2012-11-15T09:50:39-06:00 2011-12-31 340641962 BRUNER-COX LLP 388 S MAIN STREET SUITE 403 AKRON OH 44311 990 2011-01-01 340726081 ASHTABULA COUNTY MEDICAL CENTER ASHT 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 DON KEPNER 4409972262 2012-11-12 1 DANIEL R RIEMENSCHNEIDER P00074065 3303760100 2011 2016-02-24 21:20:13Z MICHAEL HABOWSKI 2420 LAKE AVENUE ASHTABULA OH 44004 103289056 0 X WWWW.ACMCHEALTH.ORG X 1902 OH TO PROVIDE THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. THE ASHTABULA COUNTY MEDICAL CENTER HEALTH CARE TEAM IS COMMITTED TO PRESERVING THE HUMAN RIGHTS AND DIGNITY OF THOSE WHO RECEIVE OUR CARE AND THOSE WHO PROVIDE IT. 18 14 1161 200 303794 -89788 330859 79181 89954226 91382700 133617 -231564 1011074 905501 91429776 92135818 0 0 0 0 48889551 51395453 0 0 0 39952806 40541860 88842357 91937313 2587419 198505 72037415 82290893 34747560 55284537 37289855 27006356 TO PROVIDE THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. THE ASHTABULA COUNTY MEDICAL CENTER HEALTH CARE TEAM IS COMMITTED TO PRESERVING THE HUMAN RIGHTS AND DIGNITY OF THOSE WHO RECEIVE OUR CARE AND THOSE WHO PROVIDE IT. 0 0 75339541 0 91672642 ASHTABULA COUNTY MEDICAL CENTER (ACMC) IS A PRIVATE, NOT-FOR-PROFIT, COMMUNITY-ORIENTED MEDICAL CENTER THAT PROVIDES THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. IN 2011 WE MET OUR MISSION OF MEETING OUR COMMUNITY'S HEALTH CARE NEEDS AS EVIDENCED BY APPROXIMATELY 34,540 EMERGENCY DEPARTMENT VISITS, 5,891 INPATIENT DISCHARGES, 1,355 INPATIENT SURGERIES, 6,627 OUTPATIENT SURGERIES, 444 BIRTHS, AND 68,951 RADIOLOGY PROCEDURES. IN 2011, ACMC PROVIDED CHARITY HEALTH CARE SERVICES TO PEOPLE UNABLE TO PAY WITH A COST OF $709,774. 75339541 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 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 1 105 0 1161 1 1 1 0 0 0 0 0 0 0 0 0 X 18 14 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DON KEPNER CFO 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 X JOE GIANGOLA 0.30 X X 0 0 0 IAN GLASS MD 0.30 X X 0 0 0 BILL DINGLEDINE 0.30 X X 0 0 0 MICHAEL HABOWSKI 40.00 X X 0 0 0 NEROY CARTER 0.30 X 0 0 0 ROGER CORLETT 0.30 X 0 0 0 ELEANOR JAMMAL 0.30 X 0 0 0 NANCY KISTER 0.30 X 0 0 0 SUSAN STOCKER PHD 0.30 X 0 0 0 JOE VENDEL 0.30 X 0 0 0 STEVE WALLING 0.30 X 0 0 0 FRED DEGRANDIS 0.30 X 0 0 0 JASON HERGENROEDER 0.30 X 0 0 0 SUK K CHOI MD 60.00 X 510723 0 15449 ROBERT DLWGOSH MD 60.00 X 274195 0 14110 ASHOK V KONDRU MD 0.30 X 0 0 0 NAFISA KONDRU MD 0.30 X 0 0 0 TIM O'BRIEN MD 60.00 X 281393 0 14643 PHILIP PAWLOWSKI 40.00 X 0 0 0 MOUHAMAD S KABBANI MD 60.00 X 591697 0 8881 ALEXANDER TAICH MD 60.00 X 582715 0 10302 JAMES CHILLCOTT MD 60.00 X 563681 0 15703 LAXMAN R CINGIREDDI MD 60.00 X 506830 0 12152 YISA B SUNMONU MD 60.00 X 492890 0 16152 3804124 0 107392 36 0 1 0 CLEVELAND CLINIC FOUNDATION PO BOX 70060 CLEVELAND OH 44193 ADMINISTRATIVE SERVICES 3434639 AVI FOODSYSTEMS INC 2590 ELM ROAD NE WARREN OH 44483 CAFETERIA AND DIETARY SERVICES 1611168 CLEVELAND CLINIC REF LAB 9500 EUCLID AVE CLEVELAND OH 44106 LABORATORY TESTING 1117474 HMP OF ASHTABULA COUNTY 4535 DRESSLER ROAD CANTON OH 44718 HOSPITALIST MED/PROF SERVICES 855296 SS&G HEALTHCARE SERVICES 32125 SOLON ROAD CLEVELAND OH 44139 PHYSICIAN BILLING SERVICE 771332 17 79181 79181 NET PATIENT SERVICE RE 624100 91382700 91382700 91382700 248489 248489 311765 0 311765 311765 311765 10662905 10280 11153238 0 -490333 10280 -480053 -480053 PREMIER FITNESS AND DA 713940 303794 303794 MISC OPERATING REVENUE 624100 175117 175117 REBATES AND REFUNDS 624100 114825 114825 593736 92135818 91672642 303794 80201 1475543 1209947 265596 39684571 32541349 7143222 1680146 1377720 302426 5757844 4721432 1036412 2797349 2293826 503523 190459 156176 34283 108480 88954 19526 1708734 1401162 307572 91032 74646 16386 7954 6522 1432 2891549 2322012 569537 2038395 1671484 366911 SUPPLIES 14375207 11787670 2587537 MEDICAL SERVICES & FEES 7778550 6378411 1400139 EQUIPMENT RENTAL/MAINTE 3885946 3186476 699470 PURCHASED ADMINISTRATIV 3156222 2588102 568120 4309332 3533652 775680 91937313 75339541 16597772 0 1680 27080487 17678045 2647219 11490263 12512862 727246 949089 897419 729144 84506516 64946380 20156254 19560136 9251291 14591088 2241148 6495420 7319517 72037415 82290893 14556794 11175200 1896081 1364894 0 16929791 44109337 34747560 55284537 X 35476912 26740265 1812943 266091 37289855 27006356 72037415 82290893 X 198505 -10482004 X 0 1 1 X 0 X 1900568 1900568 26089230 18889706 7199524 2095340 1650565 444775 52377920 44406109 7971811 2043458 2043458 19560136 SELF-INSURANCE INVESTMENTS 5068876 DEFERRED COMPENSATION 2065966 OTHER ASSETS 32727 DUE FROM AFFLIATES 151948 7319517 RESERVE FOR SELF-INSURANCE LIABILITIES 10423030 DEFERRED COMPENSATION 2065966 ACCRUED PENSION LIABILITY 12839973 DISTRIBUTION PAYABLE TO THE CLEVELAND CLINIC FOUNDATION 1095500 INVESTMENT FROM CLEVELAND CLINIC FOUNDATION 15000000 THIRD-PARTY PAYABLES 2684868 44109337 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: WHEN TAX RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD BE ULTIMATELY SUSTAINED. IN ACCORDANCE WITH THE INCOME TAXES TOPIC OF THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION, THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS TAKEN ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS RECORDED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. 1 1 X 1 X 0 1 1 0 709774 709774 0.00770 14135923 11262532 2873391 0.03130 971686 580651 391035 0.00430 15817383 11843183 3974200 0.04330 64812 64812 0.00070 6743 6743 0.00010 71555 71555 0.00080 15888938 11843183 4045755 0.04410 1 7051393 0 26288933 26931812 -642879 X 1 1 1 1 ASHTABULA COUNTY MEDICAL CENTER

2420 LAKE AVENUE ASTHABULA OH 44004

X X X ASHTABULA COUNTY MEDICAL CENTER 1 1 1 200.000000000000 0 1 X 1 1 X X X 1 0 1 X 0 1 PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: ACMC ESTIMATED CHARITY CARE COSTS BY CALCULATING A RATIO OF COST TO GROSS CHARGES AND THEN MULTIPLYING THAT RATIO BY THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS.ACMC IS PAID A PROSPECTIVELY DETERMINED RATE FOR THE MAJORITY OF INPATIENT ACUTE CARE AND OUTPATIENT, SKILLED NURSING, AND REHABILITATION SERVICES PROVIDED FOR MEDICAID. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. MEDICAID PAYMENTS FOR CAPITAL ARE RECEIVED ON A COST REIMBURSEMENT METHODOLOGY. PAYMENTS ARE RECEIVED ON A PROSPECTIVE BASIS FOR ACMC'S MEDICAL EDUCATION COSTS, SUBJECT TO CERTAIN LIMITS. PROVISION FOR ESTIMATED RETROACTIVE ADJUSTMENTS, IF ANY, RESULTING FROM REGULATORY MATTERS OR OTHER ADJUSTMENTS UNDER PAYMENT AGREEMENTS ARE ESTIMATED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED. PART I, LINE 7G: ACMC PROVIDES AN ATHLETIC TRAINER TO THREE HIGH SCHOOLS AT NO COST TO THE SCHOOL DISTRICTS FOR THIS SERVICE. COSTS OF OTHER MEANS-TESTED GOVERNMENT PROGRAMS PART I, LINE 7C ACMC PARTICIPATES IN THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP) TO FINANCIALLY SUPPORT THOSE HOSPITALS THAT SERVICE A DISPROPORTIONATE SHARE OF LOW-INCOME PATIENTS UNABLE TO PAY FOR CARE. HCAP FUNDS BASIC, MEDICALLY NECESSARY HOSPITAL SERVICES FOR PATIENTS WHOSE FAMILY INCOME IS AT OR BELOW THE FEDERAL POVERTY LEVEL, WHICH INCLUDES MEDICAID PATIENTS AND PATIENTS WITHOUT HEALTH INSURANCE. PART II N/A PART III, LINE 4: TOTAL BAD DEBT EXPENSE FOR THE ENTIRE HOSPITAL COMPLEX IS EQUAL TO THE TOTAL GROSS CHARGES WRITTEN OFF AS REPORTED ON THE 2011 MEDICARE COST REPORT.PATIENT RECEIVABLES ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, MAJOR PAYOR SOURCES AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGH THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE MODIFICATIONS TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, ACMC FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST-DUE PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY ACMC. ACMC MAINTAINS ALLOWANCES FOR LOSSES BASED ON THE EXPECTED COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE (BAD DEBTS) AND TO REFLECT NET AMOUNTS DUE FROM PATIENTS AND THIRD-PARTY PAYERS (CONTRACTUAL ADJUSTMENTS).ACMC PROVIDES CARE TO PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY AND WHO QUALIFY FOR CHARITY SERVICES PURSUANT TO ESTABLISHED POLICIES OF ACMC. CHARITY SERVICES ARE DEFINED AS THOSE FOR WHICH PATIENTS HAVE THE OBLIGATION AND WILLINGNESS TO PAY BUT DO NOT HAVE THE ABILITY TO DO SO. ACMC DOES NOT INCLUDE CHARITY CARE IN NET PATIENT SERVICE REVENUE. PART III, LINE 8: MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. THE AMOUNTS REPORTED WERE GENDERATED FROM THE MEDICARE COST REPORT FILED FOR 2011. ACMC IS PAID A PROSPECTIVELY DETERMINED RATE FOR THE MAJORITY OF INPATIENT ACUTE CARE AND OUTPATIENT, SKILLED NURSING, AND REHABILITATION SERVICES PROVIDED FOR MEDICARE. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. MEDICARE PAYMENTS FOR CAPITAL ARE RECEIVED ON A PROSPECTIVE BASIS. PAYMENTS ARE RECEIVED ON A PROSPECTIVE BASIS FOR ACMC'S MEDICAL EDUCATION COSTS, SUBJECT TO CERTAIN LIMITS. ACMC IS PAID FOR COST REIMBURSABLE ITEMS AT A TENTATIVE RATE, WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS BY ACMC AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY. PROVISION FOR ESTIMATED RETROACTIVE ADJUSTMENTS, IF ANY, RESULTING FROM REGULATORY MATTERS OR OTHER ADJUSTMENTS UNDER PAYMENT AGREEMENTS ARE ESTIMATED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED.LAWS AND REGULATIONS GOVERNING MEDICARE ARE COMPLEX AND SUBJECT TO INTERPRETATION AS WELL AS SIGNIFICANT REGULATORY ACTION, AND, IN THE NORMAL COURSE OF BUSINESS, ACMC IS SUBJECT TO CONTRACTUAL REVIEWS AND AUDITS. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE IN THE NEAR TERM. ACMC BELIEVES IT IS IN COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS GOVERNING THE MEDICARE PROGRAM AND THAT ADEQUATE PROVISIONS HAVE BEEN MADE FOR ANY ADJUSTMENTS THAT MAY RESULT FROM FINAL SETTLEMENTS. PART III, LINE 9B: REASONABLE EFFORTS ARE PERFORMED TO DETERMINE THE PATIENT'S ELIGIBILITY UNDER THE HOSPITAL'S FAP AND THE HOSPITAL DOES NOT PERFORM DEBT COLLECTION PROCEDURES BEFORE MAKING THESE REASONABLE EFFORTS. THIS IS ACHIEVED THROUGH THE HCAP APPLICATION. DOCUMENTATION OF THE PATIENT OR FAMILY INCOME FOR HCAP ELIGIBILITY WILL BE BASED UPON A BEST EVIDENCE METHODOLOGY. HOSPITAL EMPLOYEES WILL PROCEED THROUGH THE FOLLOWING IN AN EFFORT TO SECURE THE BEST EVIDENCE AVAILABLE FOR THE PATIENT OR GUARANTOR AT THE TIME OF THEIR ENCOUNTER. 1. A COMPLETED HCAP APPLICATION INCLUSIVE OF THE PATIENT OR GUARANTOR'S SIGNATURE. 2. A COMPLETED HCAP APPLICATION, WHICH INCLUDES THE SIGNATURE OF THE PATIENT REPRESENTATIVE SECURING THE INFORMATION FROM THE RESPONSIBLE PARTY. IF THE APPLICATION CANNOT BE SECURED AT THE TIME OF THE ENCOUNTER, THE RESPONSIBLE PARTY WILL BE PROVIDED WITH A RETURN ENVELOPE. THEY WILL BE ASKED TO PROVIDE THIS INFORMATION UPON THEIR RETURN TO THEIR HOME. IN THE EVENT THAT THE INFORMATION IS RECEIVED, IT IS TO BE REVIEWED AND CONSIDERED AGAINST THE ABOVE-DEFINED ELIGIBILITY DETERMINATION CRITERIA. IF IT IS NOT RETURNED WITHIN 14 DAYS OF DISCHARGE, ACMC CONTACTS THE PATIENT VIA TELEPHONE TO COMPLETE THE APPLICATION. FOR OUTPATIENT HOSPITAL SERVICES, THE ELIGIBILITY DETERMINATION IS EFFECTIVE FOR NINETY DAYS FROM THE INITIAL SERVICE DATE. DURING THIS PERIOD A NEW ELIGIBILITY DETERMINATION NEED NOT BE COMPLETED. ELIGIBILITY FOR INPATIENT HOSPITAL SERVICES MUST BE DETERMINED SEPARATELY FOR EACH ADMISSION , UNLESS THE PATIENT IS READMITTED WITHIN FORTY-FIVE DAYS OF DISCHARGE FOR THE SAME UNDERLYING CONDITION. ELIGIBILITY FOR RECIPIENTS OF THE DISABILITY ASSISTANCE PROGRAM MUST BE VERIFIED ON A MONTHLY BASIS. IN THE EVENT THE PATIENT DOES NOT COMPLETE AN APPLICATION DURING THE ENCOUNTER, AND AS A RESULT OF THE HCAP COMMUNICATION, PATIENT STATEMENTS, OR RESULT OF COLLECTION EFFORTS, HOSPITAL STAFF WILL COMPLETE THE HCAP APPLICATION, OVER THE TELEPHONE OR IN-PERSON, ON BEHALF OF THE RESPONSIBLE PARTY. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 19D: ALL PATIENTS ARE CHARGED THE SAME, STANDARD RATE, FOR A PARTICULAR SERVICE. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 21: ALL PATIENTS ARE CHARGED THE SAME, STANDARD RATE, FOR A PARTICULAR SERVICE. PART VI, LINE 2: ACMC IS CURRENTLY REVIEWING THE COMMUNITY HEALTH NEEDS ASSESSMENT RECENTLY PUBLISHED BY ASHTABULA COUNTY AND IS IN THE PROCESS OF PLANNING A CHNA FOR 2013. ACMC USES MARKET DATA THAT REFLECTS ACTUAL PATIENT VISITS (DATA THAT IS SUBMITTED TO THE OHIO HOSPITAL ASSOCIATION BY ALL HOSPITALS IN THE STATE). MANAGEMENT REVIEWS THE NUMBER OF PATIENTS FROM THE MARKET WHO LEAVE ASHTABULA COUNTY FOR HEALTHCARE, AND WHAT SERVICES THEY LEAVE FOR. ACMC CONDUCTS A PHYSICIAN SATISFACTION SURVEY EVERY OTHER YEAR; ONE COMPONENT OF THE SURVEY IS TO OBTAIN PHYSICIAN INPUT INTO WHAT SERVICES/SPECIALTIES ARE NEEDED. ACMC CONDUCTS A MEDICAL STAFF DEVELOPMENT PLAN (APPROXIMATELY EVERY THREE YEARS) IN WHICH COMMUNITY PHYSICIANS ARE ASKED ABOUT THEIR PRACTICE PLANS (PLANNING TO RETIRE, BECOME EMPLOYED, GO INDEPENDENT, EXPAND) AND WHAT SPECIALISTS ARE NEEDED IN THE COMMUNITY TO BETTER SERVE THEIR PATIENTS. THIS HELPS GUIDE THE PHYSICIAN RECRUITMENT EFFORTS TO ENSURE THE HOSPITAL IS MEETING THE HEALTH NEEDS OF THE MARKET. EVERYONE ON THE ADMINISTRATIVE TEAM IS ASSIGNED TO 8-12 PHYSICIANS WITH WHOM THEY HAVE REGULAR CONVERSATIONS ABOUT THEIR PRACTICE NEEDS, COMMUNITY NEEDS, ETC. MEMBERS OF THE MANAGEMENT TEAM ACTIVELY SERVE ON THE BOARDS OF COMMUNITY ORGANIZATIONS, MANY OF WHICH HAVE A MISSION TO ADDRESS COMMUNITY NEED; HEALTHCARE BEING ONE OF THOSE NEEDS (COMMUNITY ACTION, SALVATION ARMY, UNITED WAY, CATHOLIC CHARITIES, SENIOR ADVOCACY AND PROTECTIVE NETWORK, ETC.). PART VI, LINE 3: INFORMATION ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS IS DESCRIBED ON THE PATIENT'S BILL, THE POLICY IS POSTED ON THE HOSPITAL'S WEBSITE AND IS ALSO AVAILABLE UPON REQUEST. THE NOTICE, BOTH IN ENGLISH AND SPANISH, IS POSTED AT THE FOLLOWING LOCATIONS: EMERGENCY DEPARTMENT, ALL ADMISSIONS/REGISTRATION AREAS, PATIENT FINANCIAL SERVICES DEPARTMENT. ACMC FINANCIAL COUNSELORS MEET WITH ANY PATIENT THAT MAY NEED ANY FORM OF FINANCIAL AID PRIOR TO DISCHARGE AND EDUCATE THEM ON FINANCIAL ASSISTANCE. PART VI, LINE 4: AFFILIATED WITH THE CLEVELAND CLINIC, ACMC IS THE LARGEST AND MOST ADVANCED HOSPITAL IN ASHTABULA COUNTY. ACMC OPENS THE DOOR TO THE WORLD'S BEST HEALTHCARE BY APPLYING CLEVELAND CLINIC'S CLINICAL INFORMATION AND STATE-OF-THE-ART STANDARDS OF CARE. THE PRIMARY MARKET IS COMPRISED OF THE FOLLOWING ZIP CODES: 44004, 44005, 44010, 44030, 44032, 44041, 44048, 44068, 44082. THE SECONDARY MARKET IS COMPRISED OF THE FOLLOWING ZIP CODES: 44003, 44076, 44084, 44085, 44093, 44099. THE PAYER MIX IS 50.8% MEDICARE, 26.90% MEDICAID, 18.9% COMMERCIAL, 2.7% SELF PAY, 0.8% OTHER. 80% OF THE MARKET HAS ONLY A HIGH SCHOOL DIPLOMA; 11% HAVE A COLLEGE DEGREE. THE MEDIAN HOUSEHOLD INCOME IS APPROXIMATELY $40,000; WITH PER CAPITA INCOME AT APPROXIMATELY $19,000. PART VI, LINE 5: ACMC IS AN ACTIVE PARTICIPANT AND SPONSOR OF EVENTS LIKE RELAY FOR LIFE AND AMERICAN HEART WALK AND SPONSOR OF HEALTH-RELATED EVENTS OF COMMUNITY ORGANIZATIONS (EXAMPLE: ZONTA WOMEN'S HEALTH DAY). ACMC PUBLISHES A COMMUNITY MAGAZINE 2X/YEAR WITH HEALTHCARE INFORMATION AND TIPS FOR HEALTHY LIVING. THE WEBSITE CONTAINS HEALTH INFORMATION AND DOWNLOADABLE RESOURCES. THE HOSPITAL HOLDS TWO WOMEN'S HEALTH LUNCHEONS EACH YEAR (HEART AND CANCER). ACMC PARTICIPATES IN NUMEROUS HEALTH FAIRS AND COMMUNITY EVENTS AT WHICH THE HOSPITAL PROVIDES FREE SCREENINGS (BLOOD PRESSURE, BLOOD SUGAR, BODY MASS INDEX, BACK STRENGTH, CHOLESTEROL). THE HOSPITAL HOLDS MONTHLY DINNER EVENTS FOR THE COMMUNITY AT WHICH A PHYSICIAN DISCUSSES SPECIFIC HEALTH ISSUES. STAFF (PHYSICIANS, CLINICIANS, ETC.) APPEAR ON LOCAL CABLE TV SHOW 2X/MONTH TO SHARE HEALTH INFORMATION. ACMC OFFERS SUPPORT GROUPS (EXAMPLES DIABETES AND COPD). THE HOSPITAL IS WORKING WITH AMERICAN CANCER SOCIETY TO OFFER REACH TO RECOVERY, LOOK GOOD FEEL BETTER AND OTHER PROGRAMS IN ASHTABULA COUNTY. ACMC ALSO PROVIDES AN ATHLETIC TRAINER TO THREE HIGH SCHOOLS (NO COST TO THE SCHOOL DISTRICTS FOR THIS SERVICE). PART VI, LINE 6: ACMC IS AN AFFILIATE OF THE CLEVELAND CLINIC. THE CLEVELAND CLINIC HEATH SYSTEM ENGAGES IN MANY COMMUNITY OUTREACH PROGRAMS, INCLUDING INITIATIVES DESIGNED TO SERVE THE VULNERABLE AND AT-RISK POPULATIONS IN OUR COMMUNITIES. CLEVELAND CLINIC'S OUTREACH PROGRAMS RANGE FROM FREE HEALTH SCREENINGS AND CLINICAL SERVICES TO ENROLLMENT ASSISTANCE FOR GOVERNMENT-FUNDED HEALTH PROGRAMS. COMMUNITY OUTREACH PROGRAMS ARE ALSO THOSE PROGRAMS THAT IMPROVE ACCESS TO HEALTH SERVICES. CLEVELAND CLINIC CAREGIVERS COLLABORATE WITH COMMUNITY ORGANIZATIONS TO PROVIDE A CONTINUUM OF CARE THAT SUPPORTS ECONOMICALLY AND MEDICALLY UNDERSERVED AREAS. THE 2011 COMMUNITY BENEFIT REPORT PUBLISHED BY THE CLEVELAND CLINIC STATED $45.6 MILLION WAS SPENT BY THE CLEVELAND CLINIC IN 2011 ON COMMUNITY OUTREACH PROGRAMS. PART VI, LINE 7 N/A X X X 0 0 0 0 0 0 0 0 0 SUK K CHOI MD 467637 0 0 0 43086 0 9800 0 5649 0 526172 0 0 0 ROBERT DLWGOSH MD 273781 0 0 0 414 0 8260 0 5850 0 288305 0 0 0 TIM O'BRIEN MD 261393 0 0 0 20000 0 9764 0 4879 0 296036 0 0 0 MOUHAMAD S KABBANI MD 591577 0 0 0 120 0 4900 0 3981 0 600578 0 0 0 ALEXANDER TAICH MD 582571 0 0 0 144 0 9800 0 502 0 593017 0 0 0 JAMES CHILLCOTT MD 543969 0 0 0 19712 0 9800 0 5903 0 579384 0 0 0 LAXMAN R CINGIREDDI MD 506650 0 0 0 180 0 8300 0 3852 0 518982 0 0 0 YISA B SUNMONU MD 485150 0 0 0 7740 0 9800 0 6352 0 509042 0 0 0 PART I, LINE 3 SALARIES ARE REVIEWED AT A MINIMUM OF EVERY TWO YEARS. SALARIES ARE COMPARED TO LOCAL, REGIONAL, AND NATIONAL MARKET RATES AND IN CONJUNCTION WITH THE CEO AND CFO TO DETERMINE COMPENSATION. WHEN OPENINGS FOR KEY POSITIONS BECOME AVAILABLE, THE HR DEPARTMENT EXAMINES THE MARKET RATES TO DETERMINE A STARTING SALARY. EVERY YEAR THE TYPICAL SALARY HAS A 3% MERIT RATE INCREASE. KIMBERLY GIANGOLA WIFE OF CHAIRMAN OF BOARD OF DIRECTORS 24486 EMPLOYMENT AGREEMENT WITH ACMC 0 FORM 990, PART VI, SECTION A, LINE 3 THE CLEVELAND CLINIC FOUNDATION HOLDS AND EXERCISES A MANAGEMENT AGREEMENT WITH ACMC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 REPORT IS PUBLISHED TO THE BOARD OF DIRECTOR'S WEBSITE. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY REVIEW AND SIGN A CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT FORM. FORM 990, PART VI, SECTION B, LINE 15 SALARIES ARE REVIEWED AT A MINIMUM OF EVERY TWO YEARS. SALARIES ARE COMPARED TO LOCAL, REGIONAL, AND NATIONAL MARKET RATES AND IN CONJUNCTION WITH THE CEO AND CFO TO DETERMINE COMPENSATION. WHEN OPENINGS FOR KEY POSITIONS BECOME AVAILABLE, THE HR DEPARTMENT EXAMINES THE MARKET RATES TO DETERMINE A STARTING SALARY. EVERY YEAR THE TYPICAL SALARY HAS A 3% MERIT RATE INCREASE. FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS ARE SENT TO THE CEO FOR DISTRIBUTION. FORM 990, PART VII, SECTION A THE FOLLOWING OFFICERS WORKING FULL-TIME FOR ACMC ARE EMPLOYED BY THE CLEVELAND CLINIC AND ARE COMPENSATED THROUGH EMPLOYMENT AGREEMENTS WITH THE CLEVELAND CLINIC: MICHAEL HABOWSKI, PRESIDENT/CEO AND PHILIP PAWLOWSKI, CFO. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 206,198. EQUITY INCOME IN AFFLIATE 272,545. INTERCOMPANY TRANSFER FROM ROCK CREEK MEDICAL CENTER 10,148,820. DISTRIBUTION TO CLEVELAND CLINIC FOUNDATION -1,095,500. EFFECT OF RECOGNITION PROVISION AT MEASUREMENT DATE OF PENSION OBLIGATION -5,794,423. ADJUSTMENTS AND RECLASSIFICATIONS FROM 2010 FORM 990 -14,219,644. TOTAL TO FORM 990, PART XI, LINE 5: -10,482,004. ASHTABULA COUNTY MEDICAL CENTER FOUNDATION 2420 LAKE AVENUE ASHTABULA OH 44004 341392784 SUPPORT THE ASHTABULA COUNTY MEDICAL CENTER OH 501(C)(3) LINE 11A, I ASHTABULA COUNTY MEDICAL CENTER 0 ROCK CREEK MEDICAL CENTER DBA GLENBEIGH HEALTH SOURCES 2863 STATE ROUTE 45 ROCK CREEK OH 44084 341789783 OPERATE AND MAINTAIN A HOSPITAL AND OUTPATIENT CENTERS OH 501(C)(3) LINE 3 ASHTABULA COUNTY MEDICAL CENTER 0 ASHTABULA REGIONAL HOME HEALTH SERVICES 3949 JEFFERSON ROAD ASHTABULA OH 44004 341143158 HOME HEATH SERVICES OH 501(C)(3) LINE 9 ASHTABULA COUNTY MEDICAL CENTER 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 ASHTABULA COUNTY MEDICAL CENTER FOUNDATION R 75440 CASH RECEIVED ASHTABULA COUNTY MEDICAL CENTER FOUNDATION P 172982 CASH RECEIVED ASHTABULA COUNTY MEDICAL CENTER FOUNDATION D 122833 LOAN RECORDS ROCK CREEK MEDICAL CENTER DBA GLENBEIGH HEALTH SERVICES D 16910 LOAN RECORDS ROCK CREEK MEDICAL CENTER DBA GLENBEIGH HEALTH SERVICES P 180795 CASH RECEIVED ASHTABULA REGIONAL HOME HEALTH SERVICES D 12205 LOAN RECORDS