2012-08-15T08:19:26-05:00 2011-09-30 Berry Dunn McNeil & Parker LLC 1000 Elm Street 15th Floor Manchester NH 03101 990 2010-10-01 030107300 Brattleboro Memorial Hospital BRAT 8022570341 17 Belmont Avenue Brattleboro VT 05301 Michael Rogers 8022570341 2012-08-14 1 Rachel Williamson CPA 6036697337 2012-08-14 2010 2016-02-24 21:20:13Z Michael Rogers 17 Belmont Avenue Brattleboro VT 05301 60480911 0 X http://www.bmhvt.org X 1904 VT To provide health care services on a region-wide basis 11 10 593 105 0 0 550494 298965 57325676 58751129 329164 265171 -172598 -202505 58032736 59112760 0 0 0 0 28961795 31969160 0 0 0 28286548 27797062 57248343 59766222 784393 -653462 56778724 57406774 22321482 23788690 34457242 33618084 X Brattleboro Memorial Hospital will provide community-based quality health services delivered with compassion and respect. 0 0 46066370 56309129 Provision of Hospital Care, both inpatient and outpatient services, on a region-wide basis. Approximately 90,176 outpatients and 2,197 inpatients were served throughout the year.Brattleboro Memorial Hospital is a modern, well-equipped and professionally staffed community hospital which has been serving greater Brattleboro and the tri-state area since 1904. Throughout our more than a century of caring for our community, BMH has kept up with medical technology which, in turn, has drawn excellent physicians to our facility. The BMH Medical Staff boasts more than 100 board-certified physicians, active in both primary care and many specialties. 1379000 2442000 Charity Care:The Hospital's charity care program is designed to assist those patients who are either uninsured, underinsured or have limited financial resources that impact their ability to fully pay for their hospital care. Before completing an application for charity care, patients are first asked to investigate whether or not they may be eligible for Medicare, Medicaid, Veteran's Benefits or other governmental or public assistance programs. The Hospital's qualifications for charity care are as follows:1) Charity care is limited to medically necessary services. Patients receiving certain elective services, such as those considered cosmetic, investigational or experimental, are expected to make payment arrangements in advance, as these types of services are not covered by the charity care program.2) Patient's family income must be at or below 300% of the current Federal Poverty Income Guidelines for their applicable family size.The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the estimated cost of those services and supplies and equivalent service statistics. The following information measures the levels of the charity care provided during the year ended September 30, 2011:Equivalent percentage of charity care services to all services 2.31%Number of patients receiving charity care 4,767In addition, the Hospital also incurred payment shortfalls in the treatment of Medicare and Medicaid patients. Both of these government programs reimburse for medical services at less than published charges to provide those services. In 2011, the Hospital incurred shortfalls of approximately $2,918,000 and $4,397,000 related to treating Medicare and Medicaid patients, respectively.The Hospital also provided many other community benefits upon which no monetary value can be placed such as:-BMH provides space at no cost to the local non-profit Brattleboro Walk-in Clinic.-Promotes wellness through screening and demonstrations at our annual Health Fair.-Offers free smoking cessation classes.-Collaborates with other community agencies in publishing a community wellnes calenday twice a year. 47445370 1 1 0 1 0 0 0 0 0 1 0 0 0 1 0 1 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 1 0 0 0 1 105 0 1 593 1 0 0 0 0 0 0 0 0 0 0 X 11 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Michael Rogers 8022570341 17 Belmont Avenue Brattleboro VT 05301 James F Baker II 1.00 X 0 0 0 Kirsten Beske 1.00 X X 0 0 0 John M Meyer 1.00 X X 0 0 0 Carl Lynde 1.00 X X 0 0 0 Rick Fleming 1.00 X 0 0 0 Ben Taggard 1.00 X 0 0 0 Burton Tepfer MD 1.00 X 46935 0 0 Peter Carvell 1.00 X 0 0 0 Deborah Boyle 1.00 X 0 0 0 Leslie Morey 1.00 X 0 0 0 Denise Paasche MD 1.00 X 4048 0 0 Barry Beeman 40.00 X 0 317531 23880 Steven Gordon 40.00 X 0 0 0 Michael Rogers 40.00 X 0 184073 30452 Mary Morgan 40.00 X 0 182090 26246 Clifford Langweiler MD 40.00 X 298590 0 28387 Teresa Fitzharris-Onyon MD 40.00 X 254142 0 28798 Christopher Schmidt MD 40.00 X 232488 0 28404 Joseph Rosen MD 40.00 X 0 260206 16548 Gregory Gadowski MD 40.00 X 0 260804 18707 836203 1204704 201422 20 0 1 0 Southern VT Health Services Corp 17 Belmont Avenue Brattleboro VT 05301 Management Fees 2250000 Cummings HP Construction CO 5 High Street PO Box 269 Woodsville NH 03785 General Contractor 1783876 Anesthesia Physicians of Brattleboro 17 Belmont Avenue Brattleboro VT 05301 Medical Services 650000 Mayo Medical Laboratories PO Box 9146 Minneapolis MN 554809146 Clinical Lab Tests 365423 Lauren McClure MD 277 A Borkowski Road Brattleboro VT 05301 Medical Services 343821 5 134230 164735 298965 Patient Service Revenu 621400 58112993 58112993 Cafeteria Sales 722210 317737 317737 Other Operating Revenu 900099 126750 126750 Miscellaneous Revenue 900099 86910 86910 Contract Rebates 900099 65616 65616 41123 41123 58751129 214136 214136 255046 457551 -202505 -202505 -202505 961635 910600 51035 51035 51035 59112760 58751129 0 62666 50983 50983 24653279 19811427 4841852 1007441 809990 197451 4741993 3975547 766446 1515464 1218444 297020 2250000 252000 1998000 68701 68701 69400 69400 41235 41235 226541 93306 133235 2112664 1686717 425947 128634 127913 721 114966 74007 40959 278628 196941 81687 11007 11007 3306728 2337275 969453 998022 998022 Drugs 3430762 3430762 Contract Services & Con 3408145 2976766 431379 Provider Taxes 3088388 3088388 Medical/Surgical Suppli 2948869 2947593 1276 Service Contracts 1566721 1104729 461992 3747651 2264560 1483091 59766222 47445370 12320852 0 1303127 99431 10700200 8504708 4570934 4927944 1572408 1532236 377158 366619 51427274 28678239 23401626 22749035 14382713 18630246 470558 596555 56778724 57406774 6863967 6852333 10640000 10250000 4817515 6686357 22321482 23788690 X 34022445 33161976 157179 178520 277618 277588 34457242 33618084 56778724 57406774 X -653462 -185696 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 24692 24692 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: BMH is a member of the VT Association of Hospitals and Health Systems and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of BMH and other member organizations in furtherance of their exempt purposes. BMH does not directly perform any lobbying activities. 45499 45499 31039988 14503433 16536555 18219287 13329650 4889637 2122500 845156 1277344 22749035 Due to Medicaid 405471 Due to Medicare 5304918 Interest Rate Swap 975968 6686357 59112760 59766222 -653462 -110618 -75078 -185696 -839158 58874822 -110618 21695 -88923 58963745 41235 107780 149015 59112760 59713980 0 59713980 41235 11007 52242 59766222 Part XI, Line 8 - Other Adjustments: Unrealized Loss on Interest Rate Swap -96,773. Change in Interest in SVHSC 21,695. Part XII, Line 2d - Other Adjustments: Change in Interest in SVHSC 21,695. Part XII, Line 4b - Other Adjustments: Unrealized Loss on Interest Rate Swap 96,773. Transfer to SVHSC 11,007. Part XIII, Line 4b - Other Adjustments: Transfer to SVHSC 11,007. 1 1 X 1 X 300.000000000000 1 X 1 1 0 0 1290719 1290719 0.02160 11658589 7261519 4397070 0.07360 763689 528708 234981 0.00390 13712997 7790227 5922770 0.09910 12430 12430 0.00020 17500 17500 0.00030 29930 29930 0.00050 13742927 7790227 5952700 0.09960 1 1753105 438276 12112230 15030463 -2918233 X 1 1 1 1 Brattleboro Memorial Hospital Inc

17 Belmont Ave Brattleboro VT 05301

X X X Not required 1 Part I, Line 3c: Brattleboro Memorial Hospital's Free Care program is designed to assist those patients who are either uninsured, underinsured or have limited financial resources that impact their ability to fully pay for their hospital care. When making application for Free Care, patients are first asked to investigate whether or not they may be eligible for Medicare, Medicaid, Veterans' Benefits or other governmental or public assistance programs. Free Care should always be the payor of last resort.A. Qualifications for Free Care:1. Free Care is limited to medically necessary services. Patients receiving certain elective services, such as those considered cosmetic, investigational or experimental, are expected to make payment arrangements in advance, as these types of services are not covered by Free Care;2. Patients' family income must be at or below 300% of the current Federal Poverty Income Guidelines for their family size;3. Patients or their guarantors must complete a Free Care application and provide thehospital with verification of income. Responsible parties may be asked to disclose the identity and amounts of any assets that could be used to pay for medical expenses.NOTE: Income verification may be waived at the discretion of the Director of PatientFinancial Services, particularly in those instances in which patients have subsequently qualified for Medicaid, or are deceased, with no estate;4. Free Care applications will be processed within two weeks of the date of their receipt in our Business Office;5. Free Care applies only to those patient accounts still in active Accounts Receivable; no Free Care allowance may be applied against accounts that have been forwarded to a collection agency as Bad Debt.B. Patients will be notified in writing of their approval or denial status within 30 days of the date of receipt of the application and any required supporting documentation. All accounts written off to Free Care must be approved by the Director of Patient Financial Services or the Vice-President of Finance. Part II: 1.Health Fair 2.Director DCHHE participates in community coalitions such as Fit & Health Kid's Coalition, Healthier Communities Coalition. The HCC coalition, of which the Director of DCHHE, is a member, has been instrumental in advocating for healthy nutrition, exercise, food security, Farm to School programming & advocating for improving the built environment & town policies to support health & wellness. Many of the health improvement needs identified by & advocated for by the coalition have been incorporated into the new town plan for Brattleboro. The HCC was recognized for its success & effectiveness. The HCC has conducted Community Healthier Living Index (CHLI) assessments at Green Street School and at BMH. This YMCA tool measures community organization support for physical activity & health eating. Mini grant money will be used to implement strategies for improvements in the areas of health nutrition and exercise. 3.Our Director of Nutrition Services supports local agriculture & has been recognized for BMH's level of support. 550 BMH employees benefit from local foods & healthy choices on our breakfast, lunch & dinner menus daily. Part III, Line 4: A simple RCC was utilized to reduce charges to cost. The estimated bad debt that may be eligible for our charity care policy was based on a 25% eligibility rate. Part III, Line 8: The Medicare shortfall should be considered a community benefit in its entirety. Part III, Line 9b: Patients or their guarantors must complete a Free Care application and provide thehospital with verification of income. Responsible parties may be asked to disclose the identity and amounts of any assets that could be used to pay for medical expenses.NOTE: Income verification may be waived at the discretion of the Director of PatientFinancial Services, particularly in those instances in which patients have subsequently qualified for Medicaid, or are deceased, with no estate. Part VI, Line 2: BMH participated in the April 2009 United Way of Windham County Community Needs Assessment. The needs assessment addressed health and wellness in Windham County, inclusive of lifestyle, access to care, maternal & child health, illness & death, and injury. Methodology included data analysis, household random sample telephone survey, 8 focus groups, comments by mail, and 11 key leader interviews. Highest priority issues about healthcare & healthcare access were identified.Evaluations are given to all participants of the Wellness In Windham County series. Participants are asked what health & wellness topics they would like to have presented. These responses are compiled & prioritized. The committee for the calendar uses these priority requests to plan content of future calendars. Part VI, Line 4: BMH serves a total service area that includes: 20 towns A population of 57,600 Compared to VT/US, residents of the service area tend to be: Older Similarly well off (MI), especially in the secondary service area Less at risk for obesityService area population was projected to grow slightly between 2005-2010, with more growth in the Secondary Service Area (SSA). However more recent projections suggest a decline in population. Windham County was projected to decline by - 2.3% between 2000-2008.The 65+ population will be the fastest growing segment, while the 0-17 and 18-44 age cohorts drop. VT is the second oldest state in the country (after Maine). Median age in the PSA & SSA is higher than Vermont overall & significantly higher than the US median. By 2010 nearly half of all PSA residents will be 45+.Brattleboro area employers, like Vermont employers generally, are small in size. The 3 largest employers are: C&S Wholesale, Entergy VT, and BMH. 11,474 people commute to Brattleboro to work.* The unemployment rate for Windham county in the 3rd quarter of 2009 was 6.3%. While the "great" recession in Vermont is considered over, the return to economic health and lower unemployment is expected to be slow.*Brattleboro Situation Report, 11/2008The VT Department of Health publishes a comprehensive Health Status Report every 5 years. The most recent report is dated 2008. County data is compared to goals for VT. The indicators for Windham County for 2008 identified the following areas of concern. Access to health care - residents without a usual doctor; lack of health insurance Breast, Colon and Cervical Cancer screening rates are worse than in Vermont or less than the healthy Vermonter goal. Rates of Injury in Windham County were higher than Vermont in all age groups except 0-9 year olds. X X X X X 0 0 0 0 0 0 0 0 0 Barry Beeman 0 238415 0 64827 0 14289 0 13052 0 10828 0 341411 0 0 Michael Rogers 0 161572 0 19705 0 2796 0 13397 0 17055 0 214525 0 0 Mary Morgan 0 178788 0 7900 0 -4598 0 9830 0 16416 0 208336 0 0 Clifford Langweiler MD 293038 0 0 0 5552 0 13016 0 15371 0 326977 0 0 0 Teresa Fitzharris-Onyon MD 245438 0 0 0 8704 0 12250 0 16548 0 282940 0 0 0 Christopher Schmidt MD 230054 0 0 0 2434 0 11882 0 16522 0 260892 0 0 0 Joseph Rosen MD 0 260206 0 0 0 0 0 0 0 16548 0 276754 0 0 Gregory Gadowski MD 0 260804 0 0 0 0 0 0 0 18707 0 279511 0 0 Vermont Educational and Health Building Financing Agency 237154467 924166BQ3 2008-02-01 11180000 Advance refund of previously issued bonds 0 0 0 930000 11180000 145933 11034067 2008 1 0 1 1 0 0 0 0 0 1 1 1 Duetsche Bank 15.000000000000 0 0 0 0 0 JoAnne Rogers Spouse of Michael Rogers, VP of Finance, Treasurer & CFO 18669 JoAnne Rogers works as the gift shop manager for an average of 20 hours per week. 0 Form 990, Part VI, Section A, line 6 The sole member of the Hospital shall be Southern Vermont Health Services Corporation, a Vermont not-for-profit corporation. Form 990, Part VI, Section A, line 7a The Board of Directors of the Hospital shall consist of eleven persons elected by Southern Vermont Health Service Corporation (sole member) from among membership of the sole member, plus the President and Medical Staff President ex officio but without the power to vote. Directors shall be elected annually by the sole member to hold office for three years and until their successors have been elected and qualified or until thier death or resignation. Elected directors may serve for a maximum of three consective three-year terms. Form 990, Part VI, Section A, line 7b The Board of Directors may not take any of the following actions without the prior approval of Southern Vermont Health Service Corporation (sole member): a) Adopt any annual or long-term capital or operating budget of the Hospital; b) Authorize the Hospital to enter into any contract or engage in any transaction which is not provided for in an annual or long-term capital or operating budget of the Hospital approved by the sole member, where the amount involved exceeds an amount as determined from time to time by the sole member; c) Authorize the Hospital to transfer funds or other assets to any other organization or corporation, where the amount involved exceeds an amount as determined from time to time by the sole member; d) Authorized the Hospital to engage in, or enter into, any transaction involving the borrowing of funds, incurring of debt, and/or guaranteeing, pledging, or collateralizing of any of its assets in connection therewith; e) Adopt any new, or any changes to the existing, long-range or master plans or the Hospital; or f) Organize or acquire, or authorize the organization or acquisition of, any subsidiary or affiliate of the Hospital. Form 990, Part VI, Section B, line 11 The role of the Hospital's Audit Committee includes review of the 990. The Audit Committee engages the auditors and receives the audit and a complete copy of the Form 990, including all schedules. The Audit Committee will report to the Board that the 990 review has occurred. The Board accepts the the Audit Committee reports and the 990. All members of the Board will have access to the 990 prior to filing. Form 990, Part VI, Section B, line 12c Each December, Board Members are required to complete a Conflict of Interest Statement. Beginning FY 2010, these statements were reviewed by outside counsel and reported back to the Board of Directors along with recommendations for action. Form 990, Part VI, Section B, line 15 The Executive Compensation Committe (ECC) of the Board of Directors (BOD) engages an outside compensation consultant to review executive compensation policies, procedures and conduct an independent regional and national market survey for senior leadership positions. The ECC sets the CEO's compensation and reviews the CEO's recommendations for other senior leadership compensation. The actions of the ECC are reviewed and approved by the BOD. Form 990, Part VI, Section C, line 19 Financial statements are published on our website. Our governing documents and conflict of interest policies are not made available to the public. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -110,618. Unrealized Loss on Interest Rate Swap Change in Interest in SVHSC Form 990, Part XII, Line 2c The organization did not changed its oversight or selection during the tax year. Southern Vermont Health Services Corp 17 Belmont Ave Brattleboro VT 05301 222564588 Provide Health Management Services VT 501(c)(3) Line 7 N/A 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 Southern Vermont Health Services L 2250000 Cash Southern Vermont Health Services C 134230 Cash