2012-11-08T12:33:48-06:00 2011-12-31 271235638 MOUNTJOY CHILTON MEDLEY LLP 462 S FOURTH ST SUITE 2000 LOUISVILLE KY 402023445 990 2011-01-01 314379519 LICKING MEMORIAL HOSPITAL LICK 7403484528 1320 WEST MAIN STREET NEWARK OH 43055 CYNTHIA L WEBSTER 7403484528 2012-10-30 1 VICTORIA D BUSTER CPA P00024054 5027491900 2011 2016-02-24 21:20:13Z ROBERT A MONTAGNESE 1320 WEST MAIN STREET NEWARK OH 43055 172134377 0 X WWW.LMHEALTH.ORG X 1898 OH TO IMPROVE THE HEALTH OF THE COMMUNITY. 13 13 1450 158 0 0 0 0 166415478 169149310 221728 475778 1393002 1916078 168030208 171541166 0 0 0 0 69941046 70764828 0 0 0 73162332 74057718 143103378 144822546 24926830 26718620 130923203 139138337 65708580 82385476 65214623 56752861 X LICKING MEMORIAL HOSPITAL EXISTS TO IMPROVE THE HEALTH OF THE COMMUNITY. 0 0 126529634 169935018 LICKING MEMORIAL HOSPITAL (LMH) PROVIDES HEALTHCARE SERVICES WITHOUT REGARD TO A PATIENT'S RACE, CREED, GENDER, DISABILITY, ETHNICITY, AGE, RELIGION, CITIZENSHIP, NATIONAL ORIGIN OR SOURCES OF PAYMENT FOR CARE. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF LMH, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. FURTHER, WE BELIEVE OUR PURPOSE IS TO SERVE THE COMMUNITY BY PROVIDING HEALTHCARE SERVICES AND EDUCATION. THEREFORE, IN KEEPING WITH OUR COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, WE PROVIDE: - FREE CARE AND/OR SUBSIDIZED CARE - CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS BELOW COST - HEALTH ACTIVITIES AND PROGRAMS FREE-OF-CHARGE TO THE COMMUNITYTHE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, AND SPECIAL PROGRAMS FOR THE ELDERLY, HANDICAPPED AND MEDICALLY UNDER SERVED.LMH SERVED 6,867 INPATIENTS AND 976 NEWBORNS FOR A TOTAL OF 23,201 PATIENT DAYS, AND PROVIDED SERVICES TO 286,809 OUTPATIENTS IN 2011.ADDITIONALLY, LMH PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, BELOW COST IN MANY CASES. TO THE EXTENT REIMBURSEMENT IS BELOW CHARGES, LMH CONSIDERS THESE AMOUNTS TO BE CONTRACTUAL ADJUSTMENTS, WHICH WILL NEVER BE COLLECTED. THE UNREIMBURSED VALUE OF PROVIDING CARE TO THESE PATIENTS AMOUNTED TO $126,848,000 IN 2011.UNCOMPENSATED CARE IS PROVIDED THROUGH MANY REDUCED PRICE SERVICES AND FREE PROGRAMS OFFERED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES LMH BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED. THE HOSPITAL ROUTINELY PROVIDES UNCOMPENSATED CARE TO PATIENTS WHO ARE UNWILLING OR UNABLE TO PAY THEIR HOSPITAL BILLS. IN 2011, LMH WROTE OFF CHARGES OF APPROXIMATELY $16,825,000 IN BAD DEBTS AND $15,745,000 IN CHARITY CARE. 126529634 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 263 0 1 1450 1 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DAVID CLAYPOOL 7403484528 1320 WEST MAIN STREET NEWARK OH 43055 X PATRICK M JEFFRIES 1.50 X X 0 0 0 LINDA K DALGARN 1.30 X X 0 0 0 KIM FLEMING 1.30 X X 0 0 0 PATRICK D GUANCIALE 1.30 X X 0 0 0 GUS A ANDREWS 1.30 X 0 0 0 MICHAEL D CANTLIN 1.30 X 0 0 0 GENE BRANSTOOL 1.30 X 0 0 0 NANCY G NEELY 1.30 X 0 0 0 BONNIE L MANNING 1.30 X 0 0 0 CRAIG R BALDWIN 1.30 X 0 0 0 THOMAS MULLADY 1.30 X 0 0 0 RICHARD REED 1.30 X 0 0 0 F JENNIFER UTREVIS 1.30 X 0 0 0 ROBERT MONTAGNESE 30.00 X 368181 0 91100 CINDY WEBSTER 30.00 X 151146 0 8606 CRAIG CAIRNS 40.00 X 237940 0 13548 DEBORAH YOUNG 40.00 X 161005 0 9167 SALLIE ARNETT 40.00 X 157962 0 8994 JEAN GLASER 40.00 X 128515 0 7317 VERONICA LINK 14.00 X 143103 0 8148 1347852 0 146880 29 0 1 0 MEDICAL DOCTOR ASSOCIATES PO BOX 277185 ATLANTA GA 30384 PHYSICIAN SERVICES 1950401 JERRY MCCLAIN CONSTRUCTION 51 N 3RD STREET 701 NEWARK OH 43055 CONSTRUCTION 825645 TURNER CONSTRUCTION 375 HUDSON STREET NEW YORK NY 10014 CONSTRUCTION 695051 GE HEALTHCARE IITS 40 IDX DRIVE SOUTH BERLINGTON VT 05403 EQUIPMENT MAINTENANCE 638821 MEDICAL INFORMATION TECHNOLOGY MEDITECH CIRCLE WESTWOOD MA 02090 SOFTWARE MAINTENANCE 527435 25 PATIENT REVENUE 621110 169149310 169149310 169149310 475778 475778 593211 593211 0 0 CAFETERIA 722210 1130370 1130370 OTHER SERVICES 621110 508679 508679 VHA FEES & REBATES 621110 277029 277029 1916078 171541166 169935018 0 1606148 619033 619033 51319040 44786536 6532504 15068928 13021451 2047477 3757827 3272084 485743 107074 107074 334715 334715 98149 98149 9286745 7883203 1403542 364499 364499 1633011 1633011 38986 36534 2452 390071 260107 129964 826845 826845 11374536 8855591 2518945 1842059 1842059 MEDICAL SUPPLIES 28752730 27794312 958418 BAD DEBT EXPENSE 16824894 16824894 EQUIPMENT RENTAL 2081406 1803715 277691 MISCELLANEOUS 101998 50999 50999 144822546 126529634 18292912 0 3507331 10967375 5949809 1664804 17673624 18671084 2322584 2402193 2246727 1645249 181865585 103949642 84095753 77915943 8783917 20850881 6343458 5020808 130923203 139138337 12896301 14168068 20600000 28000000 32212279 40217408 65708580 82385476 X 65214623 56752861 65214623 56752861 130923203 139138337 X 26718620 -35180382 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 2370 2370 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LICKING MEMORIAL HOSPITAL PAYS $39,829 IN ANNUAL DUES TO OHIO HOSPITAL ASSOCIATION(OHA). OF THE TOTAL DUES PAID, 5.9% OR $2,350 ARE USED BY OHA TO SUPPORT LOBBYING ACTIVITIES OF THE ASSOCIATION. IN ADDITION, $20 WAS CONTRIBUTED TO SUPPORT A TAX LEVY ON THE COUNTY BALLOT FOR A SENIORS PROGRAM. 912878 912878 85010741 31465970 53544771 2729886 2024682 705204 92830480 70458990 22371490 381600 381600 77915943 DEFERRED PENSION AND RETIREE LIABILITY 34701529 ACCRUED INTEREST PAYABLE 83354 ACCRUED MALPRACTICE 4324519 THIRD PARTY SETTLEMENT 1108006 40217408 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) HAS ISSUED NEW STANDARDS, CONTAINED IN THE ACCOUNTING STANDARDS CODIFICATION (ASC), CLARIFYING THE ACCOUNTING FOR UNCERTAINITY IN TAXES RECOGNIZED IN ANNUAL FINANCIAL STATEMENTS FOR FISCAL YEARS BEGINNING AFTER DECEMBER 31, 2010. THESE STANDARDS REQUIRE RECOGNITION AND MEASUREMENT OF UNCERTAIN INCOME TAX POSITIONS USING A "MORE-LIKELY-THAN-NOT" APPROACH. THE ORGANIZATION ADOPTED THESE STANDARDS AS OF JANUARY 1, 2011 WITH NO MATERIAL IMPACT ON ITS FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 16925 9086872 3591513 5495359 0.04290 30356 20341927 12727642 7614285 0.05950 47281 29428799 16319155 13109644 0.10240 16771 1508058 141794 1366264 0.01070 811 442721 18000 424721 0.00330 35199 35199 0.00030 1085 413119 150 412969 0.00320 18667 2399097 159944 2239153 0.01750 65948 31827896 16479099 15348797 0.11990 320 3565 3565 0.00000 1500 36354 36354 0.00030 30 940 940 0.00000 320 222 4437 4437 0.00000 8465 8465 0.00010 2392 53761 53761 0.00040 1 16824894 4921281 29636576 33306752 -3670176 X 1 1 1 1 LICKING MEMORIAL HOSPITAL

1320 WEST MAIN STREET NEWARK OH 43055

X X X LICKING MEMORIAL HOSPITAL 1 1 1 100.000000000000 1 250.000000000000 1 X X X X 1 1 X X X X X 1 X 0 1 X 0 0 PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY LICKING MEMORIAL HEALTH SYSTEMS AND INCLUDES LICKING MEMORIAL HEALTH SYSTEMS, LICKING MEMORIAL HOSPITAL, LICKING MEMORIAL PROFESSIONAL CORPORATION, LICKING MEMORIAL HEALTH FOUNDATION. PART I, LINE 7: THE ORGANIZATION USED THE CBISA SOFTWARE TO DETERMINE THE COST ACCOUNTING METHODOLOGY. 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 $ 16824894. PART II: IT IS IMPORTANT TO NOTE THAT ALL ACTIVITIES ASSOCIATED WITH LICKING MEMORIAL HEALTH SYSTEMS REFLECT AND FURTHER THE MISSION OF "IMPROVING THE HEALTH OF THE COMMUNITY." WE DEFINE THE HEALTH OF THE COMMUNITY VERY BROADLY IN ORDER TO INCLUDE ACTIVITIES THAT ARE NOT NECESSARILY HEALTH RELATED BUT ACTIVITIES THAT WE BELIEVE ARE CRITICAL TO A HEALTHY COMMUNITY SUCH AS STRONG SCHOOLS, YOUTH PROGRAMS AND THE ARTS. WE PUBLISH A BI-MONTHLY MAGAZINE THAT IS MAILED TO 47,000 HOUSEHOLDS WHICH HIGHLIGHTS ALL OF OUR COMMUNITY BUILDING ACTIVITIES AND OPPORTUNITIES FOR HEALTH EDUCATION AND SCREENING. PART III, LINE 4: LINE 2 - THE ORGANIZATION USES THE CBISA SOFTWARE FOR COSTING METHODOLOGY, A SOFTWARE PROGRAM ENDORSED BY BOTH THE OHIO HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION.LINE 3 - THE ORGANIZATION EMPLOYED A PATIENT SCORING METHODOLOGY WHICH COMBINES NUMEROUS FINANCIAL INDICATORS TO ARRIVE AT A NUMERIC CREDIT SCORE. THIS SCORE INCLUDES THE PATIENTS ABILITY TO PAY BASED ON THE ESTIMATED HOUSEHOLD INCOME AS WELL AS THE PROBABILITY OF PAYMENT BEING MADE BASED ON HISTORICAL CREDIT INFORMATION.LINE 4 - ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: THE MEDICARE SHORTFALL REPRESENTS AN UNDERPAYMENT OF OUR COST FOR PROVIDING SERVICES TO TRADITIONAL MEDICARE PATIENTS, OUR LARGEST PAYER. SINCE THIS SHORTFALL RELATES TO SUCH A LARGE PORTION OF OUR COMMUNITY, WE FEEL THE COST SHORTFALL IS A RELEVANT FACTOR WHEN CONSIDERING COMMUNITY BENEFIT.WE USE THE MEDICARE COST REPORT FOR COSTING METHODOLOGY FOR CALCULATING THE MEDICARE SHORTFALL.IN ADDITION TO TRADITIONAL MEDICARE SHORTFALLS, THE HOSPITAL PROVIDES SERVICES TO MEDICARE HMO PATIENTS AT OR BELOW COST AS A FURTHER BENEFIT TO OUR COMMUNITY. BY ADOPTING THE SAME METHODOLOGY FOR TRADITIONAL MEDICARE ABOVE, THE MEDICARE HMO SHORTFALL AMOUNTED TO $2,860,351.ALONG THAT SAME LINE, THE LICKING MEMORIAL PROFESSIONAL CORPORATION, ANOTHER LMHS SUBSIDIARY, PROVIDED SERVICES TO MEDICARE (TRADITIONAL AND HMO) BENEFICIARIES AT A COST SHORTFALL OF $4,247,104 USING A CBISA SOFTWARE COSTING METHOD. THE CBISA SOFTWARE IS ENDORSED BY BOTH THE OHIO HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION AS A COSTING METHOD UTILIZED FOR DETERMINING SHORTFALLS. PART III, LINE 9B: THE PATIENT ACCOUNTING DEPARTMENT IS RESPONSIBLE FOR THE COLLECTION OF PATIENTS' ACCOUNTS. THE OBJECTIVE OF THE DEPARTMENT IS TO COLLECT ACCOUNTS DUE THE HOSPITAL WHILE MAINTAINING POSITIVE GUEST RELATIONS.-PRIOR TO OR UPON ADMISSION, PATIENT INFORMATION IS OBTAINED BY THE REGISTRATION DEPARTMENT. THIS INFORMATION IS FORWARDED TO THE PATIENT ACCOUNT REPRESENTATIVE FOR MEDASSIST, INC. UPON ADMISSION.-WHENEVER POSSIBLE, SELF-PAY INPATIENTS ARE INTERVIEWED BY THE PATIENT ACCOUNT REPRESENTATIVE PRIOR TO DISCHARGE. PATIENTS WILL BE SCREENED FOR POSSIBLE STATE OR FEDERAL PROGRAM ELIGIBILITY, SUCH AS MEDICAID ORSOCIAL SECURITY DISABILITY. IF PATIENTS DO NOT MEET THE CRITERIA FOR THESE PROGRAMS, THEY WILL BE INFORMED OF THE UNCOMPENSATED CARE PROGRAMS AVAILABLE.- ALL STATEMENTS CONTAIN INFORMATION AND GUIDELINES FOR UNCOMPENSATED CARE. LICKING MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY IN PLACE THAT DISCOUNTS CARE TO THOSE APPLYING FOR AND MEETING THE INCOME LIMITS FOR DISCOUNTED CARE AT A RATE THAT IS GREATER THAN THE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE. PART VI, LINE 2: WITH A MISSION OF "IMPROVING THE HEALTH OF THE COMMUNITY," LICKING MEMORIAL HEALTH SYSTEMS CONTINUOUSLY MONITORS AND ASSESSES THE NEEDS OF OUR COMMUNITY. WE DO THIS IN A VARIETY OF WAYS. OUR ENTIRE LEADERSHIP TEAM IS VERY ACTIVE IN THE COMMUNITY, SERVING ON LOCAL, NOT-FOR-PROFIT BOARDS AND IN SERVICE CLUBS SUCH AS ROTARY AND KIWANIS. AS THE LARGEST EMPLOYER IN LICKING COUNTY, THE COMMUNITY LOOKS TO OUR MANAGEMENT STAFF FOR SUPPORT AND INVOLVEMENT IN MOST, IF NOT ALL, MAJOR INITIATIVES. THIS COMMUNITY INVOLVEMENT PROVIDES THE OPPORTUNITY TO COLLECT INFORMATION REGARDING THE NEEDS OF THE DIFFERENT ORGANIZATIONS. SENIOR MANAGEMENT IS VERY RESPONSIVE IN PROVIDING ASSISTANCE WHERE NEEDED AS THIS INFORMATION BECOMES AVAILABLE. THE BOARDS OF DIRECTORS FOR LICKING MEMORIAL HOSPITAL AND LICKING MEMORIAL HEALTH SYSTEMS ARE VERY INTERESTED AND ACTIVELY ENGAGED IN THE COMMUNITY; THEREFORE, THEY ARE A GREAT RESOURCE IN MAKING ADMINISTRATION AWARE OF NEEDS. IN ADDITION, THE BOARD RECEIVES A MONTHLY REPORT AT EACH BOARD MEETING, HIGHLIGHTING ALL OF THE COMMUNITY ACTIVITIES SUPPORTED BY THE HOSPITAL INCLUDING DONATIONS MADE DURING THAT MONTH, HEALTH FAIRS AND HEALTH SCREENINGS, MANAGEMENT AND PHYSICIANS SPEAKING IN THE COMMUNITY, ETC. PROVIDING ALL OF THIS INFORMATION TO THE BOARD ALLOWS THEM TO BE SUPPORTIVE AS ADMINISTRATION RECOMMENDS IMPLEMENTING NEW SERVICES OR ENHANCING EXISTING OFFERINGS.ORGANIZED UNDER THE HOSPITAL CORPORATION IS A 75 MEMBER DEVELOPMENT COUNCIL WHOSE PURPOSE IS TO EDUCATE THE COMMUNITY ABOUT THE HOSPITAL AND TO COMPLETE FUNDRAISING ACTIVITIES IN SUPPORT OF THE ORGANIZATION. THE MEMBERS OF THE DEVELOPMENT COUNCIL ARE COMMUNITY LEADERS REPRESENTING ALL AREAS OF BUSINESS, INDUSTRY AND EDUCATION IN THE COMMUNITY. THESE ARE INDIVIDUALS WHO HAVE THEIR "FINGERS ON THE PULSE" OF THE COMMUNITY, AND ONE OF THEIR RESPONSIBILITIES AS AMBASSADORS IS TO MAKE THE ADMINISTRATION AWARE OF NEEDS IN THE COMMUNITY ESPECIALLY PERTAINING TO HEALTH CARE. AMONG MANY OUTREACH ACTIVITIES OF THE DEVELOPMENT COUNCIL, PROBABLY THE MOST PRODUCTIVE ARE THE COMMUNITY LEADER ROUNDTABLES THAT ARE SPONSORED BY THIS GROUP. THESE ARE LUNCHEONS SCHEDULED MONTHLY WITH THE HEALTH SYSTEMS CEO. DEVELOPMENT COUNCIL MEMBERS SERVE AS HOSTS, AND THEY INVITE 20-25 INDIVIDUALS REPRESENTING SIMILAR INTERESTS. SOME EXAMPLES OF RECENT ROUNDTABLE GROUPS ARE SCHOOL NURSES, SCHOOL ATHLETIC DIRECTORS AND COACHES, REALTORS, FIRE CHIEFS, LOCAL POLITICIANS, ETC. THESE FORUMS ARE ALWAYS VERY INFORMATIVE FOR BOTH THE ATTENDEES AND THE ADMINISTRATION AS WE SHARE INFORMATION ABOUT THE HOSPITAL AND THEN ASK FOR FEEDBACK FROM THE COMMUNITY LEADERS WHO ARE PRESENT. MANY TIMES, IDEAS FOR HOSPITAL INITIATIVES COME FROM THESE EVENTS.ANOTHER ACTIVITY OF THE DEVELOPMENT COUNCIL IS A QUARTERLY CORPORATE BREAKFAST. THESE EDUCATIONAL SESSIONS NORMALLY DRAW 100-125 ATTENDEES FOR BREAKFAST AND PROVIDE AN OPPORTUNITY TO EDUCATE THE COMMUNITY LEADERSHIP REGARDING HOSPITAL ACTIVITIES AND TO PROVIDE AN OPEN FORUM TO DISCUSS HEALTH CARE AND OTHER NEEDS WITHIN THE COMMUNITY. SPEAKERS AT THESE EVENTS HAVE RANGED FROM PHYSICIANS TALKING ABOUT HEART, VASCULAR, ENDOCRINOLOGY, CARING FOR AGING PATIENTS, AND SLEEP MEDICINE, TO OUR DIRECTOR OF PASTORAL CARE TALKING ABOUT HOW HIS DEPARTMENT OF THE HOSPITAL SERVES THE PATIENTS AND THE COMMUNITY. THE HEALTH SYSTEMS' WEBSITE PROVIDES DETAILED INFORMATION ON THE VARIOUS PROGRAMS AVAILABLE AND PROVIDES A MECHANISM FOR COMMUNITY FEEDBACK. ALL REQUESTS COMING THROUGH THE WEBSITE RECEIVE A RESPONSE.AN AFFILIATED PHYSICIAN GROUP, KNOWN AS THE LICKING MEMORIAL PROFESSIONAL CORPORATION, PROVIDES PHYSICIAN INPUT REGARDING THE NEEDS THEY IDENTIFY IN THEIR DAILY PRACTICE AND COMMUNITY INVOLVEMENT. THESE OBSERVATIONS ARE DISCUSSED WITH ADMINISTRATION FOR DEVELOPMENT OF PROGRAMS AND SERVICES TO ADDRESS SUCH NEEDS. PART VI, LINE 3: LICKING MEMORIAL HEALTH SYSTEMS PROVIDES CARE TO THE ENTIRE COMMUNITY REGARDLESS OF ABILITY TO PAY. THAT MESSAGE IS SHARED WITH THE COMMUNITY IN A VARIETY OF WAYS. THE HEALTH SYSTEMS' WEBSITE PROVIDES INFORMATION ON ASSISTANCE IN PAYING HOSPITAL BILLS. IN ADDITION, THE BILLING STATEMENT SENT TO THE PATIENT OR GUARANTOR PROVIDES INSTRUCTIONS FOR ACCESSING CHARITY CARE. ASSISTANCE INFORMATION IS ALSO PROVIDED TO INDIVIDUALS WHO CONTACT THE BILLING OFFICE TO DISCUSS DIFFICULTY IN MAKING PAYMENT. THE HEALTH SYSTEMS CONTRACTS WITH AN ELIGIBILITY COMPANY TO SCREEN AND IDENTIFY PATIENTS WHO ARE ELIGIBLE FOR ASSISTANCE AT CERTAIN POINTS OF SERVICE WITHIN THE ORGANIZATION. WE ALSO EMPLOY THE USE OF EARLY-OUT AGENCIES TO PERFORM SELF-PAY BILLING SERVICES ON OUR BEHALF. THESE AGENCIES ROUTINELY IDENTIFY PATIENTS WHO ARE ELIGIBLE FOR ASSISTANCE AND PROVIDE APPLICATIONS FOR COMPLETION. THE HEALTH SYSTEMS PROVIDES ASSISTANCE TO THOSE WHO ARE ABOVE THE FEDERAL POVERTY LEVEL BY OFFERING DISCOUNTED CARE BASED ON A SLIDING SCALE UP TO 250% OF THE FEDERAL POVERTY LEVEL. IN ADDITION, THE ORGANIZATION PROVIDES FREE OR DISCOUNTED CARE FOR THOSE WHO ARE CONSIDERED TO BE MEDICALLY INDIGENT. THE DEVELOPMENT COUNCIL (AMBASSADORS) HAVE BEEN EDUCATED ABOUT OUR COMMITMENT TO PROVIDE CARE FOR THE ENTIRE COMMUNITY AND THAT MESSAGE IS SHARED IN THE COMMUNITY THROUGH THEIR GRASS ROOTS EFFORTS. PART VI, LINE 4: LICKING MEMORIAL HOSPITAL LOCATED IN NEWARK, OHIO THIRTY THREE MILES EAST OF COLUMBUS. THE CITY OF NEWARK HAS A POPULATION OF ABOUT 50,000 PEOPLE WITH A MEDIAN INCOME OF APPROXIMATELY $41,000. THE HOSPITAL SERVES THE COMMUNITY OF NEWARK AND LICKING COUNTY. LICKING COUNTY HAS A POPULATION OF APPROXIMATELY 166,000 (PER U.S. CENSUS BUREAU), A PER CAPITA INCOME OF APPROXIMATELY $26,000 AND AN UNEMPLOYMENT RATE OF 8.0%. PART VI, LINE 5: THE SYSTEM PROVIDED A VARIETY OF COMMUNITY SERVICES, WHICH INCLUDED PARTICIPATION IN MANY COMMUNITY HEALTH FAIRS THROUGHOUT THE COUNTY TO ENCOURAGE AND ADVANCE HEALTHCARE EDUCATION IN AREA SCHOOLS, CHURCHES AND BUSINESSES; PROVIDED VARIOUS SEMINARS AT NOMINAL CHARGES RELATED TO LAMAZE, CAESARIAN SECTIONS, SIBLING PREPARATION, INFANT AND CHILD CPR, BABYSITTING EDUCATION, AND BREASTFEEDING; PROVIDED SUPPORT GROUPS FOR VICTIMS AND FAMILIES OF CANCER, DIABETES, AND PULMONARY AND HEART DISEASE; PROVIDED ASSISTANCE TO EDUCATORS THROUGH OUR WORK WITH STUDENT NURSES, OCCUPATIONAL THERAPY, AND PHYSICAL THERAPY INTERNS; PROVIDED SPEAKERS TO SCHOOLS, BUSINESSES CIVIC GROUPS AND OTHER ORGANIZATIONS ON HEALTH CARE SUBJECTS. SEE SCHEDULE O FOR A DETAILED LISTING OF VARIOUS PROGRAMS AND INDIVIDUALS SERVED BY THE HEALTH SYSTEM. PART VI, LINE 6: LICKING MEMORIAL HEALTH SYSTEMS (THE SYSTEM) IS A NONPROFIT CORPORATION ORGANIZED UNDER THE LAWS OF THE STATE OF OHIO TO PROVIDE AND PROMOTE HEALTH CARE SERVICES IN CENTRAL OHIO.THE SYSTEM IS THE PARENT ORGANIZATION AND SOLE CORPORATE MEMBER OF LICKING MEMORIAL HOSPITAL (THE HOSPITAL), LICKING MEMORIAL HEALTH FOUNDATION (THE FOUNDATION), AND LICKING MEMORIAL PROFESSIONAL CORPORATION (THE PROFESSIONAL CORPORATION).THE PROFESSIONAL CORPORATION EMPLOYS A STAFF OF PHYSICIANS AND SUPPORT PERSONNEL TO FURTHER THE SYSTEM'S CHARITABLE PURPOSE. THE PROFESSIONAL CORPORATION HAS A SOLE PHYSICIAN SHAREHOLDER, WHO, UNDER A SHARED CONTROL AGREEMENT, ASSIGNED THE VOTING RIGHTS OF THE STOCK TO THE SYSTEM. X X X X X X 0 1 0 0 0 0 0 0 0 ROBERT MONTAGNESE 348335 0 521 0 19325 0 91100 0 0 0 459281 0 0 0 CINDY WEBSTER 139170 0 521 0 11455 0 8606 0 0 0 159752 0 0 0 CRAIG CAIRNS 225119 0 521 0 12300 0 13548 0 0 0 251488 0 0 0 DEBORAH YOUNG 148933 0 521 0 11551 0 9167 0 0 0 170172 0 0 0 SALLIE ARNETT 145919 0 521 0 11522 0 8994 0 0 0 166956 0 0 0 VERONICA LINK 131205 0 521 0 11377 0 8148 0 0 0 151251 0 0 0 PART I, LINE 4B ROBERT MONTAGNESE, PRESIDENT, PARTICIPATES IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). A CONTRIBUTION WAS MADE TO THE PLAN ON HIS BEHALF FOR THE 2011 YEAR IN THE AMOUNT OF $70,136. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE RETURN IS REVIEWED FIRST BY INTERNAL MANAGEMENT. AFTER INTERNAL MANAGEMENT HAS REVIEWED THE RETURN AND ANY CHANGES ARE MADE A DRAFT IS MADE AVAILABLE FOR REVIEW AND PRESENTATION TO THE BOARD. ONCE THE COMMENTS FROM THE BOARD ARE REVIEWED THE FINAL RETURN IS PREPARED AND SIGNED BY THE VICE PRESIDENT OF FINANCIAL SERVICES. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ALL BOARD MEMBERS AND KEY EMPLOYEES TO SIGN A CONFLICT OF INTEREST STATEMENT ONCE A YEAR. THE ORGANIZATION DOES NOT PERMIT BOARD MEMBERS TO HAVE A CONFLICT OF INTEREST. IF A BOARD MEMBER HAS A CONFLICT OF INTEREST THEY ARE ASKED TO RESIGN FROM THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION HAS AN INDEPENDENT COMPENSATION COMMITTEE THAT DETERMINES THE COMPENSATION FOR THE CEO THAT IS THEN APPROVED BY THE BOARD. THE CEO DETERMINES THE COMPENSATION FOR THE OTHER OFFICERS BASED UPON INDEPENDENT SALARY SURVEYS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. TIME SPENT WITH RELATED ORGANIZATIONS FORM 990, PAGE 7, PART VII: EACH OF THE INDIVIDUALS LISTED BELOW WORKS FOR RELATED ORGANIZATIONS. THEIR AVERAGE HOURS WORKED EACH WEEK WITH THE RELATED ORGANIZATIONS ARE ALSO NOTED. CINDY WEBSTER - 10 HOURS/WEEK ROBERT MONTAGNESE - 10 HOURS/WEEK VERONICA LINK - 26 HOURS/WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -137,364. CHANGE IN MINIMUM PENSION LIABILITY -13,067,839. CHANGE IN RETIREE BENEFIT PLAN -79,579. NET ASSET TRANSFERS WITH RELATED 501(C)(3) -21,895,600. TOTAL TO FORM 990, PART XI, LINE 5: -35,180,382. FORM 990, PAGE 12, PART XII LINE 2C: THERE WAS NO CHANGE IN THE OVERSIGHT PROCESS OR SELECTION PROCESS OF THE INDEPENDENT AUDITOR. LICKING MEMORIAL HOSPITAL CONTINUES TO BE AUDITED AS PART OF THE LICKING MEMORIAL HEALTH SYSTEMS CONSOLIDATED GROUP. LICKING MEMORIAL HOSPITAL IS INCLUDED IN THE LICKING MEMORIAL HEALTH SYSTEMS CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION HAS A FINANCE COMMITTEE THAT OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. COMMUNITY BENEFIT FOR LICKING MEMORIAL HEALTH SYSTEM CONSOLIDATED GROUP FORM 990, PAGE 2 PROGRAM SERVICES MONETARY INPUTS OUTPUTS EXPENSES OFFSETS BENEFIT PERSONS 12 LEAD EKG PROJECT CARDIOLOGY (1712) 11,633 0 11,633 UNKNOWN 20TH CENTURY CLUB DONATIONS DEVELOPMENT (1955) 2,660 0 2,660 UNKNOWN AARP SPEAKER PUBLIC RELATIONS (1956) 348 0 348 25 ADVANTAGE CLUB SILVER SNEAKERS SPEAKER PUBLIC RELATIONS (1956) 66 0 66 10 ALEXANDRIA BUCKEYE SENIORS SPEAKER PUBLIC RELATIONS (1956) 132 0 132 80 AMERICA HERITAGE GIRLS TROOP IN KIND DONATIONS DEVELOPMENT (1955) 72 0 72 UNKNOWN AMERICAN CANCER SOCIETY SPONSORSHIPS DEVELOPMENT (1955) 2,861 0 2,861 UNKNOWN AMERICAN RED CROSS OF LICKING COUNTY EVENT SPONSORSHIPS DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN ARE YOU AT RISK FOR A HEART ATTACK? PROCESS IMPROVEMENT (1945) 178 0 178 5 ART FROM THE HEART DEVELOPMENT (1955) 8,465 0 8,465 222 ASK THE DOC AT SHEPHERD HILL OP CHEMICAL DEPENDENCY (1692) 10,211 0 10,211 1,303 AUTOMATED EXTERNAL DEFIBRILLATORS EMERGENCY DEPT (1678) 23,566 0 23,566 UNKNOWN BEATING HOLIDAY STRESS PROCESS IMPROVEMENT (1945) 147 0 147 11 BEHAVIORAL HEALTH CARE PARTNERS CASH DONATIONS DEVELOPMENT (1955) 250 0 250 UNKNOWN BEHAVIORAL HEALTH CARE PARTNERS IN KIND DONATIONS DEVELOPMENT (1955) 2,080 0 2,080 UNKNOWN BIG BROTHERS BIG SISTERS OF LICKING AND PERRY COUNTY DONATION DEVELOPMENT (1955) 40 0 40 UNKNOWN BIG BROTHERS/BIG SISTERS EVENT SPONSORSHIPS DEVELOPMENT (1955) 5,000 0 5,000 UNKNOWN BLESSED SACRAMENT SCHOOL SPONSORSHIPS DEVELOPMENT (1955) 100 0 100 UNKNOWN BOEING HEALTH & WELLNESS FAIR SPEAKER COMMUNITY CASE MANAGEMENT (1976) 202 0 202 400 BOY SCOUTS OF AMERICA SIMON KENTON COUNCIL DONATIONS DEVELOPMENT (1955) 950 0 950 UNKNOWN BREAST CA AWARENESS DAY FREE MAMMOGRAMS RADIOLOGY (1721) 13,272 0 13,272 57 BREAST CANCER AWARENESS & SCREENING EDUCATION (1616) 616 0 616 4 BREAST FEEDING BASICS MATERNAL CHILD (1646) 10,157 7,720 2,437 688 BREASTFEEDING PROMOTION & SUPPORT PROGRAM MATERNAL CHILD (1646) 56,800 0 56,800 355 C TEC ANNUAL RECOGNITION BRUNCH & EVENT SPONSOR DEVELOPMENT (1955) 200 0 200 UNKNOWN CADE AND KATELYN FUND COMMITTEE EVENT SPONSOR DEVELOPMENT (1955) 100 0 100 UNKNOWN CALL TO COLLEGE MEMORIAL DONATION DEVELOPMENT (1955) 3,000 0 3,000 UNKNOWN CAMP FEELIN' FINE RESPIRATORY THERAPY (1736) 5,701 0 5,701 40 CAMP O'BANNON EVENT SPONSOR DEVELOPMENT (1955) 50 0 50 UNKNOWN CAR SEAT INSTALLATION/EDUCATION MATERNAL CHILD (1646) 281 0 281 2 CAROL STRAWN CENTER SPONSORSHIP DEVELOPMENT (1955) 440 0 440 UNKNOWN CBISA SOFTWARE FISCAL SERVICES (1901) 900 0 900 UNKNOWN CENTER FOR DISABILITY SERVICES EVENT SPONSOR DEVELOPMENT (1955) 350 0 350 UNKNOWN CENTER FOR VISUALLY IMPAIRED SPONSORSHIP DEVELOPMENT (1955) 750 0 750 UNKNOWN CEREBRAL PALSY PATIENT CASH DONATION FOR COMMUNICATION DEVICE DEVELOPMENT (1955) 8,302 0 8,302 UNKNOWN CHERRY VALLEY ELEMENTARY IN KIND DONATIONS DEVELOPMENT (1955) 125 0 125 UNKNOWN CHILD SUPPORT AGENCY SPEAKERS PUBLIC RELATIONS (1956) 392 0 392 47 CHILDREN'S READING FOUNDATION OF LICKING COUNTY DONATION DEVELOPMENT (1955) 2,500 0 2,500 UNKNOWN CITY OF HEATH SOFTBALL TEAM SPONSORSHIP DEVELOPMENT (1955) 325 0 325 UNKNOWN CITY OF NEWARK PARKS AND RECREATION TENT LOAN DEVELOPMENT (1955) 313 0 313 UNKNOWN CLINICAL EDUCATION OF ECHOSONOGRAPHERS (CARDIOLOGY) CARDIOLOGY (1712) 13,858 0 13,858 4 COMMUNITY BENEFIT REPORTING HOURS FISCAL SERVICES (1901) 6,283 0 6,283 UNKNOWN COMMUNITY BOARD/COMMITTEE MEETINGS (COMMUNITY BENEFIT) EXECUTIVE ADMIN (1950) 16,280 0 16,280 200 COMMUNITY BOARD/COMMITTEE MEETINGS (COMMUNITY SUPPORT) EXECUTIVE ADMIN (1950) 33,756 0 33,756 1,000 COMMUNITY BOARD/COMMITTEE MEETINGS (PHYSICAL IMPROVEMENTS/HOUSING) EXECUTIVE ADMIN (1950) 718 0 718 320 COMMUNITY BOARD/COMMITTEE MEETINGS (WORKFORCE DEVELOPMENT) EXECUTIVE ADMIN (1950) 2,253 0 2,253 UNKNOWN COMMUNITY CASE MANAGEMENT SERVICES COMMUNITY CASE MANAGEMENT (1976) 681,979 129,364 552,615 UNKNOWN COMMUNITY HEALTH & RECOVERY BOARD CASH DONATIONS DEVELOPMENT (1955) 200 0 200 UNKNOWN COMMUNITY HEALTH ASSESSMENT COMMITTEE PROCESS IMPROVEMENT (1945) 966 0 966 UNKNOWN COTC LPN CLASS PUBLIC RELATIONS (1956) 287 0 287 57 COTC RADIOLOGY CLASS PUBLIC RELATIONS (1956) 102 0 102 20 CTEC SPEAKER PUBLIC RELATIONS (1956) 220 0 220 3 CTEC MEDICAL ASSISTANT EXTERNSHIP PROGRAM EXECUTIVE ADMIN LMHP (7445) 20,939 0 20,939 5 CTEC OUTSTANDING STUDENT AWARD SPONSORSHIP DEVELOPMENT (1955) 200 0 200 UNKNOWN DENISON MOVIE NIGHT HEALTH SCREENINGS PUBLIC RELATIONS (1956) 57 0 57 25 DENISON FRESHMAN CAREER FAIR HUMAN RESOURCES (1951) 1,300 0 1,300 300 DENISON UNIVERSITY SPEAKER PUBLIC RELATIONS (1956) 543 0 543 53 DENISON UNIVERSITY EMPLOYEE HEALTH FAIR PUBLIC RELATIONS (1956) 735 0 735 200 DENTISTRY FROM THE HEART COMMUNITY HEALTH EDUCATION PUBLIC RELATIONS (1956) 244 0 244 140 DENTISTRY FROM THE HEART IN KIND DONATIONS DEVELOPMENT (1955) 148 0 148 UNKNOWN DIABETES AWARENESS EDUCATION (1616) 537 0 537 5 DIGESTIVE DISORDERS PROCESS IMPROVEMENT (1945) 1,834 0 1,834 37 DINING WITH DIABETES PROCESS IMPROVEMENT (1945) 3,270 0 3,270 61 DONATION OF BEDS TO COLLEGES DEVELOPMENT (1955) 18,215 0 18,215 UNKNOWN DONATION OF LABORATORY SUPPLIES LAB (1702) 28 0 28 36 DONATION OF MEAT TO SALVATION ARMY DEVELOPMENT (1955) 511 0 511 UNKNOWN DONATION OF SUPPLIES TO IMPOVERISHED COUNTRIES PURCHASING (1675) 199,084 0 199,084 UNKNOWN DRUG ASSISTANT INDIGENT DRUG RECOVERY EXECUTIVE ADMIN LMHP (7445) 54,297 0 54,297 1,449 EMERGENCY SERVICES FOR INDIGENT PATIENTS FISCAL SERVICES (1901) 142,591 0 142,591 UNKNOWN ENGLEFIELD OIL SPEAKER PUBLIC RELATIONS (1956) 243 0 243 290 ETNA LIONS CRUISE IN HEALTH FAIR PUBLIC RELATIONS (1956) 289 0 289 30 EXERCISE & WEIGHT LOSS PROCESS IMPROVEMENT (1945) 473 0 473 4 FAMILY & FRIENDS INFANT AND CHILD CPR MATERNAL CHILD (1646) 1,699 610 1,089 126 FINDING HELP FOR HEALTH CARE NEEDS PROCESS IMPROVEMENT (1945) 106 0 106 7 FIRST METHODIST CHURCH SPEAKER PUBLIC RELATIONS (1956) 124 0 124 31 FIRST UNITED METHODIST CHURCH, NEWARK COMMUNITY SUPPORT DEVELOPMENT (1955) 379 0 379 UNKNOWN GIS RUNNING CLUB CASH DONATIONS DEVELOPMENT (1955) 250 0 250 UNKNOWN GLENN'S MARKET SCREENINGS COMMUNITY CASE MANAGEMENT (1976) 1,710 0 1,710 145 GOODWILL INDUSTRIES CAREER DAY PUBLIC RELATIONS (1956) 52 0 52 7 GRANVILLE HIGH SCHOOL SPEAKER PUBLIC RELATIONS (1956) 144 0 144 800 GRANVILLE HIGH SCHOOL SPONSORSHIP DEVELOPMENT (1955) 1,700 0 1,700 UNKNOWN GRANVILLE MIDDLE SCHOOL SPEAKER PUBLIC RELATIONS (1956) 577 0 577 48 GRANVILLE ROTARY CLUB SPEAKER PUBLIC RELATIONS (1956) 191 0 191 50 GREYSTONE COURT ASSOCIATES FUNDRAISER IN KIND DONATIONS DEVELOPMENT (1955) 374 0 374 UNKNOWN HALLOWEEN ON THE SQUARE VOLUNTEERS (1970) 616 0 616 500 HARTFORD FAIR HEALTH SCREENINGS & HEALTH EDUCATION PUBLIC RELATIONS (1956) 10,514 0 10,514 1,500 HARTFORD LIBRARY ASSOCIATION SPONSORSHIP DEVELOPMENT (1955) 200 0 200 UNKNOWN HARVEST FEDERAL CREDIT UNION SPEAKER PUBLIC RELATIONS (1956) 24 0 24 7 HEALTHY AGING PROCESS IMPROVEMENT (1945) 619 0 619 33 HEALTHY HOLIDAY RECIPES PROCESS IMPROVEMENT (1945) 102 0 102 14 HEALTHY MEALS ON A SHOESTRING BUDGET PROCESS IMPROVEMENT (1945) 572 0 572 17 HEARING LOSS & SPEECH THERAPY PROCESS IMPROVEMENT (1945) 619 0 619 35 HEARTBEATS OF LICKING COUNTY EVENT SPONSORSHIP DEVELOPMENT (1955) 450 0 450 UNKNOWN HEATH FIRE DEPARTMENT OPEN HOUSE PUBLIC RELATIONS (1956) 76 0 76 350 HEATH HIGH SCHOOL CASH DONATIONS DEVELOPMENT (1955) 150 0 150 UNKNOWN HEATH HIGH SCHOOL IN KIND DONATION DEVELOPMENT (1955) 124 0 124 UNKNOWN HEBRON HEALTH FAIR SCREENINGS PUBLIC RELATIONS (1956) 904 0 904 40 HERBAL AND OVER THE COUNTER MEDICATIONS PROCESS IMPROVEMENT (1945) 198 0 198 11 HERITAGE MIDDLE SCHOOL SPEAKER PUBLIC RELATIONS (1956) 273 0 273 25 HOPEWELL FEDERAL CREDIT UNION SPEAKER PUBLIC RELATIONS (1956) 87 0 87 30 HOSPICE OF CENTRAL OHIO SPONSORSHIPS DEVELOPMENT (1955) 800 0 800 UNKNOWN HOW TO ADJUST YOUR INSULIN PROCESS IMPROVEMENT (1945) 132 0 132 2 HSMP MANAGEMENT INSTITUTE DONATION DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN IMMUNIZATION OF PATIENTS AGES 65 AND OVER FOR TD EXECUTIVE ADMIN LMHP (7445) 7,019 0 7,019 261 INFECTION CONTROL LECTURE LAB (1702) 95 0 95 8 JOHN CLEM ELEMENTARY JUST SAY NO CLUB SPEAKER PUBLIC RELATIONS (1956) 304 0 304 60 KEEPING THE BEAT CPR EDUCATION PROCESS IMPROVEMENT (1945) 406 0 406 15 KINDERGARTEN CELEBRATION IN KIND DONATIONS DEVELOPMENT (1955) 500 0 500 450 LAKEWOOD GIRLS SUMMER SOFTBALL SPONSORSHIP DEVELOPMENT (1955) 350 0 350 UNKNOWN LAKEWOOD LITTLE LEAGUE SPONSORSHIP DEVELOPMENT (1955) 325 0 325 UNKNOWN LC CHAMBER OF COMMERCE BUSINESS AFTER HOURS SPEAKER PUBLIC RELATIONS (1956) 104 0 104 200 LC UNITED WAY ANNUAL MEETING SPONSORSHIP DEVELOPMENT (1955) 270 0 270 UNKNOWN LCESC JR. HIGH CAREER EXPLORATION HUMAN RESOURCES (1951) 793 0 793 13 LEADS HEAD START DONATION DEVELOPMENT (1955) 1,085 0 1,085 UNKNOWN LEADS HEADSTART SPEAKER PUBLIC RELATIONS (1956) 70 0 70 5 LEARN, GROW, AND PLAY DAYCARE AND DEVELOPMENT CENTER SPEAKER PUBLIC RELATIONS (1956) 38 0 38 14 LEGEND ELEMENTARY IN KIND DONATIONS DEVELOPMENT (1955) 50 0 50 UNKNOWN LESTER WILLIAMS PRIDE IN THE RED HELMET SCHOLARSHIP FUND DEVELOPMENT (1955) 100 0 100 UNKNOWN LICCO INC. SPONSORSHIP DEVELOPMENT (1955) 250 0 250 UNKNOWN LICKING COUNTY AGING PROGRAM SPEAKER PUBLIC RELATIONS (1956) 207 0 207 36 LICKING COUNTY AGING PROGRAM SPONSORSHIPS DEVELOPMENT (1955) 10,000 0 10,000 UNKNOWN LICKING COUNTY BABE RUTH ALL STARS SPONSORSHIPS DEVELOPMENT (1955) 300 0 300 UNKNOWN LICKING COUNTY BOARD OF MRDD SPEAKER PUBLIC RELATIONS (1956) 129 0 129 22 LICKING COUNTY BOARD OF MRDD SPONSORSHIP DEVELOPMENT (1955) 375 0 375 UNKNOWN LICKING COUNTY CHAMBER OF COMMERCE SPEAKER PUBLIC RELATIONS (1956) 147 0 147 150 LICKING COUNTY CHAMBER OF COMMERCE EVENT SPONSOR DEVELOPMENT (1955) 3,670 0 3,670 UNKNOWN LICKING COUNTY COALITION FOR HOUSING EVENT SPONSOR DEVELOPMENT (1955) 300 0 300 UNKNOWN LICKING COUNTY COALITION OF CARE DONATION DEVELOPMENT (1955) 500 0 500 UNKNOWN LICKING COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES DONATIONS DEVELOPMENT (1955) 3,000 0 3,000 UNKNOWN LICKING COUNTY FAMILY YMCA CASH DONATIONS DEVELOPMENT (1955) 7,500 0 7,500 UNKNOWN LICKING COUNTY FAMILY YMCA IN KIND DONATIONS DEVELOPMENT (1955) 24 0 24 UNKNOWN LICKING COUNTY FAMILY YMCA WESTERN BRANCH CAMPAIGN DONATION DEVELOPMENT (1955) 5,000 0 5,000 UNKNOWN LICKING COUNTY FOUNDATION SPONSORSHIP DEVELOPMENT (1955) 5,000 0 5,000 UNKNOWN LICKING COUNTY HEALTH DEPARTMENT SCREENING AND SURVIVOR SUPPORT PUBLIC RELATIONS (1956) 1,136 0 1,136 38 LICKING COUNTY HEALTH DEPARTMENT CHLAMYDIA/GC SCREENINGS LAB (1702) 4,221 0 4,221 108 LICKING COUNTY HEALTH DEPARTMENT DONATION DEVELOPMENT (1955) 400 0 400 UNKNOWN LICKING COUNTY HUMANE SOCIETY DONATIONS/SPONSORSHIPS DEVELOPMENT (1955) 50 0 50 UNKNOWN LICKING COUNTY JOB AND FAMILY SERVICES/EMPLOYEE HEALTH & WELLNESS PUBLIC RELATIONS (1956) 383 0 383 120 LICKING COUNTY JUNIOR ACHIEVEMENT CASH DONATIONS DEVELOPMENT (1955) 350 0 350 UNKNOWN LICKING COUNTY LEADERSHIP PROGRAM DEVELOPMENT (1955) 940 0 940 30 LICKING COUNTY POLICE CHIEF'S ASSOCIATION POLICE (1842) 119 0 119 UNKNOWN LICKING COUNTY PRAYER PARTNERS DONATION DEVELOPMENT (1955) 120 0 120 UNKNOWN LICKING COUNTY RETIRED TEACHERS SPEAKER PUBLIC RELATIONS (1956) 93 0 93 50 LICKING COUNTY WELLNESS FAIR INFORMATION TABLE PUBLIC RELATIONS (1956) 117 0 117 88 LICKING KNOX GOODWILL INDUSTRIES IN KIND DONATIONS DEVELOPMENT (1955) 400 0 400 UNKNOWN LICKING VALLEY CHURCH OF CHRIST SPONSORSHIPS DEVELOPMENT (1955) 100 0 100 UNKNOWN LICKING VALLEY HIGH SCHOOL CASH DONATIONS DEVELOPMENT (1955) 3,500 0 3,500 UNKNOWN LICKING VALLEY HIGH SCHOOL IN KIND DONATIONS DEVELOPMENT (1955) 80 0 80 UNKNOWN LICKING VALLEY YOUTH SPORTS ASSOCIATION DONATION DEVELOPMENT (1955) 825 0 825 UNKNOWN LIFE LOCAL SPEAKERS AT THE BRYN DU MANSION PUBLIC RELATIONS (1956) 120 0 120 4 LIFELINE OF OHIO ORGAN PROCUREMENT (LOOP) FISCAL SERVICES (1901) 8,534 0 8,534 1 LIONS CLUB OF HEBRON SPEAKER PUBLIC RELATIONS (1956) 82 0 82 16 LOOK UP CENTER CASH DONATIONS DEVELOPMENT (1955) 9,431 0 9,431 UNKNOWN MAKING TRACKS FOR CELIACS IN KIND DONATIONS DEVELOPMENT (1955) 100 0 100 UNKNOWN MENTAL HEALTH AMERICA SPEAKERS PUBLIC RELATIONS (1956) 747 0 747 70 MENTAL HEALTH AMERICA OF LICKING COUNTY SPONSORSHIPS DEVELOPMENT (1955) 1,100 0 1,100 UNKNOWN MISSION TRIP DRUGS AND SUPPLIES DEVELOPMENT (1955) 536 0 536 UNKNOWN MOMENTIVE PERFORMANCE MATERIALS SPEAKER PUBLIC RELATIONS (1956) 238 0 238 20 MONDAY TALKS PUBLIC RELATIONS (1956) 717 0 717 100 MUSIC AND ARTS FESTIVAL INFORMATION TABLE PUBLIC RELATIONS (1956) 318 0 318 1,250 NATIONAL MULTIPLE SCLEROSIS SOCIETY DONATION DEVELOPMENT (1955) 500 0 500 UNKNOWN NEW BEGININGS CASH DONATIONS DEVELOPMENT (1955) 250 0 250 UNKNOWN NEWARK AREA ZONTA CLUB SPONSORSHIP DEVELOPMENT (1955) 500 0 500 UNKNOWN NEWARK CAMPUS DEVELOPMENT FUND CONTRIBUTION DEVELOPMENT (1955) 25,000 0 25,000 UNKNOWN NEWARK CATHOLIC COMMUNITY SUPPORT DEVELOPMENT (1955) 373 0 373 UNKNOWN NEWARK CATHOLIC HIGH SCHOOL ATHLETIC DEPT. SPONSORSHIPS DEVELOPMENT (1955) 700 0 700 UNKNOWN NEWARK FIREFIGHTERS IAFF LOCAL 109 5K DONATION DEVELOPMENT (1955) 50 0 50 UNKNOWN NEWARK GENERALS HOCKEY CLUB SPONSORSHIP DEVELOPMENT (1955) 500 0 500 UNKNOWN NEWARK GRANVILLE SYMPHONY ORCHESTRA SPONSORSHIP DEVELOPMENT (1955) 2,500 0 2,500 UNKNOWN NEWARK HIGH SCHOOL SPONSORSHIP DEVELOPMENT (1955) 1,050 0 1,050 UNKNOWN NEWARK MIDLAND THEATRE SPONSORSHIP DEVELOPMENT (1955) 5,344 0 5,344 UNKNOWN NEWBORN BASICS MATERNAL CHILD (1646) 892 320 572 79 NORTH NEWARK LITTLE LEAGUE VARSITY AND FARM SPONSORSHIP DEVELOPMENT (1955) 600 0 600 UNKNOWN NORTHRIDGE ATHLETIC BOOSTERS DONATION DEVELOPMENT (1955) 500 0 500 UNKNOWN NORTHRIDGE SCHOOL DISTRICT SPEAKER PUBLIC RELATIONS (1956) 61 0 61 130 OBSESSIVE COMPULSIVE DISORDER PROCESS IMPROVEMENT (1945) 259 0 259 34 ODOT HEALTH FAIR PUBLIC RELATIONS (1956) 637 0 637 60 OHIO CANCER RESEARCH ASSOCIATES DONATION DEVELOPMENT (1955) 4,500 0 4,500 UNKNOWN OHIO PHYSICIANS HEALTH PROGRAM CASH DONATIONS DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN OPERATION FEED IN KIND DONATIONS VOLUNTEERS (1970) 12,605 0 12,605 UNKNOWN OSU LAB CLASS SPEAKER LAB (1702) 120 0 120 30 OSU SPEAKER PUBLIC RELATIONS (1956) 194 0 194 45 OUR SAVIOR LUTHERAN DONATION DEVELOPMENT (1955) 232 0 232 UNKNOWN OUR SAVIOR LUTHERAN CHURCH INFORMATION TABLE PUBLIC RELATIONS (1956) 228 0 228 600 PAR EXCELLENCE SPEAKERS PUBLIC RELATIONS (1956) 148 0 148 90 PAR EXCELLENCE ACADEMY SPONSORSHIP DEVELOPMENT (1955) 2,000 0 2,000 UNKNOWN PARKINSON SUPPORT GROUP SPEAKER PUBLIC RELATIONS (1956) 434 0 434 78 PATASKALA MOVIE NIGHT HEALTH SCREENINGS PUBLIC RELATIONS (1956) 228 0 228 50 PATASKALA ELEMENTARY SPEAKER PUBLIC RELATIONS (1956) 86 0 86 7 PATASKALA ELEMENTARY CAREER DAY DEVELOPMENT (1955) 39 0 39 UNKNOWN PATASKALA HISTORICAL TOWN HALL INC. SPONSORSHIP DEVELOPMENT (1955) 290 0 290 UNKNOWN PEDIATRIC DENTAL CLINIC DENTAL CLINIC (1958) 96,000 3,695 92,305 UNKNOWN PELOTONIA CASH DONATIONS DEVELOPMENT (1955) 2,500 0 2,500 UNKNOWN PINK STRIDES TRAIL RUN & WELLNESS WALK DONATION DEVELOPMENT (1955) 448 0 448 140 PRECEPTING NURSING STUDENTS 4N & 4S 4 SOUTH (1614) 37,187 0 37,187 20 PRECEPTING NURSING STUDENTS 5S 5 SOUTH (1612) 8,173 0 8,173 3 PRECEPTING NURSING STUDENTS GI LAB ENDO DIAGNOSTIC LAB (1676) 4,587 0 4,587 2 PRECEPTING NURSING STUDENTS ICU, CCU, ER INTENSIVE CARE (1640) 21,285 0 21,285 11 PRECEPTING NURSING STUDENTS MATERNAL CHILD MATERNAL CHILD (1646) 9,171 0 9,171 4 PRECEPTING NURSING STUDENTS OUTPATIENT CLINIC OUTPATIENT CLINIC (1685) 3,405 0 3,405 1 PRECEPTING NURSING STUDENTS WOUND CLINIC WOUND CLINIC (1677) 4,138 0 4,138 1 PRECEPTING STUDENTS OCCUPATIONAL THERAPY OCCUPATIONAL THERAPY (1700) 17,058 0 17,058 3 PRECEPTING STUDENTS PACU/OR SURGERY (1660) 19,187 0 19,187 6 PRECEPTING STUDENTS PHARMACY PHARMACY (1730) 49,262 18,000 31,262 6 PRECEPTING STUDENTS RADIOLOGY RADIOLOGY (1721) 98,184 0 98,184 34 PRECEPTORSHIPS FOR CERTIFIED NURSE PRACTITIONER STUDENTS FAMILY PRACTICE EAST (7425) 27,621 0 27,621 7 PRECEPTORSHIPS FOR ULTRASOUND STUDENTS VASCULAR LAB NEURO VASCULAR LAB (1674) 8,597 0 8,597 2 PREMIERE SPEAKERS DEVELOPMENT (1955) 4,961 0 4,961 UNKNOWN PROSTATE CANCER AWARENESS EDUCATION (1616) 1,011 0 1,011 15 QUICK MEALS FOR WEIGHT LOSS PROCESS IMPROVEMENT (1945) 30 0 30 11 RED CROSS BLOOD DRIVE EDUCATION (1616) 6,136 0 6,136 258 RED DRESS EVENT PUBLIC RELATIONS (1956) 25,482 0 25,482 350 RELAY FOR LIFE COMMUNITY SUPPORT DEVELOPMENT (1955) 517 0 517 UNKNOWN RENDY MURRY INDEPENDENT LIVING SPEAKER PUBLIC RELATIONS (1956) 122 0 122 17 RESOURCE CENTER/MEDICAL LIBRARY RESOURCE CENTER (1975) 1,427 0 1,427 UNKNOWN ROTARY CLUB OF GRANVILLE SPONSORSHIP DEVELOPMENT (1955) 4,500 0 4,500 UNKNOWN ROTARY CLUB OF NEWARK HEATH IN KIND DONATIONS DEVELOPMENT (1955) 296 0 296 UNKNOWN ROTARY CLUB OF PATASKALA SPONSORSHIP DEVELOPMENT (1955) 175 0 175 UNKNOWN SAINT VINCENT HAVEN CASH DONATIONS DEVELOPMENT (1955) 200 0 200 UNKNOWN SALVATION ARMY CHILDREN'S DAY CAMP DEVELOPMENT (1955) 445 0 445 45 SALVATION ARMY OF LICKING COUNTY DONATION DEVELOPMENT (1955) 200 0 200 UNKNOWN SCHOOL OF ALLIED MEDICAL PROFESSIONS ALUMNI SOCIETY SPONSORSHIPS DEVELOPMENT (1955) 150 150 0 UNKNOWN SHERIDAN HIGH SCHOOL HEALTH EXPO PUBLIC RELATIONS (1956) 329 0 329 60 SIBLING PREPARATION CLASS MATERNAL CHILD (1646) 341 85 256 35 SKIN CANCER AWARENESS AND SCREENING PROCESS IMPROVEMENT (1945) 1,202 0 1,202 9 SPORTS PHYSICALS & ECG'S TAMARACK SPORTS PHYSICALS (7487) 39,467 0 39,467 1,300 ST. FRANCIS CHURCH SPEAKER PUBLIC RELATIONS (1956) 562 0 562 51 ST. FRANCIS DE SALES SCHOOL & PARISH SPONSORSHIPS DEVELOPMENT (1955) 100 0 100 UNKNOWN ST. FRANCIS PARISH FESTIVAL COMMUNITY SUPPORT DEVELOPMENT (1955) 281 0 281 UNKNOWN STATE FARM HEALTH AND FITNESS DAY VOLUNTEERS (1970) 592 0 592 350 STUDENT INTERNSHIPS COMMUNITY CASE MANAGEMENT COMMUNITY CASE MANAGEMENT (1976) 18,350 0 18,350 6 STUDENT INTERNSHIPS LABORATORY LAB (1702) 19,617 0 19,617 2 STUDENT INTERNSHIPS MEDICAL ASSISTANT PROGRAM PAIN CLINIC PAIN MGMT (1690) 2,493 0 2,493 1 STUDENT INTERNSHIPS PHYSICAL THERAPY & SPEECH THERAPY REHAB CENTER (1737) 42,395 0 42,395 6 STUDENT NURSE & OTHER HEALTH PROFESSIONALS MANAGEMENT PROCESS EDUCATION (1616) 10,315 0 10,315 UNKNOWN STUDENT NURSE & OTHER HEALTH PROFESSIONALS ORIENTATION EDUCATION (1616) 6,899 0 6,899 687 SUMMER FOOD SAFETY PROCESS IMPROVEMENT (1945) 146 0 146 1 SUPERMARKET SWEEP FOOD PANTRY NETWORK CASH DONATIONS DEVELOPMENT (1955) 100 0 100 UNKNOWN TAMARACK FARMS DAIRY HEALTH FAIR SCREENINGS PUBLIC RELATIONS (1956) 128 0 128 41 TAXI TOKENS FISCAL SERVICES (1901) 83 0 83 UNKNOWN THE ENERGY COOPERATIVE SPEAKER PUBLIC RELATIONS (1956) 664 0 664 220 THYROID DISEASE PROCESS IMPROVEMENT (1945) 1,784 0 1,784 105 TIPS TO QUIT SMOKING PROCESS IMPROVEMENT (1945) 91 0 91 1 TOBACCO CESSATION PROGRAM TOBACCO CESSATION (1693) 221,351 0 221,351 439 TOPS HEALTHY WEIGHT LOSS GROUP EDUCATION PUBLIC RELATIONS (1956) 370 0 370 67 TUSKEGEE NATIONAL ALUMNI ASSOCIATION SPONSORSHIP DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN UNITED METHODIST CHURCH SPEAKER PUBLIC RELATIONS (1956) 493 0 493 70 UNITED WAY CAMPAIGN IN KIND DONATIONS HUMAN RESOURCES (1951) 3,000 0 3,000 UNKNOWN UNITED WAY DAY OF CARING DEVELOPMENT (1955) 2,847 0 2,847 UNKNOWN UNITED WAY DAY OF CARING IN KIND DONATIONS DEVELOPMENT (1955) 99 0 99 UNKNOWN VOLUNTEERS TWIGS & EVENTS VOLUNTEERS (1970) 0 0 0 319 WALK & TALK WITH A DOC COMMUNITY CASE MANAGEMENT (1976) 379 0 379 3 WATKINS HIGH SCHOOL DONATIONS DEVELOPMENT (1955) 600 0 600 UNKNOWN WELLNESS CENTER AT C TEC COMMUNITY BENEFIT C TEC (1977) 73,153 0 73,153 236 WEST LICKING FIRE DEPARTMENT SPEAKER & SCREENINGS PUBLIC RELATIONS (1956) 696 0 696 215 WEST MAIN STREET BILL BOARD BEHIND MCN DONATION PUBLIC RELATIONS (1956) 500 0 500 UNKNOWN WHAT'S IN A NUMBER: HOW TO MAKE SENSE OF YOUR BLOOD SUGAR NUMBERS PROCESS IMPROVEMENT (1945) 51 0 51 1 YMCA MOVIE NIGHT HEALTH SCREENINGS PUBLIC RELATIONS (1956) 122 0 122 40 YMCA SPEAKER PUBLIC RELATIONS (1956) 628 0 628 48 YMCA HEALTH AND FITNESS FEST PUBLIC RELATIONS (1956) 2,863 0 2,863 200 ZERGER HALL SPEAKER PUBLIC RELATIONS (1956) 83 0 83 12 NUMBER OF PROGRAMS 261 GRAND TOTALS 2,452,858 159,944 2,292,914 21,059 BENEFITS FOR POOR: TOTAL EXPENSE OFFSETTING REVENUE NET BENEFIT PERSONS TRADITIONAL CHARITY CARE $11,009,247 $2,238,807 $8,770,440 16,925 UNPAID COST OF MEDICAID $33,899,446 $18,293,424 $15,606,022 30,356 GRAND TOTALS $47,361,551 $20,692,175 $26,669,376 68,340 LICKING MEMORIAL HEALTH SYSTEMS 1320 WEST MAIN STREET NEWARK OH 43055 311096218 PARENT COMPANY FOR THE NONPROFIT OPERATION OF HEALTHCARE ORGANIZATIONS OH 501(C)(3) 11 TYPE III - FI N/A 0 LICKING MEMORIAL HEALTH FOUNDATION 1320 WEST MAIN STREET NEWARK OH 43055 311096217 PROVIDE FUNDING FOR HEALTHCARE PROGRAMS OH 501(C)(3) 11 TYPE I LICKING MEMORIAL HEALTH SYSTEMS 0 LICKING MEMORIAL PROFESSIONAL CORPORATION 1320 WEST MAIN STREET NEWARK OH 43055 311425530 HEALTHCARE ORGANIZATION OH 501(C)(3) 9 LICKING MEMORIAL HEALTH SYSTEMS 0 0 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1