2011-08-15T08:01:41-05:00 2010-09-30 DIXON HUGHES GOODMAN LLP 500 Ridgefield Court Asheville NC 28806 990 2009-10-01 560530234 RANDOLPH HOSPITAL INC RAND 3366255151 PO BOX 1048 ASHEBORO NC 27204 ROBERT E MORRISON 3366255151 2011-08-15 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z ROBERT E MORRISON PO BOX 1048 ASHEBORO NC 27204 116035003 0 X WWW.RANDOLPHHOSPITAL.ORG X 1931 NC TO OPERATE A HOSPITAL IN RANDOLPH COUNTY, NC 12 12 1229 150 13303 0 752954 625625 118692546 113526284 943770 757766 1091193 1004028 121480463 115913703 0 0 54818761 53448522 0 48063 62992801 60164805 117811562 113613327 3668901 2300376 154948865 156131348 75032705 76887381 79916160 79243967 THE HOSPITAL EXISTS TO PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS. THE PRIMARY SERVICE AREA IS RANDOLPH COUNTY. 0 0 102830757 112921755 RANDOLPH HOSPITAL'S MISSION IS TO "PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS". RANDOLPH HOSPITAL PROVIDED QUALITY CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. RANDOLPH HOSPITAL PROVIDES A WIDE RANGE OF PROGRAMS FOR THE MEMBERS OF OUR COMMUNITY INCLUDING WELLNESS PROGRAMS, SUPPORT GROUPS AND COMMUNITY EDUCATION PROGRAMS FOR ALL CITIZENS FROM THE ELDERLY TO THE ELEMENTARY SCHOOL AGE.RANDOLPH HOSPITAL IS AN ACUTE-CARE HOSPITAL SERVING RANDOLPH COUNTY AND SURROUNDING COUNTIES. RANDOLPH HOSPITAL SERVED 7,457 INPATIENTS, HAD 40,179 EMERGENCY ROOM VISITS, 105,365 OTHER OUTPATIENT VISITS AND 44,354 HOME CARE VISITS DURING THE PERIOD OCTOBER 1, 2009 TO SEPTEMBER 30, 2010.RANDOLPH HOSPITAL PROVIDED CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW CHARGES. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES WERE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. TO THE EXTENT REIMBURSEMENT WAS BELOW CHARGES, RANDOLPH HOSPITAL RECOGNIZES THESE AMOUNTS AS UNDER REIMBURSED CARE IN MEETING ITS MISSION TO THE COMMUNITY. THE UNDER REIMBURSED VALUE ASSOCIATED WITH THESE SERVICES IS $85,444,221 FOR THE PERIOD OCTOBER 1, 2009 TO SEPTEMBER 30, 2010. CHARGES TO PRIVATE SECTOR PATIENTS COULD HAVE BEEN REDUCED BY THIS AMOUNT IF MEDICARE AND MEDICAID MATCHED THE RATES PAID BY PRIVATE SECTOR PATIENTS. IN ADDITION, RANDOLPH HOSPITAL WAS REIMBURSED BELOW CHARGES FOR OTHER PAYERS IN THE AMOUNT OF $46,121,894 FOR THE SAME PERIOD.RANDOLPH HOSPITAL PROVIDED CARE FOR URGENT AND EMERGENCY CASES AS WELL AS INPATIENT AND OUTPATIENT SERVICES FOR ALL INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY. 26.2 % OF EMERGENCY PATIENTS WERE UNINSURED. THE UNDER REIMBURSED VALUE ASSOCIATED WITH THIS CARE (CHARITY AND BAD DEBT) WAS $20,422,138 FOR THE PERIOD OCTOBER 1, 2009 THROUGH SEPTEMBER 30, 2010.RANDOLPH HOSPITAL PROVIDES BENEFITS TO THE COMMUNITY OTHER THAN ITS TRADITIONAL HOSPITAL BASED SERVICES. SOME OF THESE SERVICES INCLUDE:AN EDUCATIONAL OPPORTUNITY AT THE HOSPITAL WAS GIVEN FOR ALL COUNTY AND CITY SCHOOL 2ND GRADERS TO LEARN ABOUT SOME OF THE PROCEDURES THEY MIGHT ENCOUNTER IF THEY WERE PATIENTS.HEALTH WATCH MONITORING SERVICES WERE PROVIDED FOR ALMOST 200 SUBSCRIBERS.A HEALTH VAN WAS DEPLOYED TO OFFER FREE HEALTH SCREENINGS THROUGHOUT THE COMMUNITY. THE SERVICE PROVIDED APPROXIMATELY 1,000 FREE SCREENINGS FOR ABOUT 250 PEOPLE.FORMAL EDUCATION PROGRAMS WERE OFFERED THAT INCLUDE CHILDBIRTH, SMOKING CESSATION, MATERNITY SUITES TOURS, CPR, BABYSITTER TRAINING AND OTHERS.SUPPORT GROUPS WERE OFFERED THAT INCLUDED BUT WERE NOT LIMITED TO, CANCER SUPPORT, DIABETES, OSTOMY, STROKE, CAREGIVER AND HIV/AIDS.FREE SCREENINGS WERE OFFERED THROUGHOUT THE YEAR FOR NUMEROUS THINGS SUCH AS VASCULAR DISEASE, OSTEOPOROSIS, PROSTATE CANCER, SKIN CANCER, ORAL CANCER, STROKE, DIABETES, AND OTHERS. FREE SEMINARS OFFERED INCLUDED SUCH TOPICS AS HEART DISEASE, CERVICAL HEALTH, CHILD SAFETY, BALANCE ISSUES AND DISEASE INTERVENTION.HEALTH LINK, A HOSPITAL AND HEALTHCARE NEWSLETTER, WAS PUBLISHED QUARTERLY AND MAILED TO OVER 35,000 HOUSEHOLDS THROUGHOUT THE SURROUNDING COMMUNITY.SCHOLARSHIPS WERE PROVIDED FOR STUDENTS STUDYING IN VARIOUS MEDICAL FIELDS INCLUDING REGISTERED NURSES, REHAB THERAPISTS, RESPIRATORY THERAPISTS, AND RADIOLOGY TECHNICIANS. RANDOLPH HOSPITAL EMPLOYEES CONTINUE TO GIVE BACK TO THE COMMUNITY BY SUPPORTING THE RANDOLPH COUNTY UNITED WAY, THE RANDOLPH HOSPITAL COMMUNITY HEALTH FOUNDATION AND THE RANDOLPH HOSPITAL CAPITAL CAMPAIGN. THROUGH EMPLOYEE CAMPAIGNS, MORE THAN $31,000, $5,000 AND MORE THAN $57,000 WERE GIVEN RESPECTIVELY.THE RANDOLPH HEALTH IMPROVEMENT PARTNERSHIP WORKED TO IDENTIFY AND ADDRESS CRUCIAL HEALTH AND WELLNESS ISSUES COUNTYWIDE.RANDOLPH HOSPITAL SERVED AS A MAJOR SPONSOR FOR THE ANNUAL RELAY FOR LIFE EVENT BY PREPARING OVER 1,000 FREE MEALS FOR CANCER SURVIVORS AND THEIR FAMILIES.A FREE SPEAKERS BUREAU WAS PROVIDED TO THE COMMUNITY AND PROVIDED OVER 50 SPEAKERS ON A VARIETY OF HEALTHCARE RELATED TOPICS. 102830757 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 220 0 1 1229 1 1 1 0 0 0 0 0 0 0 0 12 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X X LINDA CROWSHAW 3366255151 PO BOX 1048 ASHEBORO NC 27204 SAMUEL D CRANFORD JR 5.00 X X 0 0 0 ROBERT C SHAFFNER 4.00 X X 0 0 0 JOSEPH C BOSSONG 2.00 X X 0 0 0 JAMES M CAMPBELL JR 2.00 X 0 0 0 MARY COOPER 2.00 X 0 0 0 DIANE FROST PHD 2.00 X 0 0 0 JAMES B KINLAW JR MD 2.00 X 0 0 0 REYNOLDS LISK 2.00 X 0 0 0 MICHAEL MILLER 2.00 X 0 0 0 GLENN MAC PUGH 4.00 X 0 0 0 SAMUEL A RANKIN JR 2.00 X 0 0 0 ROBERT S SHACKLEFORD JR PHD 2.00 X 0 0 0 ROBERT E MORRISON 50.00 X 313250 0 85476 LYNWOOD R WHITE 50.00 X 223036 0 101505 SANDRA ALLEN 50.00 X 210734 0 154128 STEVE EBLIN 50.00 X 280531 0 36178 DEVIN GRIFFITH 50.00 X 173194 0 17838 TREMONTEO CRAWFORD 40.00 X 149093 0 4194 LISA HAMPTON 40.00 X 146265 0 3855 BETTY CHOCKLEY 40.00 X 136240 0 11055 WILLIAM BAIRD 40.00 X 128140 0 6702 ANGELA BURGESS 40.00 X 133011 0 4456 1893494 0 425387 19 0 1 0 GREENSBORO RADIOLOGY 1317 North Elm Street Suite 1B GREENSBORO NC 27401 PROFESSIONAL FEES 4078863 EMPLOYER BENEFITS SERVICE 534 RIVERCROSSING DR FT MILL SC 29715 EMPLOYEE BENEFIT SERVICES 1366588 MCNEARY INSURANCE 6525 MORRISON BLVD CHARLOTTE NC 28222 INSURANCE SERVICES 1344217 SODEXHO INC 2803 SLATER ROAD MORRISVILLE NC 27560 FOOD SERVICE 1107625 ARAMARK CTS 12483 COLLECTION CCR DR CHICAGO IL 60693 BIOMEDICAL ENGINEERING 899411 22 200000 425625 625625 PATIENT SERVICE REVENU 621400 112779235 112779235 PURCHASING DISCOUNTS 900099 376751 13303 363448 MEALS/NUTRITION 722210 161608 161608 PATIENT PHARMACY 446110 127866 127866 HEALTH WATCH REVENUE 900099 80824 80824 113526284 699266 699266 430354 121300 309054 309054 309054 58500 58500 58500 58500 COFFEE/GIFT SHOP 453220 491313 491313 MISCELLANEOUS REVENUES 900099 138480 3196 135284 REBATES 900099 65181 65181 694974 115913703 112921755 13303 2353020 1914315 1914315 39094896 34403705 4657756 33435 1345141 1129571 215570 7913470 6645270 1268200 3180700 2670966 509734 612386 537336 75050 136379 136379 57231 57231 9629748 9605456 23802 490 295884 188293 101141 6450 19515652 17890265 1620088 5299 1144830 1087590 57240 154335 154335 392689 333931 57512 1246 13006 13006 859749 859749 6494114 6494114 702748 702748 BAD DEBT EXPENSE 19898216 19898216 MISCELLANEOUS EXPENSE 217349 216206 1143 RECRUITMENT 40489 40489 113613327 102830757 10734507 48063 4843917 5146979 23190988 26767698 1112959 446559 23670979 19733843 2436546 2914775 993850 2485827 131720902 63555037 71042774 68165865 16951186 18147634 9015251 9353825 1690415 2968343 154948865 156131348 8259000 10623756 48180000 47130000 2051542 2738412 16542163 16395213 75032705 76887381 X 77823585 77922257 2092575 1321710 79916160 79243967 154948865 156131348 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12614 12614 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: THE HOSPITAL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). BOTH ASSOCIATIONS PERFORM LOBBYING OF STATE AND LOCAL GOVERNMENTS ON BEHALF OF THEIR MEMBERSHIP BODIES, AND A PORTION OF THE DUES PAID TO EACH ASSOCIATION IS ATTRIBUTABLE TO THOSE LOBBYING EXPENDITURES. FOR THE FISCAL YEAR, THE PORTION OF DUES ATTRIBUTABLE TO LOBBYING WAS $12,614 1286987 109489 1396476 1160377 126610 1286987 1.00000 0 0 3232061 3232061 78515856 28964522 49551334 1923368 523097 1400271 46906846 34067418 12839428 1142771 1142771 68165865 INVESTMENT IN RANDOLPH CANCER CENTER, LLC 2983873 F INVESTMENT IN CENTRAL PIEDMONT SURGERY CENTER 733173 F DUE FROM AFFILIATES 5636779 C 9353825 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 2203199 OTHER LONG-TERM LIABILITIES 2172026 PENSION PAYABLE 7592544 interest rate swap 3488318 DUE TO AFFILIATE 939126 16395213 115913703 113613327 2300376 581281 -473839 -3080011 -2972569 -672193 113536273 581281 121300 702581 112833692 3080011 3080011 115913703 113734627 121300 121300 113613327 0 113613327 Part V, Line 4: Description of Intended Use of Endowment Funds: ENDOWMENT FUNDS ARE SET ASIDE FOR HOSPITAL SERVICES TO BENEFIT ORPHANS BORN TO RESIDENTS OF RANDOLPH COUNTY, NC. Part XI, Line 8 - Other Adjustments: CHANGE IN PENSION LIABILITY: -1238128. CHANGE IN VALUE OF SWAP AGREEMENT: -1226354. CONTRIBUTIONS TO RESTRICTED ASSETS (NOT REPORTED ON F/S): -615529. Part XII, Line 2d - Other Adjustments: RENTAL EXPENSES: 121300. NET GAIN ON INVESTMENT IN AFFILIATES: 0. Part XII, Line 4b - Other Adjustments: CHANGE IN PENSION LIABILITY: 1238128. CHANGE IN VALUE OF SWAP AGREEMENT: 1226354. CONTRIBUTIONS TO RESTRICTED ASSETS: 615529. Part XIII, Line 2d - Other Adjustments: RENTAL EXPENSES: 121300. 1 1 1 X 1 X 1 1 1 0 1 1 1820451 0 1820451 0.01940 14635153 11008707 3626446 0.03870 16455604 11008707 5446897 0.05810 252968 6998 245970 0.00260 350 350 0.00000 253318 6998 246320 0.00260 16708922 11015705 5693217 0.06070 1081 1081 0.00000 14050 14050 0.00010 22280 22280 0.00020 10899 10899 0.00010 12563 12563 0.00010 4702 4702 0.00010 65575 65575 0.00060 1 7043968 5987373 40539360 44422537 -3883177 X 1 1 CENTRAL PIEDMONT SURGERY CENTER LLC AMBULATORY OUTPATIENT SURGICAL CENTER 0.68000 0.21000 RANDOLPH HOSPITAL

364 WHITE OAK STREET ASHEBORO NC 27204

X X X Part I, Line 7: WORKSHEET 2 OF THE 2009 SCHEDULE H INSTRUCTIONS WAS USED TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE CHARITY CARE AND UNREIMBURSED MEDICAID AT COST. Part I, Line 7f: THE AMOUNT OF TOTAL EXPENSE ON FORM 990, PART IX, LINE 25 CONTAINS A BAD DEBT EXPENSE OF $19,898,216 THAT HAS BEEN REMOVED FOR PURPOSES OF CALCULATING LINE 7, COLUMN (F). Part III, Line 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT. BAD DEBT EXPENSE AT COST WAS COMPUTED USING WORKSHEET 2 OF THE 2009 SCHEDULE H INSTRUCTIONS TO CALCULATE A COST-TO-CHARGES RATIO. THE ORGANIZATION ESTIMATES FROM HISTORICAL PERSPECTIVE AND EXPERIENCE THAT APPROXIMATELY 85% OF BAD DEBT EXPENSE MAY BE ATTRIBUTABLE TO COMMUNITY BENEFIT. Part III, Line 8: COSTS AND TOTAL REVENUES RECEIVED FROM MEDICARE REPORTED ON LINES 5 AND 6 ARE CALCULATED FROM THE ORGANIZATION'S MEDICARE COST REPORT. Part III, Line 9b: THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. RANDOLPH HOSPITAL WILL IDENTIFY ANY PATIENT FINANCIAL RESPONSIBILITY PRIOR TO SERVICE AND REQUIRE THE PATIENT/GUARANTOR TO PAY OR MAKE ACCEPTABLE FINANCIAL ARRANGEMENTS FOR PAYMENT PRIOR TO SERVICE BEING RENDERED. A SLIDING FEE SCHEDULE WILL BE AVAILABLE FOR PATIENTS WHO HAVE THE ABILITY TO MAKE PARTIAL PAYMENT. FREE CARE WILL BE AVAILABLE TO THOSE WHO SUCCESSFULLY APPLY UNDER THE HOSPITAL'S CHARITY CARE POLICY FD-PA-007. IT WILL BE THE APPLICANT'S RESPONSIBILITY TO DEMONSTRATE INABILITY TO PAY. Part V: IN ADDITION TO THE MAIN FACILITY LISTED ON PART V, THE ORGANIZATION ALSO OPERATES THE FOLLOWING FACILITIES: - CANCER CENTER - MRI FACILITY - OFF-SITE DIABETES SELF MANAGEMENT PROGRAM - OFF-SITE HOME HEALTH DEPARTMENT - HEALTH EDUCATION CENTER PART I, LINE 7(E): SUMMARY OF COMMUNITY HEALTH IMPROVEMENT SERVICES: THE HOSPITAL PROVIDES THE FOLLOWING COMMUNITY HEALTH IMPROVMENET ACTIVITIES REPORTED ON PART I, LINE 7(E) (SHOWN AT NET EXPENSE): COMMUNITY EDUCATION & SCREENING $ 70,653 TEDDY BEAR EDUCATION (2ND GRADERS) 43,200 VICTORY JUNCTION EDUCATION 6,190 VARIOUS EDUCATIONAL EVENTS AND FAIRS 20,738 ALLOCATION OF STAFF TIME TO EVENTS 105,190 Part VI, Line 2: RANDOLPH HOSPITAL, IN COORDINATION WITH THE COUNTY HEALTH DEPARTMENT, COMMISSIONS A COMMUNITY NEEDS ASSESSMENT. THIS PROCEDURE INVOLVES COMMUNITY MEETINGS, FOCUS GROUPS, AND THE REVIEW OF HISTORICAL DATA. Part VI, Line 3: RANDOLPH HOSPITAL EMPLOYEES FINANCIAL COUNSELORS WHO WORK WITH ALL SCHEDULED PATIENTS IN ADVANCE OF THEIR SERVICES TO DETERMINE ELIGIBILITY FOR CHARITY CARE. EMERGENCY PATIENTS ARE COUNSELED AFTER THEIR TREATMENT IS COMPLETE. Part VI, Line 4: RANDOLPH HOSPITAL IS A 145 BED ACUTE CARE HOSPITAL LOCATED IN ASHEBORO, NORTH CAROLINA. THE HOSPITAL PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY CARE SERVICES FOR RESIDENTS OF RANDOLPH COUNTY, NORTH CAROLINA AND SURROUNDING COUNTIES.FOR THE PERIOD OCTOBER 1, 2009 TO SEPTEMBER 30, 2010, RANDOLPH HOSPITAL SERVED 7,457 INPATIENTS, HAD 40,179 EMERGENCY ROOM VISITS, 105,365 OTHER OUTPATIENT VISITS AND 44,354 HOME CARE VISITS. RANDOLPH HOSPITAL PROVIDED THESE QUALITY SERVICES REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY.RANDOLPH HOSPITALS MISSION IS TO "PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS". THE HOSPITAL HAS PROVIDED QUALITY CARE TO ALL RESIDENTS IN AND AROUND ASHEBORO, NORTH CAROLINA. Part VI, Line 5: AMOUNTS REPORTED IN PART II INCLUDE: - $ 1,081 - HABITAT FOR HUMANITY ASSISTANCE - 14,050 - ECONOMIC DEVELOPMENT BOARD - 22,280 - VARIOUS COMMUNITY BOARD APPOINTMENTS, INCLUDING THE CHAMBER OF COMMERCE, ROTARY CLUB, AND HOSPICE. - 10,899 - RANDOLPH LEADERSHIP EDUCATION - 12,563 - COMMUNITY COALITION BOARD - 4,702 - RANDOLPH HEALTH IMPROVEMENT PARTNERSHIP 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 NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. IN ADDITION, THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY TO MOST HOSPITAL DEPARTMENTS.ANY SURPLUS OF FUNDS IN A GIVEN YEAR IS USED TO FUND CAPITAL EXPENDITURES TO ACQUIRE EQUIPMENT NECESSARY TO PROVIDE QUALITY PATIENT CARE. NC X 1 1 X X X X X X 0 1 0 0 0 0 0 0 0 ROBERT E MORRISON 264607 0 48643 0 0 0 51161 0 34315 0 398726 0 0 0 LYNWOOD R WHITE 189036 0 34000 0 0 0 87992 0 13513 0 324541 0 0 0 SANDRA ALLEN 190734 0 20000 0 0 0 140721 0 13407 0 364862 0 0 0 STEVE EBLIN 180478 0 20000 0 80053 0 24410 0 11768 0 316709 0 80053 0 DEVIN GRIFFITH 150361 0 22833 0 0 0 13745 0 4093 0 191032 0 0 0 TREMONTEO CRAWFORD 140467 0 8626 0 0 0 0 0 4194 0 153287 0 0 0 LISA HAMPTON 141797 0 4468 0 0 0 0 0 3855 0 150120 0 0 0 Part I, Line 4b: THE AMOUNTS REPRESENTED AS DEFERRED COMPENSATION ON SCHEDULE J HAVE NOT BEEN PAID TO THE INDIVIDUALS. THE AMOUNT REPRESENTS VESTED BENEFITS WHICH MAY BE PAID IN FUTURE YEARS, DEPENDING ON THE INDIVIDUAL'S LIFE SPAN AND OTHER FACTORS WHICH COULD RESULT IN FORFEITURE OF THE BENEFIT. DURING 1998, THE HOSPITAL ESTABLISHED SUPPLEMENTAL PLANS TO COVER HIGHLY COMPENSATED EMPLOYEES. THESE PLANS INCLUDED A NONQUALIFIED SUPPLEMENTAL RETIREMENT PLAN, A DEFERRED COMPENSATION PLAN, AND A SPLIT-DOLLAR LIFE INSURANCE PLAN. THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN PROVIDES ADDITIONAL BENEFITS TO SUPPLEMENT BENEFITS EARNED UNDER THE DEFINED BENEFIT PENSION PLAN. IN 2005, THE HOSPITAL INSTITUTED A NONQUALIFIED DEFERRED COMPENSATION PLAN. THE PURPOSE OF THIS PLAN IS TO PROVIDE ADDITIONAL RETENTION INCENTIVES AND RETIREMENT SECURITY FOR CERTAIN MEMBERS OF THE HOSPITAL'S SENIOR MANAGEMENT TEAM AND TO ALLOW FOR THE DEFERRAL OF COMPENSATION OF THOSE ELIGIBLE MEMBERS OF ITS SENIOR MANAGEMENT. THIS IS INTENDED TO BE A NONQUALIFIED PLAN. THE SPLIT-DOLLAR LIFE INSURANCE AGREEMENT INVOLVES THE PAYMENT OF PREMIUMS BY THE HOSPITAL FOR A LIFE INSURANCE POLICY, THE BENEFITS OF WHICH ARE SPLIT BETWEEN THE EMPLOYEES' BENEFICIARIES AND THE HOSPITAL UP TO THE AMOUNT OF PREMIUMS PAID. PREMIUMS PAID UNDER THIS PLAN WILL CONTINUE UNTIL THE AGREEMENT IS TERMINATED OR UPON THE DEATH OF THE INSURED EMPLOYEES. DISTRIBUTIONS FOR THE NONQUALIFIED SUPPLEMENTAL RETIREMENT PLAN FOR THE FISCAL YEAR TOTALED $653,901. FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2010, THE HOSPITAL CONTRIBUTED APPROXIMATELY $654,000. THE BENEFIT OBLIGATION IS RECORDED IN OTHER LONG-TERM LIABILITIES. PREMIUMS PAID UNDER THE SPLIT-DOLLAR INSURANCE POLICY WERE $9,822 FOR THE FISCAL YEAR. STEVE EBLIN RECEIVED A PAYOUT ON THE NONQUALIFIED SUPPLEMENTAL DEFERRED COMPENSATION PLAN FOR THE YEAR IN THE AMOUNT OF $80,053. NO OTHER PARTICIPANTS OF THE PLAN RECEIVED PAYOUTS IN 2009. Supplemental Information Part III SCHEDULE J, PART II: WE ARE REQUIRED TO REPORT COMPENSATION OF KEY INDIVIDUALS THAT WORK FOR AND ARE PAID BY A RELATED ORGANIZATION. COMPENSATION REPORTED ON THIS SCHEDULE DOES NOT NECESSARILY MEAN THAT THE COMPENSATION WAS PAID BY THIS ORGANIZATION. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HZR7 2007-06-14 49230000 QUALIFIED HOSPITAL REVENUE BONDS 0 0 49230000 1221880 358375 29115807 2008 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 1 Form 990, Part VI, Section A, line 6 THE CORPORATION SHALL HAVE ONE CLASS OF MEMBERS CONSISTING OF AT LEAST 23 MEMBERS AND NEVER CONSISTING OF MORE THAN 30 MEMBERS. FOUR MEMBERS SHALL BE EX OFFICIO, AS INDICATED BELOW. THE REMAINDER SHALL BE ELECTED AS PROVIDED IN DETAIL IN THE BYLAWS. THE PRINCIPAL CRITERION FOR SELECTION OF CORPORATE MEMBERS SHALL BE THE PERSON'S QUALIFICATIONS TO EVENTUALLY SERVE AS A DIRECTOR OF RANDOLPH HOSPITAL, AS SET FORTH IN SECTION 2.2 OF THE BYLAWS. AS CANDIDATES BECOME AVAILABLE, THE MEMBERS MAY EXPAND OR CONTRACT THEIR NUMBER, WITHIN THE LIMITS STATED ABOVE, IN ORDER TO PROVIDE AN ADEQUATE POOL OF MEMBERS WHO ARE QUALIFIED TO SERVE AS DIRECTORS. IN ADDITION TO THE ELECTED MEMBERS, THE MAYOR OF ASHEBORO, NORTH CAROLINA, THE CHAIRMAN OF THE BOARD OF COMMISSIONERS OF RANDOLPH COUNTY, NORTH CAROLINA, THE RANDOLPH COUNTY SUPERINTENDENT OF SCHOOLS, AND THE COUNTY HEALTH OFFICER OF RANDOLPH COUNTY, NORTH CAROLINA, SHALL SERVE AS EX OFFICIO MEMBERS OF THE CORPORATION. Form 990, Part VI, Section A, line 7a THE DIRECTORS SHALL BE ELECTED BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS FROM NOMINATIONS RECEIVED BOTH FROM THE GOVERNANCE COMMITTEE AND FROM THE FLOOR AT THE ANNUAL MEETING OF THE MEMBERS, IF ANY. DIRECTORS SHALL SERVE ONE-YEAR TERMS, AND SHALL CONTINUE TO SERVE UNTIL THEIR SUCCESSORS ARE ELECTED AND QUALIFIED. DIRECTORS MAY BE RE ELECTED. ANY DIRECTOR MAY BE REMOVED FROM OFFICE AT ANY TIME, WITH OR WITHOUT CAUSE, BY A MAJORITY VOTE OF THE MEMBERS OF THE CORPORATION. Form 990, Part VI, Section A, line 7b CHANGES TO THE BYLAWS, SALE OR MERGER OF THE HOSPITAL MUST BE APPROVED BY THE MEMBERS. Form 990, Part VI, Section B, line 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. UPON COMPLETION, THE RETURN WAS REVIEWED BY THE FINANCE AND AUDIT COMMITTEE OF THE BOARD, FOLLOWED BY A PRESENTATION TO THE FULL BOARD AT A SCHEDULED MEETING. BOARD MEMBERS WERE PROVIDED WITH A COPY OF THE RETURN A WEEK PRIOR TO THE MEETING, AND A PERIOD OF TIME WAS ALLOWED FOR QUESTIONS AND COMMENTS BEFORE FILING THE RETURN WITH THE IRS. Form 990, Part VI, Section B, line 12c THE ORGANIZATION EMPLOYS A FULL TIME CORPORATE COMPLIANCE OFFICER CHARGED WITH EDUCATING THE BOARD, OFFICERS, AND OTHER EMPLOYEES ON THE CONFLICT OF INTEREST POLICY. ALL NEW EMPLOYEES ARE GIVEN INFORMATION UPON ORIENTATION, AND ALL CURRENT EMPLOYEES ARE REQUIRED TO TAKE ANNUAL EDUCATION ON COMPLIANCE WITH THE POLICY. THERE IS A MONTHLY CORPORATE COMPLIANCE MEETING TO UPDATE KEY INDIVIDUALS ON NEW ISSUES AND NEW INFORMATION REGARDING CORPORATE COMPLIANCE. THE BOARD OF DIRECTORS IS REQUIRED ANNUALLY TO READ, SIGN, AND REMIT A COPY OF THE POLICY TO THE BOARD CHAIR. ALL BOARD MEMBERS ARE AWARE OF THE POLICY AND IN CASE OF ANY CONFLICT OF INTEREST, THEY WILL RECUSE THEMSELVES. Form 990, Part VI, Section B, line 15 RANDOLPH HOSPITAL CONTRACTS WITH AN INDEPENDENT COMPENSATION CONSULTANT TO DETERMINE APPROPRIATE COMPENSATION LEVELS FOR EXECUTIVES THAT IS COMMENSURATE WITH ORGANIZATIONS OF SIMILAR SIZE AND STRUCTURE. A COMPENSATION COMMITTEE OF THE BOARD HAS FINAL DETERMINATION OF COMPENSATION LEVELS FOR TOP EXECUTIVES. Form 990, Part VI, Section C, line 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. Form 990, Part VI, Section C, line 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. SCHEDULE K, PART II, LINE 5: COST OF ISSUANCE: PROCEEDS USED FOR BOND ISSUANCE COSTS, INCLUDING UNDERWRITER'S DISCOUNT: 298,091 PROCEEDS USED FOR CREDIT ENHANCEMENT: 60,284 TOTAL TO LINE 5: 358,375 RANDOLPH HOSPITAL COMMUNITY HEALTH FOUNDATION 346 WHITE OAK STREET ASHEBORO NC 27204 582240755 SUPPORTING ORGANIZATION NC 501(c)(3) Line 11a, I N/A RANDOLPH MEDICAL ASSOCIATES 132 WEST MILLER STREET ASHEBORO NC 27204 561853201 HEALTHCARE NC 501(c)(3) Line 9 N/A RANDOLPH SPECIALTY GROUP PRACTICE 364 WHITE OAK STREET ASHEBORO NC 27204 113827203 HEALTHCARE NC 501(c)(3) Line 9 N/A RANDOLPH CANCER CENTER LLC 364 WHITE OAK STREET ASHEBORO NC 27204 562181482 HEALTHCARE NC 501(c)(3) Line 11a, I N/A CENTRAL PIEDMONT SURGERY CENTER LLC 11221 ROE AVE SUITE 320 LEAWOOD KS 66211 234317497 HEALTHCARE KS N/A RELATED 999267 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 RANDOLPH CANCER CENTER LLC A 249000 RANDOLPH SPECIALTY GROUP PRACTICE D 1559260 RANDOLPH MEDICAL ASSOCIATES D 176573