2011-05-02T08:26:54-05:00 2010-06-30 HORNE LLP 1020 Highland Colony Pkwy Ste 400 Ridgeland MS 39157 990 2009-07-01 621046595 NORTHCREST MEDICAL CENTER NORT 6153841711 100 NORTHCREST MEDICAL CENTER SPRINGFIELD TN 371723961 JAMES F SCHMIDT 6153841711 2011-04-25 1 MARSHA H DIECKMAN CPA 6013261000 2011-04-25 2009 2016-02-24 21:20:13Z JAMES F SCHMIDT 100 NORTHCREST MEDICAL CENTER SPRINGFIELD TN 371723961 75972036 0 X www.northcrest.com X 1987 TN OPERATION OF A NONPROFIT 109-BED ACUTE CARE FACILITY IN SPRINGFIELD, TENNESSEE 13 12 807 62 0 0 592725 453302 71696914 74109475 506512 249254 1694959 1114012 74491110 75926043 170010 237184 0 28595166 29668820 0 0 44592059 44329455 73357235 74235459 1133875 1690584 77868082 78506202 55996056 58893212 21872026 19612990 NORTHCREST MEDICAL CENTER IS A TENNESSEE NONPROFIT CORPORATION THAT OPERATES A 109-BED GENERAL ACUTE CARE FACILITY. THE HOSPITAL PROVIDES A FULL RANGE OF MEDICAL SERVICES TO BOTH INPATIENTS AND OUTPATIENTS IN AND AROUND THE SPRINGFIELD, TENNESSEE AREA. 0 0 69654525 157982 74467585 IN ADDITION TO HEALTH CARE SERVICES, NORTHCREST MEDICAL CENTER SPONSORS MONTHLY SUPPORT GROUPS FOR GRIEF, CANCER AND DIABETES EDUCATION, HOSTS PRENATAL CLASSES, PUBLISHES A QUARTERLY NEWSLETTER, AND PROVIDES STROKE AND PROSTATE CANCER SCREENINGS ALONG WITH FREE BLOOD PRESSURE CHECKS. NORTHCREST MEDICAL CENTER ALSO CONDUCTS SEMINARS ON EXERCISE, NUTRITION, WEIGHT LOSS, ARTHRITIS, AND SODIUM PROTECTION. 69654525 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 1 116 0 1 807 1 0 0 0 0 0 0 0 0 0 13 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X JAMES SCHMIDT 6153841503 100 NORTHCREST DRIVE SPRINGFIELD TN 37172 TED STUBBLEFIELD 1.00 X 3000 0 0 DAVID BELLAR 1.00 X 3000 0 0 JAMES G BOWENS 1.00 X 3000 0 0 HOWARD BRADLEY 1.00 X 3000 0 0 TOMMY CRUNK MD 1.00 X 3000 0 0 DR GERALDINE FARMER 1.00 X 3000 0 0 ALVIN FOWLER 1.00 X 3000 0 0 AMY GALLAGHER 1.00 X 3000 0 0 SARBJETT KUMAR 1.00 X 3000 0 0 E DEE REID 1.00 X 3000 0 0 TRACY LANGSTON 1.00 X 3000 0 0 DAN GREEN 1.00 X 3000 0 0 WILLIAM GRACEY 1.00 X 500 0 0 SCOTT RAYNES 40.00 X 359933 0 44084 JIM SCHMIDT 40.00 X 202619 0 23640 RANDY MILLS 40.00 X 195355 0 13874 RANDY DAVIS 40.00 X 135013 0 21756 AMBER KING 40.00 X 82298 0 17965 SHARON JEHLE 40.00 X 210561 0 13867 TRACY BARKER 40.00 X 111736 0 14270 ANGELA BEARD 40.00 X 113306 0 14107 ALFRED BOYTER 40.00 X 104777 0 10050 JOAN CHATHAM 40.00 X 102795 0 5780 MIKE TINAL 40.00 X 104956 0 8905 1759849 0 188298 10 0 1 0 FAVORITE HEALTHCARE STAFFING INC PO BOX 803356 KANSAS CITY MO 64180 NURSE STAFFING 210958 MEDICAL MANAGEMENT RESOURCES OF TEAMHEAL 9485 REGENCY SQ BLVD STE 200 JACKSONVILLE FL 32225 CODING ER CHARTS 150390 OPTIMA HEALTHCARE CONSULTING 3007 OAK CREEK DR N CLEARWATER FL 33761 HEALTHCARE CONSULTING CONTRACT 107032 JJCA-JOHNSON JOHNSON CRABTREE 4551 TROUSDALE DRIVE NASHVILLE TN 37204 ARCHITECTS 106286 NRS LLC 405 DUKE DRIVE SUITE 210 FRANKLIN TN 37067 NURSE STAFFING 101376 5 28349 21620 403333 453302 HEALTHCARE REVENUE 621990 74109475 74109475 74109475 290947 290947 714209 714209 714209 714209 4300 45993 -41693 -41693 -41693 CAFETERIA SALES 722210 280923 280923 MISCELLANEOUS 623990 100376 100376 VENDING MACHINES 623990 16334 16334 2170 2170 399803 75926043 74467585 0 1005156 237184 237184 1357465 699204 658261 23881085 23089918 791167 2411123 2332699 78424 2019147 1939984 79163 303271 301301 1970 314521 120790 193731 1152177 1150535 1642 126171 95205 30966 2334841 2326981 7860 4956353 4956353 4257787 3597592 660195 SUPPLIES 10718596 10707001 11595 BAD DEBT EXPENSE 10200329 10200329 EQUIPMENT RENTAL AND MA 4148373 4041992 106381 CONTRACT SERVICES 4093395 2387642 1705753 COLLECTION FEES 422645 422645 1300996 1047170 253826 74235459 69654525 4580934 0 2356260 1633297 13523223 18964934 7107374 7254181 1672914 1274400 1224944 1252975 720191 647377 76607515 43487114 35431127 33120401 6712627 3443452 9119422 10915185 77868082 78506202 4419069 3911440 42467839 41841573 9109148 13140199 55996056 58893212 X 21872026 19612990 21872026 19612990 77868082 78506202 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3059050 3059050 38166875 19030714 19136161 23980185 17408481 6571704 11401405 7047919 4353486 33120401 INVESTMENT IN STRATEGIC SERVICES 2764 UNAMORTIZED BOND ISSUE COSTS 391668 DUE FROM AFFILIATES 10033402 THIRD-PARTY SETTLEMENTS 392578 OTHER RECEIVABLES 94773 10915185 INVESTMENT IN PHYSICIAN SERVICES 8718814 INTEREST RATE SWAP AGREEMENT 4421385 13140199 Part X: Description of Uncertain Tax Positions Under FIN 48: In July 2006, the FASB issued Interpretation No. 48, Accounting for Uncertainty in Income Taxes an interpretation of FASB Statement No. 109, codified in FASB ASC Topic 740 ("ASC 740"). This standard clarifies the accounting for uncertainty in income taxes recognized in a company's financial statements and prescribes a recognition threshold and measurement attribute for tax positions taken or expected to be taken on a tax return including the entity's status as a tax-exempt not-for-profit entity. Additionally, ASC 740 provides guidance on derecognition, classification, interest and penalties, accounting in interim periods, disclosure and transition. The Hospital adopted this standard effective July 1, 2009. The Hospital had no significant uncertain tax positions at the date of adoption or at June 30, 2010. Accordingly, the adoption did not have a material effect on the Hospital's financial position or changes in net assets. If interest and penalties are incurred related to uncertain tax positions, such amounts would be recognized in income tax expense. Tax periods for all fiscal years after 2006 remain open to examination by the federal and state taxing jurisdictions to which the Hospital is subject. 1 1 1 X 0 1 1 1 0 0 1079709 1079709 0.01450 12019628 10238716 1780912 0.02400 13099337 10238716 2860621 0.03850 12773 12773 0.00020 161559 8415 153144 0.00210 174332 8415 165917 0.00230 13273669 10247131 3026538 0.04080 1 3213367 321337 18650111 23322049 -4671938 X 1 1 NORTHCREST MEDICAL CENTER INC

100 NORTHCREST DRIVE SPRINGFIELD TN 37186

X X X Part I, Line 3c: Free care ("charity care") is provided based on 200% of FPG. Care is discounted based on similar criteria from insurance arrangements with providers. FPG is not used when determining the discounted care amount. Part I, Line 7: The costing method used was derived from Worksheet 2. Part III, Line 4: The cost of bad debt was calculated using the cost to charge ratio from worksheet 2. The amount of bad debt that could reasonably be attributable to patients qualifying for charity care is estimated at 10% based on the percent of self-pay projected to the total. Patient accounts receivable are reported at estimated net realizable amounts for services rendered collectible from federal and state agencies, managed health plans, commercial insurance companies, workers' compensation, employers and patients. The hospital manages the receivables by regularly reviewing its accounts and contracts and by providing appropriate allowances for uncollectible amounts. Receivables are generally uncollateralized, but credit risk relating to accounts receivable is limited to some extent by the diversity and number of patients and payors. Late fees and interest charges, if any, are recognized when received. Part III, Line 8: Medicare allowable costs were taken from the hospital's cost report. Part III, Line 9b: There are no collection efforts taken on the patients that qualify for charity care. Their accounts are written off so no money is owed and no charges are recorded as income. Part V: We have diagnostic centers in Pleasant View, TN and White House, TN. Part VI, Line 2: NorthCrest Medical Center is always looking for better ways to serve its community. We use many different surveys to gather information about our healthcare services from our community. The patient satisfaction survey provides our patients with the opportunity to tell us how well we are providing our services. The Community Perception survey allows those that may not use our facility the ability to provide us feedback also. Another opportunity for feedback is the Community Needs survey which allows the community to express what additional services it would like for us to provide. Part VI, Line 3: Patients are screened upon registration to see if they qualify for charity care. The paperwork is explained and presented at that time. Uninsured patients with no means of payment are also mailed charity applications after discharge and prior to collection agency placement. Collection agency is also educated in explaining charity policy and will refer qualifying patient to hospital for review. Part VI, Line 4: NorthCrest Medical Center is a community, not-for-profit hospital located in Robertson County; which is located in Northern Middle Tennessee and includes eight individual municipalities. NorthCrest Medical Center is the only hospital located in the county with a population of approximately 67,000 citizens. Robertson County has an average household income of $49,000; and its population is made up of 83% Caucasian, 8% African-American, and 7% Hispanic. Part VI, Line 6: NorthCrest Medical Center is a not-for-profit, independent, community hospital that has been providing compassionate, quality healthcare since 1956. With a mission of enhancing community and patient wellness, NorthCrest provides inpatient, outpatient, and emergency medical services to Northern Middle Tennessee and Southern Kentucky.NorthCrest Medical Center is governed by a board of trustees made up of local community minded men and women. NorthCrest's local board allows us to focus on the needs of our community and use the medical center's resources to provide advanced, high quality care in a convenient location for our citizens and support our community's organizations and events.NorthCrest's medical staff is made up of highly trained and skill physicians for throughout the world. The medical staff is dedicated to supporting the medical center and its mission. And, NorthCrest is also looking to add services and physicians that are needed for the community. 1 NORTHCREST MEDICAL CENTER FOUNDATION 100 NORTHCREST DRIVE SPRINGFIELD TN 371723961 204224449 501 (C) (3) 103670 FURTHER EXEMPT PURPOSE OF FOUNDATION BY FUNDING SALARIES OF EMPLOYEES AMERICAN CANCER SOCIETY 2000 CHARLOTTE AVE NASHVILLE TN 37172 131788491 501 (C) (3) 10000 FURTHER EXEMPT PURPOSE OF AMERICAN CANCER SOCIETY UNITED WAY 101 FIFTH AVE WEST SPRINGFIELD TN 37172 621763845 501 (C) (3) 10500 FURTHER EXEMPT PURPOSE OF UNITED WAY ROBERTSON COUNTY SCHOOLS 2121 WOODLAND STREET SPRINGFIELD TN 37172 626000810 GOVERNMENT 23750 FURTHER EXEMPT PURPOSE OF ROBERTSON COUNTY SCHOOLS VOLUNTEER STATE COMMUNITY COLLEGE 1480 NASHVILLE PARK GALLATIN TN 37066 581863050 GOVERNMENT 20000 FURTHER EXEMPT PURPOSE OF VOLUNTEER STATE COMMUNITY COLLEGE YMCA OF MIDDLE TENNESSE 900 CHURCH STREET NASHVILLE TN 37203 620476243 501 (C) (3) 6000 TO FURTHER EXEMPT PURPOSE OF YMCA OF MIDDLE TENNESSEE 6 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: NORTHCREST MEDICAL CENTER ONLY PROVIDES FUNDS TO CHARITIES AND QUALIFIED GOVERNMENTAL ENTITIES TO SUPPORT SPECIFIC PROJECTS RELATED TO THE HOSPITAL'S EXEMPT PURPOSES AND THOSE THAT BENEFIT THE COMMUNITY SERVED. X X X 0 1 X X X 1 1 0 0 0 0 0 0 0 SCOTT RAYNES 265778 0 80822 0 13333 0 25000 0 19084 0 404017 0 0 0 JIM SCHMIDT 170478 0 31051 0 1090 0 0 0 23640 0 226259 0 0 0 RANDY MILLS 195355 0 0 0 0 0 0 0 13874 0 209229 0 0 0 RANDY DAVIS 105250 0 29622 0 141 0 0 0 21756 0 156769 0 0 0 SHARON JEHLE 119413 0 5583 0 85565 0 0 0 13867 0 224428 0 0 0 Part I, Line 1b THE DUES, TRAVEL, AND TAX INDEMNIFICATION PAYMENTS ARE APPROVED ON A CASE BY CASE BASIS AT THE DISCRETION OF THE CEO. TRAVEL FOR COMPANIONS AND PERSONAL SERVICES REIMBURSEMENTS ARE NOT SPECIFICALLY LISTED IN THE EXPENSE POLICIES. HOWEVER, THEY BOTH REQUIRE DOCUMENTATION TO BE REIMBURSED AND BOTH ARE INCLUDED IN COMPENSATION IN BOX 1 OF THE W-2 OR 1099-MISC. Part I, Line 4a SHARON JEHLE RECEIVED $31,069 AS A SEVERANCE PAYMENT. SCOTT RAYNES RECEIVED $25,000 UNDER HIS 457F PLAN. THE HEALTH AND EDUCATIONAL FACILITIES BOARD OF THE CITY OF SPRINGFIELD TN 521353943 85141WAA8 2008-07-30 38020000 FUNDS BEING USED TO BUILD A NEW HOSPITAL ON A NEW CAMPUS 0 0 38020000 38020000 1995 1 0 1 1 0 0 0 0 1 1 0 1 1 morgan keegan 1.800000000000 0 0 0 DR TOMMY CRUNK DR. TOMMY CRUNK IS ON THE BOARD OF THE MEDICAL CENTER 20028 THE MEDICAL CENTER RENTS SPACE FROM DR. CRUNK. 0 DR TOMMY CRUNK DR. TOMMY CRUNK IS ON THE BOARD OF THE MEDICAL CENTER 26000 THE MEDICAL CENTER HAS A CONTRACT WITH DR. CRUNK FOR PERFORMANCE OF RAC REVIEWS. 0 Form 990, Part VI, Section B, line 11 AFTER COMPLETION OF FORM 990, NORTHCREST'S ACCOUNTANT PROVIDES THE BOARD WITH A COPY OF THE FORM 990 FOR REVIEW AND IS AVAILABLE TO PRESENT AND EXPLAIN THE FORM 990 AT REQUEST OF BOARD. Form 990, Part VI, Section B, line 12c THE CONFLICT OF INTEREST POLICY IS REVIEWED ANNUALLY BY THE BOARD AND A CONFLICT DISCLOSURE IS SIGNED. Form 990, Part VI, Section B, line 15 BOARD REVIEWS DIFFERENT SOURCES, SUCH AS MARKET ANALYSIS, BEFORE APPROVING COMPENSATION OF CEO. CEO THEN IN TURN REVIEWS AND APPROVES COMPENSATION OF KEY EMPLOYEES. Form 990, Part VI, Section C, line 19 THE REQUESTS FOR GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS GO THROUGH THE COMPLIANCE OFFICER, AND THE LEGALLY REQUIRED DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 2C AUDIT COMMITTEE THE BOARD OF DIRECTORS HAS A FINANCE COMMITTEE THAT IS RESPONSIBLE FOR OVERSIGHT OF THE AUDIT. THEIR PROCESSES FOR REVIEW AND SELECTION OF INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. NORTHCREST MEDICAL CENTER FOUNDATION 100 NORTHCREST DRIVE SPRINGFIELD TN 372123961 204224449 SUPPORT AND AID IN FINANCING THE EDUCATION OF HEALTH CARE SERVICE PROVIDERS TN 501(C)(3) 509(A)(3) N/A NORTHCREST STRATEGIC SERVICES INC 100 NORTHCREST DRIVE SPRINGFIELD TN 37172 621638556 OPERATIONS LAB TN N/A C 11991 1.00000 NORTHCREST PHYSICIAN SERVICES INC 100 NORTHCREST DRIVE SPRINGFIELD TN 37172 621638557 FAMILY PHYSICIAN TN NORTHCREST STRATEGIC SERVICES INC C 7946114 1745237 1.00000 1 1 1 0 0 0 0 0 1 0 1 0 1 0 0 0 1 0 NORTHCREST MEDICAL CENTER FOUNDATION B 24468 NORTHCREST MEDICAL CENTER FOUNDATION C 28349 NORTHCREST PHYSICIAN SERVICES A 217592 NORTHCREST PHYSICIAN SERVICES I 217592 NORTHCREST PHYSICIAN SERVICES Q 1996839 NORTHCREST MEDICAL CENTER FOUNDATION K 7576 Northcrest pHYSICIAN SERVICES K 217784 northCREST MEDICAL CENTER FOUNDATION M 1406