2012-11-14T14:02:59-06:00 2011-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-01-01 344428205 THE BELLEVUE HOSPITAL BELL 4194834040 1400 WEST MAIN STREET BELLEVUE OH 44811 DEAN MILLER 4194834040 2012-11-05 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z MICHAEL K WINTHROP 1400 WEST MAIN STREET BELLEVUE OH 44811 47906189 0 X WWW.BELLEVUEHOSPITAL.COM X 1956 OH THE BELLEVUE HOSPITAL IS A COMMUNITY BASED GENERAL ACUTE CARE HOSPITAL THAT PROVIDES CARE TO THE BELLEVUE AND SURROUNDING AREA WITHOUT REGARD TO ABILITY TO PAY. 17 16 459 85 1811 811 160422 146449 44514219 47057883 110156 129189 333320 342340 45118117 47675861 35000 58000 0 0 20519344 22313735 0 0 0 23239678 21076362 43794022 43448097 1324095 4227764 54550412 59041350 29135676 30270807 25414736 28770543 X WE CARE FOR PATIENTS AS MEMBERS OF OUR FAMILY. WE WORK TO HEAL THE SICK, TREAT THE INJURED, AND PREVENT ILLNESS. WE PROTECT THE TRUST OF OUR COMMUNITY AND EMPLOYEES, TO BE A PROGRESSIVE, QUALITY HEALTH CARE ORGANIZATION. OUR PRIMARY GOAL IS AND ALWAYS WILL BE TO CARE. 0 0 37660665 58000 47088301 SEE SCHEDULE OTHE BELLEVUE HOSPITAL IS A COMMUNITY BASED GENERAL ACUTE CARE HOSPITAL THAT PROVIDES CARE TO THE BELLEVUE AND SURROUNDING COMMUNITY WITHOUT REGARD TO ABILITY TO PAY.OUR IMPACT ON THE BELLEVUE COMMUNITY: FOR THE CALENDAR YEAR ENDING DECEMBER 31, 2011, THE BELLEVUE HOSPITAL EMPLOYED A TOTAL OF 459 INDIVIDUALS AND MAINTAINED A MEDICAL STAFF MEMBERSHIP OF OVER 150 PHYSICIANS. THE HOSPITAL PAID A TOTAL OF OVER $16 MILLION IN WAGES AND SALARIES. OUR EMPLOYEES PAID A TOTAL OF $231,187 IN BELLEVUE CITY INCOME TAX AND AN ADDITIONAL $31,789 IN BELLEVUE CITY SCHOOL TAXES TO SUPPORT THE BELLEVUE COMMUNITY INFRASTRUCTURE AND EDUCATIONAL NEEDS. OUR EMPLOYEES LIVING IN OTHER LOCAL SCHOOL DISTRICTS PAID $18,513 IN CLYDE-GREEN SPRINGS LOCAL SCHOOL DISTRICT TAXES, $8,207 IN FREMONT LOCAL SCHOOL DISTRICT TAXES, AND $5,561 IN SENECA EAST SCHOOL DISTRICT TAXES. IN ADDITION, A TOTAL OF $2,714,095 OF THE HOSPITAL'S TOTAL GOODS AND SERVICES EXPENSED DURING 2011 WERE PURCHASED LOCALLY FROM AREA BUSINESSES.SERVING THE BELLEVUE COMMUNITY: A TOTAL OF 2,085 COMMUNITY MEMBERS WERE ADMITTED TO OUR FACILITY DURING 2011. IN ADDITION, A TOTAL OF 58,037 VISITS WERE MADE FOR OUTPATIENT CARE. OUR EMERGENCY ROOM TREATED AN ADDITIONAL 17,194 PATIENTS DURING 2011 AND WE ASSISTED IN THE DELIVERY OF 345 BABIES. WE PROVIDED A TOTAL OF $9,177,691 IN FREE CARE TO OVER 5,000 UNINSURED OR UNDERINSURED PATIENTS. 37660665 1 1 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 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 47 0 1 459 1 1 1 0 0 0 0 0 0 0 0 0 X 17 16 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X RACHEL HERMAN 4194834040 1400 W MAIN ST BELLEVUE OH 44811 X MICHAEL K WINTHROP 45.00 X X 439962 0 23294 MARK PIFER OD 1.00 X X 0 0 0 DEAN MILLER 1.00 X X 0 0 0 JAMES SHELLEY 1.00 X X 0 0 0 JOE WILSON 1.00 X X 0 0 0 JOHN BACON 1.00 X 0 0 0 TOM BARTH 1.00 X 0 0 0 PAUL DOUGLAS 1.00 X 0 0 0 GORDON GIBBS 1.00 X 0 0 0 NANCY GREENSLADE 1.00 X 0 0 0 DWIGHT HOGUE 1.00 X 0 0 0 PAUL HOWARD 1.00 X 0 0 0 DOUG HOY MD 1.00 X 0 0 0 PATRICK MARTIN 1.00 X 0 0 0 BENJAMIN BALL DO 1.00 X X 0 0 0 NANCY BEIER 1.00 X 0 0 0 J WILLIAM SPRINGER 1.00 X 0 0 0 TIMOTHY BUIT 45.00 X 242373 0 1234 PATRICIA SEMER 45.00 X 149951 0 28087 JANET RUNNER 45.00 X 148912 0 18213 DEBORAH GANCI 45.00 X 141622 0 7933 CHRISTOPHER HIRT 45.00 X 119645 0 7193 DEBORAH O'TOOLE 40.00 X 100769 0 10821 1343234 0 96775 7 0 1 0 NET REVENUE ASSOCIATES 3918 CLOCK POINT TR STOW OH 44224 OR CHARGE RECOVERY 1097060 BELLEVUE ANESTHESIA ASSOCIATES LLC 1355 W MAIN ST BELLEVUE OH 44811 ANESTHESIA SERVICES 408319 SOUTH SHORE RADIOLOGY PO BOX 1800 SANDUSKY OH 44870 RADIOLOGIST SERVICES 348107 3M COMPANY PO BOX 844127 DALLAS TX 752844127 CLINICAL DOCUMENTATION IMPROVEMENT 228288 GENZYME GENETICS PO BOX 223614 PITTSBURGH PA 152513614 LAB SCREENING SERVICES 206048 10 120807 25642 10327 146449 PATIENT SERVICES 621110 46821227 46821227 HEALTH DEPARTMENT 621110 98887 98887 COMMUNITY EDUCATION 621110 53631 53631 PURCHASE DISCOUNTS 621110 50292 50292 CONTRACT THERAPY 621110 33846 33846 47057883 144027 144027 222993 204740 18253 18253 18253 10750 25588 -14838 -14838 -14838 3618 0 3618 3618 CAFETERIA/CAFE 621110 258047 258047 VENDING MACHINES 621110 9704 9704 DIET CONSULTATION 621110 6665 6665 46053 30418 1811 13824 320469 47675861 47088301 1811 439300 43000 43000 15000 15000 714973 714973 15447572 13543232 1904340 702954 610220 92734 4274268 3747347 526921 1173968 1039715 134253 192537 192537 106946 106946 5334874 4677203 657671 233992 205912 28080 6423260 5780934 642326 11455 10080 1375 2897549 2468951 428598 16589 14598 1991 602285 528037 74248 2054141 1800911 253230 1032930 1024178 8752 BAD DEBT EXPENSE 1666332 1666332 FRANCHISE FEE 242008 242008 RECRUITMENT 117480 100484 16996 PROFESSIONAL DEVELOPMEN 112605 112605 31379 29918 1461 43448097 37660665 5787432 0 4664604 7218587 4004563 5451361 24776 109128 314835 315707 409001 412208 61672714 24874248 36931597 36798466 6748272 6971440 0 650530 1452764 1113923 54550412 59041350 4736499 4844987 11500 0 22788326 21869098 153161 0 1446190 3556722 29135676 30270807 X 25414736 28770543 25414736 28770543 54550412 59041350 X 4227764 -871957 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1942 1942 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: 5.9 PERCENT OF DUES TO THE OHIO HOSPITAL ASSOCIATION WAS ALLOCATED TO LOBBYING ACTIVITIES BY THAT ORGANIZATION. 2031680 2031680 37641646 7852891 29788755 15813288 11991284 3822004 6186100 5030073 1156027 36798466 THIRD PARTY SETTLEMENT 2536441 DERIVATIVE LIABILITY 865209 DUE TO MEDICAL STAFF AND AUXILIARY 155072 3556722 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2011, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO U.S. FEDERAL, STATE AND LOCAL, OR NON-U.S. INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2008. 1 1 X 1 X 1 X 1 1 1 0 1 1 1526675 1158683 367992 0.00880 6426899 4272725 2154174 0.05160 7953574 5431408 2522166 0.06040 158536 46463 112073 0.00270 37231 37231 0.00090 43158 43158 0.00100 15381 15381 0.00040 254306 46463 207843 0.00500 8207880 5477871 2730009 0.06540 1698 1698 0.00000 3000 3000 0.00010 13580 13580 0.00030 10859 10859 0.00030 29137 29137 0.00070 0 1666332 117232 8694397 12407368 -3712971 X 1 1 1 1 THE BELLEVUE HOSPITAL

1400 WEST MAIN STREET BELLEVUE OH 44811

X X X SWING BED - SNF HOME HEALTH THE BELLEVUE HOSPITAL 1 1 1 100.000000000000 1 400.000000000000 1 X 1 1 X X 1 0 1 X 0 0 PART I, LINE 3C: THE HOSPITAL USES FEDERAL POVERTY GUIDELINES. PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 2 METHOD TO CALCULATE THE COST TO CHARGE RATIO. PART I, LINE 7G: NOT APPLICABLE 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 $ 1666332. PART II: OUR HOSPITAL PARTICIPATES IN SEVERAL COMMUNITY BUILDING ACTIVITIES WHICH ARE INCLUDED IN PART II. THESE ACTIVITIES INCLUDE: PHYSICAL IMPROVEMENTS: USED LAND OWNED BY HOSPITAL TO GROW A LOCAL CROP FOR DONATION TO BELLEVUE FISH & LOAVES FOR DISTRIBUTION TO LOW INCOME COMMUNITY MEMBERS TO ENSURE NUTRITIOUS FOOD CHOICES. ECONOMIC DEVELOPMENT: ACTIVE ROLE WITH SANDUSKY COUNTY ECONOMIC DEVELOPMENT ORGANIZATION TO CREATE NEW EMPLOYMENT OPPORTUNITIES, INCLUDING HEALTHCARE COVERAGE, IN AN AREA EXPERIENCING HIGH JOBLESS RATES. COMMUNITY SUPPORT: PROVIDE SUPPORT FOR LOCAL UNITED SELECTIVE FUND CAMPAIGN AND OTHER LOCAL NON-PROFIT ORGANIZATIONS. WORKFORCE DEVELOPMENT: PARTNERSHIP WITH COMMUNITY COLLEGE/VOCATIONAL SCHOOL TO ADDRESS THE HEALTH CARE WORK FORCE SHORTAGE AS WELL AS PARTICIPATION ON ADVISORY BOARDS OF SCHOOL-BASED PROGRAMS FOR HEALTH CARE CAREERS. PART III, LINE 4: FOOTNOTE IN FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. BAD DEBT EXPENSE REPORTED IN PART III, LINE 2, IS RECORDED PER THE FINANCIAL STATEMENTS. THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE THAT MAY BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE IS MADE ON A PRESUMPTIVE BASIS BASED ON BEST INFORMATION AVAILABLE. THE IDENTIFICATION OF PATIENTS ELIGIBLE FOR CHARITY CARE IS SOLELY BASED ON THE COOPERATION OF THE PATIENT TO PROVIDE THE ORGANIZATION WITH THE APPROPRIATE FAMILY AND FINANCIAL INFORMATION TO DETERMINE THEIR ELIGIBILITY. HISTORICALLY, IN ADDITION TO THE INTERNALLY IDENTIFIED CHARITY ACCOUNTS, 7% OF ACCOUNTS SENT TO THE STATE COLLECTION HAVE BEEN SUBSEQUENTLY IDENTIFIED AS CHARITY OR MEDICALLY INDIGENT AND RETURNED. APPLYING THIS RATIO, IT IS ESTIMATED THAT $117,232 OF OUR ORGANIZATION'S BAD DEBT EXPENSE MAY BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE AND SHOULD BE COUNTED AS COMMUNITY BENEFIT. AS A NOT-FOR-PROFIT HOSPITAL, PATIENT CARE IS PROVIDED TO ALL PATIENTS, REGARDLESS OF THEIR ECONOMIC MEANS, WHICH QUALIFIES BAD DEBT AS A COMMUNITY BENEFIT. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST-TO-CHARGE RATIO. THE HOSPITAL BELIEVES THAT THE $3,712,971 SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE PAYMENTS THAT ARE LESS THAN COST MUST BE ABSORBED BY THE HOSPITAL IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITY. IN 2011, MEDICARE ACCOUNTED FOR 34.14% OF HOSPITAL REVENUES. THE HOSPITAL PROVIDES CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVES THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. PART III, LINE 9B: COLLECTION POLICIES ARE THE SAME FOR ALL PATIENTS. THE HOSPITAL WILL PURSUE PAYMENT FOR CARE FROM EVERY REASONABLE SOURCE, GOVERNMENTAL AND PRIVATE. TO ENSURE THIS IS COMPLETED, INSURANCE VERIFICATION IS PERFORMED, A SYSTEM REVIEW IS MADE OF THE PATIENT'S INSURANCE HISTORY, AND TELEPHONE CALLS ARE MADE TO THE PATIENT. IF THE PATIENT IS ELIGIBLE FOR HCAP, THE COVERED CHARGES ARE WRITTEN OFF TO HCAP. IF THE PATIENT IS LATER FOUND TO BE ELIGIBLE FOR MEDICAID, THE HCAP WRITE-OFF IS REVERSED AND THE ACCOUNT BILLED TO MEDICAID. BAD DEBT ACCOUNTS ELIGIBLE FOR CHARITY ARE REINSTATED FROM BAD DEBT AND POSTED TO THE APPROPRIATE ADJUSTMENT OR CHARITY WRITE-OFF CODES. THE BELLEVUE HOSPITAL PART V, SECTION B, LINE 19D: PATIENTS WITH INCOMES AT OR BELOW THE FPG WOULD QUALIFY FOR HCAP AT 100%. PATIENTS WITH INCOMES EXCEEDING THE FPG MAY QUALIFY FOR CHARITY. A PERSON IS ELIGIBLE FOR WRITE-OFF OF THE SELF PAY PORTION OF THE BILL; WRITE-OFF AMOUNT IS CALCULATED ACCORDING TO SLIDING SCHEDULE FROM 200%-400% OF FPG AND DISCOUNT RANGES FROM 20%-100% OF PATIENT'S BILL. THE DISCOUNT IS WRITTEN OFF TO CHARITY. PART VI, LINE 2: THE BELLEVUE HOSPITAL IS A MEMBER OF HEALTH PARTNERS, A GROUP OF HEALTH ORGANIZATION CEO'S IN SANDUSKY COUNTY. THE GROUP DETERMINES THE ONGOING NEEDS OF THE COMMUNITY BY CONDUCTING COMPREHENSIVE HEALTH ASSESSMENTS FOR ADULTS AGES 19-75 EVERY FOUR YEARS, AND EVERY TWO YEARS FOR YOUTH AGES 12-18. IN ADDITION, THE BOARD STRATEGIC PLANNING COMMITTEE IS COMPRISED OF SEVERAL COMMUNITY BUSINESS LEADERS WHO ASSESS THE NEEDS OF THE COMMUNITY AND MAKES RECOMMENDATIONS. THE HOSPITAL ALSO USES ITS PATIENT SATISFACTION SURVEY TO OBTAIN SUGGESTIONS FOR SERVICES. PART VI, LINE 3: THE HOSPITAL POSTS NOTICES IN APPROPRIATE AREAS IN THE FACILITY, INCLUDING BUT NOT LIMITED TO THE ADMISSIONS AREAS, THE PATIENT FINANCE OFFICE, AND THE EMERGENCY DEPARTMENT. THE NOTICE SPECIFIES THE RIGHTS OF PERSONS WITH INCOMES AT OR BELOW THE FEDERAL POVERTY GUIDELINES (FPG) TO RECEIVE, WITHOUT CHARGE TO THE INDIVIDUAL, BASIC, MEDICALLY NECESSARY HOSPITAL-LEVEL SERVICES AT THE HOSPITAL. THE INITIAL BILL AND AT LEAST THE FIRST FOLLOW-UP BILL HAS A WRITTEN STATEMENT THAT EXPLAINS THAT INDIVIDUALS WITH INCOME AT OR BELOW THE FPG ARE ELIGIBLE FOR SERVICE WITHOUT CHARGE, SPECIFIES THE FPG FOR INDIVIDUALS AND FAMILIES OF VARIOUS SIZES AT THE TIME THE BILL IS SENT, AND DESCRIBES THE PROCEDURE TO APPLY FOR FREE CARE. THE PATIENT FINANCE OFFICE AND PATIENT ACCESS DEPARTMENTS WILL PROVIDE APPLICATIONS FOR FINANCIAL ASSISTANCE TO PATIENTS. A DETERMINATION OF EVERY APPLICATION WILL BE COMPLETED BY THE PATIENT FINANCE OFFICE AND A COPY SENT TO THE PATIENT. PART VI, LINE 4: BELLEVUE, OHIO IS A CITY IN ERIE, HURON, SANDUSKY AND SENECA COUNTIES OF OHIO. IT IS THE ONLY MUNICIPALITY IN THE STATE OF OHIO TO SPAN FOUR COUNTIES. ACCORDING TO THE U.S. CENSUS BUREAU, THE FOUR COUNTY AREA HAS A TOTAL LAND AREA OF 1707.34 SQUARE MILES. AS OF THE 2010 CENSUS, THE FOUR COUNTY POPULATION WAS 254,394, A 2.01% DECLINE SINCE THE 2000 CENSUS, WITH A DENSITY OF 149 PEOPLE PER SQUARE MILE, PREDOMINANTLY WHITE, HIGH SCHOOL EDUCATED. THE FOUR COUNTY AREA WAS HIT EXTREMELY HARD DURING THE RECENT ECONOMIC RECESSION, BUT IS SLOWLY RECOVERING. THE U.S. DEPARTMENT OF LABOR, BUREAU OF LABOR STATISTICS, REPORTS THE UNEMPLOYMENT RATE FOR THE FOUR COUNTY AREA AS 9.0% FOR DECEMBER 2011, DOWN FROM 10.6% IN DECEMBER 2010, AND SLIGHTLY HIGHER THAN OHIO'S STATEWIDE UNEMPLOYMENT RATE OF 8.1% AND THE NATIONWIDE UNEMPLOYMENT RATE OF 8.5%. HURON COUNTY RANKED 10TH IN THE STATE OF OHIO IN 2011 WITH AN ANNUAL AVERAGE UNEMPLOYMENT RATE OF 11.7%. MEDIAN HOUSEHOLD INCOMES RANGED FROM $42,573 IN SENECA COUNTY TO $48,056 IN SANDUSKY COUNTY. ACCORDING TO THE BUREAU OF THE CENSUS, 2010 POVERTY RATES, THE LATEST AVAILABLE, RANGED FROM 10.9% FOR SANDUSKY COUNTY TO 14.5% FOR HURON COUNTY. OHIO DEPARTMENT OF JOB & FAMILY SERVICES REPORTED THAT 46,170 RESIDENTS, OR 18.15% OF RESIDENTS IN THE FOUR COUNTY AREA WERE ENROLLED IN MEDICAID DURING 2010. SANDUSKY COUNTY IS ALSO DESIGNATED AS BOTH A MEDICALLY UNDERSERVED AREA AND AS A PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREA. PART VI, LINE 5: MEDICAL STAFF PRIVILEGES ARE OPEN TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. THE HOSPITAL BOARD OF DIRECTORS IS COMPRISED OF LOCAL MEDICAL AND BUSINESS PROFESSIONALS WHO VOLUNTEER COUNTLESS HOURS OF SERVICE TO THE HOSPITAL IN THEIR OVERSIGHT ROLE OF GENERAL STEWARDSHIP. THE HOSPITAL EXPANDS ACCESS POINTS OF CARE THROUGHOUT THE COMMUNITY BY PROVIDING FREE OR LOW-COST BLOOD PRESSURE, DIABETES, CHOLESTEROL, SKIN CANCER, PROSTATE CANCER AND OTHER SCREENINGS. EDUCATIONAL PROGRAMS AND SUPPORT GROUPS ARE HELD TO PROVIDE INFORMATION ON SUCH TOPICS AS TOBACCO CESSATION, WEIGHT MAINTENANCE, DIABETES, CHILDBIRTH, INFANT CARE, AND MORE. HOSPITAL EMPLOYEES SERVE ON THE BOARDS OF MANY COMMUNITY AND HEALTH-ORIENTED ORGANIZATIONS. THE HOSPITAL ALSO PARTICIPATES IN COMMUNITY-WIDE AND REGIONAL-WIDE MASS CASUALTY AND DISASTER PREPAREDNESS WITH 33 OTHER REGIONAL HOSPITALS AS A MEMBER OF THE HOSPITAL COUNCIL OF NORTHWEST OHIO, TO ASSURE THE SAFETY AND HEALTH OF COMMUNITY RESIDENTS IN THE EVENT OF A NATURAL DISASTER, INDUSTRIAL ACCIDENT, BIOTERRORISM OR OTHER LARGE SCALE EMERGENCY. MEMBERSHIP BENEFITS INCLUDE INCREASED PURCHASING POWER FOR DISASTER SUPPLIES, EMERGENCY RESPONSE TRAINING, INCIDENT COMMAND, AND INFORMATION SHARING TO KEEP COMPLIANT WITH HOMELAND SECURITY REGULATIONS. PART VI, LINE 6: BELLEVUE HOSPITAL IS A GENERAL ACUTE CARE PROVIDER AT ONE FACILITY IN THE BELLEVUE, OHIO AREA. BELLEVUE HOSPITAL IS THE PARENT ORGANIZATION OF BELLEVUE PROFESSIONAL SERVICES AND THE SOLE BENEFICIARY OF THE BELLEVUE HOSPITAL FOUNDATION. THE BELLEVUE HOSPITAL ASSOCIATION IS THE PARENT ORGANIZATION OF THE BELLEVUE HOSPITAL.THE BELLEVUE HOSPITAL ASSOCIATION MEETS ANNUALLY IN FEBRUARY TO ELECT THE BELLEVUE HOSPITAL BOARD OF TRUSTEES AND TO CONDUCT ANY NECESSARY BUSINESS.BELLEVUE PROFESSIONAL SERVICES PROVIDES CLINICAL AND MEDICAL PROFESSIONAL SERVICES TO RESIDENTS OF BELLEVUE AND CLYDE, OHIO AND THE SURROUNDING AREA.THE BELLEVUE HOSPITAL FOUNDATION SUPPORTS THE BELLEVUE HOSPITAL WITH FINANCIAL TRANSFERS IN THE FORM OF BOTH CASH AND NON-CASH TRANSFERS. 1 THE UNIVERSITY OF TOLEDO FOUNDATION 2801 BANKCROFT ST TOLEDO OH 43606 346555110 501(C)(3) 25000 UNIVERSITY OF TOLEDO COLLEGE OF MEDICINE SCHOLARSHIP FUND TERRA COLLEGE FOUNDATION 2830 NAPOLEON RD FREMONT OH 43420 341650500 501(C)(3) 10000 UNRESTRICTED NURSING/ALLIED HEALTH FUND VILLAGE HOUSE 350 RAWSON AVE FREMONT OH 43420 311807056 501(C)(3) 5000 TO ASSIST CHILDREN OF SANDUSKY CO. WHO HAVE BEEN AFFECTED BY ABUSE, NEGLECT, DOMESTIC VIOLENCE OR DIVORCE/SEPARATION. 3 EMPLOYEE CHILDREN'S SCHOLARSHIPS 10 15000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE HOSPITAL HAS REPRESENTATION ON THE BOARD OF VILLAGE HOUSE. THE HOSPITAL PROVIDED SCHOLARSHIP PAYMENTS MADE DIRECTLY TO THE COLLEGES AFTER PROOF OF ENROLLMENT IS RECEIVED. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 MICHAEL K WINTHROP 399230 0 30000 0 10732 0 8605 0 14689 0 463256 0 0 0 TIMOTHY BUIT 217373 0 25000 0 0 0 0 0 1234 0 243607 0 0 0 PATRICIA SEMER 134951 0 15000 0 0 0 5461 0 22626 0 178038 0 0 0 JANET RUNNER 138912 0 10000 0 0 0 4441 0 13772 0 167125 0 0 0 PART I, LINE 1A THE ORGANIZATION PAYS SOCIAL CLUB DUES ON THE BEHALF OF MICHAEL WINTHROP AS A MEANS TO NETWORK WITH PHYSICIANS. NONE OF THE SOCIAL CLUB DUES WERE TREATED AS TAXABLE COMPENSATION TO MICHAEL WINTHROP. CITY OF BELLEVUE 346400096 079277BC2 2003-08-26 11000000 ACQUISITION, CONSTRUCTION AND EQUIPPING OF NEW HOSPITAL FACILITY 0 0 0 CITY OF CLYDE 346400315 9940680S4 2003-07-23 10000000 SEE PART VI 0 0 0 COUNTY OF SANDUSKY 346401312 9940680T2 2003-08-08 6000000 ACQUISITION, CONSTRUCTION AND EQUIPPING OF NEW HOSPITAL FACILITY 0 0 0 2060068 11323999 121742 97199 11105058 2005 0 0 1 1 1989289 10023197 77750 5534858 4410589 2004 1 0 1 1 1082449 6055301 44500 6010801 2004 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 SCHEDULE K, PART I, LINE B, COLUMN (F): $4,410,588.89 OF BOND PROCEEDS WERE USED TO CURRENTLY REFUND A LOAN. $5,589,411.11 OF BOND PROCEEDS WERE USED TO ACQUIRE, CONSTRUCT AND EQUIP A NEW HOSPITAL FACILITY AND TO PAY COSTS OF ISSUANCE. SCHEDULE K, PART II, LINE 3, COLUMN A: TOTAL PROCEEDS OF THE ISSUE ARE COMPRISED OF $11,000,000 SALE PROCEEDS PLUS INVESTMENT PROCEEDS OF $323,999. SCHEDULE K, PART II, LINE 3, COLUMN B: TOTAL PROCEEDS OF THE ISSUE ARE COMPRISED OF $10,000,000 SALE PROCEEDS PLUS INVESTMENT PROCEEDS OF $23,197. SCHEDULE K, PART II, LINE 3, COLUMN C: TOTAL PROCEEDS OF THE ISSUE ARE COMPRISED OF $6,000,000 SALE PROCEEDS PLUS INVESTMENT PROCEEDS OF $55,301. SCHEDULE K, PART II, LINE 11, COLUMN B: $4,410,588.89 OF BOND PROCEEDS WERE USED TO CURRENTLY REFUND A LOAN. FORM 990, PART VI, SECTION A, LINE 2 PRESIDENT MICHAEL WINTHROP AND TRUSTEE DEAN MILLER HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE BELLEVUE HOSPITAL ENTERED INTO AN AGREEMENT WITH NORWALK AREA HEALTH SYSTEMS AND FIRELANDS REGIONAL HEALTH SYSTEM. NAHS AND FIRELANDS EACH HAVE TWENTY PERCENT MEMBERSHIP INTEREST IN THE HOSPITAL AND REPRESENTATION ON THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7A NORWALK AREA HEALTH SYSTEMS AND FIRELANDS REGIONAL HEALTH SYSTEM CAN EACH APPOINT 2 MEMBERS TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS MADE AVAILABLE BY THE PRESIDENT & VP FINANCE AT THE FINANCE MEETING FOR REVIEW AS WELL AS PRESENTATION TO THE BOARD OF DIRECTORS AT THE OCTOBER MEETING. IN ADDITION, EACH BOARD MEMBER RECEIVES A COPY OF FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, THE PRESIDENT SHALL SEND TO ALL EXECUTIVE STAFF AND SELECTED EMPLOYEES, A COPY OF THE BOARD OF TRUSTEES CONFLICT OF INTEREST POLICY TO BE COMPLETED AND RETURNED. IN ADDITION, NEW BOARD MEMBERS THAT JOIN DURING THE YEAR FILL OUT AND COMPLETE THE CONFLICT OF INTEREST POLICY WHEN THEY FIRST JOIN. AN APPROPRIATE REPORT SHALL BE SUBMITTED TO THE BOARD OF TRUSTEES CONCERNING ANY INTERESTS TO BE DISCLOSED. IF ANY CONFLICTS DO ARISE, THAT TRUSTEE WILL ABSTAIN FROM VOTING ON THE ISSUE. PERIODIC REVIEWS ARE ALSO CONDUCTED TO ENSURE THAT THE CORPORATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES, AND THAT IT DOES NOT ENGAGE IN ACTIVITIES THAT COULD JEOPARDIZE ITS STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX. THE BOARD OF DIRECTORS REVIEW THE COMPLETED CONFLICT OF INTEREST POLICIES INCLUDING THE PRESIDENT'S. THE BOARD OF DIRECTORS REVIEW THE PRESIDENT'S COMPLETED CONFLICT OF INTEREST POLICY ONCE THE PRESIDENT LEAVES THE ROOM. FORM 990, PART VI, SECTION B, LINE 15 IN DETERMINING EXECUTIVE STAFF COMPENSATION FOR THE CEO AND VICE PRESIDENTS, THE BOARD HAS A COMPENSATION COMMITTEE COMPRISED OF INDEPENDENT DIRECTORS. THE COMMITTEE UTILIZES AN OUTSIDE HEALTHCARE COMPENSATION CONSULTING COMPANY COMPARING COMPARABLE SIZED ORGANIZATIONS CONSISTENT WITH THE BOARD OF TRUSTEE COMPENSATION PHILOSOPHY STATEMENT. RECOMMENDATIONS ARE MADE FROM THE COMPENSATION COMMITTEE TO THE BOARD OF TRUSTEES. ANY COMPENSATION DECISIONS THAT ARE MADE ARE DOCUMENTED IN THE MINUTES OF THE EXECUTIVE COMPENSATION COMMITTEE AND EXECUTIVE SESSION MINUTES. THIS PROCESS WAS LAST UNDERTAKEN IN NOVEMBER 2011. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND THE FINANCIAL STATEMENTS ARE NOT CURRENTLY AVAILABLE TO THE PUBLIC. FORM 990, PAGE 7, PART VII: THE FOLLOWING OFFICER DEVOTED TIME TO BELLEVUE HOSPITAL FOUNDATION: MICHAEL WINTHROP 1 HOUR PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -172,462. CHANGE IN FMV OF INTEREST RATE SWAP AGREEMENTS -287,495. CONTRIBUTION OF CAPITAL TO BELLEVUE PROFESSIONAL SERVICES, INC. -412,000. TOTAL TO FORM 990, PART XI, LINE 5: -871,957. FORM 990, PART XII, LINE 2C THE PROCESS FOR OVERSIGHT OF THE AUDIT AS WELL AS SELECTION OF THE INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. THE BELLEVUE HOSPITAL FOUNDATION 1400 WEST MAIN STREET BELLEVUE OH 44811 341745374 SUPPORT OH 501(C)(3) LINE 11A, I THE BELLEVUE HOSPITAL 1 THE BELLEVUE HOSPITAL ASSOCIATION 1400 WEST MAIN STREET BELLEVUE OH 44811 753102199 ADMINISTRATIVE SUPPORT OH 501(C)(3) LINE 11A, I THE BELLEVUE HOSPITAL 1 BELLEVUE HEALTH NETWORK LLC 1400 WEST MAIN STREET BELLEVUE OH 44811 341870470 INSURANCE CONTRACTS OH N/A RELATED -3029 183 0 1 0.55560 BELLEVUE PROFESSIONAL SERVICES INC 1400 WEST MAIN STREET BELLEVUE OH 44811 341828724 PHYSICIAN SERVICES OH N/A C 1390264 332337 1.00000 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 BELLEVUE PROFESSIONAL SERVICES INC A 48662 LEASE PAYMENT BELLEVUE PROFESSIONAL SERVICES INC B 412000 CASH TRANSACTION THE BELLEVUE HOSPITAL FOUNDATION C 120807 CASH & BOOK VALUE TRANSACTIONS THE BELLEVUE HOSPITAL FOUNDATION K 60179 TIME SHEETS