2012-11-15T12:48:32-06:00 2011-12-31 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2011-01-01 550372580 Montgomery General Hospital Inc MONT 3044425151 401 Sixth Avenue Montgomery WV 25136 Vickie Gay 3044425151 2012-11-13 1 Dale Carpenter P00189642 3043460441 2011 2016-02-24 21:20:13Z Vickie Gay 401 Sixth Avenue Montgomery WV 25136 24181352 0 X www.mghwv.com X 1970 WV To provide quality, cost-effective, and convenient healthcare services that meet and exceed reasonable internal and external customer expectations. 12 11 270 17 0 0 84725 77692 21908840 23973504 5 -96 120311 130150 22113881 24181250 0 19176 0 0 12204151 12201219 0 0 0 10209188 11191157 22413339 23411552 -299458 769698 7787787 7437094 7243742 7219717 544045 217377 Montgomery General Hospital is a critical access hospital. It also provides outpatient services including laboratory, radiology, surgery and therapy services; physician services; and skilled nursing services. 0 0 17426072 23973504 The Hospital provided health care services including 2,177 acute inpatient days; 13,293 skilled nursing days; 22,956 outpatient visits; 9,419 emergency room visits; 1,180 ambulatory surgery procedures; and 28,277 physician office visits. Charges foregone for charity care amounted to $148,899. 17426072 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 63 0 1 270 1 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X Sherri Murray 3044421246 401 Sixth Avenue Montgomery WV 25136 Vickie Gay 40.00 X X 133360 0 1706 Rita Bohanna 1.00 X 0 0 0 Donald Smith 1.00 X 0 0 0 Barbara Crist 1.00 X 0 0 0 Robert Neal 1.00 X 0 0 0 Patsy Tucker 1.00 X 0 0 0 Ghassan Dagher MD 1.00 X 0 0 2544 Percy Mosley Jr 1.00 X 0 0 0 Robert Gilliam 1.00 X 0 0 0 Michelle Fox 1.00 X 0 0 0 Kelli Vance 1.00 X 0 0 0 Garnes Reed 1.00 X 0 0 0 Sherri Murray 40.00 X 85853 0 0 Traci Acklin 40.00 X 0 183415 0 Mohamad Sankari 40.00 X 351469 0 2515 Paul Jackson 40.00 X 395694 0 0 Myra Priddy 40.00 X 253341 0 0 Kenneth Dwyer 40.00 X 249995 0 1303 Samuel Davis 40.00 X 249995 0 0 1719707 183415 8068 13 0 1 0 Advantage Rehab 150 Hidden Valley Road Scott Depot WV 25560 Therapy Services 381634 Interim Physicians 12140 Woodcrest Executive Drive St Louis MO 63141 Physician Services 211106 SVI Laboratory 3004 Chesterfield Avenue Charleston WV 25304 Lab Services 144651 Arnett & Foster PO Box 2629 Charleston WV 25329 Accounting Services 130809 4 77692 77692 Patient services 622110 23973504 23973504 23973504 6 6 63300 0 63300 63300 63300 102 -102 -102 -102 Cafeteria 722210 44568 44568 Medical records 900099 3601 3601 18681 18681 66850 24181250 23973504 0 130054 19176 19176 223463 156399 67064 9644339 6749938 2894401 222685 155854 66831 1464564 1025028 439536 646168 452244 193924 189958 189958 89759 89759 1401680 981016 420664 21973 15379 6594 1734184 1213731 520453 105663 73952 31711 682953 477989 204964 49273 34485 14788 132310 132310 617137 431926 185211 406229 284314 121915 Bad debts 4025000 4025000 0 Medical supplies 1014419 709978 304441 Health care provided ta 384225 384225 0 Use taxes 36118 25278 10840 300276 210160 90116 23411552 17426072 5985480 0 3392931 3152512 9798 30984 341479 360535 178338 272670 30654979 27121111 3829283 3533868 35958 86525 7787787 7437094 4526718 3407844 1971979 1785303 160000 585045 2026570 7243742 7219717 X 544045 217377 544045 217377 7787787 7437094 X 769698 -1096366 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 869878 869878 12565682 11271230 1294452 16840704 15471166 1369538 378715 378715 0 3533868 Accrued pension obligation 2026570 2026570 24181250 23411552 769698 -1096366 -1096366 -326668 24162176 102 102 24162074 19176 19176 24181250 23392478 102 102 23392376 19176 19176 23411552 Part XI, Line 8 - Other Adjustments: Change in pension funded plan status -845,462. Transfer to related party -250,904. Total to Schedule D, Part XI, Line 8: -1,096,366. Part XII, Line 2d - Other Adjustments: Loss on sale included in expense on the financial statements 102. Part XII, Line 4b - Other Adjustments: Grant expenses netted with revenue on the financial statements 19,176. Part XIII, Line 2d - Other Adjustments: Loss on sale included in expense on the financial statements 102. Part XIII, Line 4b - Other Adjustments: Grant expenses netted with revenue on the financial statements 19,176. 1 1 X 1 X 0 0 0 0 64607 0 64607 0.00330 724163 605809 118354 0.00610 788770 605809 182961 0.00940 788770 605809 182961 0.00940 0 1746448 5601325 5379496 221829 X 1 1 Montgomery General Hospital Inc

401 Sixth Avenue Montgomery WV 25136

X X X Montgomery General Hospital Inc 1 0 1 1 100.000000000000 0 0 1 1 X X X 1 X X 1 X X X X X 1 0 0 Part I, Line 7: The cost of charity care has been calculated by obtaining gross charges from the audited financial statements for charity care write off's and multiplying these charges by the aggregate hospital cost to charge ratio. The resulting charity care cost was then increased for the estimated "charity portion" of broad-based taxes paid to the State of WV. The net amount was then reduced by the estimated "charity portion" of the revenue "disproportionate share" payment received from the state. Medicaid cost was computed by multiplying the Medicaid HMO charges for each hospital department by the respective cost-to-charge ratio that relates to each department. The ratios are obtained from this year's Medicare cost report. The Medicaid cost is then reduced by the payments received from medicaid HMO plans. Only Medicaid HMO charges and payments were included as "traditional" Medicaid is reimbursed by WV Medicaid at 100% of cost so the cost and related payments from non-HMO Medicaid services nets to zero. 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 $ 4025000. Part III, Line 4: Patient Accounts Receivable: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectable accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as reduction to bad debt expense when received. Interest is not charged on patient accounts receivable. Part III, Line 8: The Hospital is cost reimbursed at 101% of allowable cost for Medicare and WV Medicaid traditional payer types. HMO Medicare and HMO Medicaid payers are reimbursed based on the individual contracts signed by the hospital with each HMO payer. HMO's do not have a year end settlement process. Part III, Section B, Line 8 Medicare allowable costs were estimated using Worksheet B of the Schedule H instructions. Part VI, Line 2: Montgomery General Hospital provides acute care services, swing bed SNF services, skilled nursing services for both skilled patients and intermediate care patients and physicians in general practice and many specialites. As the only hospital in Fayette County, Montgomery General Hospital is aware of the health needs of the community and works to provide all necessary services to all citizens of the county. Part VI, Line 4: Montgomery General Hospital is a Critical Access Hospital located in Fayette County, West Virginia. Montgomery General Hospital is the only hospital for rural Fayette County. Fayette County is a low income area that must compete with Urban Kanawha county to attract and retain physicians, nurses and medical personnel. In addition of having to pay higher salaries to attract top medical professionals, Montgomery General Hospital has a high percentage of Medicare and Medicaid patient population. Montgomery General Hospital is listed as a Health Professional Shortage Area and a Medically Underserved Area for portions of Fayette County. 1 Upper Kanawha Valley Economic Development Corporation 326 Third Avenue Suite 307 Montgomery WV 25136 550652373 501(c)6 14000 To assist with the economic development purpose of the organization. X X 0 0 0 0 0 0 0 0 0 Traci Acklin 0 168881 0 14534 0 0 0 0 0 0 0 183415 0 0 Mohamad Sankari 351469 0 0 0 0 0 0 0 2515 0 353984 0 0 0 Paul Jackson 395694 0 0 0 0 0 0 0 0 0 395694 0 0 0 Myra Priddy 253341 0 0 0 0 0 0 0 0 0 253341 0 0 0 Kenneth Dwyer 249995 0 0 0 0 0 0 0 1303 0 251298 0 0 0 Samuel Davis 249995 0 0 0 0 0 0 0 0 0 249995 0 0 0 Ghassan Dagher MD Board member 11220 Rental of office space. 0 Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the CFO and CEO. Form 990, Part VI, Section B, line 12c Annually we provide the board members with the conflict of interest policy and questionnaire. Once these are completed they are returned to administration and reviewed by our in house council. Form 990, Part VI, Section B, line 15 The Board of Directors determines the President/CEO's salary based upon comparative industry standards. The CEO determines the CFO salary based upon comparative industry standards. Form 990, Part VI, Section C, line 19 The governing documents and conflict of interest policy are available upon request. The financial statements are published annually in the local newspaper. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Change in pension funded plan status -845,462. Transfer to related party -250,904. Total to Form 990, Part XI, Line 5: -1,096,366. Clarification of 'yes' response Form 990, Part XII, Line 2C The organization has not changed its oversight or selection processes in the past year. Laird Health Care Foundation Inc Washington Sixth Avenue Montgomery WV 25136 550632743 Support tax-exempt health care organizations WV 501(c)(3) 11 N/A 0 Montgomery General Elderly Care Center Washington Sixth Avenue Montgomery WV 25136 550623339 Extended care facility WV 501(c)(3) 9 N/A 0 Montgomery General Healthcare System Inc Washington Sixth Avenue Montgomery WV 25136 550632601 Provide support to affiliated exempt health care providers WV 501(c)(3) 11 N/A 0 Montgomery MedCorp Inc washington Sixth Avenue montgomery WV 25136 550767169 Physicians Practice WV 501(c)(3) 9 N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0