2012-05-15T14:06:21-05:00 2011-06-30 PLANTE & MORAN PLLC 65 EAST STATE STREET SUITE 600 COLUMBUS OH 43215 990 2010-07-01 314379491 HOLZER HOSPITAL FOUNDATION HOLZ 7404465060 100 JACKSON PIKE GALLIPOLIS OH 45631 KENNETH PAYNE 7404465060 2012-05-15 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z SEE SCHEDULE O KENNETH PAYNE 100 JACKSON PIKE GALLIPOLIS OH 45631 122045946 0 X WWW.HOLZER.ORG X 1910 OH TO ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE. 12 8 1251 32 294999 -2579 1032065 151053 117612082 115428440 187373 175814 1811010 1543831 120642530 117299138 161000 44359 0 0 45999778 45891037 0 0 0 73054862 70283349 119215640 116218745 1426890 1080393 84287923 87049156 26648001 28220286 57639922 58828870 X WE WILL ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 97980941 44359 115536656 SEE SCHEDULE OTHE HOSPITAL ACCEPTS ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. A PATIENT IS CLASSIFIED AS A CHARITY PATIENT BY REFERENCE TO CERTAIN ESTABLISHED POLICIES OF THE HOSPITAL. IN ASSESSING A PATIENT'S INABILITY TO PAY, THE HOSPITAL COMPARES INCURRED CHARGES WITH GENERALLY RECOGNIZED POVERTY INCOME LEVELS AND THE PATIENT'S FINANCIAL RESOURCES. BECAUSE THE HOSPITAL DOES NOT EXPECT TO RECEIVE PAYMENT FOR AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THESE AMOUNTS ARE NOT REPORTED AS NET PATIENT SERVICE REVENUES. CHARITY CARE PROVIDED, BASED ON ESTABLISHED RATES, WAS APPROXIMATELY $7,268,562 AND $7,587,147 IN FISCAL 2011 AND 2010 RESPECTIVELY.CONSISTENT WITH ITS MISSION, THE HOSPITAL PROVIDES COMMUNITY SERVICES INTENDED TO BENEFIT THE UNDERSERVED AND ENHANCE THE HEALTH STATUS OF THE COMMUNITY. THE HOSPITAL OPERATES A 24 HOUR PER DAY, 7 DAY PER WEEK EMERGENCY ROOM PROVIDING CARE TO ALL PATIENTS. THE HOSPITAL OPERATES HOLZER HOSPICE.CONTINUING EDUCATION, CERTIFICATION PROGRAMS, AND INFORMATIONAL SEMINARS ARE CONDUCTED FOR BOTH HOSPITAL AND MEDICAL STAFF. HEALTH FAIRS ARE CONDUCTED AT NO CHARGE. ADDITIONALLY, THE HOSPITAL'S MOBILE UNIT IS TAKEN TO COMMUNITY EVENTS TO PERFORM FREE SCREENINGS, AND DISPENSE EDUCATIONAL MATERIALS. HOSPITAL STAFF ALSO RESPONDS TO REQUESTS FROM EMPLOYERS AND COMMUNITY GROUPS, ALONG WITH SENIOR CITIZEN CENTERS, FOR SCREENINGS AND INFORMATIONAL PROGRAMS. EDUCATIONAL SUPPORT GROUPS, SUCH AS DIABETES AND CANCER, AND AN EDUCATIONAL GROUP MEETING FOR STROKES, ARE SPONSORED BY THE HOSPITAL. THE HOSPITAL'S MEETING ROOMS ARE MADE AVAILABLE TO ORGANIZATIONS AT NO CHARGE FOR HEALTH-RELATED PROGRAMMING AND MEETINGS. ADDITIONALLY, CIVIC AND PROFESSIONAL ORGANIZATIONS ARE INVITED TO THE HOSPITAL REGULARLY FOR PROGRAMS THAT ARE EDUCATIONAL AND INFORMATIONAL ON HEALTH CARE SERVICES AS DEVELOPED.SPEAKERS FROM THE HOSPITAL STAFF ARE AVAILABLE AND RESPOND TO SPEAKING INVITATIONS FOR GROUPS AND ORGANIZATIONS IN THE HOSPITAL'S SERVICE AREA. THE HOSPITAL OFFERS MANY SERVICES TO THE COMMUNITY AT NOMINAL OR NO CHARGE, INCLUDING BLOOD PRESSURE AND BLOOD SUGAR SCREENINGS, CHOLESTEROL CHECKS, HEMOGLOBIN, PULSE OXIMETRY, PROSTATE CHECKS, BONE DENSITY, AND TUMOR REGISTRY. THE PEDIATRIC UNIT WORKS IN CONJUNCTION WITH THE GALLIA COUNTY HEALTH DEPARTMENT IN PROMOTING FREE IMMUNIZATIONS. THE HOSPITAL ALSO PROVIDES EDUCATIONAL PROGRAMS AND SCREENINGS, AND DISCOUNTS AT THE HOSPITAL'S GIFT SHOP, CAFETERIA, AND PHARMACY IN CONJUNCTION WITH ITS MAXWELL 50 PROGRAM. ASSISTANCE IS ALSO PROVIDED TO SENIOR CITIZENS AND OTHER PATIENTS AND THEIR FAMILIES WITH THE SUBMISSIONS OF FORMS FOR INSURANCE, FINANCIAL COUNSELING, AND APPLICATION TO THE MEDICARE AND MEDICAID PROGRAMS FOR HEALTH SERVICE COVERAGE. COSTS ASSOCIATED WITH THESE PROGRAMS ARE INCLUDED IN THE HOSPITAL'S EXPENSES. 97980941 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 84 0 1 1251 1 1 1 0 0 0 0 1 1 0 0 0 0 X 12 8 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X KENNETH PAYNE 7404465060 100 JACKSON PIKE GALLIPOLIS OH 45631 X JAMES R PHILLIPPE 40.00 X X 286391 0 4318 BRENT SAUNDERS 40.00 X X 299928 0 0 ALAN A STOCKMEISTER 0.80 X X 0 19000 0 PHIL A BOWMAN PARTIAL YEAR 0.80 X X 0 17750 0 STEVE CHAPMAN CPA 0.80 X X 0 18750 0 THOMAS TOPE 0.80 X 427722 0 0 DANNY HOLSCHUH 0.80 X 0 18500 0 LARRY KIDD 0.80 X X 0 18750 0 M SUZANNE MIZE MD 0.80 X 0 0 0 PAUL M REED 0.80 X 0 3250 0 GARY ROACH 0.80 X 0 16500 0 REX E SHENEFIELD PARTIAL YEAR 0.80 X 0 0 0 RYAN SMITH PARTIAL YEAR 0.80 X X 0 19500 0 VERLIN L SWAIN PARTIAL YEAR 0.80 X 0 19000 0 JAMAL HADDAD MD 0.80 X 0 0 0 KENNETH PAYNE 40.00 X 265766 0 8098 LISA HALLEY 40.00 X 97193 0 1852 JOHN V VIALL MD 40.00 X 153099 0 7316 JOHN ALLEN 40.00 X 220844 0 8712 LEE SALTZGABER MD 40.00 X 47104 0 2009 CHRISTOPHER MARAZON 40.00 X 155917 0 4242 GERALD VALLEE 40.00 X 188653 0 0 SHANE E EPHLIN 40.00 X 155175 0 4342 ELAINE K BROWN 40.00 X 150868 0 3109 TERRY J SPURLIN 40.00 X 141123 0 6738 2589783 151000 50736 27 1 1 0 HOLZER CLINIC 90 JACKSON PIKE GALLIPOLIS OH 45631 PHYSICIANS 10223737 PLANTE & MORAN PLLC 67400 NORTHWESTERN HIGHWAY SOUTHFIELD MI 48034 ACCOUNTING 459649 EXECUTIVE HEALTH RESOURCES PO BOX 822688 PHILADELPHIA PA 19073 E H R COMPLIANCE SVCS 382946 FMC DS GALLIPOLIS PO BOX 101518 ATLANTA GA 30303 DIALYSIS 264612 MED SCRIBE INFORMATION SYSTEM 3325 HENDRICKS AVE JACKSONVILLE FL 32207 TRANSCRIPTIONS 246304 11 13548 130270 7235 151053 NET PATIENT SERVICES 622110 113632029 113632029 HCAP 622110 1212483 1212483 LIFELINE INCOME 622110 321724 321724 RENTAL INCOME 531120 262204 262204 115428440 147588 147588 233475 60697 172778 172778 172778 4678239 2812 4649804 3021 28435 -209 28226 28226 13895 13548 33286 -19391 -19391 CAFETERIA SALES 722320 941794 74132 867662 LAUNDRY INCOME 812300 178243 178243 GIFT SHOP SALES 900099 119567 119567 150840 108216 42624 1390444 117299138 115536656 294999 1316430 42359 42359 2000 2000 1611259 1611259 34714659 28205660 6508999 4922 3999 923 6470821 5257542 1213279 3089376 2510118 579258 1583679 1583679 -128407 -128407 72770 72770 31918361 26734820 5183541 20345484 19684663 660821 73596 61644 11952 1974881 1777393 197488 639106 535315 103791 489182 440264 48918 5205429 4684886 520543 662458 596212 66246 BAD DEBTS 6311759 6311759 FRANCHISE FEE 727643 727643 RECRUITMENT 158435 158435 COLLECTION FEES 152824 152824 LICENSURE FEES 79250 79250 16899 14155 2744 116218745 97980941 18237804 0 2768 62214 10167894 9097399 11020489 10482625 18179 1559419 998229 1902643 2185234 939569 1288150 134049070 104999048 27049615 29050022 10669686 3672724 7630173 20342629 23197418 84287923 87049156 16955247 15521322 35585 7831142 6031142 832506 5513921 993521 1153901 26648001 28220286 X 57470080 58642470 169842 186400 57639922 58828870 84287923 87049156 X 1080393 108557 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 1646 1646 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION RELATES TO LOBBYING ACTIVITY. 451456 451456 35714444 23932846 11781598 89506816 78078033 11428783 8376354 2988169 5388185 29050022 OTHER ASSETS 1111568 BOND ISSUE COSTS 172197 RELATED PARTY RECEIVABLE 21913653 23197418 COST REPORT SETTLEMENTS 131906 RELATED PARTY PAYABLE 1021995 1153901 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE INTERNAL REVENUE SERVICE HAS RULED THAT THE SYSTEM IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AS A PUBLIC CHARITY DESCRIBED IN SECTION 509(A)(2); ACCORDINGLY, NO PROVISION FOR FEDERAL INCOME TAXES HAS BEEN MADE IN THE CONSOLIDATED FINANCIAL STATEMENTS. ALL OF THE SYSTEM'S SUBSIDIARIES, WITH THE EXCEPTION OF HOLZER VANGUARD, HAVE ALSO BEEN DETERMINED TO BE TAX EXEMPT BY THE INTERNAL REVENUE SERVICE. HOLZER VANGUARD IS A TAXABLE CORPORATION. IT FILES INCOME TAX RETURNS BASED ON ITS TAXABLE INCOME. FOR THE YEARS ENDED JUNE 30, 2011 AND 2010, FEDERAL INCOME TAXES WERE NOT SIGNIFICANT. THE SYSTEM FILES FEDERAL AND STATE TAX RETURNS AND IS NO LONGER SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2008. GOLF OUTING 27443 13548 13895 33286 27443 13548 13895 33286 33286 -19391 1 1 X 1 X 1 X 1 1 1 0 0 2624946 2624946 0.02390 15226248 9864543 5361705 0.04880 17851194 9864543 7986651 0.07270 6171 115360 0 115360 0.00100 1557 71589 0 71589 0.00070 10987 0 10987 0.00010 7728 197936 197936 0.00180 7728 18049130 9864543 8184587 0.07450 0 2441715 0 31986781 39417765 -7430984 X 1 1 1 1 HOLZER HOSPITAL FOUNDATION

100 JACKSON PIKE GALLIPOLIS OH 45631

X X X NOT APPLICABLE 1 3 PHYSICIAN'S OFFICE-DR TIMOTHY DAMRON

2881 SR 160 GALLIPOLIS OH 45631

GENERAL, MEDICAL & SURGICAL PHYSICIAN'S OFFICE-DR LINDA ALSTON

2881 SR 160 GALLIPOLIS OH 45631

GENERAL, MEDICAL & SURGICAL MEDICAL PLAZA

100 JACKSON PIKE GALLIPOLIS OH 45631

GENERAL, MEDICAL & SURGICAL PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: EXPENSES WERE CALCULATED USING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2. PART I, LINE 7G: NOT APPLICABLE PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 6319759. PART II: NOT APPLICABLE PART III, LINE 4: BAD DEBT WAS RECORDED AT GROSS CHARGES ONCE AN ACCOUNT HAD BEEN THROUGH MULTIPLE ATTEMPTS FOR PAYMENT. IT WAS THEN SUBMITTED FOR COLLECTIONS, LESS ANY AMOUNTS THAT MAY HAVE BEEN PAID THROUGH INSURANCE OR PRIVATE PAYMENTS. BAD DEBT AT COST WAS CALCULATED USING A COST-TO-CHARGE RATIO. NONE OF THE BAD DEBT AT COST IS TREATED AS COMMUNITY BENEFIT. NONE OF THE BAD DEBT AT COST IS LIKELY ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE. IF IT IS UNCLEAR WHETHER AN ACCOUNT MAY QUALIFY AS CHARITY, IT IS FIRST ASSUMED TO BE CHARITY, NOT BAD DEBT, UNTIL ADDITIONAL INFORMATION SHOWS OTHERWISE.FOOTNOTE FROM FINANCIAL STATEMENTS: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE SYSTEM'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: MEDICARE COSTS AS REPORTED IN THE MEDICARE COST REPORT WERE CALCULATED USING A COST-TO-CHARGE RATIO METHODOLOGY AS REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. NONE OF THE MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: FOUR PATIENT STATEMENTS ARE SENT TO NON-MEDICARE ACCOUNTS. FIVE PATIENT STATEMENTS ARE SENT TO MEDICARE ACCOUNTS. IF NO PATIENT PAYMENT RESPONSE, ACCOUNTS ARE SELECTED AND PROCESSED TO BAD DEBT. THIS POLICY APPLIES TO PATIENTS WHO QUALIFY UNDER THE CHARITY CARE/FINANCIAL ASSISTANCE POLICY. PART VI, LINE 3: NOTICES ARE POSTED THAT SPECIFY THE RIGHTS OF THESE INDIVIDUALS TO RECEIVE WITHOUT CHARGE BASIC, MEDICALLY NECESSARY HOSPITAL-LEVEL SERVICES. THE POSTINGS ARE PRINTED IN ENGLISH AND SPANISH AND ARE LOCATED IN ADMISSIONS AREAS, THE BUSINESS OFFICE, AND THE EMERGENCY DEPARTMENT. PATIENT STATEMENTS CONTAIN FEDERAL POVERTY GUIDELINES, AN EXPLANATION OF WHAT SERVICES MAY QUALIFY FOR FREE CARE, AND INFORMATION ON HOW TO APPLY. THE ORGANIZATION ALSO EMPLOYS FINANCIAL ADVOCATES AND BENEFIT ELIGIBILITY COORDINATORS TO ASSIST IN THE INFORMATION/EDUCATION PROCESS. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR HOLZER HOSPITAL FOUNDATION IS COMPRISED OF THE FOUR-COUNTRY AREA OF GALLIA, JACKSON, AND MEIGS COUNTIES IN OHIO, AND MASON COUNTY IN WEST VIRGINIA. THE SECONDARY SERVICE AREA INCLUDES PARTS OF VINTON, LAWRENCE, ATHENS, AND SCIOTO COUNTIES IN OHIO, AND JACKSON COUNTY IN WEST VIRGINIA. PART VI, LINE 6: HOLZER MEDICAL CENTER BELIEVES THAT EDUCATIONAL AND PREVENTATIVE SERVICES ARE IMPERITIVE TO IMPROVING THE HEALTH OF OUR COMMUNITY. AS SUCH, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT AT HOLZER MEDICAL CENTER ORGANIZES AND PROVIDES HEALTH SCREENINGS THROUGHOUT THE YEAR AT OUR CAMPUS, AT VARIOUS FAIRS AND FESTIVALS IN THE COMMUNITY, AT OUR LOCAL SCHOOLS AND ALSO AT AREA BUSINESSES. NO-COST HEALTH SCREENINGS INCLUDE: BLOOD PRESSURE, GLUCOSE, CHOLESTEROL, BONE DENSITY AND BODY COMPOSITION SCREENINGS. SOME OF OUR LARGER COMMUNITY EVENTS INCLUDE: GALLIA COUNTY FAIR, MEIGS COUNTY FAIR, MASON COUNTY FAIR, BUCKEYE RURAL ELECTRIC EMPLOYEE HEALTH FAIR, BUCKEYE RURAL ELECTRIC ANNUAL MEETING AND HOLZER CENTER FOR CANCER FAIR. HOLZER MEDICAL CENTER ALSO HOSTS A MONTHLY DIABETES EDUCATION MEETING, MS SUPPORT GROUP, CANCER SUPPORT GROUP AND PROVIDES HEALTH SCREENING TO SENIOR CITIZENS IN OUR SERVICE AREA AND SPEAKERS THROUGHOUT THE YEAR TO DISCUSS VARIOUS MEDICAL TOPICS TO COMMUNITY GROUPS. ALONG WITH THESE NO-COST SCREENINGS, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT PROVIDES EDUCATIONAL INFORMATION TO LOCAL ORGANIZATIONS TO PROMOTE HEALTH AND WELLNESS FOR THEIR EMPLOYEES. IN ALL, APPROXIMATELY 4,500 SCREENINGS WERE PERFORMED BY HOLZER MEDICAL CENTER NURSES OR TECHNICIANS IN FISCAL YEAR 2010. PART VI, LINE 7: HOLZER MEDICAL CENTER AND HOLZER MEDICAL CENTER-JACKSON COMPRISE THE TWO HOSPITALS IN THE SYSTEM, WITH HOLZER MEDICAL CENTER ACCOUNTING FOR 82% OF HOSPITAL ADMISSIONS. HOLZER MEDICAL CENTER IS LOCATED IN GALLIA COUNTY AND HOLZER MEDICAL CENTER-JACKSON IS LOCATED IN JACKSON COUNTY. ALL HEALTH SCREENINGS AND PATIENT EDUCATION IS PROVIDED BY STAFF IN AREAS WITHIN OUR PRIMARY SERVICE AREA WHICH INCLUDES GALLIA, JACKSON AND MEIGS COUNTIES IN OHIO AND MASON COUNTY, WEST VIRGINIA AS WELL AS SOME SERVICES PROVIDED IN OUR SECONDARY SERVICE AREA. 1 HOLZER FOUNDATION 100 JACKSON PIKE GALLIPOLIS OH 45631 310927482 501(C) 42359 GENERAL SUPPORT 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAY PROVIDE FUNDS TO RELATED EXEMPT ORGANIZATIONS. X X X 1 0 0 0 0 0 0 0 0 JAMES R PHILLIPPE 286391 0 0 0 0 0 0 0 4318 0 290709 0 0 0 BRENT SAUNDERS 299928 0 0 0 0 0 0 0 0 0 299928 0 0 0 THOMAS TOPE 0 0 0 0 427722 0 0 0 0 0 427722 0 0 0 KENNETH PAYNE 265766 0 0 0 0 0 0 0 8098 0 273864 0 0 0 JOHN V VIALL MD 153099 0 0 0 0 0 0 0 7316 0 160415 0 0 0 JOHN ALLEN 220844 0 0 0 0 0 0 0 8712 0 229556 0 0 0 CHRISTOPHER MARAZON 155917 0 0 0 0 0 0 0 4242 0 160159 0 0 0 GERALD VALLEE 188653 0 0 0 0 0 0 0 0 0 188653 0 0 0 SHANE E EPHLIN 155175 0 0 0 0 0 0 0 4342 0 159517 0 0 0 ELAINE K BROWN 150868 0 0 0 0 0 0 0 3109 0 153977 0 0 0 PART I, LINE 4A DURING THE CALENDAR YEAR, THOMAS TOPE RECEIVED SEVERANCE PAY IN THE AMOUNT OF $427,722. UNDER THE TERMS OF THE SEVERANCE AGREEMENT, MR. TOPE WILL RECEIVE 100% OF BASE SALARY AND OTHER BENEFITS AS OF THE TERMINATION DATE, 7/1/09, THROUGH 1/1/11. HE WILL ALSO BE ENTITLED TO AN ANNUAL AUTO ALLOWANCE, PARTICIPATION IN THE HOSPITAL'S GROUP LIFE INSURANCE PLAN, QUARTERLY PAYMENTS DIRECTLY FROM THE HOSPITAL TO MR. TOPE IN AN AMOUNT EQUAL TO THE 457(F) CONTRIBUTION, AND OTHER PENSION PLAN PAYMENTS DIRECTLY FROM THE HOSPITAL TO MR. TOPE BASED ON THE MAXIMUM DEFFERAL ALLOWED. FOLLOWING THIS 18 MONTH PERIOD, MR. TOPE WILL ALSO RECEIVE AN AMOUNT EQUAL TO 22 WEEKS OF BASE SALARY, PLUS 4 WEEKS OF BASE SALARY AS ADDITIONAL RETIREMENT CONSIDERATION (BASED ON THE SALARY IN EFFECT AT THE TERMINATION DATE). SHANE EPHLIN STUDENT LOAN X 118162 18179 0 1 1 18179 FORM 990, PART VI, SECTION A, LINE 6 HOLZER CONSOLIDATED HEALTH SYSTEMS IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B HOLZER HOSPITAL FOUNDATION'S DECISIONS THAT ARE MADE BY THEIR BOARD OF DIRECTORS CAN BE OVERRULED BY HOLZER CONSOLIDATED HEALTH SYSTEM'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND THE CFO OF HOLZER CONSOLIDATED HEALTH SYSTEMS REVIEW FORM 990. A COPY WILL BE PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY BY ALL BOARD MEMBERS, OFFICERS, AND EMPLOYEES, AND ARE REVIEWED BY THE CONFLICT OF INTEREST REVIEW COMMITTEE. MEMBERS OF THE BOARD ARE AWARE THAT THEY SHOULD DISCLOSE CONFLICTS WHEN THEY ARISE, AND MEMBERS ABSTAIN FROM PARTICIPATING IN DISCUSSIONS OR VOTING ON MATTERS WHERE A CONFLICT IS PRESENT. FORM 990, PART VI, SECTION B, LINE 15 THE HOLZER CONSOLIDATED HEALTH SYSTEM BOARD APPROVES COMPENSATION OF THE CEO AND OTHER OFFICERS. THE BOARD UTILIZES WAGE RECOMMENDATIONS FROM AN UNRELATED CONSULTANT TO DETERMINE THE COMPENSATION. THE CEO MAY BE INVOLVED IN DETERMINING OTHER OFFICERS' COMPENSATION, HOWEVER THE ULTIMATE DECISION RESTS WITH THE BOARD. THE COMPENSATION DECISIONS THAT ARE MADE ARE DOCUMENTED IN THE BOARD MINUTES. THE PROCESS WAS LAST UNDERTAKEN DURING DECEMBER 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 7, PART VII: THE FOLLOWING TRUSTEES DEVOTED TIME TO HOLZER CONSOLIDATED HEALTH SYSTEMS: ALAN A. STOCKMEISTER 1 HRS PHIL A. BOWMAN 1 HRS STEVE CHAPMAN, CPA 1 HRS LARRY KIDD 1 HRS RYAN SMITH 1 HRS PAUL M. REED 1 HRS GARY ROACH 1 HRS DANNY HOLSCHUH 1 HRS VERLIN SWAIN 1 HRS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 66,198. GRANTS REPORTED ON PART IX NOT RECORDED ON FINANCIALS 42,359. TOTAL TO FORM 990, PART XI, LINE 5: 108,557. FORM 990, PART XII, LINE 2C: THE AUDIT OVERSIGHT PROCESS AND THE PROCESS OF SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PAGE 1, LINE C: DOING BUSINESS AS: HOLZER MEDICAL CENTER HOLZER MEDICAL CENTER - GALLIPOLIS HOLZER MEDICAL CENTER - JACKSON 100 JACKSON PIKE GALLIPOLIS OH 45631 311724085 HEALTH CARE OH 501(C)(3) LINE 3 HOLZER CONSOLIDATED HEALTH SYSTEMS 1 HOLZER FOUNDATION 100 JACKSON PIKE GALLIPOLIS OH 45631 310927482 CONTINUING ADVANCEMENT OF HEALTH AND MEDICAL CARE OH 501(C)(3) LINE 7 HOLZER CONSOLIDATED HEALTH SYSTEMS 1 HOLZER CONSOLIDATED HEALTH SYSTEMS 100 JACKSON PIKE GALLIPOLIS OH 45631 311156690 MANAGEMENT SERVICES OH 501(C)(3) LINE 11A, I N/A 0 HOLZER SENIOR CARE CENTER 380 COLONIAL DRIVE BIDWELL OH 45614 311534051 SKILLED NURSING FACILITY OH 501(C)(3) LINE 9 HOLZER CONSOLIDATED HEALTH SYSTEMS 1 HOLZER CARDIOVASCULAR LLC 90 JACKSON PIKE GALLIPOLIS OH 45631 311780671 MEDICAL OH N/A HOLZER VANGUARD 100 JACKSON PIKE GALLIPOLIS OH 45631 311192567 STOCK HOLDING COMPANY OH N/A C 0 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 HOLZER CONSOLIDATED HEALTH SYSTEMS I 262206 PER LEASE CONTRACT HOLZER CONSOLIDATED HEALTH SYSTEMS J 373557 PER LEASE CONTRACT HOLZER CONSOLIDATED HEALTH SYSTEMS L 1045106 PER MANAGEMENT AGREEMENT HOLZER FOUNDATION C 130270 ALLOCATION OF COSTS HOLZER CARDIOVASCULAR INSTITUTE LLC L 9700000 PER MANAGEMENT AGREEMENT HOLZER CONSOLIDATED HEALTH SYSTEMS K 500000 PER MANAGEMENT AGREEMENT