2011-08-14T20:17:16-05:00 2010-09-30 Pershing Yoakley & Associates P C One Cherokee Mills 2220 Sutherland Knoxville TN 379192363 990 2009-10-01 582149127 CENTRAL GEORGIA HEALTH SYSTEMS INC CENT 4786331407 691 CHERRY STREET SUITE 400 MACON GA 31201 RHONDA S PERRY 4786331407 2011-08-14 1 8656730844 2009 2016-02-24 21:20:13Z A Donald Faulk Jr 691 CHERRY STREET SUITE 400 MACON GA 31201 37603668 0 X WWW.MCCG.ORG X 1994 GA CENTRAL GEORGIA HEALTH SYSTEMS, INC. IS A NONPROFIT CORPORATION WHOSE PRIMARY PURPOSE IS TO SERVE AS A PARENT CORPORATION PROVIDing STRATEGIC DIRECTION TO THE MEDICAL CENTER OF CENTRAL GEORGIA, INC. AND OTHER AFFILIATES IN SUPPORT of THEIR MISSION OF PROVIDING A COMPREHENSIVE RANGE OF HIGH-QUALITY, REASONABLY PRICED HEALTH CARE SERVICES TO THE CENTRAL GEORGIA COMMUNITY. 7 5 401 0 152943 0 0 19203601 30313999 4654901 5709690 11335186 -2442689 35193688 33581000 1072605 10500221 0 10737352 23670135 0 0 5792383 7848863 17602340 42019219 17591348 -8438219 45664176 39722867 616807 1166997 45047369 38555870 CENTRAL GEORGIA HEALTH SYSTEMS, INC. (CGHS) PRIMARY PURPOSE IS TO SERVE AS A CONTROLLING BODY FOR THE MEDICAL CENTER OF CENTRAL GEORGIA, INC., HEALTH SERVICES OF CENTRAL GEORGIA, INC., CENTRAL GEORGIA SENIOR HEALTH, INC. AND MEDCEN COMMUNITY HEALTH FOUNDATION, INC. AND OTHER AFFILIATED ENTITIES IN SUPPORT OF THEIR MISSION TO PROVIDE HEALTHCARE SERVICES IN CENTRAL GEORGIA. 0 0 20038261 10500221 13568549 Central Georgia Health Systems, Inc. ("CGHS") primary purpose is to serve as a controlling body for The Medical Center of Central Georgia, Inc., Health Services of Central Georgia, Inc., Central Georgia Senior Health, Inc. and Medcen Community Health Foundation, Inc. and other affiliated entities and to provide strategic direction, financial management, resource allocation and other support to its Affiliates in the provision of healthcare services to the Central Georgia community. 12466842 27091992 Central Georgia Health Systems, Inc. operates Central Georgia Rehabilitation Hospital, LLC, the first rehabilitation facility established in central Georgia and one of two free-standing rehabilitation hospitals in the State. The Rehabilitation Hospital provides comprehensive physical rehabilitation services on an inpatient and outpatient basis. It is licensed for 58 beds and opened in September 1988. 32505103 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 401 1 1 1 1 CJ 0 0 0 0 0 0 0 7 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 GA X RHONDA S PERRY 4786331452 777 Hemlock Street mACON GA 31201 Connie Cater 1.00 X 0 0 0 JAMES TIMOTHY JACKSON 1.00 X 0 0 0 KIM W JOHNSTON MD 1.00 X X 0 0 0 RUTH KNOX 1.00 X 0 0 0 STARR PURDUE 1.00 X 0 0 0 HENRY KOPLIN 1.00 X 0 0 0 Joan Walton 1.00 X 0 0 0 A DONALD FAULK JR 40.00 X 722579 0 61910 KENNETH b BANKS 40.00 X 316434 0 31398 RHONDA S PERRY 40.00 X 411183 0 27511 ELBERT T MCQUEEN 20.00 X 216631 0 24415 Hubert Epps Jr 40.00 X 119963 0 25833 Roger Bloodworth 40.00 X 115357 0 31740 Judy K Ware 20.00 X 108054 0 13030 Darren Pearce 40.00 X 100198 0 8545 2110399 0 224382 8 0 1 0 Kaufman Hall 5202 Old Orchard Road Ste N700 Skokie IL 30077 Consulting Services 319000 Sunbelt Staffing PO Box 1024640 Atlanta GA 303684640 Temporary Staffing Svcs 182382 SunTrust Bank Inc PO Box 4655 Atlanta GA 232616489 Investment Management Svcs 144389 Munder Capital 480 Pierce Street Birmingham MI 48009 Investment Management Svcs 126426 Davita 5200 Virginia Way Brentwood TN 37024 Dialysis Services 112986 7 Medicare/Medicaid Reve 621990 14490879 14490879 SUPPORT REVENUE 541200 13848612 13695669 152943 PATIENT REVENUE 621990 1767605 1767605 Rebate Revenue 621990 157015 157015 Cafeteria Sales 621990 35396 35396 14492 14492 30313999 9732358 9732358 4022668 -4022668 -4022668 -4022668 Other Invest Inc -1140453 60542 -1200995 net Invest (988 Int) -1302236 -1302236 -2442689 33581000 30221598 152943 3206459 10500221 10500221 2153453 1446986 706467 17153967 11488339 5665628 565006 402416 162590 2471780 1801041 670739 1325929 928248 397681 400601 212319 188282 132755 70360 62395 5735 5735 639549 639549 1773797 1537349 236448 49474 49474 1150883 1064114 86769 13980 7433 6547 441144 333753 107391 199327 136387 62940 190 74 116 98860 73033 25827 176229 153278 22951 UBI Tax Refund -43956 -43956 equipment rental & main 1710494 1575004 135490 DUES AND SUBSCRIPTIONS 369152 181222 187930 Expendable Project Cost 235090 235090 TAXES AND LICENSES 166973 78745 88228 328586 230217 98369 42019219 32505103 9514116 0 6929219 1030485 1856035 2031261 93017 93934 107002 668718 1933216 1469749 459728 463467 35672868 26362402 546307 9072600 45664176 39722867 328231 1166997 288576 0 616807 1166997 X 45047369 38555870 45047369 38555870 45664176 39722867 X 0 1 1 X 0 X X X 0 0 0 Medical Center of Central Georgia 582149128 7 1 1 1 10399364 1 10399364 0 1 0 0 0 1 5000 0 0 1 735 5735 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Lobbying expenses Included in the Dues paid to various organizations and mileage/parking expenses for officer to attend Trauma Day at the Capital. 1933216 1469749 463467 463467 Investments in Subsidiaries 23318784 C Investment in Secure Health Plan of Central gA 1484997 C Investment in American Eagle 1558621 C 26362402 Receivable-Centra Professional Indemnity 272439 Miscellaneous Receivable 187 Third Party Medicare Settlement 278987 Due from Affiliates 8520987 9072600 Part X: Description of Uncertain Tax Positions Under FIN 48: CGHS and its affiliates have evaluated their tax positions and have determined that they do not have any material unrecognized tax benefits or obligations as of September 30, 2010. 1 1 1 X 125.000000000000 1 X 1 1 1 0 1 1 568468 568468 0.01360 80793 80793 0.00190 649261 649261 0.01550 649261 649261 0.01550 125780 0 0 1 1 Central GA Rehabilitation Hospital Inc

3351 Northside Drive Macon GA 31210

X Rehabilitation Part I, Line 3c: Total gross income for the previous three months will be used to determine annual income. Patient classifications will be determined in accordance with the MCCG sliding scale for indigent/charity patients. This scale has been adopted by CGRH and was based on the most recently published Federal Poverty Guidelines. Part I, Line 6a: The community benefit information for Central Georgia Rehabiliation Hospital, Inc. is included in the Medical Center of Central Georgia's annual report to the community. Part I, Line 7: The costing methodology used in determining the amount reported on line 7 is the cost to charge ratio calculated pursuant to The IRS Form 990 Schedule H worksheet 2 instructions. Part I, Line 7f: Bad debt expense in the amount of $96,427 has been removed from total expense. Part III, Line 4: The costing methodology used in determining the cost of bad debt expense is the cost to charge ratio calculated pursuant to The IRS Form 990 Schedule H worksheet 2 instructions. Part III, Line 9b: Once a patient is determined to qualify for charity care, it is noted in the patient's financial chart and any collection efforts cease. The controller of the organization reviews the finacial activity on other accounts to determine if the account should be turned over to outside collections. If a patient account turned over to collections is later determined to qualify as charity care, the account is brought back from collections and the account written off. Part VI, Line 2: We have not yet performed a community health assessment. We do work with Community Health Works (a regional health promotion organization) to improve the health in the region. Currently, the regional emphasis is on diabetes and obesity with community meetings to find ways to make actual improvements in our citizen's health. Part VI, Line 3: Patients will be informed of available assistance by the following method: The CGRH Business Office Liaison or designated Patient Account Representative (PAR) will interview patients who have little or no third party coverage and will request documents to support their need via a Financial Disclosure Form. The Financial Disclosure Form will ascertain monthly bills and assets in the determination of patient ability to pay. Part VI, Line 4: The primary service area is Bibb, Crawford, Houston, Jones, Monroe, Peach and Twiggs Counties. There are twenty-one counties in the secondary service area. The current population in the primary service area is 406,725 and the secondary service area has a population of 389,460. Part VI, Line 6: The organization is part of a multi entity hospital system that provides medical services to the community. The organization has a board comprised of members of the community. Any surplus funds are used for program services. Part VI, Line 7: The organization is part of Central Georgia Health Systems, Inc., a multi-entity healthcare system. Other organizations in the system include:Medical Center of Central Georgia, Inc. - A 637 bed hospital facility that is designated as a Level 1 Trauma Center and magnet hospital for nursing.Health Services of Central Georgia, Inc. - Provides faculty physicians to the residency training programs of the Medical Center of Central Georgia as well as other physicians, nurse practitioners, and physician assistants.Central Georgia Senior Health, Inc. - A continuing care retirement community (CCRC) offering independent living, assisted living, memory support and skilled nursing.Medcen Foundation, Inc. - provides fundraising and support for Central Georgia Health Systems, Inc. and its affiliates. GA 1 Grand Opera House 400 Poplar Street Macon GA 31201 580566167 501c3 6000 Kids Theatre Education Susan G Komen Breast Cancer Inc 248 Tom Hill Sr Blvd Macon GA 31210 752881536 501c3 25000 Race for the Cure -Breast Cancer Awareness MEDICAL CENTER OF CENTRAL GA 691 Cherry Street Macon GA 31201 582149128 501c3 10399364 Intercompany 3 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: CGHS requires all organizations that receive sponsorships to present their 501c(3) letter as proof of their Non Profit status. X X X X X 0 0 0 0 0 0 0 1 0 A DONALD FAULK JR 605874 0 0 0 116705 0 51620 0 10290 0 784489 0 0 0 KENNETH b BANKS 244306 0 0 0 72128 0 18063 0 13335 0 347832 0 0 0 RHONDA S PERRY 364579 0 3000 0 43604 0 22829 0 4682 0 438694 0 0 0 ELBERT T MCQUEEN 180038 0 0 0 36593 0 15764 0 8651 0 241046 0 0 0 Part I, Line 7 This program is administered by the CEO. A budget for the program is established for reward and recognition of executives and organizational leaders who go above and beyond the scope of their responsibilities. For example, they may complete a project, lead an organizational initiative, or excel in an area that represents excellence under one of our organizational pillars - Quality, Service Excellence, Our People, Growth, Financial Performance. Near the end of the fiscal year, nominations are solicited from the leadership team. A proposed for allocation of the award is developed and presented to the HR Committee of the Board for review, discussion, and approval (prior to distribution). Form 990, Part VI, Section B, line 11 The form 990 was prepared by an independent certified public accountant from information provided by management and from audited financial statements (prepared by another independent accountant). It is reviewed by Central Georgia Health System, Inc.'s financial management. A copy of the form 990 was provided to each board member prior to filing the return with the internal revenue service. Form 990, Part VI, Section B, line 12c The department of Audit and Compliance issues COI disclosure forms annually to our board members, administration and directors. Audit and Compliance receives, reviews and documents all potential conflicts (perceived and real.) The results are taken to the Compliance Committee where the real conflicts of interest are discussed and a plan for corrective action is developed. The corrective action recommendations are take to the various boards and administration for implementation. Any time a change in a relationship or new potential conflict evolves, the individual must amend their COI disclosure form. Form 990, Part VI, Section B, line 15 The Compensation Committee of the Board of Directors engages an executive consulting firm every 2-3 years to review and provide recommendations regarding total compensation and benefits for the executive leadership team. Base compensation, incentive compensation, and benefits are included in the review. The executive consultants review organization structure, individual job descriptions, and discuss scope of leadership and span of control with HR, the COO, and the CEO as a part of the process to determine proper placement of the pay grade and level of participation in incentive and benefits programs. The Compensation Committee periodically reaffirms the total compensation philosophy which currently targets the 75th percentile of total compensation for our leadership team. The peer group used is national hospitals and health systems of similar size and scope. Key Employees and others outside of the Executive Leadership Team have compensation set by HR guidelines and/or market compensation studies. Form 990, Part VI, Section C, line 19 CGHS provides copies of its governing and other corporate documents upon request. Central GA Rehab Hospital LLC 691 cherry street Macon GA 31201 300371539 Rehabilitation Services GA 16313000 11534000 N/A Central Georgia Medical Properties LLC 777 Hemlock St MSC 111 Macon GA 31201 Physician Relationships GA 0 0 N/A Central Georgia Senior Health Inc 691 Cherry Street Suite 400 Macon GA 31201 582345439 Retirement Community GA 501c(3) 11 N/A Health Services of Central Georgia Inc 691 Cherry Street Suite 400 macon GA 31201 582307485 Health Care Provider GA 501c(3) 3 N/A Medcen Community Health Foundation Inc 858 High Street macon GA 31201 237363555 Fundraising GA 501c(3) 7 N/A Medical Center of Central Georgia Inc 691 Cherry Street Suite 400 macon GA 31201 582149128 Hospital GA 501c(3) 3 N/A Central Georgia PET LLC 1650 Hardeman Avenue macon GA 31201 311464470 Medical Imaging Center GA Medical Center of Central Georgia Inc Related 0 0 Secure Health Plans of Georgia Inc 3920 Arkwright Road Suite 400 macon GA 31208 582306549 Managed Care GA N/A related 2879606 3091442 0 0 Central Georgia Health Ventures Inc 691 Cherry Street macon GA 31201 582164989 Management GA N/A C 2037225 5588258 1.00000 Central Georgia Home Care Services Inc 691 Cherry Street macon GA 31201 582457422 Medical Equipment Sales GA CGHV C -5512 2049456 1.00000 Centra Indemnity LTD PO Box 1363 Grand Cayman Grand Cayman CJ Insurance CJ CGHS -18696 1.00000 Centra Professional Indemnity LTD pO Box 1363 grand Cayman grand Cayman CJ insurance CJ CGHS 11018079 97286461 1.00000 American Eagle Insurance Co RRG 40 Main Street Suite 500 Burlington VT 05401 161645557 Risk Management VT N/A C 0.95000 0 0 1 1 1 0 0 0 0 1 0 0 1 1 1 1 1 1 Medical Center of Central Georgia O 25747009 medical Center of Central Georgia B 10399364 medical Center of Central Georgia J 1300000 medical Center of Central Georgia P 58026 Central Georgia Health Ventures Inc R 1300000 Central Georgia Home Care Services Inc P 132888 Centra Professional Indemnity R 10000000 Medical Center of Central Georgia P 17104089 Centra Professional Indemnity R 12116126 medical Center of Central Georgia R 9384548 centra Professional Indemnity Q 9384548 Central Georgia Senior Health Inc R 171773 Centra Professional Indemnity Q 171773 health Services of Central Georgia Inc R 968806 Centra Professional Indemnity Q 968806 Central Georgia Rehabilitation Services R 129823 Centra Professional Indemnity Q 129823 Medical Center of Central Georgia J 57756 Central Georgia PET LLC I 57756 medical Center of Central Georgia Q 1158400 Central Georgia PET LLC R 1158400 Medical Center of Central Georgia O 386223 central georgia pET LLC P 386223 Medical Center of Central Georgia R 148519 secure Health Q 148519 centra Professional Indemnity P 953134 Medical Center of Central Georgia O 953134 Health Services of Central Georgia Inc P 11228895 medical Center of Central Georgia O 11228895 Health Services of Central Georgia Inc P 448245 Medical Center of Central Georgia O 448245 Health Services of Central Georgia Inc O 22602564 Medical Center of Central Georgia P 22602564 Medical Center of Central Georgia C 11373669 health Services of Central Georgia Inc B 11373669 medical Center of Central Georgia J 448846 Health Services of Central Georgia Inc I 448846 Medcen Foundation Inc P 1816043 medical Center of Central Georgia O 1816043 medcen Foundation Inc I 53871 Medical Center of Central Georgia J 53871 medcen Foundation Inc B 1869914 medical Center of Central Georgia C 1869914 Central Georgia Senior Health Inc O 1164892 Medical Center of Central Georgia P 1164892 Central Georgia Senior Health Inc P 1459769 medical Center of Central Georgia O 1459769 Central Georgia Health Ventures Inc P 155773 Medical Center of Central Georgia O 155773 Central Georgia Health Ventures Inc O 202677 medical Center of Central Georgia P 202677 Central Georgia Home Care Services Inc P 2744937 medical Center of Central Georgia O 2744937 Medical Center of Central Georgia J 59196 Central Georgia Home Care Services Inc I 59196 Central Georgia Home Care Services Inc N 180000 Medical Center of Central Georgia N 180000 Central Georgia Home Care Services Inc O 2791850 medical Center of Central Georgia P 2791850