMPENSATED SERVICE PROGRAMS AND VERBALLY ASSIST PATIENTS WITH SUGGESTIONS AS WELL AS OUR CASHIERS HAVING ACCESS TO THE SAME INFORMATION AND TRAINING.5. OFFER ASSISTANCE TO NEWBORN MOTHERS WITHOUT INSURANCE IN THE FORM OF ASSISTANCE IN APPLYING FOR MEDICAID AND PROVIDING MINIMAL PAYMENT OPTIONS. PART VI, LINE 4: CRITTENTON IS A 290 BED ACUTE CARE HEALTH FACILITY SERVING COMMUNITIES IN OAKLAND, MACOMB, AND LAPEER COUNTIES. THE ENTIRE SERVICE AREA ENCOMPASSES 35 ZIP CODES IN THREE REGIONS AND IS FURTHER SUBDIVIDED INTO THREE SECTORS: OUR CORE SECTOR WHICH ENCOMPASSES THE THREE ROCHESTER ZIP CODES, AND THE PRIMARY AND SECONDARY SECTORS. THE DEMOGRAPHIC SKEW FOR THE AREA IS SLIGHTLY OLDER THAN THE NORM WITH HIGHER HOUSEHOLD INCOMES. REPORTS FILED WITH STATES PART VI, LINE 7 MI X 0 0 0 0 0 0 0 0 0 LYNN ORFGEN 404544 0 74085 0 44519 0 19600 0 20857 0 563605 0 0 0 CYNTHIA LONG 153227 0 0 0 7098 0 2410 0 10123 0 172858 0 0 0 FRANK SOTTILE 351560 0 43186 0 3405 0 5449 0 25110 0 428710 0 0 0 GREGORY PARTAMIAN 212314 0 23687 0 15976 0 3484 0 22284 0 277745 0 0 0 KATHLEEN VANWAGONER 150065 0 0 0 8239 0 2361 0 22090 0 182755 0 0 0 MICHELLE HORNBERGER 132871 0 0 0 5244 0 2143 0 20649 0 160907 0 0 0 SAMER KAZZIHA MD 480898 0 0 0 1880 0 0 0 25720 0 508498 0 0 0 KEVIN K FLOREK DO 243793 0 0 0 11313 0 2897 0 18664 0 276667 0 0 0 AMARBIR S KHAIRA MD 253685 0 0 0 0 0 0 0 0 0 253685 0 0 0 NACIANCENO V WOO MD 197490 0 0 0 2109 0 10480 0 18634 0 228713 0 0 0 SHERYL MAY 181548 0 0 0 5273 0 2803 0 8047 0 197671 0 0 0 MICHIGAN STATE HOSPITAL FINANCE AUTHORITY 382889417 59465E4Z3 2003-07-30 52400000 REFUNDED 2002B SERIES/ BUILDING EXPENSES 0 0 0 MICHIGAN STATE HOSPITAL FINANCE AUTHORITY 382889417 59465E5X7 2003-12-23 21480000 REIMBURSE PRIOR CAPITAL EXPENDITURES 0 0 0 52400000 490373 14485934 2005 1 0 1 1 21480000 330699 46634 2003 1 0 1 1 0 1 0 0 0 0 0 1 1 COMERICA 5.200000000000 0 0 0 0 0 SAMER KAZZIHA PURCHASE MEDICAL BUILDING X 200000 100000 0 0 1 100000 CHMC HAS A QUESTIONNAIRE FOR INDIVIDUALS AND THEIR IMMEDIATE FAMILY MEMBERS REGARDING CONFICTS OF INTEREST AND THIS MUST BE SIGNED BY THE INDIVIDUALS. THE QUESTIONNAIRE INCLUDES THE FOLLOWING: 1. IDENTIFY YOUR SERVICE ON ANY BOARD OF DIRECTORS OR TRUSTEES OF ANY OF THE COMPANY'S WITH WHICH CHMC OR ANY OF ITS' AFFILIATES DOES BUSINESS. 2. IDENTIFY WHETHER YOU ARE ASSOCIATED DIRECTLY OR INDIRECTLY OR HOLD A POSITION OR FINANCIAL INTEREST IN ANY OUTSIDE ORGANIZATION OR CONCERN WITH WHICH CRITTENTON DOES BUSINESS. 3. IDENTIFY WHETHER YOU DIRECT, MANAGE,OR PROVIDE SERVICES OR CONSULTATION TO ANY OUTSIDE ORGANIZATION OR CONCERN THAT DOES BUSINESS WITH OR COMPETES WITH CRITTENTON. 4. IDENTIFY ANY ACTIVITIES IN WHICH YOU ARE ENGAGED THAT MIGHT BE REGARDED AS CONSTITUTING A POTENTIAL CONFLICT OF INTEREST WITH CRITTENTON. 5. DISCLOSE ANY DIRECT OR INDIRECT COMPENSATION THAT YOU RECEIVE, OR ANTICIPATE RECEIVING, FROM ANY PERSON, FIRM, CORPORATION, OR MARKET IN ANY WAY RELATED TO YOUR POSITION WITH CRITTENTON. IF AT ANY TIME THERE IS A MATTER UNDER CONSIDERATION WHICH MAY CREATE A DIRECT OR INDIRECT CONFLICT OF INTEREST, IT IS THE INDIVIDUAL'S OBLIGATION TO DISCLOSE THE FACTS SURROUNDING THE POSSIBLE CONFLICT TO THE CORPORATE COMPLIANCE OFFICER OR DEPARTMENT OF HUMAN RESOURCES AND THAT THE INDIVIDUAL AGREES TO PROMPTLY REPORT ANY NEW SITUATIONS THAT REQUIRE DISCLOSURE UNDER THIS QUESTIONNAIRE. RESTATEMENT OF FINANCIAL STATEMENTS FOR THE YEARS 2010 AND 2009 FORM 990 - EXPLANATION FOR AMENDED RETURN: SUBSQUENT TO THE ISSUANCE OF THE HOSPITAL'S 2010 FINANCIAL STATEMENTS, THE HOSPITAL'S MANAGEMENT INDENTIFIED ERRORS RELATED TO THE ISSUED FINANCIAL STATEMENTS. AS A RESULT, THE CONSOLIDATED BALANCE SHEETS OF THE HOSPITAL AS OF DECEMBER 31, 2010 AND 2009, AND THE RELATED CONSOLIDATED STATEMENTS OF OPERATION AND CHANGES IN NET ASSETS, AND CASH FLOWS FOR THE YEAR THEN ENDED, HAVE BEEN RESTATED FROM THE AMOUNTS PREVIOUSLY REPORTED TO ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA. THE ADJUSTMENTS IDENTIFIED BY MANAGEMENT PRIMARILY RELATED TO SEVERAL ERRORS IN THE AREA OF THIRD PARTY PAYOR RECEIVABLES FROM BLUE CROSS AND FROM MEDICARE SETTLEMENT ESTIMATES. CERTAIN FACTS THAT WERE EXISTING AT THE TIME OF THE CREATION OF THE INITIAL ESTIMATE WERE NOT APPROPRIATELY CONSIDERED. OTHER ADJUSTMENTS WERE IDENTIFIED RELATED TO ERRORS IN JOINT VENTURE ACCOUNTING, ACCOUNTS PAYABLE, FRINGE BENEFITS AND THE CONSOLIDATION PROCESS. PART III LINE 4A; PART VIII LINES 2A AND 2C; PART IX LINES 9 AND 24A; PART X LINES 1, 4, 9, 10, 13, 17 AND 27; PART XI LINE 5, AND SCHEDULE D PART VI WERE ALL AFFECTED. PROGRAM SERVICE ACCOMPLISHMENTS FORM 990 PART III, LINE 4A THE HOSPITAL WAS INVOLVED IN A LARGE NUMBER OF VARIOUS TYPES OF COMMUNITY CARE PROJECTS, EITHER AS A PARTICIPANT OR A SPONSORING ORGANIZATION. THESE INCLUDE, BUT ARE NOT LIMITED TO: HEALTHY PREGNANCY, WOMEN'S HEALTHY HEART, NUTRITION, WEIGHT LOSS, HEALTHY AGING, CHILD SAFETY, HEALTH RISK APPRAISALS, SMOKING CESSATION, MANAGING STRESS, CPR, SLEEP DISORDER AND MEN'S HEALTH CLASSES FOR THE COMMUNITY. ALSO, FREE BLOOD PRESSURE SCREENINGS ARE MADE AVAILABLE TO THE COMMUNITY. A BEREAVEMENT PROGRAM IS OFFERED THROUGH THE OBSTETRICS DEPARTMENT FOR GRIEVING PARENTS OF INFANTS. A TRAVEL MEDICINE PROGRAM IS OFFERED FOR BUSINESS AND VACATION TRAVELS THROUGH THE OCCUPATIONAL MEDICINE DEPARTMENT. ANNUALLY, VOLUNTEEERS FROM THE HOSPITAL PARTICIPATE AT THE ROCHESTER ART AND APPLES FESTIVAL, COLLECT GIFTS FOR THE ROCHESTER NEIGHBORHOOD HOUSE FOR CHRISTMAS, COLLECT FOOD FOR THE MICHIGAN HARVEST GATHERING, AND PARTICIPATE IN THE NORTH OAKLAND AMERICAN HEART WALK. A PEDIATRIC URGENT CARE PROGRAM IS OFFERED FOR AFTER HOURS MEDICAL CARE FOR CHILDREN UNDER EIGHTEEN YEARS OF AGE. ADDITIONALLY, A GEROPSYCHIATRIC PROGRAM WAS STARTED TO ASSIST OLDER ADULTS WITH HEALTH CARE CHANGES. WOUND CARE SERVICES ARE ALSO OFFERED, INCLUDING HYPERBARIC TREATMENTS. FORM 990, PART VI, SECTION B, LINE 11 THE TAX RETURN IS PREPARED BY THE FINANCE DEPARTMENT, AND THEN IS SENT TO AN OUTSIDE CERTIFIED PUBLIC ACCOUNTANTS OFFICE WHERE THE RETURN IS REVIEWED. THE RETURN IS THEN GIVEN TO THE BOARD OF DIRECTORS VIA E-MAIL FOR REVIEW. AFTER THE REVIEW, THE RETURN IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE SECRETARY OF THE BOARD GOES OVER THE RESPONSES WITH THE COMPLIANCE OFFICER. THE HOSPITAL POLICY STATES THAT ALL EMPLOYEES HAVE A CONTINUOUS OBLIGATION TO DISCLOSE CONFLICTS OF INTEREST, AN ACTUAL IMPROPRIETY, AND/OR AN APPEARANCE OF IMPROPRIETY. EMPLOYEES AT THE MANAGER LEVEL AND ABOVE EACH SIGN A STATEMENT ON AN ANNUAL BASIS ACKNOWLEDGING THEIR UNDERSTANDING OF THE POLICY AND VERIFYING THEIR APPROPRIATE DISCLOSURE OF ANY CONFLICTS. ALL REPORTED CONFLICTS SHALL BE REVIEWED BY THE CEO IN CONJUCTION WITH THE COMPLIANCE OFFICER AND DEPARTMENT OF LEGAL AFFAIRS. IF IT IS DETERMINED THAT A CONFLICT EXISTS THE EMPLOYEEE SHALL DISCONTINUE ALL ACTIVITIES SURROUNDING THAT CONFLICT. THE EMPLOYEE MAY ALSO SEEK A WAIVER OF THE CONFLICT FROM THE CEO. CHMC ALSO HAS A QUESTIONNAIRE FOR INDIVIDUALS AND THEIR IMMEDIATE FAMILY MEMBERS REGARDING CONFICTS OF INTEREST AND THIS MUST BE SIGNED BY THE INDIVIDUALS. THE QUESTIONNAIRE INCLUDES THE FOLLOWING: 1. IDENTIFY YOUR SERVICE ON ANY BOARD OF DIRECTORS OR TRUSTEES OF ANY OF THE COMPANY'S WITH WHICH CHMC OR ANY OF ITS' AFFILIATES DOES BUSINESS. 2. IDENTIFY WHETHER YOU ARE ASSOCIATED DIRECTLY OR INDIRECTLY OR HOLD A POSITION OR FINANCIAL INTEREST IN ANY OUTSIDE ORGANIZATION OR CONCERN WITH WHICH CRITTENTON DOES BUSINESS. 3. IDENTIFY WHETHER YOU DIRECT, MANAGE,OR PROVIDE SERVICES OR CONSULTATION TO ANY OUTSIDE ORGANIZATION OR CONCERN THAT DOES BUSINESS WITH OR COMPETES WITH CRITTENTON. 4. IDENTIFY ANY ACTIVITIES IN WHICH YOU ARE ENGAGED THAT MIGHT BE REGARDED AS CONSTITUTING A POTENTIAL CONFLICT OF INTEREST WITH CRITTENTON. 5. DISCLOSE ANY DIRECT OR INDIRECT COMPENSATION THAT YOU RECEIVE, OR ANTICIPATE RECEIVING, FROM ANY PERSON, FIRM, CORPORATION, OR MARKET IN ANY WAY RELATED TO YOUR POSITION WITH CRITTENTON. IF AT ANY TIME THERE IS A MATTER UNDER CONSIDERATION WHICH MAY CREATE A DIRECT OR INDIRECT CONFLICT OF INTEREST, IT IS THE INDIVIDUAL'S OBLIGATION TO DISCLOSE THE FACTS SURROUNDING THE POSSIBLE CONFLICT TO THE CORPORATE COMPLIANCE OFFICER OR DEPARTMENT OF HUMAN RESOURCES AND THAT THE INDIVIDUAL AGREES TO PROMPTLY REPORT ANY NEW SITUATIONS THAT REQUIRE DISCLOSURE UNDER THIS QUESTIONNAIRE. THERE IS A SIGNED WRITTEN AGREEMENT/DOCUMENTATION FOR ANY BOARD MEMBER OR OFFICER IF A CONFLICT OF INTEREST ARISES. CURRENTLY THERE HAVE NOT BEEN ANY RESTRICTIONS PLACED ON ANY BOARD MEMBER OR OFFICER AS AN ISSUE HAS NOT ARISEN TO WARRANT THIS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST OF THE INDIVIDUAL. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 6,872,353. PRIOR PERIOD ADJUSTMENTS: 25,410,012. PENSION LIABILITY -3,465,705. ASSETS RELEASED FROM RESTRICTIONS -107,477. INVESTMENT IN WELLPOINTE -581,504. NET ASSETS RELEASED FROM RESTRICTIONS 14,807. TOTAL TO FORM 990, PART XI, LINE 5: 28,142,486. CRITTENTON HOSPITAL MEDICAL CENTER FOUNDATION 1101 W UNIVERSITY DR ROCHESTER MI 48307 382627336 SUPPORTING MI SECTION 501(C)(3) SCHEDULE A LINE 11A N/A 1 CRITTENTON MEDICAL EQUIPMENT 161 S LIVERNOIS RD ROCHESTER HILLS MI 48307 383433794 MEDICAL EQUIPMENT SALES MI CRITTENTON DEVELOPMENT CORPORATION UNRELATED 0 0 HBC INFUSIONS 1101 W UNIVERSITY ROCHESTER MI 48307 753123093 INFUSION SERVICES MI CRITTENTON DEVELOPMENT CORPORATION UNRELATED 0 0 BALD MOUNTAIN SURGICAL CENTER 1375 S LAPEER RD STE 3109 LAKE ORION MI 48360 030444972 SURGICAL SERVICES MI CRITTENTON DEVELOPMENT CORPORATION UNRELATED 0 0 CRITTENTON DEVELOPMENT CORPORATION 2251 N SQUIRREL RD STE 310 AUBURN HILLS MI 48326 382594115 REAL ESTATE MI N/A C 906146 17750220 1.00000 CRITTENTON MEDICAL PHARMACY 1101 W UNIVERSITY ROCHESTER MI 48307 203773341 PHARMACY SALES MI CRITTENTON DEVELOPMENT CORPORATION C 0 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 CRITTENTON DEVELOPMENT CORP N 167455 ACTUAL COST CRITTENTON DEVELOPMENT CORP P 95721 ACTUAL COST CHMC FOUNDATION C 129923 CASH CHMC FOUNDATION B 80000 CASH CHMC FOUNDATION L 267034 CASH CHMC FOUNDATION K 521111 CASH CHMC FOUNDATION P 132406 CASH