TY 2010 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) KHADAR BAIG DIRECTOR	3.0	X		0	0
(2) WAYNE BARNES DIRECTOR	3.0	X		0	0
(3) JAMES BURKE DIRECTOR	3.0	X		0	0
(4) MICHAEL CADY DIRECTOR	3.0	X		0	0
(5) C DEVADASON EX-OFFICIO	3.0	X		0	0
(6) LOUIS JENKINS JR VICE CHAIR	3.0	X	X	0	0
(7) CANDICE QUINN KELLY EX-OFFICIO	3.0	X		0	0
(8) SARA MIDDLETON CHAIR	3.0	X	X	0	0
(9) VAN MITCHELL DIRECTOR	3.0	X		0	0
(10) SEETARAMAYYA NAGULA DIRECTOR	3.0	X		0	0
(11) ASHVIN J PATEL MD CHIEF OF STAFF	4.0	X	X	0	0
(12) SURYAKANT PATEL DIRECTOR	3.0	X		0	0
(13) BARBARA STEPURA DIRECTOR	3.0	X		0	0
(14) RICHARD WINKLER SECRETARY/TREASURER	3.0	X	X	0	0
(15) NOEL CERVINO PRESIDENT & CEO	40.0	X	X	445,695	63,432
(16) ERIK BOAS CFO	40.0		X	239,415	21,308
(17) MARK DUMAIS CHIEF INFO OFFICER	40.0		X	182,189	24,816

(A) Name and business address	(B) Description of services	(C) Compensation
MARYLAND INPATIENT CARE SPECIALISTS 2007 TIDEWATER COLONY WAY STE 1-A ANNAPOLIS,MD21401	PHYSICIANS	1,300,000
DIGITRACE CARE SERVICES INC 200 CORPORATE PLACE STE 58 PEABODY,MA01960	EEG PURCHASED SERV	599,675
ROI ELIGIBILITY SERVICES CORP 1920 GREENSPRING DR STE 200 TIMONIUM,MD21094	PT ACCTG PURCH SERV	592,564
MAYFLOWER TEXTILE SERVICE PO BOX 20659 BALTIMORE,MD21223	LAUNDRY	398,752
NDG COMMUNICATIONS INC 105 CENTENNIAL STREET SUITE K LA PLATA,MD20646	MARKETING	264,148
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 24

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21	86,592	86,592
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	627,700	502,160	125,540	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	38,553,382	30,842,706	7,710,676	0
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	1,135,979	908,783	227,196	0
9	Other employee benefits .......	3,961,570	3,169,256	792,314	0
10	Payroll taxes ...........	2,854,404	2,283,523	570,881	0
11	Fees for services (non-employees):
a	Management ......	200,000	0	200,000	0
b	Legal .........	404,096	0	404,096	0
c	Accounting ...........	300,651	0	300,651	0
d	Lobbying ...........	67,500	0	67,500	0
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	0
g	Other ..........	10,160,566	8,128,453	2,032,113	0
12	Advertising and promotion ....	174,327	130,745	43,582	0
13	Office expenses .......	0
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	2,109,300	1,096,836	1,012,464	0
17	Travel ............	36,613	9,153	27,460	0
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	3,175,167	0	3,175,167	0
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	4,454,144	4,142,354	311,790	0
23	Insurance ..............	2,123,376	0	2,123,376	0
24	Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a	SUPPLIES AND DRUGS	17,088,729	15,892,518	1,196,211	0
b	BAD DEBT	7,208,495	7,208,495	0	0
c	OTHER	1,841,943	242,249	1,599,694	0
d	EQUIPMENT RENTAL AND MAINT	3,835,478	1,265,708	2,569,770	0
e	TELEPHONE	422,595	845	421,750	0
f	All other expenses
25	Total functional expenses. Add lines 1 through 24f	100,822,607	75,910,376	24,912,231	0
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........		1
2	Savings and temporary cash investments .......	29,116,660	2	33,434,372
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	10,886,077	4	9,697,092
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	1,588,468	8	1,533,556
9	Prepaid expenses and deferred charges ............	854,589	9	895,718
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	103,000,316
b	Less: accumulated depreciation. .....	10b	39,881,340	65,421,048	10c	63,118,976
11	Investments—publicly traded securities ..........	75,000	11	0
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	17,751,002	15	19,323,794
16	Total assets. Add lines 1 through 15 (must equal line 34)...	125,692,844	16	128,003,508
	17	Accounts payable and accrued expenses .	16,336,955	17	14,668,027
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........	58,529,039	20	57,930,947
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	20,920,214	23	20,008,435
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities. Complete Part X of Schedule D.....	12,608,963	25	11,111,334
26	Total liabilities. Add lines 17 through 25.....	108,395,171	26	103,718,743
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	13,665,143	27	23,796,141
28	Temporarily restricted net assets .....	3,632,530	28	488,624
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	17,297,673	33	24,284,765
34	Total liabilities and net assets/fund balances .....	125,692,844	34	128,003,508

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the the supported organization? ................

11g(i)

(ii) a family member of a person described in (i) above? ......................

11g(ii)

(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of support?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2010

Page 2

Part II

Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3..
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public Support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2010. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2009. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2009. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 3

Part III

Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public Support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2009 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2009 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2010. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 4

Part IV

Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2010

Name of organization

Civista Medical Center Inc

Employer identification number

52-0445374

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ, that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, aggregate contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not aggregate to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... Arrow Bullet

Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization Civista Medical Center Inc
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part I
Part I	Contributors (see Instructions)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization Civista Medical Center Inc
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part II
Part II	Noncash Property (see Instructions)
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Page 1 of 1 of Part III

Name of organization
Civista Medical Center Inc

Employer identification number

52-0445374

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities .................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2010

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group.
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated Group Totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots non-taxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2010

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? If "Yes," describe in Part IV ..........................

Yes

78,982

Total. lines 1c through 1i ...................................

78,982

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
Lobbying Activities		The organization does not engage in any direct lobbying activities. The organization pays Baxter Baker a monthly fee to represent Civista as well as other Maryland hospitals to assist in lobbying and advertising for the hospitals. The organization pays membership dues to the Maryland Hospital Association (MHA) and the American Hospital Association (AHA). MHA and AHA engage in many support activities including lobbying and advocating for their member hospitals. The MHA and AHA reported that 8.65% and 24.42% of member dues were used for lobbying purposes and as such, the organization has reported this amount on Schedule C, part II-B as lobbying activities.

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .......
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) ...
4	Aggregate value at end of year .......

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or pleasure) Preservation of an historically importantly land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06 ........	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................

Yes No

In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIV.

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current Year	(b)Prior Year	(c)Two Years Back	(d)Three Years Back	(e)Four Years Back
1a	Beginning of year balance ....
b	Contributions ........
c	Investment earnings or losses ...
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the year end balance held as:

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

Term endowment: SchDMd Bullet

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

InvestmentsLand, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of investment		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................	72,170,257	17,425,704	54,744,553
c	Leasehold improvements ............	2,288,604	1,190,862	1,097,742
d	Equipment ................	28,541,455	21,264,774	7,276,681
e	Other .................	0	0	0
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				63,118,976

Schedule D (Form 990) 2010

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) SECURITY DEPOSITS				3,684
(2) OTHER CURRENT RECEIVABLES				36,936
(3) INV CHES POTOMAC HEALTHCARE				2,867,151
(4) ASSETS LIMITED TO USE				6,493,301
(5) PHYSICIANS LOAN				222,589
(6) INVEST IN JV FREESTATE				15,441
(7) DEFERRED FINANCING COSTS				2,150,670
(8) INVESTMENT MARYLAND ECARE				10,000
(9) DUE FROM AFFILIATES				3,571,346
(10) ECON INT IN NET ASSETS OF FDTN				3,952,676
Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........				19,323,794

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Amount
Federal Income Taxes		0
ADVANCES FROM THIRD PARTIES		3,409,780
ACCRUED INTEREST PAYABLE		1,336,007
ACCRUED PENSION COSTS		4,197,886
DUE TO AFFILIATE		247,418
LEASE LIABILITIES		420,131
MALPRACTICE IBNR		1,500,112



Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		11,111,334
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2010

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3
4	Net unrealized gains (losses) on investments ..........................	4
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV) .................................	8
9	Total adjustments (net). Add lines 4 - 8 .............................	9
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10

Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV): ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIV): ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......		5

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIV): ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIV): ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......		5

Part XIV

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
FIN 48 Footnote		The organization accounts for uncertainty in income taxes in accordance with FIN 48 (as codified). The organization's audited financial statements do not include any liabilities for uncertain tax positions.

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE F
(Form 990)

Department of the Treasury
Internal Revenue Service

Statement of Activities Outside the United States

Complete if the organization answered "Yes" to Form 990,
Part IV, line 14b, 15, or 16.
Right pointing arrow large image

Attach to Form 990. Right pointing arrow large image

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization
Civista Medical Center Inc

Employer identification number

52-0445374

Part I

General Information on Activities Outside the United States. Complete if the organization answered
“Yes” to Form 990, Part IV, line 14b.

For grantmakers. Does the organization maintain records to substantiate the amount of the grants or

assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award

the grants or assistance? ...................................

Yes

For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside the
United States.

Activites per Region. (Use Part V if additional space is needed.)

(a) Region		(d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region)	(e) If activity listed in (d) is a program service, describe specific type of service(s) in region	(f) Total expenditures for region/investments in region
	Central America and the Caribbean	Program Services	insurance	1,651,125
















3a	Sub-total .....			1,651,125
b	Total from continuation sheets to Part I ...
c	Totals (add lines 3a and 3b)			1,651,125

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2010

Schedule F (Form 990) 2010

Page 2

Part II

Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990,

Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 ........ MediumBullet

Use Part V if additional space is needed.

1 (a) Name of organization		(b) IRS code section and EIN (if applicable)	(c) Region	(d) Purpose of grant	(e) Amount of cash grant	(f) Manner of cash disbursement	(g) Amount of of non-cash assistance	(h) Description of non-cash assistance	(i) Method of valuation (book, FMV, appraisal, other)

Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter ..... MediumBullet

Enter total number of other organizations or entities ........................ MediumBullet

Schedule F (Form 990) 2010

Schedule F (Form 990) 2010Page 3

Part III

Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.

Use Part V if additional space is needed.

(a) Type of grant or assistance		(b) Region	(c) Number of recipients	(d) Amount of cash grant	(e) Manner of cash disbursement	(f) Amount of non-cash assistance	(g) Description of non-cash assistance	(h) Method of valuation (book, FMV, appraisal, other)

Schedule F (Form 990) 2010

Page 4

Part IV

Foreign Forms

Schedule F (Form 990) 2010

Page 5

Part V

Supplemental Information
Complete this part to provide the information (see instructions) required in Part I, line 2, and any additional information.

Identifier	ReturnReference	Explanation

Schedule F (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Does the organization have a charity care policy? If "No," skip to question 6a...........

Yes

If "Yes," is it a written policy? .......................

Yes

If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.

Applied uniformly to all hospitals Applied uniformly to most hospitals Generally tailored to individual hospitals

Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.

Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low

income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If

"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....

Yes

200% 250% 300% 350% 400% Other

If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Does the organization's policy provide free or discounted care to the "medically indigent"? ......

Yes

Does the organization budget amounts for free or discounted care provided under its charity care policy? ...

Yes

If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............

Does the organization prepare an annual community benefit report?.............

Yes

If "Yes," does the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Charity Care and Certain Other Community Benefits at Cost

	(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Charity care at cost (from Worksheets 1 and 2) ..			1,410,086		1,410,086	1.410 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....			1,410,086		1,410,086	1.410 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	36	168,619	533,851	650	533,201	0.530 %
f Health professions education (from Worksheet 5) ..	7	280	330,757		330,757	0.330 %
g Subsidized health services (from Worksheet 6) ..	7	145	1,643,721	181,814	1,461,907	1.460 %
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	15	1,772	123,141		123,141	0.120 %
jTotal Other Benefits ...	65	170,816	2,631,470	182,464	2,449,006	2.440 %
kTotal. Add lines 7d and 7j. ..	65	170,816	4,041,556	182,464	3,859,092	3.850 %

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010

Schedule H (Form 990) 2010

Page 2

Part II

Community Building Activities Complete this table if the organization conducted any community building activities.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	3	142	7,790	275	7,515	0.010 %
3	Community support	7	13	36,522		36,522	0.040 %
4	Environmental improvements
5	Leadership development and training for community members	1		10,617		10,617	0.010 %
6	Coalition building	3	20	3,990		3,990
7	Community health improvement advocacy	2		447		447
8	Workforce development	5		253,270		253,270	0.250 %
9	Other
10	Total	21	175	312,636	275	312,361	0.310 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense (at cost).....

5,766,796

Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..

Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

29,165,785

Enter Medicare allowable costs of care relating to payments on line 5.....

35,194,893

Subtract line 6 from line 5. This is the surplus or (shortfall)........

-6,029,108

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Does the organization have a written debt collection policy? ...............

Yes

If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......

Yes

Part IV

Management Companies and Joint Ventures

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	Civista Medical Center 5 Garrett Ave La Plata,MD20646	X	X	X

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)

Name of Hospital Facility:Civista Medical Center

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet those needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Development of a community benefit plan for the facility
	d	Participation in community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the CHNA
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs.		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?..		9
	If “Yes,” indicate the FPG family income limit for eligibility for free care: %

Schedule H (Form 990) 2010

Page 5

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care to low income individuals?.........		10
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: %
11	Explained the basis for calculating amounts charged to patients?.................		11
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted at all times on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........		14
15	Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments or arrests
	e	Other (describe in Part VI)
16	Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?...................................		16
	If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other (describe in Part VI)
17	Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
	e	Other (describe in Part VI)

Schedule H (Form 990) 2010

Page 6

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18
	If “No,” indicate the reasons why (check all that apply):
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility did not have a policy relating to emergency medical care
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Charges for Medical Care
19	Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
	a	The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
	b	The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
	c	The hospital facility used the Medicare rate for those services
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?...................................		21
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2010

Page 7

Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, measured by total revenue per facility, from largest to smallest) How many non-hospital facilities did the organization operate during the tax year?
Name and address		Type of Facility (Describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2010

Page 8

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2	Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
Schedule H Supplemental Information		Part I, Line 6a: AN ANNUAL COMMUNITY BENEFIT REPORT IS PREPARED FOR EACH FISCAL YEAR ENDING JUNE 30. THIS REPORT IS SUBMITTED TO THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC), A STATE REGULATORY AGENCY, BY DECEMBER 31 OF EACH YEAR. IN ADDITION, A SUMMARY OF THE COMMUNITY BENEFITS PROVIDED BY THE MEDICAL CENTER IS LOCATED ON OUR WEBSITE: HTTP://WWW.CIVISTA.ORG/FUSEACTION-ABOUTUS.SHOWCOMMUNITYBENEFITS.HTM Part I, Line 7: MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE. COMMUNITY BENEFIT EXPENSES ARE EQUAL TO MEDICAID REVENUES IN MARYLAND, AS SUCH, THE NET EFFECT IS ZERO. ADDITIONALLY, NET REVENUES FOR MEDICAID SHOULD REFLECT THE FULL IMPACT ON THE HOSPITAL OF ITS SHARE OF THE MEDICAID ASSESSMENT. Part III, Line 4: CIVISTA REPORTS BAD DEBT EXPENSE IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP) HFMA 15. THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY, AS WELL AS, THE ACCUMULATION OF RECEIVABLE BALANCES BY PERIOD OUTSTANDING. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY NECESSARY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS AND THE ESTABLISHED ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER COLLECTION OF AMOUNTS DUE FROM INSURERS, THE CORPORATION FOLLOWS INTERNAL GUIDELINES FOR PLACING CERTAIN PAST DUE BALANCES WITH COLLECTION AGENCIES. Part III, Line 8: IN MARYLAND, THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC) STARTED SETTING HOSPITAL RATES IN 1974. AT THAT TIME, THE HSCRC APPROVED RATES APPLIED ONLY TO COMMERCIAL INSURERS. IN 1977, THE HSCRC NEGOTIATED A WAIVER FROM MEDICARE HOSPITAL PAYMENT RULES FOR MARYLAND HOSPITALS TO BRING THE FEDERAL MEDICARE PAYMENTS UNDER HSCRC CONTROL. MEDICARE REIMBURSES MARYLAND HOSPITALS ACCORDING TO RATES ESTABLISHED BY THE HSCRC AS LONG AS THE STATE CONTINUES TO MEET A TWO-PART TEST. THIS TWO-PART WAIVER TEST ALLOWS MEDICARE TO PARTICIPATE IN THE MARYLAND SYSTEM AS LONG AS TWO CONDITIONS ARE MET: - ALL OTHER PAYERS PARTICIPATING IN THE SYSTEM PAY HSCRC SET RATES AND - THE RATE OF GROWTH IN MEDICARE PAYMENTS TO MARYLAND HOSPITALS FROM 1981 TO THE PRESENT IS NOT GREATER THAN THE RATE OF GROWTH IN MEDICARE PAYMENTS TO HOSPITALS NATIONALLY OVER THE SAME TIME FRAME. Needs Assessment: Civista Health Inc and the Charles County Department of Health collaborated to complete a comprehensive assessment of the health needs (CHNA) of Charles County, Maryland. An epidemiologist with a Master's Degree in Public Health Epidemiology was contracted to analyze the qualitative and quantitative data. Civista lead the effort and covered 80% of the cost of the CHNA. To provide a comprehensive assessment of the health needs of the county, a four method plan was developed which included 4 different sources of data: a long online survey of Charles County residents perceptions of health and health behaviors, a short paper survey on health perceptions throughout the county, 7 focus groups with community leaders, citizens, and stakeholders, and a quantitative data analysis. The use of the multiple data collection methods strengthened the validity of the assessment's findings, as well as ensuring that Charles County residents had an opportunity to participate in the assessment process and to feel invested in its outcome. 302 Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health Inc website. The first section of the survey asked participants about their perception of health and health services within the county. The second section asked them about their health behaviors, in order to determine their risk for the development of certain health conditions. Seven focus groups were held throughout the county. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC) (community leaders and stakeholders). Approximately 165 people participated in the county focus groups. Quantitative data was analyzed for several health topics including: mortality, population and demographic data, nationality, infant mortality, heart disease, stroke, hypertension, access to health care/health insurance, cancer, asthma, injuries, diabetes, obesity, osteoporosis, arthritis, dementia/Alzheimer's disease, communicable disease, sexually transmitted diseases, HIV/AIDS, mental health, dental health, substance abuse, disabilities, and tobacco use. Cumulative analysis of all quantitative and qualitative data identified the top 10 health needs of Charles County which was presented to the Partnerships for a Healthier Charles County, a coalition of Charles County agencies and organizations. The direction of Partnerships for a Healthier Charles County is guided by the Steering Committee which consists of leadership from Civista, Charles County Department of Health, Charles County Public Schools and the College of Southern Maryland. Focus Groups Included representatives from the following organizations: Partnerships for a Healthier Charles County Civista Health Civista Health, Board Of Directors Charles County Department of Health University of Maryland Clinical Trials Program Bel Alton Alumni Association Charles County Department of Community Services, Transportation Tri County Council for Southern Maryland Minister's Alliance of Charles County CC Department of Social services Maryland Foundation for Quality healthcare Health Partner's Clinic Shiloh Community United Methodist Church CC Nursing and Rehabilitation Center Alzheimer's Association Center for Children Chesapeake Potomac Home Health Agency College of Southern Maryland Charles County Department of Aging Priority partners Big Brothers/Big sisters Community Hispanic Advocates Black Leadership Council for Excellence Young Researchers Community Project Pinnacle Center (Mental Health) Hospice Breast Cancer Support Advocates Charles County Public Schools School Nurses Charles County Commissioners Charles County Emergency Services Charles County Sheriff's Office So MD Delegates Charles County Community Foundation Community Physicians Charles County Fire and Rescue Board Surveys from Community Stakeholders 302 Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health website. A short 3 question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista waiting rooms, Charles County Department of Health waiting rooms, libraries, senior centers, community centers. 35 were completed in Spanish (17.5%). Part III, Line 9b: Regardless of the status of collections, if a patient applies for financial assistance and meets the eligibility requirements, the balance is written off according to the percentage they qualify for. Patient Education on Eligibility for Assistance: Civista Medical Center posts its charity care policy, or a summary thereof, and financial assistance contact information in admissions areas, emergency rooms, other areas of the facility in which eligible patients are likely to present. Patients are provided counseling, if applicable, on available financial assistance options upon admission and/or discharge including eligibility for government or State benefits. Assistance is provided where applicable, on completion of paperwork for such programs. In addition, the policy is available on the Civista website (www.civista.org) and is posted in the local paper twice each year.
Community Information:		Charles County Geographic and Demographic Profile: Charles County is a largely rural jurisdiction located approximately 18 miles south of Washington, D.C. It is one of five Maryland counties, which are part of the Washington, DC MD VA metropolitan area. At 461 square miles, Charles County is the eighth largest of Maryland's twenty four counties and accounts for about 5 percent of Maryland's total landmass. The northern part of the county is the "development district" where commercial, residential, and business growth is focused. The major communities of Charles County are La Plata, the county seat; Port Tobacco, Indian Head, and St Charles; and the main commercial cluster of Hughesville Waldorf White Plains. Approximately 60 percent of county's residents live in the greater Waldorf La Plata area. Charles County has experienced rapid growth since 1970, expanding its population from 47,678 to 120,546 in the 2000 census. Current US Census 2010 estimates are that the population now exceeds 146,551. This magnitude of growth can be seen in the changes in population density. The 1990 census showed that there were 219.4 individuals per square mile, and by 2000, there were 261.5 individuals per square mile an increase of 19.2 percent. This percent change in population growth continued from 2000 to 2010 when Charles County experienced a 21.6% increase in population. The percent change in the population growth for Charles County has been markedly greater than the change seen in the Maryland state population growth (9.0%). As the population of the county changes, the diversity of the county also increases. The African American population has experienced the greater increases in population. In 2000, African Americans made up 26% of the total Charles County population; by 2009, they now comprise 41% of the total county population. For 2009, minorities make up 49.7% of the Charles County population. The Hispanic community has also seen increases over the past few years. They now comprise 4.3% of the total county population. This is one of the highest percentages among the 24 Maryland jurisdictions. The age breakdown of the Charles County population shows a young population between the ages of 18 44 years. The juvenile population (under 17 years) makes up 27% of the Charles County population. The 2009 Charles County gender breakdown is approximately 50/50. Males make up 48.7% of the population, and females make up 51.3% of the county population. Employment and economic indicators for the county are fairly strong. The 2005-2009 US Census estimates for Charles County found that 73.8% of the population is currently in the labor work force. The Charles County median household income was $85,899, well above the Maryland median household income of $69,193. The percentage of all Charles County people whose income in the past 12 months is below the poverty level is 4.9%. The estimate of people with no health insurance coverage in Charles county is 9.4%. The percentage of Charles County residents who have public health insurance is 17.4%. The life expectancy from birth for a Charles County resident as calculated for 2008 2009 was 78.1 years. This is similar to the state average life expectancy of 78.6 years. There were a total of 871 deaths in Charles County in 2009. The 2007 2009 Charles County all cause mortality rate was 845.2 per 100,000 population. This rate is higher than the Maryland state all cause mortality rate of 768.4 per 100,000 population. The number one cause of death for the time period 2009 and for the time period 2007-2009 was heart disease. The 2007-2009 Charles County heart disease death rate was 228.5 per 100,000. This is also higher than the Maryland state rate of 196.8 per 100,000. Charles County had higher 2007-2009 mortality rates than Maryland for heart disease, cancer, chronic lower respiratory disease, accidents, and diabetes mellitus. Two thirds of the deaths in Charles County in 2009 were among the White population. They make up approximately half of the total county population. When comparing by 2009 calculated crude death rates, the rate is much higher in the White population. The 2009 Charles County White death rate was 739.9 per 100,000. This is much higher than the Charles County total 2009 crude death rate of 612.4 per 100,000 and higher than the death rates for Blacks (468.8), for Asians and Pacific Islanders (308.2), and for Hispanics (142.8). There is a high level of home ownership in Charles County (81.9%). The median value of a housing unit in Charles County is higher than the Maryland average ($352,000 vs. $326,400). The average number of people in a Charles County household is 2.84 persons. Charles County residents are a commuter population. They spend an average of 40.5 minutes of travel time to work each day. Charles County has a larger percentage of high school graduates than Maryland (90.2% vs. 87.5%); however, Charles County has a smaller percentage of individuals with a bachelor's degree or higher than Maryland does (25.4% vs. 35.2%). Community building activities: Civista Medical Center sponsors community building initiatives for example: 1. Physician recruitment efforts through funded Physician Recruitment position at Civista Medical Center; Staff participation in groups such the Maryland Healthcare Roundtable, Maryland Healthcare Commission; Management Agreement with University of Maryland Medical System. Recruitment of physicians to Charles County concentrating in the high priority areas of the 83 specialties lacking; Physician recruiter retained by Civista; Evaluation by number of physicians successfully recruited and placed. a. In November 2009, Civista Health signed Management Agreement with University of Maryland Medical System with physician recruitment as major initiative. b. According to the Maryland Health Commission, 83 physician specialties are in shortage in the Southern Maryland area. Of particular lack in Charles County is Obstetrics and Gynecology. In 2009, only 6 OB/GYN physicians were providing care at Civista- 4 of whom are employed by Civista Medical Center and also provider care for prenatal clinic for the uninsured and underinsured. The rising infant mortality rate in Charles County raised the recruitment of OB/GYN practitioners to priority one. Recruitment efforts are ongoing for other physician specialties are ongoing for orthopedics, oncology, general surgery and gastroenterology. 2. Civista Medical Center participates as a lead organization in Partnerships for a Healthier Charles County (PHCC), a 70 plus member organization of health providing not for profits, businesses, and organizations. The other lead organizations are Charles County Department of Health, Charles County Public Schools and College of Southern Maryland. Through PHCC, the Community Heath Needs Assessment is completed. 3. Emergency/Disaster Preparedness Civista Medical Center participates in joint disaster preparedness drills and planning sessions with federal, county, state and regional entities for issues such as H1N1, NEIMS and inaugural disaster planning and preparedness. additionally, Civista participates in Indian Head Naval Base disaster support. Disaster preparedness medical equipment is purchased for emergency purposes. Promotion of Community Health: The majority of the governing body, the Board of Directors, of Civista Medical Center is comprised of persons who reside in the community served by the hospital and who are neither employees nor contractors of the organization. Civista Medical Center extends medical privileges to all qualified medical staff in the community. Continuing Medical Education seminars and Grand Rounds are open to all community physicians. State filing of community benefit report MD,

Schedule H (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
Civista Medical Center Inc

Employer identification number
52-0445374

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance
(1) Health Partners IncPO Box 1865 Waldorf,MD20604	52-1767044	501(c)(3)	49,992				Donation
(2) Charles County Department of Health250 Williams Street La Plata,MD20646	52-2046030	501(c)(3)	15,000				Prostate Cancer Program
(3) Habitat for Humanity International IncPO BOX 2734 LA PLATA,MD20646	52-1715451	501(c)(3)		21,600	FMV	Equipment	Equipment

Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image

Enter total number of other organizations ................................ . Bullet Image

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2010

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance

Part IV

Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.

Identifier	Return Reference	Explanation
Part I, Line 2		Civista Medical Center makes financial and in-kind contributions to various charitable organizations in the community.

Schedule I (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Participate in, or receive payment from, an equity-based compensation arrangement? ........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported in prior Form 990 or Form 990-EZ
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) NOEL CERVINO	(i) (ii)	303,519 0	132,000 0	10,176 0	50,848 0	12,584 0	509,127 0	0 0
(2) ERIK BOAS	(i) (ii)	182,112 0	54,900 0	2,403 0	19,582 0	1,726 0	260,723 0	0 0
(3) MARILYN GREGORY	(i) (ii)	164,064 0	0 0	0 0	2,600 0	3,756 0	170,420 0	0 0
(4) STACEY COOK	(i) (ii)	140,006 0	7,500 0	0 0	10,832 0	9,824 0	168,162 0	0 0
(5) MARK DUMAIS	(i) (ii)	177,885 0	0 0	4,304 0	19,303 0	5,513 0	207,005 0	0 0
(6) MELANIE SAGE	(i) (ii)	156,691 0	7,500 0	0 0	16,500 0	2,232 0	182,923 0	0 0
(7) GARY HERBEK	(i) (ii)	220,560 0	7,500 0	0 0	16,500 0	6,217 0	250,777 0	0 0
(8) CHRISTINE STEFANIDES	(i) (ii)	111,214 0	0 0	0 0	19,015 0	207 0	130,436 0	0 0
(9) KEVIN BURBULES	(i) (ii)	139,235 0	7,500 0	0 0	14,972 0	3,432 0	165,139 0	0 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
Civista Medical Center Inc

Employer identification number
52-0445374

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	MARYLAND HEALTH AND HIGHER EDUCATIONAL FACILITIES	52-0936061	574217UL7	02-09-2005	60,097,615	HOSPITAL ADDITIONS/RENOVATIONS		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired. . . . .
2 Amount of bonds defeased . . . .
3 Total proceeds of issue . . . .	60,097,615
4 Gross proceeds in reserve funds . .	4,511,625
5 Capitalized interest from proceeds.
6 Proceeds in refunding escrow. . . . .
7 Issuance costs from proceeds . . .	3,796,282
8 Credit enhancement from proceeds.
9 Working capital expenditures from proceeds . .
10 Capital expenditures from proceeds . .	51,789,708
11 Other spent proceeds . .
12 Other unspent proceeds. . .
13 Year of substantial completion . . .	2007
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue?		X
15 Were the bonds issued as part of an advance refunding issue?		X
16 Has the final allocation of proceeds been made? . .	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .	X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . .		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .		X

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2010

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use?		X
b Are there any research agreements that may result in private business use of bond-financed property? . .		X
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .	X
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . .	0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .	0 %
6 Total of lines 4 and 5 . . .. . . . . .	0 %
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?	X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .	X
2 Is the bond issue a variable rate issue?		X
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?		X
b Name of provider .
c Term of hedge . .
d Was the hedge superintegrated? .
e Was a hedge terminated? .
4a Were gross proceeds invested in a GIC? .		X
b Name of provider .
c Term of GIC . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .
5 Were any gross proceeds invested beyond an available temporary period? .		X
6 Did the bond issue qualify for an exception to rebate? . . .		X

Schedule K (Form 990) 2010

Page 3

Part V

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule K (see instructions).

Identifier	Return Reference	Explanation
SEE SCHEDULE O

Schedule K (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Identifier	Return Reference	Explanation
DESCRIPTION OF 990 REVIEW PROCESS	PART VI, LINE 11	The process for reviewing the Form 990 begins with Civista's Staff Accountant working with the Controller in reviewing the first Draft Form 990. The Staff Accountant and Controller will coordinate with the independent accounting firm, KPMG, to update any necessary changes. While the Controller schedules the services of KPMG to present the Final Draft Form 990 to the Finance Committee of the Board of Directors, the Chief Financial Officer will review the document before the Final Draft is generated. Once all necessary corrections are made, copies of the Final Draft Form 990 will be provided to the Finance Committee prior to the meeting for their review (which will be required to be kept confidential until the Form 990 is finalized and signed). The Final Draft Form 990 will be presented by KPMG at the Finance Committee meeting for questions and final approval. Once the Finance Committee approves the Form 990 to be signed, the President and Chief Executive Officer will sign as Civista's authorized signer. The Final Form 990 will be provided to the full Board of Directors for informational purposes before filing.
PROCESS FOR DETERMINING COMPENSATION	PART VI, LINE 15	The organization utilizes an independent compensation committee, an independent compensation consultant, a written employment contract, a compensation survey or study, and approval by the board/compensation committee. The chief executive officer/president and the executive committee of the board reviews and approves the compensation for the organization's top management officials and other officers and key employees. The salary of management employees are based a market study of comparable positions, education, and experience as related to the manager's position. In order to determine the manager's salary, the compensation and benefits specialist completes a relative market study to obtain information about comparable jobs in the healthcare industry. Human resources evaluates the market study and then makes a recommendation. Human resources also uses data prepared by independent compensation consultants. After deciding on the compensation of the management employee, the decision is documented in the executive committee minutes. The year that this process was last undertaken for these types of positions was in the current year. The chief executive officer/president is the only employee who has a written contract. Effective October 1, 2009, the chief executive officer, chief financial officer, chief medical officer and chief information officer are employees of the University of Maryland Medical System (UMMS) and their compensation packages are determined per an UMMS executive compensation committee.
CONFLICTS MONITORING AND ENFORCEMENT	Part VI, Line 12c	The conflicts monitoring and enforcement policy is established to prohibit activities that may conflict or appear to conflict with Civista's business. Employees in key positions at Civista have an obligation to Civista to avoid conflict of interest situations. Key employees are exempt administrative and non-exempt employees who have the authority to make commitments for Civista resources. All key employees must sign a disclosure of business interest/conflict of interest statement. It is the policy of Civista that key employees disclose any detail of any activities or interests which may conflict or appear to conflict with Civista's business. Conflict of interest behaviors are varied; however, it would be prohibited for an employee to be directly connected in any manner with any business or entity which sells or provides materials, supplies, equipment, facilities or services to or which is in direct or indirect competition with or which is a customer of Civista. All employees shall refrain from any conduct during the performance of their duties that has the appearance of impropriety or that could reasonably be construed as contrary to the interests and mission of this organization. An employee may not accept cash in any amount or other personal gifts having any value or any other personal favors for performance which goes beyond common courtesy in the performance of his/her job duties from anyone with whom Civista has or is likely to have any business dealings. These individuals may include an employee, perspective employees, customers, competitors or vendors. An employee may not disclose directly or indirectly any information of any kind acquired in the course of employment or association with Civista or use any such information to further any personal interests or to the detriment of Civista. Any employee who has knowledge of activities that he or she believes may violate any of these procedures has an obligation to report them immediately to their supervisor/department manager or the Vice President, Human Resources. Any individual who knowingly violates this policy is subject to disciplinary action up to and including discharge in addition to potential criminal prosecution. While all employees are required to sign a conflict of interest disclosure, it is the policy of Civista that key employees disclose any detail of any activities or interests which may conflict or appear to conflict with Civista's business. The responses are initially reviewed by human resources. If anything is disclosed, the disclosure is sent to the compliance officer who consults with outside attorneys. After review of the disclosures, if a conflict is identified, the employee would be notified of the conflict and asked to refrain from any further activity. Depending on the conflict, the appropriate action would be for the person involved to recuse themselves. If an individual knowingly violates this policy, they will be subject to disciplinary action up to and including discharge in addition to potential criminal prosecution. As part of the annual competencies, every employee completes a online module in Healthstream, Civista's online support page, which details their responsibility for disclosure under the policy.
DOCUMENTATION AVAILABILITY	PART VI, LINE 19	THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
MANAGEMENT SERVICES AGREEMENT	PART VI, LINE 3	Effective October 1, 2009, Civista Health and its related organizations signed a management services agreement with university of Maryland medical system corporation ("UMMS", a section 501(c)(3) organization) whereby UMMS provides management supervision for the operation and strategic development of Civista with the goal of improving service, quality of care and other areas of operation. The Chief Executive Officer, the Chief Financial Officer, the Chief Medical Officer, and the Chief Information Officer are employees of UMMS, but Civista medical center reimburses UMMS for their compensation packages. In addition to reimbursing UMMS for the services of the senior executive personnel, Civista Medical Center pays UMMS a fee for other services under the agreement. Effective July 1, 2011, the company entered into an affiliated agreement with UMMS, whereby UMMS became the sole corporate member of the company. The residents of the region served by the company will benefit from accelerated deployment of clinical programs and technologies and improved access to physicians.
SCHEDULE K		Part I AMOUNTS CUSIP NUMBERS -------- $ 540,000 574217UL7 555,000 574217UM5 575,000 574217UN3 590,000 574217UP8 610,000 574217UQ6 630,000 574217UR4 650,000 574217US2 675,000 574217UT0 700,000 574217UU7 730,000 574217UV5 760,000 574217UW3 790,000 574217UX1 820,000 574217UY9 7,900,000 574217UZ6 10,425,000 574217VA0 32,050,000 574217VB8 $59,000,000 BONDS AT REDEMPTION PRICE Part II Of the proceeds reported as issuance costs, $1,180,000 of the proceeds were used for bond issuance costs (including underwriters' discount) and $2,616,282 of the proceeds were used for credit enhancement.
OTHER CHANGES IN NET ASSETS	FORM 990, PART XI, LINE 5	CHANGE IN MINIMUM PENSION LIABILITY 3,682,607 NET ASSETS RELEASED FROM RESTRICTION (1,289,019) ----------- TOTAL TO PART XI, LINE 5 2,393,588 BEGINNING NET ASSETS WERE ADJUSTED TO INCLUDE THE MEDICAL CENTER'S ECONOMIC INTEREST IN THE NET ASSETS OF CIVISTA HEALTH FOUNDATION.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) CIVISTA HEALTH INC 5 GARRETT AVE LA PLATA,MD20646 52-2155576	PARENT	MD	501(C)(3)	11C	N/A
(2) CIVISTA HEALTH FOUNDATION INC 616 E CHARLES ST LA PLATA,MD20646 52-1414564	FUNDRAISING	MD	501(C)(3)	11A	CIVISTA HLTH
(3) CIVISTA HEALTH AUXILIARY INC 5 GARRETT AVE LA PLATA,MD20646 52-1131193	AUXILIARY	MD	501(C)(3)	9	CIVISTA HLTH

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2010

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)
(1) CIVISTA CARE PARTNERS INC 5 GARRETT AVE LA PLATA,MD20646 52-2176314	HEALTHCARE	MD	CIVISTA HLTH	C Corp

Schedule R (Form 990) 2010

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III or IV.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .

Yes

m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved
(1) CIVISTA HEALTH INC	Q	1,206,066
(2) CIVISTA HEALTH FOUNDATION INC	R	1,015,000
(3) CIVISTA HEALTH FOUNDATION INC	Q	1,340,000
(4) CIVISTA HEALTH FOUNDATION INC	P	217,422
(5) CIVISTA HEALTH FOUNDATION INC	N	201,332
(6) CIVISTA CARE PARTNERS INC	R	250,000
(7) CIVISTA CARE PARTNERS INC CCS LLC	R	220,437
(8) CIVISTA CARE PARTNERS INC CCS LLC	Q	105,142
(9) CIVISTA CARE PARTNERS INC CCP LLC	R	575,000
(10) CIVISTA CARE PARTNERS INC CCP LLC	Q	460,000

Schedule R (Form 990) 2010

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Are all partners section 501(c)(3) organizations?		(e) Share of end-of-year assets	(f) Disproprtionate allocations?		(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(h) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(e) Share of end-of-year assets	Yes	No	(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2010

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: CIVISTA MEDICAL CENTER PROVIDES EXCELLENT CARE TO EACH PATIENT IN A SAFE, CARING AND FAMILY-CENTERED ENVIRONMENT.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	15
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	14
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	1,016
6	Total number of volunteers (estimate if necessary) ....	6	129
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	155,988
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	35,260

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	27,613	1,677,803
9	Program service revenue (Part VIII, line 2g) .........	101,981,695	103,083,914
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	131,108	109,879
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	526,449	544,515
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	102,666,865	105,416,111
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	93,470	86,592
14	Benefits paid to or for members (Part IX, column (A), line 4) ....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	45,152,262	47,133,035
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	55,574,825	53,602,980
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	100,820,557	100,822,607
19	Revenue less expenses. Subtract line 18 from line 12......	1,846,308	4,593,504
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	125,692,844	128,003,508
21	Total liabilities (Part X, line 26)............	108,395,171	103,718,743
22	Net assets or fund balances. Subtract line 21 from line 20 .....	17,297,673	24,284,765

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4a	(Code: ) (Expenses $ 75,910,376 including grants of $ 86,592 ) (Revenue $ 103,083,914 )
	Civista Medical Center Community Benefits Program utilizes a planned, managed, organized, and measured approach to meeting the identified community needs of the area we serve. The mission is to improve overall community health by improving access to health care, enhancing the health of the community, advancing healthcare knowledge and working with health - providing agency partners. Civista Medical Center in Partnership with the Charles County Department of Health (CCDOTT), has conducted a Health Needs Assessment of Charles County every 5 years. Beginning calendar year 2011, in accordance with new regulations, the Health Needs Assessment will be conducted every 3 years. The data included in this report was collected in calendar year 2011. Civista Medical Center and the Charles County Department of Health collaborated to complete a comprehensive health needs assessment (CHNA) of Charles County, Maryland. An epidemiologist with a Master's Degree in Public Health Epidemiology was contracted to analyze the qualitative and quantitative data. Civista lead the effort and covered 80% of the cost of the CHNA. To provide a comprehensive assessment of the health needs of the county, a four part method plan was developed which included 4 different sources of data: a long online survey of Charles County residents perceptions of health and health behaviors, a short paper survey on health perceptions throughout the county, 7 focus groups with community leaders, citizens, and stakeholders, and a quantitative data analysis. The use of the multiple data collection methods strengthened the validity of the assessment's findings, as well as ensuring that Charles County residents had an opportunity to participate in the assessment process and to feel invested in its outcome. 302 Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health website. The first section of the survey asked participants about their perception of health and health services within the county. The second section asked them about their health behaviors, in order to determine their risk for the development of certain health conditions. A short 3 question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista waiting rooms, CCDOH waiting rooms, libraries, senior centers, community centers. 35 were completed in Spanish (17.5%). Seven focus groups were held throughout the county. The focus group topics included: age-related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC) (community leaders and stakeholders). Approximately 165 people participated in the county focus groups. Quantitative data was analyzed for several health topics including: mortality, population and demographic data, natality, infant mortality, heart disease, stroke, hypertension, access to health care/health uninsurance, cancer, asthma, injuries, diabetes, obesity, osteoporosis, arthritis, dementia/Alzheimer's disease, communicable disease, sexually transmitted diseases, HIV/AIDS, mental health, dental health, substance abuse, disabilities, and tobacco use. Cumulative analysis of all quantitative and qualitative data identified the top 10 health needs of Charles County which was presented to the Partnerships for a Healthier Charles County, a coalition of Charles County agencies and organizations. The direction of Partnerships for a Healthier Charles County is guided by the Steering Committee which consists of leadership from Civista, Charles County Department of Health, Charles County Public Schools and the College of Southern Maryland. Focus Groups Included representatives from the following organizations: Partnerships for a Healthier Charles County: " Civista Health " Civista Health, Board Of Directors " Charles County Department of Health " University of Maryland Clinical Trials Program " Bel Alton Alumni Association " Charles County Department of Community Services, Transportation " Tri County Council for Southern Maryland " Minister's Alliance of Charles County " CC Department of Social services " Maryland Foundation for Quality healthcare " Health Partner's Clinic " Shiloh Community United Methodist Church " CC Nursing and Rehabilitation Center " Alzheimer's Association " Center for Children " Chesapeake Potomac Home Health Agency " College of Southern Maryland " Charles County Department of Aging " Priority partners " Big Brothers/Big sisters " Community Hispanic Advocates " Black Leadership Council for Excellence " Young Researchers Community Project " Pinnacle Center (Mental Health) " Hospice " Breast Cancer Support Advocates " Charles County Public Schools - School Nurses " Charles County Commissioners " Charles County Emergency Services " Charles County Sheriff's Office " So MD Delegates " Charles County Community Foundation " Community Physicians " Charles County Fire and Rescue Board Accomplishments: Civista Medical Center provided over $4.1 million in charity care, health professions education, community benefit operations, community health improvement services, subsidized health services, cash and in-kind donations and community building activities in FY2011. This year, we provided and supported programs and activities such as: screenings and education; Heart disease; blood pressure screenings; stroke screenings; education programs such as stroke risk reduction; and Lowering your Cholesterol and Vitamin D classes. Cancer screenings such as prostate screening, breast and cervical exams and tobacco cessation program, Community education programs and services such as, ACS's Look Good Feel Better Program, advanced directives, arthritis and osteoporosis, breastfeeding, community disaster drills, school career days, WE CAN! Childhood Obesity Program and Faith-Based Health Expo. Support groups such as Stroke Support, Parkinson's support group, Pink Ladies and Sister's at Heart. Clinics and clinic services such as pre natal and OB clinic, renal dialysis services, American Red Cross blood drives, Community committees, boards, and organizations (employee participation) such as United Way, Partnerships for a Healthier Charles County, Charles County Tobacco Coalition, Leadership Southern Maryland, Hospice of Charles County, Healthy Families, Health Partners Free Clinic Board, Fetal Infant Mortality Board, Center for Abused Persons, Juvenile Drug Court; Chamber of Commerce, Charles County Child Advocacy Partnership, community events such as Christmas Connection, ACS'S Relay for Life, Alzheimer's Walk, March of Dimes, and Safe Nights.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 75,910,376

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)				(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) MELANIE SAGE VICE PRESIDENT PATIENT CARE	40.0	X			164,191	0	18,732
(19) GARY HERBEK COO	40.0	X			228,060	0	22,717
(20) MARILYN GREGORY CLINICAL NURSE IV	40.0		X		164,064	0	6,356
(21) LISA WILTROUT PHYSICIAN	40.0		X		141,491	0	4,891
(22) JOAN HUMULOCK CLINICAL NURSE IV	40.0		X		140,603	0	3,692
(23) STACEY COOK VICE PRESIDENT, HR	40.0		X		147,506	0	20,655
(24) KATHERINE MIDDLETON RN, OR	40.0		X		131,247	0	5,933
(25) CHRISTINE STEFANIDES FORMER PRESIDENT & CEO				X	111,214	0	19,222
(26) KEVIN BURBULES FORMER CHIEF INFO OFFICER				X	146,735	0	18,404

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	2,242,410	0	230,158

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		1,587,803
e	Government grants (contributions)1e		90,000

f	All other contributions, gifts, grants, and similar amounts not included above1f		0
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			1,677,803
			Business Code
2a	NET PATIENT REVENUE		900,099	103,083,914	103,083,914
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			103,083,914
3	Investment income (including dividends, interest
	and other similar amounts).....			139,526			139,526
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross Rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses		29,647
c	Gain or (loss)		-29,647
d	Net gain or (loss)..........			-29,647			-29,647
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	ANSWERING SERVICE		561,000	155,988		155,988
b	CAFETERIA AND COFFEE BAR SALES		900,099	331,070			331,070
c	APPLICATION FEES		900,099	5,000	5,000
d	All other revenue ....			52,457	52,457
e	Total. Add lines 11a–11d ......			544,515
12	Total revenue. See Instructions....			105,416,111	103,141,371	155,988	440,949


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........				1
2	Savings and temporary cash investments .......			29,116,660	2	33,434,372
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			10,886,077	4	9,697,092
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			1,588,468	8	1,533,556
9	Prepaid expenses and deferred charges ............			854,589	9	895,718
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	103,000,316
b	Less: accumulated depreciation. .....	10b	39,881,340	65,421,048	10c	63,118,976
11	Investments—publicly traded securities ..........			75,000	11	0
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			17,751,002	15	19,323,794
16	Total assets. Add lines 1 through 15 (must equal line 34)...			125,692,844	16	128,003,508
17	Accounts payable and accrued expenses .			16,336,955	17	14,668,027
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........			58,529,039	20	57,930,947
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			20,920,214	23	20,008,435
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities. Complete Part X of Schedule D.....			12,608,963	25	11,111,334
26	Total liabilities. Add lines 17 through 25.....			108,395,171	26	103,718,743
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			13,665,143	27	23,796,141
28	Temporarily restricted net assets .....			3,632,530	28	488,624
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			17,297,673	33	24,284,765
34	Total liabilities and net assets/fund balances .....			125,692,844	34	128,003,508

1	Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926 (see instructions for Form 926).................	Yes	No
2	Did the organization have an interest in a foreign trust during the tax year? If " Yes," the organization may be required to file Form 3520 and/or Form 3520-A. (see instructions for Forms 3520 and 3520-A)..........	Yes	No
3	Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see instructions for Form 5471)..............................	Yes	No
4	Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see instructions for Form 8621)	Yes	No
5	Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see instructions for Form 8865)....................................	Yes	No
6	Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see instructions for Form 5713)................................................	Yes	No