2012-11-14T16:28:20-06:00 2011-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2011-01-01 150533577 SAMARITAN MEDICAL CENTER SAMA 3157855702 830 WASHINGTON STREET WATERTOWN NY 13601 RYAN SPEAS 3157855702 2012-11-12 1 JOSEPH J SCHLEGEL P00301329 3154463600 2011 2016-02-24 21:20:13Z RYAN SPEAS 830 WASHINGTON STREET WATERTOWN NY 13601 197033351 0 X WWW.SAMARITANHEALTH.COM X 1881 NY SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 19 15 1841 203 0 0 8701506 1599400 175797542 193307441 140863 50085 1691167 1788275 186331078 196745201 0 0 0 0 94404352 98941568 0 0 240903 72525049 77990547 166929401 176932115 19401677 19813086 192045639 198607571 106610637 113262178 85435002 85345393 X SAMARITAN MEDICAL CENTER OPERATES AN ACUTE CARE HOSPITAL FACILITY IN WATERTOWN, NEW YORK, SERVING JEFFERSON, OSWEGO AND ST. LAWRENCE COUNTIES. THIS 294-BED FACILITY PROVIDES INPATIENT CARE, PSYCHIATRIC SERVICES, AMBULATORY SURGERY, PRIMARY AND EMERGENCY CARE AND OTHER OUTPATIENT SERVICES. 0 0 145383031 195066371 PROVIDE CARE FOR 10,195 INPATIENT DISCHARGES IN ADDITION, SAMARITAN MEDICAL CENTER PROVIDED FOR 110,780 OUTPATIENT VISITS, 50,298 EMERGENCY ROOM VISITS, AND 67,290 FAMILY HEALTH CLINIC VISITS. 145383031 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 130 1 1 1841 1 0 0 0 0 0 0 0 0 0 0 X 19 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X RYAN D SPEAS 3157796686 104 PADDOCK STREET WATERTOWN NY 13601 PAUL G CARR PHD 1.00 X X 0 0 0 BRUCE DINES DMD 1.00 X X 0 0 0 KATHERINE FENLON 1.00 X X 0 0 0 ELIZABETH FIPPS 1.00 X 94450 0 12 DAVID FLINT MD 1.00 X 273525 0 35284 JUDITH J FOSTER 1.00 X 0 0 0 FRED GARRY 1.00 X 0 0 0 KATHLEEN GEBO 1.00 X 0 0 0 WENDY GRIMM 1.00 X 0 0 0 THOMAS HANLEY 1.00 X 0 0 0 MELANIE A PARKER GEURTSEN 1.00 X 0 0 0 RONALD PERCIACCANTE MD 1.00 X 0 0 0 CATHERINE BURNS QUENCER 1.00 X 0 0 0 ROBERT KIMBALL MD 1.00 X 55248 118171 0 KARL KOMAR 1.00 X 26613 0 0 DANIEL VILLA 1.00 X 0 0 0 JAN TURCOTTE MD 1.00 X 0 0 0 LISA WEBER 1.00 X 0 0 0 JOHN WHEELER 1.00 X 0 0 0 THOMAS H CARMAN 40.00 X 528909 0 96925 PAUL KRAEGER 40.00 X 326335 0 40210 MICHAEL SHORT 40.00 X 182991 0 28009 MARIO VICTORIA 40.00 X 215618 0 1284 RICHARD BROOKS 40.00 X 204017 0 25902 SIMON OUAKNINE 40.00 X 523596 0 29242 JOSEPH WETTERHAHN 40.00 X 426159 0 33763 DAVID REINDL 40.00 X 415430 0 20737 SHAHANDEH HAGIR 40.00 X 425207 0 30713 YILIN ZHANG 40.00 X 399200 0 4917 4097298 118171 346998 82 0 1 0 JEFFERSON ANESTHESIOLOGY 1571 WASHINGTON STREET WATERTOWN NY 13601 ANESTHESIOLOGY SERVICES 2599349 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 PURCHASED SERVICE 2104709 DEPARTMENT OF PHYCHIATRY 750 EAST ADAMS STREET SYRACUSE NY 13210 PURCHASED SERVICE 716751 LECESSE CONSTRUCTION 566 COFFEEN STREET WATERTOWN NY 13601 CONTRACTOR SERVICE 661928 NORTH COUNTRY EMERGENCY MEDICAL 830 WASHINGTON STREET WATERTOWN NY 13601 PURCHASED SERVICE 507189 15 200269 225219 1173912 1599400 PATIENT SERVICE REVENU 623000 193307441 193307441 193307441 120043 120043 6243 6243 79430 0 79430 79430 79430 211949 28006 260144 -28006 -48195 -76201 -76201 SOLD SERVICES 541900 960083 960083 CAFETERIA 722210 632327 632327 116435 116435 1708845 196745201 195066371 0 79430 2328886 584224 1744662 75248339 66202359 8993663 52317 6262357 5411869 850488 9532143 8179263 1285391 67489 5569843 4813405 756438 545738 21946 523792 137084 125264 11820 187213 1583 176302 9328 1731809 487741 1236863 7205 1936524 48085 1881047 7392 4400791 2622156 1778635 171381 107844 58469 5068 244584 44669 188669 11246 732715 574739 157976 256860 256860 10044740 7817563 2227177 1821590 270516 1551074 SUPPLIES 21253186 20968840 260011 24335 PROVISION FOR BAD DEBT 9137284 9137284 EQUIP REPAIR & MAINT 4999574 3594145 1405429 NYS GROSS RECEIPTS ASSE 1441744 1441744 18947730 13053056 5849971 44703 176932115 145383031 31308181 240903 7366 4624 38286411 38525340 25862332 29745918 1775165 1979598 2290720 2660952 221648311 120838323 101063379 100809988 1859618 1909989 5419957 11974215 15480691 10996947 192045639 198607571 23724411 25710514 56449781 53944423 26436445 33607241 106610637 113262178 X 75714094 75583845 8846437 8887077 874471 874471 85435002 85345393 192045639 198607571 X 19813086 -19902693 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9720908 1183545 -1142905 9761548 1686419 8606970 -572481 9720908 1772796 1137000 -1223377 1686419 1575443 240587 -43234 1772796 0.09000 0.91000 0 0 1023452 1023452 103045257 28840235 74205022 2541891 1978666 563225 111933091 90019422 21913669 3104620 3104620 100809988 CSV OF OFFICERS LIFE INSURANCE 424882 F INVESTMENT IN NEWELL ST., LLC 90000 C CWH NOTE RECEIVABLE 55192 C DUE FROM AFFILIATES 5115172 C GOODWILL INVESTMENT 110750 C ED PHYSICIAN CALL 682577 C LOC FEE - SERIES B 68686 C FINANCING COSTS - SERIES B 556073 C INTEREST RATE SWAP -1684987 F FINANCING COSTS - KEY BANK 164708 C INVESTMENT IN SENIOR LIVING VILLAGE 4461374 C MEDICAL MALPRACTICE LT INS RECOVERY 1929788 C 11974215 OTHER RECEIVABLES 10996947 10996947 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 5405804 RETIREMENT PLAN OBLIGATIONS 28201437 33607241 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SUPPORT SAMARITAN MEDICAL CENTER AND RELATED FACILITIES IN PROVIDING HEALTH CARE SERVICES TO THE PUBLIC. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: SAMARITAN QUALIFIES AS A TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2011 AND 2010, SAMARITAN DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2008 THROUGH 2011. THE HOSPITAL DOES NOT ANTICIPATE THAT THE TOTAL UNRECOGNIZED TAX BENEFITS WILL CHANGE IN THE NEXT TWELVE MONTHS. 1 1 1 X 1 X 1 1 0 1 1 1349342 452919 896423 0.00510 23280438 16037238 7243200 0.04090 24629780 16490157 8139623 0.04600 835244 68400 766844 0.00430 6200970 3691689 2509281 0.01420 30150 30150 0.00020 7066364 3760089 3306275 0.01870 31696144 20250246 11445898 0.06470 1 3687516 46769519 52952554 -6183035 X 1 1 1 1 SAMARITAN MEDICAL CENTER

830 WASHINGTON STREET WATERTOWN NY 13601

X X SAMARITAN MEDICAL CENTER 1 1 1 200.000000000000 1 300.000000000000 1 X 1 0 1 0 1 X 0 0 7 SAMARITAN FAMILY HEALTH - CLAYTON

909 STRAWBERRY LANE CLAYTON NY 13624

PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - PLAZA

1575 WASHINGTON STREET WATERTOWN NY 13601

PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - UROLOGY

19324 US ROUTE 11 WATERTOWN NY 13601

OUTPATIENT UROLOGY CLINIC SAMARITAN FAMILY HEALTH - LACONA

3 DEMOTT STREET LACONA NY 13083

PRIMARY CARE CLINIC SAMARITAN FAMILY HEALTH - WBI

428 WASHINGTON STREET WATERTOWN NY 13601

OUTPATIENT IMAGING CLINIC SAMARITAN OUTPATIENT BEHAVIOR HEALTH

165 COLEMAN STREET WATERTOWN NY 13601

OUTPATIENT PSYCHIATRIC CLINIC SAMARITAN FAMILY HEALTH - LERAY

26908 INDEPENDENCE WAY EVAN MILLS NY 13637

PRIMARY CARE CLINIC PART I, LINE 6A: SAMARITAN COMPLETES AND FILES THE COMMUNITY SERVICE PLAN ANNUALLY. A FULL REPORT IS COMPLETED AND SUBMITTED EVERY THREE YEARS, WITH UPDATES SUBMITTED EACH OF THE OTHER TWO YEARS. THE REPORTS ARE AVAILABLE TO THE PUBLIC VIA SAMARITAN'S WEBSITE (WWW.SAMARITANHEALTH.COM) OR BY CONTACTING THE SAMARITAN MARKETING OFFICE. PART I, LINE 7: THE RATIO OF COST TO CHARGES METHODOLOGY WAS UTILIZED IN COMPUTING ALL EXPENSES REPORTED ON LINES 7A. THROUGH 7G. THE WORKSHEET (#1 THROUGH #6) TEMPLATES IN THE INSTRUCTIONS FOR SCHEDULE H WERE FOLLOWED TO COMPUTE COSTS REPORTED. PART I, LINE 7G: THE COSTS REPORTED ON THIS LINE REPRESENT THE NET EXPENSE FOR THE OUTPATIENT PRIMARY CARE CLINICS OPERATED BY SAMARITAN MEDICAL CENTER. THE "NET" EXPENSE WAS COMPUTED UTILIZING WORKSHEET 6 OF THE SCHEDULE H FORM. PART III, LINE 4: AN ALLOWANCE FOR DOUBTFUL ACCOUNTS RECEIVABLE IS ESTIMATED BY SAMARITAN MEDICAL BASED ON REVIEW OF THE COLLECTABILITY OF ACCOUNTS CONSIDERING HISTORICAL EXPERIENCE AND PREVAILING ECONOMIC CONDITIONS.THE AMOUNT OF BAD DEBT AT COST REPORTED ON LINE #2 WAS CALCULATED BY APPLYING THE OVERALL HOSPITAL RCC (COMPUTED USING WORKSHEET #2) TO THE PROVISION FOR BAD DEBT EXPENSE AS REPORTED IN OUR 2011 AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS REPORTED WERE TAKEN DIRECTLY FROM THE 2011 MEDICARE COST REPORT FILED WITH NATIONAL GOVERNMENT SERVICES. THE METHODOLOGY IS BASED ON APPLYING FACILITY RATIO OF COST TO CHARGES TO THE MEDICARE (PROGRAM) CHARGES, AS PROVIDED BY NATIONAL GOVERNMENT SERVICES IN THE PS&R REPORT.THE MEDICARE SHORTFALL REPORTED SHOULD BE TREATED AS COMMUNITY BENEFIT EXPENSE. SAMARITAN MEDICAL CENTER PROVIDES MEDICAL SERVICES TO ALL PATIENTS REGARDLESS OF INSURANCE COVERAGE. THE OVERALL (INPATIENT AND OUTPATIENT) MEDICARE PAYOR MIX FOR 2011 WAS APPROXIMATELY 38%. PART III, LINE 9B: IF CHARITY CARE ASSISTANCE IS GRANTED, PATIENT ACCOUNTS THAT HAVE BEEN REFERRED TO A COLLECTION AGENCY WITHIN 60 DAYS OF APPLICATION DATE ARE ELIGIBLE FOR CHARITY CARE DISCOUNT. ANY BILL AMOUNT REMAINING AFTER APPLICATION OF THE CHARITY CARE DISCOUNT IS THE RESPONSIBILITY OF THE PATIENT. THE PATIENT WILL BE ASSISTED BY THE HOSPITAL IN MAKING SHORT TERM ARRANGEMENT TO SATISFY ANY REMAINING BALANCE ON THE ACCOUNT. SAMARITAN MEDICAL CENTER PART V, SECTION B, LINE 19D: WE USED A PERCENTAGE OF GROSS CHARGES. PART VI, LINE 2: SAMARITAN MEDICAL CENTER PARTICIPATED WITH COMMUNITY PARTNERS FROM JEFFERSON AND LEWIS COUNTY TO ASSESS THE COMMUNITY HEALTH NEEDS, IDENTIFY PREVENTION AGENDA PRIORITIES, DEFINE GOALS, OBJECTIVES AND WORK PLANS TO MEET THESE COMMUNITY HEALTH NEEDS. THESE PARTNERS INCLUDE FORT DRUM, JEFFERSON COUNTY PUBLIC HEALTH, LEWIS COUNTY PUBLIC HEALTH, CARTHAGE AREA HOSPITAL, LEWIS COUNTY GENERAL HOSPITAL, RIVER HOSPITAL, NORTH COUNTRY CHILDREN'S CLINIC, NORTHERN NEW YORK RURAL HEALTHCARE ALLIANCE, INC., FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION.SAMARITAN CONTINUES TO WORK WITH ITS PARTNERS, MEETING REGULARLY (AT MINIMUM, QUARTERLY AND AS FREQUENTLY AS MONTHLY) TO ASSESS THE EFFECTIVENESS OF OUR COLLABORATIVE ACTIVITIES.FINALLY, IN TERMS OF PRIORITIZING HEALTH ISSUES, THE RECOMMENDATIONS OF LOCAL, REGIONAL, STATE, AND NATIONAL HEALTH EXPERTS WERE REVIEWED AND CONSIDERED IN THE PROCESS OF IDENTIFYING PRIORITY ISSUES. THE PLANNING COMMITTEE SELECTED THE FINAL HEALTH PRIORITIES AS THEY RELATED TO THE NYS DOH PREVENTION AGENDA AND BY USING COMMUNITIES WORKING TOGETHER FOR A HEALTHIER NEW YORK. PART VI, LINE 3: THE CHARITY CARE PROGRAM CAN BE COMMUNICATED TO PATIENTS BY ANY SAMARITAN STAFF MEMBER; AS OUR CHARITY CARE PROGRAM IS AN EDUCATION TOPIC IN NEW EMPLOYEE ORIENTATION AND IS PART OF OUR ANNUAL MANDATORY EDUCATION REQUIREMENT. ADDITIONALLY, EACH PATIENT IS PROVIDED WITH A FINANCIAL ASSISTANCE APPLICATION AND RETURN ENVELOPE INCLUDED IN THE SAMARITAN PATIENT HANDBOOK. OUR GOVERNMENT INSURANCE LIAISON RECEIVES REFERRALS FROM PATIENT & FAMILY SERVICES REGARDING PATIENTS THAT MIGHT NEED ASSISTANCE OR EDUCATION REGARDING FEDERAL, STATE OR OTHER GOVERNMENT PROGRAMS. ADDITIONALLY, SHE ATTEMPTS TO CONTACT ALL SELF PAY ADMISSIONS. SAMARITAN PROVIDES SPACE FOR A NYS FACILITATED ENROLLER TO MEET WITH INDIVIDUALS INTERESTED IN APPLYING FOR NYS PROGRAMS. PART VI, LINE 4: SAMARITAN MEDICAL CENTER IS A 294 BED ACUTE CARE HOSPITAL SERVING SEVERAL COMMUNITIES IN UPSTATE NEW YORK. THE HOSPITAL IS LOCATED IN WATERTOWN, NEW YORK IN JEFFERSON COUNTY, WHICH LIES WITHIN A FEDERALLY DESIGNATED HPSA. THE POPULATION SERVED BY SAMARITAN MEDICAL CENTER PRIMARILY INCLUDES JEFFERSON COUNTY AND PORTIONS OF LEWIS, NORTHERN OSWEGO AND ST. LAWRENCE COUNTIES.SAMARITAN PROVIDES A FULL ARRAY OF INPATIENT AND OUTPATIENT HOSPITAL SERVICES, INCLUDING INPATIENT MEDICAL/SURGICAL, CRITICAL CARE, PEDIATRIC, MATERNITY, AND MENTAL HEALTH SERVICES AND AN EMERGENCY SERVICES DEPARTMENT.THE U.S. CENSUS REPORT LISTS THE 2009 ESTIMATED TOTAL POPULATION OF JEFFERSON COUNTY AT 118,719. THIS REPRESENTS A 6.2% GROWTH FROM THE 2000 CENSUS OF 111,738. THE INCREASE IN TOTAL POPULATION IS LARGELY DUE TO THE EXPANSION OF MILITARY PERSONNEL AT FORT DRUM. FORT DRUM DOES NOT OPERATE A HOSPITAL ON THE ARMY BASE, NOR DO THEY STAFF MEDICAL SPECIALISTS IN THEIR OUTPATIENT HEALTH CENTER.THE PERCENTAGE OF JEFFERSON COUNTY TOTAL POPULATION BELOW THE POVERTY LEVEL HAS GRADUALLY INCREASED FROM 11% IN 1990 TO 13.5% IN 2002 TO 14.6% IN 2008. MEDIAN HOUSEHOLD INCOME FOR 2008 FALLS SHORT OF STATEWIDE MEDIAN HOUSEHOLD INCOME BY APPROXIMATELY 20%. UNEMPLOYMENT IN JEFFERSON COUNTY IS APPROXIMATELY 8% - 9%. THE JEFFERSON COUNTY POPULATION CONTINUES TO BE PREDOMINANTLY WHITE, ALTHOUGH THERE ARE AN INCREASING NUMBER OF PERSONS OF OTHER RACE AND, IN PARTICULAR, HISPANIC, BLACK OR AFRICAN AMERICAN IN ORIGIN.THE CURRENT OVERALL (INPATIENT AND OUTPATIENT) PAYOR MIX EXPERIENCED AT SAMARITAN MEDICAL CENTER IS AS FOLLOWS:MEDICARE 38%, MEDICAID 14%, BLUE CROSS 16%, COMMERCIAL 10%, TRICARE 17%, NO FAULT 1%, WORKMEN'S COMPENSATION 1%, AND SELF PAY 3%. PART VI, LINE 5: AS PART OF SAMARITAN'S STRATEGIC PLAN, TWENTY (20) NEW PHYSICIANS (HOSPITAL BASED EMPLOYED AND COMMUNITY EMPLOYED) WERE RECRUITED TO THE WATERTOWN SERVICE AREA IN 2011.PHASE III OF THE FACILITY MASTER PLAN HAS BEGUN IN 2011 WHICH PROVIDES FOR RENOVATION OF THE EXISTING MAIN BUILDING. THIS RENOVATION AND RECONFIGURATION PROJECT WILL CONTRIBUTE DIRECTLY TO PROMOTING INCREASED OUTPATIENT SERVICES BY CONSOLIDATING HEALTHCARE SERVICES AND ENHANCE OUTPATIENT AND AMBULATORY CARE AT LEVELS THAT ARE BOTH EFFICIENT AND ACCESSIBLE.SAMARITAN MEDICAL CENTER EXPANDED SERVICES IN 2011 TO INCLUDE INTERVENTIONAL RADIOLOGY. PREVIOUSLY, THIS SERVICE WAS ONLY ACCESSIBLE TO COMMUNITY MEMBERS AT OUTSIDE REFERRAL CENTERS IN SYRACUSE AND BEYOND. THIS SERVICE PROVIDES AN ALTERNATIVE TO OPEN SURGERY THAT IS LESS INVASIVE WITH FASTER RECOVERY TIMES. REPORTS FILED WITH STATES PART VI, LINE 7 NY X X X X X 0 1 0 0 0 0 0 0 0 DAVID FLINT MD 263515 0 0 0 10010 0 19599 0 15685 0 308809 0 0 0 ROBERT KIMBALL MD 34248 118171 0 0 21000 0 0 0 0 0 55248 118171 0 0 THOMAS H CARMAN 425006 0 82903 0 21000 0 78612 0 18313 0 625834 0 0 0 PAUL KRAEGER 260000 0 49835 0 16500 0 29097 0 11113 0 366545 0 0 0 MICHAEL SHORT 165922 0 8773 0 8296 0 13449 0 14560 0 211000 0 0 0 MARIO VICTORIA 205350 0 0 0 10268 0 627 0 657 0 216902 0 0 0 RICHARD BROOKS 181709 0 13571 0 8737 0 14789 0 11113 0 229919 0 0 0 SIMON OUAKNINE 385008 0 0 0 138588 0 14700 0 14542 0 552838 0 0 0 JOSEPH WETTERHAHN 286333 0 0 0 139826 0 19578 0 14185 0 459922 0 0 0 DAVID REINDL 415430 0 0 0 0 0 14700 0 6037 0 436167 0 0 0 SHAHANDEH HAGIR 415002 0 0 0 10205 0 19600 0 11113 0 455920 0 0 0 YILIN ZHANG 390500 0 0 0 8700 0 4896 0 21 0 404117 0 0 0 PART I, LINE 4B PART I, LINE 4B: THOMAS H. CARMAN RECEIVED CONTRIBUTIONS TO AN IRC 457(F) PLAN OF $63,912 DURING 2011. PART I, LINE 4B: PAUL KRAEGER RECEIVED CONTRIBUTIONS TO AN IRC 457(F) PLAN OF $9,500 DURING 2011. PART I, LINE 4B: ROBERT KIMBALL RECEIVED DISTRIBUTIONS FROM ED CALL PAY PLAN OF $21,000 DURING 2011. DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DD5 2009-04-09 31660000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE 0 0 0 DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DE3 2009-04-09 23945000 CONSTRUCTION OF NEW PATIENT PAVILION AND PARKING GARAGE, REFUND 1998 SERIESA 0 0 0 30000000 31555854 867236 1589331 27652160 993775 2010 0 0 0 1 23866232 407545 1388843 18830508 1112325 2010 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 WILLIAM RANDY FIPPS HUSBAND OF BOARD MEMBER ELIZABETH FIPPS 113177 SALARY/EMPLOYMENT AT SMC 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FORM 990 AND ACCOMPANYING SCHEDULES WERE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD PRIOR TO FILING. FORM 990 WAS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL DISCLOSURE STATEMENTS ARE REQUIRED BY ALL BOARD MEMBERS AND KEY PERSONS. WE HAVE BEEN AT 100% COMPLIANCE WITH THIS REQUIREMENT EACH YEAR. RESPONSES ARE REVIEWED INITIALLY BY THE CEO AND CHIEF COMPLIANCE OFFICER FOR ACCURACY AND COMPLETENESS. THIS INFORMATION IS THEN PUT INTO A FULL REPORT TO THE BOARD OF TRUSTEES FOR REVIEW AND CONSIDERATION IN UPCOMING DECISION MAKING. BOARD MEMBERS AND KEY PERSONS AFFIRM THEIR UNDERSTANDING OF THEIR DUTY TO REPORT ANY ADDITIONAL OR NEW POTENTIAL CONFLICTS THROUGHOUT THE YEAR. BOARD MEMBERS WITH A CONFLICT ARE PROHIBITED FROM PARTICIPATION IN VOTING AND DECISION MAKING IN RELATED TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES AN EXTERNAL CONSULTANT TO ANALYZE AND ESTABLISH COMPENSATION AND BENEFITS FOR ALL EXECUTIVE POSITIONS. AN EVALUATION IS PERFORMED ANNUALLY. THE ANALYSIS INCLUDES A REVIEW OF MARKET DATA BASED ON REGION, FACILITY SIZE, AND RESPECTIVE RESPONSIBILITIES. THIS INFORMATION IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR REVIEW AND SUBSEQUENTLY PRESENTED TO THE FULL BOARD OF TRUSTEES FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE FILED AS PART OF THE ANNUAL FORM 990 AND ANNUAL NYS DEPARTMENT OF HEALTH INSTITUTIONAL COST REPORT, AND ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 28,165. PENSION AND POSTRETIREMENT LIABILITY -9,948,366. FORGIVENESS OF DEBT FROM SAMARITAN MEDICAL CENTER P.C. -8,104,948. VALUE OF INTEREST RATE SWAP -952,438. CONSOLIDATED FINANCIAL STATEMENT ELIMINATION ADJUSTMENTS -925,106. TOTAL TO FORM 990, PART XI, LINE 5: -19,902,693. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. SAMARITAN KEEP HOME 133 PRATT STREET WATERTOWN NY 13601 160969838 SKILLED NURSING FACILITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 THE SAMARITAN MEDICAL CENTER FOUNDATION OF NORTHERN NEW YORK INC 830 WASHINGTON STREET WATERTOWN NY 13601 161490523 PROVIDES FUND FOR SAMARITAN MEDICAL CENTER AND AFFLIATES NY 501(C)3 LINE 7 SCH A SAMARITAN MEDICAL CENTER 0 EJ NOBLE 104 PADDOCK STREET SUITE 104 WATERTOWN NY 13601 237227989 HOSPITAL NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON STREET WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 SAMARITAN SENIOR VILLAGE INC 830 WASHINGTON STREET WATERTOWN NY 13601 454913668 SENIOR CITIZEN COMMUNITY NY 501(C)3 LINE 3 SCH A SAMARITAN MEDICAL CENTER 0 0 0 1 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0