2012-08-03T12:09:20-05:00 2011-09-30 SASLOW LUFKIN & BUGGY LLP TEN TOWER LANE AVON CT 06001 990 2010-10-01 060669121 THE NEW MILFORD HOSPITAL INC NEWM 8603552611 21 ELM STREET NEW MILFORD CT 06776 DEBORAH WEYMOUTH 8603507204 2012-07-23 1 BETH THURZ 8606789200 2010 2016-02-24 21:20:13Z STEVEN H ROSENBERG 21 ELM STREET NEW MILFORD CT 06776 93972501 0 X WWW.NEWMILFORDHOSPITAL.ORG X 1921 CT NEW MILFORD HOSPITAL IS AN ACUTE CARE MEDICAL FACILITY DEDICATED TO MAINTAINING AND IMPROVING THE HEALTH STATUS OF THE RESIDENTS OF NEW MILFORD AND NEIGHBORING COMMUNITIES, REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. 15 14 728 100 1482862 -286002 5650883 1152058 91046180 92269157 58934 64299 377714 486987 97133711 93972501 0 0 0 0 49346058 54770792 0 0 0 42389485 39041456 91735543 93812248 5398168 160253 68919291 70984854 34214687 40595858 34704604 30388996 X TO PROVIDE OUTSTANDING HEALTH CARE TO THE COMMUNITIES WE SERVE THROUGH AN UNCOMPROMISING FOCUS ON CLINICAL QUALITY, COMPASSIONATE SERVICE, AND THE CREATION OF A MEDICAL "SAFE HAVEN" FOR OUR PATIENTS AND THEIR FAMILIES. 0 0 67857235 90855137 THROUGH EFFORTS OF ITS MEDICAL STAFF, EMPLOYEES AND VOLUNTEERS, THE HOSPITAL ENDEAVORS TO MEET THE HEALTH CARE NEEDS THROUGH THE DIRECT PROVISION OF HIGH QUALITY, COMPREHENSIVE SERVICES AT A REASONABLE COST. ALTHOUGH REIMBURSEMENT FOR SERVICES PROVIDED IS CRITICAL TO THE OPERATION AND STABILITY OF NEW MILFORD HOSPITAL, IT IS RECOGNIZED THAT NOT ALL PERSONS ARE ABLE TO PURCHASE ESSENTIAL MEDICAL SERVICE AND HEALTH CARE EDUCATION. THEREFORE, IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVICE ALL MEMBERS OF THE COMMUNITY, FREE OR SUBSIDIZED CARE IS PROVIDED WHERE THE NEED AND INDIVIDUAL'S INABILITY TO PAY CO-EXIST. HEALTH ACTIVITIES AND PROGRAMS, INCLUDING WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, FREE HEALTH SCREENINGS, AND SPECIAL PROGRAMS FOR THE ELDERLY, HANDICAPPED AND MEDICALLY UNDERSERVED ARE ALSO A MAJOR PART OF OUR COMMITMENT TO SERVE ALL RESIDENTS. NEW MILFORD HOSPITAL SERVED 2,516 INPATIENTS AND PROVIDED MORE THAN 105,162 OUTPATIENT SERVICES DURING FISCAL YEAR 2011. NEW MILFORD HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED BY BOTH MEDICARE AND MEDICAID PATIENTS WITHOUT EXCEPTION. DEDUCTION FROM GROSS PATIENT SERVICE REVENUES FOR FISCAL YEAR 2011 WAS $145,904,773 IN ALLOWANCES. THE AMOUNT OF CHARITY CARE PROVIDED DURING FISCAL YEAR 2011 WAS $2,584,646. CHARITY CARE IS ALSO PROVIDED THROUGH MANY REDUCED-PRICE SERVICES AND FREE PROGRAMS OFFERED THROUGHOUT THE YEAR. NEW MILFORD HOSPITAL OFFERS THESE ACTIVITIES AND SERVICES WITH THE BELIEF THAT THEY SATISFY A BONA FIDE COMMUNITY HEALTH NEED. 67857235 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 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 0 1 1 0 0 0 1 50 0 1 728 1 1 1 0 0 0 0 0 0 0 0 0 X 15 14 0 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X STEVEN H ROSENBERG 8603507204 21 ELM STREET NEW MILFORD CT 06776 ANTHEA DISNEY 2.00 X 0 0 0 SPENCER HOULDIN 2.00 X 0 0 0 JAY LENT 2.00 X 0 0 0 ALPHONSE ALTORELLI MD 2.00 X 0 0 0 NEIL CULLIGAN MD 2.00 X 0 0 0 DAVID CYGANOWSKI 2.00 X 0 0 0 RICHARD JABARA 2.00 X 0 0 0 JOHN M MURPHY MD 40.00 X X 0 1021607 58579 JAMES KENNEDY 2.00 X X 0 0 0 DAVID KRAMER MD 2.00 X 0 0 0 JOHN R PATRICK 2.00 X 0 0 0 JOSEPH D SKRZYPCZAK 2.00 X 0 0 0 BRIAN C WHITE 2.00 X 0 0 0 JOHN KLINE 2.00 X 0 0 0 JOHN J MARTOCCI 2.00 X X 0 0 0 SUSAN IOVINO 50.00 X 487502 0 24186 DANA DIGGINS 50.00 X 308601 0 35342 DEBORAH WEYMOUTH 50.00 X 0 365820 24895 RICHARD HENLEY 50.00 X 0 0 0 STEVEN H ROSENBERG 40.00 X 0 196362 29046 THOMAS KOOBATIAN MD 40.00 X 408822 0 63228 JOSEPH BARGELLINI MD 40.00 X 444010 0 42873 P RODRIQUES MD 40.00 X 421081 0 30347 COURTNEY CHAMBERS MD 40.00 X 427247 0 41953 TIMOTHY KAISER MD 40.00 X 360880 0 39664 WILLIAM CICIO MD 40.00 X 343164 0 34183 3201307 1583789 424296 66 0 1 0 UNIDINE PO BOX 60479 CHARLOTTE NC 282600479 DIETARY SERVICES 1073011 CONNECTICUT ONCOLOGY & HEMATOLOGY 200 KENNEDY DRIVE TORRINGTON CT 06790 MEDICAL SERVICES 808833 SECURITAS SECURITY SERVICES 108 MILL PLAIN ROAD DANBURY CT 06811 SECURITY SERVICES 393449 SLEEPTECH LLC 135 KINNELON ROAD KINNELON NJ 07405 SLEEP CENTER MANAGEMENT SERVICES 316950 CLAIMASSIST 2 WELLS AVENUE NEWTON MA 02459 CLAIM SERVICES 273859 6 846341 267333 38384 1152058 ROUTINE SERVICES 900099 89105245 89105245 OTHER PROGRAM SERVICES 900099 1681050 1681050 NON-PATENT LAB SERVICE 621500 1482862 1482862 92269157 64299 64299 68842 68842 68842 68842 CAFETERIA & VENDING 722210 341067 341067 GIFT SHOP 452000 77078 77078 418145 93972501 90855137 1482862 482444 4252233 4252233 34609099 27202932 7406167 3554607 2488225 1066382 9837141 6885999 2951142 2517712 1762398 755314 377049 377049 154860 154860 10785811 7550068 3235743 136430 136430 8615539 6030877 2584662 927466 649226 278240 1563365 1094355 469010 10817 7572 3245 148490 103943 44547 511926 511926 5855136 4098595 1756541 1611492 1128044 483448 DRUGS 5797086 5797086 BAD DEBT EXPENSE 2545989 2545989 93812248 67857235 25955013 0 4716504 8207651 3264767 2809717 10247728 10457444 1074544 450818 2043790 1944478 1486255 964220 106383423 71638392 32752705 34745031 12279618 10309928 1053380 1095567 68919291 70984854 8533353 9737514 9200232 1924491 16481102 28933853 34214687 40595858 X 28931108 26176392 1822932 525763 3950564 3686841 34704604 30388996 68919291 70984854 X 160253 -4475861 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1145712 1145712 50072773 31775266 18297507 52661809 39466710 13195099 2503129 396416 2106713 34745031 INVESTMENT IN FOUNDATION 10110186 C INVESTMENT IN NM MRI JV, LLC 199742 C 10309928 DUE TO THIRD PARTY 4184788 SERP LIABILITY 307163 ACCRUED PENSION LIABILITY 15281329 DUE TO RELATED PARTIES 9160573 28933853 93972501 93812248 160253 -4475861 -4475861 -4315608 93622553 346393 346393 93276160 696341 696341 93972501 93812248 0 93812248 0 93812248 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN PENSION FUNDING OBLIGATION -2,579,273. NET UNREALIZED LOSSES ON INVESTMENTS HELD IN TRUST BY OTHERS -263,723. CHANGE IN EQUITY IN NET ASSETS OF THE FOUNDATION 1,099,738. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 156,640. MEMBERS' DISTRIBUTION ON JOINT VENTURE -129,557. OTHER ADJUSTMENTS 25,983. TERMINATION OF AFFILIATE - NM VNA -3,005,447. NET ASSETS RELEASED FROM RESTRICTIONS 346,393. PROGRAM EXPENSES PAID BY THE FOUNDATION -126,615. PART XII, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS 346,393. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS FROM NEW MILFORD HOSPITAL DEVELOPMENT FOUNDATION 696,341. 1 1 1 X 400.000000000000 1 X 1 1 0 1 1 987335 987335 0.01050 2583469 2583469 0.02750 3570804 3570804 0.03800 448175 16099 432076 0.00460 96685 96685 0.00100 37586 37586 0.00040 3364 3364 0.00000 585810 16099 569711 0.00600 4156614 16099 4140515 0.04400 1066 1066 0.00000 833 833 0.00000 54306 2225 52081 0.00060 12077 12077 0.00010 10331 10331 0.00010 78613 2225 76388 0.00080 1 972568 0 25375815 38763176 -13387361 X 1 1 1 NEW MILFORD MRI JV LLC MRI READING 0.51000 1 1 THE NEW MILFORD HOSPITAL INC

21 ELM STREET NEW MILFORD CT 06776

X X X X THE NEW MILFORD HOSPITAL 1 1 1 400.000000000000 0 1 X X 1 1 X X X X 1 X X X 1 X X X X X X X 1 X 0 1 PART III, LINE 4: IT IS THE POLICY OF THE HOSPITAL TO PROVIDE NECESSARY CARE TO ALL PERSONS SEEKING TREATMENT WITHOUT DISCRIMINATION ON THE GROUNDS OF AGE, RACE, CREED, NATIONAL ORIGIN OR ANY OTHER GROUNDS UNRELATED TO AN INDIVIDUAL'S NEED FOR THE SERVICE OR THE AVAILABILITY OF THE NEEDED SERVICE AT THE HOSPITAL. A PATIENT IS CLASSIFIED AS A CHARITY CARE PATIENT BY REFERENCE TO ESTABLISHED POLICIES OF THE HOSPITAL. ESSENTIALLY, THESE POLICIES DEFINE CHARITY SERVICES AS THOSE SERVICES FOR WHICH NO PAYMENT IS ANTICIPATED. IN ASSESSING A PATIENT'S INABILITY TO PAY, THE HOSPITAL UTILIZES THE GENERALLY RECOGNIZED FEDERAL POVERTY INCOME GUIDELINES, BUT ALSO INCLUDES CERTAIN CASES WHERE INCURRED CHARGES ARE SIGNIFICANT WHEN COMPARED TO A RESPONSIBLE PARTY'S INCOME AND THEIR COUNTABLE ASSETS. THOSE CHARGES ARE NOT INCLUDED IN NET PATIENT SERVICE.NO AMOUNT WAS SHOWN FOR PART III, LINE #3, SINCE THE AMOUNT CANNOT BE QUANTIFIED WITH ENOUGH CERTAINTY. PART III, LINE 8: THE HOSPITAL'S MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT AS THE ORGANIZATION STRIVES TO PROVIDE AROUND THE CLOCK COVERAGE, IMPROVED PATIENT ACCESS, HIGHEST CLINICAL QUALITY AS WELL AS ADDRESSING THE NEEDS OF THE COMMUNITY BY OFFERING CRITICAL SERVICES TO OUR GEOGRAPHIC AREA. AS A RESULT, THE ORGANIZATION MUST BALANCE THE COST OF THESE PROGRAMS AGAINST THE CONTINUED DECREASING GOVERNMENT REIMBURSEMENT LEVELS, UNINSURED POPULATION AND COMMUNITY NEEDS. PART III, LINE 9B: IT IS THE POLICY OF THE HOSPITAL TO PROVIDE "FINANCIAL ASSISTANCE" (EITHER FREE CARE OR REDUCED PATIENT OBLIGATIONS) TO PERSONS OR FAMILIES WHERE: (I) THERE IS LIMITED OR NO HEALTH INSURANCE AVAILABLE; (II) THE PATIENT FAILS TO QUALIFY FOR GOVERNMENTAL ASSISTANCE (FOR EXAMPLE MEDICARE OR MEDICAID); (III) THE PATIENT COOPERATES WITH THE HOSPITAL IN PROVIDING THE REQUESTED INFORMATION; (IV) THE PATIENT DEMONSTRATES FINANCIAL NEED AND (V) THE HOSPITAL MAKES AN ADMINISTRATIVE DETERMINATION THAT FINANCIAL ASSISTANCE IS APPROPRIATE.AFTER THE HOSPITAL DETERMINES THAT A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL WILL DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE AVAILABLE TO THE PATIENT BY UTILIZING THE CHARITABLE ASSISTANCE GUIDELINES WHICH ARE BASED UPON THE MOST RECENT FEDERAL POVERTY GUIDELINES.THE HOSPITAL SHALL REGULARLY REVIEW THIS FINANCIAL ASSISTANCE POLICY TO ENSURE THAT AT ALL TIMES IT: (I) REFLECTS THE PHILOSOPHY AND MISSION OF THE HOSPITAL; (II) EXPLAINS THE DECISION PROCESSES OF WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE AND IN WHAT AMOUNTS AND (III) COMPLIES WITH ALL APPLICABLE STATE AND FEDERAL LAWS, RULES AND REGULATIONS CONCERNING THE PROVISION OF FINANCIAL ASSISTANCE TO INDIGENT PATIENTS.CONSISTENT WITH ITS MISSION, THE HOSPITAL RECOGNIZES ITS OBLIGATION TO THE COMMUNITY IT SERVES TO PROVIDE FINANCIAL ASSISTANCE TO INDIGENT PERSONS WITHIN THE COMMUNITY.IN FURTHERANCE OF ITS CHARITABLE MISSION, THE HOSPITAL WILL PROVIDE BOTH (I) EMERGENCY TREATMENT TO ANY PERSON REQUIRING SUCH CARE; AND (II) ESSENTIAL, NON-EMERGENT CARE TO PATIENTS WHO ARE PERMANENT RESIDENTS OF ITS PRIMARY SERVICE AREA WHO MEET THE CONDITIONS AND CRITERIA SET FORTH IN THIS POLICY, WITHOUT REGARD TO THE PATIENTS' ABILITY TO PAY FOR SUCH CARE. ELECTIVE PROCEDURES GENERALLY WILL NOT BE CONSIDERED ESSENTIAL, NON-EMERGENT CARE AND USUALLY WILL NOT BE ELIGIBLE FOR FINANCIAL ASSISTANCE.THE HOSPITAL WILL COLLECT FROM INDIVIDUALS ON FINANCIAL ASSISTANCE IF THEY RECEIVED A PARTIAL CHARITABLE DISCOUNT. ALL PATIENTS CAN APPLY FOR CHARITABLE CARE ON BALANCES THEY FEEL THAT THEY CANNOT AFFORD. THE NEW MILFORD HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED FEDERAL POVERTY GUIDELINES TO DETERMINE THE AMOUNTS BILLED TO INDIVIDUALS WHO DID NOT HAVE INSURANCE COVERING EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. THE NEW MILFORD HOSPITAL PART V, SECTION B, LINE 21: THE HOSPITAL FACILITY CHARGES PATIENTS AN AMOUNT EQUAL TO THE GROSS CHARGE WHEN THEY SELF-PAY. PART VI, LINE 2: THE ORGANIZATION MONITORS AND REPORTS HEALTH AND HUMAN SERVICES INFORMATION. DATA INCLUDES BASIC DEMOGRAPHICS, ALONG WITH HEALTH ISSUE-SPECIFIC INFORMATION. ADDITIONALLY, WE SURVEY OUR CONSUMERS ON A REGULAR AND ONGOING BASIS FOR THEIR OPINIONS AND CONCERNS. PART VI, LINE 3: THE HOSPITAL HAS MESSAGES ON ALL STATEMENTS PROVIDING INFORMATION REGARDING HOW THE PATIENT CAN GET ASSISTANCE WITH THEIR HOSPITAL BILL. ALSO SIGNS ARE POSTED THROUGHOUT THE HOSPITAL AND COUNSELORS ARE AVAILABLE TO PROVIDE FURTHER ASSISTANCE.ALL UNINSURED INPATIENTS ARE INTERVIEWED BY FINANCIAL COUNSELORS AND ASSESSED FOR ELIGIBILITY FOR ASSISTANCE PROGRAMS. THE HOSPITAL PROVIDES INFORMATIONAL HANDOUTS TO ALL UNINSURED PATIENTS AT THE TIME OF REGISTRATION WHICH REFERS THEM TO FINANCIAL COUNSELING IF THEY WOULD LIKE ASSISTANCE WITH THEIR BILLS. FURTHER, THE HOSPITAL MAILS NOTICES TO ALL SELF-PAY ACCOUNTS REFERRING THEM TO FINANCIAL COUNSELING IF THEY NEED ASSISTANCE. THE COLLECTION DEPARTMENT WILL ALSO REFER PATIENTS TO FINANCIAL COUNSELING WHEN A PATIENT INDICATES THAT THEY CANNOT AFFORD THEIR BALANCES; AND FINALLY, SCHEDULERS REFER UNINSURED PATIENTS TO FINANCIAL COUNSELING PRIOR TO THEIR TEST OR PROCEDURE. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA IS THE CITY OF NEW MILFORD AND SURROUNDING SUBURBAN TOWNS THAT MAKE UP CENTRAL LITCHFIELD COUNTY. THE REGION IS GENERALLY EMPLOYED AND WITH AVERAGE INCOMES. CONSTITUENTS ARE PREDOMINANTLY CAUCASIAN, SKEW SOMEWHAT OLDER THAN OTHER AREAS OF CT AND THE U.S. POVERTY LEVELS ARE BELOW OTHER AREAS. PART VI, LINE 6: DURING FISCAL YEAR 2011, NEW MILFORD HOSPITAL SERVED 2,516 INPATIENTS AND CARED FOR 105,162 OUTPATIENTS. IN ADDITION, 18,781 PATIENTS CAME THROUGH OUR EMERGENCY DEPARTMENT AND 2,473 ONE-DAY SURGERY PROCEDURES WERE PERFORMED. LED BY A TEAM OF SKILLED AND DEDICATED HEALTHCARE PROFESSIONALS, NEW MILFORD HOSPITAL'S COMMITMENT TO CLINICAL EXCELLENCE AND PATIENT SATISFACTION WERE RECOGNIZED BY NUMEROUS PRESTIGIOUS ORGANIZATIONS IN 2011.THE CREATION OF WESTERN CONNECTICUT HEALTH NETWORK, A HEALTHCARE DELIVERY SYSTEM THAT COMBINES THE RESOURCES AND EXPERTISE OF DANBURY HOSPITAL, NEW MILFORD HOSPITAL AND THEIR AFFILIATES, REPRESENTS AN HISTORIC ACHIEVEMENT. THIS AFFILIATION GIVES US AN OPPORTUNITY TO PROVIDE A HIGHER LEVEL OF CARE THROUGHOUT THE REGION IN THE MOST COST-EFFECTIVE MANNER WHILE MEETING THE CHALLENGES POSED BY HEALTHCARE REFORM HEAD ON.PROVIDING OUR PHYSICIANS AND MEDICAL TEAM WITH THE TECHNOLOGICAL ADVANCES THEY NEED TO SUCCEED REMAINS A PRIORITY. THE LINACC CANCER TREATMENT SYSTEM, 64 SLICE CT SCANNER, AND THE OPEN BORE MRI IMAGING SYSTEM, FOR EXAMPLE, OFFER PATIENTS A SOPHISTICATED LEVEL OF CARE RARELY AVAILABLE IN A COMMUNITY HOSPITAL. EVER MINDFUL OF IMPROVING THE PATIENT EXPERIENCE, THE HOSPITAL BUILDS UPON ITS ESTABLISHED HIGH LEVELS OF PATIENT SATISFACTION AND SERVICE EXCELLENCE THROUGH ITS AFFILIATION WITH PLANETREE, A RECOGNIZED PHILOSOPHY IN PATIENT-CENTERED CARE. THE PARTNERSHIP FOCUSES ON IMPLEMENTING INNOVATIVE MODELS OF CARE THAT NURTURE THE MIND, BODY AND SPIRIT BY SUPPORTING PATIENTS, FAMILY MEMBERS AND STAFF ALIKE. KNOWLEDGE IS POWER WHEN IT COMES TO IMPROVING THE HEALTH AND WELLNESS OF PEOPLE OF ALL AGES IN CONNECTICUT AND NEW YORK. THAT'S THE MESSAGE BEHIND A NUMBER OF HOSPITAL INITIATIVES DESIGNED TO BUILD HEALTHY COMMUNITIES. PART VI, LINE 7: WESTERN CONNECTICUT HEALTH NETWORK, INC. (PARENT):WESTERN CONNECTICUT HEALTH NETOWRK'S MISSION IS TO BENEFIT, UPHOLD, PROMOTE AND FURTHER THE WELFARE, PROGRAMS AND ACTIVITIES OF NEW MILFORD HOSPITAL WHICH HELPS TO FURTHER THE HOSPITAL'S EXEMPT PURPOSE.NEW MILFORD HOSPITAL:NEW MILFORD HOSPITAL PROVIDES MEDICAL SERVICES TO THE COMMUNITY REGARDLESS OF THE INDIVIDUAL'S ABILITY TO PAY. SERVICES INCLUDE ROUTINE OUTPATIENT ANCILLARY AND OUTPATIENT CARE IN SUPPORT OF THE HOSPITAL'S MISSION STATEMENT, TO ENHANCE THROUGH MEDICAL CARE AND EDUCATION THE HEALTH AND WELL BEING OF OUR COMMUNITIES IN PARTNERSHIP WITH THOSE WE SERVE.NEW MILFORD FOUNDATION:THE NEW MILFORD FOUNDATION WAS ORGANIZED FOR THE PURPOSE OF SOLICITING, RECEIVING, HOLDING, INVESTING AND ADMINISTERING CONTRIBUTIONS ON BEHALF OF THE NEW MILFORD HOSPITAL, WHICH ASSISTS THE HOSPITAL IN FURTHERING ITS COMMITMENT TO THE COMMUNITY. REPORTS FILED WITH STATES PART VI, LINE 7 CT X X 0 1 0 0 0 0 0 0 0 JOHN M MURPHY MD 0 590628 0 426415 0 4564 0 22040 0 36539 0 1080186 0 0 SUSAN IOVINO 242875 0 0 0 244627 0 0 0 24186 0 511688 0 0 0 DANA DIGGINS 308601 0 0 0 0 0 8227 0 27115 0 343943 0 0 0 DEBORAH WEYMOUTH 0 310820 0 55000 0 0 0 0 0 24895 0 390715 0 0 STEVEN H ROSENBERG 0 70340 0 125000 0 1022 0 23740 0 5306 0 225408 0 0 THOMAS KOOBATIAN MD 408822 0 0 0 0 0 36113 0 27115 0 472050 0 0 0 JOSEPH BARGELLINI MD 444010 0 0 0 0 0 24601 0 18272 0 486883 0 0 0 P RODRIQUES MD 421081 0 0 0 0 0 12801 0 17546 0 451428 0 0 0 COURTNEY CHAMBERS MD 378148 0 49099 0 0 0 17767 0 24186 0 469200 0 0 0 TIMOTHY KAISER MD 360880 0 0 0 0 0 21392 0 18272 0 400544 0 0 0 WILLIAM CICIO MD 343164 0 0 0 0 0 9997 0 24186 0 377347 0 0 0 PART I, LINE 4B THE HOSPITAL HAS ESTABLISHED A SERP UNDER IRC 457(F) TO SUPPLEMENT THE RETIREMENT BENEFITS OF ELIGIBLE EMPLOYEES AS DESIGNATED BY THE HOSPITAL'S BOARD OF DIRECTORS. EFFECTIVE OCTOBER 1, 2009 THE SERP WAS FROZEN AND CERTAIN PARTICIPANTS OF AT LEAST AGE 60 WITH 10 YEARS OF SERVICE WERE GRANDFATHERED INTO THE PLAN. CURRENT PARTICIPANTS IN THIS PLAN INCLUDE SUSAN IOVINO (PAYMENT OF $244,679), SALLY HERLIHY (PAYMENT OF $52,526) AND ROBERT SOMMER (PAYMENT OF $462,797). FORM 990, PART VI, SECTION A, LINE 3 THE INTERIM PRESIDENT RICHARD HENLEY IS AN EMPLOYEE OF NAVIGANT CONSULTING, INC. THIS COMPANY WAS PAID FEES IN THE AMOUNT OF $707,595 FOR SUCH SERVICES FROM SEPT 2009 THROUGH JANUARY 2011. FORM 990, PART VI, SECTION A, LINE 7A CORPORATORS OF THE HOSPITAL ELECT BOARD APPOINTMENTS ANNUALLY BASED ON THE NOMINATING COMMITTEE'S RECOMMENDATIONS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS APPROVED BY THE AUDIT COMMITTEE AND REVIEWED BY THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL REQUIRES AN ANNUAL DISCLOSURE STATEMENT TO BE SIGNED AND FILED FOR ALL DIRECTORS NOTING ANY POTENTIAL CONFLICTS OF INTEREST AND COMPLIANCE WITH THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR OFFICERS IS DETERMINED BY HUMAN RESOURCE SURVEYS AND IS APPROVED BY THE PRESIDENT AND/OR THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE NEW MILFORD HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN PENSION FUNDING OBLIGATION -2,579,273. NET UNREALIZED LOSSES ON INVESTMENTS HELD IN TRUST BY OTHERS -263,723. CHANGE IN EQUITY IN NET ASSETS OF THE FOUNDATION 1,099,738. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 156,640. MEMBERS' DISTRIBUTION ON JOINT VENTURE -129,557. OTHER ADJUSTMENTS 25,983. TERMINATION OF AFFILIATE - NM VNA -3,005,447. NET ASSETS RELEASED FROM RESTRICTIONS 346,393. PROGRAM EXPENSES PAID BY THE FOUNDATION -126,615. TOTAL TO FORM 990, PART XI, LINE 5: -4,475,861. FORM 990: PART XI, LINE 2C THE ORGANIZATION HAS AN AUDIT COMMITTEE THAT ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THESE PROCESSES HAVE NOT CHANGED FROM THE PRIOR YEAR. NEW MILFORD HOSPITAL FOUNDATION INC 21 ELM STREET NEW MILFORD CT 06776 222515011 SOLICITING CHARITABLE SUPPORT FOR THE NEW MILFORD HOSPITAL. INC. CT 501(C)(3) LINE 7 NEW MILFORD HOSPITAL INC 0 NEW MILFORD VISITING NURSE ASSOCIATION INC 68 PARK LANE ROAD NEW MILFORD CT 06776 060653153 HOME HEALTH CARE AND HOSPICE SERVICE CT 501(C)(3) LINE 9 NEW MILFORD HOSPITAL INC 0 WESTERN CONNECTICUT HEALTH NETWORK INC 24 HOSPITAL AVE DANBURY CT 06810 222594977 PARENT OF DANBURY HOSPITAL, NEW MILFORD HOSPITAL, AND AFFILIATED COMPANIES CT 501(C)(3) LINE 11B, II 0 WESTERN CONNECTICUT MEDICAL GROUP PC 24 HOSPITAL AVE DANBURY CT 06810 061137531 PHYSICIAN SERVICES CT 501(C)(3) LINE 9 WESTERN CONNECTICUT HEALTH NETWORK INC 0 WESTERN CONNECTICUT HEALTH NETWORK FOUNDATION INC 24 HOSPITAL AVE DANBURY CT 06810 237425557 SOLICITING CHARITABLE SUPPORT FOR DANBURY AND NEW MILFORD HOSPITALS CT 501(C)(3) LINE 7 WESTERN CONNECTICUT HEALTH NETWORK INC 0 DANBURY HOSPITAL 24 HOSPITAL AVE DANBURY CT 06810 060646597 HOSPITAL CT 501(C)(3) LINE 3 WESTERN CONNECTICUT HEALTH NETWORK INC 0 NEW MILFORD MRI JV LLC 21 ELM STREET NEW MILFORD CT 06776 271877801 MRI FACILITY CT NEW MILFORD HOSPITAL INC RELATED 264596 338907 0 1 DANBURY HEALTH SYSTEMS INSURANCE CO LTD 10 MAIN STREET GRAND CAYMAN CJ 980438151 MALPRACTICE INSURANCE CJ DANBURY HOSPITAL C 0 0 1 1 1 0 0 1 1 0 0 1 1 1 1 1 0 1 NEW MILFORD HOSPITAL FOUNDATION INC C 719726 COST NEW MILFORD HOSPITAL FOUNDATION INC N 379108 COST NEW MILFORD MRI JV LLC D 140375 COST THE NEW MILFORD HOSPITAL FOUNDATION P 126615 COST DANBURY HOSPITAL E 6439583 COST WESTERN CT MEDICAL GROUP PC E 915495 COST DANBURY HOSPITAL H 1783822 COST DANBURY HOSPITAL L 539611 COST DANBURY HOSPITAL N 1432010 COST DANBURY HOSPITAL O 4489945 COST DANBURY HOSPITAL R 3103999 COST