2013-11-15T20:00:21-06:00 2012-12-31 135381590 BDO USA LLP 3601 C STREET SUITE 600 ANCHORAGE AK 99503 990 2012-01-01 990260423 NORTH HAWAII COMMUNITY HOSPITAL NORT 8088814400 67-1125 MAMALAHOA HIGHWAY KAMUELA HI 967438496 DENNIS STILLMAN 8088814400 2013-11-14 1 KEY E GETTY CPA P00121200 9072788878 2013-11-14 2012 2016-03-07 17:11:31Z LOWELL JOHNSON 67-1125 MAMALAHOA HIGHWAY KAMUELA HI 967438496 55044562 0 X HTTP://WWW.NHCH.COM X 1989 HI ACUTE CARE HOSPITAL 10 7 446 65 0 0 3658004 1857667 44984216 51574945 22690 -153751 1308880 1571110 49973790 54849971 0 0 0 0 27301915 28293970 0 0 730133 23220217 28807598 50522132 57101568 -548342 -2251597 187907766 161337747 14738773 15277443 173168993 146060304 ACUTE CARE HOSPITAL 0 0 40698542 51574945 NORTH HAWAII COMMUNITY HOSPITAL (THE HOSPITAL), LOCATED IN KAMUELA, HAWAII ON THE ISLAND OF HAWAII, IS A NOT-FOR-PROFIT, ACUTE-CARE HOSPITAL THAT PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR THE RESIDENTS AND VISITORS OF NORTH HAWAII. THE HOSPITAL WAS CHARTERED IN NOVEMBER 1987 AND COMMENCED OPERATIONS IN MAY 1996. THE HOSPITAL IS CURRENTLY LICENSED FOR 33 BEDS. ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA. IN 2012, THE HOSPITAL SERVED PATIENTS THROUGH 73,475 OUTPATIENT VISITS AND 1,965 ADMISSIONS. 40698542 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 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 0 1 0 0 0 1 103 0 1 446 1 0 0 0 0 0 0 0 0 0 0 X 10 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X DENNIS STILLMAN CFO 8088814675 67-1125 MAMALAHOA HIGHWAY KAMUELA HI 967438496 CAROLYN QUICK 3.00 X 0 0 0 DR SHARON VITOUSEK 3.00 X 0 0 0 DR VIRGINIA PRESSLER 3.00 X X 0 0 0 KAHU BILLY MITCHELL 3.00 X 0 0 0 NEIL KUYPER 3.00 X X 0 0 0 RICHARD LEVY 3.00 X 0 0 0 ROBERT HASTINGS II 3.00 X X 0 0 0 ROBERT LINDSEY 3.00 X 0 0 0 ROBERT MOMSEN 6.00 X X 0 0 0 DR DOUGLAS HILLER 40.00 X X 502266 0 16962 DR WILLIAM PARK 40.00 X 489874 0 17773 KENNETH F WOOD 40.00 X X 303391 0 16878 WILLIAM BROWN 40.00 X X 165550 0 12603 JASON D PARET EFF 9122011 40.00 X 269599 0 21683 KERRY L HOWELL 40.00 X 171939 0 6717 LORRIE ANN MORTENSEN 40.00 X 195916 0 9992 WAYNE HIGAKI 40.00 X 173592 0 9048 ASHLEY BYNO 40.00 X 174903 0 15481 DIANE PAYNE 40.00 X 544541 0 17041 DR HOWARD WONG 40.00 X 357396 0 7542 MALCOLM MACDONALD 40.00 X 232721 0 11926 PATRICIA GUNTER 40.00 X 272864 0 21787 3854552 0 185433 32 0 1 0 CLINICAL LABS OF HAWAII LLP 33 LANIHULI ST HILO HI 96720 CONTRACT LAB SERVICES 878119 C&A INDUSTRIES INC 13609 CALIFORNIA ST OMAHA NE 68154 TRAVELLERS AND LOCUM STAFFING 685196 SANDWICH ISLES DEVELOPMENT LLC 3159 OAHU AVENUE HONOLULU HI 96822 ARCHITECTURE SERVICES 623502 MARTIN FLETCHER LOCUMS INC 400 E LAS COLINAS BLVD SUITE 300 IRVING TX 75039 TRAVELLERS AND LOCUM STAFFING 521950 COMPHEALTH MEDICAL STAFFING INC PO BOX 713100 SALT LAKE CITY UT 841713100 TRAVELLERS AND LOCUM STAFFING 476582 17 630042 1227625 22069 1857667 PATIENT SERVICE REVENU 622100 49736062 49736062 STATE OF HAWAII SUSTAI 622100 1838883 1838883 51574945 19981 19981 303990 0 303990 303990 303990 20859 194591 -173732 -173732 -173732 308123 0 308123 308123 E.H.R. MEANINGFUL USE 622100 660819 660819 MISCELLANEOUS 900099 295028 295028 INV IN LIBERTY DIALYSI 900099 3150 3150 958997 54849971 51574945 0 1417359 X 2383784 1026875 1178253 178656 21536076 16819303 4503022 213751 135391 113909 18630 2852 2622292 2016312 571466 34514 1616427 1235828 356063 24536 520530 520530 463300 463300 269048 269048 8089118 5863286 2069964 155868 75514 18484 44364 12666 888342 329836 527801 30705 1275802 45677 1219217 10908 1975376 41417 1926838 7121 151314 106055 41626 3633 61024 27590 32717 717 636778 412324 216519 7935 2843093 2109494 723174 10425 1060872 751974 295262 13636 SUPPLIES 6660066 6468909 185418 5739 BAD DEBT EXPENSE 2680823 2680823 LAND USE RIGHTS AMORTIZ 39999 27871 11592 536 1116599 602575 498089 15935 57101568 40698542 15672893 730133 92269 530166 4735373 1761693 2825270 2755005 6283153 7493288 586765 356016 1389949 1203955 464187 367392 59666693 34421852 24747811 25244841 146782989 121625391 187907766 161337747 4152597 5008158 9624232 8277087 961944 1992198 14738773 15277443 X 23405880 25727997 10276805 6663385 139486308 113668922 173168993 146060304 187907766 161337747 X -2251597 539235 -25396327 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4911169 123000 519199 476608 37584 18898 5020278 0.77620 0.22380 1 1 1 7694551 7694551 3909896 3186291 723605 21866870 12244547 9622323 25425545 18447808 6977737 769831 543206 226625 25244841 DISTRIBUTION RECEIVABLE - PARKER RANCH FOUNDATION TRUST 960000 INTEREST IN EQUITY OF PARKER RANCH FOUNDATION TRUST 109772007 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 203974 CONSTRUCTION IN PROGRESS 2576028 INVESTMENT IN LIBERTY DLYS 42106 LOAN ISSUE COSTS - UNAMORTIZED 90519 BENEFICIAL INTERESTS 5020277 CONTRIBUTED USE OF LAND 2846625 OTHER RECEIVABLES 113855 121625391 CAPITAL LEASE OBLIGATION 1992198 1992198 26772821 -25176877 -25176877 51949698 2900273 2900273 54849971 54420745 0 54420745 2680823 2680823 57101568 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION HAS BENEFICIAL INTEREST IN SEVERAL ENDOWMENTS, ALL WITH THE PURPOSE OF PROVIDING RESOURCES TO BE USED TO ENHANCE HEALTH CARE SERVICES IN NORTH HAWAII. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN VALUE OF INT IN PARKER RANCH FOUNDATION TRUST -25,762,593. CHANGE IN VALUE OF BENEFICIAL INTEREST IN EARL BAKKEN CHARITABLE TRUST LEAD 118,136. CHANGE IN VALUE OF OTHER BENEFICIAL INTERESTS 467,580. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT RECLASSED FROM REVENUE TO EXPENSE 2,680,823. RECLASS UNCOLLECTIBLE PLEDGES FROM PRIOR YEAR 219,450. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT RECLASSED FROM REVENUE TO EXPENSE 2,680,823. 1 1 X 1 X 1 X 1 1 0 0 224144 224144 0.00390 9870959 2532578 7338381 0.12850 10095103 2532578 7562525 0.13240 5650 5650 702595 1261294 -558699 0.00000 708245 1266944 -558699 10803348 3799522 7003826 0.13240 1 2680824 334359 11099350 9579278 1520072 X 1 1 1 1 NORTH HAWAII COMMUNITY HOSPITAL

67-1125 MAMALAHOA HWY KAMUELA HI 96743

X X X INCLUDES NORTH HAWAII MEDICAL GROUP AND KOHALA HOME HEALTH AGENCY. NORTH HAWAII COMMUNITY HOSPITAL 1 0 1 1 200.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X 1 X X 0 X X X 1 X 0 0 PART II: N/A PART III, LINE 4: BAD DEBT EXPENSE IS SHOWN AS A PERCENTAGE OF TOTAL EXPENSE OF THE HOSPITAL, AND REPRESENTS THE PORTION OF UNREIMBURSED EXPENSE FROM THE HOSPITAL'S APPLICABLE CHARITY CARE PROGRAMS. BAD DEBT FINANCIAL STATEMENT FOOTNOTE- BAD DEBT PROVISIONS ARE MADE FOR THE AMOUNT OF REVENUE THAT WILL NOT BE COLLECTED FROM PATIENTS TO WHOM SERVICES WERE BILLED BUT NOT PAID. THE HOSPITAL HAS DETERMINED THESE PATIENTS ARE NOT FINANCIALLY INDIGENT AND DO NOT QUALIFY FOR THE HOSPITAL'S CHARITY CARE PROGRAM. BAD DEBT PROVISIONS ARE DETERMINED BY MANAGEMENT'S ASSESSMENT WITH CONSIDERATION OF BUSINESS AND ECONOMIC CONDITIONS, CHANGES AND TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. THE ADEQUACY OF THIS PROVISION IS PERIODICALLY REVIEWED AND FURTHER MODIFIED BASED UPON THE ACCOUNTS RECEIVABLE PAYOR COMPOSITION AND AGING, AND HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. PART III, LINE 9B: CHARITY CARE WILL BE GRANTED TO ALL UNDERINSURED AND UNINSURED PATIENTS. THE SCREENING PROCESS WILL OPTIMALLY OCCUR AT THE TIME OF SERVICE, BUT MAY OCCUR ANYTIME DURING THE COLLECTION PROCESS INCLUDING POST ASSIGNMENT TO AN OUTSIDE COLLECTION AGENCY. MEASURES TO PUBLICIZE THE POLICY LINE 14G NOTICES THAT FINANCIAL ASSISTANCE IS AVAILABLE ARE POSTED IN ALL PATIENT REGISTRATION, BILLING OFFICE AND EMERGENCY DEPARTMENT AREAS. THESE NOTICES TO NOT CONTAIN THE FULL DETAILED TEXT OF THE POLICY. REGISTRATION PERSONNEL ARE KNOWLEDGEABLE TO ASSIST PATIENTS WITH QUESTIONS AND ARE ABLE TO GIVE THEM THE FINANCIAL ASSISTANCE APPLICATION. PART VI, LINE 2: ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA, AND THE BOARD IS COMPRISED OF COMMUNITY MEMBERS. THIS ALLOWS THE HOSPITAL TO ASSESS THE NEEDS OF THE COMMUNITY THAT IT SERVES. IN ADDITION, MANY COMMUNITY HEALTH INPROVEMENT SERVICES ARE OFFERED IN THE FORMS OF ACTIVITIES OR PROGRAMS THAT HELP TO ASSESS AND IMPROVE COMMUNITY HEALTH. PART VI, LINE 3: NOTICES ARE POSTED IN ALL PATIENT REGISTRATION, BILLING OFFICE AND EMERGENCY DEPARTMENT AREAS REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE TO LOW-INCOME AND UNINSURED PATIENTS. THIS INFORMATION IS ALSO POSTED ON THE HOSPITAL WEBSITE AND ON PATIENT BILLING STATEMENTS. APPRORIATE STAFF MEMBERS THAT COMMUNICATE WITH THE PUBLIC REGARDING THEIR BILLS ARE TRAINED AND KNOWLEDGEABLE ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICIES. PART VI, LINE 4: NORTH HAWAII COMMUNITY HOSPITAL ("THE HOSPITAL") IS LOCATED IN KAMUELA, HI, ALSO KNOWN AS WAIMEA, HI, IN THE KOHALA DISTRICT OF THE NORTHEASTERN REGION OF THE ISLAND OF HAWAII. IT IS A NOT-FOR-PROFIT, ACUTE CARE HOSPITAL THAT PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR ABOUT 30,000 RESIDENTS AND VISITORS OF NORTH HAWAII. THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF APPROXIMATELY ONE-FOURTH, OR 1000 SQUARE MILES, OF THE BIG ISLAND'S 4028 TOTAL SQUARE MILES. THERE ARE CURRENTLY NO OTHER GENERAL ACUTE CARE HOSPITALS IN THE PRIMARY SERVICE AREA. THE HOSPITAL WAS CHARTERED IN NOVEMBER 1987 AND COMMENCED OPERATIONS IN MAY 1995. THE HOSPITAL IS CURRENTLY LICENSED FOR 39 BEDS. ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA. PART VI, LINE 5: THE ORGANIZATION'S BOARD IS COMPRISED OF COMMUNITY MEMBERS FROM THE NORTHERN HAWAII AREA. THE HOSPITAL CONDUCTED APPROXIMATELY 34 DIFFERENT EVENTS INCLUDING HEALTH FAIRS AND EDUCATION DAYS IN THE LOCAL COMMUNITY, HOTELS, AND SCHOOLS OF THE AREA AS WELL AS TAKING A LEAD ROLE IN BREAST CANCER AWARENESS MONTH. TOTAL COMMUNITY PEOPLE REACHED WAS APPROXIMATELY 13,740. PART VI, LINE 6: N/A X 1 0 0 0 0 0 0 0 0 DR DOUGLAS HILLER 502266 0 0 0 0 0 0 0 16962 0 519228 0 0 0 DR WILLIAM PARK 437074 0 52800 0 0 0 5000 0 12773 0 507647 0 0 0 KENNETH F WOOD 303391 0 0 0 0 0 2579 0 14299 0 320269 0 0 0 WILLIAM BROWN 148150 0 17400 0 0 0 859 0 11744 0 178153 0 0 0 JASON D PARET EFF 9122011 240199 0 29400 0 0 0 5330 0 16353 0 291282 0 0 0 KERRY L HOWELL 153579 0 18360 0 0 0 0 0 6717 0 178656 0 0 0 LORRIE ANN MORTENSEN 174916 0 21000 0 0 0 2869 0 7123 0 205908 0 0 0 WAYNE HIGAKI 155592 0 18000 0 0 0 2364 0 6684 0 182640 0 0 0 ASHLEY BYNO 174903 0 0 0 0 0 0 0 15481 0 190384 0 0 0 DIANE PAYNE 544541 0 0 0 0 0 6048 0 10993 0 561582 0 0 0 DR HOWARD WONG 357396 0 0 0 0 0 0 0 7542 0 364938 0 0 0 MALCOLM MACDONALD 223796 0 8925 0 0 0 0 0 11926 0 244647 0 0 0 PATRICIA GUNTER 272864 0 0 0 0 0 5321 0 16466 0 294651 0 0 0 PART I, LINE 3 A BOARD RESOLUTION IS REQURED. PART I, LINE 4A KENNETH WOOD: SEVERANCE AGREEMENT INCLUDES BI-WEEKLY COMPENSATION OF $13,713.94 FROM 10/1/12 FOR 24 MONTHS AND COVERAGE FOR MEDICAL AND DENTAL BENEFITS AT A COST OF $529.08 PER MONTH FOR 18 MONTHS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED BY THE CPA FIRM, AND REVIEWED BY THE CFO, DIRECTOR OF FINANCIAL SERVICES, BOARD FINANCE COMMITTEE, AND BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY IS REVIEWED EACH YEAR BY ADMINISTRATION. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL OBTAINED SALARY MARKET STUDIES FROM A CONTRACTED MANAGEMENT COMPANY. THEY ALSO COMPARED SALARIES OF APPLICANTS AND FORMER CHIEF EXECUTIVE OFFICERS OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 5,863,286. MANAGEMENT AND GENERAL EXPENSES 2,069,964. FUNDRAISING EXPENSES 155,868. TOTAL EXPENSES 8,089,118. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN VALUE OF INTEREST IN PARKER RANCH FOUNDATION TRUST -25,762,593. CHANGE IN VALUE OF EARL BAKKEN CHARITABLE LEAD TRUST 118,136. CHANGE IN VALUE OF OTHER BENEFICIAL INTERESTS 467,580. UNCOLLECTIBLE PLEDGES FROM PRIOR YEARS -219,450. LUCY K HENRIQUES TRUST C/O BANK OF HAWAII PO BOX 3170 DEPT HONOLULU HI 968023170 996002291 PROVIDE SUPPORT FOR NORTH HAWAII COMMUNITY HOSPITAL AK 501C3 LINE 11C, III-FI 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 LUCY K HENRIQUES TRUST S 79500 CASH