2012-11-15T14:32:34-06:00 2011-12-31 382146751 PLANTE & MORAN PLLC 600 E FRONT ST SUITE 300 TRAVERSE CITY MI 49686 990 2011-01-01 382146751 NORTHERN MICHIGAN HOSPITALS NORT 2314874094 416 CONNABLE AVENUE PETOSKEY MI 49770 CATHERINE DEVET 2314874094 2012-11-15 1 P00053797 2319477800 2011 2016-02-24 21:20:13Z NORTHERN MICHIGAN REGIONAL HOSPITAL CATHERINE DEVET 416 CONNABLE AVENUE PETOSKEY MI 49770 201227864 0 X WWW.NORTHERNHEALTH.ORG X 1977 MI TO PROVIDE HEALTHCARE AS WE EXPECT FOR OUR OWN FAMILY. 12 11 1453 279 152452 59665 4058815 4610007 179137908 180156775 759413 937888 2383786 4270991 186339922 189975661 692174 355652 0 0 81376953 72401719 0 0 0 97284195 105047662 179353322 177805033 6986600 12170628 115530108 120103584 50677661 47367081 64852447 72736503 X ESTABLISH, MAINTAIN AND OPERATE HOSPITAL TO CARE FOR THE SICK, INJURED AND DISABLED. PREVENTION OF ILLNESS, INJURY AND DISABILITY AND MAINTENANCE OF HEALTH. MORE SPECIFICALLY, NORTHERN MICHIGAN REGIONAL HOSPITAL AND ITS 1,453 EMPLOYEES ARE DEDICATED TO PROVIDING QUALITY HEALTHCARE SERVICES TO THE PEOPLE OF NORTHERN MICHIGAN. 0 0 25386701 0 40644394 THE TREATMENT AND DIAGNOSIS OF CARDIAC DISEASE (DISCHARGES 1,748). 8826088 16209281 THE TREATMENT AND DIAGNOSIS OF ORTHOPAEDIC CARE (DISCHARGES 891). 6871098 0 13872593 THE TREATMENT AND DIAGNOSIS OF ONCOLOGY CARE (DISCHARGES 493). 91913541 355652 112774858 91913541 355652 112774858 132997428 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 173 0 1 1453 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X CATHERINE DEVET 2314874094 416 CONNABLE AVENUE PETOSKEY MI 49770 X CATHERINE DEVET 22.00 X X 0 486688 55223 DAVID BUZZELLI 2.50 X X 0 0 0 ROBERT FOSTER 2.00 X X 0 0 0 THOMAS IRWIN 2.50 X X 0 0 0 THOMAS MORAN 2.00 X X 0 0 0 STEPHEN EIBLING 2.00 X 0 0 0 JOSEPH HANCE MD 1.30 X 0 0 0 ELISE HAYES 1.30 X 0 0 0 WILLIAM KANE MD CHIEF OF STAFF 1.30 X 0 0 0 JOHN KOHLER 2.00 X 0 0 0 DAVID RYNBRANDT MD 1.30 X 0 0 0 ANN STALLKAMP 2.00 X 0 0 0 STEPHEN SCANNELL 22.00 X 0 263995 45274 EUGENE KAMINSKI 22.00 X 0 186927 39211 ROBERT DEAN JR 22.00 X 0 284283 26642 MARY-ANNE PONTI 22.00 X 0 231732 34317 CAROLINE SEAGREN 22.00 X 0 173405 37045 HOWARD BECK 5.50 X 0 34053 0 HUGH DEERY 3.00 X 0 312462 22955 MARK GRAY 2.50 X 0 174192 14153 DANIEL DRYDEN 40.00 X 159056 0 26945 KEVIN PENDLETON 40.00 X 141974 0 12519 ROLAND BROCKWAY 40.00 X 138130 0 17707 MICHAEL GRIEB 40.00 X 133797 0 9408 LINDA SCHOFIELD 40.00 X 126444 0 11446 699401 2147737 352845 21 0 1 0 NORTHERN ANESTHESIA PROVIDERS 602 JACKSON PETOSKEY MI 49770 PHYSICIAN SERVICES 1494425 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINNEAPOLIS MN 554809146 LABORATORY SERVICES 739290 NORTHERN PATHOLOGY ASSOCIATES PC 416 CONNABLE AVENUE PETOSKEY MI 49770 PHYSICIAN SERVICES 428480 PETOSKEY SURGEONS PC 521 MONROE PETOSKEY MI 49770 PHYSICIAN SERVICES 425719 NORTHERN UNITED MANAGEMENT COMPANY LLC 404 BIRCHWOOD AVENUE TRAVERSE CITY MI 49686 MANAGEMENT SERVICES 420417 11 4610007 4610007 PATIENT SERVICE REV 622110 180156775 180156775 180156775 947480 947480 437230 0 437230 437230 437230 11226799 15812 11210349 41854 16450 -26042 -9592 -9592 OTHER RELATED REVENUE 900099 1913469 1913469 CAFETERIA SALES 722210 774188 774188 PHARMACEUTICAL RESEARC 900099 510686 510686 635418 482966 152452 3833761 189975661 183501126 152452 1712076 355652 355652 58944775 50196911 8747864 9315310 7476330 1838980 4141634 3410736 730898 416667 416667 3025 3025 109631 109631 17100228 13706429 3393799 72654 72454 200 5904646 2634482 3270164 49928 49928 5484800 3263842 2220958 222830 100293 122537 127474 89772 37702 1443028 1443028 6084169 2634143 3450026 INCOME TAXES 4575 4575 MEDICAL SUPPLIES/DRUGS 35925927 35925927 HOME OFFICE EXPENSE 18938076 18938076 PROVISION FOR BAD DEBT 8388353 8388353 4771651 4737529 34122 177805033 132997428 44807605 0 1923 2046 25844080 28804386 11573066 12869874 602498 779607 5557595 6182429 1685058 1339525 175080101 119801620 52010392 55278481 985240 11529330 12197924 458627 109312 109312 4963020 2749967 115530108 120103584 13885080 10315013 27204 4207 33786346 31700960 2979031 5346901 50677661 47367081 X 61056009 70899195 3796438 1837308 64852447 72736503 115530108 120103584 X 12170628 -4286572 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 496200 496200 94387787 59798542 34589245 1216121 606220 609901 78979993 59396858 19583135 55278481 COST REPORT SETTLEMENT PAYABLE 5346901 5346901 CENTERAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENT 120000 0 0 0 0 0 0 120000 0 120000 0 0 1 0 0 0 1 1 X 1 X 1 X 1 1 0 1 1 2286591 2286591 0.01350 9566033 9003577 562456 0.00330 1289542 1289542 0.00760 13142166 9003577 4138589 0.02440 239 16410 494823 494823 0.00290 2 3 73930 73930 0.00040 12936466 9129064 3807402 0.02250 1 408760 408760 0.00240 246 1521 60560 60560 0.00040 488 17934 13974539 9129064 4845475 0.02860 488 17934 27116705 18132641 8984064 0.05300 7 1253 27548 27548 0.00020 1 233 1055 1055 0.00000 5 680 7137 7137 0.00000 4 52 5392 5392 0.00000 10 22 3035 3035 0.00000 27 2240 44167 44167 0.00020 1 7996468 1404893 30237722 40818604 -10580882 X 1 0 1 1 NORTHERN MICHIGAN HOSPITALS

416 CONNABLE AVENUE PETOSKEY MI 49770

X X X X NORTHERN MICHIGAN HOSPITALS 1 1 1 200.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X 1 0 1 X X X 0 1 PART I, LINE 7: WE UTILIZE A STEP DOWN COSTING METHODOLOGY. FIRST DIRECT EXPENSES ARE REDUCED BY ANY NON PATIENT REVENUES RECEIVED. THEN INDIRECT DEPARTMENTS (THOSE WITHOUT PATIENT CHARGES) ARE ALLOCATED TO DIRECT DEPARTMENTS USING DEPARTMENT SPECIFIC STATISTICS. THE STEP DOWN PROCESS INCLUDES NINE ITERATIONS. WHEN THE COSTING PROCESS IS COMPLETE, COSTS ARE ASSIGNED TO EACH UNIQUE PATIENT. THIS ALLOWS US TO DETERMINE THE ACTUAL COST OF PROVIDING SERVICES TO EACH UNIQUE PATIENT. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDE ACUTE REHAB, PSYCHIATRY, NEWBORNS, OB, WOMEN'S SERVICES, ACUTE INPATIENT, OUTPATIENT FIXED AND HEMODIALYSIS. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24D - BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE SCHEDULE H, PART I, COLUMN F PERCENTAGE EQUALS $8,388,353. PART II: COMMUNITY BUILDING ACTIVITIES SUPPORT IDENTIFIED COMMUNITY NEEDS AND COMMUNITY COLLABORATIVES SUCH AS POVERTY REDUCTION, TRANSPORTATION, WORKFORCE DEVELOPMENT AND COMMUNITY HEALTH, BY PROVIDING IN-KIND SERVICES, FINANCIAL RESOURCES AND STAFF EXPERTISE FROM THE HOSPITAL. PART III, LINE 4: ACCOUNTS RECEIVABLE FINANCIAL STATEMENT FOOTNOTE:ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE SYSTEM ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKEY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE SYSTEM RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.TO DETERMINE THE ESTIMATED AMOUNT OF THE ORGANIZATIONS'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS UNDER THE ORGANIZATIONS FINANCIAL ASSISTANCE POLICY, ADMINISTRATION ESTIMATED A PERCENTAGE OF INDIVIDUALS WHO DID NOT COMPLETE THE CHARITY CARE APPLICATION PROCESS, OR DID NOT TAKE THE TIME TO APPLY - WHICH AMOUNTS TO $1,404,893.THE BAD DEBT EXPENSE OF $7,996,468 INCLUDES TOTAL BAD DEBT EXPENSE FROM FORM 990, PART IX, LINE 25 OF $8,388,353 LESS NON-PATIENT RELATED BAD DEBTS OF $391,885. PART III, LINE 8: TO DETERMINE THE COST OF MEDICARE SHORTFALLS, WE ISOLATED ALL PATIENT ACCOUNTS WHERE MEDICARE WAS THE PRIMARY PAYOR, AND OFFSET THE COST OF SERVICES PROVIDED BY ANY PAYMENT RECEIVED, FROM EITHER THE PATIENT, PRIMARY, SECONDARY, OR TERTIARY PAYORS. WE THEN ROLLED THOSE ACCOUNTS UP BY SUB SERVICE LINE FOR BOTH IN- AND OUT-PATIENT ACCOUNTS, AND REPORTED THE NET SHORTFALL OF SERVICES PROVIDED AT A LOSS. ONE HUNDRED PERCENT OF THAT SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: THE ORGANIZATION'S WRITTEN DEBT COLLECTION POLICY DOES NOT CONTAIN PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE BECAUSE IF POSSIBLE WE TRY TO IDENTIFY AND DETERMINE ELIGIBILITY FOR CHARITY CARE BEFORE SERVICES ARE PROVIDED. ALSO, IT IS STATED IN OUR CHARITY CARE POLICY THAT ONCE ELIGIBLE, NO COLLECTION AGENCIES OR OTHER COLLECTION PROCESSES WILL BE FOLLOWED UNLESS THE PATIENT'S FINANCIAL CIRCUMSTANCES MATERIALLY CHANGE. NORTHERN MICHIGAN HOSPITALS PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USES THE MEDICARE RATES FOR SERVICES WHEN REQUESTED BY THE PATIENT. ALSO, THE FACILITY USES 50% ON UNINSURED CLAIMS FOR 2011. NORTHERN MICHIGAN HOSPITALS PART V, SECTION B, LINE 21: FOR PATIENTS THAT HAVE NOT RESPONDED TO CHARITY CARE APPLICATIONS OR STATEMENTS RECEIVED GROSS CHARGES ARE LEFT ON THEIR ACCOUNT. ONCE THEY ARE ELIGIBLE UNDER OUR FAP, WE WOULD ADJUST THEIR ACCOUNT ACCORDING TO OUR POLICIES. PART VI, LINE 2: NORTHERN MICHIGAN REGIONAL HOSPITAL ASSESSES THE NEEDS AND ASSETS OF THE COMMUNITY BY COLLABORATING WITH COMMUNITY AND STRATEGIC PARTNERS, REVIEWING DEMOGRAHICS, HEALTH INDICATORS, MORBIDITY AND MORTALITY DATA, ANALYZING COST DRIVERS, AND CONDUCTING FOCUS GROUPS, SURVEYS, AND COMMUNITY FORUMS. PART VI, LINE 3: AS PATIENTS ARE REGISTERED EITHER IN PERSON OR OVER THE PHONE THEY ARE GIVEN CONTACT INFORMATION FOR PATIENT FINANCIAL SERVICES REPRESENTATIVES IF THEY HAVE NO INSURANCE, ARE UNDER INSURED OR HAVE HIGH CO-PAY'S. THERE ARE PATIENT FINANCIAL SERVICES BROCHURES DISPLAYED AT ALL REGISTRATION AREAS THAT DESCRIBE THE VARIOUS FINANCIAL ASSISTANCE PROGRAMS AVAILABLE. THROUGH OUR CARE COORDINATION PROGRAM ALL PATIENTS WITH NO INSURANCE ARE SEEN TO ASSIST WITH FINANCIAL ASSISTANCE PROGRAMS. PART VI, LINE 4: NORTHERN MICHIGAN REGIONAL HOSPITAL IS A 202-BED REGIONAL REFERRAL CENTER SERVING A 22-COUNTY REGION SPANNING NORTHERN MICHIGAN AND THE EASTERN PART OF THE UPPER PENINSULA. WITH A TOTAL MARKET POPULATION OF OVER 440,000, US CENSUS BUREAU DATA (2006) ESTIMATES THAT NEARLY 30% ARE AGE 45-64, AND NEARLY 20% ARE OVER AGE 65. ACCORDING TO THE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH, TOP ADULT HEALTH CONCERNS INCLUDE: OVERWEIGHT AND OBESE, HIGH CHOLESTEROL, HIGH BLOOD PRESSURE, SMOKING, DIABETES AND UNINSURED. PREDICATED ON A VISION TO PROVIDE PATIENT-CENTERED CARE, EXTENSIVE EFFORTS IN TARGETING REGIONAL HEALTH CONCERNS HAS LED TO COLLABORATIVE PROGRAMS AND SERVICES IN PRIMARY CARE, HEART, CANCER AND DIAGNOSTICS. THIS APPROACH TO HIGH QUALITY, COST EFFECTIVE HEALTHCARE DELIVERY IN THIS RURAL AND REMOTE AREA HAS BEEN STRENGTHENED BY A LONG STANDING PRACTICE OF SPECIALTY PHYSICIANS HOSTING ON-SITE CLINIC VISITS TO OUTLYING COMMUNITIES. NORTHERN MICHIGAN REGIONAL HOSPITAL IS WORKING TO INFLUENCE BEHAVIOR THROUGH EDUCATION, PREVENTION THROUGH SCREENING, AND PROVIDING ACCESSIBLE TREATMENT THROUGH PHYSICIAN CLINIS AND HEALTH CENTERS THROUGHOUT THE REGION. PART VI, LINE 5: THE HOSPITAL HAS AN ESTABLISHED REGIONAL COMMUNITY ADVISORY BOARD WHICH MEETS TO ACTIVELY ADDRESS HEALTHCARE ISSUES IN THE REGION. THE HOSPITAL PROVIDES COMMUNITY BENEFIT ACTIVITIES INCLUDING COMMUNITY HEALTH IMPROVEMENT AND HEALTH EDUCATION PROGRAMS AND SERVICES TO IMPROVE ACCESS TO HEALTHCARE, PROMOTE HEALTH AND WELLNESS, AND MANAGE CHRONIC DISEASE. PART VI, LINE 6: AFFILIATES OF NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM INCLUDE THE FOLLOWING ORGANIZATIONS, EACH OF WHICH CONTRIBUTE TO HEALTH PROMOTION IN THE MANNER INDICATED: * NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM FOUNDATION - RAISES, MANAGES, AND DISPENSES FUNDS TO SUPPORT THE MISSION OF NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM AND PROVIDE PROGRAMS THAT ENHANCE THE WELL-BEING OF THE COMMUNITY. * COMMUNITY FREE CLINIC - PROVIDES MEDICAL TREATMENT TO THE AREA'S UNINSURED. * BOULDER PARK TERRACE - PROVIDES SKILLED NURSING AND SUB-ACUTE REHABILITATION SERVICES. * VITAL CARE - PROVIDES HOME HEALTH SERVICES, HOME MEDICAL EQUIPMENT ADN SUPPLIES, HOSPICE SERVICES, PRIVATE DUTY SERVICES, AND ADULT DAY SERVICES. * PHYSICIAN PRACTICES - OFFER THE OPPORTUNITY FOR SEAMLESS PATIENT CARE WITHIN THE REGION THROUGH A SYSTEM OF WHOLLY-OWNED SPECIALTY MEDICINE PRACTICES: MICHIGAN HEART & VASCULAR SPECIALISTS, NORTHERN MICHIGAN INFECTIOUS DISEASES, NORTHERN MICHIGAN HEMATOLOGY/ONCOLOGY, ROGERS CITY MEDICAL GROUP (PRIMARY CARE), AND NORTHERN MICHIGAN REGIONAL HOSPITAL NEUROSURGERY SERVICES. * PRESCRIPTION SERVICES PHARMACY - OFFERS RETAIL PHARMACY SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 MI 1 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM FOUNDATION 360 CONNABLE AVENUE PETOSKEY MI 49770 382445611 501 (C) (3) 60684 N/A N/A RENT PETOSKEY COMMUNITY FREE CLINIC 416 CONNABLE AVENUE PETOSKEY MI 49770 202675817 501 (C) (3) 224110 N/A N/A GENERAL OPERATIONS ALCONA HEALTH CENTER PO BOX 655 ALPENA MI 49707 382170985 501 (C) (3) 70317 N/A N/A GENERAL OPERATIONS HEALTH CLINIC 3 0 SCHEDULE I, PART I, LINE 2 GRANTS MADE TO RELATED ORGANIZATIONS ARE MONITORED THROUGH THE MONTHLY ACCOUNTING PROCESSES. GRANTS MADE TO ALCONA HEALTH CENTER, A FQHC, ARE BASED ON A PERCENT OF THEIR OPERATING LOSSES AS PRESENTED ON THEIR FINANCIAL STATEMENTS. 0 1 0 0 0 0 0 0 0 CATHERINE DEVET 0 327018 0 90050 0 69620 0 48852 0 6371 0 541911 0 0 STEPHEN SCANNELL 0 241305 0 5000 0 17690 0 24663 0 20611 0 309269 0 0 EUGENE KAMINSKI 0 167489 0 100 0 19338 0 25213 0 13998 0 226138 0 0 ROBERT DEAN JR 0 266832 0 0 0 17451 0 9745 0 16897 0 310925 0 0 MARY-ANNE PONTI 0 214236 0 0 0 17496 0 27233 0 7084 0 266049 0 0 CAROLINE SEAGREN 0 155337 0 50 0 18018 0 15636 0 21409 0 210450 0 0 HUGH DEERY 0 272602 0 36050 0 3810 0 9800 0 13155 0 335417 0 0 MARK GRAY 0 171354 0 0 0 2838 0 6954 0 7199 0 188345 0 0 DANIEL DRYDEN 158602 0 0 0 454 0 6148 0 20797 0 186001 0 0 0 KEVIN PENDLETON 140782 0 0 0 1192 0 5713 0 6806 0 154493 0 0 0 ROLAND BROCKWAY 132628 0 4506 0 996 0 4939 0 12768 0 155837 0 0 0 PART I, LINE 3 THE CEO/EXECUTIVE DIRECTOR IS COMPENSATED BY NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM, A RELATED ORGANIZATION. THEY UTILIZE AN INDEPENDENT COMPENSATION CONSULTANT AND BOARD APPROVAL TO ESTABLISH COMPENSATION. PART I, LINE 4B SIX INDIVIDUALS PARTICIPATE IN A NONQUALIFIED 457(F) RETIREMENT PLAN, OF WHICH INCLUDE CATHERINE DEVET, EUGENE KAMINSKI, STEPHEN SCANNELL, ROBERT DEAN, JR., MARY-ANNE PONTI, AND CAROLINE SEAGREN. CATHERINE DEVET RECEIVED A PAYMENT OF $50,918 FROM THE NONQUALIFIED 457(F) RETIREMENT PLAN IN 2011. PETOSKEY HOSPITAL FINANCE AUTHORITY 382834360 NONEAVAIL 2003-10-15 10000000 ER/HEART CTR ADDITION 0 0 0 10000000 110249 9889751 2004 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM IS THE SOLE MEMBER OF NORTHERN MICHIGAN REGIONAL HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER OF NORTHERN MICHIGAN REGIONAL HEALTH, NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM SHALL HOLD AN ANNUAL MEETING IN JANUARY OF EACH YEAR AT SUCH TIME AND PLACE AS MAY BE DESIGNATED BY THE BOARD OF TRUSTEES FOR THE PURPOSE OF ELECTING MEMBERS TO THE BOARD OF TRUSTEES AND TRANSACTING SUCH OTHER BUSINESS AS MAY COME BEFORE THE MEETING. FORM 990, PART VI, SECTION B, LINE 11 ONCE THE FORM 990 HAS BEEN PREPARED, IT IS REVIEWED BY THE FINANCE MANAGER, THE CFO, AND THE CEO. THE COMPLETED FORM 990 IS THEN PROVIDED TO THE BOARD OF TRUSTEES BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF TRUSTEES, MEDICAL STAFF, OFFICERS AND KEY EMPLOYEES REVIEW AND SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY. IF ANY SPECIFIC CONFLICTS OF INTEREST ARISE DURING A BOARD MEETING, THE TRUSTEE WILL LEAVE THE ROOM OR REFRAIN FROM VOTING. COLLEAGUES ARE REMINDED AT THEIR ANNUAL EVALUATION TO ABIDE BY THE CODE OF CONDUCT, WHICH INCLUDES A STATEMENT ON CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 TO DETERMINE EXECUTIVE COMPENSATION FOR THE CEO, VICE PRESIDENTS, AND OFFICERS OF THE CORPORATION, NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM USES AN INDEPENDENT CONSULTANT TO CONDUCT SALARY SURVEYS OF THE HEALTH CARE MARKET. RECOMMENDATIONS ARE REVIEWED AT THE BOARD LEVEL AND APPROVED BEFORE IMPLEMENTATION. THIS WAS LAST REVIEWED JANUARY-APRIL OF 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR THE FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990 PART VII SECTION A: THESE INDIVIDUALS DEVOTE THE FOLLOWING HOURS PER WEEK TO, RELATED ORGANIZATIONS, NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM, NORTHERN MICHIGAN MEDICAL MANAGEMENT, NORTHERN MICHIGAN HEMATOLOGY AND ONCOLOGY, CARDIAC INSTITUTE MICHIGAN HEART AND VASCULAR SPECIALISTS, PETOSKEY COMMUNITY FREE CLINIC, NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM FOUNDATION, HOSPICE OF LITTLE TRAVERSE BAY, CHARLEVOIX NURSING HOME CORPORATION, HEALTHSHARE REAL ESTATE, AND VITALCARE INC. CATHERINE DEVET: 35.0 HOURS STEPHEN SCANNELL: 35.0 HOURS EUGENE KAMINSKI: 31.5 HOURS ROBERT DEAN,JR: 27.5 HOURS MARY-ANNE PONTI: 35.0 HOURS CAROLINE SEAGREN: 44.8 HOURS HOWARD BECK: 27.5 HOURS HUGH DEERY: 51.5 HOURS MARK GRAY: 35.0 HOURS DAVID BUZZELLI: 2.5 HOURS ROBERT FOSTER: 2.0 HOURS THOMAS IRWIN: 2.5 HOURS THOMAS MORAN: 2.0 HOURS STEPHEN EILBING: 4.5 HOURS JOSEPH HANCE: 1.3 HOURS ELISE HAYES: 4.3 HOURS WILLIAM KANE: 1.3 HOURS JOHN KOHLER: 2.0 HOURS DAVID RYNBRANDT: 1.3 HOURS ANN STALLKAMP: 1.3 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -927,442. DECREASE IN TEMPORARILY RESTRICTED NET ASSETS -1,959,130. TRANSFER TO AFFILIATE -1,400,000. TOTAL TO FORM 990, PART XI, LINE 5: -4,286,572. FORM 990, PART XII, LINE 2C: THE FINANCE COMMITTEE OF THE HEALTH SYSTEM ASSUMES RESPONSIBILITY FOR REVIEW OF FINANCIAL STATEMENTS AND OVERSIGHT OF THE CONSOLIDATED AUDIT. THIS PROCESS HAS NOT CHANGED FORM THE PRIOR YEAR. NORTHERN MICHIGAN MEDICAL MANAGEMENT 416 CONNABLE AVENUE PETOSKEY MI 49770 208458840 PHYSICIAN PRACTICE MI 501(C)(3) LINE 3 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 THE CARDIAC INSTITUTE DBA MICHIGAN HEART & VASCULAR SPECIALISTS 416 CONNABLE AVENUE PETOSKEY MI 49770 262774689 PHYSICIAN PRACTICE MI 501(C)(3) LINE 3 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 HOSPICE OF LITTLE TRAVERSE BAY 1 HILAND DRIVE PETOSKEY MI 49770 382425019 HOSPICE CARE MI 501(C)(3) LINE 7 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 PETOSKEY COMMUNITY FREE CLINIC 416 CONNABLE AVENUE PETOSKEY MI 49770 203675817 HEALTH SERVICES MI 501(C)(3) LINE 3 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 416 CONNABLE AVENUE PETOSKEY MI 49770 382445613 HEALTH SERVICES MI 501(C)(3) LINE 11A, I N/A 0 CHARLEVOIX NURSING HOME CORPORATION DBA BOULDER PARK TERRACE 14676 WEST UPRIGHT CHARLEVOIX MI 49720 383038683 SKILLED NURSING FACILITY MI 501(C)(3) LINE 9 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 HEALTHSHARE REAL ESTATE 416 CONNABLE AVENUE PETOSKEY MI 49770 382492223 REAL ESTATE HOLDINGS MI 501(C)(2) NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM FOUNDATION 360 CONNABLE AVENUE PETOSKEY MI 49770 382445611 FUNDRAISING MI 501(C)(3) LINE 11A, I NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 VITALCARE INC 761 LAFAYETTE AVENUE CHEBOYGAN MI 49721 382527255 HOSPICE CARE/HOME HEALTH SERVICES MI 501(C)(3) LINE 9 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 NORTHERN MICHIGAN HEMATOLOGY AND ONCOLOGY 416 CONNABLE AVENUE PETOSKEY MI 49770 320020293 PHYSICIAN PRACTICE MI 501(C)(3) LINE 3 NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM 1 VITALCARE HOME MEDICAL EQUIPMENT INC 761 LAFAYETTE AVENUE CHEBOYGAN MI 49721 382662954 SALE AND RENTAL OF DURABLE MEDICAL EQUIPMENT MI VITALCARE INC C PETOSKEY ASSURANCE LTD 68 WEST BAY ROADPO BOX 1109 GRAND CAYMAN CJ KY1-1102 980628316 PROFESSIONAL AND GENERAL LIABILITY COVERAGE CJ NORTHERN MICHIGAN HOSPITALS C 5150078 1.00000 RAPIN & RAPIN INC DBA PRESCRIPTION SERVICES PHARMACY 416 CONNABLE AVENUE PETOSKEY MI 49770 383465261 RETAIL PHARMACY MI NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM C 0 1 1 1 0 0 0 0 1 1 0 0 0 0 1 1 1 0 PETOSKEY COMMUNITY FREE CLINIC B 224110 COST NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM FOUNDATION B 60684 COST NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM FOUNDATION C 4610007 COST NORTHERN MICHIGAN HEMATOLOGY AND ONCOLOGY O 363295 COST NORTHERN MICHIGAN MEDICAL MANAGEMENT O 2980326 COST PETOSKEY COMMUNITY FREE CLINIC P 100145 COST NORTHERN MICHIGAN HEMATOLOGY AND ONCOLOGY P 1168740 COST NORTHERN MICHIGAN MEDICAL MANAGEMENT P 370894 COST THE CARDIAC INSTITUTE P 1774243 COST RAPIN & RAPIN INC P 54006 COST NORTHERN MICHIGAN REGIONAL HEALTH SYSTEM Q 1400000 COST NORTHERN MICHIGAN REGIOANL HEALTH SYSTEM O 74006037 COST CHARLEVOIX NURSING HOME CORPORATION P 213217 COST