2012-05-14T16:05:39-05:00 2011-06-30 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-07-01 314446959 SHELTERING ARMS HOSPITAL FOUNDATION SHEL 7405935551 55 HOSPITAL DRIVE ATHENS OH 45701 KEN DICKEN 7405935551 2012-05-08 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z O'BLENESS MEMORIAL HOSPITAL JOHN YANES 55 HOSPITAL DRIVE ATHENS OH 45701 76200347 0 X WWW.OBLENESS.ORG X 1948 OH SEE SCHEDULE OTO OPERATE AN ACUTE CARE HOSPITAL FACILITY IN ATHENS, OHIO FOR THE CITIZENS OF ATHENS, OHIO AND THE SURROUNDING COMMUNITIES AND COUNTIES. 16 14 571 245 6523477 -379560 385025 462880 73449385 73137198 647625 241702 1811881 -1968224 76293916 71873556 0 0 0 0 29823353 31301742 0 0 15976 41219934 37457827 71043287 68759569 5250629 3113987 69420064 74721530 42951005 44149330 26469059 30572200 TO PROVIDE SUPERIOR HEALTHCARE AT A COST THAT REPRESENTS VALUE TO THE COMMUNITY. 0 0 61526500 0 64645497 PATIENT CARE PROVIDED INCLUDED 9,124 INPATIENT DAYS OF CARE TO 2,920 ACUTE PATIENTS; 27,164 EMERGENCY ROOM VISITS; 88,626 OTHER OUTPATIENT VISITS; 1,576 INPATIENT AND OUTPATIENT SURGERIES; AND 601 BIRTHS. PROCEDURES AND TESTS PERFORMED INCLUDED 849,431 LAB TESTS; 27,013 X-RAYS; 3,204 MAMMOGRAPHIES; 2,420 ULTRASOUNDS; 1,516 NUCLEAR MEDICINE SCANS; 7,263 CT SCANS; 316 CARDIOVASCULAR CATHETERIZATIONS; 18,366 PHYSICAL THERAPY MODALITIES; 74,363 CARDIOPULMONARY PROCEDURES; 2,302 MRIS; AND 9,937 EKGS. THE HOSPITAL ALSO SPONSORED OR PARTICIPATED IN VARIOUS FAIRS OR HEALTH SCREENINGS THROUGHOUT THE COMMUNITY AND SURROUNDING AREAS. CHARGES FOREGONE FOR CHARITY AMOUNTED TO $7,337,969. 61526500 1 1 0 1 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 123 0 1 571 1 1 1 0 0 0 0 0 0 0 0 0 X 16 14 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 OH X KEN DICKEN 7405935551 55 HOSPITAL DRIVE ATHENS OH 45701 CLIFFORD YOUNG 40.00 X X 177985 0 15750 BICK WEISSENRIEDER 2.00 X X 0 0 0 BOB NORRIS 2.00 X X 0 0 0 LARRY CORRIGAN 2.00 X 0 0 0 JIM RIESTENBERG DDS 2.00 X X 0 0 0 SUSAN QUINN OD 2.00 X X 0 0 0 MICHAEL BERNSTEIN 2.00 X 0 0 0 GREG BLOWER 2.00 X 0 0 0 DOUGLAS BOLON PHD 2.00 X 0 0 0 MICHAEL CLARK DO 2.00 X 0 0 0 RAY KARR 2.00 X 0 0 0 JACQUELINE LEGG 2.00 X 0 0 0 GERALD A MOLLICA 2.00 X 0 0 0 MIKE SOSTARICH 2.00 X 0 0 0 LARRY THORNHILL 40.00 X X 0 0 0 JOHN YANES 40.00 X X 0 0 0 NICOLE WADSWORTH DO 2.00 X 0 0 0 KIMBERLY DETTWILLER 40.00 X 101500 0 9000 JODY GEROME ZUCHOWSKI 40.00 X 271928 0 7431 STENNETH ADAMS 40.00 X 306212 0 15036 MARK ROTHSTEIN 40.00 X 367803 0 14429 NEAL NESBITT 40.00 X 397170 0 13746 JASON REED 40.00 X 773620 0 25667 2396218 0 101059 7 0 1 0 PHILIPS MEDICAL SYSTEMS PO BOX 100355 ATLANTA GA 303840355 HEALTHCARE SOLUTIONS 604593 BRICKER & ECKLER LLP 100 SOUTH THIRD STREET COLUMBUS OH 432154291 LEGAL SERVICES 490660 RADIOLOGY ASSOCIATESATHENS PO BOX 2608 ATHENS OH 45701 RADIOLOGY 344417 MALONE MEDICAL ANESTHESIOLOGY 227 1/2 WEST UNION ST ATHENS OH 45701 ANESTHESIOLOGY 233400 BAILEY CAVALIERI LLC PO BOX 932338 CLEVELAND OH 44193 LEGAL SERVICES 206089 7 462880 462880 PATIENT SERVICES 622110 73069998 66790626 6279372 RENT- APPLACHIAN COMMU 631110 67200 67200 73137198 193827 193827 1208813 4311188 -3102375 -3102375 -3102375 5482 57996 2561 13042 2921 44954 47875 47875 CAFETERIA 722210 324470 324470 S-CORP INVESTMENTS 621500 217991 217991 PHARMACY 561000 188694 188694 402996 376882 26114 1134151 71873556 64645497 6523477 241702 299485 268339 31146 22273499 19957055 2316444 1302722 1167239 135483 5628544 5043176 585368 1797492 1610553 186939 716871 716871 151218 151218 12120184 10859685 1260499 313119 280555 32564 12079566 10823291 1256275 58402 52328 6074 849158 760845 88313 138122 123758 14364 45297 40586 4711 2167006 1941638 225368 46572 41729 4843 1849362 1657029 192333 BAD DEBTS EXPENSE 6827363 6827363 DUES AND SUBSCRIPTIONS 79611 71331 8280 DEV COUNCIL & COMMUNITY 15976 15976 68759569 61526500 7217093 15976 780975 17753513 17756071 3690328 176636 0 9951468 9706500 188525 818262 752993 1023605 1289115 79532343 48845231 32734573 30687112 3403323 691205 755893 2083946 9897551 69420064 74721530 7248688 5923382 28905000 27937083 1893163 798941 4904154 9489924 42951005 44149330 X 25682555 29801418 176636 160914 609868 609868 26469059 30572200 69420064 74721530 X 3113987 989154 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 1136 1136 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LOBBYING EXPENSES RELATE TO THE PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION WHICH IS USED FOR LOBBYING. 786504 -15727 770777 801779 -15275 786504 663242 138537 801779 0.21170 0.78830 0 0 2389777 2389777 32868939 15835067 17033872 41742822 31140103 10602719 2530805 1870061 660744 30687112 BOND ISSUE COSTS 900958 COST REPORT SETTLEMENT RECEIVABLE 591844 OTHER CURRENT ASSETS 7909749 OTHER NONCURRENT ASSETS 495000 9897551 LEASED PROPERTY DEPOSITS 3726065 ACCRUED WAGES 3230154 OTHER ACCRUED LIABILITIES 1222766 OTHER LIABILITIES 1310939 9489924 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENTS ARE INTENDED FOR THE SUPPORT OF THE ORGANIZATION'S HEALTHCARE ACTIVITIES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: O'BLENESS MEMORIAL HOSPITAL AND THE APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES, INC. ARE EXEMPT FROM FEDERAL TAXES UNDER SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ATHENS MEDICAL LABORATORY ASSOCIATES, INC., ATHENS SURGERY CENTER, LTD., AND ATHENS MEDICAL ASSOCIATES, LLC ARE FOR-PROFIT SUBSIDIARIES SUBJECT TO FEDERAL INCOME TAXES. FEDERAL INCOME TAX EXPENSE IS NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL FILES FEDERAL, STATE, AND APPLICABLE LOCAL TAX RETURNS AND IS NO LONGER SUBJECT TO RELATED EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2008. 1 1 X 1 X 0 1 1 1 0 0 4031224 2200242 1830982 0.02960 11614856 6442495 5172361 0.08350 15646080 8642737 7003343 0.11310 8589 435 8154 0.00010 846808 846808 855397 847243 8154 0.00010 16501477 9489980 7011497 0.11320 1 2007362 60221 16511647 13946914 2564733 X 1 1 1 ATHENS SURGERY CENTER LTD OUTPATIENT SURGERY 0.59790 0.04120 0.36090 1 1 O'BLENESS MEMORIAL HOSPITAL

55 HOSPITAL DRIVE ATHENS OH 45701

X X X X NA 1 1 ATHENS MEDICAL ASSOCIATES LLC

55 HOSPITAL DRIVE ATHENS OH 45701

PHYSICIAN SERVICES PART I, LINE 3C: THE HOSPITAL HAS MORE THAN ONE POLICY CONCERNING FREE OR DISCOUNTED CARE.O'BLENESS MEMORIAL HOSPITAL WILL OFFER AND PROVIDE FREE CARE TO ANY PATIENT WHO MEETS THE ELIGIBILITY REQUIREMENT FOR FREE CARE UNDER THE OCAP OR HCAP FINANCIAL ASSISTANCE POLICIES.THE FOLLOWING STEPS WILL BE USED TO DETERMINE ELIGIBILITY FOR FREE CARE UNDER OCAP (O'BLENESS CARE ASSURANCE PROGRAM):1. A RECIPIENT OF THE OHIO MEDICAID PROGRAM IS NOT ELIGIBLE. (OAC RULE 5 10 1 :3-2-07.17)2. IF THE PATIENT IS COVERED UNDER A THIRD-PARTY INSURER OR A GOVERNMENTAL PROGRAM, THE THIRD PARTY WILL BE BILLED AND ANY PAYMENT RECEIVED WILL BE APPLIED TO THE ACCOUNT FIRST. ANY BALANCE ON THE ACCOUNT WILL BE CONSIDERED FOR THE OCAP WRITE-OFF.3. OCAP ASSISTANCE WILL BE APPROVED ONLY WHEN SERVICES ARE PROVIDED BY O'BLENESS MEMORIAL HOSPITAL. THESE SERVICES ALSO INCLUDE ANESTHESIA PROFESSIONAL FEES, PHYSICIAN INTERPRETATION FEES FOR CARDIOPULMONARY SERVICES, AND SERVICE PROVIDED IN THE O'BLENESS FAMILY PRACTICE CLINIC. 4. FAMILY INCOME IS BETWEEN 100 TO 150% OF THE FEDERAL POVERTY GUIDELINES.FAMILY: FAMILY SHALL BE DEFINED AS THE PATIENT, THE PATIENT'S SPOUSE, AND ALL OF THE PATIENT'S CHILDREN, NATURAL AND ADOPTIVE UNDER THE AGE OF EIGHTEEN WHO LIVE AT HOME. IF THE PATIENT IS UNDER THE AGE OF EIGHTEEN THE FAMILY SHALL INCLUDE THE PATIENT, THE PATIENT'S NATURAL OR ADOPTIVE PARENT(S) AND THE PARENT(S) CHILDREN, NATURAL OR ADOPTIVE UNDER THE AGE OF EIGHTEEN WHO LIVE IN THE HOME. IF THE PATIENT IS A CHILD OF A MINOR PARENT WHO STILL RESIDES IN THE HOME OF THE PATIENT'S GRANDPARENTS, THE FAMILY SHALL INCLUDE ONLY THE PARENT(S) OF ANY OF THE PARENT(S) NATURAL OR ADOPTIVE CHILDREN WHO RESIDE IN THE HOME. INCOME: INCOME SHALL BE DEFINED AS THE TOTAL SALARIES, WAGES AND CASH RECEIPTS BEFORE TAXES: RECEIPTS THAT REFLECT REASONABLE DEDUCTION FOR BUSINESS EXPENSES SHALL BE COUNTED FOR BOTH FARM AND NON-FARM SELF-EMPLOYMENT.THE FOLLOWING STEPS WILL BE USED TO DETERMINE ELIGIBILITY FOR FREE CARE UNDER HCAP (HOSPITAL CARE ASSURANCE PROGRAM):1. A COMPLETED APPLICATION WILL BE OBTAINED FROM ALL PATIENTS SEEKING FREE CARE UNDER HCAP.2. A PATIENT MUST BE A RESIDENT OF THE STATE OF OHIO TO BE ELIGIBLE FOR HCAP.3. O'BLENESS MEMORIAL HOSPITAL WILL DEFINE INCOME REQUIREMENTS USING THE FEDERAL POVERTY GUIDELINES AS INDICATED YEARLY.4. O'BLENESS MEMORIAL HOSPITAL WILL DEFINE A FAMILY AS INDICATED IN BALDWIN'S OHIO ADMINISTRATIVE CODE CHAPTER 5101:3-2-0717.5. THE INCOME PROVIDED BY THE APPLICANT WILL BE VERIFIED VIA SWORN SIGNATURE.6. A RECIPIENT OF THE OHIO MEDICAID PROGRAM IS NOT ELIGIBLE (OAC RULE: 5101:3-2-0717)IF A PATIENT HAS INSURANCE COVERAGE, O'BLENESS MEMORIAL HOSPITAL WILL FIRST BILL THE INSURANCE AND RECEIVE A PAYMENT OF A DENIAL BEFORE THE HCAP APPLICATION IS PROCESSED. PART I, LINE 7: THE COST OF CHARITY CARE, UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS WAS ESTIMATED USING A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS.COSTING METHODOLOGY USED TO DETERMINE THE COST OF COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS. THE HOSPITAL USES THE COMPUTER SOFTWARE CBISA TO TRACK OUR PROGRAMS THAT HAPPEN IN THE COMMUNITY OR AT THE HOSPITAL FOR THE COMMUNITY. THE COMPUTER TRACKS DIRECT EXPENSES ASSOCIATED WITH THE PROGRAMS AS WELL AS ANY OFFSETTING REVENUE THAT WILL DECREASE THE COMMUNITY BENEFIT. THE SYSTEM ACCOUNTS FOR UTILITIES USED IF THE ACTIVITY OCCURS AT THE FACILITY (HOSPITAL). THE SYSTEM ALSO ACCOUNTS FOR ANY SUPPLIES USED AND WAGES OF ANY EMPLOYEE THAT IS PRESENT AT THE ACTIVITY. A HOSPITAL WIDE WAGE AVERAGE IS USED IN DETERMINING THE AMOUNT OF SALARY TO USE IN THE DIRECT EXPENSES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 6827363. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLES ARE CARRIED AT THE ORIGINAL CHARGE LESS AN ESTIMATE MADE FOR DOUBTFUL OR UNCOLLECTIBLE ACCOUNTS. THE ALLOWANCE IS BASED UPON A REVIEW OF THE OUTSTANDING BALANCES AGED BY FINANCIAL CLASS. MANAGEMENT USES COLLECTION PERCENTAGES BASED UPON HISTORICAL COLLECTION EXPERIENCE TO DETERMINE COLLECTABILITY. MANAGEMENT ALSO REVIEWS TROUBLED, AGED ACCOUNTS TO DETERMINE COLLECTION POTENTIAL. PATIENT ACCOUNTS RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO BAD DEBT EXPENSE WHEN RECEIVED. INTEREST IS NOT CHARGED ON PATIENT ACCOUNTS RECEIVABLE. FINANCIAL STATEMENT FOOTNOTE: ACCOUNTS RECEIVABLE ARE STATED NET OF CONTRACTUAL ALLOWANCES AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS DETERMINED UTILIZING A NUMBER OF FACTORS INCLUDING ACCOUNT AGING AND FINANCIAL CLASS INFORMATION AS WELL AS RECENT AND HISTORICAL COLLECTION ACTIVITY.THE COST OF BAD DEBT EXPENSE WAS ESTIMATED USING A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS ESTIMATED AT 3% OF BAD DEBT AT COST. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING METHODOLOGY REQUIRED FOR THE MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE ASKED TO FILL OUT THE PAPERWORK ASSOCIATED WITH THE PROGRAMS WE HAVE AVAILABLE TO PATIENTS WITH LOW INCOME. WE DO NOT HAVE A COLLECTIONS PROCESS FOR CHARITY CARE PATIENTS AND THE FULL AMOUNT IS WRITTEN OFF TO THE ASSOCIATED PROGRAM. THIS DOES NOT APPLY TO PATIENTS THAT DO NOT QUALIFY FOR EITHER OF THE PROGRAMS. IF IT IS DETERMINED THAT THE PATIENT IS CAPABLE OF PAYING FOR THEIR MEDICAL CARE THAN AT THAT POINT THEY ARE CHARGED FOR THE SERVICES. IF FAILURE TO PAY THEIR MEDICAL BILLS OCCURS, AT THAT POINT COLLECTION PRACTICES ENSUE. AFTER A CHANCE TO PAY THEIR BILL AT A REDUCED PRICE, THEY ARE REMINDED UNTIL ULTIMATELY DEBT COLLECTIONS. PART VI, LINE 2: THE HOSPITAL DOES NOT CURRENTLY HAVE AN ESTABLISHED ASSESSMENT OF HEALTH NEEDS OF THE COMMUNITIES IT SERVES. HOWEVER, IN ORDER TO BE COMPLIANCE WITH FUTURE HEALTHCARE LEGISLATION, WE ARE CURRENTLY EXPLORING OPTIONS ON HOW TO BEST ASSESS OUR COMMUNITIES AND THEIR HEALTH NEEDS. PART VI, LINE 3: THE HOSPITAL INFORMS PATIENTS OF THEIR ELIGIBILITY FOR ASSISTANCE IN DIFFERENT WAYS. THERE IS A SIGN IN THE ADMITTING AREA THAT DIRECTS THEIR ATTENTION TO THE FACT THAT THERE IS AVAILABLE CARE AT A REDUCED FEE OR FREE OF CHARGE. ON EACH DATA MAILER THAT IS SENT OUT TO PATIENTS, THERE IS A SECTION THAT INFORMS THEM OF THE AVAILABILITY OF THIS CARE. ANY PATIENT THAT COMES IN WITHOUT INSURANCE OR PROOF OF INSURANCE IS SUPPLIED A SELF-PAY PACKET. IN THIS PACKET IS AN OUTLINE ON HOW TO OBTAIN FREE OR DISCOUNTED CARE; THE PACKET ALSO DETAILS THE PARAMETERS OF EACH PROGRAM. IF ANY OF OUR EMPLOYEES ARE ASKED IN ADMISSIONS OR DURING THEIR CARE IF THERE ARE ANY OPTIONS AVAILABLE FOR PAYMENT OF THEIR CARE, THE EMPLOYEES WILL DESCRIBE TO THE PATIENTS THE PROGRAMS AVAILABLE OR PROVIDE THEM WITH MATERIALS ON HOW TO APPLY AND BE ACCEPTED INTO THE FREE OR DISCOUNTED CARE PROGRAMS. PART VI, LINE 4: O'BLENESS MEMORIAL HOSPITAL IS A COMMUNITY HOSPITAL IN A RURAL AREA OF APPALACHIA. OUR PRIMARY SERVICE AREA INCLUDES THE COMMUNITIES WITHIN ATHENS COUNTY, OHIO, WHICH HAS BEEN IDENTIFIED BY THE APPALACHIAN REGIONAL COMMISSION AS AN ARC-DESIGNATED DISTRESSED COUNTY. ACCORDING TO THE UNITED STATES CENSUS BUREAU, THE POPULATION OF ATHENS COUNTY IN 2010 WAS 64,757. THE MEDIAN INCOME OF $31,559 IS NOT TRULY REPRESENTATIVE OF THE POPULATION, AS THE COMMUNITY INCLUDES A MAJOR UNIVERSITY. ATHENS COUNTY HAS THE HIGHEST POVERTY LEVEL OF ANY COUNTY IN OHIO, AS 30.3% OF THE COMMUNITY RESIDENTS HAVE INCOMES AT OR BELOW THE FEDERAL POVERTY GUIDELINE. UNINSURED INDIVIDUALS IN ATHENS COUNTY REPRESENT 20% OF THE POPULATION. THE HOSPITAL'S PATIENT POPULATION INCLUDES 8.3% WHO ARE UNINSURED AND 21.46% WHO ARE MEDICAID RECIPIENTS. LOCATED WITHIN O'BLENESS' PRIMARY SERVICE AREA OF ATHENS COUNTY IS ONE ADDITIONAL HOSPITAL, DOCTORS HOSPITAL OF NELSONVILLE AFFILIATED WITH OHIOHEALTH BASED IN COLUMBUS, OHIO. PORTIONS OF THE PATIENT POPULATION ARE ALSO SERVED BY EIGHT OTHER HOSPITALS IN WASHINGTON, GALLIA, JACKSON, HOCKING, FAIRFIELD AND ROSS COUNTIES IN OHIO AND WOOD COUNTY IN WEST VIRGINIA, AS WELL AS THREE MAJOR HEALTH SYSTEMS WITH MULTIPLE FACILITIES IN FRANKLIN COUNTY, OHIO. THREE TOWNSHIPS IN ATHENS COUNTY HAVE BEEN DESIGNATED AS MEDICALLY UNDERSERVED AREAS/POPULATIONS BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: LODI, WATERLOO AND TRIMBLE. PART VI, LINE 6: AT O'BLENESS MEMORIAL HOSPITAL IT IS OUR GOAL TO GIVE ACCESS TO ANY PERSON IN OUR COMMUNITY TO MODERN DAY HEALTHCARE AT A COST EFFECTIVE PRICE. AS THE ONLY HOSPITAL IN ATHENS, WE STRIVE TO GIVE HELP WHERE HELP IS NEEDED. TO FURTHER OUR COMMITMENT TO THE COMMUNITY AND OUR EXEMPT PURPOSE WE ENGAGE IN MANY ACTIVITIES. OUR BOARD IS COMPILED OF PEOPLE WHO RESIDE IN OUR COMMUNITY WITHOUT A CONFLICT OF INTEREST WITH THE HOSPITAL. WE BELIEVE THE MORE DIVERSE THE BOARD, THE BETTER THEY WILL BE ABLE TO IDENTIFY THE NEEDS OF THE COMMUNITY, THEY HAVE NO CONNECTION TO THE ORGANIZATION NOR ARE CONTRACTED WITH THE HOSPITAL. THEY PROVIDE THEIR CONSULT AND GUIDANCE OUT OF THE PURE DESIRE TO SEE THEIR COMMUNITY BE AFFORDED THE SAME QUALITY OF CARE AS BIGGER MARKETS. WE EXTEND MEDICAL PRIVILEGES TO QUALIFIED PHYSICIANS THAT HAVE A DESIRE TO PRACTICE WITHIN OUR FACILITIES. WE CONTINUE TO SEARCH FOR PROGRAMS AND ACTIVITIES THAT WILL BE NEW TO THE COMMUNITY IN ORDER TO GIVE THE POPULATION VARIETY AND HEALTH ORIENTED ALTERNATIVES. FUNDS ARE USED TO PURCHASE CAPITAL EQUIPMENT THAT IS VITAL IN KEEPING UP WITH AN EVER EVOLVING MEDICAL WORLD. IT IS ALSO USED TO FUND ACTIVITIES INSIDE AND OUTSIDE OF THE HOSPITAL THAT INVOLVES THE COMMUNITY ON VARIOUS LEVELS WHETHER IT BE A HEALTH FAIR OR AN INTERACTIVE EXERCISE PROGRAM. WE HAVE MANY VOLUNTEERS FROM THE COMMUNITY THAT ARE INSTRUMENTAL IN CARRYING OUT VARIOUS ACTIVITIES. PART VI, LINE 7: THE O'BLENESS HEALTH SYSTEM IS DESIGNED TO OFFER THE MOST COMPREHENSIVE MEDICAL ATTENTION TO A MAINLY CENTRALIZED LOCATION TO THE COMMUNITY IN WHICH WE LIVE. THE AFFILIATES OF THE SYSTEM WORK TOGETHER IN A COLLABORATIVE EFFORT TO INCREASE THE EFFICIENCY AND COST OF HEALTHCARE TO THE PATIENT. THE O'BLENESS MEMORIAL HOSPITAL IS THE MAIN COMPONENT OF THE HEALTH SYSTEM. AT THE HOSPITAL WE OFFER A VARIETY OF INPATIENT AND OUTPATIENT SERVICES. THE EMERGENCY DEPARTMENT IS OPERATIONAL 24 HOURS A DAY 7 DAYS A WEEK. WE OFFER CARE TO ANYONE REGARDLESS OF ABILITY TO PAY. WE ARE THE ONLY FULLY FUNCTIONAL HOSPITAL IN THE COMMUNITY. IT IS OUR GOAL NOT TO EXCLUDE ANYONE FROM OUR COMMUNITY THAT IS IN NEED OF CARE. THE ATHENS MEDICAL LAB (AML) IS AN AFFILIATE OF THE SYSTEM THAT IS A MEDICAL REFERENCE LAB THAT OFFERS CONVENIENCE AND COST EFFICIENCY FOR THE PATIENT. THIS ALLOWS US TO KEEP PATIENTS CLOSE TO HOME AND SPEED UP RESULT TIME. THE ATHENS MEDICAL ASSOCIATES (AMA) IS A MULTI-PHYSICIAN PRACTICE THAT OFFERS A VARIETY OF SERVICES TO PATIENTS. AMA IS COMPRISED OF A MULTIFACETED OB/GYN PRACTICE, AN ORTHOPEDIC SURGEON, AND A FAMILY PRACTICE CLINIC THAT SERVICE NUMEROUS MEMBERS OF THE COMMUNITY. THERE IS ALSO APPALACHIAN COMMUNITY VISITING NURSES ASSOCIATION, HOSPICE AND HEALTH SERVICES (ACVNAHHS). THIS AFFILIATE PROVIDES HOSPICE SERVICES TO NOT ONLY ATHENS COUNTY BUT SURROUNDING COUNTIES. THEY ARE ALSO PROVIDERS OF VISITING NURSES THAT SERVE OUR CLIENTS OUT OF THE COMFORT OF THEIR OWN HOME. X 0 0 0 0 0 0 0 0 0 CLIFFORD YOUNG 177985 0 0 0 0 0 15750 0 0 0 193735 0 0 0 JODY GEROME ZUCHOWSKI 271928 0 0 0 0 0 7350 0 81 0 279359 0 0 0 STENNETH ADAMS 306212 0 0 0 0 0 6103 0 8933 0 321248 0 0 0 MARK ROTHSTEIN 367803 0 0 0 0 0 7350 0 7079 0 382232 0 0 0 NEAL NESBITT 397170 0 0 0 0 0 7350 0 6396 0 410916 0 0 0 JASON REED 773620 0 0 0 0 0 7350 0 18317 0 799287 0 0 0 COUNTY OF ATHENS OHIO 316400063 047075BA3 2003-08-21 31263724 BOND REFUNDING , HOSPITAL CONSTRUCTION & RENOVATION 0 0 0 31263724 2493813 625274 2005 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 JODY GEROME ZUCHOWSKI PHYSICIAN EDUCATION LOAN X 40000 30000 0 0 1 JASON REED PHYSICIAN EDUCATION LOAN X 170000 113333 0 0 1 STENNETH ADAMS PHYSICIAN RETENTION LOAN X 50000 45192 0 0 1 188525 FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIP BETWEEN MICHAEL BERNSTEIN (BOARD MEMBER), LARRY THORNHILL (OFFICER AND BOARD MEMBER), AND JOHN YANES (OFFICER AND BOARD MEMBER). FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION ENTERED INTO A MANAGEMENT AGREEMENT WITH OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC, AN OHIO NONPROFIT LIMITED LIABILITY COMPANY, EFFECTIVE AUGUST 1, 2010 FOR A FIVE YEAR TERM. OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC IS A WHOLLY OWNED SUBSIDIARY OF OHIOHEALTH CORPORATION, AN OHIO NONPROFIT CORPORATION THAT IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE IRS. FORM 990, PART VI, SECTION B, LINE 11 V.P. OF FINANCE REVIEWS THE FORM 990 THROUGHOUT THE PREPARATION PROCESS AS WELL AS CONDUCTING A FINAL REVIEW PRIOR TO FILING. THE FINAL VERSION IS PRESENTED TO THE BOARD FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS AND DIRECTORS ANNUALLY DISCLOSE INTERESTS THAT COULD GIVE RISE TO CONFLICT THROUGH AN ANNUAL QUESTIONNAIRE. IF A CONFLICT ARISES, RESTRICTIONS ARE IMPOSED SUCH AS PROHIBITING THEM FROM PARTICIPATING IN THE GOVERNING BODY'S DELIBERATIONS AND DECISIONS RELATED TO TRANSACTIONS RELATED TO THE CONFLICT. THOSE WITH ANY CONFLICTS THROUGHOUT THE YEAR ARE INSTRUCTED TO DISCLOSE AS SOON AS DISCOVERED. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION OF THE EXECUTIVE DIRECTOR IS DETERMINED BASED ON COMPARABILITY DATA, CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION AND BY A COMPENSATION COMMITTEE WITH THE FULL BOARD'S APPROVAL. THE EXECUTIVE IS PAID THROUGH OHIOHEATH HOSPITAL MANAGEMENT SERVICES, LLC. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023, 990 AND 990-T ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 468,011. S-CORPORATION INCOME TAXABLE ON RETURN NOT ON BOOKS -217,991. CAPITAL CONTRIBUTION FROM AFFILIATE 850,000. BEGINNING OF YEAR NET ASSETS OF ATHENS MEDICAL ASSOCIATES, LLC -110,866. TOTAL TO FORM 990, PART XI, LINE 5: 989,154. FORM 990, PART XI, LINE 2C THERE WAS NO CHANGE IN THE OVERSIGHT OF THE AUDIT SINCE THE PRIOR YEAR. FORM 990, PART I, LINE 6 O'BLENESS HAD 231 VOLUNTEERS SERVE DURING THE 2011 FISCAL YEAR. TOTAL WAGES ACCORDING TO THE BUREAU OF LABOR STATISTICS IS $512,978 (BASED ON NON-FARM LABOR PLUS BENEFITS). ATHENS MEDICAL ASSOCIATES LLC 55 HOSPITAL DRIVE ATHENS OH 45701 020734615 PHYSICIAN SERVICES OH 6305803 1302954 SHELTERING ARMS HOSPITAL FOUNDATION APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION 30 HERROLD AVENUE ATHENS OH 45701 311045101 HOSPICE AND HEALTH SERVICES OH 501(C)(3) LINE 9 SHELTERING ARMS HOSPITAL FOUNDATION 1 ATHENS SURGERY CENTER LTD 75 HOSPITAL DRIVE ATHENS OH 45701 550840856 OUTPATIENT SURGERY OH N/A RELATED 297277 547845 0 0 0.59793 ATHENS MEDICAL LABORATORY ASSOCIATES INC 400 E STATE STREET ATHENS OH 45701 311381808 MEDICAL LABORATORY OH SHELTERING ARMS HOSPITAL FOUNDATION S 216850 1059707 1.00000 1 0 0 1 0 0 0 0 1 0 1 0 1 1 1 1 0 1 ATHENS SURGERY CENTER LTD O 62497 ALLOCATION OF COSTS ATHENS MEDICAL LABORATORY ASSOCIATES INC O 63695 ALLOCATION OF COSTS APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION A 67200 LEASE AGREEMENT ATHENS SURGERY CENTER LTD A 476409 LEASE AGREEMENT APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION D 265000 LOAN AGREEMENT ATHENS SURGERY CENTER LTD R 225423 DISTRIBUTIONS