2012-03-06T10:56:26-07:00 2011-06-30 990 2010-07-01 020222156 MEMORIAL HOSPITAL MEMO 6033565461 3073 White Mountain Highway North Conway NH 038605001 Roger Clapp 6033565461 2012-03-07 2010 2016-02-24 21:20:13Z Scott McKinnon 3073 White Mountain Highway North Conway NH 03860 68119444 0 X http://www.thememorialhospital.org/ X 1910 NH Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire. 15 12 527 85 0 0 263252 138066 60311639 66202243 622555 405020 478814 418877 61676260 67164206 0 0 0 0 26564314 26637412 0 0 738546 33374589 36881732 59938903 63519144 1737357 3645062 66074571 68611842 25349880 23662522 40724691 44949320 Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire 0 0 54080709 0 66202243 Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire. 0 0 0 54080709 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 1 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 0 0 1 81 0 1 527 1 0 0 0 0 0 0 X 15 12 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X John Newton 6033565461 3073 White Mtn Highway North Conway NH 038605001 Gene Bergoffen 0 X X 0 0 0 Bayard Kennett 0 X X 0 0 0 Phil Davies 0 X X 0 0 0 John Stratton 0 X X 0 0 0 Roger Clapp 0 X X 0 0 0 Ellen Schwartz 0 X 0 0 0 Daphne Wall 0 X 0 0 0 Judy Kennedy 0 X 0 0 0 Melissa Myers 0 X 0 0 0 James Mallon MD 0 X 0 0 0 Janice Crawford 0 X 0 0 0 Jack Loynd 0 X 0 0 0 Barbara Hopkins 0 X 0 0 0 Thaire Bryant 0 X 0 0 0 George Epstein 0 X 0 0 0 Laura Jawitz 0 X 0 0 0 Scott McKinnon 40 X 250554 0 28472 Raymond Rabideau 40 X 4900 272481 31625 Allen Stam MD 40 X 192398 0 22479 John Newton 40 X 349196 0 18026 Douglas Taylor 40 X 4000 420134 26015 Morice Dennery 40 X 0 450075 32397 Victor Lazaron 40 X 4000 412853 32397 David Riss 40 X 0 406447 23617 Brian Sponseller 40 X 0 361250 18026 805048 2323240 233054 17 0 1 0 MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 Physician Services 7332442 NORDX 102 Campus Drive Scarborough ME 04074 Lab Services 267005 Burgess Advertising & Marketing 1290 Congress St Portland ME 04102 Advertising & Marketing 221144 Specialty Laboratories PO Box 54920 Loas Angeles CA 90054 Lab Services 143242 Navix Diagnostics PO Box 3698 Boston MA 02241 Nuclear Imaging Services 135805 0 0 0 21653 0 0 116413 0 138066 Hospital Services 622110 66202243 66202243 0 0 0 0 0 0 66202243 352222 352222 0 0 0 0 0 0 0 0 0 0 115436 0 228725 0 -113289 0 -113289 -113289 0 0 779311 0 726513 0 52798 0 52798 0 0 52798 21653 Employee Prescriptions 446110 75500 75500 0 0 Cafeteria & Vending 722210 212715 212715 0 0 Community Health Staff Support 621300 161100 161100 0 0 82851 82851 0 0 532166 67164206 66973342 0 52798 954047 219451 734596 0 0 0 0 18237779 14600945 3417556 219278 387743 310422 72659 4662 5707314 4559096 1079749 68469 1350529 1072305 261848 16376 125654 125654 80887 80887 28105 28105 9670808 9525363 145445 286966 18737 268229 972430 24472 827595 120363 224646 224646 3160236 2711133 425458 23645 146605 69693 76178 734 14469 14469 3319634 2861608 441236 16790 709331 709331 Medical Supplies 8472593 8472593 0 0 Bad Debt 5326157 5326157 0 0 Medicaid Enhancement Tax 2806983 2806983 0 0 Equipment Lease & Maintenance 1088392 1058183 30209 0 Miscellaneous 447836 447836 0 0 63519144 54080709 8699889 738546 11324383 9680140 10404353 10086647 6410450 7676147 1900250 1895249 50340 105102 60605534 29707693 31460947 30897841 4114714 7599753 113501 385565 0 0 295633 285398 66074571 68611842 4452042 3388295 19899867 19513257 997971 760970 25349880 23662522 X 39862284 44053700 249044 282257 613363 613363 40724691 44949320 66074571 68611842 X 3645062 579567 X 0 1 1 X 0 X 3575593 2400000 663551 0 0 0 6639144 3311669 0 263924 0 0 0 3575593 3205137 640000 -533468 0 0 0 3311669 0.89 0.09 0.02 0 0 0 598483 598483 0 42742577 19084739 23657838 0 0 0 0 0 15487041 9614822 5872219 0 1777433 1008132 769301 30897841 67164206 63519144 3645062 579567 0 0 0 0 579567 4224629 67944393 579567 0 0 0 579567 67364826 28105 -228725 -200620 67164206 63719764 0 0 0 228725 228725 63491039 28105 0 28105 63519144 SchD_P05_S00_L04 Schedule D, Part V, Line 4 The Endowment Fund contains permanently restricted funds with income available for general purposes. Also a portion of the earnings are to be used to assist patients with free care. The remainder of the fund is board designated. SchD_P12_S00_L04b Schedule D, Part XII, Line 4b Rental expenses. SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Rental Expenses Annual Golf Tournament 44012 21653 22359 0 0 17873 0 0 4486 0 0 44012 21653 22359 0 0 17873 0 0 4486 22359 0 1 1 1 X 2.50 1 X 0 1 0 1 1 3442048 3325972 116076 0.0018 7544757 6658879 885878 0.0139 0 0 0 0 0 0 10986805 9984851 1001954 0.0157 308354 950 307404 0.0048 6000 0 6000 0.0001 0 0 0 0 0 0 0 4900 0 0 0.0001 0 0 319254 950 313404 0.0050 0 0 11306059 9985801 1315358 0.0207 0 2869201 0 15531286 15686599 -155313 X 1 1 1 1 Memorial Hospital

3073 White Mountain Hwy North Conway NH 03860

X X X X Memorial Hospital 1 1 SchH_P01_S00_L03c Schedule H, Part I, Line 3c In conjunction with the FPL guidelines the Hospital uses a Net Worth Criteria. For an individual to qualify for a 100% discount the Net Worth must be at or below $200000. SchH_P01_S00_L06a Schedule H, Part I, Line 6a The Hospital files an annual report with the State of New Hampshire. SchH_P01_S00_L07 Schedule H, Part I, Line 7 Worksheet 2 Ratio of Patient Care Cost to Charges was used to calculate cost. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f The amount of Bad Debt excluded from the calculation was $5326157. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 No Footnote. Worksheet 2 was used to calculate cost. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The filed Medicare Cost Report was used to extract cost for Part A and Part B hospital services. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b With the exception of insurance coverage the collection activity shall not be initiated or pursued for any amounts approved under the Memorial Hospital Healthcare Assistance Program. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 The MWV Community Healthcare Collaborative formed to cooperatively search for solutions to local health needs. In January 2010 they began a Community Needs Assessment. The Six Step Community Needs Assessment Process developed by the Association of Community Health Improvement was utilized to build the core framework for the project. The Assessment was completed in the fall of 2010. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Hospital utilizes several methods for communicating and educating patients regarding financial assistance with their hospital bills. At our registraction and credit and collections offices it is visible to all with handouts. Our website includes information regarding the Healthcare Assistance Program. Hospital bills with a patient liability include information regarding the availability of financial assistance. Also the State Hospital Association website has links to various programs. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The hospital serves the northern part of Carroll County in New Hampshire and the western portion of Oxford County in Maine. The Mount Washington Valley is a four season destination resort area and serves the tourists that frequent the area. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 New Hampshire X X 1 1 X X X X X X 0 0 0 0 0 1 0 0 0 Scott McKinnon 224199 0 20900 0 5455 0 3425 0 25047 0 279026 0 128744 0 John Newton 330000 0 20000 0 -804 0 0 0 18026 0 367222 0 359143 0 Allen Stam MD 163202 0 0 0 29196 0 4453 0 18026 0 214877 0 192107 0 Raymond Rabideau 0 212481 0 60000 4900 0 0 6578 0 25047 4900 304106 10800 299365 Douglas Taylor 0 420134 0 0 4000 0 0 968 0 25047 4000 446149 0 470679 Morice Dennery 0 450075 0 0 0 0 0 7350 0 25047 0 482472 0 443682 Victor Lazaron 0 400853 0 0 4000 12000 0 7350 0 25047 4000 445250 5600 428216 David Riss 0 406447 0 0 0 0 0 3022 0 20595 0 430064 0 408175 Brian Sponseller 0 361250 0 0 0 0 0 0 0 18026 0 379276 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a The Hospital will reimburse for Travel for Companions if prior approval by the Chairman of the Board is granted. As part of the recrutiment of a new CEO a housing allowance was granted for a temporary period of time. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 The CEO compensation was partially contingent upon acheiving financial goals. FY10 financial goal was to Complete fiscal year at minimum of 4 percent margin performance with stretch goal of 5 percent. FY11 financial goal was Operating and total margin performance. NH Health & Education Facilities Authority 020279866 644614QC6 2006-06-14 21069204 To Construct & Renovate Hospital Facility & Payoff Existing Debt 0 0 0 375000 0 19513257 0 0 0 0 0 0 0 0 0 2009 0 0 1 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 The sole member of The Memorial Hospital is The Memorial Development Foundation F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b The sole member The Memorial Development Foundation ratifies the appointments to the Board of Trustees of The Memorial Hospital F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a The form 990 was provided to the Finance Committee and the full Board of Trustees. It was reviewed by the Finance Committee on January 17 2012. It was then forwarded to the full Board of Trustees on January 18,2012 for approval before submission. These reviews were led by the Treasurer. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Conflict of Interest declaration forms are submitted annually in January by members of the Board of Trustees and are shared with the full board for information purposes and reviewed in depth by the Governance Committee. It is the members responsibility to notify the board should any conflict arise in between signings and of all members of the board to immediately raise any conflicts that they become aware of and the Board member with a conflict will recuse themselves from discussions and votes on that issue F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Compensation Committee of the baord conducts the CEO evaluation and compensation process. The CEOs performance is reviewed against targets set for the year and his semi annual bonus determination. The CEO compensation is compared to the Sullivan Cotter and Associates information and periodically reviewed by our compensation consultant. No one with a conflict of interest relative to the hospital is involved in these discussions and minutes are recorded by the Secretary of the Board F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Memorial Hospital will make copies of such documents available to the general public upon request. F990_P11_S00_L05 Form 990, Part XI, Line 5 Unrealized Gains on investments carried at Market Value Memorial Development Foundation PO Box 5001 North Conway NH 03860 223160795 Coordinate healthcare NH 501(c)(3) 509(a)(3) Type 1 N/A Visiting Nurse & Hospice Care Services of Northern Carroll County PO Box 432 North Conway NH 03860 020311473 Visiting Nurse & Hospice Services NH 501(c)(3) 9 N/A White Mountain Community Health PO Box 2800 Conway NH 03818 020358715 Community Health Center NH 501(c)(3) 7 N/A Carroll County Health & Home Care Services Inc PO Box 420 Chocorua NH 03817 237337000 Home Care Services NH 501(c)(3) 7 N/A MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 020477066 Contract with Healthcare Professionals & Retail Pharmacy NH Memorial Hospital C 100 100 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 MWV Healthcare Assoc Inc a-iv 1309 MWV Healthcare Assoc Inc o 7903581 White Mountain Community Health i 59004 White Mountain Community Health p 120270 White Mountain Community Health o 60800 Carroll County Health & Home Care Services Inc p 165830 Visiting Nurse & Hospice Care Services of Northern Carroll County p 174787