2013-11-14T12:25:56-06:00 2012-12-31 990 2012-01-01 160755761 CUBA MEMORIAL HOSPITAL INC CUBA 5859682000 140 WEST MAIN ST CUBA NY 147271398 ANDREW H BOSER III CEO 5859682000 2013-11-13 2012 2016-02-24 21:20:13Z ANDREW H BOSER III 140 WEST MAIN ST CUBA NY 147271398 9514519 0 X WWW.CUBAMEMORIALHOSPITAL.COM X 1925 NY ACUTE AND LONG TERM PATIENT CARE 9 9 287 3 0 0 524988 227327 8957568 8861762 137 18 524788 414796 10007481 9503903 0 0 0 0 7257510 6990710 0 0 0 5239673 4144149 12497183 11134859 -2489702 -1630956 10111133 9633646 7819325 8972794 2291808 660852 TO PROVIDE A CONTINUUM OF APPROPRIATE HEALTH RELATED SERVICES TO ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 8189570 9236896 CUBA MEMORIAL HOSPITAL IS A NOT FOR PROFIT PUBLIC BENEFIT CORPORATION. ACUTE AND SKILLED NURSING HOME CARE IS PROVIDED IN ADDITION TO A 24 HOUR URGENT CARE CENTER AND TWO DENTAL CLINICS. THE HOSPITAL PROVIDED $448,199 IN CHARITY CARE AND FREE CARE ASSESSMENTS TO THE STATE OF NEW YORK. 8189570 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 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 0 0 0 1 17 0 1 287 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 NY X JOHN T ORMOND 5859682000 140 W MAIN ST CUBA NY 14727 TOM BROWN 1.00 X X 0 0 0 JODY SPEARS 1.00 X X 0 0 0 RALPH FOX 1.00 X 0 0 0 JOHN FOELS 1.00 X 0 0 0 AMY BLACK 1.00 X 0 0 0 LARRY POELMA 1.00 X 0 0 0 DR JAMES MOOR 1.00 X 0 0 0 JEAN SWITALSKI 1.00 X 0 0 0 JOHN HASPER 1.00 X 0 0 0 ANDREW H BOSER III 37.50 X 135813 0 12559 JOHN T ORMOND 37.50 X 135720 0 5276 DAVID HANRAHAN 48.00 X 141683 0 288 MARK STANCOMBE 48.00 X 140303 0 12559 KEVIN J BRICELAND 48.00 X 127651 0 4864 CHRISTOPHER L YOUNG 37.50 X 134310 0 12350 MICHAEL WILT 48.00 X 133477 0 12860 948957 0 60756 7 0 1 0 MCKESSON TECHNOLOGIES PO BOX 403421 ATLANTA GA 30384 COMPUTER MAINTENANCE 336874 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING SERVICE 257249 SYNERGY GLOBAL SOLUTIONS PO BOX 8000 BUFFALO NY 14267 COMPUTER SUPPORT 198491 ANGELICA-BATAVIA PO BOX 823283 PHILADELPHIA PA 19182 LAUNDRY SERVICES 135925 ACM MEDICAL LABORATORY 160 ELMGROVE PARK ROCHESTER NY 14624 LABORATORY SERVICES 123551 5 1890 215385 10052 227327 NET PATIENT REVENUE 621110 8861762 8861762 8861762 18 18 27850 0 27850 27850 27850 22428 1890 10616 11812 11812 OTHER REVENUE 621110 289470 289470 MEANINGFUL USE INCENTI 900099 85664 85664 375134 9503903 9236896 0 39680 289368 217402 71966 5699199 4281808 1417391 567887 426654 141233 434256 326257 107999 15894 15894 15867 15867 811060 676287 134773 30402 30402 1370523 1295462 75061 296894 223056 73838 381783 225896 155887 7083 5509 1574 11243 10236 1007 947460 214661 732799 77277 77277 BAD DEBT EXPENSE 178663 178663 11134859 8189570 2945289 0 336546 441194 228670 267262 1358490 1259738 75102 80402 49737 60727 18847856 11365661 7998476 7482195 64112 42128 10111133 9633646 3118421 2617716 4700904 6355078 7819325 8972794 X -264571 -1854645 743446 702564 1812933 1812933 2291808 660852 10111133 9633646 -1630956 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 200274 200274 9528358 4807295 4721063 195631 139998 55633 8923593 6418368 2505225 7482195 9325240 -178663 -178663 9503903 0 9503903 10956196 0 10956196 178663 178663 11134859 PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -178,663. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 178,663. GOLF TOURNAMENT 24318 1890 22428 1500 1570 1750 4117 150 1529 24318 1890 22428 1500 1570 1750 4117 150 1529 10616 11812 1 1 1 X 250.000000000000 1 X 1 1 0 1 0 678000 363033 314967 0.02880 5969034 4132863 1836171 0.16770 6647034 4495896 2151138 0.19650 7054 4972 2082 0.00020 7054 4972 2082 0.00020 6654088 4500868 2153220 0.19670 1 178663 3017276 2282306 734970 X 1 1 1 1 CUBA MEMORIAL HOSPITAL

140 W MAIN ST CUBA NY 14727

X CUBA MEMORIAL HOSPITAL INC 1 0 1 1 250.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X 1 X X X 1 X X X X X X X 1 X X 0 1 PART I, LINE 6A: A COMMUNITY BENEFIT REPORT WAS PREPARED IN ACCORD WITH NYS DEPARTMENT OF HEALTH REQUIREMENTS AND WAS FILED WITH THIS AGENCY. PART I, LINE 7: SPECIFIED WORKSHEETS WERE UTILIZED TO DETERMINE APPROPRIATE REVENUES AND COSTS TO BE REPORTED USING A RATIO OF COST TO CHARGES AS DEFINED IN THE WORKSHEETS. PART III, LINE 4: 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 HOSPITAL 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 ACUTALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 9B: IF A PATIENT IS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE, THE ACCOUNT IS MOVED TO A PRESUMED CHARITY CATEGORY AND COLLECTION EFFORTS ARE TERMINATED. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 19D: WHERE A MEDICARE FEE SCHEDULE IS NOT AVAILABLE, SUCH AS FOR DENTAL SERVICES, THE LARGEST COMMERCIAL INSURER FEE SCHEDULE IS UTILIZED TO DETERMINE MAXIMUM CHARGES FOR THE SERVICES. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 20D: ESTABLISHED HOSPITAL CHARGES ARE BILLED. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 22: HOSPITAL GROSS CHARGES ARE BILLED TO ALL PATIENTS OR THEIR INSURANCE COVERAGE. PAYMENT ADJUSTMENTS ARE MADE AS SEPARATE ALLOWANCE ON INDIVIDUAL ACCOUNTS.2. NEEDS ASSESSMENTS - DUE TO THE NATURE OF THE HOSPITAL AS A CRITICAL ACCESS HOSPITAL, THE NEEDS OF THE COMMUNITY THAT CAN BE MET THROUGH THE LIMITED SERVICES PROVIDED BY THE FACILTY ARE IDENTIFIED THROUGH PARTICIPATION IN REGIONAL AND COUNTY HEALTH PLANNING GROUPS WHICH FOCUS ON THE HEALTH NEEDS OF OUR SERVICE AREA.3. PATIENT EDUCATION - EACH PATIENT SEEKING SERVICES AT THE FACILITY WHO DOES NOT PROVIDE VERIFIABLE INSURANCE COVERAGE IS PROVIDED WITH THE FINANCIAL ASSISTANCE POLICY AND APPLICATION AT THE TIME OF REGISTRATION FOR THE SERVICES PROVIDED. IN ADDITION, THE AVAILABILITY OF FINANCIAL ASSISTANCE IS NOTED ON BILLINGS SENT TO THE PATIENT AFTER INSURANCE. CALLS ARE ALSO MADE TO ALL SELF PAY PATIENTS THAT FIRST BUSINESS DAY AFTER SERVICE TO EITHER IDENTIFY ALTERNATIVE INSURANCE COVERAGE OR TO REMIND THE PATIENT OF THE AVAILABILITY OF THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY.4. THE FACILITY SERVES A REGION COVERED PRIMARILY BY ALLEGANY AND CATTARAUGUS COUNTIES IN SOUTH WESTERN NEW YORK STATE. THE HOSPITAL WAS DESIGNATED AS A CRITICAL ACCESS HOSPITAL BY THE NEW YORK STATE DEPARTMENT OF HEALTH IN FEBRUARY 1997 AND HAS FUNCTIONED PRIMARILY FOCUSING ON GERIATRIC ACUTE AND REHAB MEDICINE IN ADDITION TO SKILLED NURSING CARE AND AN URGENT CARE CENTER.5. CUBA MEMORIAL HOSPITAL PARTICIPATES IN COMMUNITY WIDE CANCER SCREENING PROGRAMS AND PARTICIPATES IN REGIONAL RURAL HEALTH PLANNING ACTIVITIES. THE BOARD OF TRUSTEES IS MADE UP OF COMMUNITY BASED REPRESENTATIVES WHO PROVIDE DIRECTION AND OVERSIGHT OF ALL FACILITY SERVICES AND ACTIVITIES.6. THE CUBA MEMORIAL HOSPITAL IS NOT CURRENTLY AFFILIATED WITH ANY OTHER HEALTH CARE SYSTEM.7. CUBA MEMORIAL HOSPITAL ANNUALLY FILES A COMMUNITY BENEFIT REPORT WITH THE NEW YORK STATE DEPARTMENT OF HEALTH. X X X X 0 0 0 0 0 0 0 0 0 MARK STANCOMBE 140303 0 0 0 0 0 0 0 12559 0 152862 0 0 0 A ALLEGANY COUNTY INDUSTRIAL DEVELOPMENT AGENCY 470942108 2004-11-12 3000000 REFINANCING OF HOSPITAL MORTGAGE 0 1 0 A 2004 1 0 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEE FINANCE COMMITTEE WAS PROVIDED A COPY OF THE DRAFT 990 FOR REVIEW. A MEETING WAS THEN HELD TO REVIEW ANY QUESTIONS OR ISSUES RELATED TO THE SUBMISSION. QUESTIONS WERE DISCUSSED AND RESOLVED AND THE REVISED SUBMISSION WAS SENT TO OUR INDEPENDENT AUDITORS FOR REVIEW. THE FINALIZED VERSION OF THE 990 IS THEN PROVIDED TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL TRUSTEES AND OFFICERS COMPLETE AND SIGN AN ATTESTATION FORM IDENTIFYING ANY PERSONAL AND/OR FAMILY POTENTIAL CONFLICT SITUATIONS. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY, THE BOARD OF TRUSTEES EXECUTIVE COMMITTEE REVIEWS CEO AND CFO PERFORMANCE AND COMPENSATION. KEY EMPLOYEE COMPENSATION IS REVIEWED AND ESTABLISHED BY EXECUTIVE OFFICER CONSISTENT WITH THE BOARD APPROVED OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 MONTHLY AND ANNUAL FINANCIAL STATEMENTS ARE FILED WITH ALL FINANCIAL INSTITUTIONS WITH RELATIONSHIPS WITH THE HOSPITAL. ANNUAL COST REPORTS ARE FILED WITH MEDICARE AND MEDICAID. THE 990 IS ELECTRONICALLY FILED AND IS AVAILABLE FROM THE ORGANIZATION UPON REQUEST. CMHR CORPORATION 140 WEST MAIN ST CUBA NY 14727 562495396 PROPERTY MANAGEMENT NY SECTION 501(C)3 9 CUBA MEMORIAL HOSPITAL INC 0 CUBA MEMORIAL RETIREMENT COMMUNITY INC 140 WEST MAIN ST CUBA NY 14727 271463624 ASSISTED LIVING NY SECTION 501(C)3 9 CUBA MEMORIAL HOSPITAL INC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 PART V, SECTION 2 PAID OFFICERS OF CUBA MEMORIAL HOSPITAL, INC ARE FUNCTIONING AS THE OFFICERS OF BOTH SUBSIDIARY CORPORATION UNTIL THERE IS ACTIVITY WHICH JUSTIFIES ADDITIONAL STAFF. DURING THE YEAR, ONLY PLANNING ACTIVITIES WERE INVOLVED IN IDENTIFYING POTENTIAL FINANCING FOR THE PLANNED ASSISTED LIVING CAMPUS TO BE DEVELOPED WHEN FINANCING CAN BE IDENTIFIED.