2011-11-09T13:10:56-06:00 2010-12-31 990 2010-01-01 160755761 CUBA MEMORIAL HOSPITAL INC CUBA 5859682000 140 WEST MAIN ST CUBA NY 147271398 ANDREW H BOSER III 5859682000 2011-11-09 2010 2016-02-24 21:20:13Z ANDREW H BOSER III 140 WEST MAIN ST CUBA NY 147271398 12079201 0 X WWW.CUBAMEMORIALHOSPITAL.COM X 1925 NY ACUTE AND LONG TERM PATIENT CARE 9 9 289 3 0 0 615220 684258 10849009 10648815 13695 1040 396040 745088 11873964 12079201 0 0 0 0 7059604 7372801 0 0 0 4513384 5067729 11572988 12440530 300976 -361329 10932083 12197938 5789244 7416428 5142839 4781510 TO PROVIDE A CONTINUUM OF APPROPRIATE HEALTH RELATED SERVICES TO ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY. 0 0 9208212 11380437 CUBA MEMORIAL HOSPITAL IS A NOT FOR PROFIT PUBLIC BENEFIT CORPORATION. ACUTE AND SKILLED NURSING HOME CARE IS PROVIDED IN ADDITION TO A 24 HOUR URGENT CARE CENTER AND TWO DENTAL CLINICS. THE HOSPITAL PROVIDED $568,405 IN CHARITY CARE AND FREE CARE ASSESSMENTS TO THE STATE OF NEW YORK. 9208212 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 289 1 0 0 0 0 0 0 0 0 0 1 1 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X JOHN T ORMOND 5859682000 140 W MAIN ST CUBA NY 14727 KAREN PERRIGO 1.00 X X 0 0 0 SANDY SLEGGS 1.00 X X 0 0 0 JODY COLLINS 1.00 X X 0 0 0 JOHN FOELS 1.00 X 0 0 0 NICO VANZWANENBERG 1.00 X 0 0 0 LARRY POELMA 1.00 X 0 0 0 JAMES MOOR 1.00 X 0 0 0 JEAN SWITALSKI 1.00 X 0 0 0 JOHN HASPER 1.00 X 0 0 0 ANDREW H BOSER III 37.50 X 127431 0 21119 JOHN T ORMOND 37.50 X 130874 0 13329 DAVID HANRAHAN 48.00 X 135900 0 8592 MARK STANCOMBE 48.00 X 124757 0 12794 KEVIN J BRICELAND 48.00 X 108285 0 8192 CHRISTOPHER L YOUNG 37.50 X 138323 0 13907 765570 0 77933 6 0 1 0 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING SERVICE 250010 ARGENTIERI BROS INC 50 W HANOVER ST WELLSVILLE NY 14895 LAUNDRY 117789 2 14353 668549 1356 684258 NET PATIENT REVENUE 621110 10648815 10648815 10648815 1040 1040 13466 13466 13466 13466 0 14353 0 0 OTHER INCOME 621110 731622 731622 731622 12079201 11380437 0 14506 292753 215320 77433 5691604 4186175 1505429 961174 706943 254231 427270 313103 114167 42933 42933 27219 27219 37863 37863 698961 601869 97092 73199 73199 1627279 1535826 91453 279652 204929 74723 756711 641290 115421 8565 6116 2449 11428 8720 2708 1007183 217986 789197 98568 98568 BAD DEBT EXPENSE 398168 398168 12440530 9208212 3232318 0 29922 1786874 1042117 346681 440206 1119116 1570650 68990 60709 47089 90659 18208378 9300877 7425331 8907501 108080 86096 10932083 12197938 1809658 2219333 362500 122500 3617086 5074595 5789244 7416428 X 2343349 2044990 986557 923587 1812933 1812933 5142839 4781510 10932083 12197938 -361329 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 226039 226039 8737568 4487429 4250139 169866 115542 54324 8481718 4697906 3783812 593187 593187 8907501 12079201 12440530 -361329 0 -361329 12079201 0 12079201 0 12079201 12440530 0 12440530 0 12440530 1 1 1 X 250.000000000000 1 X 1 1 0 1 0 568405 868304 -299899 0.00000 2801071 1293667 1507404 0.12520 3369476 2161971 1207505 0.12520 2956 2177 779 0.00010 2956 2177 779 0.00010 3372432 2164148 1208284 0.12530 0 398169 409358 3128254 4122309 -994055 X 1 1 2 1 CUBA MEMORIAL HOSPITAL

140 W MAIN ST CUBA NY 14727

X X X X 2 ANDOVER DENTAL CLINIC

2 S MAIN ST ANDOVER NY 14806

DENTAL CLINIC CUBA MEMORIAL HOSPITAL INC 1 0 1 1 250.000000000000 1 300.000000000000 1 X X X X 1 1 X X X 1 X X X 1 X X X X X X X 1 X X 0 1 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 $ 398168. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE: PATIENT ACCOUNTS RECEIVABLE ARE PRESENTED NET OF AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL COLLECTIONS BASED UPON A REVEIW OF OUTSTANDING RECEIVABLES, HISTORICAL DEBT COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS. PATIENT ACCOUTNS RECEIVABLE ARE DUE 30 DAYS AFTER THE DATE OF DISCHARGE. RECEIVABLES PAST DUE MORE THAN 120 DAYS ARE CONSIDERED DELINQUENT. DELINQUENT ACCOUNTS RECEIVABLES ARE GENERALLY WRITTEN OFF BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT AND OTHER THIRD PARTY PAYERS. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: DISCUSSED THE POLICY WITH SELF PAY PATIENTS. CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 19D: ESTABLISHED HOSPITAL CHARGES ARE BILLED CUBA MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 21: HOSPITAL GROSS CHARGES ARE BILLED TO ALL PATIENTS OR THEIR INSURANCE COVERAGE. PAYMENT ADJUSTMENTS ARE MADE AS SEPARATE ALLOWANCE ON INDIVIDUAL ACCOUNTS. X X 0 0 0 0 0 0 0 0 0 CHRISTOPHER L YOUNG 138323 0 0 0 0 0 0 0 13907 0 152230 0 0 0 ALLEGANY COUNTY INDUSTRIAL DEVELOPMENT AGENCY 470942108 2004-11-12 3000000 REFINANCING OF HOSPITAL MORTGAGE 0 1 0 3000000 2004 1 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEE FINANCE COMMITTEE WAS PROVIDED A COPY OF THE DRAFT 990 FOR REVIEW. A MEETING WAS THEN HELD TO REVIEW ANY QUESTIONS OR ISSUES RELATED TO THE SUBMISSION. QUESTIONS WERE DISCUSSED AND RESOLVED AND THE REVISED SUBMISSION WAS SENT TO OUR INDEPENDENT AUDITORS FOR REVIEW. THE FINALIZED VERSION OF THE 990 IS THEN PROVIDED TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL TRUSTEES AND OFFICERS COMPLETE AND SIGN AN ATTESTATION FORM IDENTIFYING ANY PERSONAL AND/OR FAMILY POTENTIAL CONFLICT SITUATIONS. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY, THE BOARD OF TRUSTEES EXECUTIVE COMMITTEE REVIEWS CEO AND CFO PERFORMANCE AND COMPENSATION. KEY EMPLOYEE COMPENSATION IS REVIEWED AND ESTABLISHED BY EXECUTIVE OFFICER CONSISTENT WITH THE BOARD APPROVED OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 MONTHLY AND ANNUAL FINANCIAL STATEMENTS ARE FILED WITH ALL FINANCIAL INSTITUTIONS WITH RELATIONSHIPS WITH THE HOSPITAL. ANNUAL COST REPORTS ARE FILED WITH MEDICARE AND MEDICAID. THE 990 IS ELECTRONICALLY FILED AND IS AVAILABLE FROM THE ORGANIZATION UPON REQUEST. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. CMHR CORPORATION 140 WEST MAIN ST CUBA NY 14727 562495396 PROPERTY MANAGEMENT NY SECTION 501(C)3 9 N/A 0 CUBA MEMORIAL RETIREMENT COMMUNITY INC 140 WEST MAIN ST CUBA NY 14727 271463624 ASSISTED LIVING NY SECTION 501(C)3 9 N/A 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 CMHR CORPORATION J 18000 CASH VALUE CUBA MEMORIAL RETIREMENT COMMUNITY INC D 60700 CASH VALUE