2012-05-14T14:23:36-05:00 2011-06-30 JOHNSON HICKEY & MURCHISON PC 651 E 4TH ST STE 200 CHATTANOOGA TN 37403 990 2010-07-01 621220402 SISKIN HOSPITAL FOR PHYSICAL REHABILITATION INC SISK 4236341200 ONE SISKIN PLAZA CHATTANOOGA TN 37403 CAROL ARNHART 4236341200 2012-05-07 JOEL D SUSMAN 4237560052 2010 2016-02-24 21:20:13Z ROBERT MAIN ONE SISKIN PLAZA CHATTANOOGA TN 37403 31416496 0 X WWW.SISKINREHAB.ORG X 1984 TN REHABILITATION HEALTH CARE 16 15 464 20 0 0 521001 351537 26848865 29199576 2201491 884501 1076016 610284 30647373 31045898 0 0 0 0 17028717 18607210 0 0 34895 9419746 10089675 26448463 28696885 4198910 2349013 80739904 83788487 37869275 34649080 42870629 49139407 X REHABILITATION HEALTH CARE 0 0 10048814 13204051 DURING THE FYE 06/30/11 THE HOSPITAL PROVIDED QUALITY ADULT AND PEDIATRIC NURSING SERVICES FOR ALL CATEGORIES OF PATIENTS. 17,681 INPATIENT SERVICE DAYS AND 9,250 SUBACUTE SERVICE DAYS WERE PROVIDED DURING THIS PERIOD. 4814985 6326846 THE HOSPITAL PROVIDED 94,221 INPATIENT UNITS AND 80,689 OUTPATIENT UNITS OF PHYSICAL THERAPY SERVICE DURING FYE 06/30/11. 2135793 2806413 THE HOSPITAL PROVIDED 56,399 INPATIENT UNITS AND 16,571 OUTPATIENT UNITS OF OCCUPATIONAL THERAPY SERVICE DURING THE FYE 06/30/11. 5222461 7160470 ALL OTHER ACHIEVEMENTS - THE HOSPITAL PROVIDED 15,951 INPATIENT UNITS AND 4,477 OUTPATIENT UNITS OF SPEECH THERAPY AND ALL OTHER HOSPITAL SERVICES PROVIDED BY SISKIN. 5222461 7160470 22222053 1 1 0 1 0 0 0 0 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 31 0 1 464 1 0 0 0 0 0 1 1 0 0 0 0 X 16 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 TN X X CAROL ARNHART 4236341200 ONE SISKIN PLAZA CHATTANOOGA TN 37403 ROBERT P MAIN 50.00 X X 432679 0 106320 LAWRENCE M RICHEY 1.00 X X 0 0 0 JAMES W CECIL 1.00 X 0 0 0 ROSE E DECOSIMO CPA 1.00 X 0 0 0 CLAIRE S BINDER 1.00 X 0 0 0 R PHILLIP BURNS MD 1.00 X 0 0 0 ROBERT A MAXWELL MD 1.00 X 0 0 0 JO ANN YATES 1.00 X 0 0 0 JUDITH E BRITAIN 1.00 X X 0 0 0 RICHARD L BROWN JR EDD 1.00 X 0 0 0 MARSHAL D MIZE 1.00 X 0 0 0 WILLIAM C MATHENEY CPA 1.00 X 0 0 0 ROBERT O BEST 1.00 X X 0 0 0 JOHN F BOXELL MD 1.00 X X 0 0 0 HUGH P BROWN MD 1.00 X 0 0 0 FREDERICK W OBEAR PHD 1.00 X 0 0 0 LINDA K LIND 50.00 X 290470 0 18614 CAROL E ARNHART 50.00 X 134281 0 19593 TOD CAIN OTRL 40.00 X 115406 0 18402 JAMES D RYMER 40.00 X 120754 0 15512 HERMAN GRIER 40.00 X 108098 0 17954 1201688 0 196395 6 0 1 0 HUMPHREYS & ASSOCIATES CONTRACTORS PO BOX 206 SODDY DAISY TN 37384 BUILDING RENOVATION 1078514 ERLANGER MEDICAL CENTER 975 E THIRD STREET CHATTANOOGA TN 37403 MEDICAL AND DIAGNOSTICS 841431 MCKESSON PO BOX 409521 ATLANTA GA 30384 PHARMACEUTICALS 754594 SODEXHO MARRIOTT SERVICES PO BOX 536922 ATLANTA GA 30353 FOOD & FOOD SERVICE 611834 SISKIN SPINE AND REHAB 1 SISKIN PLAZA CHATTANOOGA TN 37403 MEDICAL DIR SVS 278333 10 126806 224731 351537 NET PATIENT REVENUE 621990 29199576 29199576 29199576 1132034 1132034 213712 213712 213712 213712 247533 -247533 -247533 -247533 187612 126806 123065 64547 64547 CAFETERIA 621990 202370 202370 MISCELLANEOUS REVENUE 621990 37932 37932 OTHER SERVICES 621990 32739 32739 58984 58984 332025 31045898 29497780 0 1196581 1001957 1001957 14566253 11735317 2830936 609564 459489 150075 1322412 996834 325578 1107024 834475 272549 38404 29037 9367 59225 44780 14445 1431403 1082284 349119 813 615 198 534293 487759 31959 14575 1641390 1241055 400335 96305 72816 23489 82407 62308 20099 1264544 885181 379363 1627193 1139035 488158 214688 150282 64406 MEDICAL SUPPLIES & DRUG 1818940 1818940 BAD DEBTS 877347 877347 OTHER EXPENSES 122951 92964 9667 20320 OTHER TAXES 90315 68287 22028 EQUIPMENT RENTAL 87678 66293 21385 101779 76955 24824 28696885 22222053 6439937 34895 22039 84936 6929164 9295013 682971 435636 4138658 3505432 469499 348618 115187 119226 220634 320767 46886212 22999704 23167601 23886508 29067923 31390738 3632047 438656 12294181 13962957 80739904 83788487 3041989 2969867 10109 4664 32300158 29571184 2517019 2103365 37869275 34649080 X 42711471 48993181 159158 146226 42870629 49139407 80739904 83788487 X 2349013 3919765 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4477 4477 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: PORTION OF HOSPITAL MEMBERSHIP DUES THAT ARE USED FOR LOBBYING. 9085153 1672467 10757620 7130934 1954220 9085154 7958122 -827188 7130934 1.00000 1 0 260000 260000 29209218 7800159 21409059 15323768 13543590 1780178 2093226 1655955 437271 23886508 BOARD DESIGNATED FUNDS 13747414 BOND ISSUE & DEFERRED FINANCING COST 215543 13962957 SWAP AGREEMENT - LIABILITY 2090365 COST SETTLEMENT 13000 2103365 31045898 28696885 2349013 3932697 -12932 3919765 6268778 34965663 3932697 -12932 3919765 31045898 0 31045898 28696885 0 28696885 0 28696885 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TO PROVIDE RESOURCES FOR VARIOUS ACTIVITIES CONSISTENT WITH THE MISSION OF THE HOSPITAL. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. IN JULY 2006, THE FINANCIAL ACCOUNTING STANDARDS BOARD(FASB) ISSUED ASC 740-10 (FORMERLY KNOW AS FASB INTERPETATION NO.48,(ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES). ASC 740-10 PROVIDES GUIDANCE ON DERECOGNITION OF TAX BENEFITS, CLASSIFICATION ON THE BALANCE SHEET, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, DISCLOSURE AND TRANSITION. THE HOSPITAL ASC 740-10 AS OF JULY 1, 2009. THERE WAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS AS A RESULT OF IMPLEMENTATION OF ASC 740-10. THE HOSPITAL'S FORM 990, RETURN OF ORGANIZATION EXEMPT FROM TAX, FOR THE YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE IRS, GENERALLY FOR THREE YEARS AFTER THEY WERE FILED. GOLF TOURNAMENT 155023 72456 82567 53485 12814 1684 5465 POSSIBILITIES 159395 54350 105045 535 15015 16117 17950 314418 126806 187612 53485 13349 16699 16117 23415 123065 64547 1 1 1 X 1 X 0 1 0 1 1 242940 242940 0.00870 461699 216615 245084 0.00880 704639 216615 488024 0.01750 857998 365952 492046 0.01770 50000 50000 0.00180 65597 65597 0.00240 973595 365952 607643 0.02190 1678234 582567 1095667 0.03940 1 679154 18165125 14172684 3992441 X 0 1 1 SISKIN HOSPITAL PHYSICAL REHABILITATION

1 SISKIN PLAZA CHATTANOOGA TN 37403

X INPATIENT REHABILITATION SISKIN HOSPITAL PHYSICAL REHABILITATION 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X 0 1 X X X X X 0 X X 0 0 4 SISKIN HOSPITAL SUBACUTE UNIT

1 SISKIN PLAZA CHATTANOOGA TN 37403

SKILLED NURSING FACILITY SISKIN HOSPITAL FOR PHYSICAL REHAB

1755 GUNBARREL ROAD SUITE 206 CHATTANOOGA TN 37421

OUTPATIENT CLINIC SISKIN HOSPITAL FOR PHYSICAL REHAB

3820 KEITH STREET CLEVELAND TN 37312

OUTPATIENT CLINIC SISKIN HOSPITAL FOR PHYSICAL REHAB

813 RIDGEWAY AVENUE SIGNAL MOUNTAIN TN 37377

OUTPATIENT CLINIC 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 $ 877347. PART III, LINE 4: TO DETERMINE THE AMOUNTS REPORTED IN PART III, LINE 2, SISKIN HOSPITAL REVIEWS INDIVIDUAL PATIENT ACCOUNTS ON AN ONGOING BASIS TO DETERMINE BAD DEBTS. THIS BAD DEBT EXPENSE IS REPORTED IN THE FINANCIAL STATEMENTS AT 100% OF PATIENT CHARGES, BUT IS ADJUSTED TO COST USING COST TO CHARGE RATIO TO DETERMINE THE AMOUNT REPORTED ON PART III, LINE 2. BAD DEBT EXPENSE HAS NOT BEEN INCLUDED AS COMMUNITY BENEFIT. NOTE FROM SISKIN HOSPITAL'S AUDITED FINANCIAL STATEMENTS, IN PERTINENT PART:NOTE A - DESCRIPTION OF ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES...PATIENT RECEIVABLES - FOR PATIENT RECEIVABLES, THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED ON MANAGEMENT'S ASSESSMENT OF THE COLLECTIBILITY OF SPECIFIC PATIENT ACCOUNTS AND THE AGING OF ACCOUNTS RECEIVABLE. IF THERE IS A DETERIORATION OF A PATIENT'S CREDITWORTHINESS OR ACTUAL DEFAULTS ARE HIGHER THAN HISTORICAL EXPERIENCE, MANAGEMENT'S ESTIMATES OF RECOVERABILITY OF AMOUNTS DUE TO THE HOSPITAL COULD BE ADVERSELY AFFECTED..." PART V, SECTION A: PART V - 1 INPATIENT REHABILITATION FACILITY, 1 SKILLED NURSING FACILITY, 3 OUTPATIENT CLINICS. PART VI, LINE 2: HEALTHCARE NEEDS ARE ASSESSED BY SISKIN HOSPITAL FOR PHYSICAL REHABILITATION THROUGH A VARIETY OF MECHANISMS, INCLUDING SURVEYS OF THOSE SERVED BY OUR PROGRAMS, FOLLOW-UP TELEPHONE CALLS WITH SERVICE USERS, FEEDBACK FROM VARIOUS SUPPORT GROUPS AND THE INPUT GATHERED FROM ANNUAL ACCESSIBILITY PLANNING. THE HOSPITAL ALSO CONSIDERS COMMUNITY NEEDS THROUGH ITS STRATEGIC PLANNING PROCESS, WHERE INPUT IS SOUGHT FROM A VARIETY OF STAKEHOLDERS, INCLUDING COMMUNITY LEADERS, BOARD MEMBERS, OTHER PROVIDERS, EMPLOYEES AND PATIENTS. PART VI, LINE 3: INFORMATION TO INFORM AND EDUCATE PATIENTS REGARDING ASSISTANCE UNDER FEDERAL, STATE OR LOCAL PROGRAMS AND SISKIN HOSPITAL'S POLICIES IS AVAILABLE UPON ADMISSION AND IS POSTED IN PATIENT ROOMS. BUSINESS OFFICE REPRESENTATIVES ARE AVAILABLE BEFORE, DURING AND FOLLOWING PATIENT STAYS TO DISCUSS PAYMENT ARRANGEMENTS,FINANCIAL ASSISTANCE, AND QUESTIONS ABOUT BILLING. FOR INPATIENT AND SUBACUTE REFERRALS, THE HOSPITAL'S NURSE LIAISONS ARE THE FIRST POINT OF CONTACT FOR INFORMATION DISSEMINATION TO PROSPECTIVE PATIENTS REGARDING AVAILABILITY OF ASSISTANCE, ELIGIBILITY CRITERIA AND APPLICATION INFORMATION. PART VI, LINE 4: SISKIN HOSPITAL FOR PHYSICAL REHABILITATION HAS A PRIMARY SERVICE AREA OF 14 COUNTIES IN THE TRI-STATE AREA OF TENNESSEE, GEORGIA AND ALABAMA. THIS INCLUDES URBAN AND RURAL AREAS OF THE CUMBERLAND PLATEAU. SISKIN HOSPITAL OPERATES SATELLITE CLINICS AND PROVIDES FREE SCREENINGS FOR REHABILITATION CONDITIONS. THE POPULATIONS WE SERVE ENCOMPASS ALL ECONOMIC LEVELS. PART VI, LINE 6: SISKIN HOSPITAL IS AN INDEPENDENT, FREE STANDING REHABILITATION HOSPITAL WHICH IS GOVERNED BY A COMMUNITY BOARD. SISKIN HOSPITAL OFFERS A CONTINUUM OF REHABILITATION SERVICES FROM ACUTE INPATIENT REHABILITATION AND SUBACUTE REHABILITATION TO DAY HOSPITAL AND OUTPATIENT REHABILITATION SERVICES. SISKIN HOSPITAL PROVIDES SPEAKERS TO CIVIC GROUPS TO PROVIDE INFORMATION AND EDUCATION ON REHABILITATION NEEDS. IN ADDITION, SISKIN HOSPITAL OFFERS MANY UNFUNDED OR UNDER-FUNDED SERVICES, FOR WHICH IT IS THE SOLE COMMUNITY PROVIDER. SOME OF THESE INCLUDE COMMUNITY RE-ENTRY, VOCATIONAL EVALUATION AND SUPPORTED EMPLOYMENT, DRIVER EVALUATION AND TRAINING, AND ADAPTED SPORTS AND LEISURE SKILLS TRAINING. SISKIN HOSPITAL ALSO PARTICIPATES IN VARIOUS AREA HEALTH FAIRS AND COMMUNITY EVENTS.SISKIN HOSPITAL UNDERSTANDS THE IMPORTANCE OF CAMARADERIE AND ENCOURAGEMENT OUTSIDE THE HOSPITAL SETTING. THE HOSPITAL HOSTS AND OR/SPONSORS SUPPORT GROUPS DESIGNED TO ADDRESS THE SOCIAL, EMOTIONAL, MEDICAL AND LEGAL ISSUES FACING COMMUNITY MEMBERS AND THEIR FAMILIES EXPERIENCING MANY DIFFERENT CONDITIONS. THESE INCLUDE SUPPORT GROUPS FOR AMPUTEES, ADULTS WITH ASSISTANCE DOGS, LYMPHEDEMA, PARKINSON'S DISEASE AND STROKE SURVIVORS/CAREGIVERS. PROGRAMS ARE ALSO SUPPORTED FOR BRAIN INJURIES AND EPILEPSY IN CONJUNCTION WITH THE CHATTANOOGA AREA BRAIN INJURY ASSOCIATION AND THE EPILEPSY FOUNDATION OF SOUTHEAST TENNESSEE. X 1 0 X X X X 0 0 0 0 0 0 0 0 0 ROBERT P MAIN 338928 0 0 0 93751 0 102241 0 4079 0 538999 0 495364 0 LINDA K LIND 238700 0 46970 0 4800 0 14535 0 4079 0 309084 0 301773 0 CAROL E ARNHART 110614 0 19790 0 3877 0 7711 0 11882 0 153874 0 80029 0 FORM 990, PART VI, SECTION B, LINE 11 THE TAX RETURN WILL BE REVIEWED BY THE AUDIT COMMITTEE BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL DISCLOSURE FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PROCESS FOR TOP OFFICIAL: THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS FUNCTIONS AS THE COMPENSATION COMMITTEE RESPONSIBLE FOR THE PERFORMANCE REVIEW OF THE CHIEF EXECUTIVE OFFICER AND ANY ADJUSTMENTS IN COMPENSATION AND HIS IMMEDIATE SUBORDINATES AT THE EXECUTIVE LEVEL. THE EXECUTIVE COMMITTEE UTILIZES DATA FROM SALARIES AND COMPENSATION PROGRAMS, AND SELECTED BENEFIT PROGRAMS. THESE ARE COMPILED BY THE US DEPARTMENT OF JUSTICE/FEDERAL TRADE COMMISSION GUIDELINES ON SALARY SURVEYS. THESE DATA ARE FROM NATIONALLY RECOGNIZED FREE-STANDING REHABILITATION HOSPITALS IN THE UNITED STATES. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,932,697. DECREASE IN TEMPORARILY RESTRICTED ASSETS -12,932. TOTAL TO FORM 990, PART XI, LINE 5: 3,919,765.