2011-11-03T09:42:33-05:00 2010-12-31 MOUNTJOY CHILTON MEDLEY LLP 462 S FOURTH ST 2000 MEIDINGER TOWE LOUISVILLE KY 402023445 990 2010-01-01 314379519 LICKING MEMORIAL HOSPITAL LICK 7403484528 1320 WEST MAIN STREET NEWARK OH 43055 CYNTHIA L WEBSTER 7403484528 2011-10-31 1 VICTORIA D BUSTER CPA 5027491900 2010 2016-03-07 17:11:31Z ROBERT A MONTAGNESE 1320 WEST MAIN STREET NEWARK OH 43055 168627298 0 X WWW.LMHEALTH.ORG X 1898 OH TO IMPROVE THE HEALTH OF THE COMMUNITY. 13 13 1451 164 0 0 0 0 166183433 166415478 13673 221728 1659290 1393002 167856396 168030208 0 0 0 0 73024990 69941046 0 0 0 74160052 73162332 147185042 143103378 20671354 24926830 143479422 130923203 74685375 65708580 68794047 65214623 X LICKING MEMORIAL HOSPITAL EXISTS TO IMPROVE THE HEALTH OF THE COMMUNITY. 0 0 128518628 166698593 LICKING MEMORIAL HOSPITAL (LMH) PROVIDES HEALTHCARE SERVICES WITHOUT REGARD TO A PATIENT'S RACE, CREED, GENDER, DISABILITY, ETHNICITY, AGE, RELIGION, CITIZENSHIP, NATIONAL ORIGIN OR SOURCES OF PAYMENT FOR CARE. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF LMH, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. FURTHER, WE BELIEVE OUR PURPOSE IS TO SERVE THE COMMUNITY BY PROVIDING HEALTHCARE SERVICES AND EDUCATION. THEREFORE, IN KEEPING WITH OUR COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, WE PROVIDE: - FREE CARE AND/OR SUBSIDIZED CARE - CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS BELOW COST - HEALTH ACTIVITIES AND PROGRAMS FREE-OF-CHARGE TO THE COMMUNITYTHE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, AND SPECIAL PROGRAMS FOR THE ELDERLY, HANDICAPPED AND MEDICALLY UNDER SERVED.LMH SERVED 7,386 INPATIENTS AND 1,089 NEWBORNS FOR A TOTAL OF 25,904 PATIENT DAYS, AND PROVIDED SERVICES TO 278,049 OUTPATIENTS IN 2010.ADDITIONALLY, LMH PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, BELOW COST IN MANY CASES. TO THE EXTENT REIMBURSEMENT IS BELOW CHARGES, LMH CONSIDERS THESE AMOUNTS TO BE CONTRACTUAL ADJUSTMENTS, WHICH WILL NEVER BE COLLECTED. THE UNREIMBURSED VALUE OF PROVIDING CARE TO THESE PATIENTS AMOUNTED TO $116,215,000 IN 2010.UNCOMPENSATED CARE IS PROVIDED THROUGH MANY REDUCED PRICE SERVICES AND FREE PROGRAMS OFFERED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES LMH BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED. THE HOSPITAL ROUTINELY PROVIDES UNCOMPENSATED CARE TO PATIENTS WHO ARE UNWILLING OR UNABLE TO PAY THEIR HOSPITAL BILLS. IN 2010, LMH WROTE OFF CHARGES OF APPROXIMATELY $16,990,000 IN BAD DEBTS AND $15,275,000 IN CHARITY CARE. 128518628 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 72 0 1 1451 1 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DAVID CLAYPOOL 7403484528 1320 WEST MAIN STREET NEWARK OH 43055 PATRICK M JEFFRIES 1.50 X X 0 0 0 LINDA K DALGARN 1.30 X X 0 0 0 JACK E CROCKFORD 1.30 X X 0 0 0 PATRICK D GUANCIALE 1.30 X X 0 0 0 GUS A ANDREWS 1.30 X 0 0 0 MICHAEL D CANTLIN 1.30 X 0 0 0 GENE BRANSTOOL 1.30 X 0 0 0 KIM FLEMING 1.30 X 0 0 0 BONNIE L MANNING 1.30 X 0 0 0 ROBERT H MCGAUGHY 1.30 X 0 0 0 THOMAS MULLADY 1.30 X 0 0 0 RICHARD REED 1.30 X 0 0 0 F JENNIFER UTREVIS 1.30 X 0 0 0 ROBERT MONTAGNESE 30.00 X 364655 0 103079 CINDY WEBSTER 30.00 X 120834 0 18544 CRAIG CAIRNS 40.00 X 230345 0 26150 DEBORAH YOUNG 40.00 X 152863 0 20769 SALLIE ARNETT 40.00 X 143985 0 20152 JEAN GLASER 40.00 X 122074 0 18631 VERONICA LINK 14.00 X 131766 0 19303 1266522 0 226628 22 0 1 0 TURNER CONSTRUCTION 375 HUDSON STREET NEW YORK NY 10014 CONSTRUCTION 3378068 MEDICAL DOCTOR ASSOCIATES PO BOX 277185 ATLANTA GA 30384 PHYSICIAN SERVICES 1329449 MARSH USA INC 10 WEST BROAD STREET COLUMBUS OH 43215 INSURANCE SERVICES 1036759 GE HEALTHCARE IITS USA 40 IDX DRIVE SOUTH BERLINGTON VT 05403 MEDICAL EQUIPMENT AND MAINTENANCE 819406 MID OHIO CARDIOLOGY 3705 OLENTANGY RIVER ROAD SUITE 10 COLUMBUS OH 43214 CARDIOLOGY SERVICES 777203 46 NET PATIENT REVENUE 621110 166415478 166415478 166415478 232719 232719 586099 586099 0 0 10991 -10991 -10991 -10991 CAFETERIA 722210 1109887 1109887 VHA FEES & REBATES 621110 225883 225883 OTHER SERVICES 621110 57232 57232 1393002 168030208 166698593 0 1331615 490039 490039 50299184 45340463 4958721 15458290 14066831 1391459 3693533 3321968 371565 149293 149293 435090 435090 28890 28890 9800188 6841706 2958482 854332 241277 613055 1491928 1491928 35995 34389 1606 376505 155073 221432 1122314 1122314 11537068 9049907 2487161 809514 809514 MEDICAL SUPPLIES 27085046 27085046 BAD DEBT 16989615 16989615 EQUIPMENT RENTAL 1895984 1895984 FRANCHISE FEES/TAXES 1319157 1116554 202603 MISCELLANEOUS -768587 49483 -818070 143103378 128518628 14584750 0 3803407 3507331 17226292 5949809 19557230 17673624 2336522 2322584 1107503 2246727 183870405 99774652 86529041 84095753 6461874 8783917 6457553 6343458 143479422 130923203 10861618 12896301 29200000 20600000 34623757 32212279 74685375 65708580 X 68794047 65214623 68794047 65214623 143479422 130923203 X 24926830 -28506256 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 1960 1960 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LICKING MEMORIAL HOSPITAL PAYS $39,207 IN ANNUAL DUES TO OHIO HOSPITAL ASSOCIATION(OHA). OF THE TOTAL DUES PAID, 5% OR $1,960 ARE USED BY OHA TO SUPPORT LOBBYING ACTIVITIES OF THE ASSOCIATION. 912879 912879 83507018 28219409 55287609 2702000 1900283 801717 96748508 69654960 27093548 84095753 DEFERRED PENSION AND RETIREE LIABILITY 28288618 ACCRUED INTEREST PAYABLE 79142 ACCRUED MALPRACTICE 3844519 32212279 1 1 1 X 1 X 1 1 0 1 1 14739 7959709 2241253 5718456 0.04530 27082 24789356 13345692 11443664 0.08000 41821 32749065 15586945 17162120 0.12530 16556 1352197 211881 1140316 0.00800 891 478715 18000 460715 0.00320 72006 72006 0.00050 400 280835 280835 0.00200 17847 2183753 229881 1953872 0.01370 59668 34932818 15816826 19115992 0.13900 1 32 2180 2180 0.00000 0 0 0 5 450 34738 34738 0.00030 0 0 0 0 0 0 0 0 0 0 0 0 3 315 4301 4301 0.00000 3 421 12195 12195 0.00010 12 1218 53414 53414 0.00040 1 7611348 2683101 32043450 33441728 -1398278 X 1 1 1 1 LICKING MEMORIAL HOSPITAL

1320 WEST MAIN STREET NEWARK OH 43055

X X X LICKING MEMORIAL HOSPITAL 1 PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY LICKING MEMORIAL HEALTH SYSTEMS AND INCLUDES LICKING MEMORIAL HEALTH SYSTEMS, LICKING MEMORIAL HOSPITAL, LICKING MEMORIAL PROFESSIONAL CORPORATION, LICKING MEMORIAL HEALTH FOUNDATION. PART I, LINE 7: THE ORGANIZATION USED THE CBISA SOFTWARE TO DETERMINE THE COST ACCOUNTING METHODOLOGY. 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 $ 16989615. PART II: IT IS IMPORTANT TO NOTE THAT ALL ACTIVITIES ASSOCIATED WITH LICKING MEMORIAL HEALTH SYSTEMS REFLECT AND FURTHER THE MISSION OF "IMPROVING THE HEALTH OF THE COMMUNITY." WE DEFINE THE HEALTH OF THE COMMUNITY VERY BROADLY IN ORDER TO INCLUDE ACTIVITIES THAT ARE NOT NECESSARILY HEALTH RELATED BUT ACTIVITIES THAT WE BELIEVE ARE CRITICAL TO A HEALTHY COMMUNITY SUCH AS STRONG SCHOOLS, YOUTH PROGRAMS AND THE ARTS. WE PUBLISH A BI-MONTHLY MAGAZINE THAT IS MAILED TO 55,000 HOUSEHOLDS WHICH HIGHLIGHTS ALL OF OUR COMMUNITY BUILDING ACTIVITIES AND OPPORTUNITIES FOR HEALTH EDUCATION AND SCREENING. PART III, LINE 4: BAD DEBT EXPENSE FOOTNOTE FOR LICKING MEMORIAL HEALTH SYSTEMS AND SUBSIDIARIES.IN ADDITION TO CHARITY CARE, THE SYSTEM PROVIDES SERVICES TO PATIENTS WHO ARE UNWILLING TO PAY THEIR BILLS. MANY OF THESE PATIENTS WOULD LIKELY QUALIFY FOR CHARITY CARE IF THEY APPLIED FOR THIS BENEFIT. IN 2010, AND 2009 THE SYSTEM CHARGED $19.7 MILLION AND $20.5 MILLION TO EXPENSE RESPECTIVELY, OF CHARGES RELATED TO THESE PATIENTS.LINE 2 - THE ORGANIZATION USES THE CBISA SOFTWARE FOR COSTING METHODOLOGY, A SOFTWARE PROGRAM ENDORSED BY BOTH THE OHIO HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION.LINE 3 - THE ORGANIZATION EMPLOYED A PATIENT SCORING METHODOLOGY WHICH COMBINES NUMEROUS FINANCIAL INDICATORS TO ARRIVE AT A NUMERIC CREDIT SCORE. THIS SCORE INCLUDES THE PATIENTS ABILITY TO PAY BASED ON THE ESTIMATED HOUSEHOLD INCOME AS WELL AS THE PROBABILITY OF PAYMENT BEING MADE BASED ON HISTORICAL CREDIT INFORMATION. PART III, LINE 8: THE MEDICARE SHORTFALL REPRESENTS AN UNDERPAYMENT OF OUR COST FOR PROVIDING SERVICES TO TRADITIONAL MEDICARE PATIENTS, OUR LARGEST PAYER. SINCE THIS SHORTFALL RELATES TO SUCH A LARGE PORTION OF OUR COMMUNITY, WE FEEL THE COST SHORTFALL IS A RELEVANT FACTOR WHEN CONSIDERING COMMUNITY BENEFIT.WE USE THE MEDICARE COST REPORT FOR COSTING METHODOLOGY FOR CALCULATING THE MEDICARE SHORTFALL.IN ADDITION TO TRADITIONAL MEDICARE SHORTFALLS, THE HOSPITAL PROVIDES SERVICES TO MEDICARE HMO PATIENTS AT OR BELOW COST AS A FURTHER BENEFIT TO OUR COMMUNITY. BY ADOPTING THE SAME METHODOLOGY FOR TRADITIONAL MEDICARE ABOVE, THE MEDICARE HMO SHORTFALL AMOUNTED TO $1,098,587.ALONG THAT SAME LINE, THE LICKING MEMORIAL PROFESSIONAL CORPORATION, ANOTHER LMHS SUBSIDIARY, PROVIDED SERVICES TO MEDICARE (TRADITIONAL AND HMO) BENEFICIARIES AT A COST SHORTFALL OF $4,626,825 USING A CBISA SOFTWARE COSTING METHOD. THE CBISA SOFTWARE IS ENDORSED BY BOTH THE OHIO HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION AS A COSTING METHOD UTILIZED FOR DETERMINING SHORTFALLS. PART III, LINE 9B: THE PATIENT ACCOUNTING DEPARTMENT IS RESPONSIBLE FOR THE COLLECTION OF PATIENTS' ACCOUNTS. THE OBJECTIVE OF THE DEPARTMENT IS TO COLLECT ACCOUNTS DUE THE HOSPITAL WHILE MAINTAINING POSITIVE GUEST RELATIONS.-PRIOR TO OR UPON ADMISSION, PATIENT INFORMATION IS OBTAINED BY THE REGISTRATION DEPARTMENT. THIS INFORMATION IS FORWARDED TO THE PATIENT ACCOUNT REPRESENTATIVE FOR MEDASSIST, INC. UPON ADMISSION.-WHENEVER POSSIBLE, SELF-PAY INPATIENTS ARE INTERVIEWED BY THE PATIENT ACCOUNT REPRESENTATIVE PRIOR TO DISCHARGE. PATIENTS WILL BE SCREENED FOR POSSIBLE STATE OR FEDERAL PROGRAM ELIGIBILITY, SUCH AS MEDICAID ORSOCIAL SECURITY DISABILITY. IF PATIENTS DO NOT MEET THE CRITERIA FOR THESE PROGRAMS, THEY WILL BE INFORMED OF THE UNCOMPENSATED CARE PROGRAMS AVAILABLE.- ALL STATEMENTS CONTAIN INFORMATION AND GUIDELINES FOR UNCOMPENSATED CARE. PART VI, LINE 2: WITH A MISSION OF "IMPROVING THE HEALTH OF THE COMMUNITY," LICKING MEMORIAL HEALTH SYSTEMS CONTINUOUSLY MONITORS AND ASSESSES THE NEEDS OF OUR COMMUNITY. WE DO THIS IN A VARIETY OF WAYS. OUR ENTIRE LEADERSHIP TEAM IS VERY ACTIVE IN THE COMMUNITY, SERVING ON LOCAL, NOT-FOR-PROFIT BOARDS AND IN SERVICE CLUBS SUCH AS ROTARY AND KIWANIS. AS THE LARGEST EMPLOYER IN LICKING COUNTY, THE COMMUNITY LOOKS TO OUR MANAGEMENT STAFF FOR SUPPORT AND INVOLVEMENT IN MOST, IF NOT ALL, MAJOR INITIATIVES. THIS COMMUNITY INVOLVEMENT PROVIDES THE OPPORTUNITY TO COLLECT INFORMATION REGARDING THE NEEDS OF THE DIFFERENT ORGANIZATIONS. SENIOR MANAGEMENT IS VERY RESPONSIVE IN PROVIDING ASSISTANCE WHERE NEEDED AS THIS INFORMATION BECOMES AVAILABLE. THE BOARDS OF DIRECTORS FOR LICKING MEMORIAL HOSPITAL AND LICKING MEMORIAL HEALTH SYSTEMS ARE VERY INTERESTED AND ACTIVELY ENGAGED IN THE COMMUNITY; THEREFORE, THEY ARE A GREAT RESOURCE IN MAKING ADMINISTRATION AWARE OF NEEDS. IN ADDITION, THE BOARD RECEIVES A MONTHLY REPORT AT EACH BOARD MEETING, HIGHLIGHTING ALL OF THE COMMUNITY ACTIVITIES SUPPORTED BY THE HOSPITAL INCLUDING DONATIONS MADE DURING THAT MONTH, HEALTH FAIRS AND HEALTH SCREENINGS, MANAGEMENT AND PHYSICIANS SPEAKING IN THE COMMUNITY, ETC. PROVIDING ALL OF THIS INFORMATION TO THE BOARD ALLOWS THEM TO BE SUPPORTIVE AS ADMINISTRATION RECOMMENDS IMPLEMENTING NEW SERVICES OR ENHANCING EXISTING OFFERINGS.ORGANIZED UNDER THE HOSPITAL CORPORATION IS A 75 MEMBER DEVELOPMENT COUNCIL WHOSE PURPOSE IS TO EDUCATE THE COMMUNITY ABOUT THE HOSPITAL AND TO COMPLETE FUNDRAISING ACTIVITIES IN SUPPORT OF THE ORGANIZATION. THE MEMBERS OF THE DEVELOPMENT COUNCIL ARE COMMUNITY LEADERS REPRESENTING ALL AREAS OF BUSINESS, INDUSTRY AND EDUCATION IN THE COMMUNITY. THESE ARE INDIVIDUALS WHO HAVE THEIR "FINGERS ON THE PULSE" OF THE COMMUNITY, AND ONE OF THEIR RESPONSIBILITIES AS AMBASSADORS IS TO MAKE THE ADMINISTRATION AWARE OF NEEDS IN THE COMMUNITY ESPECIALLY PERTAINING TO HEALTH CARE. AMONG MANY OUTREACH ACTIVITIES OF THE DEVELOPMENT COUNCIL, PROBABLY THE MOST PRODUCTIVE ARE THE COMMUNITY LEADER ROUNDTABLES THAT ARE SPONSORED BY THIS GROUP. THESE ARE LUNCHEONS SCHEDULED MONTHLY WITH THE HEALTH SYSTEMS CEO. DEVELOPMENT COUNCIL MEMBERS SERVE AS HOSTS, AND THEY INVITE 20-25 INDIVIDUALS REPRESENTING SIMILAR INTERESTS. SOME EXAMPLES OF RECENT ROUNDTABLE GROUPS ARE SCHOOL NURSES, SCHOOL ATHLETIC DIRECTORS AND COACHES, REALTORS, FIRE CHIEFS, LOCAL POLITICIANS, ETC. THESE FORUMS ARE ALWAYS VERY INFORMATIVE FOR BOTH THE ATTENDEES AND THE ADMINISTRATION AS WE SHARE INFORMATION ABOUT THE HOSPITAL AND THEN ASK FOR FEEDBACK FROM THE COMMUNITY LEADERS WHO ARE PRESENT. MANY TIMES, IDEAS FOR HOSPITAL INITIATIVES COME FROM THESE EVENTS.ANOTHER ACTIVITY OF THE DEVELOPMENT COUNCIL IS A QUARTERLY CORPORATE BREAKFAST. THESE EDUCATIONAL SESSIONS NORMALLY DRAW 100-125 ATTENDEES FOR BREAKFAST AND PROVIDE AN OPPORTUNITY TO EDUCATE THE COMMUNITY LEADERSHIP REGARDING HOSPITAL ACTIVITIES AND TO PROVIDE AN OPEN FORUM TO DISCUSS HEALTH CARE AND OTHER NEEDS WITHIN THE COMMUNITY. SPEAKERS AT THESE EVENTS HAVE RANGED FROM PHYSICIANS TALKING ABOUT HEART, VASCULAR, ENDOCRINOLOGY, CARING FOR AGING PATIENTS, AND SLEEP MEDICINE, TO OUR DIRECTOR OF PASTORAL CARE TALKING ABOUT HOW HIS DEPARTMENT OF THE HOSPITAL SERVES THE PATIENTS AND THE COMMUNITY. THE HEALTH SYSTEMS' WEBSITE PROVIDES DETAILED INFORMATION ON THE VARIOUS PROGRAMS AVAILABLE AND PROVIDES A MECHANISM FOR COMMUNITY FEEDBACK. ALL REQUESTS COMING THROUGH THE WEBSITE RECEIVE A RESPONSE.AN AFFILIATED PHYSICIAN GROUP, KNOWN AS THE LICKING MEMORIAL PROFESSIONAL CORPORATION, PROVIDES PHYSICIAN INPUT REGARDING THE NEEDS THEY IDENTIFY IN THEIR DAILY PRACTICE AND COMMUNITY INVOLVEMENT. THESE OBSERVATIONS ARE DISCUSSED WITH ADMINISTRATION FOR DEVELOPMENT OF PROGRAMS AND SERVICES TO ADDRESS SUCH NEEDS. PART VI, LINE 3: LICKING MEMORIAL HEALTH SYSTEMS PROVIDES CARE TO THE ENTIRE COMMUNITY REGARDLESS OF ABILITY TO PAY. THAT MESSAGE IS SHARED WITH THE COMMUNITY IN A VARIETY OF WAYS. THE HEALTH SYSTEMS' WEBSITE PROVIDES INFORMATION ON ASSISTANCE IN PAYING HOSPITAL BILLS. IN ADDITION, THE BILLING STATEMENT SENT TO THE PATIENT OR GUARANTOR PROVIDES INSTRUCTIONS FOR ACCESSING CHARITY CARE. ASSISTANCE INFORMATION IS ALSO PROVIDED TO INDIVIDUALS WHO CONTACT THE BILLING OFFICE TO DISCUSS DIFFICULTY IN MAKING PAYMENT. THE HEALTH SYSTEMS CONTRACTS WITH AN ELIGIBILITY COMPANY TO SCREEN AND IDENTIFY PATIENTS WHO ARE ELIGIBLE FOR ASSISTANCE AT CERTAIN POINTS OF SERVICE WITHIN THE ORGANIZATION. WE ALSO EMPLOY THE USE OF EARLY-OUT AGENCIES TO PERFORM SELF-PAY BILLING SERVICES ON OUR BEHALF. THESE AGENCIES ROUTINELY IDENTIFY PATIENTS WHO ARE ELIGIBLE FOR ASSISTANCE AND PROVIDE APPLICATIONS FOR COMPLETION. THE HEALTH SYSTEMS PROVIDES ASSISTANCE TO THOSE WHO ARE ABOVE THE FEDERAL POVERTY LEVEL BY OFFERING DISCOUNTED CARE BASED ON A SLIDING SCALE UP TO 250% OF THE FEDERAL POVERTY LEVEL. IN ADDITION, THE ORGANIZATION PROVIDES FREE OR DISCOUNTED CARE FOR THOSE WHO ARE CONSIDERED TO BE MEDICALLY INDIGENT. THE DEVELOPMENT COUNCIL (AMBASSADORS) HAVE BEEN EDUCATED ABOUT OUR COMMITMENT TO PROVIDE CARE FOR THE ENTIRE COMMUNITY AND THAT MESSAGE IS SHARED IN THE COMMUNITY THROUGH THEIR GRASS ROOTS EFFORTS. PART VI, LINE 4: LICKING MEMORIAL HOSPITAL LOCATED IN NEWARK, OHIO THIRTY THREE MILES EAST OF COLUMBUS. THE CITY OF NEWARK HAS A POPULATION OF ABOUT 50,000 PEOPLE WITH A MEDIAN INCOME OF APPROXIMATELY $41,000. THE HOSPITAL SERVES THE COMMUNITY OF NEWARK AND LICKING COUNTY. LICKING COUNTY HAS A POPULATION OF APPROXIMATELY 166,000 (PER U.S. CENSUS BUREAU), A PER CAPITA INCOME OF APPROXIMATELY $26,000 AND AN UNEMPLOYMENT RATE OF 9.73%. PART VI, LINE 6: THE SYSTEM PROVIDED A VARIETY OF COMMUNITY SERVICES, WHICH INCLUDED PARTICIPATION IN MANY COMMUNITY HEALTH FAIRS THROUGHOUT THE COUNTY TO ENCOURAGE AND ADVANCE HEALTHCARE EDUCATION IN AREA SCHOOLS, CHURCHES AND BUSINESSES; PROVIDED VARIOUS SEMINARS AT NOMINAL CHARGES RELATED TO LAMAZE, CAESARIAN SECTIONS, SIBLING PREPARATION, INFANT AND CHILD CPR, BABYSITTING EDUCATION, AND BREASTFEEDING; PROVIDED SUPPORT GROUPS FOR VICTIMS AND FAMILIES OF CANCER, DIABETES, AND PULMONARY AND HEART DISEASE; PROVIDED ASSISTANCE TO EDUCATORS THROUGH OUR WORK WITH STUDENT NURSES, OCCUPATIONAL THERAPY, AND PHYSICAL THERAPY INTERNS; PROVIDED SPEAKERS TO SCHOOLS, BUSINESSES CIVIC GROUPS AND OTHER ORGANIZATIONS ON HEALTH CARE SUBJECTS. SEE SCHEDULE O FOR A DETAILED LISTING OF VARIOUS PROGRAMS AND INDIVIDUALS SERVED BY THE HEALTH SYSTEM. PART VI, LINE 7: LICKING MEMORIAL HEALTH SYSTEMS (THE SYSTEM) IS A NONPROFIT CORPORATION ORGANIZED UNDER THE LAWS OF THE STATE OF OHIO TO PROVIDE AND PROMOTE HEALTH CARE SERVICES IN CENTRAL OHIO.THE SYSTEM IS THE PARENT ORGANIZATION AND SOLE CORPORATE MEMBER OF LICKING MEMORIAL HOSPITAL (THE HOSPITAL), LICKING MEMORIAL HEALTH FOUNDATION (THE FOUNDATION), AND LICKING MEMORIAL PROFESSIONAL CORPORATION (THE PROFESSIONAL CORPORATION).THE PROFESSIONAL CORPORATION EMPLOYS A STAFF OF PHYSICIANS AND SUPPORT PERSONNEL TO FURTHER THE SYSTEM'S CHARITABLE PURPOSE. THE PROFESSIONAL CORPORATION HAS A SOLE PHYSICIAN SHAREHOLDER, WHO, UNDER A SHARED CONTROL AGREEMENT, ASSIGNED THE VOTING RIGHTS OF THE STOCK TO THE SYSTEM. X X X X X X 0 1 0 0 0 0 0 0 0 ROBERT MONTAGNESE 359994 0 111 0 4550 0 89982 0 13097 0 467734 0 0 0 CRAIG CAIRNS 230234 0 111 0 0 0 14138 0 12012 0 256495 0 0 0 DEBORAH YOUNG 152752 0 111 0 0 0 9382 0 11387 0 173632 0 0 0 SALLIE ARNETT 143874 0 111 0 0 0 8837 0 11315 0 164137 0 0 0 VERONICA LINK 131655 0 111 0 0 0 8087 0 11216 0 151069 0 0 0 PART I, LINE 4B ROBERT MONTAGNESE, PRESIDENT, PARTICIPATES IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). A CONTRIBUTION WAS MADE TO THE PLAN ON HIS BEHALF FOR THE 2010 YEAR IN THE AMOUNT OF $67,600. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE RETURN IS REVIEWED FIRST BY INTERNAL MANAGEMENT. AFTER INTERNAL MANAGEMENT HAS REVIEWED THE RETURN AND ANY CHANGES ARE MADE A DRAFT IS MADE AVAILABLE FOR REVIEW AND PRESENTATION TO THE BOARD. ONCE THE COMMENTS FROM THE BOARD ARE REVIEWED THE FINAL RETURN IS PREPARED AND SIGNED BY THE VICE PRESIDENT OF FINANCIAL SERVICES. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ALL BOARD MEMBERS AND KEY EMPLOYEES TO SIGN A CONFLICT OF INTEREST STATEMENT ONCE A YEAR. THE ORGANIZATION DOES NOT PERMIT BOARD MEMBERS TO HAVE A CONFLICT OF INTEREST. IF A BOARD MEMBER HAS A CONFLICT OF INTEREST THEY ARE ASKED TO RESIGN FROM THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION HAS AN INDEPENDENT COMPENSATION COMMITTEE THAT DETERMINES THE COMPENSATION FOR THE CEO THAT IS THEN APPROVED BY THE BOARD. THE CEO DETERMINES THE COMPENSATION FOR THE OTHER OFFICERS BASED UPON INDEPENDENT SALARY SURVEYS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: ROUNDING 2. NET ASSET TRANSFERS WITH RELATED 501(C)(3) -26,140,758. CHANGE IN RETIREE BENEFIT PLAN -156,321. UNREALIZED GAIN/LOSS 743,370. CHANGE IN MINIMUM PENSION LIABILITY -2,952,549. TOTAL TO FORM 990, PART XI, LINE 5: -28,506,256. FORM 990, PAGE 12, PART XII LINE 2C: THERE WAS NO CHANGE IN THE OVERSIGHT PROCESS OR SELECTION PROCESS OF THE INDEPENDENT AUDITOR. LICKING MEMORIAL HOSPITAL CONTINUES TO BE AUDITED AS PART OF THE LICKING MEMORIAL HEALTH SYSTEMS CONSOLIDATED GROUP. LICKING MEMORIAL HOSPITAL IS INCLUDED IN THE LICKING MEMORIAL HEALTH SYSTEMS CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION HAS A FINANCE COMMITTEE THAT OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. COMMUNITY BENEFIT FOR LICKING MEMORIAL HEALTH SYSTEM CONSOLIDATED GROUP FORM 990, PAGE 2 PROGRAM SERVICES MONETARY INPUTS OUTPUTS EXPENSES OFFSETS BENEFIT PERSONS 12 LEAD EKG PROJECT CARDIOLOGY (1712) 72,006 0 72,006 UNKNOWN 20TH CENTURY CLUB DONATION DEVELOPMENT (1955) 2,000 0 2,000 UNKNOWN AARP SPEAKER PUBLIC RELATIONS (1956) 294 0 294 36 ADAMS MIDDLE SCHOOL JOHNSTOWN SCREENINGS AND HEALTH FAIR PUBLIC RELATIONS (1956) 47 0 47 23 ADD / ADHD PROCESS IMPROVEMENT (1945) 411 0 411 22 ALEXANDRIA BUCKEYE SENIORS SPEAKER PUBLIC RELATIONS (1956) 364 0 364 85 AMERICAN CANCER SOCIETY SPONSORSHIPS DEVELOPMENT (1955) 3,250 0 3,250 UNKNOWN AMERICAN RED CROSS OF LICKING COUNTY EVENT SPONSORSHIPS DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN ANXIETY STRESS MANAGEMENT PROCESS IMPROVEMENT (1945) 473 0 473 57 ART FROM THE HEART DEVELOPMENT (1955) 11,884 0 11,884 389 ARVIN MERITOR SPEAKER PUBLIC RELATIONS (1956) 1,343 0 1,343 118 ASK THE DOC AT SHEPHERD HILL OP CHEMICAL DEPENDENCY (1692) 7,552 0 7,552 1,216 BEATING HOLIDAY STRESS PROCESS IMPROVEMENT (1945) 99 0 99 3 BIG BROTHERS/BIG SISTERS EVENT SPONSORSHIPS DEVELOPMENT (1955) 5,000 0 5,000 UNKNOWN BLESSED SACRAMENT SCHOOL SPONSORSHIPS DEVELOPMENT (1955) 400 0 400 UNKNOWN BOEING HEALTH & WELLNESS FAIR SPEAKER COMMUNITY CASE MANAGEMENT (1976) 210 0 210 110 BOY SCOUTS OF AMERICA SIMON KENTON COUNCIL DEVELOPMENT (1955) 850 0 850 UNKNOWN BREAST CA AWARENESS DAY FREE MAMMOGRAMS RADIOLOGY (1721) 8,443 0 8,443 55 BREAST CANCER AWARENESS & SCREENING EDUCATION (1616) 476 0 476 9 BREAST FEEDING BASICS MATERNAL CHILD (1646) 10,980 8,004 2,976 669 BREASTFEEDING PROMOTION & SUPPORT PROGRAM MATERNAL CHILD (1646) 57,600 0 57,600 360 BUSINESS AFTER HOURS INFORMATION TABLE PUBLIC RELATIONS (1956) 267 0 267 200 C TEC ANNUAL RECOGNITION BRUNCH & EVENT SPONSOR DEVELOPMENT (1955) 400 0 400 UNKNOWN C TEC DONATIONS DEVELOPMENT (1955) 10,000 0 10,000 UNKNOWN CAMP FEELIN' FINE RESPIRATORY THERAPY (1736) 6,367 0 6,367 41 CAMP O'BANNON EVENT SPONSOR DEVELOPMENT (1955) 350 0 350 UNKNOWN CANDLEWICK APARTMENTS SPEAKER COMMUNITY CASE MANAGEMENT (1976) 119 0 119 5 CAR SEAT INSTALLATION/EDUCATION MATERNAL CHILD (1646) 153 0 153 26 CAROL STRAWN CENTER SPONSORSHIP DEVELOPMENT (1955) 820 0 820 UNKNOWN CBISA SOFTWARE FISCAL SERVICES (1901) 800 0 800 UNKNOWN CENTER FOR DISABILITY SERVICES EVENT SPONSOR DEVELOPMENT (1955) 350 0 350 UNKNOWN CENTER FOR VISUALLY IMPAIRED SPONSORSHIP DEVELOPMENT (1955) 59 0 59 UNKNOWN CENTRAL OHIO AREA AGENCY ON AGING PUBLIC RELATIONS (1956) 107 0 107 12 CHAPEL GROVE SPEAKER PUBLIC RELATIONS (1956) 298 0 298 55 CHILDHOOD VACCINATIONS PROCESS IMPROVEMENT (1945) 68 0 68 3 CHRISTIAN COMPANIONS OF SECOND CHURCH OF CHRIST PUBLIC RELATIONS (1956) 120 0 120 6 CITY OF HEATH SOFTBALL TEAM SPONSORSHIP DEVELOPMENT (1955) 350 0 350 UNKNOWN CLINICAL EDUCATION OF ECHOSONOGRAPHERS (CARDIOLOGY) CARDIOLOGY (1712) 12,034 0 12,034 7 COLORECTAL AWARENESS EDUCATION (1616) 310 0 310 18 COMMUNITY BENEFIT REPORTING HOURS FISCAL SERVICES (1901) 3,136 0 3,136 UNKNOWN COMMUNITY BOARD/COMMITTEE MEETINGS (COMMUNITY BENEFIT) EXECUTIVE ADMIN (1950) 14,827 0 14,827 200 COMMUNITY BOARD/COMMITTEE MEETINGS (COMMUNITY SUPPORT) EXECUTIVE ADMIN (1950) 32,568 0 32,568 UNKNOWN COMMUNITY BOARD/COMMITTEE MEETINGS (WORKFORCE DEVELOPMENT) EXECUTIVE ADMIN (1950) 2,199 0 2,199 UNKNOWN COMMUNITY CASE MANAGEMENT SERVICES COMMUNITY CASE MANAGEMENT (1976) 710,404 125,496 584,908 UNKNOWN COMMUNITY HEALTH & RECOVERY BOARD DONATION FOOD SERVICE (1801) 287 0 287 UNKNOWN COMMUNITY HEALTH ASSESSMENT COMMITTEE PROCESS IMPROVEMENT (1945) 483 0 483 UNKNOWN COMPEER SPEAKER PUBLIC RELATIONS (1956) 97 0 97 8 COTC LPN CLASS PUBLIC RELATIONS (1956) 114 0 114 34 COTC RADIOLOGY CLASS PUBLIC RELATIONS (1956) 102 0 102 18 CTEC SPEAKER PUBLIC RELATIONS (1956) 367 0 367 35 CTEC MA EXTERNSHIP PROGRAM EXECUTIVE ADMIN LMHP (7445) 11,960 0 11,960 5 CTEC CLINICAL CAREER CLASS LAB (1702) 59 0 59 22 DAWES ARBORETUM SPONSORSHIP DEVELOPMENT (1955) 700 0 700 UNKNOWN DENISON FRESHMAN CAREER FAIR HUMAN RESOURCES (1951) 1,354 0 1,354 300 DENISON UNIVERSITY EMPLOYEE HEALTH FAIR PUBLIC RELATIONS (1956) 1,732 0 1,732 212 DIABETES AND SMART HOLIDAY EATING PROCESS IMPROVEMENT (1945) 97 0 97 2 DIABETES AWARENESS EDUCATION (1616) 246 0 246 10 DINING WITH DIABETES PROCESS IMPROVEMENT (1945) 240 0 240 163 DONATION OF MEAT TO SALVATION ARMY VOLUNTEERS (1970) 469 0 469 UNKNOWN DONATION OF SUPPLIES TO IMPOVERISHED COUNTRIES PURCHASING (1675) 188,347 0 188,347 UNKNOWN DOWNS SYNDROME ASSOCIATION OF CENTRAL OHIO ANNUAL WORKSHOP PUBLIC RELATIONS (1956) 106 0 106 40 DRUG ASSISTANT INDIGENT DRUG RECOVERY EXECUTIVE ADMIN LMHP (7445) 2,257 0 2,257 83 EMERGENCY SERVICES FOR INDIGENT PATIENTS FISCAL SERVICES (1901) 77,606 0 77,606 UNKNOWN ETNA LIONS CRUISE IN HEALTH FAIR PUBLIC RELATIONS (1956) 266 0 266 24 FAMILY & FRIENDS INFANT AND CHILD CPR MATERNAL CHILD (1646) 862 385 477 73 FOUR TOWN LA SERTOMA SPEAKER PUBLIC RELATIONS (1956) 173 0 173 16 FUNERAL DIRECTORS CONFERENCE DEVELOPMENT (1955) 243 0 243 22 GIRLS SCOUT TROOP 1931 SPEAKER PUBLIC RELATIONS (1956) 162 0 162 6 GIS RUNNING CLUB DEVELOPMENT (1955) 250 0 250 UNKNOWN GLENN'S MARKET SCREENINGS PUBLIC RELATIONS (1956) 1,456 0 1,456 136 GRANVILLE HIGH SCHOOL SPEAKER PUBLIC RELATIONS (1956) 77 0 77 20 GRANVILLE HIGH SCHOOL SPONSORSHIP DEVELOPMENT (1955) 2,500 0 2,500 UNKNOWN GRANVILLE INTERMEDIATE SCHOOL RUNNING CLUB SPEAKER PUBLIC RELATIONS (1956) 116 0 116 135 GRANVILLE PTO AUCTION DONATION DEVELOPMENT (1955) 500 0 500 UNKNOWN GRANVILLE ROTARY CULINARY FESTIVAL SPONSORSHIP DEVELOPMENT (1955) 1,500 0 1,500 UNKNOWN HALLOWEEN ON THE SQUARE VOLUNTEERS (1970) 405 0 405 150 HARTFORD FAIR HEALTH SCREENINGS & HEALTH EDUCATION PUBLIC RELATIONS (1956) 9,448 0 9,448 1,000 HEALTHY EATING AND WEIGHT LOSS EDUCATION (1616) 605 0 605 82 HEART HEALTH & SLEEP DISTURBANCES PROCESS IMPROVEMENT (1945) 310 0 310 35 HEATH FIRE DEPARTMENT OPEN HOUSE PUBLIC RELATIONS (1956) 163 0 163 200 HOSPICE OF CENTRAL OHIO SPONSORSHIPS DEVELOPMENT (1955) 800 0 800 UNKNOWN HOW TO BE A SAFE PATIENT PROCESS IMPROVEMENT (1945) 149 0 149 3 HUMANE SOCIETY CAMPAIGN PUBLIC RELATIONS (1956) 1,145 0 1,145 100 IMMUNIZATION OF PATIENTS AGES 65 AND OVER FOR TD EXECUTIVE ADMIN LMHP (7445) 12,567 0 12,567 469 INSTRUCTIONAL INTERNSHIP LAB STUDENTS LAB (1702) 9,797 0 9,797 2 INTERNSHIP MEDICAL ASSISTANT PROGRAM PAIN CLINIC PAIN MGMT (1690) 1,290 0 1,290 1 KIWANIS MAPLE LEAF 5K PUBLIC RELATIONS (1956) 127 0 127 150 KRANER BEHAVIORAL HEALTH HISTORIC HOME AND OPEN HOUSE DONATION DEVELOPMENT (1955) 250 0 250 UNKNOWN KROGER SPEAKER PUBLIC RELATIONS (1956) 203 0 203 200 LADIES CIRCLE OF UTICA CHURCH OF CHRIST PUBLIC RELATIONS (1956) 394 0 394 12 LAKEWOOD GIRLS SUMMER SOFTBALL SPONSORSHIP DEVELOPMENT (1955) 350 0 350 UNKNOWN LAKEWOOD YOUTH BASEBALL ASSOCIATION SPONSORSHIP FUND DEVELOPMENT (1955) 200 0 200 UNKNOWN LC CHAMBER OF COMMERCE BUSINESS AFTER HOURS SPEAKER PUBLIC RELATIONS (1956) 521 0 521 190 LC MENTAL HEALTH AMERICA EVE ELLIOT EASTER BASKET PROJECT IP PSYCH DETOX (1691) 68 0 68 10 LC UNITED WAY ANNUAL MEETING SPONSORSHIP DEVELOPMENT (1955) 450 0 450 UNKNOWN LCESC JR. HIGH CAREER EXPLORATION HUMAN RESOURCES (1951) 748 0 748 15 LEADS HEADSTART SPEAKER PUBLIC RELATIONS (1956) 118 0 118 8 LEARN, GROW, AND PLAY DAYCARE AND DEVELOPMENT CENTER SPEAKER PUBLIC RELATIONS (1956) 179 0 179 21 LICCO INC. SPONSORSHIP DEVELOPMENT (1955) 250 0 250 UNKNOWN LICKING CO HEALTH DEPT CHLAMYDIA/GC LAB (1702) 5,415 0 5,415 126 LICKING COUNTY AGING PROGRAM SPEAKER PUBLIC RELATIONS (1956) 193 0 193 30 LICKING COUNTY AGING PROGRAM SPONSORSHIPS DEVELOPMENT (1955) 460 0 460 UNKNOWN LICKING COUNTY BOARD OF DEVELOPMENTAL DISABILITIES SPEAKER PUBLIC RELATIONS (1956) 50 0 50 115 LICKING COUNTY CHAMBER OF COMMERCE EVENT SPONSOR DEVELOPMENT (1955) 2,515 0 2,515 UNKNOWN LICKING COUNTY COALITION FOR HOUSING EVENT SPONSOR DEVELOPMENT (1955) 550 0 550 UNKNOWN LICKING COUNTY COALITION OF CARE DONATION DEVELOPMENT (1955) 700 0 700 UNKNOWN LICKING COUNTY FAMILY YMCA EVENT SPONSORSHIPS DEVELOPMENT (1955) 1,350 0 1,350 UNKNOWN LICKING COUNTY HEALTH DEPARTMENT SASS PUBLIC RELATIONS (1956) 1,813 0 1,813 100 LICKING COUNTY HEALTH DEPARTMENT SPEAKER PUBLIC RELATIONS (1956) 400 0 400 15 LICKING COUNTY HEALTH DEPARTMENT DONATION DEVELOPMENT (1955) 400 0 400 UNKNOWN LICKING COUNTY JOB AND FAMILY SERVICES/EMPLOYEE HEALTH & WELLNESS PUBLIC RELATIONS (1956) 161 0 161 50 LICKING COUNTY PRAYER PARTNERS DONATION DEVELOPMENT (1955) 750 0 750 UNKNOWN LICKING COUNTY SETTLERS DONATION DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN LICKING COUNTY SHERIFF''S DEPARTMENT CONTRIBUTION DEVELOPMENT (1955) 292 0 292 UNKNOWN LICKING COUNTY SOIL,WATER AND FARM BUREAU BREAKFAST SCREENINGS PUBLIC RELATIONS (1956) 298 0 298 75 LICKING COUNTY SPECIAL OLYMPICS DEVELOPMENT (1955) 100 0 100 UNKNOWN LICKING COUNTY SPORTS ASSOCIATION SIGN SPONSORSHIP RENEWAL DEVELOPMENT (1955) 350 0 350 UNKNOWN LICKING VALLEY HIGH SCHOOL SPEAKER PUBLIC RELATIONS (1956) 473 0 473 150 LICKING VALLEY HIGH SCHOOL SPONSORSHIPS DEVELOPMENT (1955) 340 0 340 UNKNOWN LICKING VALLEY YOUTH SPORTS ASSOCIATION DEVELOPMENT (1955) 500 0 500 UNKNOWN LOWES SAFETY SATURDAY PUBLIC RELATIONS (1956) 90 0 90 75 MATERNAL CHILD STUDENT PRECEPTORS MATERNAL CHILD (1646) 23,910 0 23,910 12 MENTAL HEALTH AMERICA OF LICKING COUNTY SPONSORSHIPS DEVELOPMENT (1955) 600 0 600 UNKNOWN MILLERSPORT WRESTLING TEAM SPEAKER PUBLIC RELATIONS (1956) 136 0 136 12 MITCHELL RETIREMENT CENTER SPEAKER PUBLIC RELATIONS (1956) 162 0 162 15 MOTHERS OF PRESCHOOLERS PUBLIC RELATIONS (1956) 184 0 184 15 MPW LUNCH AND LEARN PUBLIC RELATIONS (1956) 134 0 134 15 MUSCULAR DYSTROPHY ASSOCIATION SPONSORSHIP DEVELOPMENT (1955) 40 0 40 UNKNOWN NAVIGATING YOUR INSURANCE PROCESS IMPROVEMENT (1945) 129 0 129 3 NEW ALBANY HEALTH AND WELLNESS EXPO PUBLIC RELATIONS (1956) 653 0 653 200 NEW LIFE COMMUNITY KIDS FAIR PUBLIC RELATIONS (1956) 214 0 214 25 NEWARK CATHOLIC HIGH SCHOOL SPEAKER PUBLIC RELATIONS (1956) 105 0 105 22 NEWARK CATHOLIC HIGH SCHOOL ATHLETIC DEPT. SPONSORSHIPS DEVELOPMENT (1955) 646 0 646 UNKNOWN NEWARK FIRE FIGHTERS LOCAL 109 DEVELOPMENT (1955) 500 0 500 UNKNOWN NEWARK GENERALS HOCKEY CLUB SPONSORSHIP DEVELOPMENT (1955) 500 0 500 UNKNOWN NEWARK HIGH SCHOOL SPONSORSHIP DEVELOPMENT (1955) 450 0 450 UNKNOWN NEWARK MIDLAND THEATRE SPONSORSHIP DEVELOPMENT (1955) 5,000 0 5,000 UNKNOWN NORTH NEWARK LITTLE LEAGUE VARSITY AND FARM SPONSORSHIP DEVELOPMENT (1955) 600 0 600 UNKNOWN NORTHRIDGE ATHLETIC BOOSTERS DONATION DEVELOPMENT (1955) 500 0 500 UNKNOWN NORTHRIDGE SCHOOL DISTRICT SPEAKER PUBLIC RELATIONS (1956) 917 0 917 700 NUTRITION CLASS COMMUNITY CASE MANAGEMENT (1976) 66 0 66 23 OCCUPATIONAL THERAPY ASSISTANT STUDENT OCCUPATIONAL THERAPY (1700) 16,293 0 16,293 2 ODOT HEALTH FAIR PUBLIC RELATIONS (1956) 784 0 784 140 OHIO CANCER RESEARCH ASSOCIATES DONATION DEVELOPMENT (1955) 4,400 0 4,400 UNKNOWN OP CHEMICAL DEPENDENCY & IP PSYCH STUDENT INTERNSHIPS OP CHEMICAL DEPENDENCY (1692) 11,443 0 11,443 6 OPERATION FEED VOLUNTEERS (1970) 5,020 0 5,020 UNKNOWN OSU ADENA HALL LECTURE COMMUNITY CASE MANAGEMENT (1976) 98 0 98 40 OSU SPEAKER PUBLIC RELATIONS (1956) 715 0 715 8 OWENS CORNING EMPLOYEE HEALTH FAIR PUBLIC RELATIONS (1956) 530 0 530 80 PAR EXCELLENCE ACADEMY SPONSORSHIP DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN PARENTING CLASS MATERNAL CHILD (1646) 724 190 534 44 PARK NATIONAL BANK SPEAKER PUBLIC RELATIONS (1956) 847 0 847 95 PARKINSON SUPPORT GROUP SPEAKER PUBLIC RELATIONS (1956) 218 0 218 65 PATASKALA ELEMENTARY SCHOOL VISIT VOLUNTEERS (1970) 441 0 441 120 PATASKALA HISTORICAL TOWN HALL INC. SPONSORSHIP DEVELOPMENT (1955) 1,394 0 1,394 UNKNOWN PATASKALA STREET FAIR PATASKALA (7404) 1,431 0 1,431 650 PEDIATRIC DENTAL CLINIC DENTAL CLINIC (1958) 96,000 77,641 18,359 UNKNOWN PHYSICIAN MISSION SUPPLIES DONATED KOREA LAB (1702) 319 0 319 50 PINK STRIDES TRAIL RUN & WELLNESS WALK DEVELOPMENT (1955) 386 0 386 150 PRECEPTING NURSING STUDENTS IN GI LAB ENDO DIAGNOSTIC LAB (1676) 1,503 0 1,503 1 PRECEPTING NURSING STUDENTS IN OUTPATIENT CLINIC OUTPATIENT CLINIC (1685) 6,146 0 6,146 2 PRECEPTING NURSING STUDENTS IN THE WOUND CLINIC WOUND CLINIC (1677) 9,198 0 9,198 4 PRECEPTING NURSING STUDENTS ON 4N & 4S 4 SOUTH (1614) 12,301 0 12,301 7 PRECEPTING PHARMACY STUDENTS PHARMACY (1730) 94,275 18,000 76,275 8 PRECEPTING RADIOLOGY STUDENTS RADIOLOGY (1721) 108,290 0 108,290 27 PRECEPTING STUDENTS FOR 5S 5 SOUTH (1612) 9,397 0 9,397 7 PRECEPTORSHIP FOR CERTIFIED NURSE PRACTITIONER STUDENTS FMC EAST (7425) 29,580 0 29,580 9 PRECEPTORSHIP FOR RN STUDENTS ICU, CCU, ER INTENSIVE CARE (1640) 44,453 0 44,453 25 PRECEPTORSHIP FOR ULTRASOUND STUDENT VASCULAR LAB NEURO VASCULAR LAB (1674) 9,082 0 9,082 2 PRECEPTORSHIP IN PACU/OR SURGERY (1660) 22,677 0 22,677 9 PUBLIC HEALTH PARTNERSHIP, INC. THINK PINK DONATION DEVELOPMENT (1955) 400 0 400 UNKNOWN RED CROSS BLOOD DRIVE EDUCATION (1616) 7,973 25 7,948 278 RED DRESS EVENT PUBLIC RELATIONS (1956) 20,624 0 20,624 300 REESE ADULT DAY CARE SPONSORSHIP DEVELOPMENT (1955) 500 0 500 UNKNOWN RESOURCE CENTER RESOURCE CENTER (1975) 14,219 0 14,219 UNKNOWN ROTARY CLUB OF GRANVILLE SPONSORSHIP DEVELOPMENT (1955) 1,500 0 1,500 UNKNOWN ROTARY CLUB OF PATASKALA SPONSORSHIP DEVELOPMENT (1955) 1,000 0 1,000 UNKNOWN SALVATION ARMY FOOD ASSISTANCE FOOD SERVICE (1801) 2,996 0 2,996 UNKNOWN SALVATION ARMY WOMENS LEAGUE SPEAKER PUBLIC RELATIONS (1956) 377 0 377 87 SHERIDAN HIGH SCHOOL VOLLEYBALL TEAM BREAST CANCER AWARENESS PUBLIC RELATIONS (1956) 131 0 131 150 SIBLING PREPARATION CLASS MATERNAL CHILD (1646) 564 140 424 50 SKIN CANCER AWARENESS AND SCREENING PROCESS IMPROVEMENT (1945) 1,293 0 1,293 57 SOUTHWEST LICKING SCHOOLS SPEAKER PUBLIC RELATIONS (1956) 321 0 321 26 SOUTHWEST LICKING SCHOOLS SPONSORSHIP DEVELOPMENT (1955) 200 0 200 UNKNOWN SPIRITUALITY AND HEALING PROCESS IMPROVEMENT (1945) 169 0 169 17 SPORTS PHYSICALS & ECG'S TAMARACK SPORTS PHYSICALS (7487) 41,830 0 41,830 1,072 ST. FRANCIS DE SALES SCHOOL & PARISH SPONSORSHIPS DEVELOPMENT (1955) 100 0 100 UNKNOWN STUDENT INTERNSHIPS RESPIRATORY THERAPY RESPIRATORY THERAPY (1736) 887 0 887 1 STUDENT INTERNSHIPS PHYSICAL THERAPY & SPEECH THERAPY REHAB CENTER (1737) 25,860 0 25,860 5 STUDENT NURSE & OTHER HEALTH PROFESSIONALS MANAGEMENT PROCESS EDUCATION (1616) 10,557 0 10,557 UNKNOWN STUDENT NURSE & OTHER HEALTH PROFESSIONALS ORIENTATION EDUCATION (1616) 6,216 0 6,216 749 STUDENTS TO SHADOW CCM STAFF COMMUNITY CASE MANAGEMENT (1976) 11,363 0 11,363 2 TAXI TOKENS IP PSYCH DETOX (1691) 120 0 120 UNKNOWN TECH INTERNATIONAL SPEAKER PUBLIC RELATIONS (1956) 298 0 298 51 THE ENERGY COOPERATIVE SPEAKER PUBLIC RELATIONS (1956) 608 0 608 2,036 THE WOODLANDS EVENT SPONSORSHIPS DEVELOPMENT (1955) 1,075 0 1,075 UNKNOWN THE WORKS SPONSORSHIPS DEVELOPMENT (1955) 2,500 0 2,500 UNKNOWN TOBACCO CESSATION PROGRAM TOBACCO CESSATION (1693) 211,532 0 211,532 2,182 TOPS HEALTHY WEIGHT LOSS GROUP EDUCATION PUBLIC RELATIONS (1956) 603 0 603 83 TREND MAGAZINE WOMEN'S EXPO PUBLIC RELATIONS (1956) 376 0 376 400 UNITED WAY AGENCIES DONATION HUMAN RESOURCES (1951) 1,713 0 1,713 UNKNOWN UNITED WAY CAMPAIGN HUMAN RESOURCES (1951) 3,000 0 3,000 UNKNOWN UNITED WAY DAY OF CARING DEVELOPMENT (1955) 2,180 0 2,180 32 VELVET ICE CREAM SPEAKER PUBLIC RELATIONS (1956) 237 0 237 16 VINEYARD GRACE FELLOWSHIP DONATION LAB (1702) 417 0 417 UNKNOWN VOLUNTEERS TWIGS & EVENTS VOLUNTEERS (1970) 0 0 0 140 WASHINGTON SQUARE APARTMENTS SPEAKER PUBLIC RELATIONS (1956) 56 0 56 20 WATKINS MEMORIAL SPONSORSHIP DEVELOPMENT (1955) 200 0 200 UNKNOWN WEATHERVANE PLAYHOUSE SPONSORSHIP DEVELOPMENT (1955) 2,500 0 2,500 UNKNOWN WEST LICKING FIRE DEPARTMENT SPEAKER & SCREENINGS PUBLIC RELATIONS (1956) 747 0 747 150 WEST MAIN STREET BILL BOARD BEHIND MCN PUBLIC RELATIONS (1956) 500 0 500 UNKNOWN YMCA ACTIVATE OHIO COMMUNITY CASE MANAGEMENT (1976) 281 0 281 95 ZONTA CLUB OF NEWARK DEVELOPMENT (1955) 500 0 500 UNKNOWN NUMBER OF PROGRAMS 213 GRAND TOTALS 2,237,167 229,881 2,007,286 19,065 BENEFITS FOR POOR: TOTAL EXPENSE OFFSETTING REVENUE NET BENEFIT PERSONS TRADITIONAL CHARITY CARE $9,538,335 $2,241,253 $7,297,082 14,739 UNPAID COST OF MEDICAID $31,420,456 $15,565,644 $15,854,812 27,082 GRAND TOTALS $43,195,958 $18,036,778 $25,159,180 60,886 LICKING MEMORIAL HEALTH SYSTEMS 1320 WEST MAIN STREET NEWARK OH 43055 311096218 PARENT COMPANY FOR THE NONPROFIT OPERATION OF HEALTHCARE ORGANIZATIONS OH 501(C)(3) 11 TYPE III - FI N/A 0 LICKING MEMORIAL HEALTH FOUNDATION 1320 WEST MAIN STREET NEWARK OH 43055 311096217 PROVIDE FUNDING FOR HEALTHCARE PROGRAMS OH 501(C)(3) 11 TYPE I LICKING MEMORIAL HEALTH SYSTEMS 0 LICKING MEMORIAL PROFESSIONAL CORPORATION 1320 WEST MAIN STREET NEWARK OH 43055 311425530 HEALTHCARE ORGANIZATION OH 501(C)(3) 9 LICKING MEMORIAL HEALTH SYSTEMS 0 0 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1