2011-05-16T10:34:10-05:00 2010-06-30 LarsonAllen LLP 101 N Tryon Street Suite 1000 Charlotte NC 28246 990 2009-07-01 560611546 Chatham Hospital Inc CHAT 9197994000 PO Box 649 Siler City NC 27344 Carol Straight 9197994000 2011-05-13 1 7049985200 2009 2016-02-24 21:20:13Z Carol Straight PO Box 649 Siler City NC 27344 29238100 0 X www.chathamhospital.org X 1939 NC Provides short-term medical care on an inpatient and outpatient basis. 15 7 305 40 1072431 57734 197305 487591 18764495 28499121 117907 140114 85727 111274 19165434 29238100 0 0 8029531 10630679 0 0 11340272 19956326 19369803 30587005 -204369 -1348905 44887818 50351188 38709406 36537635 6178412 13813553 To participate in and promote the provision of patient care, facilitate the education of physicians and other health care providers, promote research in collaboration with the health sciences schools of the university of north carolina at chapel hill, and facilitate and promote the delivery of other services designed to promote the health and well-being of the citizens of north carolina. 0 0 27401693 28499121 Chatham Hospital is a 25 bed critical access hospital and is part of UNC Health Care System. The Hospital has a 70 year history of providing quality health services. The hospital provides comprehensive care, including emergency, general surgery, lab, CT, MRI, nuclear medicine, pharmacy, cardio-pulmonary and intensive care on its campus. The Hospital reaches beyond the hospital setting to provide diabetes education, physical therapy, and cardiac rehabilitation in temporary leased space located in Siler City near the main hospital campus. The year ended June 30, 2010 continued to be a time of transition. There were changes in personnel, the start of construction on a medical office building, and an information system implementation that carries on into subsequent years. The hospital continued its focus on quality measures from the year before which resulted in significant improvements. During 2010 Chatham had 3,017 patient days and an average length of stay of 3.7 days. There were 815 discharges and 369 inpatient and outpatient surgeries as well as 528 endoscopic procedures. There were 13,877 emergency room visits. 27401693 1 1 0 0 0 0 0 0 0 1 1 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 0 0 0 1 14 0 305 1 1 1 0 0 0 0 0 0 0 0 15 7 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X Bob Blackwell 9197994000 PO Box 649 Siler City NC 27344 X Laura Clapp 1.00 X 0 0 0 Barry Wilkie 1.00 X 0 0 0 Mary Beck 1.00 X 0 244678 48297 Warren Newton MD 1.00 X 0 0 0 Barry Hayes 1.00 X 0 0 0 Mel Hurston 1.00 X 0 208660 76683 Charles Johnson 1.00 X 0 0 0 John Lewis 1.00 X 0 387639 71727 Todd Peterson 1.00 X 0 436719 99826 magaraet pollard 1.00 X 0 0 0 gabriel soltren 1.00 X 0 0 0 tim weiner md 1.00 X 0 0 0 mark zeringue md 1.00 X 0 0 0 mark gwynne do 1.00 X 0 0 0 Carl thompson 1.00 X 0 0 0 carol straight 40.00 X X 0 167587 45836 leslie gura 40.00 X 0 98114 0 Bob Blackwell 40.00 X 0 164249 30105 Rebecca W Quate 40.00 X 106244 0 9086 Donna B Sessoms 40.00 X 100136 0 8661 206380 1707646 390221 2 0 1 0 Rodgers Builders PO Box 18446 Charlotte NC 28218 Construction 991531 Labcorp 458 S Main Burlington NC 27215 Laboratory 384185 Alliance Imaging PO Box 96485 Chicago NC 60693 medical equipment 181300 Chatham Anesthesia 209 Glenhaven Drive Chapel Hill NC 27516 Medical Services 166666 Mcneary 6525 Morrison Blvd Charlotte NC 28211 medical equipment 106779 5 487591 487591 patient revenue 621110 27751843 26679412 1072431 747278 747278 28499121 140114 140114 69205 69205 69205 69205 42069 42069 42069 29238100 27426690 1072431 251388 331837 331837 8231044 7271976 959068 93063 82219 10844 1285349 1135582 149767 689386 609060 80326 158000 158000 49721 49721 89291 89291 4261465 3444682 816783 44665 44665 1836652 1634864 201788 1938088 1938088 46543 34953 11590 6139 6139 2084101 2084101 389119 389119 bad debt expense 8601164 8601164 Food 119518 119518 331860 50228 281632 30587005 27401693 3185312 0 1000 1000 2119363 2718595 220190 133190 5214815 5795452 361467 408101 209796 77617 33768167 7769144 26346238 25999023 8475961 12629686 1938988 2588524 44887818 50351188 4614799 3633399 32033797 30905236 13421 2047389 1999000 38709406 36537635 X 5751432 13205277 426980 608276 6178412 13813553 44887818 50351188 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 444983 444983 26975248 7534466 19440782 6347936 234678 6113258 25999023 investments 2564155 F restricted assets 10065531 F 12629686 Deferred Financing Costs 1113134 Estimated Third-Party Payer Settlements 1442337 Siler City Country Club Bond 2375 RRG Consortium 30678 2588524 Note Payable to related entity 1999000 1999000 29238100 30587005 -1348905 8984046 8984046 7635141 29620982 382882 382882 29238100 0 29238100 21985841 0 21985841 8601164 8601164 30587005 Part XI, Line 8 - Other Adjustments: capital contributed from sole member: 8984046. Part XII, Line 2d - Other Adjustments: capital contributed from sole member: 8984046. bad debt expense: -8601164. Part XIII, Line 4b - Other Adjustments: bad debt expense: 8601164. 1 1 1 X 250.000000000000 0 0 1 0 1 1 111827 111827 0.00510 2634539 2201671 432868 0.01970 2746366 2201671 544695 0.02480 19 2000 2000 0.00010 10 1000 1000 0.00000 1 200 200 0.00000 30 3200 3200 0.00010 30 2749566 2201671 547895 0.02490 1 6445 6445 0.00030 1 1000 1000 0.00000 1 1200 1200 0.00010 3 8645 8645 0.00040 1 4300582 2150291 5981687 6594519 -612832 X 1 1 chatham hospital

475 progress blvd siler city NC 27344

X X X X chatham hospital off site clinic

128 village lake rd siler city NC 27344

Cardiac Rehabilitation, Diabetes Education, PT/OT Part I, Line 3c: Persons who have no health insurance coverage or who obtain services not covered by their health insurance will be eligible for a 35% discount of their Chatham Hospital charges, except for Category 3 services in the Financial Assistance Exceptions Table (Appendix A). This discount will be given regardless of income or North Carolina residency. Part III, Line 4: Specific patient balances are written off at the time they are determined to be uncollectible. Part III, Line 8: As a Critical Access Hospital, the difference between revenue received from Medicare and the Medicare Allowable Cost is the amount due from the patients in the form of co-payments, co-insurance and deductibles. The patient amounts that are not collected end up as bad debts which are partially recoverable on future cost reports. Part III, Line 9b: Policy does contain provisions on the collection practices to be followed for patients who are known to qualify for charity care Part VI, Line 2: Less than 20% of our countys residents live in incorporated towns. The county has about 85 residents per square mile, which reflects its generally rural nature. a critical access hospital is essential for a rural community such as this.Chatham Hospital addresses the community's emergency health needs by providing around-the-clock emergency services to more than 1,000 patients each month. Our 5,500-square foot emergency room is newly renovated and equipped with the advanced diagnostic and monitoring equipment required to deliver excellent care.Chatham hospital strives to improve emergency care for kids by increasing medication safety. Also, the hospital has a diabetes self-management program for individuals with diabetes within the community. Part VI, Line 3: patient financial services is available to patients who wish to discuss payment options. Part VI, Line 4: Population Information: The official 2010 Census places our 2010 population at 63,505, an increase of 28.74% since 2000. The state average growth for this decade was 18.5%. Less than 20% of our county's residents live in incorporated towns. The county has about 85 residents per square mile, which reflects its generally rural nature. Ethnic/Racial Diversity: The overall, racial/ethnic composition of Chatham County is: 71% white, 13% African American, 12% Hispanic, 2% Asian and 2% other.Age: The 2009 estimated median age for Chatham County residents is 42, up from 38.7 in 2007 and above the state average. The greatest percentage of our population (54%) is in the range of 20 to 60 years old, and 21.9% are age 60 or older. Income and Poverty: The estimated median household income for Chatham County in 2008 was $46,574, a significant drop from $51,794 in 2007, but still ranks us 8th in the state Per capita income for 2008 was $43,894, which ranks third out of the 100 counties. The percentage of individuals living in poverty in 2008 was estimated at 10.3%, lower than the state average of 14.6%, but still significant. This points out the challenges of a county with residents at extreme ends of the income spectrum. Part VI, Line 5: Chatham hospital strives to improve emergency care for kids by increasing medication safety. Also, the hospital has a diabetes self-management program for individuals with diabetes within the community. Part VI, Line 6: Chatham Hospital and UNC Health Care are partnering to bring nationally-recognized health care to Chatham County. Our partnership means you'll continue to have access to advanced health care close to home, with the personal touch you've come to expect from us. NC X X 0 0 0 0 0 0 0 0 0 Mary Beck 0 225253 0 15304 0 4121 0 23633 0 24664 0 292975 0 0 Mel Hurston 0 193373 0 13138 0 2149 0 54891 0 21792 0 285343 0 0 John Lewis 0 386640 0 0 0 999 0 47583 0 24144 0 459366 0 0 Todd Peterson 0 401094 0 27250 0 8375 0 65478 0 34348 0 536545 0 0 carol straight 0 149249 0 10140 0 8198 0 28019 0 17817 0 213423 0 0 Bob Blackwell 0 152637 0 9971 0 1641 0 11828 0 18277 0 194354 0 0 North Carolina Medical Care Commission 521309402 657905ES0 2007-02-08 30540000 FHA Insured Mortgage Revenue Bonds 0 0 30540000 639326 1370283 29976186 2008 0 0 1 1 0 0 0 0 1 1 Form 990, Part VI, Section A, line 4 Effective August 1, 2006, the hospital entered into a five-year contract with UNCH to provide a CEO and a CFO to manage the day-to-day operations of the hospital. In addition to the salaries of the ceo and cfo, the hospital paid unch a management fee of $150,000 for the first-year term of the contract. this fee will increase each subsequent year by a percentage equal to the increase in the consumer price index as published by the bureau of labor statistics. Form 990, Part VI, Section A, line 6 See response to question 7a. Form 990, Part VI, Section A, line 7a In addition to such powers and rights as are vested in it by law, the amended and restated articles of incorporation of the corporation or the amended and restated bylaws, the member ("unchcs") shall have the following powers: (a) the power to appoint the chairman of the board, vice chairman, president, executive vice presidents, secretary/treasurer and other corporate officers of the corporation; (b) the power to appoint individual members of the corporation's board of trustees; (c) the power to establish and maintain quality, service delivery, and financial standards to be observed by all members of unchcs, including the corporation; (d) the power to establish a schedule of cost-based assessments payable by provider components of unchcs for the support of that portion of its operating budget attributable to unchcs-wide administration and initiatives and reflecting operating entity performance; (e) the power to negotiate, develop, and approve all managed care products and contracts for the corporation; (f) the power to approve (i) the corporation's name, (ii) capital and operating budgets of the corporation, and (iii) non-budgeted material expenditures of the corporation (as "material" is established by the member from time to time), provided that only the board of trustees shall have the authority to initiate a change in the name of the corporation of the hospital, which shall be subject to final approval by unchcs; and (g) other powers mutually agreed to by unchcs and the corporation. Form 990, Part VI, Section A, line 7b See response to question 7a. Form 990, Part VI, Section B, line 11 Form 990, Part VI, Section A,line 10: The form 990 was reviewed prior to filing by the president and cfo of the hospital. In addition, it was made available to every member of the governing body before it was filed with the IRS. Form 990, Part VI, Section B, line 12c The conflict of interest statements are completed by the board members annually to be reviewed by the hospital president. the chatham hospital conflict of interest policy outlines the process to be followed in determining the existence of a potential conflict, and how to address the situation when decisions face a fha insured mortgage revenue bonds. Form 990, Part VI, Section B, line 15 Effective August 1, 2006, the hospital enetered into a five-year contract with unch to provide a CEO and a CFO to manage the day-to-day operations of the hospital. the president of chatham hospital reports monthly to the president of unc hospitals, discussing surveys of compensation data and planned ranges of salary offers for employees of chatham. Target levels are based on level of education and experience. with input from the management of unc hospitals, the president of chatham hospital makes the final decision on salaries, with the exception of his/her own, which is set by the president of unch with input from the unc hospitals management team. Form 990, Part VI, Section C, line 19 Photocopies of the form 1023 and recent copies of the form 990 are available upon request at the organization's administrative office. in additon, recent copies of form 990 are available online at www.guidestar.org. form 990, part xi, line 2c: This process has not changed from the prior year. University of North Carolina Healthcare System 211 Friday Center Drive Chapel Hill NC 27517 562206970 Healthcare NC 501(c)(3) Rex Hospital Inc 4420 Lake Boone Trail Raleigh NC 27607 561509260 Healthcare NC 501(c)(3) University of North Carolina Hospitals 101 Manning Drive Chapel Hill NC 27514 561118388 Healthcare NC 501(c)(3) Rex Healthcare Inc 4420 Lake Boone Trail Raleigh NC 27607 561509129 healthcare NC 501(c)(3) Rex Healthcare Foundation Inc 4420 Lake Boone Trail Raleigh NC 27607 566052117 HEalthcare NC 501(c)(3) Rex Home Services Inc 4420 Lake Boone Trail Raleigh NC 27607 561636242 Healthcare NC 501(c)(3) Triangle Physician Network 211 Friday Center Drive Chapel Hill NC 27517 271081647 Healthcare NC 501(c)(3) UNC Department of Family Medicine 590 Manning Drive Chapel Hill NC 27599 566001393 Healthcare NC 501(c)(3) Rex Enterprises Company Inc 4420 Lake Boone Trail Raleigh NC 27607 Holding Company NC C 0 0 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 0 University of North Carolina Hospitals L 124498 Triangle Physician Network L 1433775 University of North Carolina Healthcare System C 8984046