2011-05-12T16:00:58-05:00 2010-06-30 DIXON HUGHES GOODMAN LLP 500 Ridgefield Court Asheville NC 28806 990 2009-07-01 320090450 SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE INC SOUT 7708977600 11 UPPER RIVERDALE ROAD RIVERDALE GA 30274 WILLIAM E CASEY 7708977600 2011-05-12 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z WILLIAM E CASEY 11 UPPER RIVERDALE ROAD RIVERDALE GA 30274 12937468 0 X N/A X 2002 GA TO PROVIDE HIGH-QUALITY, LONG-TERM ACUTE CARE TO THE COMMUNITIES WE SERVE. 7 7 0 1 0 0 0 11893572 12926964 91997 8182 2375 2322 11987944 12937468 127784 465522 0 4108208 4590503 0 0 5533479 14592074 9769471 19648099 2218473 -6710631 7793564 9620489 1169798 9707354 6623766 -86865 THE MISSION OF SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE IS TO PROVIDE HIGH-QUALITY, LONG-TERM ACUTE CARE TO THE COMMUNITIES WE SERVE. 0 0 9118267 465522 12926964 TO FULFILL ITS MISSION, THE SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES LONG TERM ACUTE INPATIENT CARE TO INDIVIDUALS WHOSE CONDITION IS SO SIGNIFICANT THAT A HOSPITAL STAY OF ONE MONTH OR MORE IS ANTICIPATED. THE HOSPITAL CARES FOR PATIENTS WHO ARE MEDICALLY COMPLEX AND MAY REQUIRE DAILY MONITORING; VENTILATOR DEPENDENT PATIENTS, OXYGEN DEPENDENT PATIENTS NEEDING RESPIRATORY REHABILITATION, PATIENTS WITH SLOW HEALING WOUNDS, PATIENTS BENEFITING FROM PHYSICAL, OCCUPATIONAL OR SPEECH THERAPY, AND FOR PATIENTS REQUIRING PALLIATIVE AND END OF LIFE CARE. THE MEDICAL AND THERAPEUTIC NEEDS OF THE PATIENTS ARE MET USING AN INTERDISCIPLINARY, HOLISTIC TEAM APPROACH INCORPORATING MEDICAL MANAGEMENT, PHYSICAL, RESPIRATORY, OCCUPATIONAL AND SPEECH THERAPIES IN AN EFFORT TO RESTORE INDIVIDUAL QUALITY OF LIFE TO AS HIGH A DEGREE AS POSSIBLE AND TO PROMOTE SELF-HELP AND INDEPENDENCE TO THE EXTENT FEASIBLE. THE SPIRITUAL NEEDS OF THE PATIENTS, FAMILIES AND SIGNIFICANT OTHERS ARE PROVIDED FOR AS WELL. PATIENT CARE PROGRAM SERVICESTO THE LIMITS OF ITS RESOURCES, SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE IS AN INSTITUTION OF PUBLIC CHARITY; THUS, THE MOST TANGIBLE EXPRESSION OF CHARITABLE PURPOSE IS THE PROVISION OF HEALTHCARE SERVICES TO THOSE PERSONS WHO ARE UNABLE TO PAY (CHARITY CARE). INPATIENT CHARITY CARE - UNREIMBURSED COSTS OF PROVIDING CARE FOR THE FINANCIALLY AND MEDICALLY INDIGENT.IN KEEPING WITH MISSION, VALUES, AND VISION, SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES CHARITY CARE SERVICES IN A MANNER THAT RESPECTS THE DIGNITY OF THE PATIENTS AND THEIR FAMILIES. CHARITY CARE IS PROVIDED WITHOUT CHARGE OR AT A CHARGE THAT IS LESS THAN THE USUAL CHARGE FOR SUCH SERVICES. THE DETERMINATION AS TO THE AMOUNT TO BE CHARGED, IF ANY, IS MADE ACCORDING TO A PATIENT'S ABILITY TO PAY, CONSIDERATION OF THE PATIENT'S ASSETS AND LIABILITIES, AND DETERMINED BY THE ESTABLISHED ELIGIBILITY CRITERIA BASED ON THE MOST CURRENT FEDERAL POVERTY GUIDELINES. A FINANCIALLY INDIGENT PATIENT IS ONE WHO IS UNINSURED OR UNDERINSURED AND WHOSE ECONOMIC CIRCUMSTANCES PLACE THEM AT OR UNDER 200% OF THE FEDERAL POVERTY GUIDELINES. A MEDICALLY INDIGENT PATIENT IS A PERSON WHOSE MEDICAL OR HOSPITAL BILLS AFTER PAYMENT BY THIRD-PARTY PAYERS EXCEEDS 25% OF THEIR ANNUAL GROSS INCOME. NO PATIENT IS REFUSED NECESSARY MEDICAL CARE ON THE BASIS OF THEIR INABILITY TO PAY.OTHER COMMUNITY BENEFITSUNREIMBURSED GOVERNMENT SPONSORED PROGRAMSIN ADDITION TO THE PROVISION OF CARE WITHOUT EXPECTATION OF PAYMENT (CHARITY CARE), SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES SERVICES TO PERSONS COVERED UNDER GOVERNMENT SPONSORED PROGRAMS, INCLUDING MEDICARE, DOD, CHAMPUS, TRICARE, AND TRICARE FOR LIFE. SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES SERVICES TO PERSONS COVERED UNDER THE FEDERAL MEDICARE PROGRAM AND, IN FACT, THIS IS THE LARGEST SINGLE PAYER CLASSIFICATION OF PATIENTS SERVED BY THIS HEALTH SYSTEM. THE PAYMENT RATE FOR INPATIENT SERVICES IS ON A PER DISCHARGE RATE, CALCULATED BASED ON THE DIAGNOSTIC-RELATED GROUP INTO WHICH THE PATIENT IS CATEGORIZED. TOTAL PATIENTS SERVED: 293TOTAL PATIENT DAYS OF CARE PROVIDED: 8,214CHARITY CARE PATIENT DAYS PROVIDED: 339CHARITY CARE COST: $ 291,905 9118267 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 28 0 1 0 0 0 0 0 0 0 0 0 0 7 7 0 1 0 0 0 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 GA X PAUL VEILLON CFO OF CHRISTUS DUBUIS HEALTH SYSTEM 7132772300 1700 WEST LOOP SOUTH STE 1100A HOUSTON TX 77027 MITCH JOHNSON 2.00 X X 1100 0 0 WILLIAM E CASEY 1.00 X 1700 0 0 RONALD M DODSON 1.00 X 600 0 0 WILLIAM B LEWIS JR 1.00 X 600 0 0 MARGARET L MANOS 1.00 X 1242 0 0 BENNY R WHITMORE 1.00 X 1068 0 0 DR CLAIRE WILLIE 1.00 X 600 0 0 JAN HAMILTON-CRAWFORD 40.00 X 171032 0 4034 177942 0 4034 1 0 1 1 SOUTHERN REGIONAL MEDICAL CENTER 11 UPPER RIVERDALE ROAD SW RIVERDALE GA 30274 ANCILLIARY HOSPITAL SERVICES 1243465 CHRISTUS DUBUIS HEALTH SYSTEM 1700 WEST LOOP SOUTH STE 1100A HOUSTON TX 77027 MANAGEMENT SERVICES 871128 MEDTEMPS INC 6560 HIGHWAY 5 RIVERDALE GA 30274 CONTRACT LABOR 280574 PRECISE HEALTHCARE SOLUTIONS LLC 5300 MEMORIAL DR STE 134 STONE MOUNTAIN GA 30083 CONTRACT LABOR 251587 WESLEY MEDICAL STAFFING 5901B PEACHTREE DUNWOODY ATLANTA GA 30328 CONTRACT LABOR 113354 5 PATIENT SERVICE REVENU 900099 12926964 12926964 12926964 8182 8182 MEDICAL RECORDS TRANSC 561499 2322 2322 2322 12937468 12926964 0 10504 465522 465522 181976 181976 3736778 3479575 257203 129983 115366 14617 261965 231017 30948 279801 248337 31464 871128 871128 318618 318618 2066 2066 2587830 2440553 147277 15508 15508 1412184 1312508 99676 575294 575294 39894 10962 28932 105818 8583 97235 99197 99197 96161 72121 24040 LITIGATION EXPENSE 8409144 8409144 BAD DEBT EXPENSE 59232 59232 19648099 9118267 10529832 0 5781618 7045916 1416923 1780874 49812 54732 74123 60505 1541533 863071 471088 678462 7793564 9620489 648402 804128 521396 8903226 1169798 9707354 X 6623766 -86865 6623766 -86865 7793564 9620489 X 0 1 0 X 0 X 0 0 0 0 0 0 0 0 1 2066 2066 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: THE HOSPITAL IS A MEMBER OF THE NATIONAL ASSOCIATION OF LONG TERM HOSPITALS AND THE GEORGIA HOSPITAL ASSOCIATION. THESE ORGANIZATIONS ENGAGE IN LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES, AND EACH YEAR, A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING EXPENDITURES. FOR THE CURRENT YEAR, DUES ALLOCATED TO LOBBYING WAS APPROXIMATELY $2,066. 21250 6375 14875 1520283 856696 663587 678462 THIRD PARTY SETTLEMENTS PAYABLE 134498 DUE TO SOUTHERN REGIONAL 134019 DUE TO CHRISTUS DUBUIS HEALTH SYSTEM 225565 LITIGATION ACCRUAL 8409144 8903226 12937468 19648099 -6710631 0 -6710631 12937468 0 12937468 0 12937468 19648099 0 19648099 0 19648099 1 1 1 X 1 X 1 1 0 1 1 282460 282460 0.01440 282460 282460 0.01440 349509 349509 0.01780 349509 349509 0.01780 631969 631969 0.03220 0 20109 0 9470028 7978258 1491770 X 1 1 SOUTHERN CRESCENT HOSP FOR SPEC CARE

11 UPPER RIVERDALE ROAD RIVERDALE GA 30274

X LONG-TERM ACUTE CARE HOSPITAL Part I, Line 3c: IN ADDITION TO PROVIDING CHARITY CARE BASED ON THE FEDERAL POVERTY GUIDELINES, THE HOSPITAL PROVIDES CARE TO MEDICALLY INDIGENT PATIENTS WHOSE MEDICAL OR HOSPITAL BILLS AFTER PAYMENT BY THIRD-PARTY PAYERS EXCEED 25% OF THE PATIENT'S ANNUAL GROSS INCOME AND THE PATIENT IS UNABLE TO PAY THE REMAINING BILL. Part I, Line 7: WORKSHEET 2 OF THE 2009 SCHEDULE H INSTRUCTIONS WAS USED TO DERIVE A COST-TO-CHARGES RATIO USED TO CALCULATE AMOUNTS OF COMMUNITY BENEFIT EXPENSE AT COST FOR PART I, LINE 7. Part I, Line 7f: THE AMOUNT OF TOTAL EXPENSE ON FORM 990, PART IX, LINE 25 INCLUDES $59,232 OF BAD DEBT THAT HAS BEEN REMOVED FOR PURPOSES OF CALCULATING COMMUNITY BENEFIT EXPENSE PERCENTAGE REPORTED ON LINE 7, COLUMN (F). Part III, Line 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE FOR BAD DEBT. THE ORGANIZATION USED AN INTERNAL COST-TO-CHARGE RATIO TO COMPUTE BAD DEBT AT COST. Part III, Line 8: THE ORGANIZATION USED THE MEDICARE COST REPORT TO DETERMINE COSTS OF CARE RELATING TO MEDICARE PAYMENTS. Part III, Line 9b: SOUTHERN CRESCENT HOSPITAL DOES NOT OUTSOURCE PATIENT BALANCES TO A THIRD PARTY DEBT COLLECTION AGENCY. ALL COLLECTIONS ARE DONE BY IN-HOUSE COLLECTORS USING COLLECTION LETTERS. PATIENTS ARE NOT SUBJECT TO HARASSMENT OR LEGAL ACTION DUE TO THEIR INCAPACITY TO PAY. PATIENTS THAT ARE UNABLE TO PAY ARE SENT CHARITY CARE INFORMATION.PATIENTS RECEIVE PRIVATE LETTERS/BILLS EACH MONTH INDICATING BALANCE DUE. PATIENTS WHO HAVE NOT MADE PAYMENTS FOR A 30-DAY PERIOD WILL RECEIVE A LETTER REQUESTING PAYMENT. PATIENTS WHO ARE UNABLE TO PAY THEIR BALANCE WILL BE CONSIDERED FOR CHARITY CARE IF APPROPRIATE. COLLECTION EFFORTS WILL CONTINUE FOR 120 DAYS DURING WHICH AT LEAST 3 COLLECTION ATTEMPTS ARE MADE. AFTER THIS PERIOD THE BALANCE IS WRITTEN OFF EITHER AS BAD DEBT OR CHARITY CARE. MEDICAID PATIENTS OR MEDICARE PATIENTS WHO HAVE MEDICAID WILL BE CONSIDERED INDIGENT. MEDICAID DENIALS OF PAYMENT FOR VALID REGULATIONS, SUCH AS CODE 238 "MEDICAID PAID EQUAL TO OR GREATER THAN MEDICAID PAID, NO FURTHER PAYMENT", WILL RESULT IN THE DEDUCTIBLE AND COINSURANCE TO BE CONSIDERED BAD DEBT AND ANY OTHER BALANCE WILL BE CONSIDERED CHARITY CARE. Part VI, Line 2: SOUTHERN CRESCENT HOSPITAL ASSESSES THE NEEDS OF THE COMMUNITY THROUGH A STRATEGIC PLANNING PROCESS. Part VI, Line 3: ALL PATIENTS ARE ASSESSED DURING THE REGISTRATION PROCESS. PATIENTS IDENTIFIED AS POSSIBLE CHARITY CASES WILL BE ASKED TO COMPLETE AN APPLICATION FOR FINANCIAL ASSISTANCE. PATIENTS WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE FROM A GOVERNMENTAL PROGRAM BUT ARE NOT CURRENTLY ENROLLED ARE REFERRED TO THE APPROPRIATE PROGRAM. PATIENTS WHO CAN PROVE ELIGIBILITY FOR MEDICAID BUT ARE NOT PATIENTS IN A MEDICAID APPROVED HOSPITAL WILL BE DEEMED AS INDIGENT AND AUTOMATICALLY QUALIFY FOR CHARITY CARE. PATIENTS ADMITTED TO THE HOSPITAL WITH MEDICARE AS THE ONLY INSURANCE WILL BE MONITORED AS MEDICARE DAYS NEAR DEPLETION. THIRTY DAYS PRIOR TO THE END OF THE MEDICARE COVERAGE, AN INTERVIEW AND AN APPLICATION FOR FINANCIAL ASSISTANCE WILL BE REQUESTED AS APPROPRIATE. THESE PATIENTS ARE ASSESSED AS TO MEETING THE GUIDELINES FOR RECEIVING CHARITY CARE IF THE STAY SHOULD EXCEED MEDICARE COVERAGE LIMITS. AS SOON AS SUFFICIENT INFORMATION IS AVAILABLE CONCERNING THE PATIENT'S FINANCIAL RESOURCES AND ELIGIBILITY FOR GOVERNMENT ASSISTANCE, A DETERMINATION IS MADE CONCERNING THE PATIENT'S ELIGIBILITY FOR CHARITY. NO COLLECTION EFFORT IS PURSUED ON A CHARITY ACCOUNT AFTER SUCH DETERMINATIONS ARE MADE. Part VI, Line 4: SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE (SCHSC), PART OF THE NATION'S LEADING NONPROFIT, FAITH-BASED LONG-TERM ACUTE CARE SYSTEMS, IS DEDICATED TO PROVIDING EXCEPTIONAL INTERDISCIPLINARY HEALTH CARE TO PATIENTS WHO REQUIRE EXTENDED HOSPITAL STAYS. SOUTHERN CRESCENT HOSPITAL SERVES A POPULATION BASE OF 600,000 IN OUR PRIMARY SERVICE AREA. THERE ARE FOUR ACUTE CARE HOSPITALS AND ONE ADDITIONAL LONG-TERM ACUTE HOSPITAL SERVING THESE ZIP CODES. THERE ARE NO FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS OR POPULATIONS PRESENT IN THE COMMUNITY. Part VI, Line 5: Part VI, Line 6: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES OR INDEPENDENT CONTRACTORS OF THE ORGANIZATION NOR FAMILY MEMBERS THEREOF. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. THE ORGANIZATION MAKES DONATIONS TO VARIOUS FOUNDATIONS AND ORGANIZATIONS THAT PROVIDE HEALTH CARE TO THE COMMUNITY. IN ADDITION TO THE PROVISION OF CARE WITHOUT EXPECTATION OF PAYMENT (CHARITY CARE), SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES SERVICES TO PERSONS COVERED UNDER GOVERNMENT SPONSORED PROGRAM, INCLUDING MEDICARE, DOD, CHAMPUS, TRICARE AND TRICARE FOR LIFE. GA 1 SOUTHSIDE MEDICAL CENTER INC 1046 RIDGE AVENUE SW ATLANTA GA 30315 581131002 501(C)(3) 173146 OPERATIONAL SUPPORT TO PROMOTE EXEMPT PURPOSE SOUTHERN REGIONAL MEDICAL CENTER FOUNDATION 11 UPPER RIVERDALE ROAD RIVERDALE GA 30274 581983516 501(C)(3) 266365 FUND WIRELESS SYSTEMS TO 7 EMS PROGRAMS, SPONSOR CRESCENT BALL, AND SPONSOR WOMEN CONNECTING WOMEN EVENT 2 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: THE GRANT TO SOUTHSIDE MEDICAL CENTER, INC., A TAX EXEMPT ENTITY, WAS APPROVED BY THE BOARD AND DOCUMENTED IN THE BOARD MINUTES AND IS MADE ACCORDING TO AN AGREEMENT EFFECTIVE 11/14/2008 BETWEEN SOUTHSIDE MEDICAL CENTER, INC. AND SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. THE AGREEMENT STATES THAT SOUTHERN CRESCENT HOSPITAL WILL PROVIDE IN TOTAL FINANCIAL ASSISTANCE UP TO $400,000 DURING THE THREE YEAR TERM OF THE AGREEMENT TO COVER OPERATION SHORTFALLS AND A ONE-TIME START UP COST REIMBURSEMENT. THE AGREEMENT WAS ENTERED INTO SO THAT SOUTHSIDE MEDICAL CENTER WOULD BE ABLE TO SERVE THE UNDERSERVED PATIENT COMMUNITY WITHIN THE SERVICE AREAS OF SOUTHERN CRESCENT HOSPITAL REGARDLESS OF THE PATIENT'S ABILITY TO PAY. SOUTHSIDE MEDICAL CENTER IS REQUIRED TO SUBMIT AN ITEMIZATION OF COSTS TO BE APPROVED BY SOUTHERN CRESCENT PRIOR TO EACH PAYMENT. X X 0 0 0 0 0 1 0 0 0 JAN HAMILTON-CRAWFORD 140837 0 18255 0 11940 0 0 0 4034 0 175066 0 0 0 Part I, Line 6 THE ORGANIZATION MAINTAINS AN INCENTIVE COMPENSATION PLAN. IT IS CONTINGENT UPON THE ACHIEVEMENT OF TWO INDEPENDENT TRIGGERS: (1) AT LEAST 100% OF THE BUDGETED OVERALL SYSTEM NET PROFIT TARGET AND (2) 100% OF COMMUNITY BENEFIT INDICATOR MUST BE MET SYSTEM WIDE. IF THESE TRIGGERS ARE NOT MET,EITHER AN AMOUNT UP TO 5% OF BASE PAY MAY BE AWARDED FOR OUTSTANDING PERFORMANCE AS EVIDENCED BY MEETING INDIVIDUAL INCENTIVE COMPENSATION GOALS OR AN AMOUNT APPROVED BY THE BOARD OF DIRECTORS. JAN HAMILTON-CRAWFORD WAS PAID $18,255 BY REACHING GOALS RELATED TO THIS INCENTIVE COMPENSATION PLAN. Supplemental Information Part III COMPENSATION FROM UNRELATED ORGANIZATIONS: JAN HAMILTON-CRAWFORD RECEIVED COMPENSATION FROM CHRISTUS CONTINUING CARE (D/B/A "CHRISTUS DUBUIS HEALTH SYSTEM"), AN UNRELATED ORGANIZATION THAT MANAGES SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE AND WHO LEASES THEIR EMPLOYEES TO PERFORM SERVICES FOR SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. IN ADDITION, SHE RECEIVED NO DIRECT COMPENSATION FROM SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. COMPENSATION REPORTED ON PART II REFLECTS AN AMOUNT OF TOTAL COMPENSATION ALLOCATED TO SERVICES PERFORMED SPECIFICALLY FOR SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. Form 990, Part VI, Section A, line 3 SOUTHERN CRESCENT HOSPITAL IS MANAGED BY CHRISTUS CONTINUING CARE D/B/A "CHRISTUS DUBUIS HEALTH SYSTEM"). THE EMPLOYEES OF DUBUIS HEALTH SYSTEM, INC. ARE LEASED TO SOUTHERN CRESCENT HOSPITAL TO PERFORM SERVICES. ALL EMPLOYEE POLICIES OF DUBUIS HEALTH SYSTEM, INC. APPLY TO EMPLOYEES WORKING WITHIN CHRISTUS DUBUIS HEALTH SYSTEM AND EMPLOYEES LEASED TO SOUTHERN CRESCENT HOSPITAL. Form 990, Part VI, Section A, line 7a THE ORGANIZATION HAS NO OFFICIAL MEMBERS; HOWEVER, SOUTHERN REGIONAL HEALTH SYSTEM, A GEORGIA NONPROFIT CORPORATION, APPOINTED THE INITIAL BOARD, AND RETAINS THE RIGHT TO APPOINT UP TO TWO MEMBERS. Form 990, Part VI, Section A, line 8b THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. Form 990, Part VI, Section B, line 11 THE RETURN IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM. THE ORGANIZATION REVIEWS THE PREPARED RETURN FOR ACCURACY. UPON COMPLETION OF THE FINAL FORM 990 BY THE INDEPENDENT ACCOUNTING FIRM, THE 990 IS SUBMITTED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING THE RETURN WITH THE INTERNAL REVENUE SERVICE. Form 990, Part VI, Section B, line 12c THE ORGANIZATION MAINTAINS SEPARATE CONFLICT OF INTEREST POLICIES FOR EMPLOYEES OF THE ORGANIZATION AND FOR THE MEMBERS OF THE BOARD OF DIRECTORS. BOTH POLICIES REQUIRE ANNUAL DISCLOSURE OF ANY CONFLICTS OF INTEREST. THE EMPLOYEE POLICY INCLUDES OFFICERS, MEDICAL DIRECTORS AND OTHER DIRECTORS, AND ALL OTHER ASSOCIATES. THE EMPLOYEE DISCLOSURE IS REVIEWED BY THE EMPLOYEE'S IMMEDIATE SUPERVISOR. IN ADDITION, KEY LEADERS MUST CERTIFY ANNUALLY THEIR RECEIPT AND UNDERSTANDING OF THE CONFLICT OF INTEREST POLICY. IF ANY CONFLICTS ARE PRESENT, THE EMPLOYEE AND THE ORGANIZATION'S ADMINISTRATION WILL IMPLEMENT A MUTUALLY AGREED UPON PLAN TO RESOLVE THE CONFLICT. IN ADDITION, THE ORGANIZATION IMPLEMENTS AN INTEGRITY PROGRAM TO SUPPORT AND MAINTAIN THE CORPORATE INTEGRITY OF THE ORGANIZATION. THE POLICY FOR THE MEMBERS OF THE BOARD OF DIRECTORS REQUIRES ANY BOARD MEMBER, UPON DETERMINATION OF A CONFLICT OF INTEREST, TO ABSENT HIMSELF OR HERSELF WITHOUT COMMENT FROM NOT ONLY THE VOTE BUT ALSO FROM THE DELIBERATION. BOARD MEMBERS ARE NOT ALLOWED TO BE EMPLOYED BY THE ORGANIZATION UNLESS THEY HAVE FIRST RESIGNED FROM THE BOARD. IN ADDITION, AT THE BEGINNING OF EACH BOARD MEETING, THE BOARD CHAIR ASKS THE BOARD MEMBERS TO REVIEW THE AGENDA AND SHARE ANY POTENTIAL CONFLICTS OF INTEREST PRIOR TO THE BEGINNING OF BUSINESS. Form 990, Part VI, Section B, line 15a THE SALARY FOR THE PRESIDENT/CHAIRMAN OF THE BOARD OF DIRECTORS WAS BASED ON COMPARATIVE SALARIES FROM OTHER BOARDS. IN DETERMINING THE SALARY FOR THE TOP MANAGMENT OFFICER, THE ORGANIZATION USES THE SAME PROCEDURE AS USED FOR ALL OTHER EMPLOYEES. THE HUMAN RESOURCES DEPARTMENT USES CITY AND STATE SALARY SURVEYS AVAILABLE TO THE PUBLIC. THE SALARY RATES ARE REVIEWED BY THE HUMAN RESOURCES DEPARTMENT PERIODICALLY BASED ON CHANGES IN THE MARKET PLACE. THE BOARD OF DIRECTORS HAS FINAL APPROVAL OVER THE COMPENSATION LEVELS SET. Form 990, Part VI, Section C, line 18 PHOTOCOPIES OF THE FORM 1023 AND RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. Form 990, Part VI, Section C, line 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE THROUGH THE STATE OF GEORGIA'S SECRETARY OF STATE, OR UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. FINANCIAL STATEMENTS AND THE CONFLICT OF INTEREST POLICY ARE ALSO AVAILABLE UPON REQUEST OR ONLINE AT WWW.DUBUIS.ORG. FORM 990, PART V, LINE 2 SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE ENTERED INTO A MANAGEMENT AGREEMENT WITH CHRISTUS DUBUIS HEALTH SYSTEM, AN UNRELATED ORGANIZATION. AS PROVIDED BY THE MANAGEMENT AGREEMENT, CHRISTUS DUBUIS HEALTH SYSTEM AGREES TO PROVIDE TO THE HOSPITAL AN ADMINISTRATOR AND ALL OTHER EMPLOYEES REQUIRED TO STAFF THE HOSPITAL. SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PAYS DIRECTLY FROM THEIR BANK ACCOUNT THE SALARIES OF ALL EMPLOYEES OTHER THAN THE ADMINISTRATOR AND REIMBURSES CHRISTUS DUBUIS HEALTH SYSTEM FOR THE SALARY EXPENSE OF THE ADMINISTRATOR AND THE PAYROLL TAXES AND EMPLOYEE BENEFITS ASSOCIATED WITH THE ADMINISTRATOR AND ALL OTHER EMPLOYEES. UNDER THIS ARRANGEMENT THERE ARE NO EMPLOYEES OF SOUTHERN CRESCENT HOSPITAL AND THUS NO FORMS W-2 ISSUED BY SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. HOWEVER, THE EXPENSES RELATED TO THESE EMPLOYEES ARE SHOWN AS SALARY, PAYROLL TAX AND EMPLOYEE BENEFIT EXPENSES ON FORM 990 PART IX. FORM 990, PART IX, LINE 24A: LITIGATION EXPENSE: The Hospital is currently undergoing an investigation by the U.S Department of Justice. The Hospital has received correspondence from the U.S. Department of Justice stating that the Hospital has been overpaid for Medicare claims in the amount of $8.4 million.