2012-04-07T10:28:52-05:00 2011-06-30 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2010-07-01 020226774 SPEARE MEMORIAL HOSPITAL SPEA 6032382231 16 HOSPITAL ROAD PLYMOUTH NH 03264 MICHELLE MCEWEN 6035361120 2012-03-19 1 W JAY SIMMS 6036530044 2010 2016-02-24 21:20:13Z MICHELLE MCEWEN 16 HOSPITAL ROAD PLYMOUTH NH 03264 53086318 0 X SPEAREHOSPITAL.COM X 1899 NH TO PROVIDE INPATIENT, OUTPATIENT AND PHYSICIAN HEALTH CARE SERVICES 14 13 461 0 0 0 178498 164713 46319533 50484604 418915 89775 371777 398985 47288723 51138077 310000 310000 0 0 21156458 22144814 0 0 133722 26462902 27686727 47929360 50141541 -640637 996536 55545738 59183953 24116856 25075585 31428882 34108368 X TO MAINTAIN A HOSPITAL AND OTHER SUCH INSTITUTIONS WITHIN THE STATE OF NEW HAMPSHIRE, WITH FACILITIES THAT INCLUDE MEDICAL SERVICES TO PROVIDE FOR THE DIAGNOSIS AND TREATMENT OF PATIENTS THAT MAY REQUIRE INPATIENT, OUTPATIENT, EMERGENCY CARE AND OTHER PURSUITS DESIGNED TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. SMH DOES NOT DISCRIMINATE RELATIVE TO RACE, RELIGION OR NATIONAL ORIGIN, ABILITY TO PAY AND WILL ASSURE THAT ALL PATIENTS RECEIVE THE SAME LEVEL OF CARE THROUGH QUALITY ASSESSMENT MONITORING AND IMPROVEMENT ACTIVITIES. 0 0 45521428 310000 50484604 SMH IS A 25-BED ACUTE-CARE HOSPITAL THAT PROVIDES INPATIENT AND OUTPATIENT SERVICES TO THE SURROUNDING COMMUNITY. 45521428 1 1 0 1 0 0 0 0 1 1 0 0 0 1 0 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 1 1 0 0 0 1 0 0 0 0 1 31 0 1 461 1 0 0 0 0 0 1 1 0 0 0 0 X 14 13 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 NH X X KATHLEEN BERIAU-DIRECTOR OF FINANCE 6032382160 SPEARE MEMORIAL HOSPITAL PLYMOUTH NH 03264 MICHELLE MCEWEN 40.00 X X 201999 0 41984 COLLEEN BRICKLEY 1.00 X X 0 0 0 BRIAN CHALMERS 1.00 X X 0 0 0 ELDWIN WIXSON 1.00 X 0 0 0 SUSAN KARKHECK 1.00 X X 0 0 0 STANLEY LEE FREEMAN 1.00 X X 0 0 0 QUENTIN BLAINE 1.00 X 0 0 0 CLINT HUTCHINS 1.00 X 0 0 0 WILLIAM LARSEN 1.00 X X 0 0 0 ALISON RITZ 1.00 X 0 0 0 DAVID TALBOT 1.00 X 0 0 0 RONALD SIBLEY 1.00 X 0 0 0 LINDA CRAWFORD MD 1.00 X 0 0 0 STEVE TAKSAR 1.00 X 0 0 0 RICHARD F WERKOWSKI 40.00 X 122289 0 15233 TIMOTHY LYONS MD 40.00 X 307835 0 37488 MICHAEL P GIOVAN MD 40.00 X 420935 0 60140 CLIFFORD A CHAPIN 40.00 X 315264 0 37244 VICTOR GENNARO MD 40.00 X 400721 0 60101 JOSEPH CASEY 40.00 X 315893 0 51070 2084936 0 303260 27 0 1 0 HARVEY CONSTRUCTION CORP OF NH 10 HARVEY ROAD BEDFORD NH 03110 CONSTRUCTION 735952 1 2045 162668 67183 164713 NET PATIENT REVENUE 624100 49786904 49786904 OTHER OPERATING REVENU 900099 697700 697700 50484604 358386 358386 35718 35718 35718 35718 1663588 1519474 412725 144114 -412725 -268611 -268611 36260 2045 16042 20218 20218 PHARMACY INCOME 446110 211280 211280 CAFETERIA INCOME 722210 131594 131594 GIFT COUNTER INCOME 453220 175 175 343049 51138077 50484604 0 488760 310000 310000 409570 409570 15482728 13233477 2183480 65771 1172908 1004395 163521 4992 3790985 3191598 583525 15862 1288623 1076899 206372 5352 58644 58644 28250 28250 63474 63474 100091 100091 4482461 4383941 61907 36613 1251217 1175872 75345 100942 80445 17649 2848 8971 8971 955201 955201 2700745 2700745 BAD DEBT 4454701 4454701 PHYSICIAN FEES & WAGES 4300868 4300868 PURCHASED SERVICES 3923665 3853296 68825 1544 PROVIDER TAX STATE OF N 2103863 2103863 COST OF DRUGS 2003094 2003094 1150540 583971 565829 740 50141541 45521428 4486391 133722 4078242 4967151 9402 2000 5923440 7123855 2590151 2427998 717164 777014 408230 363056 45111802 19555429 25858278 25556373 11660773 12959711 3221560 2826829 1032407 1078498 1147559 55545738 59183953 2782948 2397560 16815000 16544082 1221045 920466 3297863 5213477 24116856 25075585 X 30908631 33608916 279026 233320 241225 266132 31428882 34108368 55545738 59183953 X 996536 1682950 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9153 9153 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: SPEARE MEMORIAL HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF SPEARE MEMORIAL HOSPITAL AND THE OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSE. SPEARE MEMORIAL HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITES. 248354 25000 5 2314 271045 223344 25000 10 248354 137808 40000 45536 223344 0.98200 0.01800 0 0 564517 564517 27758685 9075523 18683162 924617 373150 551467 15782622 10106756 5675866 81361 81361 25556373 OTHER CURRENT LIABILITIES 2459349 EST. THIRD-PARTY PAYER SETTLEMENTS 1798406 RELATED PARTY NOTE PAYABLE 335426 INVESTMENT IN SUB-BOULDER 620296 5213477 51138077 50141541 996536 1725987 -43037 1682950 2679486 46429412 -4445551 -4445551 50874963 63474 199640 263114 51138077 45313366 0 45313366 63474 4764701 4828175 50141541 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUND IS USED TO SUPPORT OPERATIONS OF THE HOSPITAL. PART XI, LINE 8 - OTHER ADJUSTMENTS: BAD DEBT EXPENSE ON MSHC RECEIVABLE 110,360. RESTRICTED CONTRIBUTIONS 32,500. RESTRICTED PLEDGE LOSS -3,734. PRIOR PERIOD RECLASSIFICATION -182,163. PART XII, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS 9,150. BAD DEBT EXPENSE -4,454,701. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE 310,000. BAD DEBT EXPENSE ON MSHC RECEIVABLE -110,360. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE 310,000. BAD DEBT EXPENSE 4,454,701. GOLF TOURNAMENT 36260 2045 34215 690 11904 3244 36260 2045 34215 690 11904 3244 15838 18377 1 1 1 X 125.000000000000 1 X 225.000000000000 1 1 0 1 1 3014798 2007527 1007271 0.02010 4411604 2731057 1680547 0.03350 105071 105071 0.00210 7531473 4738584 2792889 0.05570 610574 610574 0.01220 0 358800 358800 0.00720 348973 348973 0.00700 1318347 1318347 0.02640 8849820 4738584 4111236 0.08210 1 2316445 74126 16445343 16213777 231566 X 1 1 1 PLYMOUTH REGIONAL REHABILITATION SERVICES PHYSICAL THERAPY, OCCUPATIONAL THERAPY & MEDICAL FITNESS 0.50000 1 1 SPEARE MEMORIAL HOSPITAL

16 HOSPITAL ROAD PLYMOUTH NH 03264

X X X X SPEARE MEMORIAL HOSPITAL 1 1 X X X X X X X X 10 1 0 1 X X X X X X X X X X X 1 1 1 1 100.000000000000 1 X X X X X X X 1 1 X 1 X 1 X X X 1 X 0 0 PART III, LINE 4: SMH HAS NO APPROPRIATE FOOTNOTE IN THE APPLICABLE AUDITED FINANCIAL STATEMENT. THE HOSPITAL USED 2.2% (DETERMINED FOR SMALL CRITICAL ACCESS HOPSITALS), WHICH WAS GIVEN IN THE AHA SCHEDULE H PROJECT BENCHMARK REPORT FOR ITS RATIONALE TO ESTIMATE THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO ELIGIBLE PATIENTS UNDER THE HOSPITAL'S CHARITY CARE POLICY. SMH HAS USED A RATIO OF COSTS TO CHARGES OF 52% IN DETERMINING THE COST OF BAD DEBT EXPENSE. PART III, LINE 8: 100% OF THE SHORTFALL FROM MEDICARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT. THE SOURCE USED TO DETERMINE THIS AMOUNT IS THE MEDICARE CHARGES LESS THE MEDICARE PAYMENTS MADE TO SPEARE MEMORIAL HOSPITAL. SERVICES THAT INCUR SUCH COSTS ARE PROVIDED BY THE HOSPITAL TO PROMOTE THE WELL-BEING OF THE COMMUNITY. THE SERVICES ARE RENDERED IN CONJUNCTION WITH THE HOSPITAL'S CHARITABLE TAX EXEMPT PURPOSE. TREATING THE SHORTFALL AS A COMMUNITY BENEFIT RELIEVES THE BURDEN ON LOCAL SOCIAL SERVICES AND GOVERNMENT SUPPORTED PROGRAMS. PART III, LINE 9B: SPEARE MEMORIAL HOSPITAL HAS BOTH A COLLECTIONS POLICY, AND A CHARITY CARE POLICY THAT DESCRIBES CHARITY ELIGIBILITY AND THE STEPS TO BE COMPLETED BEFORE A PATIENT'S ACCOUNT IS WRITTEN OFF TO BAD DEBT. SPEARE MEMORIAL HOSPITAL PART V, SECTION B, LINE 1J: SPEARE MEMORIAL HOSPITAL CONDUCTED A COMMUNITY WIDE PUBLIC PRESENTATION OF THE NEEDS ASSESSMENT REPORT IN OCTOBER 2011. PART VI, LINE 2: INFORMATION GATHERING THROUGH SURVEYS, FOCUS GROUPS, COMMUNITY REPRESENTATION, PUBLIC FORUMS, INPUT FROM HEALTH CARE PROVIDERS, INDUSTRY LEADERS, OUTSIDE CONSULTANTS,AND ANALYSIS OF INTERNAL DATA AND EXTERNAL DATA PROVIDED BY HOSPITAL ASSOCIATIONS, PAYERS, ETC. PART VI, LINE 3: PATIENTS ARE EDUCATED AT TIME OF REGISTRATION OR THROUGH EDUCATIONAL MATERIALS THAT ARE DISTRIBUTED THROUGH THE HOSPITAL'S WEBSITE OR BY COMMUNITY OUTREACH. SPEARE MEMORIAL HOSPITAL IS A MEMBER OF A STATE-WIDE COMMUNITY HEALTH NETWORK THAT PROVIDES ASSISTANCE, SUPPORT,AND EDUCATION RELATING TO ELIGIBILITY ASSISTANCE. PART VI, LINE 4: SPEARE MEMORIAL HOSPITAL IS LOCATED IN THE MOUNTAIN AND LAKES REGION OF NEW HAMPSHIRE AND PRIMARLY SERVES CONSTITUENTS IN GRAFTON COUNTY. GRAFTON COUNTY POPULATION SIZE IS APPROXIMATELY 86,000 WITHIN ITS 40 DISTINCT MUNICIPALITIES. ITS SERVICE AREA INCLUDES 17 TOWNS WITH AN APPROXIMATE TOTAL POPULATION OF 30,000. PART VI, LINE 6: SPEARE MEMORIAL HOSPITAL PROVIDES PRESCRIPTION MEDICATION ASSISTANCE, PRIMARY-CARE CLINCS, MULTIPLE SUPPORT GROUPS, COMMUNITY EDUCATION PROGRAMS, SCHOOL DENTAL PROGRAM, ETC. AND HAS AFFLIATIONS AND PARTNERSHIPS WITH MANY COMMUNITY ORGANIZATIONS; AN OPEN MEDICAL STAFF AND COMMUNITY BOARD. OPERATING FUNDS ARE USED FOR ONGOING CAPITAL EXPENDITURES. REPORTS FILED WITH STATES PART VI, LINE 7 NH 1 MID-STATE HEALTH CENTER 101 BOULDER POINT DRIVE NO 1 PLYMOUTH NH 03264 020487172 501 (C)(3) 310000 FMV COMMUNITY BENEFIT GRANT 1 X X X X X 0 0 0 0 0 0 0 0 0 MICHELLE MCEWEN 201999 0 0 0 0 0 19151 0 22833 0 243983 0 0 0 TIMOTHY LYONS MD 307835 0 0 0 0 0 14079 0 23409 0 345323 0 0 0 MICHAEL P GIOVAN MD 420935 0 0 0 0 0 36731 0 23409 0 481075 0 0 0 CLIFFORD A CHAPIN 315264 0 0 0 0 0 14026 0 23218 0 352508 0 0 0 VICTOR GENNARO MD 400721 0 0 0 0 0 36692 0 23409 0 460822 0 0 0 JOSEPH CASEY 315893 0 0 0 0 0 28291 0 22779 0 366963 0 0 0 NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY 020279866 64461TCH5 2004-11-01 13520000 CONSTRUCTION AND RENOVATION PROJECT 0 0 0 NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY 020279866 64461TCH5 2010-05-19 4000000 CONSTRUCTION AND RENOVATION PROJECT 0 0 0 13520000 978181 318768 13201232 2007 0 0 1 1 4000000 58963 3941037 2010 0 0 1 1 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 X 1 67183 FMV- APPRAISAL 0 1 1 FORM 990, PART VI, SECTION A, LINE 2 THE COMMUNITY RELATIONS DIRECTOR IS THE SPOUSE OF A BOARD MEMBER. FORM 990, PART VI, SECTION A, LINE 3 THE REHABILITATION DEPARTMENT IS NOW MANAGED BY ORTHOPEDIC HEALTH SERVICES. INC. FORM 990, PART VI, SECTION A, LINE 6 THE PROVISIONS OF SMH GOVERNING DOCUMENTS PROVIDES THE BOARD OF DIRECTORS IS COMPRISED OF ASSOCIATION MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE ASSOCIATION MEMBERS ELECT THE BOARD MEMBERS FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE HOSPITAL CFO, THE PRESIDENT/CEO, AND THE FINANCE COMMITTEE WITH A REPORT TO THE FULL BOARD OF DIRECTORS. THE FORM 990 IS THEN SIGNED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL COMPLIANCE FORM COMPLETED BY EACH MEMBER OF THE BOARD FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION FOR THE CEO IS DETERMINED VIA A COMPENSATION COMMITTEE, COMPENSATION SURVEY OR STUDY, COMPARISON OF OTHER ORGANIZATIONS 990 INFORMATION, BOARD APPROVAL AND WRITTEN EMPLOYMENT CONTACT. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,725,987. BAD DEBT EXPENSE ON MSHC RECEIVABLE 110,360. RESTRICTED CONTRIBUTIONS 32,500. RESTRICTED PLEDGE LOSS -3,734. PRIOR PERIOD RECLASSIFICATION -182,163. TOTAL TO FORM 990, PART XI, LINE 5: 1,682,950. SPEARE MEMORIAL AT BOULDER POINT BOULDER POINT DR PLYMOUTH NH 03264 263888977 REAL ESTATE NH 501(C)(3) LINE 9 SPEARE MEMORIAL HOSPITAL 0 SPEARE HEALTH VENTURE 16 HOSPITAL ROAD PLYMOUTH NH 03264 020366565 HEALTHCARE SERVICES NH C 4904 239995 1.00000 SPEARE HEALTH NETWORK LLC 16 HOSPITAL ROAD PLYMOUTH NH 03264 043372339 PHYSICIAN/HOSPITAL ORGANIZATION NH C 743 26344 0.50000 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 SPEARE MEMORIAL AT BOULDER POINT-LEASES ALL OF ITS SPACE TO SMH J 693188 ACTUAL SPEARE HEALTH VENTURE D 215673 FAIR MARKET VALUE SPEARE MEMORIAL AT BOULDER POINT D 2040520 FAIR MARKET VALUE SPEARE MEMORIAL AT BOULDER POINT P 8550 ACTUAL SSPEAR MEMORIAL AT BOULDER POINT E 335426 FAIR MARKET VALUE