2011-08-10T15:46:34-05:00 2010-09-30 FEELEY & DRISCOLL PC 200 PORTLAND STREET BOSTON MA 02114 990 2009-10-01 222472997 BROCKTON HOSPITAL INC BROC 5089417000 680 CENTRE STREET BROCKTON MA 02302 kim hollon 5089417000 2011-07-28 1 Alan Garofalo 6177427788 2009 2016-02-24 21:20:13Z Kim Hollon 680 Centre Street Brockton MA 02302 218030084 0 X www.signature-healthcare.org X 1890 MA The hospital operates a 253 bed acute care facility that provides health care services to 20 communities in Southeastern Massachusetts. In fiscal year 2010 the hospital provided $16,282,280 of unreimbursed charity care. This equates to thousands of visits to primary care and specialty clinics. The hospital's children and youth program, a hospital-based primary care practice that treats under-privileged children, accommodated approximately 12,500 patient visits. Thousands of underinsured people took advantage of ongoing community health lectures, screenings, classes and support groups both at the hospital and in the community. 18 14 2090 140 408621 -174619 284728 60422 195495962 208030249 -2032134 1489191 7034322 8450222 200782878 218030084 0 0 117677269 108265722 0 0 80875927 90074266 198553196 198339988 2229682 19690096 107598921 113969058 110591058 106711042 -2992137 7258016 Brockton Hospital's Mission is to be a private not-for-profit community based hospital that is recognized as the "hospital of choice" by staff, patients, and the community it serves. 0 0 174715491 213351670 the hospital operates a 253 bed acute care facility that provides health care services to 20 communities in southeastern Massachusetts. In fiscal year 2010 the hospital provided $16,282,280 of unreimbursed charity care. this equates to thousands of visits to primary care and specialty clinics. the hospital's children and youth program, a hospital-based primary care practice that treats under-priviledged children, accomodated approximately 12,500 patient visits. thousands of underinsured people took advantage of ongoing community health lectures, screenings, classes and support groups both at the hospital and in the community. 174715491 1 1 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 288 0 1 2090 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 18 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 MA X X Kim Hollon 5089417000 680 CENTRE STREET BROCKTON MA 023023395 dennis p jones 1.00 X 0 0 0 Timothy R Lynch MD 40.00 X 220939 35270 16268 James E Leary 1.00 X 0 0 0 Michael J Sullivan 1.00 X 0 0 0 Allan Lauer MD 1.00 X 0 0 0 Robert D Sullivan 1.00 X 0 0 0 Robert S Greenberg MD 1.00 X 0 312867 48102 Julie White MD 40.00 X 351445 0 29487 Eileen C Williams 1.00 X 0 0 0 David R Wolohojian 1.00 X 0 0 0 Timothy J Cruz 1.00 X 0 0 0 DAVID P FRENETTE 1.00 X 0 0 0 patti roland 1.00 X 0 0 0 john j svagzdys 1.00 X 0 0 0 David Drinkwater MD 40.00 X 489446 0 30964 wallace h peckham iii 1.00 X 0 0 0 Joseph P Drier III 1.00 X 0 0 0 mary v waldron 1.00 X 0 0 0 kevin p leonard 40.00 X 178393 0 21034 Eugene C Wallace 40.00 X 206315 0 32081 kim n hollon 40.00 X 0 0 0 Kenneth Lawson MD 40.00 X 337552 0 28338 deborah wilson 40.00 X 308344 0 64860 Jean-pierre geageamd 40.00 X 535086 0 15500 george c brown md 40.00 X 501142 0 42969 abdel-hai hammo md 40.00 X 455086 0 16268 Daniel A Muse MD 40.00 X 372651 0 22209 marc greenwald 40.00 X 320857 0 33809 NORMAN B GOODMAN 40.00 X 598093 0 31273 4875349 348137 433162 152 1 1 0 ropes & gray ONE INTERNATIONAL PLACE BOSTON MA 021102624 legal 1623796 Pratt Pediatric Associates 750 WASHINGTON STREEt BOSTON MA 02111 Physician services 729570 The Outsource Group PO Box 414144 BOSTON MA 02241 Collection Services 432650 ANESTHETICS OF BROCKTON 42 HEMINGWAY DRIVE E PROVIDENCE RI 02915 Physician services 414000 PriceWaterhouseCoopers PO Box 7247-8001 Philadelphia PA 19170 Audit Services 360893 18 60422 60422 PATIENT SERVICE Revenu 900099 207621628 207621628 OUTREACH LAB Services 541380 408621 408621 208030249 1019610 1019610 469581 469581 469581 469581 school of nursing 900099 4365908 4365908 Vantage Joint Venture 900099 1185424 1185424 cafeteria 900099 685189 685189 2213701 178710 2034991 8450222 218030084 213351670 408621 4209371 4875351 3412746 1462605 84880069 77983403 6896666 3332377 2332664 999713 8232144 5762501 2469643 6945781 4862047 2083734 194857 136400 58457 1043376 730363 313013 264827 185379 79448 108000 75600 32400 392300 274620 117680 2838314 2342404 495910 1261749 883224 378525 2816747 1971723 845024 1917656 1342359 575297 2514000 2514000 6056411 4239488 1816923 2497017 1747912 749105 OTHER PROFESSIONAL SERV 16217691 14638007 1579684 BAD DEBT 10687901 10687901 Medical and Surgical Su 10094035 10066311 27724 Drugs and medications 6035117 6028754 6363 Clinical Supplies 5961267 5933833 27434 19173001 16563852 2609149 198339988 174715491 23624497 0 6075204 2641451 1000000 21150102 18725912 6650244 25478617 854290 933518 1755460 1813185 166820053 128970949 38221622 37849104 16864122 13448523 15027877 13078748 107598921 113969058 51916835 54711622 1502100 1698400 42706297 38110794 7372549 6901961 4050000 1414622 3043277 3873643 110591058 106711042 X -7114690 2963745 1065140 1160379 3057413 3133892 -2992137 7258016 107598921 113969058 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 0 0 1 184096 184096 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: THE HOSPITAL PAID THE FOLLOWING COMPANIES FOR LOBBYING ON BEHALF OF THE HOSPITAL REGARDING VARIOUS STATE AND FEDERAL LEGISLATION IMPACTING BOTH THE HOSPITAL AND THE HEALTHCARE INDUSTRY AS A WHOLE. THESE ACTIVITIES REPRESENT AN INSUBSTANTIAL PART OF THE HOSPITAL'S ACTIVITIES. $56,000 WENT TO DENNIS A. SMITH ASSOCIATES, $50,000 WAS PAID TO NELSON, MULLINS, RILEY AND SCARBOROUGH. THE ALLOCATED PORTION OF DUES TO THE FOLLOWING ORGANIZATIONS: $29,771 MASSACHUSETTS HOSPITAL ASSOCIATION; $8,672 AMERICAN HOSPITAL ASSOCIATION. ADDITIONALLY, $39,653 OF STAFF WAGES HAS BEEN ALLOCATED TO LOBBYING IN RELATION TO STAFF EFFORTS TO SIMILARLY REPRESENT THE INTERESTS OF THE HOSPITAL AND THE HEALTHCARE INDUSTRY AS A WHOLE IN RELATION TO VARIOUS FEDERAL AND STATE LEGISLATION. 3187674 147716 3335390 3404596 250 -217172 3187674 0.96000 0.04000 0 0 30564 30564 53859953 32137791 21722162 109984071 95213185 14770886 2945465 1619973 1325492 37849104 interest in signature healthcare, inc. investments 13448523 F 13448523 assets whose use is limited 12023766 unamortized bond issuance costs 192563 Investment in Joint Venture 484419 Loan Receivable - Split Dollar Life Insurance 378000 13078748 amounts due 3rd party payors 3873643 3873643 218030084 198339988 19690096 132011 -9571954 -9439943 10250153 218030084 0 218030084 0 218030084 198339988 0 198339988 0 198339988 Part V, Line 4: Description of Intended Use of Endowment Funds: The Hospital's endowment consists of individual donor restricted endowment funds for a variety of purposes as well as split interest agreements, which have been designated for endowment. Part XI, Line 8 - Other Adjustments: adjustment to minimum pension liability: -5781363. change in interest in investments of signature healthcare, inc.: -3962309. Change in interest in investments of signature healthcare corporation: 95239. change in fair value of split-interest agreements: 76479. 1 1 1 X 0 1 0 0 1 1 11657371 8157920 3499451 0.01860 53461486 43050064 10411422 0.05550 7460963 5249405 2211558 0.01180 72579820 56457389 16122431 0.08590 9652 9652 0.00010 7136185 7056803 79382 0.00040 7414703 5381808 2032895 0.01080 10253 10253 0.00010 14570793 12438611 2132182 0.01140 87150613 68896000 18254613 0.09730 45 30 45 30 1 10687903 0 49933442 52164215 -2230773 X 1 1 Brockton Hospital Inc

680 Centre Street Brockton MA 02302

X X X Part III, Line 4: The Hospital provides an allowance for doubtful accounts equal to estimated bad debt losses. The estimated losses are based on historical collection experience together with a review of the current status of existing receivables.The Hospital used a ratio of its total costs to charges to calculate the amount of bad debt expense at cost. Part III, Line 8: The shortfall experienced by the Hospital from providing care to Medicare beneficiaries should be treated as a community benefit as it represents the Hospital's contribution to providing care to the frail and elder citizens of the community it serves beyond the amount it receives from the Medicare program. This contribution is consistent with the Hospital's overall charitable mission to provide care to all individuals, regardless of the level of payment received for providing that care.The Hospital used a ratio of its total costs to charges to calculate the allowable costs related to Medicare revenue received. X X 0 1 X X X X X X 1 1 0 1 0 1 0 0 0 Timothy R Lynch MD 220939 35270 0 0 0 0 0 0 16268 0 237207 35270 0 0 Robert S Greenberg MD 0 312867 0 0 0 0 0 22000 0 26102 0 360969 0 0 Julie White MD 351445 0 0 0 0 0 16430 0 13057 0 380932 0 0 0 David Drinkwater MD 489446 0 0 0 0 0 14696 0 16268 0 520410 0 0 0 kevin p leonard 175393 0 3000 0 0 0 12000 0 9034 0 199427 0 0 0 Eugene C Wallace 206315 0 0 0 0 0 22000 0 10081 0 238396 0 0 0 Kenneth Lawson MD 337552 0 0 0 0 0 15281 0 13057 0 365890 0 0 0 deborah wilson 301586 0 0 0 6758 0 36047 0 28813 0 373204 0 0 0 Jean-pierre geageamd 535086 0 0 0 0 0 15500 0 0 0 550586 0 0 0 george c brown md 501142 0 0 0 0 0 29805 0 13164 0 544111 0 0 0 abdel-hai hammo md 455086 0 0 0 0 0 0 0 16268 0 471354 0 0 0 Daniel A Muse MD 372651 0 0 0 0 0 22000 0 209 0 394860 0 0 0 marc greenwald 320857 0 0 0 0 0 20882 0 12927 0 354666 0 0 0 NORMAN B GOODMAN 281731 0 0 0 316362 0 14470 0 16803 0 629366 0 0 0 Part I, Line 1b The compensation elements indicated on Schedule J, part I (tax indemnification/gross-up payments and health or social club dues) were provided pursuant to the employment contract maintained between the Hospital and the individual. Part I, Lines 4a-b: The former President and Chief Executive Officer resigned from the Hospital in June 2009. Pursuant to an agreement between the parties, the former President and Chief Executive Officer received certain separation payments from the Hospital in calendar year 2009 and will continue to receive through 2011. Consistent with reporting requirements for IRS Form 990, the Hospital reports compensation and other payments to employees and former employees on a calendar year (Form W-2) basis. Consequently, separation payments to the former President and Chief Executive Officer made in calendar year 2009 amounting to $129,377 are reported for the fiscal year ending 9/30/2010. The Senior Vice President of Ambulatory Services/Physician Network has a severance arrangement which states that in the event of termination of employment without cause, the Senior Vice President would receive base salary plus continuation of benefits for two years. During the year ended 9/30/2010 the Hospital made supplemental nonqualified retirement plan contributions for two employees. Consistent with reporting requirements for IRS Form 990, the Hospital reports compensation and other payments to employees and former employees on a calendar year (Form W-2) basis. Consequently, the following amounts are reported for the fiscal year ending 9/30/2010: Deborah Wilson - $16,500 George Brown, MD - $7,805 Part I, Line 5 During FY 2010, the interim CEO was eligible to receive and was paid incentive compensation as a result of the achievement of certain financial goals. Michael L Connors Loan receivable - Split dollar life insurance policy X 378000 378000 0 1 1 378000 Robert D Sullivan Sister and brother-in-law 222169 The Hospital paid for moving services and record storage fees to this interested person. 0 Form 990, Part VI, Section B, line 11 The Organization's Form 990 is prepared by an outside independent certified public accountant in conjuction with input provided by Organization management. The completed Form 990 was provided to each board member electronically. In addition, a board meeting was convened to review the Form 990 in advance of the filing date. Form 990, Part VI, Section B, line 12c Each year the Organization circulates a conflict of interest questionnaire. Responses to the statement are reviewed and presented to the board for review and action. Form 990, Part VI, Section B, line 15 Compensation for officers and key employees is reviewed annually by the board of directors and adjustments to compensation are based on performance standards and comparison of compensation levels to similar provider organizations. Form 990, Part VI, Section C, line 18 The Organization makes its 990 and 990-T available upon request. Additionally, the Organization's Form 990 is available on the website of the Massachusetts Attorney General. Form 990, Part VI, Section C, line 19 The Organization makes its conflict of interest, financial statements and governing documents available to the public upon request. Additionally, the Organization's financial statements are available on the website of the Massachusetts Attorney General as well as with the Municipal Securities Rulemaking Board. The Organization's audit process is overseen by the audit committee. The audit committee's recommendations are reviewed and accepted by the full board on an annual basis. This process is consistent with the Organization's prior years' process. Loan Receivable (Split Dollar Life Insurance Policy) - Michael Connors - The amount reported as a loan represents premiums made over several years, since 2004, pursuant to a split-dollar life insurance arrangement intended to provide life insurance or supplemental retirement income to the participant. Premiums paid by the Hospital plus accrued interest will be reimbursed from the proceeds of the policy upon either the termination of the policy or the death of the participant. Signature Healthcare Corporation 680 Centre Street Brockton MA 02302 042103554 Management MA 501(c)(3) Public Charity N/A Brockton Hospital Ambassadors Club 680 Centre Street Brockton MA 02302 043160078 Fundraising MA 501(c)(3) Public Charity Signature Healthcare Corporation Signature Healthcare Medical Group 680 Centre Street Brockton MA 02302 043306782 Medical Care MA 501(c)(3) Public Charity Signature Healthcare Corporation Brockton Radiation Oncology LLC 680 Centre Street Brockton MA 02302 222472997 Radiation Oncology Services MA Related 1185424 1289600 0 0 Bridgewater Goddard Park Medical Associates 680 Centre Street Brockton MA 02302 042530255 Physician Group MA C Brockton Physician Hospital Organization 680 Centre Street Brockton MA 02302 043189274 Medical Management MA C 8521 162728 0.50000 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1