2011-06-01T08:35:58-05:00 2010-09-30 DIXON HUGHES GOODMAN LLP 500 Ridgefield Court Asheville NC 28806 990 2009-10-01 560642846 HUGH CHATHAM MEMORIAL HOSPITAL INC HUGH 3365277000 180 PARKWOOD DR ELKIN NC 28621 DAVID LOVING 3365277000 2011-05-31 1 Michael Rauchwarg 8282542254 2009 2016-02-24 21:20:13Z DAVID LOVING 180 PARKWOOD DR ELKIN NC 28621 117224616 0 X WWW.HUGHCHATHAM.COM X 1930 NC TO PROVIDE BIRTHING AND ACUTE CARE SERVICES IN ADDITION TO SKILLED NURSING, RETIREMENT COMMUNITY, HOME HEALTH, AND HOSPICE SERVICES PRIMARILY TO THE RESIDENTS OF AND SURROUNDING COUNTIES TO SURRY COUNTY, NORTH CAROLINA. 14 12 924 80 0 0 680164 501575 91295354 93765884 -4918897 4031593 1515298 1519558 88571919 99818610 11228 0 39899221 41046303 0 40010 49819287 55128875 89718508 96186406 -1146589 3632204 190981604 187391793 98479891 96629680 92501713 90762113 TO CONSISTENLY DELIVER EXCEPTIONAL QUALITY AND SERVICE BY DEMONSTRATING THE VALUES OF SERVICE, TEAMWORK, ACCOUNTABILITY, RESPECT, AND SAFE CARE. 0 0 90087989 11228 93765884 NESTLED IN THE WESTERN PIEDMONT WINE COUNTRY OF NORTH CAROLINA, HUGH CHATHAM MEMORIAL HOSPITAL HAS PROVIDED HIGH QUALITY MEDICAL CARE FOR RESIDENTS OVER A DISTINGUISHED 80-YEAR HISTORY. A PRIVATE, NOT-FOR-PROFIT, 501(c)(3) HOSPITAL, HCMH EMPLOYS MORE THAN 840, AND IS SERVED BY MORE THAN 70 PHYSICIANS REPRESENTING 26 SPECIALTIES OR SUBSPECIALTIES. IN A RECENT NATIONAL PATIENT SATISFACTION SURVEY, THE HOSPITAL'S PATIENTS GAVE THE OUTPATIENT DEPARTMENT A 99% EXCELLENT RATING; THE EMERGENCY DEPARTMENT 94% AND THE OB/GYN SERVICES 98%. IN ADDITION, FOLLOWING A 2009 QUALITY EVALUATION, THE NATIONAL PRESS GANEY FIRM AWARDED THE HOSPITAL'S OUTPATIENT SURGERY DEPARTMENT A PRESTIGIOUS SUMMIT AWARD, RESERVED FOR CLIENTS WHO ACHIEVE AND MAINTAIN EXTRAORDINARY RESULTS. OVER THE YEARS, HCHM PATIENTS HAVE MADE THE HOSPITAL OUR REGIONS'S CHOICE FOR TECHNOLOGIES AND CARE. RECENT NATIONAL RANKINGS OF SEVERAL IMPORTANT MEASURES REINFORCE THIS CHOICE. THE JOINT COMMISSION AWARDED FULL ACCREDITATION TO THE HOSPITAL'S LABORATORY, AND THE NORTH CAROLINA NURSES ASSOCIATION (NCNA) GAVE HUGH CHATHAM MEMORIAL HOSPITAL THE COVETED HALLMARKS RECOGNITION. THIS AWARD AFFIRMS WHAT GENERATIONS OF PATIENTS HAVE KNOWN: THE NURSES AT HCMH ARE EXCELLENT, WORK WELL TOGETHER, AND ARE DEDICATED TO CARING FOR THEIR PATIENTS. HUGH CHATHAM MEMORIAL HOSPITAL HAS ONCE AGAIN BEEN RECOGNIZED BY ALLIANT MANAGEMENT SERVICES (AMS) FOR ACHIEVING OUTSTANDING LEVELS OF PATIENT AND PHYSICIAN SATISFACTION. HUGH CHATHAM EARNED THE SAME AWARD IN 2009 AND RECEIVED THE HONOR AT ALLIANT MANAGEMENT SERVICES' ANNUAL RECOGNITION CEREMONY LAST FALL IN LOUISVILLE, KENTUCKY. AS A RECIPIENT OF THE PATIENT SATISFACTION AWARD, HUGH CHATHAM MEMORIAL HOSPITAL EARNED TOP SCORES ON SURVEYS COMPLETED BY INPATIENTS, OUTPATIENTS AND PHYSICIANS. INPATIENT = 95TH PERCENTILE EMERGENCY DEPARTMENT = 95TH PERCENTILE OUTPATIENT DEPARTMENT = 99TH PERCENTILE - VISION STATEMENT -TO BE THE BEST COMMUNITY HOSPITAL IN THE NATION, WITH SERVICE AS OUR GUIDING PRINCIPLE - GEOGRAPHIC SERVICE AREA AND TARGET POPULATIONS FOR COMMUNITY INITIATIVES - THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES NINE ZIP CODES COMPRISING ROUGHLY A FIFTEEN-MILE DIAMETER AROUND ELKIN, NORTH CAROLINA. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL FIVE ZIP CODES WIDENING THE DIAMETER TO THIRTY MILES AROUND ELKIN. BOTH OF THE ABOVE MARKETS INCLUDE PART, BUT NOT ALL, OF THE NORTH CAROLINA COUNTIES OF WILKES, ALLEGHANY, YADKIN AND SURRY AND THE ENTIRE POPULATION OF EACH COMMUNITY IS TARGETED FOR ALL SERVICES AND INITIATIVES. ADDITIONAL TARGET MARKETS INCLUDE PORTIONS OF THE SOUTH WESTERN VIRGINIA COUNTIES OF CARROLL, GRAYSON, AND PATRICK. - FUNDING OF INITIATIVE PROGRAMS -THE RESOURCES OF HUGH CHATHAM MEMORIAL HOSPITAL FUND THE PROGRAMS. - DETERMINING COMMUNITY PRIORITIES AND COLLABORATION -THROUGH A GRANT FROM THE DUKE ENDOWMENT, A COMMUNITY NEEDS ASSESSMENT SURVEY WAS CONDUCTED IN A RECENT YEAR. USING INFORMATION FROM THIS SURVEY, ADMISSIONS DATA AND VOLUME DATA FROM THE HOSPITAL, AND PARTNERSHIPS WITH YADKIN AND SURRY SENIOR CENTERS, SURRY COMMUNITY COLLEGE, AND OTHER AGENCIES, NEEDS ARE IDENTIFIED, PRIORITIES ESTABLISHED, AND LEADERSHIP ROLES ASSIGNED FROM WITHIN THE COLLABORATIVE GROUP. THE HOSPITAL'S BOARD OF TRUSTEES, PHYSICIANS, AND ADMINISTRATION MEET EACH YEAR TO DETERMINE STRATEGIC NEEDS OF THE COMMUNITY AT THEIR ANNUAL PLANNING RETREAT. - COMMUNITY SERVICE PROGRAMS SPONSORED BY HUGH CHATHAM MEMORIAL HOSPITAL --PATIENT EDUCATION PROGRAMS- LAMAZE AND CHILDBIRTH INFANT AND CHILD CPR BREASTFEEDING CARDIAC REHABILITATION WOMEN'S HEALTH EDUCATIONAL SEMINARS-COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS- CANCER SCREENINGS (PROSTATE, BREAST, SKIN, COLON) CHOLESTEROL/GLUCOSE BLOOD PRESSURE/HEART RATE/OXYGEN SATURATION WEIGHT/BODY MASS INDEX FALLS ASSESSMENT BONE DENSITY TETANUS/FLU-HEALTH PROMOTION, OUTREACH, AND SUPPORT GROUPS- CANCER HEART AND SOUL LOOK GOOD FEEL BETTER CANCER SUPPORT HOSPICE GRIEF CAMP FOR CHILDREN BEREAVEMENT AND THE GRIEF PROCESS STROKE SUPPORT AMPUTEE SUPPORT ALZHEIMER'S SUPPORT CPR FOR INDUSTRY, DAY CARE WORKERS, AND LIFEGUARDS SENIOR FITNESS CLASSES CARDIAC REHABILITATIONDURING 2010, HUGH CHATHAM MEMORIAL HOSPITAL OPENED A GI CLINIC, AS WELL AS, A DERMATOLOGY OFFICE IN ORDER TO BETTER SERVE THE COMMUNITY'S NEEDS. EMPLOYEES OF THE HOSPITAL ROUTINELY DONATE THEIR TIME TO THE HOSPITAL'S VARIOUS PROGRAMS, SUCH AS THE LOCAL GRACE CLINIC, IN ADDITION TO THE PROGRAMS LISTED ABOVE. 90087989 1 1 0 1 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 0 0 1 0 0 0 0 0 1 1 0 0 1 77 0 924 1 0 0 0 0 0 0 0 0 0 14 12 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X CHERYL PARDUE 3365277595 180 PARKWOOD DRIVE ELKIN NC 28621 BOB BALL 1.00 X X 0 0 0 PHIL HARRIS 1.00 X X 0 0 0 DR STEVEN ISAACS 1.00 X 24000 0 0 DAVID CLINE 1.00 X X 0 0 0 GEORGE DENKA 1.00 X 0 0 0 FRED EIDSON 1.00 X 0 0 0 REBECCA MAYNARD 1.00 X 0 0 0 RAYMOND PARKER 1.00 X 0 0 0 ALAN PAYNE 1.00 X 0 0 0 FRANK SELLS 1.00 X 0 0 0 DONNA THOMPSON 1.00 X 0 0 0 DR SKIP WHITMAN 1.00 X 0 0 0 CAROL JERNIGAN 1.00 X 0 0 0 BOB MIDKIFF 1.00 X 0 0 0 MIKE STANLEY 1.00 X 0 0 0 DAVID LOVING 40.00 X 0 0 0 STEPHEN PENNINGTON 40.00 X 242574 0 0 STUART POSTON 40.00 X 142716 0 0 DONALD TRIPPEL 40.00 X 182589 0 11317 DOMINICK CARBONE JR 40.00 X 730434 0 13247 MURUGANATHAN SUBBIAH 40.00 X 313144 0 9401 NAVNEET SHARMA 40.00 X 306546 0 10810 NAYANA ABROL 40.00 X 246816 0 5760 RIZWAN AHMED 40.00 X 219979 0 16235 2408798 0 66770 19 0 1 0 THE ROBINS & MORTON GROUP 5500 MARYLAND WAY BRENTWOOD TN 37027 CONSTRUCTION CONTRACTORS 6718320 SODEXO INC PO BOX 536922 ATLANTA GA 30353 CONTRACT HOUSEKEEPING AND DIETARY 2926304 US BANK OPERATIONS PO BOX 86 MINNEAPOLIS MN 55486 BANKING TRANSACTION 2512673 CARDINAL DISTRIBUTION PHARMACY 25025 NETWORK PLACE CHICAGO IL 60673 PHARMACY SUPPLIES & MEDICATIONS 1810077 CARDINAL HEALTH PO BOX 905867 CHARLOTTE NC 28290 PATIENT AND HOSPITAL SUPPLIES 1692205 78 501575 501575 PATIENT CARE SERVICES 621400 93361657 93361657 NET HOSPICE INVESTMENT 623000 313943 313943 OTHER JOINT VENTURES 623000 90284 90284 93765884 3069728 3069728 213062 213062 1563786 349605 1214181 1214181 1214181 17805204 17056401 748803 748803 748803 MEALS & VENDING 722210 301205 301205 MISCELLANEOUS REVENUE 900099 4172 4172 305377 99818610 93765884 0 5551151 11228 11228 539188 138019 368410 32759 33067420 31396515 1670905 507708 476404 30809 495 4622955 4337919 280530 4506 2309032 2166665 140117 2250 232814 232814 137299 137299 124254 124254 61371 61371 10930206 9965305 964901 490773 20368 470405 14310562 13677679 632883 1194836 1194836 247316 216282 31034 2532592 2532592 7625849 7625849 205461 205461 BAD DEBT EXPENSE 15405001 15405001 MISCELLANEOUS EXPENSES 1063240 717866 345374 RECRUITMENT 567301 567301 96186406 90087989 6058407 40010 5375049 6179810 10171727 8923725 325000 1194931 1342850 5016822 3811686 147784567 54001906 80781558 93782661 81507451 67394460 2802492 3206690 3806574 2749911 190981604 187391793 9937406 7525858 81785000 80985000 6757485 8118822 98479891 96629680 X 92939963 91262113 -438250 -500000 92501713 90762113 190981604 187391793 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 61371 0 1 11000 72371 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: PART II-B, LINE 1G: THE ORGANIZATION RETAINS THE SERVICES OF RUSS REID, AN AGENCY EXCLUSIVELY DEDICATED TO ADVOCACY OF NONPROFIT ORGANIZATION, TO ACCOMPANY AND ASSIST OFFICERS AND KEY MANAGEMENT PERSONNEL ON TRIPS TO WASHINGTON, D.C. TO DISCUSS HEALTHCARE LEGISLATION RELEVANT TO THE ORGANIZATION. PART II-B, LINE 1I: THE ORGANIZATION IS A MEMEBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). THESE ORGANIZATIONS ENGAGE IN LOBBYING EFFORTS TO LEGISLATIVE BODIES ON BEHALF OF THEIR MEMBERSHIP BASES. EACH YEAR, A PORTION OF MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING ENDEAVORS. FOR THE CURRENT YEAR, THE PORTION OF DUES PAID ALLOCATED TO LOBBYING IS APPROXIMATELY $ 11,000. 2405188 2405188 92070450 19073615 72996835 9032473 3639056 5393417 44254896 31289235 12965661 21560 21560 93782661 INVESTMENT IN HOSPICE OF SURRY COUNTY 3206690 C 3206690 OTHER RECEIVABLES 724157 INTELLECTUAL PROPERTY & OTHER INTANGIBLES 2025754 2749911 INTEREST PAYABLE 999091 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 2608345 PHYSICIAN GUARANTEE 588377 INTEREST RATE SWAP 3423009 DUE TO FOUNDATION 500000 8118822 99818610 96186406 3632204 -122387 -5249417 -5371804 -1739600 95400225 -122387 -4645603 -4767990 100168215 -349605 -349605 99818610 96899718 0 96899718 -713312 -713312 96186406 Part XI, Line 8 - Other Adjustments: CHANGE IN VALUE OF SWAP AGREEMENT: -2805560. TRANSFER OF EQUITY TO FOUNDATION: -193538. IMPAIRMENT OF GOODWILL: -1157871. LOSS ON IMPAIRMENT OF ASSET: -1092448. Part XII, Line 2d - Other Adjustments: REVENUES OF AFFILIATED ENTITIES: 603814. TRANSFER OF EQUITY TO FOUNDATION: -193538. CHANGE IN VALUE OF SWAP AGREEMENT: -2805560. IMPAIRMENT OF GOODWILL: -1157871. LOSS ON IMPAIRMENT OF ASSETS: -1092448. Part XII, Line 4b - Other Adjustments: RENTAL EXPENSES: -349605. Part XIII, Line 4b - Other Adjustments: RENTAL EXPENSES: -349605. EXPENSES OF AFFILIATED ENTITIES: -363707. 1 1 1 X 1 X 1 1 1 0 1 1 1551755 0 1551755 0.01920 12810748 8595892 4214856 0.05220 14362503 8595892 5766611 0.07140 31016 31016 0.00040 18000 18000 0.00020 87700 87700 0.00110 11228 11228 0.00010 147944 147944 0.00180 14510447 8595892 5914555 0.07320 3593 3593 0.00000 3593 3593 6225834 2179042 23153375 24287271 -1133896 X 1 0 HUGH CHATHAM MEMORIAL HOSPITAL

180 PARKWOOD DRIVE ELKIN NC 28621

X X X DISPROPORTIONATE SHARE HOSPITAL Part I, Line 7: WORKSHEET 2 OF THE 2009 SCHEDULE H INSTRUCTIONS WAS USED TO COMPUTE A COST-TO-CHARGES RATIO THAT WAS USED TO CALCULATE COSTS USED IN PART I, LINE 7. Part I, Line 7g: SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G REPRESENTS THE ORGANIZATION'S EXPENSES FOR THE GRACE CLINIC, A FREE MEDICAL CARE AND HEALTH MONITORING CLINIC LOCATED IN ELKIN, NORTH CAROLINA. THE CLINIC IS STAFFED MAINLY BY VOLUNTEERS, AND ACCEPTS PATIENTS WITHOUT HEALTH INSURANCE AND WHO MEET INCOME AND OTHER ELIGIBILITY CRITERIA. Part I, Line 7f: THE TOTAL EXPENSE AMOUNT LISTED ON FORM 990, PART IX, LINE 26 CONTAINS BAD DEBT EXPENSE OF $15,405,001 THAT WAS REMOVED FOR THE PURPOSE OF CALCULATING TOTAL CHARITY CARE PERCENTAGE ON LINE 7, COLUMN (F). Part III, Line 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT. THE BAD DEBT EXPENSE AT COST ON PART III, LINE 2 WAS COMPUTED BY USING THE GROSS BAD DEBT EXPENSE PER AUDITED FINANCIAL STATEMENTS REDUCED TO COST USING THE COST TO CHARGE RATIO CALCULATED THROUGH WORKSHEET 2 PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H.DUE TO THE FACT THAT APPROXIMATELY 30% OF THE SURROUNDING COMMUNITY'S RESIDENTS ARE CONSIDERED TO BE LIVING BELOW THE POVERTY LINE, IN COMBINATION WITH THE FACT THAT THE UNEMPLOYMENT PERCENTAGE FOR THE AREA IS APPROXIMATELY 12.7%, THE ORGANIZATION FEELS THAT APPROXIMATELY 35% OF BAD DEBT IS AN APPROPRIATE ESTIMATION OF THE AMOUNT OF BAD DEBT THAT MAY CONSTITUTE A COMMUNITY BENEFIT. Part III, Line 8: AN INTERNAL COST-TO-CHARGE RATIO WAS USED TO COMPUTE MEDICARE ALLOWABLE COSTS OF CARE ON PART III, LINE 6. Part III, Line 9b: HCMH MAKES EVERY EFFORT TO EVALUATE PATIENTS PRIOR TO PLACEMENT WITH A COLLECTIONS AGENCY TO SEE IF THEY ARE QUALIFIED FOR MEDICAID OR HOSPITAL CHARITY CARE. WE HAVE AN IN-HOUSE EMPLOYEE DESIGNATED TO ASSISTING PATIENTS ELIGIBLE FOR MEDICAID AND/OR FINANCIAL ASSISTANCE. AT THE POINT OF THE PATIENT NOT BEING ELIGIBLE AND FAILURE TO RESPOND FOR OUR PAYMENT PLAN OPTIONS, THE ACCOUNT IS PLACED WITH A COLLECTION AGENCY AND THE AGENCY MAKES AN EFFORT FOR 30 DAYS PRIOR TO PLACING ON THE CREDIT SCORE, TO OBTAIN PAYMENT. Part V: IN ADDITION TO THE FACILITY REQUIRED TO BE LICENSED AS A HEALTHCARE FACILITY REPORTED ON PART V, THE ORGANIZATION ALSO OPERATES THE FOLLOWING FACILIES (DIRECTLY OR BY JOINT VENTURE) THAT ARE NOT REQUIRED TO BE LICENSED AS A HEALTHCARE FACILITY BY THE STATE OF NORTH CAROLINA: - ONE REHAB CENTER (HCMH REG. REHABILITATION CENTER) - ONE NURSING CENTER (HUGH CHATHAM NURSING CENTER) - ONE HOME HEALTH CENTER (YADKIN VALLEY HOME HEALTH) - ONE DIAGNOSTIC CENTER (G.I. CLINIC) - EIGHT PHYSICIANS OFFICES (YADKIN VALLEY ADULT MEDICINE) (CLINGMAN MEDICAL CENTER) (YADKIN VALLEY UROLOGY) (HUGH CHATHAM FAMILY MEDICINE) (SOUTHWEST VIRGINIA OTHOPEDICS) (YADKIN VALLEY PULMONARY & CRITICAL CARE) (YADKIN VALLEY DERMATOLOGY) PART I, LINE 6A: THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS FILED THROUGH THE MEDICAL CARE COMMISSION OF NORTH CAROLINA. Part VI, Line 2: THE ORGANIZATION TRACKS THE RESULTS OF HEALTH SCREENINGS PROVIDED THROUGH ITS QUARTERLY HEALTH FAIRS AND LOOKS FOR TRENDS. THESE SCREENINGS PROVIDE INSIGHT INTO FURTHER MEDICAL NEEDS OF THE COMMUNITY MEMBERS. THE FAIRS ARE HELD QUARTERLY AND ARE ATTENDED BY HUNDREDS OF PEOPLE WHO ARE OFFERED THIRTEEN DIFFERENT TYPES OF SCREENS. ADDITIONALLY, THE ORGANIZATION SUBSCRIBES TO NATIONAL AFFILIATED ORGANIZATIONS THAT PROVIDE DATA ON REGIONAL HEALTH NEEDS. LAST YEAR, THIS DATA SHOWED A RISE IN STROKE RELATED DEATHS. SUBSEQUENTLY,HCMH FOCUSED ON STROKE EDUCATION AND PREVENTION AT ALL LOCAL EVENTS, FAIRS, FESTIVALS, ETC. Part VI, Line 3: FINANCIAL ASSISTANCE EDUCATION IS MADE AVAILABLE AT ADMISSION AND ON THE WEBSITE. AT REGISTRATION THERE ARE BROCHURES WITH FINANCIAL ASSISTANCE INFORMATION MADE AVAILABLE. SIGNAGE IS LOCATED THROUGHOUT THE FACILITY TO INFORM AND EDUCATE THE PUBLIC OF THEIR FINANCIAL RIGHTS. HUGH CHATHAM MEMORIAL HOSPITAL OFFERS A LANGUAGE LINE FOR THE NON-ENGLISH SPEAKING COMMUNITY AND PHONETREE ASSISTANCE WHERE NEEDED. Part VI, Line 4: THE PRIMARY SERVICE AREA OF THE HOSPITAL INCLUDES NINE ZIP CODES--ROUGHLY A FIFTEEN MILE DIAMETER AROUND ELKIN, NC. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL FIVE ZIP CODES WIDENING THE DIAMETER TO THIRTY MILES AROUND ELKIN. BOTH OF THE ABOVE MARKETS INCLUDE PART, BUT NOT ALL, OF THE NORTH CAROLINA COUNTIES OF WILKES, ALLEGHANY, YADKIN, AND SURRY. SOUTHERN VIRGINIA COUNTIES OF GRAYSON, PATRICK, AND CARROLL ARE ALSO INCLUDED. THESE AREAS HAVE BEEN SEVERELY AFFECTED BY THE ECONOMIC CLIMATE OF THE PAST YEAR. THE AREA CURRENTLY HAS AN UNEMPLOYMENT PERCENTAGE OF 12.7%. DOBSON, NC, WHICH IS IN THE CENTER OF SURRY COUNTY, IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA. HUGH CHATHAM IS THE ONLY HOSPITAL IN THE PRIMARY SERVICE AREA. Part VI, Line 5: Part VI, Line 6: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. IN ADDITION, THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR SOME OF ITS DEPARTMENTS.HCMH OFFERS A WIDE VARIEY OF SERVICES TO OUR COMMUNITY, SUCH AS WOMEN'S HEALTH EDUCATION SEMINARS,INFANT AND CHILD CPR CLASSES, LAMAZE AND CHILDBIRTH CLASSES, CARDIAC REHABILITATION, AND VARIOUS PATIENT EDUCATIONAL PROGRAMS. THE HOSPITAL PARTICIPATES IN AND HOSTS MANY COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS, CANCER SCREENINGS (PROSTRATE, BREAST, SKIN, AND COLON), AS WELL AS SCREENINGS IN THE FOLLOWING AREAS: CHOLESTEROL/GLUCOSE, BLOOD PRESSURE, HEART RATE,OXYGEN SATURATION, WEIGHT AND BODY MASS INDEX ASSESSMENT, FALLS ASSESSMENT, BONE DENSITY TESTING, TETANUS AND FLU CLINICS. THE EMPLOYEES AT HCMH ARE COMMITTED TO THE AREAS NEEDS. COMMITTMENT IS DEMONSTRATED THRU PARTICIPATION IN THE FOLLOWING: THE STOP HUNGER FOOD DRIVE, MARCH OF DIMES, UNITED WAY, TRI C MINISTRIES, SUSAN G. KOMEN WALKATHONS, SPECIAL OLYMPICS, THE AMERICAN CANCER SOCIETY, THE NATIONAL MS SOCIETY, AND A LOCAL ORGANIZATION TRIAD FIRST IN FAMILIES THAT HELPS CHILDREN IN NEED.HCMH IS COMMITTED TO THE PROMOTION OF HEALTH, OUTREACH, AND SUPPORT GROUPS. THE HOSPITAL SPONSORS THE FOLLOWING:CANCER HEART AND SOUL, LOOK GOOD FEEL BETTER CANCER SUPPORT, HOSPICE GRIEF CAMP FOR CHILDREN, BEREAVEMENT AND THE GRIEF PROCESS, STROKE SUPPORT, AMPUTEE SUPPORT, ALZHEIMER'S SUPPORT, CPR FOR INDUSTRY, DAY CARE WORKERS, AND LIFEGUARDS, SENIOR FITNESS CLASSES, AND CARDIAC REHABILITATION CLASSES. HCMH ALSO HAS "LUNCH AND LEARNS" WHICH ARE OFFERED TO THE COMMUNITY PROMOTING DIFFERENT TOPICS OF HEALTH RELATED INTEREST.THE HOSPITAL ALSO SPONSORS THE GRACE CLINIC WHICH IS A LOCAL FREE CLINIC WHICH OPERATES ON DONATED SERVICES AND SUPPLIES. NC 1 X 0 0 X X X X 0 0 0 0 0 1 0 0 0 STEPHEN PENNINGTON 201837 0 38337 0 2400 0 0 0 0 0 242574 0 0 0 DONALD TRIPPEL 162641 0 18632 0 1316 0 5079 0 6238 0 193906 0 0 0 DOMINICK CARBONE JR 367765 0 362278 0 391 0 7379 0 5868 0 743681 0 0 0 MURUGANATHAN SUBBIAH 299330 0 13625 0 189 0 3185 0 6216 0 322545 0 0 0 NAVNEET SHARMA 270210 0 36147 0 189 0 4611 0 6199 0 317356 0 0 0 NAYANA ABROL 230401 0 16280 0 135 0 0 0 5760 0 252576 0 0 0 RIZWAN AHMED 169785 0 50000 0 194 0 0 0 16235 0 236214 0 0 0 Part I, Line 6 MEMBERS OF THE ADMINISTRATIVE DEPARTMENT ARE ELIGIBLE FOR AN ADMINISTRATIVE BONUS BASED ON THE FINANCIAL PERFORMANCE OF THE PRIOR YEAR. AMOUNTS PAID OUT TO INDIVIDUALS LISTED ON PART VII OF THE FORM 990 FOR 2009 WERE: STEPHEN PENNINGTON: $ 38,337 DONALD TRIPPEL: 18,632 NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 657902F31 2003-04-01 39673032 REFUNDING, NEW STRUCTURES, EQUIPMENT 0 0 NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65821DAF8 2008-09-24 45455000 NEW STRUCTURES, EQUIPMENT 0 0 39348576 4406642 2408200 33365900 2005 1 0 1 1 46063394 1248462 307120 44507812 2010 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 1 1 0 0 0 ELKINS EMERGENCY PHYSICIANS PRACTICE OWNED IN PART BY BOARD MEMBER DR. STEVEN ISAACS 139010 PAYMENT FOR MEDICAL SERVICES PERFORMED 0 FINGER PARKER AVRAM LAW FIRM IN WHICH BOARD MEMBER RAYMOND PARKER IS PARTNER 12000 RETAINER FOR LEGAL SERVICES 0 Form 990, Part VI, Section A, line 2 BOARD MEMBERS PHIL HARRIS AND DAVID CLINE HAVE A BUSINESS RELATIONSHIP. Form 990, Part VI, Section A, line 3 THE HOSPITAL ENTERED INTO A MANAGEMENT AGREEMENT IN JUNE 2006 WITH ALLIANT, AN UNRELATED CORPORATION WHEREBY THE MANAGEMENT COMPANY WILL PERFORM MANAGEMENT AND ADMINISTRATION SERVICES ON A DAY-TO-DAY BASIS AND PROVIDE A CHIEF EXECUTIVE OFFICER. THE AGREEMENT, WHICH IS TO EXPIRE IN JUNE 2011, CALLS FOR A BASE MANAGEMENT FEE OF APPROXIMATELY $220,000 IN THE FIRST YEAR WITH ANNUAL INCREASES TO APPROXIMATE THE INCREASE IN CONSUMER PRICE INDEX. IN ADDITION TO THE ANNUAL FEE, THE HOSPITAL IS REQUIRED TO PAY THE SALARIES, BONUSES AGREED UPON BY THE BOARD, AND ALL FRINGE BENEFITS OF THE MANAGEMENT COMPANY'S KEY PERSONNEL WHO PERFORM THE ADMINISTRATIVE DUTIES. FOR THE YEAR ENDED SEPTEMBER 30, 2010, THE MANAGEMENT FEES WERE APPROXIMATELY $233,000. THE AMOUNT OF SALARY AND FRINGE BENEFIT EXPENSE RELATED TO THE AGREEMENT WAS APPROXIMATELY $361,000 FOR THE YEAR ENDED SEPTEMBER 30, 2010. Form 990, Part VI, Section B, line 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH SUPERVISION AND ASSISTANCE BY MANAGEMENT. UPON COMPLETION, THE RETURN WAS REVIEWED BY MANAGEMENT AND DELIVERED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR APPROVAL. THE RETURN WAS THEN PRESENTED AT A SCHEDULED MEETING OF THE BOARD OF DIRECTORS BY A REPRESENTATIVE OF THE ACCOUNTING FIRM, AND EACH VOTING MEMBER OF THE BOARD WAS PROVIDED A COPY FOR DISCUSSION AND QUESTIONS. FOLLOWING THE MEETING AND A PERIOD OF TIME FOR COMMENT, THE RETURN WAS FILED WITH THE IRS. Form 990, Part VI, Section B, line 12c ANNUALLY, ALL VOTING BOARD MEMBER ARE PRESENTED WITH THE GOVERNANCE POLICIES CONCERNING THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. UPON REVIEW AND DISCUSSION CONCERNING RELATIONSHIPS WITH THE ORGANIZATION, ITS AFFILIATES, OR AMONGST EACH OTHER, THE BOARD MEMBER ARE REQUIRED TO COMPLETE AND RETURN THE POLICY STATEMENT TO THE ADMINISTRATION. THESE STATEMENTS ARE REVIEWED BY THE BOARD CHAIR AND ARE PRESENTED TO THE AUDITORS DURING THE ANNUAL AUDIT AS WELL. Form 990, Part VI, Section B, line 15 A REPRESENTATIVE FROM THE ALLIANT, THE OUTSIDE MANAGEMENT COMPANY MEETS WITH THE FINANCE COMMITTEE TO REVIEW SALARIES, AND THE SALARIES OF THE TOP EXECUTIVE AND OTHER MEMBERS OF THE ADMINISTRATIVE DEPARTMENT ARE DETERMINED IN THE CONTRACT NEGOTIATIONS. Form 990, Part VI, Section C, line 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. 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. SCHEDULE K, PART II, LINE 5: COST OF ISSUANCE: COSTS OF ISSUANCE IS COMPRISED OF THE FOLLOWING: BOND A: COST OF ISSUANCE - 289,506 BOND INSURANCE - 1,878,294 UNDERWRITER'S SPREAD - 240,000 TOTAL - 2,408,200 BOND B: COST OF ISSUANCE - 292,120 ATTORNEY'S FEES - 15,000 TOTAL - 307,120 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC 180 PARKWOOD DRIVE ELKIN NC 28621 562049537 FUNDRAISING NC 501(c)(3) Line 11a, I N/A HUGH CHATHAM MEMORIAL HOSPITAL AUXILIARY 180 PARKWOOD DRIVE ELKIN NC 28621 561199949 THRIFT/GIFT SHOP NC 501(c)(3) Line 11a, I N/A 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC B 193538 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC C 501575 HUGH CHATHAM MEMORIAL HOSPITAL AUXILIARY P 20888