2011-10-03T06:45:36-05:00 2010-12-31 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2010-01-01 020260334 WENTWORTH-DOUGLASS HOSPITAL WENT 6037425252 789 CENTRAL AVENUE DOVER NH 038202526 PETER E WALCEK 6037422804 2011-09-27 1 TIMOTHY R HEPBURN 2078792100 2011-09-26 2010 2016-03-07 17:11:31Z GREGORY J WALKER 789 CENTRAL AVENUE DOVER NH 038202526 267963444 0 X WWW.WDHOSPITAL.COM X 1905 NH HELP INDIVIDUALS AND THEIR FAMILIES ATTAIN THEIR HIGHEST LEVEL OF HEALTH 15 12 1938 146 49754 -74329 339037 457903 217797771 231897057 1405612 4296908 -11189015 3127926 208353405 239779794 255980 0 0 0 102177523 109299227 0 0 0 94403496 99588377 196836999 208887604 11516406 30892190 297036119 311808165 125866477 122256744 171169642 189551421 X WENTWORTH-DOUGLASS IS THE LARGEST ACUTE CARE HOSPITAL IN THE SEACOAST REGION OF NEW HAMPSHIRE AND SOUTHERN MAINE, SPECIALIZING IN TRAUMA AND EMERGENCY SERVICES, SURGERY, CANCER CARE, BIRTHING, ORTHOPEDIC SERVICES, CARDIOVASCULAR SERVICES, SLEEP DISORDERS, REHABILITATION, PAIN MANAGEMENT, WOUND HEALING, WELLNESS AND PREVENTION PROGRAMS, PLUS EXTENSIVE DIAGNOSTIC SERVICES.A HEALTHCARE LEADER IN THE SEACOAST REGION SINCE 1906, WENTWORTH-DOUGLASS HOSPITAL IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. 0 0 181806388 235268931 WENTWORTH-DOUGLASS HOSPITAL (WDH OR THE HOSPITAL) IS AN ACUTE CARE HOSPITAL LOCATED IN DOVER, NEW HAMPSHIRE. WDH IS A NOT-FOR-PROFIT ORGANIZATION, AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. WENTWORTH-DOUGLASS HOSPITAL IS THE LARGEST ACUTE CARE HOSPITAL IN THE SEACOAST REGION OF NEW HAMPSHIRE AND SOUTHERN MAINE, SPECIALIZING IN TRAUMA AND EMERGENCY SERVICES, SURGERY, CANCER CARE, BIRTHING, ORTHOPEDIC SERVICES, CARDIOVASCULAR SERVICES, SLEEP DISORDERS, REHABILITATION, PAIN MANAGEMENT, WOUND HEALING, WELLNESS, AND PREVENTION PROGRAMS PLUS EXTENSIVE DIAGNOSTIC SERVICES. A HEALTHCARE LEADER IN THE SEACOAST SINCE 1906, WENTWORTH-DOUGLASS HOSPITAL IS ACCREDITED BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. AT WENTWORTH-DOUGLASS HOSPITAL, WE ARE COMMITTED TO SERVING OUR COMMUNITY AND ADDRESSING THE NEEDS OF ALL OUR PATIENTS. OUR COMMUNITY BENEFITS PROGRAMS ARE AVAILABLE TO LOCAL RESIDENTS WITH INCOME AT OR BELOW 300% OF FEDERAL POVERTY LEVEL GUIDELINES, ONE OF THE MOST GENEROUS PROGRAMS IN THE STATE OF NH. WDH FILES AN ANNUAL COMMUNITY BENEFITS REPORT WITH THE STATE OF NH WHICH OUTLINES THE COMMUNITY AND CHARITABLE BENEFITS PROVIDED. NUMEROUS PROGRAMS WERE DEVELOPED TO ASSIST PEOPLE IN THE AREA WE SERVE, INCLUDING FINANCIAL AID, FAMILY RESOURCE COUNSELOR PROGRAM, MEDICATION ASSISTANCE PROGRAM, PHYSICIAN REFERRAL SERVICES, CARE-VAN TRANSPORTATION SERVICES, AND WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER. THE HOSPITAL PROVIDED $16,915,000 OF COMMUNITY ASSISTANCE PROGRAMS IN 2010 (AS MEASURED BY GROSS CHARGES) IMPACTING 23,831 PATIENTS. IN TOTAL, THE HOSPITAL AND WDPC TOGETHER PROVIDED $17,754,966 OF COMMUNITY ASSISTANCE PROGRAMS IN 2010 (AS MEASURED BY GROSS CHARGES) IMPACTING 35,635 PATIENTS.THE HOSPITAL'S CORE PROGRAMS INCLUDE OUR CANCER CENTER, EMERGENCY DEPARTMENT, AND SURGICAL SERVICES. IN ADDITION, WDH OFFERS OTHER KEY SERVICES IN THE AREAS OF WOMEN'S AND CHILDREN'S SERVICES AND CARDIOLOGY SERVICES.1. THE SEACOAST CANCER CENTER AT WENTWORTH-DOUGLASS HOSPITAL OFFERS THE MOST COMPREHENSIVE CANCER TREATMENT SERVICES COVERING THE SEACOAST REGION OF NEW HAMPSHIRE AND SOUTHERN MAINE. FOUNDED 30 YEARS AGO AS A SINGLE ROOM ADJACENT TO THE EMERGENCY DEPARTMENT, THE CANCER CENTER'S SERVICES NOW INCLUDE EXTENSIVE, STATE OF THE ART MEDICAL AND RADIATION ONCOLOGY DIAGNOSTIC SERVICES WITH MULTIPLE TREATMENT OPTIONS. IN 2008, A $9.3 MILLION EXPANSION PROJECT BROUGHT THE NOVALIS TX STEREOTACTIC RADIOSURGERY TO THE SEACOAST, SAVING PATIENTS TRAVEL TIME TO DISTANT TREATMENT CENTERS. THE NEW SERVICE GIVES HOPE TO PATIENTS WITH COMPLEX TUMORS OF THE BRAIN, LIVER AND OTHER VITAL ORGANS. WENTWORTH-DOUGLASS HOSPITAL WAS THE FIRST HOSPITAL, NATIONWIDE, TO INSTALL THE NOVALIS TX SYSTEM CREATED BY BRAINLAB AND VARIAN MEDICAL.A MULTIDISCIPLINARY CHEST CLINIC, LOCATED IN THE SEACOAST CANCER CENTER, SAW ITS FIRST PATIENTS IN OCTOBER 2008. THE MEDICAL TEAM FOCUSES ON TIMELY ACCESS TO SERVICES FOR PATIENTS WITH LUNG NODULES AND LUNG CANCER. 2. THE EMERGENCY DEPARTMENT AT WENTWORTH-DOUGLASS HOSPITAL IS THE BUSIEST IN THE SEACOAST AND FOURTH BUSIEST IN THE STATE OF NEW HAMPSHIRE. CLOSE LINKAGES TO LOCAL EMERGENCY SERVICES PERSONNEL AND FIRE & RESCUE DEPARTMENTS CONTINUE TO EXTEND THE SKILL AND CAPABILITIES OF THE DEPARTMENT. THROUGH INTERNAL AND EXTERNAL EDUCATION EFFORTS, THE EMERGENCY DEPARTMENT FOCUSED ON IMPROVING PATIENT CARE FOR SPECIFIC TYPES OF HEART ATTACK (STEMI) AND STROKE. THE DEPARTMENT'S EFFORTS IN THE FALL OF 2008, THROUGH A CLINICAL COLLABORATION WITH MASSACHUSETTS GENERAL HOSPITAL, CREATED THE STROKE INITIATIVE TO FORM A CENTER OF EXCELLENCE FOR STROKE CARE. IN OCTOBER 2009 THE AMERICAN HEART/STROKE ASSOCIATION AWARDED WDH THE BRONZE AWARD FOR ACHIEVING THEIR HIGH STANDARD, QUALITY GUIDELINES FOR SIX CONSECUTIVE MONTHS. IN JUNE 2010 THE HOSPITAL RECEIVED NOTICE OF THEIR SILVER PLUS AWARD FOR 12 CONSECUTIVE MONTHS OF ACHIEVEMENT.TO ACCOMMODATE INCREASING PATIENTS THE DEPARTMENT ALSO ADDED ADDITIONAL SPACE FOR SIX TREATMENT ROOMS AND OPENED A WALK-IN URGENT CARE CENTER IN LEE, NH TO SUPPORT THE GROWING POPULATION AREAS IN THE TOWNS SURROUNDING LEE.THE HOSPITAL'S GENEROUS CHARITY CARE PROGRAM OFFERS EMERGENCY, WALK-IN AND OTHER HOSPITAL SERVICES AT NO CHARGE FOR QUALIFYING PATIENTS AT 300% OF THE FEDERAL POVERTY LEVEL. 3. SURGICAL SERVICES AT WENTWORTH-DOUGLASS HOSPITAL INCLUDE A WIDE ARRAY OF SERVICES AND TECHNOLOGICAL ADVANCES FREQUENTLY ASSOCIATED WITH LARGER MEDICAL CENTERS. A RECENT RENOVATION TO ENLARGE OPERATING ROOMS CREATED DIGITAL ORS AND SPACE FOR NEW EQUIPMENT SUCH AS THE DAVINCI ROBOTIC SURGICAL SYSTEM. NOW IN ITS FOURTH YEAR, THE ROBOTIC PROGRAM BEGAN WITH OB/GYN SURGEONS, AND NOW INCLUDES THORACIC, GENERAL SURGERY AND UROLOGY. ANOTHER CLINICAL COLLABORATION WITH MGH AT WDH BRINGS A GYN/ONCOLOGY SURGEON TO WDH TO PERFORM "MEDICAL CENTER" SURGERY IN THE COMMUNITY SETTING, ELIMINATING THE TIME AND THE FRUSTRATION OF TRAVEL TO AND PARKING AT METROPOLITAN CITIES.A RANGE OF MINIMALLY INVASIVE PROCEDURES INCLUDING ROBOTIC SURGERY, SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) USED BY GENERAL SURGEONS AND VIDEO ASSISTED THORACIC SURGERY (VATS) PROCEDURES USED BY THE THORACIC SURGEON OFFER PATIENTS THE BENEFITS OF COMPLEX SURGERY WITH LESS BLOOD LOSS, LESS INFECTION AND FASTER RECOVERY.THE JOINT REPLACEMENT PROGRAM INTRODUCED IN 2006 OFFERS A UNIQUE APPROACH TO JOINT REPLACEMENT SURGERY WITH PRE-OP GROUP EDUCATION AND POST-OP GROUP REHAB. SURGEONS, ANESTHESIOLOGISTS, NURSING, REHAB AND NUTRITION STAFF WORKED COLLABORATIVELY TO CREATE THIS NEW APPROACH TO JOINT REPLACEMENT CARE. IN 2009 THE HOSPITAL CREATED THE NORTHERN NEW ENGLAND SPINE CENTER, A PARTNERSHIP OF SPECIALISTS TO COORDINATE AND EXPEDITE THE CARE OF PATIENTS WITH NECK AND BACK PAIN. THE SPINE CENTER MEMBERS INCLUDE A SPINE SURGEON, PHYSIATRY SPECIALISTS, PAIN SPECIALISTS, WDH REHAB, BEHAVIORAL HEALTH SPECIALISTS AND A WDH SPINE COORDINATOR. THE VIRTUAL CENTER HOLDS BIMONTHLY MULTIDISCIPLINARY CONFERENCES TO COORDINATE THE CARE AND TREATMENT OF SPINE CENTER PATIENTS.OTHER SERVICES:IN ADDITION TO THE SERVICES LISTED ABOVE, WENTWORTH-DOUGLASS HOSPITAL OFFERS TRADITIONAL SERVICES WITH NON-TRADITIONAL COMPONENTS. ONE EXAMPLE IS THE BIRTH CENTER. CURRENTLY THE BIRTH CENTER IS THE FASTEST GROWING BIRTHING SERVICE IN THE SEACOAST AREA WITH NEARLY 1,000 BIRTHS PER YEAR. IN AN EFFORT TO SUPPORT A SMALL BUT GROWING AND YOUNG INDONESIAN POPULATION, THE BIRTH CENTER TRANSLATED ALL FORMS AND INFORMATION FOR NEW MOMS INTO INDONESIAN. LOCAL CHURCH GROUPS WELCOMED INDONESIAN FAMILIES INTO THEIR COMMUNITIES.CARDIOLOGY SERVICES RECENTLY REPLACED THE CATH LAB WITH NEW EQUIPMENT AND THE DEPARTMENT ADDED NON-INVASIVE CARDIOVASCULAR SERVICES AT A NEW, OFFSITE MEDICAL OFFICE BUILDING IN DOVER, EXTENDING THE OPTIONS NOW AVAILABLE FOR PATIENTS. A SECOND CARDIOVASCULAR INTERVENTIONAL LAB WILL BE OPEN LATE IN 2010 TO ACCOMMODATE GROWING PATIENT VOLUME AND URGENT CASES.ALL THE COMMUNITY ASSISTANCE (BENEFIT) SERVICES SUPPORT LOW INCOME, UNINSURED INDIVIDUALS AND FAMILIES IN THE HOSPITAL'S SERVICE AREA WITH CHARITY CARE (FINANCIAL ASSISTANCE), MEDICATION ASSISTANCE, THE WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER AND THE CARE-VAN FREE PATIENT TRANSPORT SERVICE. 181806388 1 1 0 1 0 0 0 0 1 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 258 0 1 1938 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NH X X PETER E WALCEK CFOVP OF FINANCE 6037402804 789 CENTRAL AVENUE DOVER NH 038202526 X THEODORE RISTAINO 5.00 X X 0 0 0 NEIL GARVEY 3.00 X X 0 0 0 ROGER HAMEL 3.00 X X 0 0 0 WILLIAM BOC 3.00 X X 0 0 0 CAROL BAILEY 2.00 X 0 0 0 GERALD DALEY EDD 2.00 X 0 0 0 LISA DESTEFANO 2.00 X 0 0 0 PETER DIRKSMEIER MD 2.00 X 0 0 0 DAVID FLAVIN MD 2.00 X 0 0 0 WILLIAM HASSETT MD 8.00 X 0 315100 18030 WES KENNEDY 2.00 X 0 0 0 DONNA RINALDI 2.00 X 0 0 0 MICHAEL STEINBERG 2.00 X 0 0 0 STEVEN C WEBB 3.00 X 0 0 0 ANN TORR 2.00 X 0 0 0 JOSEPH WHITE MD 2.00 X 61000 0 0 ROBERT DECOLFMAKER 0.10 X 0 0 0 LINDA HAGAN 2.00 X 0 0 0 GREGORY J WALKER 55.00 X X 605304 0 147782 PETER E WALCEK 55.00 X 302237 0 74502 PAUL R CASS 45.00 X 290495 0 73795 ELLEN L CAILLE 55.00 X 257999 0 72398 SHEILA M WOOLLEY 45.00 X 244314 0 42386 DANIEL N DUNN 45.00 X 242460 0 32464 MALCOLM D ROSENSON MD 45.00 X 218464 0 25434 2222273 315100 486791 120 0 1 0 SODEXHO INC & AFFILIATES 9801 WASHINGTONIAN BOULEVARD GAITHERSBURG MD 208785355 FOOD SERVICES/MANAGEMENT 1539861 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 55480 REFERENCE LAB 1129925 HEALTH PLAN PREMIUMS 1500 W PACK DR SUITE 330 WESTBOROUGH MA 01581 TPA FEES - HEALTH PLAN 844404 SIEMENS MEDICAL SOLUTIONS 51 VALLEY STREAM PARKWAY MALVERN PA 19355 INFORMATION SERVICES 839085 KLEEN INC 1 FOUNDRY STREET LEBANON NH 03776 LAUNDRY/LINEN SERVICES 660357 24 354119 103784 457903 NET PATIENT SERVICE RE 900099 229462892 229462892 CAFETERIA 722320 1073341 1046926 26415 CHILD CARE SERVICE 624410 876148 876148 REBATES 900099 360588 360588 MEDICAL & SURGICAL SUP 900099 58125 58125 65963 65963 231897057 1301464 19739 1281725 2462439 433840 2028599 2028599 2302562 -273963 30685070 60184 27676713 73097 3008357 -12913 2995444 2995444 OTHER 541200 775105 771505 3600 TRANSCRIPTION 900099 319218 319218 MANAGEMENT FEES 900099 5004 5004 1099327 239779794 235268931 49754 4003206 1129824 1129824 83124077 71776525 11347552 2964088 2687617 276471 14481508 12285694 2195814 7599730 6436971 1162759 596788 596788 119603 119603 32072 32072 66416 66416 2417284 2314812 102472 618202 618202 3482322 2959974 522348 3650471 2865620 784851 427335 320501 106834 3406916 3236570 170346 16802274 14281933 2520341 872075 828471 43604 SUPPLIES & OTHER EXPENS 29663058 25260747 4402311 PROVISION FOR BAD DEBT 12881022 12881022 PHARMACY 8142420 8142420 PURCHASED SERVICES 7758425 7370504 387921 SERVICE CONTRACTS 4946441 4204475 741966 3705253 3334330 370923 208887604 181806388 27081216 0 36419 52444 35663824 32204188 27487526 27170789 3051612 3116219 2342187 2420487 276758368 145170838 135591471 131587530 61449522 81902090 14951672 17549525 13976602 13279816 2485284 2525077 297036119 311808165 29474358 30194996 193148 128258 91929006 84841863 4269965 7091627 125866477 122256744 X 168102683 186712004 1968164 1672323 1098795 1167094 171169642 189551421 297036119 311808165 X 30892190 -12510411 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 11200 0 0 0 0 1 32072 43272 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: DURING 2010, WDH REPRESENTATIVES ATTENDED NEW HAMPSHIRE HOSPITAL ASSOCIATION MEETINGS AND CONTACTED STATE LEGISLATORS TO PROVIDE EDUCATIONAL INFORMATION AND WDH'S POSITION ON KEY BILLS. IN ADDITION, GREGORY WALKER, CEO, PROVIDED CORRESPONDENCE TO SENATORS REGARDING PERTINENT FEDERAL AND STATE ISSUES. NHHA, PORTION OF DUES ALLOCATED TO LOBBYING, $25,194 AHA, PORTION OF DUES ALLOCATED TO LOBBYING, $6,878 89122889 25362 21394694 -10553631 121096576 87480527 9452164 9150040 -16959842 89122889 98989793 17943608 -29452874 87480527 0.92930 0.00900 0.06160 0 0 3292772 3292772 94049595 34806591 59243004 8471566 1272431 7199135 110874154 85947297 24926857 60070281 23144519 36925762 131587530 ALTERNATIVE INVESTMENTS 17549525 F 17549525 EST THIRD-PARTY PAYOR SETTLEMENT 7091627 7091627 239779794 208887604 30892190 5472259 -17982670 -12510411 18381779 227202967 5472259 -17982670 -12510411 239713378 66416 66416 239779794 208821188 0 208821188 66416 66416 208887604 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TO FURTHER THE HOSPITAL'S CHARITABLE MISSION. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN FV OF INTEREST RATE SWAP AGREEMENT -707,597. NET CHANGE IN RESTRICTED ASSETS HELD BY WDHHF 128,796. NET LOSS ON INVESTMENTS IN JOINT VENTURES & RELATED ORGANIZATIONS -17,403,869. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FV OF INTEREST RATE SWAP AGREEMENT -707,597. NET INCREASE IN RESTRICTED CONTRIBUTIONS HELD BY WDHHF 128,796. INVESTMENT IN JOINT VENTURES & RELATED ORGANIZATIONS -17,403,869. 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 11757 6953658 6953658 0.03550 8943822 8943822 0.04560 11757 15897480 15897480 0.08110 12074 898817 898817 0.00460 427335 427335 0.00220 440063 440063 0.00220 12074 1766215 1766215 0.00900 23831 17663695 17663695 0.09010 1 5750345 575034 56284764 96168292 -39883528 X 1 0 1 NONE 1 1 WENTWORTH-DOUGLASS HOSPITAL

789 CENTRAL AVENUE DOVER NH 038202526

X X X WENTWORTH-DOUGLASS HOSPITAL 1 32 STRAFFORD HEALTH ALLIANCE

200 ROUTE 108 3 SOMERSWORTH NH 038781106

PHYSICAL THERAPY CLINICS & WOMEN'S IMAGING SERVICES WDH PROFESSIONAL CENTER AT DOVER

10 MEMBERS WAY DOVER NH 03820

DIAGNOSTIC SERVICES LEE OTPTIMAGINGURGENT CARE

65 CALEF HIGHWAY LEE NH 03861

OCCUPATIONAL/PHYSICAL THERAPY, IMAGING & URGENT CARE WDPC - HOSPITALISTS

789 CENTRAL AVENUE LEVEL 2 DOVER NH 03820

INPATIENT PHYSICIAN SERVICES WDPC - STRAFFORD MEDICAL ASSOCIATES

10 MEMBERS WAY SUITE 302 DOVER NH 03820

PRIMARY CARE PRACTICE WDPC - DOVER FAMILY PRACTICE

10 MEMBERS WAY DOVER NH 03820

PRIMARY CARE PRACTICE WDPC - ENDOCRINOLOGY & DIABETES

19 WEBB PLACE DOVER NH 03820

SPECIALTY CARE PRACTICE WDPC - ADULT & CHILDREN'S MEDICINE

10 MEMBERS WAY SUITE 201 DOVER NH 03820

PRIMARY CARE PRACTICE WDPC - SEACOAST PULMONARY (INTENSIVISTS)

789 CENTRAL AVENUE LEVEL 3 DOVER NH 03820

SPECIALTY CARE PRACTICE WENTWORTH HOMECARE & HOSPICE

113 NEW ROCHESTER ROAD DOVER NH 03820

HOSPICE AND HOME CARE SERVICES LEE URGENT CARE

65 CALEF HIGHWAY LEE NH 03861

URGENT CARE FACILITY & DIAGNOSTIC SERVICES WDPC - PRIMARY CARE OF DOVER

10 MEMBERS WAY SUITE 300 DOVER NH 03820

PRIMARY CARE PRACTICE WDPC - DOVER INTERNAL AND GERIATRIC MEDI

10 MEMBERS WAY SUITE 301 DOVER NH 03820

PRIMARY CARE PRACTICE WDPC - DURHAM HEALTH CENTER

36 MADBURY ROAD DURHAM NH 03824

PRIMARY CARE PRACTICE WDPC - HILLTOP FAMILY PRACTICE

85 MAIN STREET SOMERSWORTH NH 03878

PRIMARY CARE PRACTICE DURHAM REHAB AND SPORTS THERAPY CENTER

16 JENKINS COURT DURHAM NH 03824

SPECIALTY CARE PRACTICE WDPC - LEE FAMILY PRACTICE

65 CALEF HIGHWAY SUITE 200 LEE NH 03861

PRIMARY CARE PRACTICE WDPC - SOUTH BERWICK FAMILY PRACTICE

31 COLCORD STREET SOUTH BERWICK ME 03908

PRIMARY CARE PRACTICE WDPC - BELLAMY HEALTH CENTER

15 OLD ROLLINSFORD ROAD DOVER NH 03820

PRIMARY CARE PRACTICE WDPC - BARRINGTON HEALTH CENTER

2 CENTURY PINES DRIVE BARRINGTON NH 03825

PRIMARY CARE PRACTICE WDPC - MARSHWOOD FAMILY CARE

19 LEVESQUE DRIVE SUITE 2 ELIOT ME 03903

PRIMARY CARE PRACTICE WDPC - WENTWORTH COMMUNITY DENTAL CARE

668 CENTRAL AVENUE DOVER NH 03820

DENTAL SERVICES MEDICAL ONCOLOGY

789 CENTRAL AVENUE DOVER NH 03820

SPECIALTY CARE PRACTICE WDPC - SEACOAST ARTHRITIS & OSTEOPOROSIS

15 OLD ROLLINSFORD ROAD SUITE 204 DOVER NH 03820

SPECIALTY CARE PRACTICE WDPC - GREAT BAY FAMILY PRACTICE

60 EXETER ROAD UNIT 3 NEWMARKET NH 03857

PRIMARY CARE PRACTICE HEALTH PARTNERS OF NEW HAMPSHIRE INC

789 CENTRAL AVENUE DOVER NH 038202526

PHYSICIAN/HOSPITAL ORGANIZATION WDPC - DOVER INTERNAL AND GERIATRIC MEDI

31 COLCORD STREET SOUTH BERWICK ME 03908

PRIMARY CARE PRACTICE WDPC - SUMMIT INFECTIOUS DISEASE

15 OLD ROLLINSFORD ROAD DOVER NH 03820

INPATIENT SPECIALTY CARE WDPC - PALLIATIVE CARE

789 CENTRAL AVENUE LEVEL 3 DOVER NH 03820

INPATIENT PHYSICIAN SERVICES WDPC - WENTWORTH INTERNAL MEDICINE

10 MEMBERS WAY SUITE 303 DOVER NH 03820

PRIMARY CARE PRACTICE CENTER FOR MEDICAL GENETICS

17 OLD ROLLINSFORD ROAD SUITE 6 DOVER NH 03842

SPECIALTY CARE PRACTICE WENTWORTH-DOUGLASS HOSPITAL EARLY LEARNI

789 CENTRAL AVENUE DOVER NH 03820

CHILDCARE SERVICES PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: THE HOSPITAL USES THE RATIO OF COST TO CHARGE METHODOLOGY TO CALCULATE THE COST OF THE COMMUNITY BENEFITS IT PROVIDES. THE RATIO OF COST TO CHARGE METHODOLOGY WAS USED TO REDUCE CHARITY CARE CHARGES DOWN TO COSTS AND WAS ALSO USED TO CALCULATE THE MEDICAID SHORTFALL. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 12881022. PART II: SEE FORM 990, PART III, LINE 4A. PART III, LINE 4: FROM FOOTNOTE 1 OF THE 2010 AUDITED CONSOLIDATED FINANCIAL STATEMENTS:"THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS PROVIDED BASED ON AN ANALYSIS BY MANAGEMENT OF THE COLLECTIBILITY OF OUTSTANDING BALANCES. MANAGEMENT CONSIDERS THE AGE OF OUTSTANDING BALANCES AND PAST COLLECTION EFFORTS IN DETERMINING THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. ACCOUNTS DEEMED UNCOLLECTIBLE ARE CHARGED OFF AGAINST THE ESTABLISHED ALLOWANCE." THE HOSPITAL USES THE RATIO OF COST TO CHARGE METHODOLOGY TO REDUCE BAD DEBT EXPENSES DOWN TO COST. IN 2010, IT COST THE HOSPITAL $5,750,345 TO PROVIDE CARE TO PATIENTS, FOR WHICH THE HOSPITAL RECEIVED NO PAYMENTS FOR SERVICES RENDERED. WHILE THE HOSPITAL CONSIDERS THE $5,750,345 TO BE THE COST OF CARE PROVIDED TO PATIENTS FOR SERVICES RENDERED FOR WHICH NO PAYMENT WAS RECEIVED, WE DO NOT CONSIDER THIS TO BE A COMMUNITY BENEFIT AND THEREFORE HAVE NOT REPORTED IT IN PART I, LINE 7. PART III, LINE 8: IN 2010, THE HOSPITAL PROVIDED CARE COSTING $96M TO MEDICARE PATIENTS, FOR WHICH IT WAS REIMBURSED $56M, REPRESENTING A LOSS ON MEDICARE SERVICES OF $39M. THIS AMOUNT REPRESENTS THE AMOUNT BY WHICH THE HOSPITAL WAS UNDERPAID (RELATIVE TO COST) BY THE FEDERAL GOVERNMENT FOR CARE PROVIDED TO MEDICARE PATIENTS, WHO ARE 65 AND OLDER, REGARDLESS OF INCOME OR DISABILITY. WHILE THE HOSPITAL CONSIDERS THE $39M COST TO BE A SIGNIFICANT SHORTFALL COMPARED TO THE COST OF PROVIDING THE SERVICES RENDERED, WE DO NOT CONSIDER THIS AMOUNT TO BE A COMMUNITY BENEFIT AND THEREFORE HAVE NOT REPORTED IT IN PART I, LINE 7. PART III, LINE 9B: HOSPITALS IN NEW HAMPSHIRE WORK HARD TO MAKE HIGH-QUALITY HEALTH CARE AVAILABLE, AFFORDABLE, AND ACCESSIBLE TO ALL, REGARDLESS OF ABILITY TO PAY. WENTWORTH-DOUGLASS HOSPITAL OFFERS MANY FINANCIAL ASSISTANCE AND REFERRAL PROGRAMS TO ENSURE THAT COST WILL NOT BE A BARRIER TO ANYONE IN OUR COMMUNITY GETTING THE HEALTH CARE SERVICES THEY NEED. IF PAYMENT OF HEALTH CARE EXPENSES CREATES A FINANCIAL HARDSHIP FOR PATIENTS, OUR STAFF PROVIDES ASSISTANCE TO COMPLETE THE FINANCIAL APPLICATION PROCESS. AS PART OF THIS FINANCIAL APPLICATION PROCESS, THE HOSPITAL WILL ASSESS PATIENTS' ELIGIBILITY FOR HEALTH INSURANCE COVERAGE THROUGH FEDERAL OR STATE PROGRAMS SUCH AS NEW HAMPSHIRE MEDICAID. IF IT IS DETERMINED THAT PATIENTS MAY BE ELIGIBLE FOR ONE OF THESE PROGRAMS, THE HOSPITAL ASSISTS PATIENTS THROUGH THE APPLICATION PROCESS. PATIENTS ARE REQUIRED TO SUPPLY THE FINANCIAL OR MEDICAL DOCUMENTATION THAT IS NECESSARY TO SECURE SUCH INSURANCE COVERAGE.THE HOSPITAL UNDERSTANDS THAT HEALTH CARE COSTS CAN COME UP UNEXPECTEDLY. WHETHER PATIENTS ARE INSURED OR UNINSURED, AND WHETHER OR NOT PATIENTS QUALIFY FOR FINANCIAL ASSISTANCE, WE UNDERSTAND THAT PATIENTS MAY HAVE DIFFICULTY PAYING HEALTHCARE COSTS IN FULL AT THE TIME OF SERVICE OR IN A LUMP SUM. OUR BILLING TEAM WORKS WITH PATIENTS TO SET UP INTEREST-FREE PAYMENT PLANS TO HELP EASE THE FINANCIAL BURDEN OF HEALTH CARE COSTS. PART VI, LINE 2: WENTWORTH-DOUGLASS HOSPITAL'S COMMUNITY BENEFIT TASK FORCE, A COMMITTEE OF THE BOARD OF TRUSTEES THAT WAS ESTABLISHED IN 2000, CONDUCTS COMMUNITY NEEDS ASSESSMENTS EVERY 3-5 YEARS. THE MOST RECENT NEEDS ASSESSMENT, COMPLETED IN 2008, INCLUDED FIVE FOCUS GROUPS WITH KEY LEADERS FROM PROVIDERS, GOVERNMENT, HEALTHCARE, SCHOOLS AND SOCIAL SERVICE AGENCIES IN THE HOSPITAL'S PRIMARY SERVICE AREA. FOUR MAIN PROJECTS ARE CONTAINED IN THE ANNUAL COMMUNITY ASSISTANCE (BENEFIT) PLAN AS A RESULT OF THE NEEDS IDENTIFIED IN THE ORIGINAL AND SUBSEQUENT ASSESSMENTS: FINANCIAL ASSISTANCE (CHARITY CARE), MEDICATION ASSISTANCE, CARE-VAN FREE PATIENT TRANSPORT AND THE WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER WHICH PROVIDES DENTAL HEALTH SERVICES AND ACCESS TO DENTAL CARE TO NEEDY FAMILIES IN THE COMMUNITY. PART VI, LINE 3: WDH & WDPC TAKE AN ACTIVE ROLE IN ASSISTING PATIENTS WHO MAY BE INTERESTED AND QUALIFY FOR FINANCIAL ASSISTANCE, WHETHER IT IS STATE, FEDERAL OR OUR OWN CHARITY CARE BENEFITS. OUR FAMILY RESOURCE/COMMUNITY BENEFITS DEPARTMENT HAS SEVERAL PROCESSES IN PLACE TO ENSURE PATIENTS ARE AWARE OF THE FINANCIAL ASSISTANCE AVAILABLE TO THEM.PATIENTS CAN LEARN MORE ABOUT THESE PROGRAMS BY VISITING OUR WEBSITE, READING OUR FOUNDATION NEWSLETTERS, OR CONTACTING OUR FINANCIAL ASSISTANCE OFFICE. FROM THE TIME OF REGISTRATION THROUGH OUR BILLING PROCESS, PATIENTS HAVE AVAILABLE THE OPPORTUNITY TO OBTAIN AN APPLICATION FOR FINANCIAL ASSISTANCE. ALL SELF PAY PATIENTS AT THE TIME OF REGISTRATION ARE PROVIDED WITH OUR CHARITY CARE COVER LETTER AND APPLICATION, WITH INFORMATION ABOUT THE CHARITY CARE PROGRAM AND DETAILS ON HOW TO CONTACT OUR FINANCIAL ASSISTANCE REPRESENTATIVE(S). OUR REPRESENTATIVES ALSO SEE MANY PATIENTS WHILE THEY ARE HERE FOR SERVICES. SOCIAL WORK SERVICES AND COMMUNITY BENEFITS TEAM UP TO ASSIST AND MAKE SURE OUR PATIENTS ARE RECEIVING THE OPPORTUNITIES TO GET ANY AND ALL ASSISTANCE AVAILABLE TO THEM. WE SEND FIVE BILLING STATEMENTS TO OUR PATIENTS WITH THE FINANCIAL ASSISTANCE GUIDELINES AND CONTACT INFORMATION IF PATIENTS FEEL THEY MAY MEET THESE GUIDELINES AND NEED ASSISTANCE WITH THEIR BILL(S). PART VI, LINE 4: WENTWORTH-DOUGLASS HOSPITAL SERVES THE SEACOAST AREA OF NEW HAMPSHIRE AND SOUTHERN MAINE - STRAFFORD COUNTY, ROCKINGHAM COUNTY AND YORK COUNTY, MAINE. OUR COMMUNITY INCLUDES A SMALL BUT GROWING INDONESIAN POPULATION, WELCOMED BY LOCAL CHURCH GROUPS. THE COMMUNITY ALSO INCLUDES LOW-INCOME, UNINSURED ADULTS AND CHILDREN SUPPORTED BY THE HOSPITAL'S COMMUNITY ASSISTANCE PLAN PROGRAMS. PART VI, LINE 6: WDH OWNS 100% OF WENTWORTH-DOUGLASS PHYSICIAN CORPORATION (WDPC), WHICH FILES ITS OWN FORM 990 (SEE SCHEDULE R FOR MORE DETAILS). WDH OVERSEES ALL OF WDPC'S PRIMARY CARE PRACTICES, SPECIALTY PRACTICES, AND ITS DENTAL CLINIC. ACCORDINGLY, ALL OF WDPC'S FACILITY LOCATIONS HAVE BEEN LISTED ON WDH'S SCHEDULE H. WDPC PROVIDED COMMUNITY BENEFITS EXCEEDING $867,000 IN 2010. THE CORPORATION SUPPORTS NUMEROUS COMMUNITY BASED PROGRAMS, INCLUDING THE COMMUNITY DENTAL CENTER AND PETE'S PLACE, WHICH IS A GRIEF SUPPORT ORGANIZATION FOR CHILDREN WHO HAVE SUFFERED THE LOSS OF A LOVED ONE OR FRIEND. THE PROGRAM ALSO PROVIDES GROUP COUNSELING AT AREA SCHOOLS FOR STUDENTS WHO HAVE LOST A CLASSMATE.THE WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER IS OPEN TO LOW-INCOME, UNINSURED ADULTS AND CHILDREN LIVING IN THE HOSPITAL'S PRIMARY SERVICE AREA (DOVER, DURHAM, MADBURY, LEE, BARRINGTON, SOMERSWORTH, ROLLINSFORD, NH AND BERWICK AND SO. BERWICK, ME) OR PATIENTS OF THE PHYSICIAN PRACTICES WHO HAVE A FAMILY INCOME AT OR BELOW 300% OF THE FEDERAL POVERTY GUIDELINES IN CONJUCTION WITH A DISCOUNTED FEE SCHEDULE. IN 2010, THE DENTAL CENTER PROVIDED $493,000 OF COMMUNITY-BASED CLINIC SERVICES THROUGH 4,760 VISITS.WDPC PROVIDES FINANCIAL AID INFORMATION AND RESOURCES TO ASSIST PATIENTS WITH THEIR HEALTHCARE BILLS. MEDICAL CARE IS PROVIDED AT NO CHARGE FOR ELIGIBLE PATIENTS AT 300% OF THE FEDERAL POVERTY LEVEL. IN 2010 WDPC PROVIDED $374,000 OF FINANCIAL AID (STATED AT COST).MEDICAID COSTS EXCEEDING REIMBURSEMENT TOTALED $520,639 FOR THE CORPORATION IN 2010. PART VI, LINE 7: THE AFFILIATES OF WENTWORTH-DOUGLASS HOSPITAL INCLUDE WENTWORTH-DOUGLASS PHYSICIAN CORPORATION, WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION AND THE WENTWORTH-DOUGLASS HOSPITAL AND HEALTH FOUNDATION. OUR AFFILIATES SERVE TO FURTHER OUR MISSION OF HELPING OUR PATIENTS AND THEIR FAMILIES ATTAIN THEIR HIGHEST LEVEL OF HEALTH. THE WENTWORTH-DOUGLASS PHYSICIAN CORPORATION WAS FORMED IN RESPONSE TO A COMMUNITY NEEDS ASSESSMENT THAT IDENTIFIED A LACK OF PRIMARY CARE SERVICES IN THE COMMUNITY. THE FORMATION OF THE PHYSICIAN CORPORATION AND RECRUITMENT OF PRIMARY CARE PHYSICIANS CLOSED THE GAP BY IMPROVING ACCESS TO PRIMARY CARE MEDICAL SERVICES IN OUR COMMUNITY. WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION (THE WORKS) SERVES TO PROMOTE COMMUNITY HEALTH AND WELLNESS, WHILE REMAINING FAMILY FOCUSED. THE WORKS OFFERS SPECIALLY DESIGNED AND SUPERVISED FITNESS PROGRAMS, AIMED TO HELP MANAGE DIABETES, LOWER RISK OF HEART DISEASE, AND IMPROVE QUALITY OF LIFE. IN ADDITION, THE HOSPITAL COLLABORATES WITH THE WORKS TO OFFER GROUP EXERCISE PROGRAMS TO OUR PATIENTS, INCLUDING CANCER CENTER PATIENTS, WHO ARE PROVIDED A FREE THREE MONTH MEMBERSHIP AND INVITED TO PARTICIPATE IN A PROGRAM THAT COMBINES REHABILITATION AND GROUP EXERCISE.THE WENTWORTH-DOUGLASS HOSPITAL AND HEALTH FOUNDATION SERVES TO CULTIVATE, SECURE AND STEWARD PHILANTHROPIC GIFTS THAT WILL SUPPORT THE CAPITAL, PROGRAMMATIC AND ENDOWMENT NEEDS OF WENTWORTH-DOUGLASS HOSPITAL. REPORTS FILED WITH STATES PART VI, LINE 7 NH X 1 1 X X X X 0 1 0 0 0 0 0 1 0 WILLIAM HASSETT MD 0 153396 0 36984 0 124720 0 9600 0 8430 0 333130 0 0 GREGORY J WALKER 406373 0 65462 0 133469 0 127804 0 19978 0 753086 0 0 0 PETER E WALCEK 271159 0 21465 0 9613 0 55200 0 19302 0 376739 0 0 0 PAUL R CASS 266258 0 20737 0 3500 0 54450 0 19345 0 364290 0 0 0 ELLEN L CAILLE 224833 0 23146 0 10020 0 46320 0 26078 0 330397 0 0 0 SHEILA M WOOLLEY 216734 0 17036 0 10544 0 33620 0 8766 0 286700 0 0 0 DANIEL N DUNN 213377 0 18149 0 10934 0 14679 0 17785 0 274924 0 0 0 MALCOLM D ROSENSON MD 214464 0 0 0 4000 0 8732 0 16702 0 243898 0 0 0 PART I, LINE 1A CERTAIN RETIREMENT AND FRINGE BENEFITS FOR GREGORY J. WALKER (PRESIDENT/CEO) HAVE BEEN GROSSED-UP UTILIZING THE APPLICABLE MARGINAL FEDERAL TAX RATE AS THE MOST EFFICIENT AND COST EFFECTIVE MEANS TO FULFILL THE TARGET BENEFIT GOAL AT RETIREMENT. PART I, LINE 4B GREGORY J. WALKER (PRESIDENT/CEO) - 2010 TOTAL CONTRIBUTIONS TO THE 457(F) PLAN = $113,104. THIS SUPPLEMENTAL RETIREMENT PLAN CONTRIBUTION IS INTENDED TO FUND BENEFITS ACCRUING AND PAYABLE AT RETIREMENT FOR MULTIPLE YEARS OF SERVICE THAT BEGAN IN CALENDAR YEAR 1997. IN 2010, THE HOSPITAL ALSO EXECUTED A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN WHICH PROVIDES BENEFITS TO OTHER QUALIFYING EXECUTIVES. THE CONTRIBUTIONS ARE INTENDED TO PROVIDE A FORFEITABLE SUPPLEMENTAL RETIREMENT BENEFIT AND ARE BEING PROVIDED IN CONSIDERATION FOR MANY YEARS OF SERVICE TO THE HOSPITAL. THE RESPECTIVE CONTRIBUTIONS FOR THE 2010 PLAN YEAR, FOR THOSE INDIVIDUALS IDENTIFIED IN SCHEDULE J - PART II, ARE AS FOLLOWS: PETER E. WALCEK = $40,500, PAUL R. CASS = $39,750, ELLEN L. CAILLE =$37,500 AND SHEILA M. WOOLLEY = $21,320. PART I, LINE 7 AT-RISK COMPENSATION, WHICH IS SUBJECT TO REVIEW AND PAID ANNUALLY. NHHEFA CAPITAL ANTICIPATION NOTEWDH ISSUE SERIES 2009G 020279866 NONEAVAIL 2009-04-01 30000000 ASSIST IN FUNDING OF SIGNIFICANT CAPITAL PROJECTS AND REFINANCING 0 0 0 30000000 37500 2010 1 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 PETER DIRKSMEIER MD EMPLOYEE OF SOSMED 317453 IN 2010, SOSMED PAID THE HOSPITAL $82,460 AS RENTAL FEES FOR PROFESSIONAL MEDICAL SPACE LOCATED AT THE WD PROFESSIONAL CENTER IN LEE, NH AND $40,509 FOR PRACTICE SUPPORT SERVICES. THE HOSPITAL COLLECTED ON BEHALF OF SOSME ACCOUNTS RECEIVABLES FOR A SUPPORTED PHYSICIAN IN THE AMOUNT OF $183,720. THE HOSPITAL RECEIVED, ON BEHALF OF WENTWORTH-DOUGLASS PHYSICIAN CORPORATION, $10,764 FOR THE RESPECTIVE BILLING SERVICES RENDERED. 0 WENTWORTH HOMECARE AND HOSPICE LLC CURRENT OFFICER SERVES BOTH ORGANIZATIONS 880050 THE HOSPITAL HAS A 50% OWNERSHIP INTEREST IN WENTWORTH HOMECARE AND HOSPICE, LLC. THE HOSPITAL ACCOUNTS FOR ITS INVESTMENT IN JOINT VENTURES UNDER THE EQUITY METHOD. THE 2010 INCOME RECORDED FOR THE HOSPITAL SHARE OF REVENUES EQUALED $880,050 FROM WHICH IT RECEIVED A DISTRIBUTION OF $725,000. 1 GRANITE STATE INSURANCE EXCHANGE CURRENT OFFICER SERVES BOTH ORGANIZATIONS 350000 IN DECEMBER OF 2010, THE HOSPITAL MADE AN INITIAL CAPITAL CONTRIBUTION TO GRANITE STATE INSURANCE EXCHANGE (GSIE) OF $100,000. A SECOND CAPITAL CONTRIBUTION OF $250,000 WAS MADE TO GSIE IN FEBRUARY OF 2011 BRINGING THE HOSPITAL'S OWNERSHIP INTEREST IN GSIE TO APPROXIMATELY 11%. NO OPERATING ACTIVITY OCCURRED IN GSIE DURING 2010. 1 STRAFFORD HEALTH ALLIANCE CURRENT OFFICER SERVES BOTH ORGANIZATIONS 243652 THE HOSPITAL HAS A 50% OWNERSHIP INTEREST IN STRAFFORD HEALTH ALLIANCE (SHA). THE HOSPITAL ACCOUNTS FOR INVESTMENT IN JOINT VENTURES UNDER THE EQUITY METHOD. THE HOSPITAL MADE A CAPITAL CONTRIBUTION IN 2010 TO SHA OF $100,000. THE 2010 ALLOCATED LOSS TO THE HOSPITAL EQUALED $42,887. IN ADDITION, SHA PURCHASED VARIOUS MANAGEMENT SERVICES FROM THE HOSPITAL THAT AMOUNTED TO LESS THAN $10,000. SHA LEASED SPACE FOR THE WOMEN'S LIFE IMAGING CENTER PROGRAM AND ADMINISTRATIVE OFFICES THROUGH A RELATED ENTITY OF THE HOSPITAL. THE AMOUNT PAID IN 2010 WAS $80,157. SHA ALSO LEASED ADDITIONAL SPACE FROM A RELATED ENTITY OF THE HOSPITAL FOR A THORACIC SURGEON THAT INCLUDED OTHER OPERATING EXPENSES. THE TOTAL AMOUNT PAID DURING CALENDAR YEAR 2010 EQUALED $96,382. 1 FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS INITIALLY REVIEWED IN DETAIL BY THE FINANCE COMMITTEE AND KEY FINANCE EMPLOYEES. THEREAFTER, THE FINAL DRAFT IS PRESENTED TO THE FULL BOARD PRIOR TO FILING WITH THE IRS. EACH MEMBER OF THE BOARD AND FINANCE COMMITTEE IS PROVIDED WITH A DRAFT OF THE FORM 990 IN ADVANCE OF EACH MEETING. FORM 990, PART VI, SECTION B, LINE 12C A COPY OF THE HOSPITAL CONFLICT OF INTEREST POLICY IS DISTRIBUTED ANNUALLY TO ALL OFFICERS, TRUSTEES, MEDICAL STAFF OFFICERS AND COMMITTEE MEMBERS, AND THE MANAGEMENT TEAM. ALL ARE REQUIRED TO REPORT ANY CONFLICTS AND SIGN, DATE, AND RETURN THE POLICY, WHETHER OR NOT A CONFLICT EXISTS, TO CONFIRM COMPLIANCE. CONFLICTS ARE DISCLOSED IN ACCORDANCE WITH STATE OF NEW HAMPSHIRE RSA 7:19-A IN THE LOCAL NEWSPAPER AND SUBMITTED TO THE NEW HAMPSHIRE ATTORNEY GENERAL. FORM 990, PART VI, SECTION B, LINE 15 CEO'S COMPENSATION: THE CEO'S COMPENSATION AND BENEFITS ARE REVIEWED, ADJUSTED AND VOTED ON BY THE FULL BOARD ANNUALLY. EVERY OTHER YEAR, A NATIONAL INDEPENDENT CONSULTING FIRM IS ENGAGED BY THE BOARD TO PROVIDE COMPARATIVE MARKET COMPENSATION DATA FOR EXECUTIVE AND MANAGEMENT POSITIONS AT THE HOSPITAL. THE BOARD OF TRUSTEES USES THE DATA TO COMPARE WENTWORTH-DOUGLASS' CEO COMPENSATION WITH THAT OF OTHER HOSPITAL EXECUTIVES NATIONALLY AND IN THE NORTHEAST REGION TO DETERMINE THE CEO'S ANNUAL SALARY. ON ALTERNATE YEARS, WHEN THE CONSULTING FIRM IS NOT ENGAGED, THE BOARD USES SALARY RANGES ESTABLISHED THE PRIOR YEAR AND MARKET ECONOMIC DATA TO VALIDATE THAT THE CEO'S SALARY IS COMPETITIVE AND MAKE MARKET ADJUSTMENTS. THE CEO IS EXCUSED FROM BOARD DISCUSSION AND VOTING ON ISSUES SURROUNDING CEO COMPENSATION AND BENEFITS. COMPENSATION OF KEY EMPLOYEES: THE CEO REVIEWS THE SALARIES OF KEY EMPLOYEES ANNUALLY AND DETERMINES COMPENSATION BASED ON PERFORMANCE, SALARY RANGES AND MARKET COMPETITIVE DATA. COMPENSATION DATA IS PROVIDED BY AN INDEPENDENT NATIONAL CONSULTING FIRM EVERY OTHER YEAR. THE CEO PRESENTS SALARY RANGE DATA FOR KEY EMPLOYEES TO THE BOARD ANNUALLY FOR APPROVAL. USING THE BOARD APPROVED SALARY RANGE DATA, THE CEO RECOMMENDS SALARY INCREASES FOR VICE PRESIDENTS TO THE BOARD FOR APPROVAL AND THE VICE PRESIDENTS RECOMMEND SALARY INCREASES FOR DIRECTORS AND OTHER MANAGEMENT POSITIONS TO THE CEO, FOR APPROVAL. PHYSICIAN SALARY RANGES ARE ESTABLISHED ANNUALLY USING THE MEDICAL GROUP MANAGEMENT ASSOCIATION (MGMA) SALARY SURVEY DATA. DUE TO A POTENTIAL CONFLICT OF INTEREST, DR. WILLIAM HASSETT, PRESIDENT OF THE MEDICAL STAFF AND AN EMPLOYEE OF A RELATED ORGANIZATION (WENTWORTH-DOUGLASS PHYSICIAN CORPORATION), IS EXCLUDED FROM SALARY DISCUSSIONS. FORM 990, PART VI, SECTION C, LINE 19 WENTWORTH-DOUGLASS HOSPITAL FILES AUDITED FINANCIAL STATEMENTS ANNUALLY WITH THE NEW HAMPSHIRE ATTORNEY GENERAL'S CHARITABLE TRUST UNIT AND INFORMS THE DIRECTOR OF CHARITABLE TRUSTS OF PECUNIARY BENEFIT TRANSACTIONS THAT HAVE OCCURRED BETWEEN WDH AND A BOARD MEMBER OR OFFICER. NOTICES OF SUCH TRANSACTIONS OF $5,000 OR MORE ARE ALSO PUBLISHED IN THE LOCAL NEWSPAPER IN ACCORDANCE WITH NH RSA 7:19-A, II(D). CURRENT COPIES OF THE BYLAWS, CONFLICT OF INTEREST POLICY AND FORM 990 ARE ON FILE WITH THE CHARITABLE TRUST UNIT. REPORTABLE COMPENSATION FROM THE ORGANIZATION FORM 990, PART VII, SECTION A, COLUMN D THE 2010 COMPENSATION REPORTED FOR DR. JOSEPH WHITE WAS PAID BY WENTWORTH-DOUGLASS HOSPITAL FOR HIS SERVICES AS A MEDICAL DIRECTOR. DR. WHITE IS NOT COMPENSATED FOR HIS SERVICES AS A NON-VOTING TRUSTEE OF WDH. REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A, COLUMN E THE 2010 COMPENSATION REPORTED FOR DR. WILLIAM HASSETT WAS PAID BY WENTWORTH-DOUGLASS PHYSICIAN CORPORATION FOR HIS SERVICES AS A FULL-TIME PHYSICIAN. DR. HASSETT IS NOT COMPENSATED FOR HIS SERVICES AS A TRUSTEE OF WDH. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 5,472,259. CHANGE IN FV OF INTEREST RATE SWAP AGREEMENT -707,597. NET CHANGE IN RESTRICTED ASSETS HELD BY WDHHF 128,796. NET LOSS ON INVESTMENTS IN JOINT VENTURES & RELATED ORGANIZATIONS -17,403,869. TOTAL TO FORM 990, PART XI, LINE 5: -12,510,411. AUDIT REVIEW PROCESS FORM 990, PART XI, LINE 2C THE FINANCE COMMITTEE OVERSEES THE AUDIT PROCESS FOR WENTWORTH-DOUGLASS HOPSPITAL AND ALL RELATED ORGANIZATIONS. THE AUDIT PROCESS FOR THE FINANCIAL STATEMENTS DID NOT CHANGE FROM THE PRIOR YEAR. INDEPENDENT ACCOUNTANTS PERFORMED THE AUDIT IN BOTH 2009 AND 2010. GOVERNING BODY AND MANAGEMENT FORM 990, PART VI, LINE 1A AND LINE 1B STEVEN C. WEBB IS A TRUSTEE OF THE HOSPITAL AND AN EXECUTIVE AT TD BANKNORTH. THE HOSPITAL MAINTAINS OPERATING AND PAYROLL ACCOUNTS WITH TD BANKNORTH. TRANSACTIONS IN 2010 WERE IN EXCESS OF $10,000. AN EXACT FIGURE CANNOT BE STATED DUE TO DAILY ACCOUNT ACTIVITY AND BALANCE CHANGES. BOTH ACCOUNTS WERE ACTIVE PRIOR TO MR. WEBB JOINING THE BOARD AND ALL TRANSACTIONS WITH TD BANKNORTH ARE AT A FAIR MARKET RATE. FOR 2010, MR. WEBB HAS BEEN CLASSIFIED AS AN INDEPENDENT BOARD MEMBER. FORM 990, PART IV, LINE 26 AND PART X, LINE 15 WDH SPONSORS A SPLIT-DOLLAR LIFE INSURANCE EMPLOYEE BENEFIT PROGRAM FOR CERTAIN OFFICERS AND KEY EMPLOYEES. SPLIT DOLLAR LIFE INSURANCE IS AN ARRANGEMENT IN WHICH THE EMPLOYEE IS THE OWNER OF THE LIFE INSURANCE POLICY AND THE PREMIUMS ARE PAID BY BOTH THE EMPLOYER AND EMPLOYEE. PURSUANT TO WDH'S SPLIT-DOLLAR AGREEMENT, AND THE COLLATERAL ASSIGNMENT THEREIN, THE EMPLOYER'S SHARE OF THE POLICY PREMIUMS PAID IS RECOVERED EITHER UPON TERMINATION OF THE POLICY OR AT THE DEATH OF THE PARTICIPANT. NOTE THAT THE SPLIT-DOLLAR ARRANGEMENT IS PART OF AN EMPLOYEE BENEFIT PROGRAM AND ECONOMICALLY NOT A DIRECT EXTENSION OF CREDIT. FURTHERMORE, THE REPORTABLE COMPENSATION OF THE RESPECTIVE EMPLOYEES INCLUDES THE ANNUAL VALUE OF THE LIFE INSURANCE. FUNDRAISING EXPENSES FORM 990, PART IX, COLUMN D WENTWORTH-DOUGLASS HOSPITAL AND HEALTH FOUNDATION (A RELATED ORGANIZATION) PERFORMS ALL FUNDRAISING ACTIVITIES ON BEHALF OF WENTWORTH-DOUGLASS HOSPITAL. ALL FUNDRAISING EXPENSES ARE REPORTED ON THE FOUNDATION'S SEPARATE FORM 990. WENTWORTH-DOUGLASS PHYSICIAN CORPORATION 789 CENTRAL AVENUE DOVER NH 03820 020497927 HEALTH CARE NH 501(C)(3) 170(B)(1) (A)(III) N/A 1 WENTWORTH-DOUGLASS HOSPITAL & HEALTH FOUNDATION 789 CENTRAL AVENUE DOVER NH 03820 510491062 PHILANTHROPIC FUND RAISING & STEWARDSHIP NH 501(C)(3) 509(A)(3) N/A 1 WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION 789 CENTRAL AVENUE DOVER NH 03820 020399963 HEALTH FITNESS CENTER NH N/A C -76535 11842875 1.00000 1 1 1 0 0 0 0 0 1 1 1 0 1 1 0 1 1 1 WENTWORTH-DOUGLASS HOSPITAL & HEALTH FOUNDATION C 354119 ACTUAL PER BOOKS WENTWORTH-DOUGLASS HOSPITAL & HEALTH FOUNDATION B 68752 ACTUAL PER BOOKS WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION A 19739 ACTUAL PER BOOKS WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION J 144000 ACTUAL PER BOOKS WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION N 129679 ACTUAL PER BOOKS WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION P 83178 ACTUAL PER BOOKS WENTWORTH-DOUGLASS COMMUNITY HEALTH CORPORATION Q 482201 ACTUAL PER BOOKS WENTWORTH-DOUGLASS PHYSICIAN CORPORATION P 315586 ACTUAL PER BOOKS WENTWORTH-DOUGLASS PHYSICIAN CORPORATION B 16252278 ACTUAL PER BOOKS WENTWORTH-DOUGLASS PHYSICIAN CORPORATION I 2302562 ACTUAL PER BOOKS