2011-05-12T10:54:46-05:00 2010-06-30 DIXON HUGHES GOODMAN LLP 500 Ridgefield Court Asheville NC 28806 990 2009-07-01 562276994 DAVIE COUNTY EMERGENCY HEALTH CORPORATION DAVI 3367518100 223 HOSPITAL STREET MOCKSVILLE NC 27028 DANNY SQUIRES 3367518100 2011-05-06 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z DAVIE COUNTY HOSPITAL DANNY SQUIRES 223 HOSPITAL STREET MOCKSVILLE NC 27028 10273857 0 X WWW.DAVIEHOSPITAL.ORG X 2001 NC PROVISION OF PATIENT-CENTERED HEALTHCARE SERVICES TO THE SURROUNDING AREA 13 6 213 2 0 0 18384 8655 10946034 10212430 4320 3237 32091 49535 11000829 10273857 0 0 5047562 4598932 0 0 7738211 7350845 12785773 11949777 -1784944 -1675920 4426763 3126737 1899498 2275392 2527265 851345 DAVIE COUNTY HOSPITAL PROVIDES PATIENT-CENTERED HEALTH CARE SERVICES FOR THE RESIDENTS AND INDUSTRIES OF THE COUNTY AND SURROUNDING COMMUNITIES. 0 0 10944013 10212430 PROVIDED MEDICAL, EMERGENCY, AND OUTPATIENT CARE SERVICES TO THE RESIDENTS OF DAVIE COUNTY, NORTH CAROLINA, AND THE SURROUNDING AREAS. DURING THE FISCAL YEAR, THE HOSPITAL HAD 7,133 OUTPATIENT VISITS AND 9,295 EMERGENCY ROOM VISITS. IN ADDITION, THE HOSPITAL PERFORMED 205 CATARACT SURGERIES, 67 OTHER SURGERIES, AND 71 SLEEP STUDIES. 10944013 1 0 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 45 0 1 213 1 0 0 0 0 0 0 0 0 0 13 6 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X DANNY SQUIRES 3362384287 223 HOSPITAL STREET MOCKSVILLE NC 27028 DONNY C LAMBETH 1.00 X X 0 691497 158024 DAN BARRETT 1.00 X X 0 0 0 TERRY BRALLEY 1.00 X X 0 0 0 STEPHEN ROBERTSON 1.00 X 0 0 0 KEN WHITE 1.00 X 0 0 0 DR RUSSELL HOWERTON 1.00 X 0 0 0 WILLIAM F JUNKER 1.00 X 0 0 0 RONALD SMALL 1.00 X 0 301092 114808 STEVEN C SNELGROVE 1.00 X 0 304368 42665 BETH DIRKS 1.00 X 0 0 0 H GREGORY BRAY 1.00 X X 0 184694 22767 HEATHER L HAYES 1.00 X 0 70173 7818 RALPH HOLTHOUSER 1.00 X X 0 87539 561 MARK R KELLER MD 1.00 X 0 0 0 LYNNE DOSS 40.00 X 99836 0 4781 TERRY BOWMAN 40.00 X 91475 0 4770 191311 1639363 356194 0 0 1 0 ERX COMPANY 109 LANDOAK LANE KNOXVILLE TN 37922 PHYSICIAN FEES 1242782 MEDTRONIC USA PO BOX 409201 ATLANTA GA 30384 NERVE STIMULATOR SUPPLIER 218574 SIGHTPATH MEDICAL INC 575 W OLD SHAKOPEE ROAD STE 90 BLOOMINGTON MN 55437 CATARACT SURGERY SUPPLIER 139157 BRANDON REHABILITATION 135 MEDICAL DRIVE STE 101 ADVANCE NC 27006 PHYSICAL THERAPIST 115150 4 8655 8655 PATIENT SERVICE REVENU 621400 10212430 10212430 10212430 3237 3237 22029 22029 22029 22029 NON-PATIENT MEALS 722210 17029 17029 medical record transcr 900099 5135 5135 5342 5342 27506 10273857 10212430 0 52772 191311 191311 3669561 3221215 448346 448837 448837 289223 289223 187 187 27500 27500 2236602 2044788 191814 26744 26744 1432441 1337647 94794 937583 937583 14604 12029 2575 17163 17163 305167 305167 106242 97290 8952 BAD DEBT EXPENSE 2190789 2190789 MISCELLANEOUS EXPENSE 55823 15538 40285 11949777 10944013 1005764 0 85293 116683 738800 1814673 1435475 160868 145879 47313 6135 2206859 1333230 1164331 873629 57134 67848 358351 481088 4426763 3126737 1289811 1783515 393935 289949 215752 201928 1899498 2275392 X 1787453 850333 739812 1012 2527265 851345 4426763 3126737 X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 1458 1458 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). A PORTION OF THE MEMBERSHIP DUES PAID ARE ALLOCATED TO LOBBYING EFFORTS BY THOSE ORGANIZATIONS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR THE YEAR, THE PORTION OF MEMBERSHIP DUES ALLOCATED TO LOBBYING WAS 23.76% or $1,458 . 2206859 1333230 873629 873629 OTHER RECEIVABLES 384391 estimated third party receivables 96697 481088 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1928 NOTE DUE TO NC BAPTIST HOSPITAL 200000 201928 10273857 11949777 -1675920 0 -1675920 10273857 0 10273857 0 10273857 11949777 0 11949777 0 11949777 1 1 X 1 X 190.000000000000 0 1 1 1 0 1 1 137961 137961 0.01410 2248780 1610454 638326 0.06540 2386741 1610454 776287 0.07950 2386741 1610454 776287 0.07950 1 2190787 0 2773772 2110232 663540 X 1 1 DAVIE COUNTY EMERGENCY HEALTH CORP

PO BOX 1209 / 223 HOSPITAL STREET MOCKSVILLE NC 27028

X X X X Part I, Line 6a: NORTH CAROLINA BAPTIST HOSPITAL Part III, Line 4: There is not a footnote in the financial statements which describes bad debt expense. Accounts are written off to bad debt after 4 statements have been sent and two collection letters. The account is not written off before 120 days after the insurance pays. Also if there is payment with in the last 60 days the account is not written off to bad debt. Part III, Line 8: Davie County Hospital is a Critial Access hospital and is reimbursed 100 to 101% of costs. Part III, Line 9b: Each patient is sent four statements for collection, one every 28 days. After the four statements are sent, two "collection" letters are sent. If there is no response, the account is sent to a collection agency. The hospital does not place garnishments, liens, or personal attachments on patients. A 10% discount is offered to private pay patients who pay their bill in full within 30 days. Private pay patients are offered a charity care application and told about payment plans at registration. The charity care application is available online and offered to private pay patients at registration. Personal face to face meetings are available Monday through Friday 8 am to 5 pm. Payment plans are offered to all patients when initial phone contact is made. Phone calls are made after three statements have been sent out. Part VI, Line 2: Representatives from the organization attend health fairs and senior health fairs around the county. No community needs assessment has been done as of the end of the 2009 tax year. However, one will be conducted in the near future so as to be in compliance with the law. Part VI, Line 3: Information about the charity care program is available on the website and is disclosed at the patient registration stage. Registration and Business Office staff are trained to educate patients on assistance policies. Copies of the application are widely available, through the internet, registration desk, and business office desk. Business Office staff will direct patients to social services if they qualify for assistance. Part VI, Line 4: Davie County Hospital is a critical access hospital serving Davie County and the surrounding areas. The Hospital is the only hospital located in the county. The population of Davie County is approximately 42,000 according to the US Census Bureau. 10.8% of the population is at or below the poverty line. 91% of the population is white, 7% is black, and 2 % is made up of other races. The unemployment level in June 2010 was 10.3%. The median income is $52,408. The growth rate of the community is 2%. Part VI, Line 6: The hospital attends health fairs in the community and performs cholestrol checks at the senior center health fair. Part VI, Line 7: 100% owned subsidiary of North Carolina Baptist Hospital. X X X X 0 0 0 0 0 0 0 0 0 DONNY C LAMBETH 0 604495 0 70030 0 16972 0 136459 0 21565 0 849521 0 0 RONALD SMALL 0 271424 0 24063 0 5605 0 100690 0 14118 0 415900 0 0 STEVEN C SNELGROVE 0 256208 0 27846 0 20314 0 23813 0 18852 0 347033 0 0 H GREGORY BRAY 0 171066 0 9481 0 4147 0 8084 0 14683 0 207461 0 0 PAMELA SMALL FAMILY MEMBER OF BOARD MEMBER RONALD SMALL 13855 COMPENSATION AS EMPLOYEE 0 Form 990, Part VI, Section A, line 6 THE SOLE MEMBER OF THE ORGANIZATION IS NORTH CAROLINA BAPTIST HOSPITAL, A NORTH CAROLINA NONPROFIT CORPORATION. Form 990, Part VI, Section A, line 7a THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE THE RIGHT AT ALL TIMES, WITH RESPECT TO THE ORGANIZATION, TO ELECT AND REMOVE THE TRUSTEES, AS PROVIDED IN THE ORGANIZATION'S BYLAWS. Form 990, Part VI, Section A, line 7b THE SOLE MEMBER OF THE ORGANIZATION SHALL HAVE THE RIGHT AT ALL TIMES, WITH RESPECT TO THE ORGANIZATION, TO APPROVE OF THE SALE, LEASE, OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION, AS PROVIDED IN THE ORGANIZATION'S BYLAWS. THE SOLE MEMBER MAY ACT WITHOUT A MEETING. Form 990, Part VI, Section B, line 11 The return was prepared by an independent accountant with assistance and oversight by management. THE FORM 990 WAS REVIEWED AT THE QUARTERLY FINANCE MEETING WITH THE BOARD PRIOR TO FILING THE FORM WITH THE IRS. A MEMBER OF THE ORGANIZATION'S TAX PREPARER'S FIRM WAS PRESENT TO EXPLAIN THE FORM AND ANSWER QUESTIONS. Form 990, Part VI, Section B, line 12c DIRECTORS, TRUSTEES, OFFICERS, AND KEY EMPLOYEES ARE SURVEYED ANNUALLY FOR POTENTIAL CONFLICTS OF INTEREST. IN DECEMBER THE POLICY IS DISTRIBUTED TO ALL DIRECTORS, TRUSTEES, OFFICERS, AND KEY EMPLOYEES ALONG WITH A QUESTIONNAIRE. AT THE DECEMBER BOARD MEETING, ALL ARE REQUIRED TO SUBMIT THE COMPLETED QUESTIONNAIRES. Form 990, Part VI, Section B, line 15 NORTH CAROLINA BAPTIST HOSPITAL, THE ORGANIZATION'S SOLE MEMBER, CONDUCTED SALARY SURVEYS OF OTHER AREA HOSPITALS, AND CONTRACTS WERE REVIEWED BY THE HUMAN RESOURCES DEPARTMENT OF THAT ORGANIZATION. Form 990, Part VI, Section C, line 18 PHOTOCOPIES OF THE FORM 1023 AND RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. Form 990, Part VI, Section C, line 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. NORTH CAROLINA BAPTIST HOSPITAL MEDICAL CENTER BLVD WINSTON SALEM NC 27157 560552787 HEALTHCARE NC 501(c)(3) Line 3 N/A NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION MEDICAL CENTER BLVD WINSTON SALEM NC 27157 561685120 SUPPORTING ORGANIZATION NC 501(c)(3) Line 11a, I N/A THE REHABILITATION & SKILLED NURSING FACILITY AT OAK SUMMIT MEDICAL CENTER BLVD WINSTON SALEM NC 27157 561826396 HEALTHCARE (INACTIVE) NC 501(c)(3) Line 9 NORTH CAROLINA BAPTIST HOSPITAL FOUNDATION BAPTIST HOSPITAL RX MEDICAL CENTER BLVD WINSTON SALEM NC 27157 542136894 HEALTHCARE (INACTIVE) NC 501(c)(3) Line 9 N/A THE HAWTHORNE INN & CONFERENCE CENTER INC 420 HIGH STREET WINSTON SALEM NC 27101 561793617 LODGING/ CONFERENCE ACCOMMODATION NC 501(c)(3) Line 11a, I N/A CARENET INC 2000 WEST FIRST STREET SUITE 410 WINSTON SALEM NC 27104 561977341 HEALTHCARE NC 501(c)(3) Line 11a, I N/A WAKE FOREST UNIV BAPTIST MEDICAL CNTR COMMUNITY PHYSICIANS 3540 CLEMMONS ROAD CLEMMONS NC 27012 561903275 HEALTHCARE NC 501(c)(3) Line 3 N/A CENTER FOR CONGREGATIONAL HEALTH INC MEDICAL CENTER BLVD WINSTON SALEM NC 27157 237426944 HEALTHCARE NC 501(c)(3) Line 9 N/A STOKES-REYNOLDS MEMORIAL HOSPITAL HWY 8 89 NORTH DANBURY NC 28016 561793620 HEALTHCARE NC 501(c)(3) Line 3 N/A 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0