2013-11-15T09:35:10-06:00 2012-12-31 310800053 Clark Schaefer Hackett & Co 10100 Innovation Drive Suite 400 Dayton OH 45342 990 2012-01-01 270712680 Beavercreek Medical Center BEAV 9373844550 2110 Leiter Road Miamisburg OH 45342 Clifton Patten 9373844550 2013-11-14 1 Herbert L Lemaster CPA P00039882 9372260070 2013-11-14 2012 2016-02-25 16:41:14Z The Indu and Raj Soin Medical Center Terry Burns 2110 Leiter Road Miamisburg OH 45342 32103668 0 X www.khnetwork.org X 2009 OH Provide quality healthcare to individuals and the community as a whole in a Judeo-Christian manner 11 5 0 145 0 0 575500 14230 0 31892630 606860 195183 0 0 1182360 32102043 0 0 0 0 238340 23145945 0 0 0 2582628 37041551 2820968 60187496 -1638608 -28085453 135107554 168211497 100575898 106541394 34531656 61670103 X Provide quality healthcare to individuals and the community as a whole in a Judeo-Christian manner 1 0 51372599 31695262 Care was provided for 2,164 discharges, adult & ped days of 6,451, and 26,434 outpatient visits. 51372599 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 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 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 11 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X X CLIFTON PATTEN 9373844550 2110 LEITER ROAD MIAMISBURG OH 45342 X Fred Manchur 1.00 39.00 X 0 1391797 390260 Terry Burns 40.00 X X 0 736819 40016 David Weigley 1.00 X 0 10000 0 Raj Attiken 1.00 X 0 0 0 Donald Harting 1.00 X 0 0 0 Michael McCullough MD 1.00 X 0 0 0 Thomas Peebles 1.00 X 0 0 0 Phillip Parker 1.00 X 0 0 0 Amol Soin MD 1.00 X 0 0 0 Troy Tyner DO 1.00 X 0 0 0 Stephen Zimmer 1.00 X 0 0 0 Ronald Connovich 40.00 X 0 221933 17507 Tim Ko 40.00 X 0 208927 27221 Steve Chavez 40.00 X 0 153117 17450 Belinda Mallett 40.00 X 0 350296 29042 James Porter 40.00 X 0 129317 20971 Jill Hope 40.00 X 0 122914 19945 Tim Garrity 40.00 X 0 121787 9266 Andrew Cain 40.00 X 0 115770 9655 Peggy Doyle 40.00 X 0 115647 10437 Mark Smith 0.00 40.00 X 0 433775 37812 Greg Henderson 0.00 X 0 372384 12029 Frank Perez 0.00 10.00 X 0 204000 0 0 4688483 641611 0 1 1 0 0 14171 59 14230 Patient care services 622000 31892630 31695262 197368 31892630 196808 196808 1625 -1625 -1625 -1625 32102043 31695262 0 392551 1174510 1174510 18005243 15665480 2339763 749829 652389 97440 2104502 1831024 273478 1111861 967376 144485 249138 249138 62648 1836 60812 1870 1870 3333746 2077517 1256229 302554 12893 289661 1236218 1086554 149664 626438 31851 594587 3335648 3051146 284502 45625 42296 3329 72387 72287 100 6517250 5961383 555867 8970515 8205406 765109 884375 811668 72707 Medical supplies 7440637 7423862 16775 Physician services 2856547 2856547 Cost of goods sold 330761 330761 Minor equipment 183239 182383 856 591955 107940 484015 60187496 51372599 8814897 0 4500000 6124841 832 1446264 3500 57567 155593772 8248597 117638519 147345175 11505464 11849333 1459239 1388317 135107554 168211497 2448395 7856450 98127503 98218510 0 466434 100575898 106541394 X 29456656 61095103 5075000 575000 34531656 61670103 135107554 168211497 X -28085453 7750 55216150 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 122722048 4429016 118293032 31350486 3819581 27530905 1521238 1521238 147345175 Estimated amounts due to third-party payors -279000 Professional self-insurance liability 745434 466434 X Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Network completed an analysis of its tax positions in accordance with applicable accounting guidance at December 31, 2012 and 2011 and determined that no amounts were required to be recognized in the consolidated financial statements at December 31, 2012 or 2011. 1 1 X 1 X 1 X 1 1 1 0 1 1 6069647 0 6069647 0.10080 4251592 3245028 1006564 0.01670 10321239 3245028 7076211 0.11750 1635984 836912 799072 0.01330 36391 36391 0.00060 1672375 836912 835463 0.01390 11993614 4081940 7911674 0.13140 1 1624904 38998 8337768 12107363 -3769595 X 1 1 1 1 Beavercreek Medical Center

3535 Pentagon Boulevard Beavercreek OH 45431

ketteringhealth.org/soin/ X X X Beavercreek Medical Center 1 0 1 1 100.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 X X X 1 X 0 1 Part I, Line 7: Charity care is calculated using a cost to charge ratio following the methodology of Worksheet 2. Medical costs are calculated using a cost accounting system that addresses all patient segments. Subsidized health services is calculated based on the non-Medicare, Medicaid, and charity care proportion of departmental losses for the specific programs. Cash and in-kind contributions are calculated on the basis of direct expenditures. Part I, Line 7g: Subsidized health services represent the non-needs based and non-Medicare program losses of services the hospital offers. Part III, Line 4: A cost to charge ratio was used to determine the amount reported in Part III, line 2. An industry average was used to compute the amount on line 3. Discounts and payments on patient accounts reduce bad debt expense. Text of footnote describing bad debt expense is as follows:"Based on historical experience, a significant portion of the Network's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Network records a significant provision for bad debts related to uninsured patients in the period the services are provided." Part III, Line 8: The costing methodology used to determine Medicare costs is the the Medicare cost report. Medicare costs have not been included in Community Benefit in Part I. A reconciliation between Medicare program amounts reported in Section B and the total Medicare program is below: Revenues Costs (Shortfall)SurplusMedicare Section B $ 8,337,768 $12,107,363 ($3,769,595) Other Medicare Programs $ 2,160,062 ($135,824) $2,295,887Total Medicare Programs $10,497,830 $11,971,539 ($1,473,708)Other Medicare programs include Medicare Part C and clinical laboratory and therapy programs not reportable in the Medicare Cost Report. Revenues and Costs for these programs are offset by differences in estimates of costs per the Medicare Cost Report and estimated total program costs during the hospital's first year of operations. Part III, Line 9b: Financial Counselors work out a payment program for any amount due after the charity sliding scale discounts are applied. Collection procedures consistent with self-pay accounts are applied to these balances. Beavercreek Medical Center Part V, Section B, Line 20d: The hospital provided a discount on medically necessary hospital services to uninsured patients who do not qualify under the charity care policy. Beavercreek Medical Center Part V, Section B, Line 22: The hospital charged patients an amount equal to gross charges in select circumstances. This includes, for example, claims with insurance denials for non-cooperation. Part VI, Line 3: SOIN informs and educates patients or persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs or under SOIN's charity care policy as follows:-SOIN has a financial assistance brochure that is included in all of the patient information kits given at the time of intake or registration into any facility or department.-There is information posted in all of the admitting and registration areas about charity care and financial assistance.-During the registration process there is specific scripting to ask patients if they would like to disclose family size and income to screen them for federal/state/local and hospital based charity/assistance programs. This is done regardless of insured or uninsured status. This data is available for future visits as well.-SOIN has the reporting capability to review and screen any patient who may have been admitted during registration "off hours" for eligibility and assistance.-SOIN contracts with an outside agency for patient assistance in the application process.-The back of the patient statement shows the current and prior year Federal Poverty Guidelines and has the Financial Assistance Form to complete and mail in for consideration for SOIN's HCAP or Charity Sliding Scale program. SOIN's patient account representatives in customer service screen patients that are unable to pay their bill for the various financial assistance programs. Part VI, Line 4: KHN serves a population of 1,631,000 in its primary and secondary service area. The nine county service area includes Butler, Clark, Clinton, Darke, Greene, Miami, Montgomery, Preble and Warren counties. Out of this service area, 11.2% of area residents have income below $15,000. 10.3% have income between $15,000 and $24,000 and 27.3% have income between $25,000 and $49,000. Portions of Darke and Montgomery counties have been identified as medically underserved by the Health Resources and Services Administration. This nine county area is served by 15 hospitals, 8 of which are part of Kettering Health Network. Part VI, Line 5: SOIN furthers its exempt purpose by promoting the health of the community by:-Retaining a Board of Directors with a majority (excluding employees and contractors) living in the primary service area;-Extending medical staff privileges to all qualified physicians in its community for a majority of its departments.-Utilizing surplus funds to help support ongoing improvements in patient care through equipment upgrades and establishment of new programs. Part VI, Line 6: SOIN promotes the health of the communities served as described below:-SOIN, a part of the Kettering Health Network, is dedicated to the creation and maintenance of community wellness programs, support groups and health education programs. SOIN provides numerous screenings, family-focused classes, donations and education programs to ensure the long-term well-being of people living in the community.-Kettering Affiliated Health Services, Inc. includes Sycamore Glen Health Center, Sycamore Glen Retirement Community, and Kettering Breast Evaluation Centers. These health care areas provide services to the surrounding communities which complement those services provided by SOIN as part of the Kettering Health Network.-Medical research is supported through the Innovation Center, cultivating new technologies and fostering best practices among partners from industry, academia and health care. Reports Filed With States Part VI, Line 7 OH 0 1 0 0 0 0 0 0 0 Fred Manchur 0 1115235 0 191039 0 85523 0 373845 0 16415 0 1782057 0 0 Terry Burns 0 366858 0 0 0 369961 0 10550 0 29466 0 776835 0 0 Ronald Connovich 0 221267 0 0 0 666 0 0 0 17507 0 239440 0 0 Tim Ko 0 206481 0 0 0 2446 0 10891 0 16330 0 236148 0 0 Steve Chavez 0 152417 0 0 0 700 0 0 0 17450 0 170567 0 0 Belinda Mallett 0 235350 0 0 0 114946 0 13687 0 15355 0 379338 0 77973 James Porter 0 125076 0 81 0 4160 0 5821 0 15150 0 150288 0 0 Mark Smith 0 379840 0 50985 0 2950 0 13687 0 24125 0 471587 0 0 Greg Henderson 0 372384 0 0 0 0 0 0 0 12029 0 384413 0 0 Frank Perez 0 204000 0 0 0 0 0 0 0 0 0 204000 0 0 Part I, Line 3 Compensation is established by a related organization. The process of determining compensation of CEO's, executive directors, officers, and key employees is to have an independent board approve the compensation. The compensation is determined to be reasonable compared to independent comparability data. The approval of the amounts is documented in the Board minutes within the appropriate time frame. At year end the organization reviews executive compensation by comparing the amounts approved to the amounts paid. Part I, Line 4b The Network has a Supplemental Executive Retirement Plan available only to a certain class of management. A County of Greene Ohio 316000271 394650BV6 2009-11-03 97931091 Construct and equip a hospital 0 0 0 A 100032163 10520948 2633592 1612304 85213731 51588 2012 0 0 1 1 A 0 0 1 1 1 1 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 0 0 0 0 1 A 1 Part II, Line 3, Column A Includes investment earnings of $2,101,072 New Program Services Form 990, Part III, line 2 Beavercreek Medical Center officially opened in 2012. This is the first year with patient revenue. Form 990, Part VI, Section B, line 11 A tax specialist is engaged to review the 990. The 990 is reviewed and accepted by the audit committee which reports this to the governing body (board). Form 990, Part VI, Section B, line 12c The Network regularly and consistently monitors and enforces compliance with the conflict of interest policy by making it part of the employees' annual reviews. Employees must certify that they have read the conflict of interest policy and have disclosed any potential conflicts and agree to immediately notify Corporate Integrity if one should arise. Board members are required to annually review the Network's policy, sign a conflict of interest statement, and notify the Network if a conflict should arise. Form 990, Part VI, Section B, line 15 The process of determining compensation of CEO's, executive directors, officers, and key employees is to have an independent board approve the compensation. The compensation is determined to be reasonable compared to independent comparability data. The approval of the amounts is documented in the Board minutes within the appropriate time frame. At year end the organization reviews executive compensation by comparing the amounts approved to the amounts paid. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are available upon request. Officers Compensation Part VII; Section A Tim Ko was the financial officer until March 2012. Ron Connovich was the financial officer from March 2012 to August 2012 and November 2012 to present. Steve Chavez was the financial officer from September 2012 to November 2012. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Net transfers from affiliate 55,216,150. Alliance Physicians Inc 2110 Leiter Road Miamisburg OH 45342 311175717 Physician Services OH 501(c)(3) 509(a)(3) Kettering Adventist Healthcare 0 Dayton Osteopathic Hospital 2110 Leiter Road Miamisburg OH 45342 310564121 Hopsital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 The Fort Hamilton Hospital 2110 Leiter Road Miamisburg OH 45342 310536662 Hopsital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 Greene Foundation 2110 Leiter Road Miamisburg OH 45342 310886949 Fundraising OH 501(c)(3) 509(a)(1) Greene Memorial Hospital 0 Greene Memorial Hospital 2110 Leiter Road Miamisburg OH 45342 310809436 Hopsital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 Greene Memorial Hospital Services Inc 2110 Leiter Road Miamisburg OH 45342 311358549 Physician Services OH 501(c)(3) 509(a)(3) Kettering Adventist Healthcare 0 Kettering Adventist Healthcare 2110 Leiter Road Miamisburg OH 45342 311051688 Management OH 501(c)(3) 509(a)(3) Kettering Adventist Healthcare 0 Kettering Medical Center 2110 Leiter Road Miamisburg OH 45342 310621866 Hospital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 Kettering Medical Center Foundation 2110 Leiter Road Miamisburg OH 45342 237419897 Fundraising OH 501(c)(3) 509(a)(3) Kettering Medical Center 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 Alliance Physicians Inc M 0 FMV Kettering Medical Center M 0 FMV Kettering Medical Center N 0 FMV Kettering Medical Center O 0 FMV Kettering Medical Center P 0 FMV Kettering Medical Center S 55216150 FMV Transactions with Related Organizations Part V; Line 2 Kettering Medical Center is the conduit through which revenue is received and expenses are paid.