2011-08-15T09:01:13-05:00 2010-09-30 Postlethwaite & Netterville 8550 United Plaza Blvd Suite 1001 Baton Rouge LA 70809 990 2009-10-01 720535375 LAFAYETTE GENERAL MEDICAL CENTER INC LAFA 3372898125 1214 COLLIDGE BLVD LAFAYETTE LA 705032621 ROGER MATTKE 3372898125 2011-08-12 1 Ralph Stephens 2259224600 2009 2016-02-24 21:20:13Z DAVID CALLECOD 1214 COOLIDGE BLVD LAFAYETTE LA 70503 203413644 0 X www.lafayettegeneral.com X 1911 LA The organization provides medical care to improve, maintain, and restore the health of the people in the communities we serve, regardless of the patients' ability to pay. 17 17 1875 113 3575017 0 148309 38700 174058746 191746083 3762222 3194256 4019089 3683321 181988366 198662360 136298 191479 0 77593234 79967336 0 0 102345244 111203046 180074776 191361861 1913590 7300499 275827848 332063015 115087536 158906541 160740312 173156474 Lafayette General Medical Center's mission is to improve, maintain and restore the health of the people in the communities we serve. 0 0 146056859 191479 191403918 Program services statistics related to providing community medical care for the Hospital: total acute patient days were 66,272, total psychiatric days were 2,424, total nursery days were 3,784, and total rehab days were 3,249. Other significant healthcare services provided included 51,588 emergency room visits, 9,198 surgeries (inpatient and outpatient), and 1,891 deliveries.The organization provides needed medical care to the community, regardless of the patient's ability to pay. Services included inpatient and outpatient care in furtherance of the organization's healthcare mission. The revenues from these services are $393,610,346 and $231,990,008, respectively. There were acute and skilled care services not fully compensated. These included Medicare / Medicaid contractuals with $283,422,438 of uncompensated services, other contractuals with $131,579,886 of uncompensated services, and bad debts of $18,851,947. The net revenues of the services provided were $191,746,083.Lafayette General Medical Center (LGMC) serves the nine parishes in Louisiana designated Acadiana with 329 beds and over 1800 employees. LGMC remains the area's largest, full service, acute-care medical center.Our hospital mission is to improve, maintain and restore the health of people in the communities we serve. We are a community-owned and locally managed hospital that stays true to our mission by dedicating significant resources to compensate a compassionate, highly skilled staff; acquire advanced technology; and develop service improvements each year.Our accolades and accreditations grow each year. In our fiscal year 2010 we received the following: HealthGrades 2010 Awards:Ranked Among the Top 5 or 10 in LA Vascular SurgeryRanked 2 - Qualified Five Star Rated for Carotid Surgery - 3 YEars in a row (2008-2010)Five Star Rated for Prostatectomy - 1 year (2010)Ranked among the top 5% in the Nation for Prostatectomy, 2010Recipient of the HealthGrades Gastrointestinal Surgery Excellence Award - 3 years in a row (2008-2010)Ranked Among the top 10% in the NAtion of GI Surgery - 3 years in a row (2008-2010)Ranked 1 in LA for 2010 Five Star Rated GI Surgery - 3 Years in a row (2008-2010)Five Star Rated for Cholecystectomy - 3 years in a row (2008-2010)Ranked 1 in LA for GI Surgery - 2010 Ranked Among the Top 5 or 10 in LA for GI Services Ranked 4 - Qualified Ranked Among the Top 5 or 10 in LA for GI SurgeryRecipient of the HealthGrades Orthopedic Surgery Excellence AwardRanked Among the Top 5% in the Nation for Overall Orthopedic Ranked #1 in LA for Overall Orthopedic Services Ranked #3 in LA for Joint Replacement Ranked #4 in LA for Spine SurgeryFive-Star Rated for Overall Orthopedic Services Five-Star Rated for Joint Replacement Five-Star Rated for Spine Surgery - 5 years in a row (2006 - 2010)Five-Star Rated for Total Knee Replacement Five-Star Rated for Hip Fracture Repair Five-Star Rated for Back and Neck Surgery (Spinal Fusion) - 6 years in a row (2005 - 2010)2009 Louisiana Hospital Quality Award - Bronze Level: Eco-Health Solutions2009 Medcal of Honor Recipient, awarded by the Louisiana Organ Procurement AssociationRecipient of Southern Eye Bank 2009 Gift of Sight Hospital of the Year Award Recipient of Excellence in Patient Care for Physicians Award by the Studer Group2010 Recipient of Press Ganey's Top Performer in Patient Satisfaction for Emergency Department Lafayette General Medical Center assumes the role of a community partner in a variety of ways. Through financial contributions we work to preserve the prosperity of our community, further medical education and research and help our constituents' access the medical care they need. We coordinate events and screenings free of charge to maintain the health of the local public. We also extend our workforce beyond their daily responsibilities to participate in activities that provide for the safety and betterment of our community. FINANCIAL CONTRIBUTIONS:In 2010 we donated (monetarily, time, man-hours) over $178,000 supporting organizations that parallel our mission in the community, employees through continuing education and helping to improve the health of those we serve. From offering clinical support to Camp Bon Ceur attendees to sponsoring events that raise research money and awareness for illnesses like breast cancer, diabetes and heart disease. In 2010 these monies were donated to over 35 different organizations in our community. Lafayette General Medical Center also contributed over $60,000 to the University of Louisiana Lafayette to partially fund the School of Nursing's Accelerated Option Nursing Program for students wishing to obtain a second degree in nursing. COMMUNITY OUTREACH & HEALTH CARE ACCESS CONTRIBUTIONS:Lafayette General Medial Center maintains a proactive approach to education and wellness in our community. Annually LGMC provides a multitude of educational seminars aimed at educating the public on preventative care and maintaining a healthy lifestyle. LGMC administered 1,050 free flu shots to employees at a cost of $10,258.Donated over $9,300 in diagnostic imaging as part of a partnership with the Lafayette Community Health Care Clinic.Administered over 30 Free Peripheral Vascular Disease ultrasound screenings.Women's and Children's Services currently offers 4 free classes on a monthly basis which include newborn care, labor and delivery process, breastfeeding your infant and infant CPR. These classes serve approximately 75 people per month.LGMC staff administered approximately 297 immunizations to 112 children with our quarterly participation in the Shots for Tots program. Staffed free health booths including AHA Go Red for Women, American Diabetes Association Annual 5K Walk, Susan G Koeman's Race for the Cure, NAMI walk and the Walk from Obesity. Conducted four community education luncheons, "Health in General", at which different physicians spoke to various topics, including orthopedic surgery, minimally invasive spine surgery, colorectal screenings, and breast cancer.LGMC also provides free transportation for patients with special needs, in order to allow them access to medical care at the hospital.To improve health care access for those uninsured workers living at or below poverty level, LGMC maintains a referral agreement with the local Lafayette Community Healthcare Clinic to provide diagnostic testing to their patient population. Lafayette General Medical Center is truly a community owned hospital caring for the needs of the community and investing in the future wellness of our neighbors. 146056859 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 1 275 0 1 1875 1 1 1 0 0 0 0 0 0 17 17 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X LAFAYETTE GENERAL MEDICAL CENTER 3372898125 1214 COOLIDGE BLVD LAFAYETTE LA 705032621 MICHAEL ALEXANDER MD 1.00 X 0 0 0 CLAY ALLEN 1.00 X 0 0 0 DAVID CALHOUN 1.00 X 0 0 0 BRADLEY J CHASTANT MD 1.00 X 6000 0 0 IRVIN DAVID 1.00 X 0 0 0 WILLIAM H FENSTERMAKER 1.00 X 0 0 0 ROBERT GILES 1.00 X 0 0 0 G GARY GUIDRY MD 1.00 X 43200 0 0 ROSE KENNEDY MD 1.00 X 0 0 0 EDWARD KRAMPE 1.00 X 4800 0 0 FLO MEADOWS 1.00 X 0 0 0 DONALD REED MD 1.00 X 0 0 0 RAE ROBINSON BRODNAX 1.00 X 0 0 0 GARY SALMON 1.00 X 0 0 0 E GREGORY VOORHLES 1.00 X 0 0 0 BRADEN DESPOT 1.00 X 0 0 0 JULIE FALGOUT 1.00 X 0 0 0 PHILIP GACHASSIN 1.00 X 93213 0 0 JOBY JOHN 1.00 X 0 0 0 DANIEL BOURQUE 1.00 X 8800 0 0 DAVID CALLECOD 40.00 X 519795 0 92604 PATRICK W GANDY JR 40.00 X 277291 0 37922 ROGER MATTKE 40.00 X 273828 0 44825 DEBRA CLARK 40.00 X 190733 0 38370 GORDON E ROUNTREE JR 40.00 X 229921 0 38154 SHIRLEY LAFFERTY 59.00 X 151116 0 4676 KATHERINE HEBERT 40.00 X 162395 0 16055 MATTHEW P LIPARI 54.00 X 150911 0 804 CHRISTINE A HANSEN 54.00 X 148493 0 1638 DANIEL R OVERBET 61.00 X 142972 0 10913 2403468 0 285961 52 0 1 0 HOSPITAL HOUSEKEEPING SYSTEMS LTD PO BOX 826 SAN ANTONIO TX 782930826 HOUSEKEEPING SERVICES 2614900 WASHER HILL LIPSCOMB 1744 OAKDALE DR BATON ROUGE LA 70810 ARCHITECTURE 1673990 PARISH ANESTHESIA OF LAFAYETTE 3510 N CAUSEWAY BLVD STE 404 METAIRIE LA 70002 ANESTHESIA SERVICES 1349275 ASSOC REGIONAL & UNIVERSITY PATHOLOGIST PO BOX 27964 SALT LAKE CITY UT 84112 REFERENCE LAB 802664 med-staff PO BOX 404691 ATLANTA GA 30384 CONTRACT NURSING 779448 23 38500 200 38700 MEDICAL PATIENT SERVIC 621990 191746083 191403918 342165 191746083 3156376 3156376 263 263 3218804 136436 3082368 3082368 542684 2539684 4651965 500 4614848 37117 500 37617 37617 HOSPITAL CAFETERIA 722210 1158795 0 1158795 INTERCOMPANY REVENUE 561000 947348 798622 148726 REFERENCE LAB 621500 687101 687101 -2192291 1204445 -3396736 600953 198662360 191403918 3575017 3644725 178154 178154 13325 13325 1818254 1818254 65777685 54635944 11141741 651190 588797 62393 6944930 4720263 2224667 4775277 3841940 933337 222249 222249 668201 668201 367095 367095 218697 218697 16213923 9698814 6515109 722146 36445 685701 54482143 53082346 1399797 3602797 9676 3593121 3231843 480636 2751207 289300 14923 274377 2485586 2485550 36 547006 572461 -25455 12127612 6480718 5646894 4301239 4301239 EQUIPMENT RENTAL AND MA 9089366 6710838 2378528 98 bond funding 1361732 1361732 0 BOND FUND EXPENSE 332866 332866 0 RECRUITING 291213 19411 271802 COMMUNITY AND PHYSICIAN 150672 3248 147424 497360 347826 149534 191361861 146056859 45305002 0 9260 9360 43852851 33354380 35591183 37246717 1082073 1388458 5459446 5837931 1797579 2227116 274315896 135686229 107210510 138629667 60368100 65148967 9778 9778 17235587 19089105 1466667 1403925 1744814 27717611 275827848 332063015 21271701 32237951 40170 12922 27041962 84140736 55675000 34363100 3859010 7199693 8151832 115087536 158906541 X 160740312 173156474 160740312 173156474 275827848 332063015 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 22710 22710 191339151 191361861 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 21046 22141 20618 22710 86515 250000 250000 250000 250000 1000000 1500000 21046 22141 20618 22710 86515 Part IV, Supplemental Information: 990 SCHEDULE C PART II-A, LINE 1A: ALL LOBBYING ACTIVITIES OCCUR INDIRECTLY THROUGH THE AMERICAN HOSPITAL ASSOCIATION AND THE LOUISIANA HOSPITAL ASSOCIATION. THE HOSPITAL DOES NOT HAVE ANY CONTROL OR DIRECTION IN DETERMINING HOW SUCH DUES PAID TO THESE TWO ORGANIZATIONS ARE USED. 8897052 8897052 158709794 60009448 98700346 2525788 1070859 1454929 104183262 74605922 29577340 138629667 LAFAYETTE HEALTH VENTURES INC 14641289 C PREMIER 84500 C SAINT MARTIN HOSPITAL 1420028 C LAFAYETTE INVESTMENT GROUP 1309600 C LAFAYETTE GENERAL SURGICAL HOSPITAL LLC 1633688 C 19089105 LIFE INSURANCE - CASH SURRENDER VALUE ON EXECUTIVES 265185 UNVESTED VALUE OF SERP 479817 BOND TRUSTEE FUNDS 25123415 BOND ISSUE COSTS 1843991 UTILITY COMPANY DEPOSIT 5203 27717611 SElf INSURANCE RESERVES 3750468 INTERCOMPANY PAYABLE - LAFAYETTE HEALTH VENTURES INC 4322644 INTERCOMPANY PAYABLE - LAFAYETTE GENERAL IMAGING 1246 SAINTS STREET LAFAYETTE GENERAL AMB ENDOCOPY CENTER 20810 LAFAYETTE GENERAL IMAGING 56664 8151832 198662360 191361861 7300499 5115662 5115662 12416161 221019055 5115662 17459729 22575391 198443664 218697 218697 198662361 208602893 17459729 17459729 191143164 218697 218697 191361861 Part XII & PART XIII, LINE 2D: BAD DEBT 18,851,947 RENTAL EXPENSE 136,436 ELIMINATED AUXILLARY CONTRIBUTIONS 32,675 MINERAL RIGHTS & PARTNERSHIP INCOME (199,596) DEBT REFINANCING (1,361,732) ROUNDING (1) TOTAL 17,459,729 1 1 X 1 X 1 X 1 1 1 0 1 1 1745969 1745969 0.00910 25309084 9182479 16126605 0.08430 27055053 9182479 17872574 0.09340 225092 225092 0.00130 393697 264025 129672 0.00070 178154 178154 0.00090 796943 264025 532918 0.00290 27851996 9446504 18405492 0.09630 1 5433395 1147200 63692527 65834531 -2142004 X 0 LAFAYETTE GENERAL MEDICAL CENTER INC

1214 COOLIDGE BLVD LAFAYETTE LA 70503

X X X Part I, Line 7: Part I, Line 7. A cost to charge ratio was used to estimate cost included in Line 7. The cost-to-charge was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charge as provided in the instructions to Schedule H. Part I, Line 7f: Part I, line 7, column (f). The hospital used total expenses from Form 990, Part IX, line 25 which excluded bad debt expense. Part III, Line 4: Part III, line 4. Footnote to the audited financial statements:The Medical Center reports accounts receivable net of estimated allowances for uncollectible accounts and adjustments. To provide for accounts receivable that could become uncollectible in the future, the Medical Center establishes an allowance for uncollectible accounts to reduce the carrying amount of such receivables to their estimated net realizable value. The amount charged to the provision for doubtful accounts is based upon the Medical Center's assessment of historical and expected net collections, business and economic conditions, and trends in government reimbursement. Uncollectible accounts are written off when the Medical Center has determined the account will not be collected.Worksheet A, Estimate Bad Debt Expense (at cost) was used to determine the amount of bad debt expense reported on line 2. The Hospital analyzed the population that was written off to both charity and bad debt during the year. It was estimated that 44% of the uninsured outpatient emergency room visits that were adjusted to bad debt may have been patients that could have qualified for the Hospital's charity care policy but did not initiate or complete the necessary documentation.The hospital did not include any bad debts in our community benefit calculations. Part III, Line 8: Part III, line 8. The costing methodology used for line 6 was the standard Medicare Cost Report cost system. The amounts were recapped from the hospital's filed 2010 cost report. The corresponding revenue amounts were included on line 5. The hospital did not include the Medicare shortfall in our community benefit calculations reported on Part I, line 7. Part VI, Line 2: Part VI, line 2 Needs assessment. A formal needs assessment has not been undertaken; however, the hospital does have a Board of Trustees and members of the corporation comprised of individuals from the local community, which are independently aware of the medical needs of the community. Surplus receipts over disbursements are invested to improve the quality of patient care, expand hospital facilities and equipment, advance medical training and education. The hospital also maintains an open medical staff. Part VI, Line 3: Part VI, line 3. Patient education of eligibility for assistance. The hospital complies with federal and JACHO requirements of posting notices to patients as required by federal programs. Handouts are included with the admission package that informs the patient of contact information to discuss payment options. The hospital is a Medicaid enrollment facility, and as such, the hospital offers screening services for eligibility for Medicaid and possible charity care assistance. Hospital personnel also screen larger accounts after the original bill is issued, and contact the patient to determine qualifications for charity care policy. Part VI, Line 4: Part VI, line 4 Community information. The hospital serves the nine parishes in Louisiana designated as Acadiana as the largest, full service, acute care medical center. Approximately one third of the hospitals discharges come from Lafayette parish. The hospital maintains an emergency room open to all people requiring emergency care without regard to their ability to pay. Part VI, Line 6: Part VI, line 6 Other information. The hospital does maintain an open medical staff thus allowing it to offer a variety of specialists, and continues to recruit physicians to our area to ensure that the hospital will continue to be the full service healthcare provider that the community expects. The hospital joins forces with other local organizations to provide healthcare screenings and test at local events. Part VI, Line 7: Part VI, line 7. The hospital is affiliated with other healthcare organizations. See Form 990 schedule R for a complete listing. All of the organizations are local healthcare organizations with the same purpose as the Hospital. 1 ACADIANA OUTREACH CENTER 125 S BUCHANAN ST LAFAYETTE LA 70501 581925867 501(C)3 12500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. AMERICAN CANCER SOCIETY 1604 W PINHOOK ROAD SUITE 182 LAFAYETTE LA 70508 640329009 501(C)3 6000 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. AMERICAN HEART ASSOCIATION 139B JAMES COMEAUX RAOD 596 LAFAYETTE LA 70508 360726140 501(C)3 17500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. CAMP BON COUER 405 W MAINT ST LAFAYETTE LA 70501 581710741 501(C)3 13000 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. HEARTS OF HOPE 911 GENERAL MOUTON AVE LAFAYETTE LA 70501 721321800 501(C)3 5040 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. HOSPICE OF ACADIA 2600 JOHNSTON ST LAFAYETTE LA 70501 720966231 501(C)3 5125 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. LAFAYETTE COMMUNITY HEALTH 1317 JEFFERSON ST LAFAYETTE LA 70501 721227982 501(C)3 1500 9294 fee schedule lab services CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. UNITED WAY OF ACADIANA PO BOX 52033 LAFAYETTE LA 70501 720513639 501(C)3 22500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. MILES PERRETT CENTER 2130 KALISTE SALOOM RD LAFAYETTE LA 70501 753023211 501(C)3 12500 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. OIL CENTER RENAISSANCE ASSOC 1005 E SAINT MARY BLVD LAFAYETTE LA 70501 721257087 501(C)6 20000 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. LOUISIANA OPEN INC 124 HEYMANN BLVD LAFAYETTE LA 70501 721043611 501(C)3 6400 CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFT AND GOVERNMENT ORGAINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. CHANCES FOR CHILDREN 20343 N HAYDEN RD SCOTTSDALE AZ 85255 205835605 501(C)3 9295 COST MEDICAL SUPPLIES HAITI EARTHQUAKE 36 1 DISBURSEMENT TO QUALIFYING LPN SCHOOL STUDENTS - HENRY P. HEBERT SCHOLARSHIPS 17 13325 Other Information: Part IV: CHARITABLE DONATIONS ARE MADE TO LOCAL NON-PROFIT GOVERNMENT ORGINIZATIONS THAT PARALLEL OUR HEALTHCARE MISSION IN THE COMMUNITY. DISBURSEMENTS FOR SCHOLARSHIPS, FELLOWSHIPS, AND STUDENT LOANS ARE MADE DIRECTLY IN FURTHERANCE OF THE ORGANIZATION'S EXEMPT PROGRAMS - THE PURPOSE OF WHICH THE HOSPITAL WAS ORGANIZED AND OPERATES. THE DISBURSEMENTS ARE BASED ON PERSONAL INTERVIEWS, ACADEMIC ACHIEVEMENTS, AND THE APPROVAL OF THE HOSPITAL'S ADMINISTRATION. CERTAIN STANDARDS AND CONDITIONS ARE ESTABLISHED TO ENSURE THAT RECIPIENTS ARE QUALIFIED AND THE DISBURSEMENTS ARE FOR HEALTH CARE OCCUPATIONS. THE CRITERIA FOR EDUCATIONAL LOANS ARE: 1. EMPLOYEES MUST HAVE COMPLETED ONE YEAR OF EMPLOYMENT 2. EMPLOYEE HAS ATTEMPTED TO GAIN OTHER FINANCIAL ASSISTANCE. 3. MUST HAVE A LETTER OF RECOMMENDATION FROM DEPARTMENT DIRECTOR. 4. MUST NOT HAVE AN UNSATISFACTORY EVALUATION. 5. THE EMPLOYEE MUST SIGN A CONTRACT. 6. ANY SINGLE LOAN MUST NOT EXCEED $10,000. X X X X 1 1 X X X X X 0 1 0 0 0 1 1 0 0 DAVID CALLECOD 446250 0 0 0 73545 0 82350 0 10254 0 612399 0 0 0 PATRICK W GANDY JR 268400 0 0 0 8891 0 29576 0 8346 0 315213 0 0 0 ROGER MATTKE 253892 0 0 0 19936 0 34979 0 9846 0 318653 0 0 0 DEBRA CLARK 184748 0 0 0 5985 0 35100 0 3270 0 229103 0 0 0 GORDON E ROUNTREE JR 225773 0 0 0 4148 0 29608 0 8546 0 268075 0 0 0 SHIRLEY LAFFERTY 151116 0 0 0 0 0 3037 0 1639 0 155792 0 0 0 KATHERINE HEBERT 142830 0 18017 0 1548 0 13371 0 2684 0 178450 0 0 0 MATTHEW P LIPARI 150911 0 0 0 0 0 0 0 804 0 151715 0 0 0 CHRISTINE A HANSEN 148493 0 0 0 0 0 0 0 1638 0 150131 0 0 0 DANIEL R OVERBET 142972 0 0 0 0 0 2874 0 8039 0 153885 0 0 0 Part I, Line 1a THE ORGANIZATION DOES ALLOW FOR SPOUSAL TRAVEL FOR THE TRUSTEES AND OFFICERS. SUCH EXPENSES ARE REPORTED ON THEIR W-2S OR 1099S. A HOUSING ALLOWANCE WAS PAID TO THE PRESIDENT/CEO, BUT WAS INCLUDED AS COMPENSATION ON HIS W-2. SOCIAL CLUB DUES WERE PAID FOR THE PRESIDENT/CEO AND THE COO AND WERE INCLUDED AS WELL AS COMPENSATION ON THEIR W-2S. TAXABLE FRINGE BENEFITS SUCH AS SPOUSAL TRAVEL AND SOCIAL CLUB DUES ARE ACCUMULATED AND GROSSED UP WHEN ADDED TO THE W-2 EARNINGS FOR THE YEAR. Part I, Line 4a A supplemental Employee Retirement Plan (SERP) was adopted effective January 01, 2008. The SERP iS classified as a supplemental non-qualified retirement plan, the purpose of which is to provide participants with supplemental retirement benefits. COntribution for the year was $231,475. The Board determines which employees are eligible for plan contributions. Participants were David Callecod, CEO, Patrick Gandy, COO, ROger Mattke, CFO, Gordon ROuntree, General Counsel, Debra Clark, CNO, Katherine Hebert, Vice President, and Carolyn Huval, Vice President. Part I, Line 6 THE ORGANIZATION DOES HAVE A PROFIT SHARING PLAN (SUCCESS SHARING) FOR ALL EMPLOYEES IN GOOD STANDING, DETERMINED IN PART ON NET EARNINGS. THE CRITERIA USED TO DETERMINE IF PROFIT SHARING WILL BE MADE IS BASED ONE THIRD ON NET EARNINGS OF THE ORGANIZATION, ONE THIRD ON QUALITY MEASURES, AND ONE THIRD ON PATIENT SATISFACTION SCORES. PART 1, LINE 6B: OFFICERS', AS LISTED ON PART VII OF FORM 990, CALCULATION OF PROFIT SHARING IS IN PART BASED ON THE CONSOLIDATED NET EARNINGS. LOUISIANA PUBLIC FACILITIES AUTHORITY 720895871 546395H80 2010-08-12 84137555 CAPITAL IMPROVEMENT RENOVATIONS PROJECT & REFUND OF 8/18/98 ISSUE 0 0 84137555 27900219 25123415 1527554 29586629 2011 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 LAFAYETTE INVESTMENT GROUP LLC SEE SCHEDULE O 562735 SEE SCHEDULE O 0 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC SEE SCHEDULE O 2596087 SEE SCHEDULE O 0 LAFAYETTE HEALTH VENTURES INC SEE SCHEDULE O 9687001 SEE SCHEDULE O 0 Form 990, Part VI, Section A, line 2 Trustees, Clay Allen and Robert Giles, are involved in a separate business venture together that is wholly unrelated to the organization. Form 990, Part VI, Section A, line 6 The organization is a non-stock not-for-profit corporation with one class of membership. Form 990, Part VI, Section A, line 7a The members ratify the selection of the individuals that serve on the Board of Trustees (Governing Body) after those individuals have been selected as a Trustee by the Board of Trustees. Form 990, Part VI, Section A, line 7b Yes, the individuals of the Trustees (Governing Body) and the members must be approved by the Membership body. Form 990, Part VI, Section B, line 11 The Form 990s are prepared and reviewed by the organizations accounting staff. The completed forms are reviewed by the officers and then presented to the Board for review, comment and corrections if needed before filing with the IRS. Form 990, Part VI, Section B, line 12c An annual survey is sent to the Board members and officers requiring them to disclose conflicts of interest. After receipt of these surveys, the Governance Committee and its Chairperson review all conflicts and report on same to the Governance Committee. Thereafter the Chairperson of the Governance Committee and the organization's General Council (who attends all Board meetings) insures that all conflicts are timely disclosed and appropriate recusals are made on business matters that may be related to the conflict. Form 990, Part VI, Section B, line 15 An independent external consultant firm, Sullivan Cotter and Associates, is engaged by the Compensation Committee of the Board of Trustees, which is comprised of Disinterested Directors, to prepare compensation survey and fair market value report. The Compensation Committee annually reviews the market comparables and makes adjustment the President/CEO's compensation thereafter. This same process is followed for the following Senior Executives of the Organization: Chief Operating Officer, Chief Financial Officer, Chief Nursing Officer and General Counsel. Form 990, Part VI, Section C, line 19 Basic financial information is made available and sent out to the community by means of the Organization's Annual Report. Other documents and more detailed financial information are available to the public upon request within the parameters of regulatory / legal authorities. SCH. L PART IV Lafayette Investment Group LLC (LIG) is a related organization of Lafayette General Medical Center Inc. Current trustees, Bradley J Chastant, MD and David Callecod, President/CEO serve on both boards. The group owns and operates a surgical hospital and medical office building. LGMC paid LIG building rent of $417,068 and loans of $142,117 to pay for construction related expenses Lafayette General Surgical Hospital LLC (LGSH) is a related organization of LGMC. Current trustee Bradley J Chastant, MD, David Callecod, President/CEO, and Patrick W Gandy Jr. COO serve on both boards. Former trustee WW Rucks III serves on the LGSH board. The surgical hospital operates a 10-licensed-bed acute care hospital specializing in short stay surgical procedures located in the LIG building. LGMC reimbursed LGSH for expenses of $1,141. LGSH paid LGMC $203,262 for an equipment loan, $937,500 in distributions, and $1,456,466 for expenses and services. Lafayette Health Ventures Inc (LHVI) is a related organization owned entirely by LGMC. Current trustees Joby John, Ph.D., Braden Despot, Rae Robinson and Gary Salmon and current officers David Callecod and Patrick Gandy Jr. serve on LHVI's board. Former trustee Irvin David served on the LHVI board. LHVI operates a collection agency, retail store for durable medical equipment, operates medical clinics, and employs physician practices. ST MARTIN HOSPITAL INC 210 CHAMPAGNE BLVD BREAUX BRIDGE LA 70517 264626264 HOSPITAL LA PENDING 501(C)(3) HOSPITAL N/A LAFAYETTE INVESTMENT GROUP 1000 W PINHOOK SUITE 206 LAFAYETTE LA 70503 421594593 MANAGEMENT LA N/A RELATED HEALTHCARE 90028 2403250 0 0 lafayette general surgical hospital llc 1000 W PINHOOK LAFAYETTE LA 70503 481300080 surgical hospital LA N/A RELATED HEALTHCARE 1079905 1371820 0 0 LAFAYETTE HEALTH VENTURES PO BOX 53092 LAFAYETTE LA 70505 721006966 SUPPORT SERVICES LA N/A C 15690314 11015947 1.00000 GREATER LAFAYETTE PHYSICIANS HOSPITAL ORG 117 AUDUBON BLVD LAFAYETTE LA 70503 721286969 SUPPORT SERVICES LA N/A C 1.00000 0 0 1 1 1 0 0 0 0 1 1 1 0 0 1 1 0 0 ST MARTIN HOSPITAL INC D 530000 ST MARTIN HOSPITAL INC O 162848 ST MARTIN HOSPITAL INC K 867540 LAFAYETTE INVESTMENT GROUP J 417068 LAFAYETTE INVESTMENT GROUP D 142117 LAFAYETTE INVESTMENT GROUP O 3550 ST MARTIN HOSPITAL INC E 699000 ST MARTIN HOSPITAL INC P 353227 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC O 1141 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC E 203262 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC P 1456466 LAFAYETTE GENERAL SURGICAL HOSPITAL LLC C 937500 LAFAYETTE HEALTH VENTURES INC O 20670805 LAFAYETTE HEALTH VENTURES INC L 700196 LAFAYETTE HEALTH VENTURES INC P 11684000