2012-11-09T15:43:34-06:00 2011-12-31 990 2011-01-01 160755761 CUBA MEMORIAL HOSPITAL INC CUBA 5859682000 140 WEST MAIN ST CUBA NY 147271398 ANDREW H BOSER III 5859682000 2012-11-09 2011 2016-02-24 21:20:13Z ANDREW H BOSER III 140 WEST MAIN ST CUBA NY 147271398 10018840 0 X WWW.CUBAMEMORIALHOSPITAL.COM X 1925 NY ACUTE AND LONG TERM PATIENT CARE 9 9 280 3 0 0 684258 524988 10648815 8957568 1040 137 745088 524788 12079201 10007481 0 0 0 0 7372801 7257510 0 0 0 5067729 5239673 12440530 12497183 -361329 -2489702 12197938 10111133 7416428 7819325 4781510 2291808 TO PROVIDE A CONTINUUM OF APPROPRIATE HEALTH RELATED SERVICES TO ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 9250145 9480142 CUBA MEMORIAL HOSPITAL IS A NOT FOR PROFIT PUBLIC BENEFIT CORPORATION. ACUTE AND SKILLED NURSING HOME CARE IS PROVIDED IN ADDITION TO A 24 HOUR URGENT CARE CENTER AND TWO DENTAL CLINICS. THE HOSPITAL PROVIDED $558,980 IN CHARITY CARE AND FREE CARE ASSESSMENTS TO THE STATE OF NEW YORK. 9250145 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 22 0 1 280 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X JOHN T ORMOND 5859682000 140 W MAIN ST CUBA NY 14727 KAREN PERRIGO 1.00 X X 0 0 0 SANDY SLEGGS 1.00 X X 0 0 0 JODY SPEARS 1.00 X X 0 0 0 JOHN FOELS 1.00 X 0 0 0 NICO VAN ZWANENBERG 1.00 X 0 0 0 LARRY POELMA 1.00 X 0 0 0 JAMES MOOR 1.00 X 0 0 0 JEAN SWITALSKI 1.00 X 0 0 0 JOHN HASPER 1.00 X 0 0 0 ANDREW H BOSER III 37.50 X 121587 0 13131 JOHN T ORMOND 37.50 X 123471 0 5001 DAVID HANRAHAN 48.00 X 145718 0 5972 MARK STANCOMBE 48.00 X 142640 0 13131 KEVIN J BRICELAND 48.00 X 127481 0 5566 CHRISTOPHER L YOUNG 37.50 X 140400 0 14857 MICHAEL WILT 48.00 X 114935 0 13097 916232 0 70755 7 0 1 0 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING SERVICE 256567 ANGELICA-BATAVIA PO BOX 823283 PHILADELPHIA PA 19182 LAUNDRY 124021 2 4655 517552 2781 524988 NET PATIENT REVENUE 621110 8957568 8957568 8957568 137 137 16250 0 16250 16250 16250 22623 4655 11359 11264 11264 OTHER INCOME 621110 522574 522574 CONTRIBUTION INCOME 900099 -25300 -25300 497274 10007481 9480142 0 2351 263190 198050 65140 5814663 4375533 1439130 739740 556654 183086 439917 331038 108879 18048 18048 35006 35006 32701 32701 835142 736265 98877 61403 61403 1592572 1513475 79097 294418 221550 72868 649135 518128 131007 9128 6948 2180 14647 13357 1290 1194134 214405 979729 95605 95605 BAD DEBT EXPENSE 407734 407734 12497183 9250145 3247038 0 1042117 336546 440206 228670 1570650 1358490 60709 75102 90659 49737 18471503 10473027 8907501 7998476 86096 64112 12197938 10111133 2219333 3118421 122500 5074595 4700904 7416428 7819325 X 2044990 -264571 923587 743446 1812933 1812933 4781510 2291808 12197938 10111133 -2489702 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 226039 226039 8737568 4735190 4002378 220202 121460 98742 8589865 5616377 2973488 697829 697829 7998476 10007481 12497183 -2489702 -2489702 10007481 0 10007481 0 10007481 12497183 0 12497183 0 12497183 GOLF TOURNAMENT 27278 4655 22623 1700 2363 1625 4149 100 1422 27278 4655 22623 1700 2363 1625 4149 100 1422 11359 11264 1 1 1 X 250.000000000000 1 X 1 1 0 1 0 616629 714467 -97838 0.00000 4508496 2041423 2467073 0.20410 5125125 2755890 2369235 0.20410 8849 3816 5033 0.00040 8849 3816 5033 0.00040 5133974 2759706 2374268 0.20450 0 407734 315619 4629428 4387130 242298 X 1 1 2 1 CUBA MEMORIAL HOSPITAL

140 W MAIN ST CUBA NY 14727

X X X X 2 ANDOVER DENTAL CLINIC

2 S MAIN ST ANDOVER NY 14806

DENTAL CLINIC CUBA MEMORIAL HOSPITAL INC 1 0 1 1 250.000000000000 1 300.000000000000 1 X X X X 1 1 X X X 1 X X X 1 X X X X X X X 1 X X 0 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 $ 407734. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE: PATIENT ACCOUNTS RECEIVABLE ARE PRESENTED NET OF AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL COLLECTIONS BASED UPON A REVEIW OF OUTSTANDING RECEIVABLES, HISTORICAL DEBT COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS. PATIENT ACCOUNTS RECEIVABLE ARE DUE 30 DAYS AFTER THE DATE OF DISCHARGE. RECEIVABLES PAST DUE MORE THAN 120 DAYS ARE CONSIDERED DELINQUENT. DELINQUENT ACCOUNTS RECEIVABLES ARE GENERALLY WRITTEN OFF BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT AND OTHER THIRD PARTY PAYERS. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: DISCUSSED THE POLICY WITH SELF PAY PATIENTS. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 19D: ESTABLISHED HOSPITAL CHARGES ARE BILLED. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 21: HOSPITAL GROSS CHARGES ARE BILLED TO ALL PATIENTS OR THEIR INSURANCE COVERAGE. PAYMENT ADJUSTMENTS ARE MADE AS SEPARATE ALLOWANCE ON INDIVIDUAL ACCOUNTS. X X X X 0 0 0 0 0 0 0 0 0 DAVID HANRAHAN 145718 0 0 0 0 0 0 0 5972 0 151690 0 0 0 MARK STANCOMBE 142640 0 0 0 0 0 0 0 13131 0 155771 0 0 0 CHRISTOPHER L YOUNG 140400 0 0 0 0 0 0 0 14857 0 155257 0 0 0 ALLEGANY COUNTY INDUSTRIAL DEVELOPMENT AGENCY 470942108 2004-11-12 3000000 REFINANCING OF HOSPITAL MORTGAGE 0 1 0 3000000 2004 1 0 1 1 0 0 0 0 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEE FINANCE COMMITTEE WAS PROVIDED A COPY OF THE DRAFT 990 FOR REVIEW. A MEETING WAS THEN HELD TO REVIEW ANY QUESTIONS OR ISSUES RELATED TO THE SUBMISSION. QUESTIONS WERE DISCUSSED AND RESOLVED AND THE REVISED SUBMISSION WAS SENT TO OUR INDEPENDENT AUDITORS FOR REVIEW. THE FINALIZED VERSION OF THE 990 IS THEN PROVIDED TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL TRUSTEES AND OFFICERS COMPLETE AND SIGN AN ATTESTATION FORM IDENTIFYING ANY PERSONAL AND/OR FAMILY POTENTIAL CONFLICT SITUATIONS. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY, THE BOARD OF TRUSTEES EXECUTIVE COMMITTEE REVIEWS CEO AND CFO PERFORMANCE AND COMPENSATION. KEY EMPLOYEE COMPENSATION IS REVIEWED AND ESTABLISHED BY EXECUTIVE OFFICER CONSISTENT WITH THE BOARD APPROVED OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 MONTHLY AND ANNUAL FINANCIAL STATEMENTS ARE FILED WITH ALL FINANCIAL INSTITUTIONS WITH RELATIONSHIPS WITH THE HOSPITAL. ANNUAL COST REPORTS ARE FILED WITH MEDICARE AND MEDICAID. THE 990 IS ELECTRONICALLY FILED AND IS AVAILABLE FROM THE ORGANIZATION UPON REQUEST. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. CMHR CORPORATION 140 WEST MAIN ST CUBA NY 14727 562495396 PROPERTY MANAGEMENT NY SECTION 501(C)3 9 N/A 0 CUBA MEMORIAL RETIREMENT COMMUNITY INC 140 WEST MAIN ST CUBA NY 14727 271463624 ASSISTED LIVING NY SECTION 501(C)3 9 N/A 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0