2012-03-12T08:19:47-05:00 2011-09-30 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2010-10-01 020276210 UPPER CONNECTICUT VALLEY HOSPITAL UPPE 6032374971 CORLISS LANE COLEBROOK NH 03576 JAMES TIBBETTS 6032374971 2012-03-08 1 W JAY SIMMS 6036530044 2010 2016-02-24 21:20:13Z WINSTON YOUNG CORLISS LANE COLEBROOK NH 03576 15218602 0 X WWW.DARTMOUTH-HITCHCOCK.ORG/UCVH X 1969 NH TO PROVIDE HEALTH CARE SERVICES. 12 11 178 10 0 0 289409 94567 15311159 14309260 -90458 388046 381051 408329 15891161 15200202 0 75000 0 0 7462102 7449464 0 0 12177 8119979 8109993 15582081 15634457 309080 -434255 15323454 16103171 4077709 4352765 11245745 11750406 UPPER CONNECTICUT VALLEY HOSPITAL STRIVES TO IMPROVE THE WELL-BEING OF THE RURAL COMMUNITIES IT SERVES BY PROMOTING HEALTH AND ASSURING ACCESS TO QUALITY CARE. 0 0 12733592 14684941 UPPER CONNECTICUT VALLEY HOSPTIAL PROVIDED HOSPITAL CARE AND INPATIENT AND OUTPATIENT SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2011 WAS $789,632. 12733592 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 40 0 1 178 1 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X THE ORGANIZATION 6032374971 UCVH CORLISS LANE COLEBROOK NH 03576 E HARLAN CONNARY 1.00 X X 0 0 0 NEIL P COUTURE 1.00 X 0 0 0 SHIRLEY POWELL 1.00 X 0 0 0 MARGARET CLEARY 1.00 X X 0 0 0 GREG E PLACY 1.00 X X 0 0 0 JAMES TIBBETTS 1.00 X X 0 0 0 WINSTON YOUNG 1.00 X X 0 0 0 THE REV CRAIG CHENEY 1.00 X 0 0 0 PALMER LEWIS 1.00 X 0 0 0 BRUCE BEAN 1.00 X 0 0 0 ODETTE CRAWFORD 1.00 X 0 0 0 ED LAVERTY PA-C 1.00 X 0 0 0 LOUISE MCCLEERY 40.00 X X 128635 0 11881 ROBERT SOUCY 43.00 X 194643 0 22828 WILLIAM SPINA 40.00 X 175557 0 26230 GERALD WESTOVER 54.00 X 201199 0 14905 EDWARD LAVERTY 51.00 X 162253 0 21249 FERIAL LADAK 46.00 X 238133 0 16681 1100420 0 113774 12 0 1 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 PT AND OT STAFF/SERVICE 481483 CPSI 6600 WALL STREET MOBILE AL 36695 SERVICE CONTRACTS 337892 LIQUID AGENTS HEALTHCARE LLC 6900 DALLAS PARKWAY PLANO TX 75024 HEALTHCARE STAFFING FIRM 201431 LEADERS FOR TODAY 50 RESNIK ROAD PLYMOUTH MA 02360 HEALTHCARE STAFFING FIRM 129800 VIRTUAL RADIOLOGIC CORPORATION PO BOX 4246 CAROL STREAM IL 60197 RADIOLOGY SERVICES 106603 5 67691 26876 94567 NET PATIENT REVENUE 621990 14309260 14309260 14309260 40864 40864 365582 18400 365582 -18400 347182 347182 OTHER INCOME 900099 190702 190702 SCHOOL NURSE PROGRAM 900099 169804 169804 CAFETERIA 900099 32648 32648 15175 15175 408329 15200202 14684941 0 420694 75000 75000 90727 90727 5886819 5228431 658388 71489 63917 7572 1007257 886180 121077 393172 344264 48908 256798 256798 63444 63444 64000 64000 1351699 1245458 106241 289273 289273 87109 58900 28209 16305 16305 716683 716683 96716 96716 PURCHASED SERVICES 1571278 1176401 394877 PROVISION FOR BAD DEBT 1249259 1249259 MEDICAID ENHANCEMENT TA 637827 637827 PHYSICIAN FEES 600925 511675 89250 MISCELLANEOUS 416054 388207 15670 12177 692623 499944 192679 15634457 12733592 2888688 12177 294199 565903 1053141 1713405 1746800 1517504 274613 279493 226949 204376 11210058 6687366 4718358 4522692 6068555 5916947 579110 808417 361729 574434 15323454 16103171 741642 1303529 85173 24790 1863899 1767718 1386995 1256728 4077709 4352765 X 9872249 10595930 1304311 1085291 69185 69185 11245745 11750406 15323454 16103171 X -434255 938916 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3832 3832 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: UPPER CONNECTICUT VALLEY HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF UCVH AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT DIRECLTY PERFORM ANY LOBBYING ACTIVITIES. 125114 2130 127244 112258 12856 125114 111704 554 112258 0.00000 0.54370 0.45620 0 0 9700 9700 4284323 1978224 2306099 351255 194726 156529 6539748 4514416 2025332 25032 25032 4522692 CASH AND CASH EQUIVALENTS 149403 F SHORT TERM INVESTMENTS 659014 F 808417 DUE TO THIRD PARTY PAYERS 1225246 CAPITAL LEASE 31482 1256728 15200202 15634457 -434255 -310343 1249259 938916 504661 14774311 -310343 -310343 15084654 115548 115548 15200202 14373021 0 14373021 1261436 1261436 15634457 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INVESTMENTS ARE TO BE HELD IN PERPETUITY. THE INCOME FROM THE INVESTMENTS IS EXPENDABLE TO SUPPORT THE HOSPITAL'S HEALTH CARE SERVICES. PART XI, LINE 8 - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 12,177. NET ASSETS RELEASED FOR CAPITAL EXPENDITURS 103,371. PART XIII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 12,177. PROVISION FOR BAD DEBTS 1,249,259. 1 1 1 X 1 X 1 1 0 1 1 789227 340283 448944 0.03120 1907633 1520143 387490 0.02690 2696860 1860426 836434 0.05810 10895 10895 0.00080 462105 462105 0.03210 12450 12450 0.00090 485450 485450 0.03380 3182310 1860426 1321884 0.09190 640 640 0.00000 670 670 0.00000 1310 1310 0 695984 22271 7640191 7739629 -99438 X 1 0 1 1 UPPER CONNECTICUT VALLEY HOSPITAL

181 CORLISS LANE COLEBROOK NH 03576

X X X X UPPER CONNECTICUT VALLEY HOSPITAL 1 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 $ 1249259. PART III, LINE 8: ALLOWABLE COSTS COME FROM THE FILED COST REPORT. AS UCVH OPERATES AT A LOSS FROM MEDICARE, THE SHORTFALL COULD BE TREATED AS A COMMUNITY BENEFIT AS THERE ARE NO OTHER FUNDS AVAILABLE TO SUBSIDIZE THE LOSS. PART VI, LINE 2: UCVH ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES THROUGH A VARIETY OF METHODOLOGIES. FOR EXAMPLE, UCVH CONDUCTS COMMUNITY HEALTH CARE SCREENINGS AT BUSINESSES AND SCHOOLS FOR "REAL TIME" ASSESSMENTS. THESE SCREENINGS ASSESS HEALTH THROUGH SUCH THINGS AS BLOOD TESTING FOR GLUCOSE AND CHOLESTEROL, BLOOD PRESSURE CHECKS, AND SKIN CANCER AWARENESS EDUCATION. VOUCHERS ARE OFFERED FOR COUNSELING ABOUT THE TEST RESULTS, AND DIRECT FEEDBACK FROM THE PARTICIPANTS ABOUT THEIR HEALTH CARE NEEDS IS RECEIVED ONE-ON-ONE IN A PRIVATE AREA. FEEDBACK FROM THE SCREENINGS IS USED TO PREPARE EDUCATIONAL TOPICS FOR PUBLIC EDUCATION, AND TO HELP PLAN FOR FUTURE SCREENINGS. ANOTHER METHODOLOGY USED BY UCVH IS A COMMUNITY NEEDS ASSESSEMENT USING FOCUS GROUP INTERVIEWS, AN ANAYLSIS OF COOS COUNTY BEHAVIORAL AND RISK FACTOR SURVEILLANCE STATISTICS, AND COMPARISONS OF PREVIOUS COMMUNITY NEEDS ASSESSMENTS. PART VI, LINE 3: UCVH IS A CHARITABLE HEALTH CARE ORGANIZATION AND A DESIGNATED CRITICAL ACCESS HOSPITAL. UCVH WILL TREAT PATIENTS WHO COME TO US FOR NON-ELECTIVE, MEDICALLY NECESSARY CARE, REGARDLESS OF THEIR FINANCIAL STATUS. WE OFFER FINANCIAL ASSISTANCE FOR THESE SERVICES - IN THE FORM OF FREE OR DISCOUNTED CARE - TO THOSE PATIENTS WHO ARE UNABLE TO PAY THEIR BILLS.THE PATIENTS OR THEIR FAMILY REPRESENTATIVES MUST COMPLETE AN APPLICATION AND PROVIDE INFORMATION THAT SUPPORTS THEIR FINANCIAL NEED. ALL APPLICATIONS RECEIVED WILL BE PROCESSED UNDER BOTH THE NHHAN GUIDELINES, AS PUBLISHED IN THE NHHAN MANUAL, AND THE UCVH GUIDELINES. PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE NHHAN GUIDELINES WILL RECEIVE A PORTABLE CARD THAT WILL BE HONORED AT OTHER NEW HAMPSHIRE PARTICIPATING MEDICAL FACILITIES. UCVH GUIDELINES ARE ONLY APPLICABLE TO SERVICE RENDERED AT OUR SERVICE LOCATIONS AND ARE NOT PORTABLE. PART VI, LINE 4: THE UCVH SERVICE AREA IS COMPRISED OF SIX COMMUNITIES IN NORTHERN NEW HAMPSHIRE (COLEBROOK, STRATFORD, PITTSBURG, STREWARTSTOWN, COLUMBIA, ERROL, AND CLARKSVILLE), AS WELL AS EIGHT OTHER SMALL COMMUNITIES IN VERMONT AND TWO IN MAINE. THE REGIONAL HEALTH PROFILE ASSESSED OUR POPULATION AT APPROXIMATELY 8,500 COVERING 850 SQUARE MILES. THE MAJOR ISSUES OF THE COMMUNITY THAT UCVH SERVES ARE GEOGRAPHIC AND ECONOMIC BARRIERS, AND THE POVERTY-RELATED ISSUES OF SUBSTANCE ABUSE AND TEEN PREGNANCY. REPORTS FILED WITH STATES PART VI, LINE 7 NH 0 45TH PARALLEL EMS 46 RAMSEY ROAD COLEBROOK NH 03576 262005001 501(C)3 25000 FMV AMBULANCE SERVICES INDIAN STREAM HEALTH CENTER INC 2 CORLISS LN RR2 BOX 14 COLEBROOK NH 03576 200999212 501(C)3 50000 FMV MEDICAL SERVICES X X 0 0 0 0 0 0 0 0 0 ROBERT SOUCY 194643 0 0 0 0 0 4032 0 18796 0 217471 0 0 0 WILLIAM SPINA 175557 0 0 0 0 0 4800 0 21430 0 201787 0 0 0 GERALD WESTOVER 201199 0 0 0 0 0 0 0 14905 0 216104 0 0 0 EDWARD LAVERTY 162253 0 0 0 0 0 2534 0 18715 0 183502 0 0 0 FERIAL LADAK 238133 0 0 0 0 0 0 0 16681 0 254814 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE FINANCE COMMITTEE FOR REVIEW AND APPROVAL BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS, AMD KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST DOCUMENT. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL CEO'S COMPENSATION AND BENEFIT PACKAGE IS REVIEWED PERIODICALLY BY COMMUNITY BOARD MEMBERS WHO GOVERN THE NON-PROFIT ORGANZATION AS UNPAID, INDEPENDENT VOLUNTEERS. THE PERIODIC REVIEW INCLUDES COMPARABILITY DATA, AND THE DELIBERATION AND DECISION-MAKING IS SUBSTANTIATED BY WRITTEN MINUTES. FORM 990, PART VI, SECTION C, LINE 18 UVCH MAKES ITS FORM 990 AVAILABLE UPON REQUEST AND ON THE GUIDESTAR WEBSITE FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -310,343. PROVISION FOR BAD DEBTS 1,249,259. TOTAL TO FORM 990, PART XI, LINE 5: 938,916. WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 020222242 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 MARY HITCHCOCK MEMORIAL HOSPITAL 1 MEDICAL CENTER DRIVE LEBANON NH 03756 020222140 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 DARTMOUTH-HITCHCOCK CLINIC 1 MEDICAL CENTER DRIVE LEBANON NH 03756 222519596 MEDICAL CLINIC NH 501C(3) 509(A)(2) 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 020280367 HOSPITAL NH 501C(3) 170(B)(1)(A)III 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 MARY HITCHCOCK MEMORIAL HOSPITAL E 203423 CASH PAID MARY HITCHCOCK MEMORIAL HOSPITAL L 16161 FMV NEW ENGLAND ALLIANCE FOR HEALTH L 145811 FMV DARTMOUTH-HITCHCOCK CLINIC L 19117 FMV WEEKS MEDICAL CENTER L 29910 FMV ANDROSCOGGIN VALLEY HOSPITAL L 465757 FMV