2012-08-15T14:29:22-07:00 2011-09-30 990 2010-10-01 610461767 T J SAMSON COMMUNITY HOSPITAL TJSA 2706514114 1301 North Race Street Glasgow KY 42141 Anthony Sudduth 2706514114 2012-08-15 2010 2016-02-24 21:20:13Z Anthony Sudduth 1301 North Race Street Glasgow KY 42141 126647269 0 X WWW.TJSAMSON.ORG X 1928 KY TJ SAMSON COMMUNITY HOSPITAL WILL PROMOTE AND PROVIDE FOR THE HEALTH AND WELL-BEING OF THOSE THEY SERVE. 11 9 1123 82 25165 25165 5000 5121 116884206 123535448 1958704 1983301 507329 980171 119355239 126504041 0 0 0 0 59439542 60059982 0 0 0 54759391 64500845 114198933 124560827 5156306 1943214 124226796 156424783 42087446 65319178 82139350 91105605 TJ SAMSON COMMUITY HOSPITAL PROVIDES HEALTHCARE SERVICES TO BARREN AND SURROUNDING COUNTIES IN KENTUCKY. 0 0 109281330 123535448 ACUTE HOSPITAL AND EMERGENCY ROOM CARE: PATIENT DAYS-25,086 ER VISITS-31,553 OUTPATIENT VISITS-71,712. THE HOSPITAL ALSON PROVIDES CARE TO PATIENTS WITHOUT REGARD TO THE PATIENT'S ABILITY TO PAY. THE AMOUNT OF CHARGES FORGONE AS CHAR 0 0 0 109281330 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 62 0 1 1123 1 1 1 0 0 0 0 0 0 1 1 1 1 0 X 11 9 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 X TJ SAMSON COMMUNITY HOSPITAL 2706514112 1020 COUNTRY CLUB ROAD GLASGOW KY 42141 HENRY ROYSE 1.3 X X 0 0 0 DAN FOUTCH 1.2 X X 0 0 0 BUDDY UNDERWOOD 1.2 X X 0 0 0 FOLLIS CROW III 1.2 X X 0 0 0 ELLEN BALE 1 X 0 0 0 KAREN SMALL 1 X 0 0 0 MIKE BRYANT 1.00 X 0 0 0 CHRIS LAWERENCE 1 X 0 0 0 JOEY BOTTS 1.00 X 0 0 0 VENKATA REDDY 40 X X 506035 0 0 BOGDAN MARCOL 40 X X 518220 0 0 WILLIAM KINDRED 40 X X X 280250 0 0 ANTHONY SUDDUTH 40 X X X 221580 0 0 NEIL THORNBURY 40 X 129023 0 0 MARGARET BILLINGSLEY 40 X 105064 0 0 MELANIE WATSON 40 X 132816 0 0 LAURA BELCHER 40 X 90025 0 0 JOHN NESBITT 40 X 514079 0 0 RODNEY SAAMAN 40 X 206253 0 0 KEVIN ADAMS 40 X 131845 0 0 KENNETH JOHNSON 40 X 134941 0 0 2970131 0 0 14 0 1 0 APOGEE MEDICAL MANAGEMENT 2525 E CAMELBACK RD SUITE 1100 PHOENIX AZ 85016 HOSPITALIST 1330794 SURGICAL SOLUTIONS 702 A BARRETT BLVD HENDERSON KY 42420 SURGERY 849891 STENGEL HILL ARCHITECTURE 613 WEST MAIN LOUISVILLE KY 40202 ARCHITECTURE 732764 UNIDINE ONE GATEWAY CENTER SUITE 751 NEWTON MA 02458 DINING SERVICES 657398 DEPARTMENT OF FAMILY & COMM MEDICINE 501 E BROADWAY 2ND FLOOR SUITE 26 LOUISVILLE KY 40202 MEDICAL DIRECTOR 396429 27 0 0 0 0 0 5121 0 5121 HOSPITAL PROGRAM SERVICE 622000 123150537 123150537 0 0 PARTNERSHIP INCOME 541900 272492 271957 535 0 OUTSIDE LAB 621500 112419 0 112419 0 0 0 0 0 123535448 1984528 0 0 1984528 0 0 0 0 0 0 0 0 176495 0 84001 0 92494 0 92494 92494 0 0 0 58000 0 59227 0 -1227 -1227 -1227 0 0 0 CHILD CARE SERVICES 624410 -45390 42319 -87709 0 LAUNDRY 812300 -80 0 -80 0 PRIME ADVANTAGE 624100 10341 10341 0 0 922806 701038 0 221768 887677 126504041 124267459 25165 2206296 0 0 0 0 0 0 0 0 1201114 0 1201114 0 0 0 0 0 45530643 40522272 5008371 0 4048244 3602937 445307 0 5914006 5263465 650541 0 3365975 2995176 370799 0 0 0 0 0 362264 0 362264 0 170811 0 170811 0 0 0 0 0 0 0 8250 0 8250 0 3176732 3176732 0 0 459445 459445 0 0 554558 493557 61001 0 0 0 0 0 0 0 0 1656267 1656267 0 0 490602 490602 0 0 0 0 0 0 7372 0 7372 0 260452 260452 0 4579706 0 4579706 5758552 5758552 0 0 977302 977302 0 0 SUPPLIES 21945093 19531132 2413961 0 REPAIRS 3698910 3698910 0 0 TAXES 2148467 2148467 0 0 CONTRACT SERVICES 4751491 4751491 0 0 BAD DEBT 11801701 11801701 0 0 1692870 1692870 0 0 124560827 109281330 15279497 0 1763265 368398 50562584 76058264 0 0 21589355 21172436 0 0 0 0 4444 3330 2211827 2289884 2763905 4101782 128620640 86682385 38019221 41938255 2017395 4230248 0 0 2594684 3270466 0 0 2700116 2991720 124226796 156424783 30240905 25540847 0 0 0 0 10932482 39174702 0 0 0 0 0 0 0 914059 603629 42087446 65319178 X 82139350 91105605 0 0 0 0 82139350 91105605 124226796 156424783 X 1943214 7023041 X 0 1 1 X 0 X 0 0 0 0 0 0 0 1 11866 0 11866 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 THE HOSPITAL PAYS MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION AS WELL AS THE KENTUCKY HOSPITAL ASSOCIATION OF WHICH SOME OF THE DUES ARE USED FOR LOBBYING PURPOSES. 0 1961573 1961573 0 38896375 17058076 21838299 0 1653940 1281180 372760 0 86108752 68343129 17765623 0 0 0 0 41938255 0 THIRD PARTY PAYOR SETTLEMENTS 424984 PROVIDER TAX PAYABLE 178645 603629 1 1 1 X 1 X 1 1 1 0 0 3098994 944132 2154862 15647512 12406581 3240931 0 0 18746506 13350713 5395793 0 300000 815000 0 815000 23000 64350 0 0 815000 0 1202350 0 0 0 19561506 13350713 6598143 0 500 500 75350 75350 2485 2485 7423 7423 26126 26126 22640 22640 30000 30000 0 0 164524 0 164524 0 1 4679386 1263434 29704348 36933006 -7228658 X 1 1 1 1 TJ SAMSON COMMUNITY HOSPITAL

1301 NORTH RACE STREET GLASGOW KY 42141

X X X TJ SAMSON COMMUNITY HOSPITAL 1 1 1 100 1 200 1 X X X X X X X 1 1 X 1 X X X 1 X X X X X X X 1 X 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 THIS IS REPORTED AS COST THAT IS CALCULATED BY APPLYING THE TOTAL COST TO CHARGES RATIO SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f N/A SchH_P01_S00_L07g Schedule H, Part I, Line 7g N/A SchH_P02_S00_L00 Schedule H, Part II THE HOSPITAL TRIES TO PERFORM BUILDING ACTIVITIES TO IMPROVE RESIDENTS HEALTH SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 FOOTNOTE- PATIENT ACCOUNTS RECEIVABLE ARE STATED AT NET REALIZABLE VALUE. THE HOSPITAL AND PARTNERS MAINTAIN ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS AND FOR ESTIMATED LOSSES RESULTING FROM A PAYOR'S INABILITY TO MAKE PAYMENTS ON ACCOUNTS. MANAGEMENT ESTIMATES THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON THEIR ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL AND CURRENT BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. ACCOUNTS RECEIVABLE ARE CHARGED TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS WHEN THEY ARE DEEMED UNCOLLECTIBLE. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 THE HOSPITAL BELIEVES THAT 100% OF THE SHORTFALL IS COMMUNITY BENEFIT SINCE IT IS AN UNREIMBURSED COST TO THE HOSPITAL FOR PROVIDING THE GOVERNMENT PROGRAM. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b THE HOSPITAL PROVIDES ASSISTANCE TO PATIENTS THAT QUALIFY UNDER THE GUIDELINES. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 THE HOSPITAL PARTICIPATES IN A COMMUNITY NEEDS ASSESSMENT WITH OTHER LOCAL HEALTH PROVIDERS. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 THE HOSPITAL HAS EMPLOYEES THAT WORK WITH PATIENTS TO DETERMINE IF THEY QUALIFY FOR ANY TYPE OF ASSISTANCE. PATIENTS ARE NOTIFIED UPON REGISTRATION. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 THE HOSPITAL SERVES A 3 COUNTY PRIMARY SERVICE AREA AND AN 8 COUNTY SECONDARY MARKET AREA. X 0 0 0 0 0 0 0 0 0 WILLIAM KINDRED 238110 0 42140 0 0 0 20315 0 14080 0 314645 0 312579 0 ANTHONY SUDDUTH 189679 0 31901 0 0 0 18373 0 13594 0 253547 0 248902 0 VENKATA REDDY 506035 0 0 0 0 0 20315 0 5700 0 532050 0 522451 BOGDAN MARCOL 518220 0 0 0 0 0 20315 0 15535 0 554070 0 549024 0 NEIL THORNBURY 114647 0 14376 0 0 0 10698 0 15882 0 155603 0 0 MARGARET BILLINGSLEY 105061 0 3 0 0 0 8712 0 5490 0 119266 0 0 MELANIE WATSON 118554 0 14262 0 0 0 11012 0 12030 0 155858 0 0 0 LAURA BELCHER 90025 0 0 0 0 0 7465 0 12218 0 109708 0 0 0 JOHN NESBITT 514079 0 0 0 0 0 20315 0 20382 0 554776 0 546171 RODNEY SAAMAN 206253 0 0 0 0 0 17102 0 5516 0 228871 0 0 0 KENNETH JOHNSON 134941 0 0 0 0 0 11189 0 9980 0 156110 0 0 0 KEVIN ADAMS 131845 0 0 0 0 0 10932 0 12430 0 155207 0 0 0 CITY OF GLASGOW KENTUCKY 616001831 376844AT3 2011-08-24 29632455 FOR CONSTRUCTION 0 0 0 0 0 30000000 2212852 1646869 0 221767 0 0 0 0 0 2013 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b THE 990 IS REVIEWED BY THE CFO BEFORE SUBMISSION. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c MEMBERS ARE REQUIRED TO COMPLETE ANNUAL DISCLOSURE. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 THE HOSPITAL USES OUTSIDE AGENCY TO HELP DETERMINE COMPENSATION LEVELS. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 THESE ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. F990_P11_S00_L05 Form 990, Part XI, Line 5 NET UNREALIZED LOSS -322560, CHANGE IN PENSION PLAN 7,407,452- DIFFERENCE IN BOOK RECORD AND K-1 RECORDING OF PREMIER -49,147, GIFT SHOP PROFIT 12,703 TJ REGIONAL HEALTH INC 1301 NORTH RACE STREET GLASGOW KY 42141 273988336 PARENT ORGANIZATION OF HEALTHCARE FACILITY KY 501c3 N/A 1 TJ HEALTH PARTNERS LLC 1301 NORTH RACE STREET GLASGOW KY 42141 273988456 TO PROVIDE DOCTOR SERVICES IN BARREN AND SURROUNDING COUNTIES IN KENTUCKY KY N/A 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 TJ REGIONAL HEALTH INC b 4579708 CASH AMOUNT DONATED TO TJ REGIONAL HEALTH INC. TJ HEALTH PARTNERS LLC d 1342473 BOOK (COST) AMOUNT DUE FROM TJ HEALTH PARTNERS