2013-11-14T07:48:03-06:00 2012-12-31 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2012-01-01 550629032 Minnie Hamilton Health Care Center Inc MINN 3043549244 186 Hospital Drive Grantsville WV 26147 Kyle Pierson 3043549244 2013-11-07 1 Harry C Harless P01042847 3043460441 2012 2016-02-25 16:41:14Z Minnie Hamilton Health System Stephen S Whited 186 Hospital Drive Grantsville WV 26147 18537469 0 X www.mhhcc.com X 1983 WV The organization operates a critical access hospital, community health center, federal qualified health center, and long-term care unit. 9 9 291 22 0 0 1723695 1622700 15246541 16633968 5466 7255 155930 273546 17131632 18537469 0 0 0 0 11290134 11646451 0 0 0 5792391 6641201 17082525 18287652 49107 249817 6475988 6328766 3173386 2776347 3302602 3552419 Minnie Hamilton Health System is dedicated to maintaining the health and improving the quality of life of all people in our service area through an innovative delivery system of services and education. 0 0 15700842 16633968 Inpatient services provided included 1,075 acute care days, 8,124 long-term care days and 702 swing bed days. Outpatient services included 21,353 outpatient visits and 1,877 emergency room visits. Primary care services included 41,683 clinic and dental visits. 15700842 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10 0 1 291 1 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Stephen S Whited 3043549244 186 Hospital Drive Grantsville WV 26147 Jean Simers 4.00 X 0 0 0 Randy Ball 2.00 X 0 0 0 Reta Kight 1.00 X 0 0 0 Kathy Frederick 1.00 X 0 0 0 Neal Benson 1.00 X 0 0 0 Ronald Blankenship 1.00 X 0 0 0 Harold Carpenter 1.00 X 0 0 0 John Lowther 1.00 X 0 0 0 Helen Johnson 1.00 X 0 0 0 Larry Baker 1.00 X 0 0 0 Randy Lindauer 40.00 X 74407 0 435 Stephen S Whited 40.00 X 137248 0 5715 Kyle Pierson 40.00 X 5762 0 0 Suresh Balasubramony 52.00 X 615207 0 18480 Alfonso Cinco 52.00 X 418269 0 9223 John D'Angelo 38.00 X 218877 0 0 Chadwick Smith 32.00 X 464641 0 8745 Matthew Siwicki 40.00 X 168683 0 15562 2103094 0 58160 13 0 1 0 CPSI 600 Wall Street Mobile AL 36695 Computer Operating Systems 339304 Radiological Physician Associates 700 Village Drive Fairmont WV 26554 Radiological Professional Services 254553 Labcorp of America 231 Maple Ave Burlington NC 27216 Reference Lab 132580 NextGen PO Box 809390 Chicago IL 60680 Computer software 130546 4 1620689 2011 1622700 Patient services 622110 16378796 16378796 Other health care 622110 255172 255172 16633968 7255 7255 6672 0 6672 6672 6672 Rebates/refunds 900099 115185 115185 Cafeteria 722210 80107 80107 Day care 624410 65147 65147 6435 6435 266874 18537469 16633968 0 280801 223617 191014 32603 9927667 8480213 1447454 156870 133998 22872 632122 539959 92163 706175 603215 102960 33127 33127 98813 98813 647808 553358 94450 56563 48316 8247 837755 715610 122145 278963 238290 40673 247372 211305 36067 102868 87870 14998 111425 111425 751088 641579 109509 139978 139978 Bad debts 1564132 1564132 Medical supplies 964770 964770 Healthcare provider tax 218647 218647 Repairs & maintenance 139243 118941 20302 448649 389625 59024 18287652 15700842 2586810 0 4349 8174 581857 755485 55860 21663 2258766 2407588 116548 120449 40058 84022 8979294 6049909 3354978 2929385 2000 63572 0 6475988 6328766 1165218 1139219 2106 50341 1315680 1063383 388329 314862 302053 208542 3173386 2776347 X 3302602 3552419 3302602 3552419 6475988 6328766 249817 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 72395 72395 2135216 1262487 872729 462218 108146 354072 6309465 4679276 1630189 2929385 Capital leases 195687 Estimated third-party payor settlements 12855 208542 16973337 0 16973337 1564132 1564132 18537469 16723520 0 16723520 1564132 1564132 18287652 Part XI, Line 4b - Other Adjustments: Bad debts netted against revenue in the financial statements 1,564,132. Part XII, Line 4b - Other Adjustments: Bad debts 1,564,132. 1 1 X 1 X 1 X 1 1 0 0 794917 794917 1469207 1503209 -34002 0.00000 2264124 2298126 -34002 15 715 83250 78250 5000 0.00030 12 100 2500 2500 0.00010 27 815 85750 78250 7500 0.00040 27 815 2349874 2376376 -26502 0.00040 0 1239887 3589531 3589531 X 1 1 1 1 Minnie Hamilton Health Care Center

186 Hospital Drive Grantsville WV 26147

X X X X Long Term Care Minnie Hamilton Health Care Center Inc 1 0 1 1 200.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X X X 0 X X X X 1 X 0 0 1 Gilmer Primary Care

809 Medical Drive Suite 1 Glenville WV 26351

Federally Qualified Health Center Part I, Line 3c: 1. The qualifications for the Sliding Fee Program are based on both the number of people in the household and the total gross income received in the household. 2. The applicants are required to complete the Sliding Fee Program application and to provide a proof of income within 30 days after filing their application. Acceptable proof of income includes: wage statement, W-2 forms, check stub, retirement statement, unemployment statement, social security check or benefit letter, alimony check, child support check, food stamp voucher, or other documents approved by financial management.3. If the patient has no income, they are asked to declare so by signing a Lack of Income Verification form. 4. The Financial Assistance Application, along with the above mentioned documents verifying income or lack of it, will be processed promptly by the cashier/clerk.5. After the patient has been approved for the Sliding Fee Program, they will receive a Sliding Fee identification card describing the benefits such as: A. Fee of $5 or $10 for an office visit, collected at the time of the visit B. 40% or 50% discount for lab tests C. 40% to 50% discount for the technical component of diagnostic, non-invasive radiology services D. 40 to 50% discount on respiratory procedures E. 40 to 50% discount on spreech pathology procedures6. Qualification for Sliding Fee remains in effect for one year from the date of approval, unless the patient or the household income should change within that year.7. The Sliding Fee Program benefits may apply to the outstanding patient accounts which do not exceed 365 days from the day of service. Accounts which have already been sent to a collection agency may not qualify for this program. 8. It is the patient's responsibility to reapply annually for continued participation in the Sliding Fee Program. Part I, Line 7: Cost of community health improvement and commumity benefit services includes cost of supplies and employee costs. Cash and in-kind contributions to community groups includes cost of employee time and donated space. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 1564132. Part III, Line 4: The cost of bad debts was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions.Financial statement footnote that describes bad debt expense: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectible accounts. In evaluating the collectability of accounts receivable, the System analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectability. Management also reviews troubled, aged accounts to determine collection potential. For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Systemn records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. Recoveries of accounts previously written off are recorded as a reduction to the provision for bad debt expense when received. Interest is not charged on patient accounts receivable. Part III, Line 8: Medicare allowable costs were estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part III, Line 9b: All uncollectible accounts will be reviewed by the Collector before being sent to a collection agency or magistrate cours. Any account over $500 will be reviewed by the Collector to determine whether it could be taken to magistate court. The CFO will sign off on any account sent to magistrate court. Once a month a list of all accounts to be written off is prepared for approval by the Finance Committee and Board of Directors. Minnie Hamilton Health Care Center, Inc. Part V, Section B, Line 16e: Utilize collection agencies as well as magistrate court. Part VI, Line 2: Records of types of visits and diagnosis are kept and analyzed for adjustment of appropriate services. Official community needs assessments are periodically performed by an outside agency. Part VI, Line 3: The organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs or under the organization's financial assistance policy by making information available as follows:1) Posting on the facility's website2) Attaching information to billing invoices3) Posting information in emergency rooms, waiting rooms and admission offices4) Providing in writing to patients on admission to the facility5) Making information available on request Part VI, Line 4: The organization services a rural area of 16,000 people in Calhoun, Gilmer and surrounding counties. The county has one of the highest unemployment rates in the State of WV. Patient principal payers percentages are: 40% medicare, 21% medicaid, 19% commercial, and 20% private pay. The nearest Hospital is over 30 miles away. The Health Care Center is designated as an HPSA site. Part VI, Line 5: All board members reside in the service area and none are employed by, or have contractual arrangements with Minnie Hamilton Health Care Center. The medical staff privileges are available to all qualified providers in the area. All profit and available funding is utilized for continuation and improvement of the provision of appropriate health services through staffing and acquisition of equipment and supplies. A 24-hour emergency room doctor is provided regardless of a patient's ability to pay. The nearest hospital is 40 minutes away, by car. An active auxiliary is made up of local volunteers and has been present during all years of the facilities hospital services. X X X X 0 0 0 0 0 0 0 0 0 Suresh Balasubramony 615207 0 0 0 0 0 9350 0 9159 0 633716 0 0 0 Alfonso Cinco 416288 0 0 0 1981 0 0 0 9223 0 427492 0 0 0 John D'Angelo 218877 0 0 0 0 0 0 0 0 0 218877 0 0 0 Chadwick Smith 464641 0 0 0 0 0 0 0 8745 0 473386 0 0 0 Matthew Siwicki 168683 0 0 0 0 0 6620 0 8942 0 184245 0 0 0 A Calhoun County Building Commission 556000308 2006-12-13 2455000 Refinance existing debt and new capital expenditures 0 0 0 A 1391617 2455000 53570 902044 1499386 2007 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section B, line 11 Form 990 is reviewed by Senior Management, the Finance Committee and the Board of Directors. Form 990, Part VI, Section B, line 12c The Board of Directors sign the statement annually. Individual members are excused from decision making on issues where conflicts may arise. Board of Directors members recuses themselves from voting on issues where a conflict may exist. Form 990, Part VI, Section B, line 15 A survey of like facilities in the state, utilizing the Health Care Authority information that is available, to compare salaries of top executives, as well as looking at job responsibilities and years of experience. The CEO is a contracted position and approved by the Board of Directors. Senior management is approved by the CEO. Form 990, Part VI, Section C, line 19 Audited Financial Statements are available upon request to the public. Annually the audited balance sheet and income statement are published in the local newspaper as per the Health Care Authority financial disclosure requirements. Volunteers Form 990, Page 1, Line 6 Volunteers of the organization include members of the hospital auxiliary and teenagers involved in a volunteer program.