2013-08-12T13:40:25-05:00 2012-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 560530234 RANDOLPH HOSPITAL INC RAND 3366255151 364 WHITE OAK STREET ASHEBORO NC 27204 MURRAY S MARSH JR 3366255151 2013-08-07 1 AMY BIBBY P00445891 8282542254 2011 2016-02-24 21:20:13Z STEVE E EBLIN 364 WHITE OAK STREET ASHEBORO NC 27204 123803216 0 X WWW.RANDOLPHHOSPITAL.ORG X 1931 NC OPERATION OF NONPROFIT HOSPITAL IN RANDOLPH COUNTY, NC 12 12 1271 233 2949 0 82906 615714 115026675 120787025 825355 -328915 1135578 1766752 117070514 122840576 9267 2619 0 0 51867748 53127430 0 0 73284 63281689 72186397 115158704 125316446 1911810 -2475870 155662010 152699418 76896374 75507546 78765636 77191872 X RANDOLPH HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS. 0 0 113990678 2619 117207481 RANDOLPH HOSPITAL'S MISSION IS TO "PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS". RANDOLPH HOSPITAL PROVIDED QUALITY CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. RANDOLPH HOSPITAL PROVIDES A WIDE RANGE OF PROGRAMS FOR THE MEMBERS OF OUR COMMUNITY INCLUDING WELLNESS PROGRAMS, SUPPORT GROUPS AND COMMUNITY EDUCATION PROGRAMS FOR ALL CITIZENS FROM THE ELDERLY TO THE ELEMENTARY SCHOOL AGE.RANDOLPH HOSPITAL IS AN ACUTE-CARE HOSPITAL SERVING RANDOLPH COUNTY AND SURROUNDING COUNTIES. RANDOLPH HOSPITAL SERVED 6,722 INPATIENTS, HAD 39,076 EMERGENCY ROOM VISITS, 105,570 OTHER OUTPATIENT VISITS AND 43,903 HOME CARE VISITS DURING THE PERIOD OCTOBER 1, 2011 TO SEPTEMBER 30, 2012.RANDOLPH HOSPITAL PROVIDED CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW CHARGES. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES WERE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. TO THE EXTENT REIMBURSEMENT WAS BELOW CHARGES, RANDOLPH HOSPITAL RECOGNIZES THESE AMOUNTS AS UNDER REIMBURSED CARE IN MEETING ITS MISSION TO THE COMMUNITY. THE UNDER REIMBURSED VALUE ASSOCIATED WITH THESE SERVICES IS $86,565,360 FOR THE PERIOD OCTOBER 1, 2011 TO SEPTEMBER 30, 2012. CHARGES TO PRIVATE SECTOR PATIENTS COULD HAVE BEEN REDUCED BY THIS AMOUNT IF MEDICARE AND MEDICAID MATCHED THE RATES PAID BY PRIVATE SECTOR PATIENTS. IN ADDITION, RANDOLPH HOSPITAL WAS REIMBURSED BELOW CHARGES FOR OTHER PAYERS IN THE AMOUNT OF $57,458,600 FOR THE SAME PERIOD.RANDOLPH HOSPITAL PROVIDED CARE FOR URGENT AND EMERGENCY CASES AS WELL AS INPATIENT AND OUTPATIENT SERVICES FOR ALL INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY. 28.7 % OF EMERGENCY PATIENTS WERE UNINSURED. THE UNDER REIMBURSED VALUE ASSOCIATED WITH THIS CARE (CHARITY AND BAD DEBT) WAS $34,154,802 FOR THE PERIOD OCTOBER 1, 2011 THROUGH SEPTEMBER 30, 2012.RANDOLPH HOSPITAL PROVIDES BENEFITS TO THE COMMUNITY OTHER THAN ITS TRADITIONAL HOSPITAL BASED SERVICES. SOME OF THESE SERVICES INCLUDE: - AN EDUCATIONAL OPPORTUNITY AT THE HOSPITAL WAS GIVEN FOR ALL COUNTY AND CITY SCHOOL 2ND GRADERS TO LEARN ABOUT SOME OF THE PROCEDURES THEY MIGHT ENCOUNTER IF THEY WERE PATIENTS. - HEALTH WATCH MONITORING SERVICES WERE PROVIDED FOR ALMOST 175 SUBSCRIBERS. - A HEALTH VAN WAS DEPLOYED TO OFFER FREE HEALTH SCREENINGS THROUGHOUT THE COMMUNITY. THE SERVICE PROVIDED APPROXIMATELY 500 FREE SCREENINGS FOR ABOUT 125 PEOPLE. - FORMAL EDUCATION PROGRAMS WERE OFFERED THAT INCLUDE CHILDBIRTH, SMOKING CESSATION, MATERNITY SUITES TOURS, CPR, BABYSITTER TRAINING AND OTHERS. - SUPPORT GROUPS WERE OFFERED THAT INCLUDED BUT WERE NOT LIMITED TO, CANCER SUPPORT, DIABETES, OSTOMY, STROKE, CAREGIVER AND HIV/AIDS. - FREE SCREENINGS WERE OFFERED THROUGHOUT THE YEAR FOR NUMEROUS THINGS SUCH AS VASCULAR DISEASE, OSTEOPOROSIS, PROSTATE CANCER, SKIN CANCER, ORAL CANCER, STROKE AND OTHERS. - FREE SEMINARS OFFERED INCLUDED SUCH TOPICS AS HEART DISEASE, CERVICAL HEALTH, CHILD SAFETY, BALANCE ISSUES AND DISEASE INTERVENTION. - HEALTH LINK, A HOSPITAL AND HEALTHCARE NEWSLETTER, WAS PUBLISHED QUARTERLY AND MAILED TO OVER 35,000 HOUSEHOLDS THROUGHOUT THE SURROUNDING COMMUNITY. - SCHOLARSHIPS WERE PROVIDED FOR STUDENTS STUDYING IN VARIOUS MEDICAL FIELDS INCLUDING REGISTERED NURSES AND RADIOLOGY TECHNICIANS. - RANDOLPH HOSPITAL EMPLOYEES CONTINUE TO GIVE BACK TO THE COMMUNITY BY SUPPORTING THE RANDOLPH COUNTY UNITED WAY AND THE RANDOLPH HOSPITAL COMMUNITY HEALTH FOUNDATION. THROUGH EMPLOYEE CAMPAIGNS, MORE THAN $54,000, AND $4,000 WERE GIVEN RESPECTIVELY. - THE RANDOLPH HEALTH IMPROVEMENT PARTNERSHIP WORKED TO IDENTIFY AND ADDRESS CRUCIAL HEALTH AND WELLNESS ISSUES COUNTYWIDE. - RANDOLPH HOSPITAL SERVED AS A MAJOR SPONSOR FOR THE ANNUAL RELAY FOR LIFE EVENT BY PREPARING OVER 1,000 FREE MEALS FOR CANCER SURVIVORS AND THEIR FAMILIES. - A FREE SPEAKERS BUREAU WAS PROVIDED TO THE COMMUNITY AND PROVIDED OVER 50 SPEAKERS ON A VARIETY OF HEALTHCARE RELATED TOPICS. 113990678 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 229 0 1 1271 1 1 1 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X X LINDA CROWSHAW 3366255151 346 WHITE OAK STREET ASHEBORO NC 27204 X SAMUEL D CRANFORD JR 4.00 X X 0 0 0 ROBERT C SHAFFNER 3.00 X X 0 0 0 GLENN MAC PUGH 2.00 X X 0 0 0 MARY COOPER 2.00 X 0 0 0 ELBERT LASSITER 2.00 X 0 0 0 DIANE FROST PHD 2.00 X 0 0 0 REYNOLDS LISK 2.00 X 0 0 0 CRANFORD KNOTT 2.00 X 0 0 0 MICHAEL C MILLER 2.00 X 0 0 0 SAMUEL A RANKIN JR 2.00 X 0 0 0 ROBERT S SHACKLEFORD JR 2.00 X 0 0 0 STEVE E EBLIN 40.00 X 187570 0 35406 MURRAY S MARSH JR 40.00 X 0 0 0 SANDRA L ALLEN 40.00 X 436291 0 62512 DEVIN L GRIFFITH 40.00 X 168483 0 28699 BARBARA E WOLFE 40.00 X 111245 0 14854 ROB S CLAUSER 0.00 X 0 144566 12340 ROBERT E MORRISON 40.00 X 1112524 0 182900 LYNWOOD R WHITE 40.00 X 266539 0 28491 TREMONTEO CRAWFORD 40.00 X 144070 0 13721 LISA HAMPTON 40.00 X 139859 0 20063 MICHELLE LUTHER 40.00 X 134146 0 3625 WILLIAM WARD 40.00 X 126858 0 15360 ANGELA BURGESS 40.00 X 121304 0 24664 2948889 144566 442635 23 0 1 0 GREENSBORO RADIOLOGY 1317 NORTH ELM STREET SUITE 1B GREENSBORO NC 27401 PROFESSIONAL FEES 3628988 MCNEARY INSURANCE 6525 MORRISON BLVD CHARLOTTE NC 28222 INSURANCE SERVICES 1550192 EMPLOYEE BENEFITS SERVICE 534 RIVERCROSSING DR FT MILL SC 29715 EMPLOYEE BENEFIT SERVICES 1350478 SODEXHO INC 2803 SLATER ROAD MORRISVILLE NC 27560 FOOD SERVICE 1204028 ARAMARK CTS 12483 COLLECTION CCR DR CHICAGO IL 60693 BIOMEDICAL ENGINEERING 948291 23 7574 100000 508140 615714 PATIENT SERVICE REVENU 621400 117008632 117008632 PATIENT PHARMACY 446110 3078086 3078086 MEALS/NUTRITION 722210 501458 501458 CANCER CENTER REVENUES 621400 111199 111199 HEALTHWATCH REVENUE 900099 87650 87650 120787025 515721 515721 432511 118004 314507 314507 314507 844636 -844636 -844636 -844636 MISCELLANEOUS REVENUES 900099 1094684 1094684 DISCOUNTS & REBATES 900099 261098 2949 258149 COFFEE/GIFT SHOP 453220 96463 96463 1452245 122840576 117207481 2949 5014432 2619 2619 2653573 2653573 39513334 35770500 3702593 40241 1359351 1153148 204906 1297 6217400 5274267 937200 5933 3383772 2870479 510064 3229 583733 386727 197006 136393 135614 779 68389 68389 9474387 9455609 17935 843 385168 277373 98836 8959 13958615 12131886 1817952 8777 1438065 1386521 51544 2489327 2359405 129922 440326 376652 62125 1549 13978 13978 941324 941324 6521918 6521918 526337 526337 BAD DEBTS 26111179 26111179 MEDICAL SUPPLIES 8253417 8253417 MISCELLANEOUS 705508 703676 155 1677 RECRUITMENT 138333 138333 125316446 113990678 11252484 73284 2909826 4397436 27272799 21613959 201282 0 18864797 21785392 2651497 2990893 1281034 1295095 141521349 76464755 68347346 65056594 18330864 19804569 1141256 4504439 4104513 10156870 11650967 155662010 152699418 6418679 9806813 46080000 4978937 47177798 19418758 18522935 76896374 75507546 X 77067162 75983761 1698474 1208111 78765636 77191872 155662010 152699418 X -2475870 902106 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12072 12072 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). BOTH ASSOCIATIONS PERFORM LOBBYING OF STATE AND LOCAL GOVERNMENTS ON BEHALF OF THEIR MEMBERSHIP BODIES, AND A PORTION OF THE DUES PAID TO EACH ASSOCIATION IS ATTRIBUTABLE TO THOSE LOBBYING EXPENDITURES. FOR THE FISCAL YEAR, THE PORTION OF DUES ATTRIBUTABLE TO LOBBYING WAS ESTIMATED AT $12,072. 1 3232061 3232061 78479386 34229794 44249592 1923368 730529 1192839 54554333 41504432 13049901 3332201 3332201 65056594 OTHER RECEIVABLES 1434189 OTHER LONG-TERM ASSETS 149515 DEFERRED FINANCING COSTS, NET 159504 ASSETS LIMITED AS TO USE 1238323 DUE FROM AFFILIATES 8669436 11650967 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1164105 OTHER LONG-TERM LIABILITIES 1429497 PENSION PAYABLE 7163692 INTEREST RATE SWAP 4564732 DUE TO AFFILIATE 4200909 18522935 122840576 125316446 -2475870 1538085 -635979 902106 -1573764 123860686 1538085 -517975 1020110 122840576 0 122840576 125434450 118004 118004 125316446 0 125316446 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL, RMA, RSG, AND FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AEC AND CPSC ARE LIMITED LIABILITY COMPANIES, WHICH DO NOT PRODUCE TAXABLE INCOME TO THEIR NOT-FOR-PROFIT OWNER. THE ORGANIZATIONS HAVE DETERMINED THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN PENSION LIABILITY 99,914. CHANGE IN VALUE OF INTEREST RATE SWAP -246,791. OTHER CHANGES TO NET ASSETS -489,102. TOTAL TO SCHEDULE D, PART XI, LINE 8: -635,979. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES 118,004. OTHER CHANGES TO NET ASSETS -489,102. CHANGE IN PENSION LIABILITY 99,914. CHANGE IN VALUE OF INTEREST RATE SWAP -246,791. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES 118,004. 1 1 X 1 X 1 X 1 1 1 0 0 4607444 4607444 0.04590 14676541 14643199 33342 0.00030 19283985 14643199 4640786 0.04620 140508 140508 0.00140 140508 140508 0.00140 19424493 14643199 4781294 0.04760 24583 24583 0.00020 24583 24583 0.00020 1 26088402 22175142 24341178 26721256 -2380078 X 1 1 1 CENTRAL PIEDMONT SURGERY CENTER LLC AMBULATORY OUTPATIENT SURGICAL CENTER 0.68000 0.21000 1 1 RANDOLPH HOSPITAL

364 WHITE OAK STREET ASHEBORO NC 27204

X X X RANDOLPH HOSPITAL 1 0 1 1 150.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 1 X 0 0 2 HOME HEALTH OF RANDOLPH HOSPITAL

341 N FAYETTEVILLE STREET ASHEBORO NC 27203

HOME CARE RANDOLPH HEALTH EDUCATION CENTER

200-A FOUST STREET ASHEBORO NC 27203

HEALTH EDUCATION CENTER PART I, LINE 7: WORKSHEET 2 OF THE 2011 SCHEDULE H INSTRUCTIONS WAS USED TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE CHARITY CARE AND UNREIMBURSED MEDICAID AT COST. PART I, L7 COL(F): THE AMOUNT OF TOTAL EXPENSE ON FORM 990, PART IX, LINE 25 HAS BEEN ADJUSTED TO REMOVE A BAD DEBT EXPENSE OF $26,111,179 AND TO INCLUDE ALLOCATED TOTAL EXPENSES OF A JOINT VENTURE OF $1,231,778 FOR PURPOSES OF CALCULATING LINE 7, COLUMN (F). PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT. BAD DEBT EXPENSE WAS OBTAINED FROM THE AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION ESTIMATES FROM HISTORICAL PERSPECTIVE AND EXPERIENCE THAT APPROXIMATELY 85% OF BAD DEBT EXPENSE MAY BE ATTRIBUTABLE TO COMMUNITY BENEFIT. PART III, LINE 8: COSTS AND TOTAL REVENUES RECEIVED FROM MEDICARE REPORTED ON LINES 5 AND 6 ARE CALCULATED FROM THE ORGANIZATION'S MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. RANDOLPH HOSPITAL WILL IDENTIFY ANY PATIENT FINANCIAL RESPONSIBILITY PRIOR TO SERVICE AND REQUIRE THE PATIENT/GUARANTOR TO PAY OR MAKE ACCEPTABLE FINANCIAL ARRANGEMENTS FOR PAYMENT PRIOR TO SERVICE BEING RENDERED. A SLIDING FEE SCHEDULE WILL BE AVAILABLE FOR PATIENTS WHO HAVE THE ABILITY TO MAKE PARTIAL PAYMENT. FREE CARE WILL BE AVAILABLE TO THOSE WHO SUCCESSFULLY QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY FD-PA-007. IT IS THE APPLICANT'S RESPONSIBILITY TO DEMONSTRATE INABILITY TO PAY. RANDOLPH HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL'S FAP PROVIDES A DISCOUNT FOR INDIVIDUALS THAT QUALIFY UNDER THE POLICY'S PROVISIONS. THE HOSPITAL HAS MADE PLANS TO IMPLEMENT A METHOD OF DETERMINING AMOUNTS GENERALLY BILLED (AGB) PER THE RECENTLY RELEASED PROPOSED REGULATIONS UNDER SECTION 1.501(R), HOWEVER GIVEN THE HIGH LEVEL OF DISCOUNT AVAILABLE UNDER THE CURRENT POLICY, THE ORGANIZATION IS CONFIDENT THAT ITS POLICIES ARE WELL WITHIN GUIDELINES. PART VI, LINE 2: RANDOLPH HOSPITAL, IN COORDINATION WITH THE COUNTY HEALTH DEPARTMENT, COMMISSIONS A COMMUNITY NEEDS ASSESSMENT. THIS PROCEDURE INVOLVES COMMUNITY MEETINGS, FOCUS GROUPS, AND THE REVIEW OF HISTORICAL DATA. THE ORGANIZATION COMPLETES NEEDS ASSESSMENTS GENERALLY EVERY THREE YEARS, AND THE NEXT ASSESSMENT IS CURRENTLY IN PROCESS FOR COMPLETION IN 2012. PART VI, LINE 3: RANDOLPH HOSPITAL EMPLOYS FINANCIAL COUNSELORS WHO WORK WITH ALL SCHEDULED PATIENTS IN ADVANCE OF THEIR SERVICES TO DETERMINE ELIGIBILITY FOR CHARITY CARE. EMERGENCY PATIENTS ARE COUNSELED AFTER THEIR TREATMENT IS COMPLETE. THE ORGAINIZATION ALSO PROVIDES FINANCIAL ASSISTANCE OPTIONS INFORMATION ON ITS WEBSITE AND CONTACTS THE SCHEDULED PATIENTS BY TELEPHONE TO PROVIDE THIS INFORMATION. PART VI, LINE 4: RANDOLPH HOSPITAL IS A 145 BED ACUTE CARE HOSPITAL LOCATED IN ASHEBORO, NORTH CAROLINA. THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF RANDOLPH COUNTY, NORTH CAROLINA AND SURROUNDING COUNTIES.FOR THE PERIOD OCTOBER 1, 2011 TO SEPTEMBER 30, 2012, RANDOLPH HOSPITAL SERVED 6,722 INPATIENTS, HAD 39,076 EMERGENCY ROOM VISITS, 105,570 OTHER OUTPATIENT VISITS AND 43,903 HOME CARE VISITS. RANDOLPH HOSPITAL PROVIDED THESE QUALITY SERVICES REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY.RANDOLPH HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS. THE HOSPITAL HAS PROVIDED QUALITY CARE TO ALL RESIDENTS IN AND AROUND ASHEBORO, NORTH CAROLINA. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. IN ADDITION, THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY TO MOST HOSPITAL DEPARTMENTS.ANY SURPLUS OF FUNDS IN A GIVEN YEAR IS USED TO FUND CAPITAL EXPENDITURES TO ACQUIRE EQUIPMENT NECESSARY TO PROVIDE QUALITY PATIENT CARE. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NC 1 X X X X X 0 1 0 0 0 0 0 0 0 STEVE E EBLIN 187210 0 0 0 360 0 30804 0 4602 0 222976 0 0 0 SANDRA L ALLEN 231158 0 0 0 205133 0 57062 0 5450 0 498803 0 0 0 DEVIN L GRIFFITH 168296 0 0 0 187 0 27341 0 1358 0 197182 0 0 0 ROB S CLAUSER 0 144386 0 0 0 180 0 5733 0 6607 0 156906 0 0 ROBERT E MORRISON 387202 0 0 0 725322 0 158990 0 23910 0 1295424 0 0 0 LYNWOOD R WHITE 264955 0 0 0 1584 0 24296 0 4195 0 295030 0 0 0 TREMONTEO CRAWFORD 142296 0 0 0 1774 0 13490 0 231 0 157791 0 0 0 LISA HAMPTON 139679 0 0 0 180 0 18903 0 1160 0 159922 0 0 0 PART I, LINE 1A PART I, LINE 4B THE AMOUNTS REPRESENTED AS DEFERRED COMPENSATION ON SCHEDULE J HAVE NOT BEEN PAID TO THE INDIVIDUALS. THE AMOUNT REPRESENTS VESTED BENEFITS WHICH MAY BE PAID IN FUTURE YEARS, DEPENDING ON THE INDIVIDUAL'S LIFE SPAN AND OTHER FACTORS WHICH COULD RESULT IN FORFEITURE OF THE BENEFIT. DURING 1998, THE HOSPITAL ESTABLISHED A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN TO COVER HIGHLY COMPENSATED EMPLOYEES. THIS PLAN INCLUDED A NONQUALIFIED SUPPLEMENTAL RETIREMENT PLAN, A NONQUALIFIED DEFERRED COMPENSATION PLAN (REVISED IN 2005), AND A SPLIT-DOLLAR LIFE INSURANCE PLAN. THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN PROVIDES ADDITIONAL BENEFITS TO SUPPLEMENT BENEFITS EARNED UNDER THE ORGANIZATION'S BROADER DEFINED BENEFIT PENSION PLAN. IN 2005, THE HOSPITAL INSTITUTED A NONQUALIFIED DEFERRED COMPENSATION PLAN. THE PURPOSE OF THIS PLAN IS TO PROVIDE ADDITIONAL RETENTION INCENTIVES AND RETIREMENT SECURITY FOR CERTAIN MEMBERS OF THE HOSPITAL'S SENIOR MANAGEMENT TEAM AND TO ALLOW FOR THE DEFERRAL OF COMPENSATION OF THOSE ELIGIBLE MEMBERS OF ITS SENIOR MANAGEMENT. THIS IS INTENDED TO BE A NONQUALIFIED PLAN. PARTICIPANTS ARE 100% VESTED AFTER 30 YEARS OF SERVICE OR AT AGE 67, TOTAL CONTRIBUTIONS TO THIS PLAN FOR THE FISCAL YEAR TOTALED $1,143,000. THE SPLIT-DOLLAR LIFE INSURANCE AGREEMENT INVOLVES THE PAYMENT OF PREMIUMS BY THE HOSPITAL FOR A LIFE INSURANCE POLICY, THE BENEFITS OF WHICH ARE SPLIT BETWEEN THE EMPLOYEES' BENEFICIARIES AND THE HOSPITAL UP TO THE AMOUNT OF PREMIUMS PAID. PREMIUMS PAID UNDER THIS PLAN WILL CONTINUE UNTIL THE AGREEMENT IS TERMINATED OR UPON THE DEATH OF THE INSURED EMPLOYEES. PREMIUMS PAID UNDER THE SPLIT-DOLLAR INSURANCE POLICY WERE $9,822 FOR THE FISCAL YEAR. ROBERT E. MORRISON AND SANDRA ALLEN RECEIVED A PAYOUT OF PREVIOUSLY DEFERRED COMPENSATION FROM THE NONQUALIFIED SUPPLEMENTAL DEFERRED COMPENSATION PLAN IN 2011 IN THE AMOUNT OF $723,738 AND $203,549. NO OTHER PARTICIPANTS OF THE PLAN RECEIVED PAYOUTS DURING THE YEAR. FOR THE YEAR, THE FOLLOWING INDIVIDUALS ACCRUED COMPENSATION UNDER THE SERP: STEVE EBLIN $9,470 SANDRA ALLEN $9,513 DEVIN GRIFFITH $7,848 ROBERT MORRISON $129,012 LYNWOOD WHITE $10,273 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART II: WE ARE REQUIRED TO REPORT COMPENSATION OF KEY INDIVIDUALS THAT WORK FOR AND ARE PAID BY A RELATED ORGANIZATION. COMPENSATION REPORTED ON THIS SCHEDULE DOES NOT NECESSARILY MEAN THAT THE COMPENSATION WAS PAID BY THIS ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 1 THERE STANDS AN EXECUTIVE COMMITTEE CONSISTING OF THE CHAIRMAN, VICE CHAIRMAN, CHAIRMAN-ELECT, THE SECRETARY, THE CHAIRMAN OF FINANCE, AUDIT, INVESTMENT AND RETIREMENT COMMITTEE, AND UP TO TWO OTHER DIRECTORS AS DESIGNATED BY THE CHAIRMAN. THE COMMITTEE HAS AND MAY EXERCISE THE AUTHORITY OF THE BOARD IN THE MANAGEMENT OF THE ORGANIZATION, TO THE EXTENT PERMITTED BY LAW, DURING THE INTERVALS BETWEEN MEETINGS OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATION SHALL HAVE ONE CLASS OF MEMBERS CONSISTING OF AT LEAST 23 MEMBERS AND NEVER CONSISTING OF MORE THAN 30 MEMBERS. FOUR MEMBERS SHALL BE EX OFFICIO, AS INDICATED BELOW. THE REMAINDER SHALL BE ELECTED AS PROVIDED IN DETAIL IN THE BYLAWS. THE PRINCIPAL CRITERION FOR SELECTION OF CORPORATE MEMBERS SHALL BE THE PERSON'S QUALIFICATIONS TO EVENTUALLY SERVE AS A DIRECTOR OF RANDOLPH HOSPITAL, AS SET FORTH IN SECTION 2.2 OF THE BYLAWS. AS CANDIDATES BECOME AVAILABLE, THE MEMBERS MAY EXPAND OR CONTRACT THEIR NUMBER, WITHIN THE LIMITS STATED ABOVE, IN ORDER TO PROVIDE AN ADEQUATE POOL OF MEMBERS WHO ARE QUALIFIED TO SERVE AS DIRECTORS. IN ADDITION TO THE ELECTED MEMBERS, THE MAYOR OF ASHEBORO, NORTH CAROLINA; THE CHAIRMAN OF THE BOARD OF COMMISSIONERS OF RANDOLPH COUNTY, NORTH CAROLINA; THE RANDOLPH COUNTY SUPERINTENDENT OF SCHOOLS; AND THE COUNTY HEALTH OFFICER OF RANDOLPH COUNTY, NORTH CAROLINA, SHALL SERVE AS EX OFFICIO MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS SHALL BE ELECTED BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS FROM NOMINATIONS RECEIVED BOTH FROM THE GOVERNANCE COMMITTEE AND FROM THE FLOOR AT THE ANNUAL MEETING OF THE MEMBERS, IF ANY. DIRECTORS SHALL SERVE ONE-YEAR TERMS, AND SHALL CONTINUE TO SERVE UNTIL THEIR SUCCESSORS ARE ELECTED AND QUALIFIED. DIRECTORS MAY BE RE-ELECTED. ANY DIRECTOR MAY BE REMOVED FROM OFFICE AT ANY TIME, WITH OR WITHOUT CAUSE, BY A MAJORITY VOTE OF THE MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B CHANGES TO THE BYLAWS, SALE OR MERGER OF THE HOSPITAL MUST BE APPROVED BY THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. UPON COMPLETION, THE RETURN WAS REVIEWED BY THE FINANCE AND AUDIT COMMITTEE OF THE BOARD, FOLLOWED BY A PRESENTATION TO THE FULL BOARD AT A SCHEDULED MEETING. BOARD MEMBERS WERE PROVIDED WITH A COPY OF THE RETURN A WEEK PRIOR TO THE MEETING, AND A PERIOD OF TIME WAS ALLOWED FOR QUESTIONS AND COMMENTS BEFORE FILING THE RETURN WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION EMPLOYS A FULL TIME CORPORATE COMPLIANCE OFFICER CHARGED WITH EDUCATING THE BOARD, OFFICERS, AND OTHER EMPLOYEES ON THE CONFLICT OF INTEREST POLICY. ALL NEW EMPLOYEES ARE GIVEN INFORMATION UPON ORIENTATION, AND ALL CURRENT EMPLOYEES ARE REQUIRED TO TAKE ANNUAL EDUCATION ON COMPLIANCE WITH THE POLICY. THERE IS A MONTHLY CORPORATE COMPLIANCE MEETING TO UPDATE KEY INDIVIDUALS ON NEW ISSUES AND NEW INFORMATION REGARDING CORPORATE COMPLIANCE. THE BOARD OF DIRECTORS IS REQUIRED ANNUALLY TO READ, SIGN, AND REMIT A COPY OF THE POLICY TO THE BOARD CHAIR. ALL BOARD MEMBERS ARE AWARE OF THE POLICY AND IN CASE OF ANY CONFLICT OF INTEREST, THEY WILL RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15 RANDOLPH HOSPITAL CONTRACTS WITH AN INDEPENDENT COMPENSATION CONSULTANT TO DETERMINE APPROPRIATE COMPENSATION LEVELS FOR EXECUTIVES THAT IS COMMENSURATE WITH ORGANIZATIONS OF SIMILAR SIZE AND STRUCTURE. A COMPENSATION COMMITTEE OF THE BOARD HAS FINAL DETERMINATION OF COMPENSATION LEVELS FOR TOP EXECUTIVES. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. FORM 990, PART VII, LINE 1A ROBERT CLAUSER IS THE EXECUTIVE DIRECTOR OF RANDOLPH MEDICAL ASSOCIATES AND RANDOLPH SPECIALTY GROUP PRACTICE AND SPLITS HIS TIME BETWEEN THESE TWO ENTITIES. HIS TITLE WITH THE HOSPITAL IS VP OF PHYSICIAN PRACTICE AND EMPLOYEE HEALTH. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,538,085. CHANGE IN PENSION LIABILITY 99,914. CHANGE IN VALUE OF INTEREST RATE SWAP -246,791. OTHER CHANGES TO NET ASSETS -489,102. TOTAL TO FORM 990, PART XI, LINE 5: 902,106. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. ASHEBORO ENDOSCOPY CENTER LLC 700 SUNSET AVENUE ASHEBORO NC 27203 680530308 HEALTHCARE NC 452335 241391 RANDOLPH HOSPITAL INC RANDOLPH HOSPITAL COMMUNITY HEALTH FOUNDATION 346 WHITE OAK STREET ASHEBORO NC 27204 582240755 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11A, I RANDOLPH HOSPITAL INC 1 RANDOLPH MEDICAL ASSOCIATES 132 WEST MILLER STREET ASHEBORO NC 27204 561853201 HEALTHCARE NC 501(C)(3) LINE 9 RANDOLPH HOSPITAL INC 1 RANDOLPH SPECIALTY GROUP PRACTICE 364 WHITE OAK STREET ASHEBORO NC 27204 113827203 HEALTHCARE NC 501(C)(3) LINE 9 RANDOLPH HOSPITAL INC 1 RANDOLPH CANCER CENTER LLC 364 WHITE OAK STREET ASHEBORO NC 27204 562181482 HEALTHCARE NC 501(C)(3) LINE 11A, I RANDOLPH HOSPITAL INC 1 CENTRAL PIEDMONT SURGERY CENTER LLC 11221 ROE AVE SUITE 320 LEAWOOD KS 66211 234317497 HEALTHCARE KS RANDOLPH HOSPITAL INC RELATED -1231778 129513 0 1 0.68000 0 0 0 1 0 0 0 0 1 0 0 0 1 1 0 0 0 0 RANDOLPH MEDICAL ASSOCIATES I 138154 INTERCOMPANY RANDOLPH SPECIALTY GROUP PRACTICE D 1220269 A/R BALANCE CENTRAL PIEDMONT SURGERY CENTER D 272000 A/R BALANCE RANDOLPH CANCER CENTER LLC I 249000 A/R BALANCE