2012-05-11T13:33:58-05:00 2011-06-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-07-01 562276994 DAVIE COUNTY EMERGENCY HEALTH CORPORATION DAVI 3367518100 223 HOSPITAL STREET MOCKSVILLE NC 27028 DANNY SQUIRES 3367518100 2012-05-08 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z DAVIE COUNTY HOSPITAL DANNY SQUIRES 223 HOSPITAL STREET MOCKSVILLE NC 27028 11391047 0 X WWW.WAKEHEALTH.EDU/DAVIE-HOSPITAL/ X 2001 NC PROVISION OF PATIENT-CENTERED HEALTHCARE SERVICES TO THE SURROUNDING AREA 15 6 214 2 0 0 8655 12412 10212430 11299132 3237 14563 49535 60195 10273857 11386302 0 850 0 0 4598932 4643897 0 0 0 7350845 8140117 11949777 12784864 -1675920 -1398562 3126737 3240109 2275392 3367638 851345 -127529 DAVIE COUNTY HOSPITAL PROVIDES PATIENT-CENTERED HEALTH CARE SERVICES FOR THE RESIDENTS AND INDUSTRIES OF THE COUNTY AND SURROUNDING COMMUNITIES. 0 0 11397795 850 11299132 DAVIE COUNTY HOSPITAL PROVIDED MEDICAL, EMERGENCY, AND OUTPATIENT CARE SERVICES TO THE RESIDENTS OF DAVIE COUNTY, NORTH CAROLINA, AND THE SURROUNDING AREAS. DURING THE FISCAL YEAR, THE HOSPITAL HAD 6,073 OUTPATIENT VISITS AND 9,436 EMERGENCY ROOM VISITS. IN ADDITION, THE HOSPITAL PERFORMED 217 CATARACT SURGERIES, 84 OTHER SURGERIES, AND 40 SLEEP STUDIES. 11397795 1 0 0 1 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 31 0 1 214 1 0 0 0 0 0 0 0 0 0 0 X 15 6 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X DANNY SQUIRES 3362384287 223 HOSPITAL STREET MOCKSVILLE NC 27028 X DONNY C LAMBETH 1.00 X X 0 749092 408315 DAN BARRETT 1.00 X X 0 0 0 TERRY BRALLEY 1.00 X X 0 0 0 STEPHEN ROBERTSON 1.00 X 0 0 0 KEN WHITE 1.00 X 0 0 0 DR RUSSELL HOWERTON 1.00 X 0 0 0 WILLIAM F JUNKER 1.00 X 0 0 0 RONALD SMALL 1.00 X 0 552513 57788 STEVEN C SNELGROVE 1.00 X 0 357177 98423 BETH DIRKS 1.00 X 0 0 0 DOUG NELSON 1.00 X X 0 0 0 HEATHER L HAYES 1.00 X 0 90812 9395 RALPH HOLTHOUSER 1.00 X X 0 42533 984 LYNN PITMAN 1.00 X 0 171876 36569 CHARLES TEGELER MD 1.00 X 0 0 0 KEVIN WALSH 40.00 X 0 0 0 DANNY SQUIRES 2.00 X 0 0 0 TERRY BOWMAN 2.00 X 89588 0 4372 SHARON T DOSS 40.00 X 101409 0 0 190997 1964003 615846 1 0 1 0 ERX COMPANY 109 LANDOAK LANE KNOXVILLE TN 37922 PHYSICIAN FEES 1115975 MEDTRONIC USA PO BOX 409201 ATLANTA GA 30384 NERVE STIMULATOR SUPPLIER 680423 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 CONTRACTED MRI SERVICES 236398 SIGHTPATH MEDICAL INC 575 W OLD SHAKOPEE ROAD STE 90 BLOOMINGTON MN 55437 CATARACT SURGERY SUPPLIER 179023 4 12412 12412 PATIENT SERVICE REVENU 621400 11299132 11299132 11299132 508 508 33570 33570 33570 33570 18800 4745 14055 14055 14055 MEALS 722210 15692 15692 MISCELLANEOUS 900099 6496 6496 MEDICAL RECORD TRANSCR 900099 4437 4437 26625 11386302 11299132 0 74758 850 850 93960 93960 3883434 3171087 712347 377639 302111 75528 288864 231092 57772 14634 14634 32182 32182 2471953 2229476 242477 36120 36120 2227485 2115607 111878 621502 621502 15946 11740 4206 11311 11311 217764 217764 156791 154089 2702 BAD DEBT EXPENSE 2280915 2280915 MISCELLANEOUS EXPENSE 53514 14131 39383 12784864 11397795 1387069 0 116683 8960 1435475 1655160 145879 123546 6135 6269 2139757 1455174 873629 684583 67848 0 481088 761591 3126737 3240109 1783515 2971085 289949 196553 201928 200000 2275392 3367638 X 850333 -135637 1012 8108 851345 -127529 3126737 3240109 X -1398562 419688 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 1500 1500 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). A PORTION OF THE MEMBERSHIP DUES PAID ARE ALLOCATED TO LOBBYING EFFORTS BY THOSE ORGANIZATIONS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR THE YEAR, THE PORTION OF MEMBERSHIP DUES ALLOCATED TO LOBBYING WAS APPROXIMATELY $1,500. 2139757 1455174 684583 684583 OTHER RECEIVABLES 567922 ESTIMATED THIRD PARTY RECEIVABLES 193669 761591 NOTE DUE TO NC BAPTIST HOSPITAL 200000 200000 11386302 12784864 -1398562 419688 419688 -978874 11805990 419688 419688 11386302 0 11386302 12784864 0 12784864 0 12784864 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A TAX-EXEMPT ORGANIZATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS GENERALLY EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES IS MADE IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. FISCAL YEARS ENDING ON OR AFTER JUNE 30, 2008 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 190.000000000000 0 0 1 0 1 1 99205 0 99205 0.00940 1622269 1559059 63210 0.00600 1721474 1559059 162415 0.01540 2774 2774 0.00030 850 850 0.00010 3624 3624 0.00040 1725098 1559059 166039 0.01580 1 1334793 989942 5359797 5359797 X 1 1 1 1 DAVIE COUNTY EMERGENCY HEALTH CORP

223 HOSPITAL STREET MOCKSVILLE NC 27028

X X X X NA FOR 2010 1 PART I, LINE 3C: DAVIE COUNTY HOSPITAL USES 190% OF THE FPG TO DETERMINE ELIGIBILITY FOR FREE CARE. IF INCOME FALLS BELOW 190%, THE PATIENT'S BALANCE IS WRITTEN OFF TO CHARITY CARE. THERE ARE NO SLIDING SCALES TO DETERMINE ELIGIBLITY. DAVIE HOSPITAL OFFERS A 10% DISCOUNT TO PRIVATE PAY ACCOUNTS PAID WITH IN 30 DAYS OF DISCHARGE. PART I, LINE 6A: NORTH CAROLINA BAPTIST HOSPITAL PART I, LINE 7: THE ORGANIZATION USED A METHODOLOGY FROM THE NORTH CAROLINA HOSPITAL ASSOCIATION COMMUNITY BENEFITS GUIDELINE TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE FINANCIAL ASSISTANCE BENEFITS AND UNREIMBURSED MEDICAID AT COST. 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 $ 2280915. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE - PATIENT ACCOUNTS RECEIVABLE REPRESENT THE ESTIMATED NET REALIZABLE AMOUNT FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED. A SUBSTANTIAL PORTION OF THE PATIENTS SEEN BY THE HOSPITAL ARE COVERED BY MEDICARE/MEDICAID OR COMMERCIAL INSURANCE, AND THE HOSPITAL'S RECEIVABLES ARE ESTIMATED TO BE PAID BY THESE THIRD-PARTY PAYORS. ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS ARE COMPUTED BASED ON HISTORICAL COLLECTION EXPERIENCE AND A REVIEW OF THE CURRENT STATUS OF EXISTING RECEIVABLES. THE HOSPITAL GRANTS CREDIT TO PATIENTS WITHOUT COLLATERAL OR OTHER PROOF OF ABILITY TO PAY, SUBSTANTIALLY ALL OF WHOM ARE FROM DAVIE AND SURROUNDING COUNTIES.THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBTS. ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER FOUR STATEMENTS AND TWO COLLECTION LETTERS HAVE BEEN SENT. THE ACCOUNT IS NOT WRITTEN OFF BEFORE 120 DAYS AFTER THE INSURANCE PAYS. IF PAYMENT IS MADE WITHIN THE LAST 60 DAYS THE ACCOUNT IS NOT WRITTEN OFF TO BAD DEBT.THE ORGANIZATION USED WORKSHEET 2 OF THE 2010 SCHEDULE H INSTRUCTIONS TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE BAD DEBT AT COST. PART III, LINE 8: DAVIE COUNTY HOSPITAL IS A CRITIAL ACCESS HOSPITAL AND IS REIMBURSED 100 TO 101% OF COSTS. PART III, LINE 9B: EACH PATIENT IS SENT FOUR STATEMENTS FOR COLLECTION-- ONE EVERY 28 DAYS. PHONE CALLS ARE MADE AFTER THREE STATEMENTS HAVE BEEN SENT OUT. AFTER THE FOURTH STATEMENT, TWO "COLLECTION" LETTERS ARE SENT. IF THERE IS NO RESPONSE, THE ACCOUNT IS SENT TO AN OUTSIDE COLLECTION AGENCY. THE HOSPITAL DOES NOT PLACE GARNISHMENTS, LIENS, OR PERSONAL ATTACHMENTS ON PATIENTS. A 10% DISCOUNT IS OFFERED TO PRIVATE PAY PATIENTS WHO PAY THEIR BILL IN FULL WITHIN 30 DAYS. PRIVATE PAY PATIENTS ARE OFFERED A CHARITY CARE APPLICATION AND TOLD ABOUT PAYMENT PLANS AT REGISTRATION. THE CHARITY CARE APPLICATION IS AVAILABLE ONLINE AND OFFERED TO PRIVATE PAY PATIENTS AT REGISTRATION. PERSONAL FACE TO FACE MEETINGS ARE AVAILABLE MONDAY THROUGH FRIDAY 8 AM TO 5 PM. PAYMENT PLANS ARE OFFERED TO ALL PATIENTS WHEN INITIAL PHONE CONTACT IS MADE. PART VI, LINE 2: REPRESENTATIVES FROM THE ORGANIZATION ATTEND HEALTH FAIRS AND SENIOR HEALTH FAIRS AROUND THE COUNTY. NO COMMUNITY NEEDS ASSESSMENT HAS BEEN DONE AS OF THE END OF THE 2010 TAX YEAR; HOWEVER, AN ASSESSMENT WILL BE CONDUCTED IN THE NEAR FUTURE SO AS TO BE IN COMPLIANCE WITH THE FEDERAL REQUIREMENTS. PART VI, LINE 3: INFORMATION ABOUT THE FINANCIAL ASSISTANCE APPLICATION PROCESS IS AVAILABLE ON THE HOSPITAL'S WEBSITE AND IS MENTIONED AT THE PATIENT REGISTRATION STAGE. REGISTRATION AND BUSINESS OFFICE STAFF ARE TRAINED TO EDUCATE PATIENTS ON ASSISTANCE POLICIES. COPIES OF THE APPLICATION ARE WIDELY AVAILABLE THROUGH THE INTERNET, REGISTRATION DESK, AND BUSINESS OFFICE DESK. BUSINESS OFFICE STAFF WILL DIRECT PATIENTS TO SOCIAL SERVICES IF THEY QUALIFY FOR ASSITANCE. PART VI, LINE 4: DAVIE COUNTY HOSPITAL IS A CRITICAL ACCESS HOSPITAL SERVING DAVIE COUNTY, NORTH CAROLINA AND THE SURROUNDING AREAS. THE HOSPITAL IS THE ONLY ONE LOCATED IN THE COUNTY. THE POPULATION OF DAVIE COUNTY IS APPROXIMATELY 42,000 ACCORDING TO THE U.S. CENSUS BUREAU. 11.7 % OF THE POPULATION IS AT OR BELOW THE POVERTY LEVEL. 87.5% OF THE POPULATION IS WHITE, 6.3% IS AFRICAN AMERICAN, AND 6.2% IS OTHER DEMOGRAPHICS. THE UNEMPLOYMENT RATE IN MARCH 2011 WAS 9.7%. THE MEDIAN INCOME IS $59,503. THE GROWTH RATE OF THE COMMUNITY IS 1.9%. PART VI, LINE 6: HOSPITAL REPRESENTATIVES ATTEND NUMEROUS HEALTH FAIRS AND PERFORMS CHOLESTROL SCREENING CHECKS. THE HOSPITAL ALSO INVITES THE COMNUNITY TO ATTEND ITS LADIES' NIGHT OUT EVENT TO PROMOTE BREAST HEALTH AND BREAST CANCER AWARENESS. THE HOSPITAL IS INVOLVED WITH THE LOCAL SENIOR CENTER AND PROVIDES HEALTH EDUCATION ON VARIOUS TOPICS THROUGH OUT THE YEAR. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY TO ALL OF ITS DEPARTMENTS. PART VI, LINE 7: THE MEMBER OF THE ORGANIZATION IS NORTH CAROLINA BAPTIST HOSPITAL. REPORTS FILED WITH STATES PART VI, LINE 7 NC X X X 0 1 0 0 0 0 0 0 0 DONNY C LAMBETH 0 537997 0 186261 0 24834 0 388496 0 19819 0 1157407 0 0 RONALD SMALL 0 224601 0 88558 0 239354 0 47428 0 10360 0 610301 0 0 STEVEN C SNELGROVE 0 249147 0 69521 0 38509 0 83334 0 15089 0 455600 0 0 LYNN PITMAN 0 148845 0 19516 0 3515 0 19058 0 17511 0 208445 0 0 PART I, LINE 4B THE INDIVIDUALS LISTED BELOW PARTICIPATE IN OR RECEIVE PAYMENTS FROM SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLANS PROVIDED BY A RELATED ORGANIZATION. THE NON-QUALIFIED RETIREMENT PLAN'S STRUCTURE IS DETERMINED BY A MATRIX INCLUDING NATIONAL RANKINGS IN THE EXECUTIVE'S SPECIALTY, PEER COMPARISONS, AND FINANCIAL OPERATING PERFORMANCE. THE DETERMINATION OF THE AMOUNT OF THE NON-QUALIFIED RETIREMENT PLANS FOLLOWED THE RELATED ORGANIZATION'S COMPENSATION PROCEDURES AS OUTLINED IN PART VI, SECTION B, LINE 15 OF ITS FORM 990. - DONNY C. LAMBETH - STEPHEN C. SNELGROVE - RONALD SMALL PAMELA SMALL FAMILY MEMBER OF BOARD MEMBER RONALD SMALL 15749 COMPENSATION AS EMPLOYEE 0 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS NORTH CAROLINA BAPTIST HOSPITAL, A NORTH CAROLINA NONPROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE THE RIGHT AT ALL TIMES, WITH RESPECT TO THE ORGANIZATION, TO ELECT AND REMOVE THE TRUSTEES, AS PROVIDED IN THE ORGANIZATION'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE THE RIGHT AT ALL TIMES, WITH RESPECT TO THE ORGANIZATION, TO APPROVE OF THE SALE, LEASE, OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION, AS PROVIDED IN THE ORGANIZATION'S BYLAWS. THE SOLE MEMBER MAY ACT WITHOUT A MEETING. FORM 990, PART VI, SECTION B, LINE 11 THE FILING ORGANIZATION'S BOARD OF DIRECTORS RECEIVES COPIES OF THE FORM 990 WITH SUFFICIENT TIME TO PERMIT REVIEW, COMMENT, AND QUESTIONS PRIOR TO ITS FILING. THE AUDIT AND COMPLIANCE COMMITTEES OF THE GOVERNING BOARDS OF WFUHS AND NCBH REVIEW IN ADDITIONAL DETAIL THE FILING ORGANIZATION'S FORM 990 WITH THE ORGANIZATION'S CHIEF FINANCIAL OFFICER OR HIS DESIGNEE, WHO ANSWERS QUESTIONS AND ADDRESSES CONCERNS RAISED BY SUCH COMMITTEE MEMBERS OR OTHER FILING ORGANIZATION DIRECTORS. IF MODIFICATIONS ARE REQUIRED FOLLOWING SUCH REVIEW AND COMMENT, THE REVISED FORM 990 IS REDISTRIBUTED TO ALL DIRECTORS PRIOR TO ITS FILING WITH THE IRS, ALONG WITH A REPORT NOTING THE MODIFICATIONS. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS, TRUSTEES, OFFICERS, AND KEY EMPLOYEES ARE SURVEYED ANNUALLY FOR POTENTIAL CONFLICTS OF INTEREST. IN DECEMBER THE POLICY IS DISTRIBUTED TO ALL DIRECTORS, TRUSTEES, OFFICERS, AND KEY EMPLOYEES ALONG WITH A QUESTIONNAIRE. AT THE DECEMBER BOARD MEETING, ALL ARE REQUIRED TO SUBMIT THE COMPLETED QUESTIONNAIRES. FORM 990, PART VI, SECTION B, LINE 15 NORTH CAROLINA BAPTIST HOSPITAL, THE ORGANIZATION'S SOLE MEMBER, CONDUCTED SALARY SURVEYS OF OTHER AREA HOSPITALS, AND CONTRACTS WERE REVIEWED BY THE HUMAN RESOURCES DEPARTMENT OF THAT ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 1023 AND RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. ADDITIONALLY, RECENT FILINGS OF THE FORM 990 CAN BE ACCESSED THROUGH GUIDESTAR.ORG, A NON-PROFIT WEBSITE. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. AVERAGE HOURS FOR RELATED ORGANIZATIONS: FORM 990, PART VII, LINE 1, COLUMN (B): THE FOLLOWING PERSONS WERE COMPENSATED DIRECTLY BY NORTH CAROLINA BAPTIST HOSPITAL, A RELATED ORGANIZATION, OR WAKE FOREST UNIVERSITY HEALTH SCIENCES, AN UNRELATED ORGANIZATION, FOR SERVICES PERFORMED FOR THE FILING ORGANIZATION. EACH PERSON'S POSITION IN EACH ORGANIZATION, AND THE AVERAGE HOURS PER WEEK THAT THEY DEVOTE TO EACH ENTITY, ARE SHOWN BELOW. - DONNY LAMBETH - CHAIRMAN, FILING ORGANIZATION 1 HOUR PER WEEK SECRETARY, NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION (7/1 - 12/31) 0.1 HOURS PER WEEK TRUSTEE, CARENET 0.1 HOURS PER WEEK PRESIDENT, NCBH 36 HOURS PER WEEK PRESIDENT, WFUBMC COMMUNITY PHYSICIANS 1 HOUR PER WEEK DIRECTOR, DAVIDSON HEALTHCARE, INC. 1 HOUR PER WEEK DIRECTOR, LEXINGTON MEMORIAL HOSPITAL, INC. 1 HOUR PER WEEK DIRECTOR, LEXMEDICAL, INC. 1 HOUR PER WEEK CHAIRMAN, HAWTHORNE INN & CONFERENCE CENTER 0.1 HOURS PER WEEK SECRETARY, THE NURSING CENTER AT OAK SUMMIT (7/1 - 12/31) 0.1 HOURS PER WEEK MEMBER, NORTHWEST COMMUNITY CARE NETWORK, INC. 0.1 HOURS PER WEEK TRUSTEE, SECRETARY, TREASURER, THE MEDICAL FND. OF WFUHS AND NCBH 0.1 HOURS PER WEEK - RUSSELL M. HOWERTON, MD - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK CMO, WFUBMC 5 HOURS PER WEEK CMO, WFU BAPTIST HEALTH SYSTEM, WFUHS 15 HOURS PER WEEK CMO, WFU BAPTIST HEALTH SYSTEM, NORTH CAROLINA BAPTIST HOSPITAL 20 HOURS PER WEEK - DOUGLAS NELSON - TREASURER, FILING ORGANIZATION 1 HOUR PER WEEK FORMER TREASURER / SECRETARY, WFUBMC 5 HOURS PER WEEK - STEVEN C. SNELGOVE - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK VP OPERATIONS, FILING ORGANIZATION 39 HOURS PER WEEK TRUSTEE, HAWTHORNE INN & CONFERENCE CENTER 0.1 HOURS PER WEEK - RONALD H. SMALL - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK VP QUALITY & SERVICES EXCELLENCE, FILING ORGANIZATION 39 HOURS PER WEEK - DANNY SQUIRES - CFO, FILING ORGANIZATION 2 HOURS PER WEEK VP / CFO, DAVIDSON HEALTHCARE, INC. 1 HOUR PER WEEK VP / CFO, LEXINGTON MEMORIAL HOSPITAL, INC. 26 HOURS PER WEEK VP / CFO, LEXINGTON MEMORIAL HOSPITAL FOUNDATION, INC. 2 HOURS PER WEEK VP / CFO, LEXMEDICAL, INC. 7 HOURS PER WEEK VP / CFO, LEXPROPERTIES, INC. 1 HOUR PER WEEK VP / CFO, LEXHEALTH, INC. 1 HOUR PER WEEK - TERRY BOWMAN - CFO, FILING ORGANIZATION 2 HOURS PER WEEK - STEPHEN L. ROBERTSON - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK TRUSTEE, WFUBMC 2 HOURS PER WEEK TRUSTEE, NCBH 2 HOURS PER WEEK - DAN BARRETT - VICE CHAIR, FILING ORGANIZATION 1 HOUR PER WEEK - TERRY BRALLEY - SECRETARY, FILING ORGANIZATION 1 HOUR PER WEEK - KEN WHITE - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - WILLIAM F. JUNKER - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - BETH DIRKS - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - HEATHER L. HAYES - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - RALPH HOLTHOUSER - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - LYNN PITMAN - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - CHARLES TEGELER, M.D. - MEMBER, FILING ORGANIZATION 1 HOUR PER WEEK - BRUCE BOLLING, M.D. - PRESIDENT/MEDICAL STAFF, FILING ORGANIZATION 1 HOUR PER WEEK - KEVIN WALSH - ADMINISTRATOR, FILING ORGANIZATION 40 HOURS PER WEEK - SHARON T. DOSS - ADMINISTRATOR (RETIRED), FILING ORGANIZATION 40 HOURS PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: DONATED SERVICES AND USE OF FACILITIES: 419,688. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. DISCLOSURE ON MANAGEMENT ARRANGEMENT: FORM 990, PART VI, LINE 3: EFFECTIVE JULY 1, 2010, THE GOVERNING BOARDS OF FOUR NORTH CAROLINA NONPROFIT CORPORATIONS (WAKE FOREST UNIVERSITY, NORTH CAROLINA BAPTIST HOSPITAL, WAKE FOREST UNIVERSITY HEALTH SCIENCES, AND WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER) ENTERED INTO AN AGREEMENT (THE "MEDICAL CENTER INTEGRATION AGREEMENT" OR "MCIA") UNDER WHICH THE POWER TO OPERATE EACH OF NORTH CAROLINA BAPTIST HOSPITAL ("NCBH") AND WAKE FOREST UNIVERSITY HEALTH SCIENCES ("WFUHS"), INCLUDING THEIR RESPECTIVE "SUBSIDIARIES, AFFILIATES, AND JOINT VENTURES", WAS DELEGATED TO WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER ("WFUBMC"). WFUHS IS A WHOLLY-CONTROLLED SUBSIDIARY OF WAKE FOREST UNIVERSITY ("WFU"). WFUBMC IS NOW A MEMBERSHIP NONPROFIT CORPORATION WHOSE TWO EQUAL MEMBERS ARE NCBH (WHICH ENTITY IS UNRELATED TO WFU) AND WFU. THIS CONSOLIDATION OF MANAGEMENT IN WFUBMC OF THE VARIOUS ACADEMIC MEDICAL CENTER OPERATIONS, SUBJECT TO SUBSTANTIAL RESERVED POWERS IN EACH OF THE WFU AND NCBH CONSTITUENT MEMBERS' (OR IN WFUHS') BOARDS, MANDATED CHANGES IN THE GOVERNANCE DOCUMENTS OF EACH ORGANIZATION (WFUHS, NCBH, AND WFU), WHICH CHANGES WERE MADE DURING THE TAX YEAR. THE FILING ORGANIZATION [DAVIE COUNTY EMERGENCY HEALTH CORPORATION] IS A WHOLLY-OWNED SUBSIDIARY OF NCBH. WHILE NO CONFORMING CHANGES TO THE FILING ORGANIZATION'S GOVERNANCE DOCUMENTS WERE MADE DURING THE TAX YEAR, THE FILING ORGANIZATION'S MANAGEMENT HAS BEEN DIRECTLY IMPACTED BY THE MCIA, AS REFLECTED IN THE CHANGES MADE TO THE GOVERNANCE DOCUMENTS OF WFUBMC, WFUHS, AND NCBH. NORTH CAROLINA BAPTIST HOSPITAL MEDICAL CENTER BLVD WINSTON SALEM NC 27157 560552787 HEALTHCARE NC 501(C)(3) LINE 3 N/A 0 NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION MEDICAL CENTER BLVD WINSTON SALEM NC 27157 561685120 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11A, I NORTH CAROLINA BAPTIST HOSPITAL 0 THE REHABILITATION & SKILLED NURSING FACILITY AT OAK SUMMIT MEDICAL CENTER BLVD WINSTON SALEM NC 27157 561826396 HEALTHCARE (INACTIVE) NC 501(C)(3) LINE 9 NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION 0 THE HAWTHORNE INN & CONFERENCE CENTER INC 420 HIGH STREET WINSTON SALEM NC 27101 561793617 LODGING/ CONFERENCE ACCOMMODATION NC 501(C)(3) LINE 11A, I NORTH CAROLINA BAPTIST HOSPITAL 0 CARENET INC 2000 WEST FIRST STREET SUITE 410 WINSTON SALEM NC 27104 561977341 HEALTHCARE NC 501(C)(3) LINE 11B, II NORTH CAROLINA BAPTIST HOSPITAL 0 WAKE FOREST UNIV BAPTIST MEDICAL CNTR COMMUNITY PHYSICIANS 3540 CLEMMONS ROAD CLEMMONS NC 27012 561903275 HEALTHCARE NC 501(C)(3) LINE 3 WAKE FOREST UNIVERSITY HEALTH SCIENCES 0 CENTER FOR CONGREGATIONAL HEALTH INC MEDICAL CENTER BLVD WINSTON SALEM NC 27157 237426944 HEALTHCARE NC 501(C)(3) LINE 9 NORTH CAROLINA BAPTIST HOSPITAL 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 PART II: THE MEMBERSHIP OF WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER COMMUNITY PHYSICIANS CHANGED OWNERSHIP DURING THE TAX YEAR. THE MEMBER OF THE ORGANIZATION WAS PREVIOUSLY NORTH CAROLINA BAPTIST HOSPITAL, BUT WAS CHANGED TO WAKE FOREST UNIVERSITY HEALTH SCIENCES.