2012-11-15T13:22:50-06:00 2011-12-31 920088037 MIKUNDA COTTRELL & CO CPA'S 3601 C STREET SUITE 600 ANCHORAGE AK 99503 990 2011-01-01 990260423 NORTH HAWAII COMMUNITY HOSPITAL NORT 8088814400 67-1125 MAMALAHOA HIGHWAY KAMUELA HI 967438496 JASON PARET 8088814400 2012-11-15 1 KEY E GETTY CPA P00121200 9072788878 2012-11-13 2011 2016-02-24 21:20:13Z WILLIAM BROWN 67-1125 MAMALAHOA HIGHWAY KAMUELA HI 967438496 50070804 0 X HTTP://WWW.NHCH.COM X 1989 HI ACUTE CARE HOSPITAL 9 8 417 55 0 0 6049371 3658004 39664994 44984216 634876 22690 5566275 1308880 51915516 49973790 0 0 0 0 23178835 27301915 200000 0 571453 22973660 23220217 46352495 50522132 5563021 -548342 189501488 187907766 14328240 14738773 175173248 173168993 X ACUTE CARE HOSPITAL 1 0 35459648 44984216 NORTH HAWAII COMMUNITY HOSPITAL (THE HOSPITAL), LOCATED IN KAMUELA, HAWAII ON THE ISLAND OF HAWAII, IS A NOT-FOR-PROFIT, ACUTE-CARE HOSPITAL THAT PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR THE RESIDENTS AND VISITORS OF NORTH HAWAII. THE HOSPITAL WAS CHARTERED IN NOVEMBER 1987 AND COMMENCED OPERATIONS IN MAY 1996. THE HOSPITAL IS CURRENTLY LICENSED FOR 39 BEDS. ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA. TOTAL OUTPATIENT VISITS FOR 2011 WERE: 54,459. TOTAL ADMISSIONS FOR 2011 WERE: 2,687. 35459648 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 82 0 1 417 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SHANNON OLSEN DIRECTOR OF FINANCIAL SERVICES 8088814675 67-1125 MAMALAHOA HIGHWAY KAMUELA HI 967438496 ROBERT MOMSEN 6.00 X 0 0 0 DR VIRGINIA PRESSLER 3.00 X 0 0 0 DR SHARON VITOUSEK 3.00 X 0 0 0 WILLIAM HUTCHINSON 3.00 X 0 0 0 ROBERT HASTINGS II 3.00 X 0 0 0 DR DANA LEE 3.00 X 0 0 0 KAHU BILLY MITCHELL 3.00 X 0 0 0 CAROLYN QUICK 3.00 X 0 0 0 DR WILLIAM PARK 40.00 X 447041 0 16100 NIEL KUYPER 3.00 X 0 0 0 RICHARD LEVY 3.00 X 0 0 0 KENNETH F WOOD 40.00 X 250000 0 18284 WAYNE CHARLES ALLEN UNTIL 51511 40.00 X 155385 0 8499 JASON D PARET EFF 9122011 40.00 X 70673 0 10449 GERARD SZCZYGIEL 40.00 X 260000 0 16609 LORRIE ANN MORTENSEN 40.00 X 165781 0 17220 KERRY L HOWELL 40.00 X 152884 0 7190 DIANE PAYNE 40.00 X 560625 0 20693 HOWARD WONG 40.00 X 355284 0 7438 WILLIAM HILLER 40.00 X 344231 0 9317 PATRICIA GUNTER 40.00 X 271384 0 19002 ASHLEY BYNO 40.00 X 240252 0 15060 3273540 0 165861 35 0 1 0 CLINICAL LABS OF HAWAII LLP 33 LANIHULI ST HILO HI 96720 LAB SERVICES FOR ENTIRE HOSPITAL 813502 EDWARD D HON MD PO BOX 6629 KAMUELA HI 96743 MEDICAL STAFF 455208 QUORUM HEALTH RESOURCES LLC 105 CONTINENTAL PLACE BRENTWOOD TN 37027 INTERIM DIRECTOR 421051 SANDWICH ISLES DEVELOPMENT LLC 3159 OAHU AVENUE HONOLULU HI 96822 CONSTRUCTION ARCHITECT AND PROJECT MANA 375449 C&A INDUSTRIES INC 13609 CALIFORNIA ST OMAHA NE 68154 LOCUMS 371121 19 353500 3304504 78573 3658004 PATIENT SERVICE REVENU 622100 44984216 44984216 44984216 19067 19067 309005 0 309005 309005 309005 67936 32701 67936 29078 0 3623 3623 3623 285312 0 285312 285312 MISCELLANEOUS 900099 698813 698813 INV IN LIBERTY DIALYSI 900099 15750 15750 714563 49973790 44984216 0 1331570 1596115 739750 696291 160074 21626605 16961936 4561371 103298 41646 30582 10291 773 2539451 1933759 576371 29321 1498098 1164648 319122 14328 2531621 1469868 1061753 167053 167053 248023 248023 3928650 2613882 1247709 67059 106051 6757 30550 68744 379539 145455 206782 27302 1090551 1090551 1803110 122792 1672463 7855 137227 99687 34040 3500 69679 38642 26735 4302 618382 440172 169193 9017 2658770 1878018 765412 15340 960002 700545 247168 12289 SUPPLIES 6148416 5724192 404457 19767 BAD DEBT EXPENSE 422146 422146 1950997 1388963 533550 28484 50522132 35459648 14491031 571453 2850 92269 6748536 4735373 1343982 2825270 4877068 6283153 427915 586765 1143756 1389949 734747 464187 59754051 35006240 25169239 24747811 149053395 146782989 189501488 187907766 3261153 4152597 10816975 9624232 250112 961944 14328240 14738773 X 24189085 23405880 8907899 10276805 142076264 139486308 175173248 173168993 189501488 187907766 X -548342 -1455913 X X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7694551 7694551 20981869 11762932 9218937 3289029 3180574 108455 26616518 19612229 7004289 1172084 450505 721579 24747811 DISTRIBUTION RECEIVABLE - PARKER RANCH FOUNDATION TRUST 960000 INTEREST IN EQUITY OF PARKER RANCH FOUNDATION TRUST 136494600 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 79664 CONSTRUCTION IN PROGRESS 1709572 INVESTMENT IN LIBERTY DLYS 42106 LOAN ISSUE COSTS - UNAMORTIZED 120423 BENEFICIAL INTERESTS 4371934 CONTRIBUTED USE OF LAND 2886625 OTHER RECEIVABLES 118065 146782989 CAPITAL LEASE OBLIGATION 961944 961944 49973790 50522132 -548342 -1455913 -1455913 -2004255 48095731 -1455913 -1455913 49551644 422146 422146 49973790 50099986 0 50099986 422146 422146 50522132 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN VALUE OF INT IN PARKER RACH FOUNDATION TRUST -1,442,481. CHANGE IN VALUE OF OTHER BENEFICIAL INTERESTS -13,432. TOTAL TO SCHEDULE D, PART XI, LINE 8: -1,455,913. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN VALUE OF INT IN PARKER RACH FOUNDATION TRUST -1,442,481. CHANGE IN VALUE OF OTHER BENEFICIAL INTERESTS -13,432. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT RECLASSED FROM REVENUE TO EXPENSE 422,146. PART XIII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT RECLASSED FROM REVENUE TO EXPENSE 422,146. 1 1 X 1 X 1 X 1 1 0 0 135114 0 135114 0.00270 10129737 4510912 5618825 0.11120 10264851 4510912 5753939 0.11390 5650 5650 5650 5650 10270501 4516562 5753939 0.11390 1 442146 128820 6673334 6244634 428700 X 1 1 1 1 NORTH HAWAII COMMUNITY HOSPITAL

67-1125 MAMALAHOA HWY KAMUELA HI 96743

X X X INCLUDES NORTH HAWAII MEDICAL GROUP AND KOHALA HOME HEALTH AGENCY. NORTH HAWAII COMMUNITY HOSPITAL 1 0 1 1 200.000000000000 1 400.000000000000 0 1 1 X X X X 1 X X 0 0 X X 0 1 PART III, LINE 4: BAD DEBT EXPENSE IS SHOWN AS A PERCENTAGE OF TOTAL EXPENSE OF THE HOSPITAL, AND REPRESENTS THE PORTION OF UNREIMBURSED EXPENSE FROM THE HOSPITAL'S APPLICABLE CHARITY CARE PROGRAMS. BAD DEBT FINANCIAL STATEMENT FOOTNOTE- BAD DEBT PROVISIONS ARE MADE FOR THE AMOUNT OF REVENUE THAT WILL NOT BE COLLECTED FROM PATIENTS TO WHOM SERVICES WERE BILLED BUT NOT PAID. THE HOSPITAL HAS DETERMINED THESE PATIENTS ARE NOT FINANCIALLY INDIGENT AND DO NOT QUALIFY FOR THE HOSPITAL'S CHARITY CARE PROGRAM. BAD DEBT PROVISIONS ARE DETERMINED BY MANAGEMENT'S ASSESSMENT WITH CONSIDERATION OF BUSINESS AND ECONOMIC CONDITIONS, CHANGES AND TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. THE ADEQUACY OF THIS PROVISION IS PERIODICALLY REVIEWED AND FURTHER MODIFIED BASED UPON THE ACCOUNTS RECEIVABLE PAYOR COMPOSITION AND AGING, AND HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. BAD DEBT EXPENSE PART III LINE 4 THE HOSPITAL PROVIDES CARE WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY. SINCE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, SUCH AMOUNTS ARE NOT REPORTED AS NET PATIENT REVENUE. THE CHARGES AT ESTABLISHED RATES FOREGONE FOR SERVICES AND SUPPLIES PROVIDED BY THE HOSPITAL IN 2010 AND 2009 FOR CHARITY CARE TOTALED $283,293 AND $643,551, RESPECTIVELY. EXPLANATION OF SHORTFALL AS COMMUNITY BENEFIT PART III LINE 8 THE ENTIRE SHORTFALL IS ATTRIBUTABLE TO COMMUNITY BENEFIT. NEEDS ASSESSMENT PART VI ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA, AND THE BOARD IS COMPRISED OF COMMUNITY MEMBERS. THIS ALLOWS THE HOSPITAL TO ASSESS THE NEEDS OF THE COMMUNITY THAT IT SERVES. IN ADDITION, MANY COMMUNITY HEALTH IMPROVEMENT SERVICES ARE OFFERED IN THE FORMS OF ACTIVITIES OR PROGRAMS THAT HELP TO ASSESS AND IMPROVE COMMUNITY HEALTH. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI HOSPITAL ADMITTING STAFF MEMBERS ADVISE AND ASSIST ALL SELF-PAY PATIENTS OF THE OPTIONS FOR AVAILABLE ASSISTANCE. COMMUNITY INFORMATION PART VI NORTH HAWAII COMMUNITY HOSPITAL (HOSPITAL) IS LOCATED IN KAMUELA, HI, ALSO KNOWN AS WAIMEA, HI, IN THE KOHALA DISTRICT OF THE NORTHEASTERN REGION OF THE ISLAND OF HAWAII. IT IS A NOT-FOR-PROFIT, ACUTE CARE HOSPITAL THAT PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR ABOUT 30,000 RESIDENTS AND VISITORS OF NORTH HAWAII. THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF APPROXIMATELY ONE FOURTH, OR 1,000 SQUARE MILES OF THE BIG ISLAND'S 4,028 TOTAL SQUARE MILES. THERE ARE CURRENTLY NO OTHER GENERAL ACUTE CARE HOSPITALS IN THE PRIMARY SERVICE AREA.THE HOSPITAL WAS CHARTERED IN NOVEMBER 1987 AND COMMENCED OPERATIONS IN MAY 1996. THE HOSPITAL IS CURRENTLY LICENSED FOR 39 BEDS. ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA. PART VI N/A AFFILIATED HEALTH CARE SYSTEM ROLES AND PROMOTION PART VII N/A STATES WHERE COMMUNITY BENEFIT REPORT FILED PART VI HI X 1 0 0 0 0 0 0 0 0 DR WILLIAM PARK 447041 0 0 0 0 0 4499 0 11601 0 463141 0 0 0 KENNETH F WOOD 250000 0 0 0 0 0 2524 0 15760 0 268284 0 0 0 WAYNE CHARLES ALLEN UNTIL 51511 155385 0 0 0 0 0 0 0 8499 0 163884 0 0 0 GERARD SZCZYGIEL 260000 0 0 0 0 0 2650 0 13959 0 276609 0 0 0 LORRIE ANN MORTENSEN 165781 0 0 0 0 0 1679 0 15541 0 183001 0 0 0 KERRY L HOWELL 152884 0 0 0 0 0 0 0 7190 0 160074 0 0 0 DIANE PAYNE 560625 0 0 0 0 0 5627 0 15066 0 581318 0 0 0 HOWARD WONG 355284 0 0 0 0 0 0 0 7438 0 362722 0 0 0 WILLIAM HILLER 344231 0 0 0 0 0 0 0 9317 0 353548 0 0 0 PATRICIA GUNTER 271384 0 0 0 0 0 2743 0 16259 0 290386 0 0 0 ASHLEY BYNO 240252 0 0 0 0 0 0 0 15060 0 255312 0 0 0 PART I, LINE 3 A BOARD RESOLUTION IS REQURED. PART I, LINE 4A PART I, LINE 4A: MICHAEL KENDALL: 55,000 SEVERANCE PAYMENT 1,500 CAREER TRANSITION ASSISTANCE 6 MONTHS COBRA BENEFITS PAID BY HOSPITAL WAYNE ALLEN 97,500 SEVERANCE PAYMENT 9 MONTHS COBRA BENEFITS PAID BY HOSPITAL X 6 78573 FMV AT TIME OF SALE 0 0 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 A NEW NATIVE HAWAIIAN CLINIC WAS INCORPORATED INTO THE PROGRAM IN SEPTEMBER 2011. THIS IS A CLINIC THAT WORKS WITH NATIVE HAWAIIANS TO INTEGRATE CULTURAL ISSUES INTO MEDICAL TREATMENT AS WELL AS BEHAVIORAL TREATMENT. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED BY THE CPA FIRM, AND REVIEWED BY THE CFO, DIRECTOR OF FINANCIAL SERVICES, BOARD FINANCE COMMITTEE, AND BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY IS REVIEWED EACH YEAR BY ADMINISTRATION. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL OBTAINED SALARY MARKET STUDIES FROM A CONTRACTED MANAGEMENT COMPANY. THEY ALSO COMPARED SALARIES OF APPLICANTS AND FORMER CHIEF EXECUTIVE OFFICERS OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN VALUE OF INT IN PARKER RACH FOUNDATION TRUST -1,442,481. CHANGE IN VALUE OF OTHER BENEFICIAL INTERESTS -13,432. TOTAL TO FORM 990, PART XI, LINE 5: -1,455,913. AUDIT OVERSIGHT FORM 990 PART XII, LINE 2C FINAL SIGN OFF OF THE AUDIT IS BY THE BOARD, BASED ON RECOMMENDATIONS FROM THE FINANCE COMMITTEE. LUCY K HENRIQUES TRUST C/O BANK OF HAWAII PO BOX 3170 DEPT HONOLULU HI 968023170 996002291 PROVIDE SUPPORT FOR NORTH HAWAII COMMUNITY HOSPITAL AK 501C3 LINE 11C, III-FI 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 LUCY K HENRIQUES TRUST C 87000 CASH