2011-01-21T09:32:05-07:00 2010-06-30 990 2009-07-01 020222156 MEMORIAL HOSPITAL MEMO 6033565461 3073 White Mountain Highway North Conway NH 038605001 Roger Clapp 6033565461 2011-01-21 2009 2016-02-24 21:20:13Z Scott Mckinnon 3073 White Mtn Highway North Conway NH 03860 65193589 0 X http://www.thememorialhospital.org/ X 1910 NH Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire. 18 15 521 85 0 0 218478 263252 59143229 60311639 -364637 622555 541875 478814 59538945 61676260 0 0 0 0 27955899 26564314 30748 0 735878 31558789 33374589 59545436 59938903 -6491 1737357 64202118 66074571 24911479 25349880 39290639 40724691 Memorial Hospital provides Healthcare Services to the residents and visitors of the Mount Washington Valley area of New Hampshire 0 0 0 0 0 Ambulatory & Primary Health Care: Memorial Hospital provided care for 38,248 Outpatients and 13,065 Emergency Room patients. Program service expenses and revenues are included with Inpatient Care 0 0 0 Ambulatory & Primary Health Care: Memorial Hopsital operates Physician practices that provide Primary Care as well as Womens Health, Orthopedics, and several other specialties. Program service expenses and revenues are included with Inpatient Care. (51,693 visits) 51065554 0 60905281 Inpatient Care: Provided care for 1,915 admissions during FY '09. (The cost for the Outpatient, Emergency Room, and Physician Practices are included. 0 0 0 51065554 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 82 0 521 1 0 0 0 0 0 18 15 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X John Newton 6033565461 3073 White Mtn Highway North Conway NH 038605001 Calvin Hunnsicker 0 X 0 0 0 Scott CoteCrosskill 0 X 0 0 0 Ellen Schwartz 0 X 0 0 0 Daphne Wall 0 X 0 0 0 Gene Bergoffen 0 X X 0 0 0 Bayard Kennett 0 X X 0 0 0 Judy Kennedy 0 X X 0 0 0 Roger Clapp 0 X X 0 0 0 Phil Davies 0 X X 0 0 0 Melissa Myers 0 X 0 0 0 James Mallon MD 0 X 0 0 0 Janice Crawford 0 X 0 0 0 John Stratton 0 X 0 0 0 Scott McKinnon 40 X 117716 0 11028 Gary Poquette 40 X X 248676 0 16236 Raymond Rabideau 40 X 10800 269117 30248 Allen Stam MD 40 X 171343 0 20764 Diane Snow MD 40 X 32200 322651 32458 John Newton 40 X 344263 0 14880 Douglas Taylor 40 X 0 434123 36556 Morice Dennery 40 X 0 408508 35174 Victor Lazaron 40 X 5600 393022 35194 David Riss 40 X 0 376232 31943 Richard Noonan 40 X 315313 0 29993 1245911 2203653 294474 20 1 1 0 MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 Physician Services 6802903 Specialty Laboratories PO Box 54920 Loas Angeles CA 90054 Lab Services 255314 NORDX 102 Campus Drive Scarborough ME 04074 Lab Services 248968 Navix Diagnostics PO Box 3698 Boston MA 02241 Nuclear Imaging Services 197399 Burgess Advertising & Marketing 1290 Congress St Portland ME 04102 Advertising & Marketing 193834 7 0 0 28489 0 0 234763 0 263252 Hospital Services 621990 60311639 60311639 0 0 0 0 0 0 60311639 114828 114828 0 0 0 0 0 0 0 0 0 0 143735 0 243998 0 -100263 0 -100263 -100263 0 0 3734970 0 3227243 0 507727 0 507727 0 0 507727 46088 7701 46088 0 0 0 0 Employee Prescriptions 446110 216761 216761 0 0 Cafeteria & Vending 722210 200385 200385 0 0 Community Health Staff Support 621300 83600 83600 0 0 78331 78331 0 0 579077 61676260 60905281 0 507727 599300 31467 567833 0 0 0 0 18230356 14846769 3166664 216923 419818 341899 72924 4995 5964043 4829616 1063863 70564 1350797 1090840 243954 16003 30109 0 30109 0 76772 0 76772 0 29829 29829 9220931 9100860 120071 251512 0 12353 239159 915180 29457 738978 146745 213893 0 213893 0 3284377 2823294 436356 24727 169450 78922 90399 129 10064 10064 0 0 0 0 3120436 2656498 447305 16633 752932 0 752932 0 Medical Supplies 8202965 8202965 0 0 Equipment Lease & Maint 1190691 1117455 73236 0 Community Support 235509 235509 0 0 Physician Recruitment & Support 189173 189173 0 0 Bad Debt 5480766 5480766 0 0 59938903 51065554 8137471 735878 7190883 11324383 10147049 10404353 0 7723791 6410450 1713937 1900250 238514 50340 57747466 26286519 32520480 31460947 4197760 4114714 162683 113501 307021 295633 64202118 66074571 4642936 4452042 20268543 19899867 997971 24911479 25349880 X 38435892 39862284 241384 249044 613363 613363 39290639 40724691 64202118 66074571 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3311669 0 263924 0 0 0 3575593 3205137 640000 -533468 0 0 0 3311669 0.8 0.17 0.03 0 0 0 598483 598483 0 39580322 15818957 23761365 0 0 0 0 0 15791228 9679230 6111998 0 1777433 788332 989101 31460947 113501 113501 Unamortized Bond Issuance Costs 295633 295633 61676260 59938903 1737357 -303302 0 0 0 0 -303302 1434055 61587127 -303302 0 0 0 -303302 61890429 29829 -243998 -214169 61676260 60153072 0 0 0 243998 243998 59909074 29829 0 29829 59938903 SchD_P05_S00_L04 Schedule D, Part V, Line 4 The Endowment Fund retains permanently restricted funds with income available for general purposes. Also, a portion of the earnings are to be used to assist patients with free care. The remainder of the fund is board restricted. SchD_P12_S00_L04b Schedule D, Part XII, Line 4b Rental Expenses SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Rental Expenses Annual Golf Tournament 58810 28489 30321 0 0 17817 0 0 12504 0 0 58810 28489 30321 0 0 17817 0 0 12504 30321 0 1 1 1 X 2.5 1 X 0 1 1 0 1 1 1863553 677 1862876 0.0311 6574807 4928721 1646086 0.0275 0 0 0 0 0 0 8438360 4929398 3508962 0.0586 298122 1650 296472 0.0049 6000 0 6000 0.0001 0 0 0 0 0 0 0 0 1950 0 1950 0.00 0 0 306072 1650 304422 0.0050 0 0 8744432 4931048 3813384 0.0636 0 3008941 0 15161267 15011155 150112 X 1 1 Memorial Hospital

3073 White Mountain Hwy North Conway NH 03860

X X X X In conjunction with the FPL guidelines the Hospital uses a Net Worth criteria. For an individual to qualify for a 100% discount the Net Worth must be at or below $200,000. Worksheet 2 Ratio of Patient Care Cost to Charges was used to calculate cost No Footnote. Worksheet 2 was used to calculate cost. The filed 2010 Medicare Cost report was used to report Hospital costs and revenues The policy include the following statement: With the exception of insurance coverage, collection activity shall not be initiated or pursued for any amounts approved under the Memorial Hospitals Healthcare Assistance Program The members of the Memorial Deveopment Foundation and other local agencies, providers and businesses, came together to form the MWV Community Heathcare Collaborative to cooperatively search for solutions to local health needs. In January 2010 they began a Community Needs Assessment. The "Six-Step Community Health Assessment Process" developed by the Association of Community Health Improvement was recommended to build the core framework for the project. The Hospital uses several methods for communicating and educating patients regarding assistance with the bills. At our registration and credit and collections offices it is visible to all with handouts. Our webiste includes information regarding the Healthcare Assistance program. On all bills with a patient liability a note is recorded that informs the patient or guarantor of the availability of assistance. Also the State Hospital Association website has links to various programs at the state and local levels. The hospital serves the northern part of Carroll County in NH and the western portion of Oxford County in Maine. The Mount Washington Valley is a four-season destination resort area and serves the tourists the frequent the area. X X 1 1 X X X X X X 0 0 0 0 0 0 0 0 0 Gary Poquette 185250 0 46183 0 17243 0 3250 0 12986 0 264912 0 Scott McKinnon 82500 0 22000 0 13216 0 0 0 11028 0 128744 0 John Newton 330000 0 15000 0 -737 0 0 0 14880 0 359143 0 Diane Snow MD 0 261829 0 0 32200 60822 0 10284 0 22174 32200 355109 Allen Stam MD 143623 0 0 0 27720 0 6509 0 14255 0 192107 0 Raymond Rabideau 0 197007 0 60000 10800 12110 0 8074 0 22174 10800 299365 Douglas Taylor 0 412123 0 0 0 22000 0 14382 0 22174 0 470679 Morice Dennery 0 392008 0 0 0 16500 0 13000 0 22174 0 443682 Victor Lazaron 0 364022 0 0 5600 29000 0 13020 0 22174 5600 428216 David Riss 0 322660 0 31572 0 22000 0 12376 0 19567 0 408175 Richard Noonan 297087 0 0 0 18226 0 14031 0 15962 0 345306 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a The Hospital will reimburse for Travel for Companions if prior approval by the Chairman of the Board is granted. As part of the recruitment for a ne CEO a housing allowance was granted for a temporary period of time. New Hampshire Health & Education Facilities Authority 020279866 644614QC6 2006-06-14 21069204 To Construct & Renovate Hospital Facilities and Payoff Existing Debt 0 0 21069204 0 0 0 324775 0 20226123 2009 0 0 1 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 The sole member of The Memorial Hospital is The Memorial Development Foundation, a 501(c)(3) organization F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b The sole member Memorial Development Foundation ratifies the appointments to the Board of Trustees of the Memorial Hospital F990_P06_S0B_L11 Form 990, Part VI, Section B, Line 11 The form 990 was provided to the Finance committee and the full Board of Trustees. It was reviewed by the Finance Committee on January 18, 2011, and then forwarded to the full Board of Trustees on January 19, 2011 for approval before submission. These reviews were led by the Treasurer. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Conflict of Interest declaration forms are submitted annually in January by members of the Board of Trustees and are distributed to the full board for information puposes, and reviewed in depth by the Governance Committee. It is the members responsibility to notify the board should any conflicts arise in between signings and of all members of the board to immediately raise any conflicts that they become aware of. Board members with conflicts will recuse themselves from discussions and votes on that issue. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Compensation Committee of the board conducts the CEO evaluation and compensation process. The CEOs performance is reviewed against the targets set for the year and his semi annual bonus determination. The CEOs compensation is compared vs the Sullivan Cotter and Associates information and periodically reviewed by our compensation consultant. No one with a conflict of interest relative to the hospital is involved in these discussions, and minutes are recorded by the Secretary of the Board. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Memorial Hospital will make copies of such documents available to the general public upon request. Memorial Development Foundation PO Box 5001 North Conway NH 03860 223160795 Coordinate healthcare NH 501(c)(3) 509(a)(3) Type 1 N/A Visiting Nurse & Hospice Care Services of Northern Carroll County PO Box 432 North Conway NH 03860 020311473 Visiting Nurse & Hospice Services NH 501(c)(3) 9 N/A White Mountain Community Health PO Box 2800 Conway NH 03818 020358715 Community Health Center NH 501(c)(3) 7 N/A Carroll County Health & Home Care Services Inc PO Box 420 Chocorua NH 03817 237337000 Home Care Services NH 501(c)(3) 7 N/A MWV Healthcare Assoc Inc PO Box 2540 North Conway NH 03860 020477066 Contract with Healthcare Professionals & Retail Pharmacy NH Memorial Hospital C 100 100 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 MWV Healthcare Assoc Inc a-iv 15708 MWV Healthcare Assoc Inc o 7045987 White Mountain Community Health i 59004 White Mountain Community Health p 67727 White Mountain Community Health o 61050 Carroll County Health & Home Care Services Inc p 133609 Carroll County Health & Home Care Services Inc o 33063 Visiting Nurse & Hospice Care Services of Northern Carroll County p 116282