2012-08-13T16:06:15-05:00 2011-09-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-10-01 560530234 RANDOLPH HOSPITAL INC RAND 3366255151 364 WHITE OAK STREET ASHEBORO NC 27204 STEVE E EBLIN 3366255151 2012-08-13 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z STEVE E EBLIN 364 WHITE OAK STREET ASHEBORO NC 27204 117503660 0 X WWW.RANDOLPHHOSPITAL.ORG X 1931 NC OPERATION OF NONPROFIT HOSPITAL IN RANDOLPH COUNTY, NC 12 12 1229 246 403 0 625625 82906 113526284 115026675 757766 825355 1004028 1135578 115913703 117070514 0 9267 0 0 53448522 51867748 0 0 57134 60164805 63281689 113613327 115158704 2300376 1911810 156131348 155662010 76887381 76896374 79243967 78765636 X RANDOLPH HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS. 0 0 104209940 9267 114714592 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 7,128 INPATIENTS, HAD 39,440 EMERGENCY ROOM VISITS, 106,502 OTHER OUTPATIENT VISITS AND 43,523 HOME CARE VISITS DURING THE PERIOD OCTOBER 1, 2010 TO SEPTEMBER 30, 2011.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 $93,558,794 FOR THE PERIOD OCTOBER 1, 2010 TO SEPTEMBER 30, 2011. 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 $40,659,205 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. 28.1 % OF EMERGENCY PATIENTS WERE UNINSURED. THE UNDER REIMBURSED VALUE ASSOCIATED WITH THIS CARE (CHARITY AND BAD DEBT) WAS $25,242,882 FOR THE PERIOD OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011.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 200 SUBSCRIBERS. - A HEALTH VAN WAS DEPLOYED TO OFFER FREE HEALTH SCREENINGS THROUGHOUT THE COMMUNITY. THE SERVICE PROVIDED APPROXIMATELY 1,000 FREE SCREENINGS FOR ABOUT 250 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, THE RANDOLPH HOSPITAL COMMUNITY HEALTH FOUNDATION AND THE RANDOLPH HOSPITAL CAPITAL CAMPAIGN. THROUGH EMPLOYEE CAMPAIGNS, MORE THAN $38,000, $5,000 AND MORE THAN $60,000 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. 104209940 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 228 0 1 1229 1 0 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 364 WHITE OAK STREET ASHEBORO NC 27204 SAMUEL D CRANFORD JR 4.00 X X 0 0 0 ROBERT C SHAFFNER 2.00 X X 0 0 0 GLENN MAC PUGH 2.00 X X 0 0 0 JAMES M CAMPBELL JR 2.00 X 0 0 0 MARY COOPER 2.00 X 0 0 0 DIANE FROST PHD 2.00 X 0 0 0 JAMES B KINLAW JR MD 2.00 X 0 0 0 REYNOLDS LISK 2.00 X 0 0 0 MICHAEL MILLER 2.00 X 0 0 0 SAMUEL A RANKIN JR 2.00 X 0 0 0 ROBERT S SHACKLEFORD JR PHD 2.00 X 0 0 0 CRANFORD KNOTT 2.00 X 0 0 0 ROBERT E MORRISON 50.00 X 915260 0 36500 LYNWOOD R WHITE 50.00 X 195749 0 17632 SANDRA ALLEN 50.00 X 221798 0 52122 STEVE EBLIN 50.00 X 176924 0 29040 DEVIN GRIFFITH 50.00 X 152409 0 20766 TREMONTEO CRAWFORD 40.00 X 145431 0 13014 LISA HAMPTON 40.00 X 138820 0 19185 MICHELLE LUTHER 40.00 X 132797 0 4859 WILLIAM WARD 40.00 X 133081 0 16445 ANGELA BURGESS 40.00 X 119838 0 14214 2332107 0 223777 10 0 1 0 GREENSBORO RADIOLOGY 1317 NORTH ELM STREET SUITE 1B GREENSBORO NC 27401 PROFESSIONAL FEES 3899946 EMPLOYER BENEFITS SERVICE 534 RIVERCROSSING DR FT MILL SC 29715 EMPLOYEE BENEFIT SERVICES 1404550 SODEXHO INC 2803 SLATER ROAD MORRISVILLE NC 27560 FOOD SERVICE 1138274 MCNEARY INSURANCE 6525 MORRISON BLVD CHARLOTTE NC 28222 INSURANCE SERVICES 1053334 ARAMARK CTS 12483 COLLECTION CCR DR CHICAGO IL 60693 BIOMEDICAL ENGINEERING 900549 26 82906 82906 PATIENT SERVICE REVENU 621400 113622731 113622731 CANCER CENTER REVENUES 621400 1009441 1009441 MEALS/NUTRITION 722210 200207 200207 PATIENT PHARMACY 446110 111876 111876 HEALTHWATCH REVENUE 900099 82420 82420 115026675 1114525 1114525 432395 143976 288419 288419 288419 289170 -289170 -289170 -289170 COFFEE/GIFT SHOP 453220 389043 389043 DISCOUNTS & REBATES 900099 264736 403 264333 MISCELLANEOUS REVENUES 900099 193380 193380 847159 117070514 114714592 403 2272613 9267 9267 1662140 1662140 38893143 34492894 4367868 32381 1281834 1090220 190591 1023 6833264 5811796 1016012 5456 3197367 2719410 475404 2553 816695 565301 251394 137133 135634 1499 75604 75604 8819705 8794993 24117 595 213212 112054 96620 4538 20362932 18567405 1788137 7390 1201953 1152697 49256 189338 189338 396097 344993 50707 397 14891 14891 947269 947269 6387799 6387799 638373 638373 BAD DEBT EXPENSE 22825196 22825196 MISCELLANEOUS EXPENSE 187076 184417 1357 1302 RECRUITMENT 68416 68416 115158704 104209940 10891630 57134 5146979 2909826 26767698 27272799 446559 201282 19733843 18864797 2914775 2651497 2485827 1281034 138290182 69942836 68165865 68347346 18147634 18330864 1141256 9353825 4504439 2968343 10156870 156131348 155662010 10623756 6418679 47130000 46080000 2738412 4978937 16395213 19418758 76887381 76896374 X 77922257 77067162 1321710 1698474 79243967 78765636 156131348 155662010 X 1911810 -2390141 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 11645 11645 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: 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 $11,645 1 3232061 3232061 79135800 31483897 47651903 1923368 626839 1296529 48581193 37832100 10749093 5417760 5417760 68347346 OTHER RECEIVABLES 8621154 OTHER LONG-TERM ASSETS 138034 DEFERRED FINANCING COSTS, NET 166044 ASSETS LIMITED AS TO USE 1231638 10156870 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 949074 OTHER LONG-TERM LIABILITIES 2240055 PENSION PAYABLE 8678172 INTEREST RATE SWAP 4317941 DUE TO AFFILIATE 3178496 ENDOSCOPY CENTER DUE TO ALLILIATES 55020 19418758 117070514 115158704 1911810 -988591 -1401550 -2390141 -478331 114824349 -988591 -1257574 -2246165 117070514 0 117070514 115302680 143976 143976 115158704 0 115158704 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN PENSION LIABILITY -946,541. CHANGE IN VALUE OF INTEREST RATE SWAP -829,623. OTHER CHANGES TO NET ASSETS 374,614. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 143,976. OTHER CHANGES TO NET ASSETS 374,614. CHANGE IN PENSION LIABILITY -946,541. CHANGE IN VALUE OF INTEREST RATE SWAP -829,623. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 143,976. 1 1 X 1 X 1 X 1 1 1 0 0 2029104 2029104 0.02190 14710320 12185343 2524977 0.02730 16739424 12185343 4554081 0.04920 589524 11629 577895 0.00620 750 750 0.00000 590274 11629 578645 0.00620 17329698 12196972 5132726 0.05540 18 50 1012 1012 0.00000 175 2500 6659 6659 0.00010 883 6500 34248 34248 0.00040 928 12000 39756 39756 0.00040 692 3200 14803 14803 0.00020 684 9000 29354 29354 0.00030 720 6 48254 48254 0.00050 133 700 7958 7958 0.00010 4233 33956 182044 182044 0.00200 1 8147813 6926306 41963362 46797789 -4834427 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 NA FOR 2010 - IRS ANNON 2011-37 1 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 2010 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 $22,825,196 AND TO INCLUDE ALLOCATED TOTAL EXPENSES OF A JOINT VENTURE OF $221,506 FOR PURPOSES OF CALCULATING LINE 7, COLUMN (F). PART II: AMOUNTS REPORTED IN PART II INCLUDE: - $ 1,012 - HABITAT FOR HUMANITY ASSISTANCE - 6,659 - ECONOMIC DEVELOPMENT BOARD - 34,248 - VARIOUS COMMUNITY BOARD APPOINTMENTS, THE UNITED WAY CHAMPION, COMMUNITY COLLEGE PROGRAMS, ETC. - 39,756 - ROTARY CLUB, FORUMS AND CLASSES - 14,803 - OUTREACH GROUPS - 29,354 - SCREENINGS - 48,254 - STUDENT NURSE MENTORING - 7,958 - MEETINGS ON GENERAL IMPROVEMENT INFORMATION PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT. BAD DEBT EXPENSE AT COST WAS COMPUTED USING WORKSHEET 2 OF THE 2010 SCHEDULE H INSTRUCTIONS TO CALCULATE A COST-TO-CHARGES RATIO. 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. PART I, LINE 7(E): SUMMARY OF COMMUNITY HEALTH IMPROVEMENT SERVICES: THE HOSPITAL PROVIDES THE FOLLOWING COMMUNITY HEALTH IMPROVEMNET ACTIVITIES REPORTED ON PART I, LINE 7(E) (SHOWN AT NET EXPENSE): COMMUNITY EDUCATION & SCREENING $ 250,380 COMMUNITY IMPROVEMENT 61,150 TEDDY BEAR EDUCATION (2ND GRADERS) 52,300 COMMUNITY HEALTH MANAGER 43,664 COMMUNITY INVOLVEMENT 170,401 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, 2010 TO SEPTEMBER 30, 2011, RANDOLPH HOSPITAL SERVED 7,128 INPATIENTS, HAD 39,440 EMERGENCY ROOM VISITS, 106,502 OTHER OUTPATIENT VISITS AND 43,523 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 6: 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 7: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NC 1 X X X 1 1 X X X X X X 0 1 0 0 0 0 0 0 0 ROBERT E MORRISON 261359 0 0 0 653901 0 27505 0 8995 0 951760 0 381643 0 LYNWOOD R WHITE 185234 0 0 0 10515 0 12484 0 5148 0 213381 0 0 0 SANDRA ALLEN 185263 0 0 0 36535 0 47525 0 4597 0 273920 0 0 0 STEVE EBLIN 176924 0 0 0 0 0 21375 0 7665 0 205964 0 0 0 DEVIN GRIFFITH 141894 0 0 0 10515 0 19449 0 1317 0 173175 0 0 0 TREMONTEO CRAWFORD 137203 0 0 0 8228 0 11014 0 2000 0 158445 0 0 0 LISA HAMPTON 136569 0 0 0 2251 0 18897 0 288 0 158005 0 0 0 PART I, LINE 1A THE ORGANIZATION PROVIDES COUNTRY CLUB DUES TO THE CEO AND TRAVEL FOR BOARD MEMBERS' SPOUSES TO EDUCATIONAL EVENTS. THESE AMOUNTS ARE REPORTED AS TAXABLE INCOME ON THE RECIPIENTS' W-2 AND/OR 1099-MISC FORMS. 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 $927,287. 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 $653,901 AND $32,240. NO OTHER PARTICIPANTS OF THE PLAN RECEIVED PAYOUTS DURING THE YEAR. 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. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HZR7 2007-06-14 49230000 REFUNDING, CONSTRUCTION 0 0 0 3150000 50016167 1231628 358375 29115807 20670000 2008 1 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 1 1 BANK OF AMERICA 29.000000000000 1 0 0 0 1 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -988,591. CHANGE IN PENSION LIABILITY -946,541. CHANGE IN VALUE OF INTEREST RATE SWAP -829,623. OTHER CHANGES TO NET ASSETS 374,614. TOTAL TO FORM 990, PART XI, LINE 5: -2,390,141. 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 37597 72683 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 -229 656225 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 129684 INTERCOMPANY RANDOLPH SPECIALTY GROUP PRACTICE D 263333 A/R BALANCE RANDOLPH MEDICAL ASSOCIATES D 110731 A/R BALANCE RANDOLPH CANCER CENTER LLC D 62250 A/R BALANCE