2011-08-11T10:12:47-07:00 2010-09-30 Taylor Polson & Company CPAs PSC PO BOX 1804 GLASGOW KY 421421804 990 2009-10-01 610461767 TJ Samson Community Hospital TJSA 2706514444 1301 NORTH RACE STREET GLASGOW KY 42141 Anthony Sudduth 2706518877 2011-08-11 1 Belinda Coulter 2706518877 2011-08-11 2009 2016-02-24 21:20:13Z Bill Kindred CEO 1301 North Race Street Glasgow KY 42141 119421894 0 X WWW.TJSAMSON.ORG X 1929 KY The organization provides medical care for Barren and the surrounding counties in Kentucky. 11 11 1073 103 -1662 -1662 23723 5000 116887980 116884206 1070327 1958704 424142 507329 118406172 119355239 0 0 0 0 58311362 59439542 0 0 0 50068813 54759391 108380175 114198933 10025997 5156306 116436664 124226796 44491464 42087446 71945200 82139350 TJ SAMSON COMMUNITY HOSPITAL WILL PROMOTE AND PROVIDE FOR THE HEALTH AND WELLBEING OF THOSE THEY SERVE. 0 0 104448674 119227329 ACUTE HOSPITAL AND EMERGENCY ROOM CARE- PATIENT DAYS 28,371; ER VISITS 30,511; OUTPATIENT VISITS 65,907. THE HOSPITAL ALSO PROVIDES CARE TO PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. THE AMOUNT OF CHARGES FOREGONE AS CHARITY CARE WAS 1,430,714 FOR THE YEAR ENDED SEPTEMBER 30, 2010 0 0 0 104448674 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 57 0 1 1073 1 1 1 0 0 0 0 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X TJ SAMSON COMMUNITY HOSPITAL 2706514444 1301 NORTH RACE STREET GLASGOW KY 42141 ELLEN BALE 1 X 0 0 78 CHRIS LAWRENCE 1 X 0 0 78 BRENT WRIGHT 1 X 0 0 0 KAREN SMALL 1 X 0 0 11726 WALTER DAVIS 1 X 0 0 806 MIKE BRYANT 1 X 0 0 78 MICHAEL SHADOWEN 1 X 0 0 0 VENKATA REDDY 1 X X 506035 0 20593 FOLLIS CROW III 1.2 X 0 0 862 BUDDY UNDERWOOD 1.2 X 0 0 78 HENRY ROYSE 1.3 X 0 0 12342 DAN FOUTCH 1.2 X 0 0 78 ANTHONY SUDDUTH 40 X 221580 0 27322 WILLIAM KINDRED 40 X 280250 0 32328 BOGDAN MARCOL 40 X 518220 0 30804 VIVEK JAIN 40 X 176114 0 0 ANUPAMA KAUL 35 X 175712 0 27264 OLIVIA COICULESCU 40 X 235137 0 28523 JOHN NESBITT 40 X 514080 0 32091 2627128 0 225051 16 0 1 0 SURGICAL SOLUTIONS 702 A BARRETT BLVD HENDERSON KY 42420 SURGERY 658145 ASSOCIATED PATHOLOGY SUITE 350 3 MARYLAND FARMS BRENTWOOD TN 37244 PATHOLOGY 375757 UNIDINE 1 GATEWAY CENTER SUITE 751 NEWTON MA 02458 DINING SERVICES 539046 APOGEE MEDICAL MANAGEMENT 2525 E CAMELBACK ROAD SUITE 1100 PHOENIX AZ 85016 HOSPITALIST 698964 ALLIANCE IMAGING INC PO BOX 96485 CHICAGO IL 60693 PET SCAN 345550 24 0 0 0 0 0 5000 0 5000 HOSPITAL PROGRAM SERVICE 622000 116598783 116598783 0 0 PARTNERSHIP INCOME 541900 241044 230476 10568 0 OUTSIDE LAB 621500 44379 0 44379 0 0 0 0 0 116884206 1957611 0 0 1957611 0 0 0 0 0 0 0 0 188065 0 66248 0 121817 0 121817 121817 0 0 0 1500 0 407 0 1093 1093 1093 0 0 0 CHILD CARE SERVICES 624410 -27528 0 -56849 29321 LAUNDRY 812300 240 0 240 0 PRIME ADVANTAGE 624100 9475 9475 0 0 403325 161176 0 242149 385512 119355239 117122820 -1662 2229081 0 0 0 0 0 0 0 0 508782 0 508782 0 0 0 0 46457660 41347317 5110343 0 3371576 3000703 370873 0 5777731 5142181 635550 0 3323793 2958176 365617 0 0 0 0 0 341409 0 341409 0 52350 0 52350 0 0 0 0 0 0 0 121848 0 121848 0 2823414 2823414 0 0 393567 393567 0 0 532750 474148 58602 0 0 0 0 0 0 0 0 0 1888813 1888813 0 0 394545 394545 0 0 0 0 0 0 9645 0 9645 0 219985 219985 0 0 0 0 0 0 5543288 5543288 0 0 1279491 1279491 0 0 SUPPLIES 19774912 17599672 2175240 0 REPAIRS 3337199 3337199 0 0 PROVIDER TAX 2153902 2153902 0 0 CONTRACT SERVICES 4910418 4910418 0 0 DUES AND SUBS 277335 277335 0 0 10704520 10704520 0 0 114198933 104448674 9750259 0 2096932 1763265 43024184 50562584 0 0 18345098 21589355 0 0 0 0 116622 4444 2011621 2211827 3675314 2763905 119002627 80983406 38201739 38019221 2017395 2017395 0 2280980 2594684 0 4666779 2700116 116436664 124226796 30838081 30240905 0 0 0 0 11990174 10932482 0 0 0 0 0 1663209 914059 44491464 42087446 X 71945200 82139350 0 0 0 0 71945200 82139350 116436664 124226796 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 1 12243 0 12243 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 THE HOSPITAL PAID MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION OF WHICH 24% OR 5986 WAS USED FOR LOBBYING ACTIVITIES. THEY ALSO PAID MEMBERSHIP TO THE KENTUCKY HOSPITAL ASSOCIATION OF WHICH 17% OR 6257 WAS FOR LOBBYING. 0 1961573 1961573 0 34167310 15802775 18364535 0 1590467 1215504 374963 0 81283277 63965127 17318150 0 0 0 0 38019221 0 0 0 CANCER CENTER JOINT VENTURE 2594684 F 2594684 THIRD PARTY SETTLEMENTS 1099918 OTHER RECEIVABLES 1324153 INTEREST RECEIVABLE 182684 INVESTMENT IN PREMIER LLP 93361 2700116 0 THIRD PARTY PAYOR SETTLEMENTS 730626 PROVIDER TAX PAYABLE 183433 914059 119355239 114198933 5156306 457969 0 0 0 -7076263 -6618294 -1461988 119787278 457969 0 0 243959 701928 119085350 0 269889 269889 119355239 121249266 0 0 0 7050340 7050340 114198926 0 7 7 114198933 SchD_P10_S00_L00 Schedule D, Part X N/A SchD_P11_S00_L08 Schedule D, Part XI, Line 8 CHANGE IN PARTNERSHIP INCOME FROM BOOK TO TAX 2,915 CHANGE IN RETIREMENT PLAN -7,050,340 PARTNERSHIP SECTION 1231 AND CAPITAL GAIN PER K-1 -1,088 GIFT SHOP PROFIT -27,757 PARTNERSHIP SECTION 1231 LOSS PER K-1 7 SchD_P12_S00_L02d Schedule D, Part XII, Line 2d PARTNERSHIP INCOME RECODED ON BOOK 243,959 SchD_P12_S00_L04b Schedule D, Part XII, Line 4b PARTNERSHIP INCOME ON K-1 241,044; PARTERSHIP INVESTMENT INCOME PER K-1 1,088; GIFT SHOP PROFIT 27,757 SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d CHANGE IN THE RETIREMENT PLAN SchD_P13_S00_L04b Schedule D, Part XIII, Line 4b PARTNERSHIP SECTION 1231 LOSS 1 1 1 X 1 X 1 1 1 0 1 1 1497226 576851 920375 0.0081 1 19357301 11067786 8289515 0.0726 1 0 20854527 11644637 9209890 0.0807 584 11246 267400 0.0023 13 43 650920 650920 0.0057 113 1277 56811 0.0005 710 12566 650920 0 975131 0.0085 711 12566 21505447 11644637 10185021 0.0892 196 0 2192 0 2376 0 16647 0.0001 6562 0.0001 0 0 0 0 27973 0.0002 1 3650431 1003671 31849068 35197391 -3348323 X 1 1 TJ SAMSON COMMUNITY HOSPTAL

1304 NORTH RACE STREET GLASGOW KY 42141

X X X X IS REPORTED AS COST THAT IS CALCULATED BY APPLYING THE TOTAL COST TO CHARGES RATION N/A N/A ACCOUNTS RECEIVABLE ARE STATED AT THE AMOUNT THE HOSPITAL EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THE HOSPITAL PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS THROUGH A PROVISION FOR BAD DEBT EXPENSE AND AN ADJUSTMENT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF THE CURRENT STATUS OF INDIVIDUAL RECEIVABLES FROM CONTRACTS, MEDICAID/MEDICARE, AND OTHERS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION ERRORS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO THE APPLICABLE ACCOUNTS RECEIVABLE. BAD DEBT ON THIS REPORT IS REPORTED AT COST AS CALCULATED BY APPLYING THE TOTAL COST TO CHARGE RATIO TO TOTAL CHARGES WRITTEN OFF TO BAD DEBT. COST TO CHARGE METHODLOGY. WE BELIEVE THAT A 100% OF THE SHORTFALL IS COMMUNITY BENEFIT SINCE IT IS AN UNREIMBURSED COST TO THE HOSPITAL FOR PROVIDING A GOVERNMENT PROGRAM. Yes we have established collection practices that qualify for charity care or financial assistance. HOSPITAL PARTICIPATES IN A COMMUNITY NEEDS ASSESSMENT WITH OTHER LOCAL HEALTH PROVIDERS. PATIENTS ARE NOTIFIED ABOUT THESE PROGRAMS AT REGISTRATION. HOSPITAL SERVES A 3 COUNTY PRIMARY SERVICE AREA AND AN 8 COUNTY SECONDARY MARKET AREA. N/A THE HOSPITAL GOVERNING BOARD CONSISTS OF LOCAL COMMUNITY MEMBERS. WE HAVE AN OPEN MEDICAL STAFF POLICY AND SURPLUS FUNDS ARE USED TO REPLACE AND EXTEND HEALTHCARE FACILIATIES AND EQUIPMENT. N/A X 0 0 0 0 0 0 0 0 0 VENKATA REDDY 506035 0 0 0 0 0 16416 0 0 0 522451 0 3432 0 WILLIAM KINDRED 238110 0 42140 0 0 0 19862 0 12467 0 312579 0 0 0 ANTHONY SUDDUTH 189679 0 31901 0 0 0 15375 0 11947 0 248902 0 0 0 BOGDAN MARCOL 518220 0 0 0 0 0 16968 0 13836 0 549024 0 0 0 JOHN NESBITT 514080 0 0 0 0 0 16968 0 15123 0 546171 0 0 0 ANUPAMA KAUL 125232 0 50480 0 0 0 16968 0 10297 0 202977 0 0 0 OLIVIA COICULESCU 235137 0 0 0 0 0 16968 0 10297 0 262402 0 0 0 VIVEK JAIN 176114 0 0 0 0 0 0 0 0 0 176114 0 0 0 F990_P06_S0B_L11 Form 990, Part VI, Section B, Line 11 THE CFO REVIEWED THE 990 AND EMAILED TO BOARD MEMBERS. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c THE BOARD REVIEWS COMPLIANCE F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 THE HOSPITAL HAS AN INDEPENDENT CONSULTANT REVIEW THE SALARIES FOR THE CEO AND CFO. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 ALL ARE AVAILABLE UPON REQUEST