TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) DREW BAGWELL MD DIRECTOR	1.00	X				350,948	13,033
(2) COLIN TOOGOOD DIRECTOR	1.00	X				0	0
(3) GABE EVANS CHAIRMAN	1.00	X	X			0	0
(4) MATT GREER DIRECTOR	1.00	X				0	0
(5) J DAVID ARNETT MD DIRECTOR	1.00	X				0	0
(6) ARTHUR JOHNSON DIRECTOR	1.00	X				0	0
(7) JON LOTT DIRECTOR	1.00	X				0	0
(8) MIKE WILLS DIRECTOR	1.00	X				0	0
(9) GUY MOORMAN DIRECTOR	1.00	X				0	0
(10) THAD CARTER DIRECTOR	1.00	X				0	0
(11) GEORGE HECK CEO	40.00		X			370,229	32,620
(12) DONALD C LEWIS CFO	40.00		X			256,265	22,755
(13) SHERRY THOMAS VP PT. CARE	40.00			X		214,258	11,747
(14) EDDY N DUNCAN MD ANESTHESIOLO	40.00				X	496,531	13,048
(15) THOMAS C HENRIS MD ANESTHESIOLO	40.00				X	480,538	13,048
(16) GEORGE EGOLF CRNA	40.00				X	223,930	12,053
(17) PATRICIA COLLINS CRNA	40.00				X	217,332	11,993

(A) Name and business address	(B) Description of services	(C) Compensation
REHABILITATION SPECIALISTS 169 MEADOWLARK LANE FITZGERALD,GA31750	PHYSICAL THERAP	305,400
STEVEN JOHNSON MD P O BOX 30256 SEA ISLAND,GA31561	E.R. PHYSICIAN	160,500
ROWE CONSTRUCTION 684 COLUMBUS ROAD PEARSON,GA31642	CONSTRUCTION	132,281
DARRELL COLLINS MD P O BOX 2109 DOUGLAS,GA31534	CARDIOLOGIST	126,412
DRAFFIN & TUCKER LLP P O BOX 6 ALBANY,GA31702	ACCOUNTING	120,470
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 7

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 United States. See Part IV, line 21
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	1,271,855	363,981	907,874
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	31,868,714	28,711,816	3,156,898
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	927,504	845,032	82,472
9	Other employee benefits .......	6,339,762	5,600,909	738,853
10	Payroll taxes ...........	2,270,724	1,996,149	274,575
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	147,767		147,767
c	Accounting ...........	120,470		120,470
d	Lobbying ...........	11,726		11,726
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......	86,136		86,136
g	Other ..........	5,733,049	5,537,325	195,724
12	Advertising and promotion ....
13	Office expenses .......	11,837,533	10,733,328	1,104,205
14	Information technology ......	11,050		11,050
15	Royalties ..
16	Occupancy ...........	1,457,667	1,457,074	593
17	Travel ............	265,975	226,990	38,985
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	1,722,681	1,722,681
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	5,435,441	4,845,152	590,289
23	Insurance ..............	1,370,395	75,919	1,294,476
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	BAD DEBTS	18,208,960	18,208,960
b	REPAIRS AND MAINT	2,615,963	1,675,499	940,464
c	TAXES & LICENSES	863,410	31,881	831,529
d	MISCELLANEOUS	332,216	124,524	207,692
e
f	All other expenses	379,019	231,324	147,695
25	Total functional expenses. Add lines 1 through 24f	93,278,017	82,388,544	10,889,473	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........		1
2	Savings and temporary cash investments .......	3,845,201	2	3,394,014
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	8,069,070	4	8,211,976
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 .............	76	7	240
8	Inventories for sale or use ..............	640,037	8	741,718
9	Prepaid expenses and deferred charges ............	2,581,612	9	920,654
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	91,753,445
b	Less: accumulated depreciation. .....	10b	58,629,796	31,960,968	10c	33,123,649
11	Investments—publicly traded securities ..........	33,603,163	11	36,554,150
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........	302,953	14
15	Other assets. See Part IV, line 11 ...........	8,938,573	15	9,387,261
16	Total assets. Add lines 1 through 15 (must equal line 34)...	89,941,653	16	92,333,662
	17	Accounts payable and accrued expenses .	12,937,858	17	14,468,214
18	Grants payable ..........		18
19	Deferred revenue ..........	20,695	19
20	Tax-exempt bond liabilities ..........	33,771,282	20	33,048,769
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 ..	684,789	23	3,785,228
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....		25
26	Total liabilities. Add lines 17 through 25.....	47,414,624	26	51,302,211
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	42,527,029	27	41,031,451
28	Temporarily restricted net assets .....		28
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 .....	42,527,029	33	41,031,451
34	Total liabilities and net assets/fund balances .....	89,941,653	34	92,333,662

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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

2011

Open to Public
Inspection

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

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) 2011

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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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—2011. 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—2010. 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—2011. 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—2010. 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) 2011

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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2011. 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—2010. 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) 2011

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) 2011

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

2011

Name of organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

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, total 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 total 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 on line H of its
Form 990-EZ or on Part I, 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) (2011)

Page 2

Name of organization COFFEE REGIONAL MEDICAL CENTER INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part I	Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total 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) Total 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) Total 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) Total 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) Total 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) Total 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) (2011)

Page 3

Name of organization COFFEE REGIONAL MEDICAL CENTER INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part II	Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
(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) (2011)

Page 4

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Name of organization
COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total 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

$
Use duplicate copies of Part III if additional space is needed

(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) (2011)

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

2011

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, line 35c (Proxy Tax), then
Round Bullet

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

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

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 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 function 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) 2011

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 (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) Total

2a	Lobbying non-taxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

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)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(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? ..........................

Yes

11,726

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

11,726

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 carry over 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) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.

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

Section 162(e) nondeductible 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, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
	SCHEDULE C, PART II-B, LINE 1	THE ORGANIZATION BELONGS TO GEORGIA HOSPITAL ASSOCIATION AND TO AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE ANNUAL DUES PAID ARE ALLOCATED TO THE LOBBYING ACTIVITIES OF THESE ASSOCIATIONS.

Schedule C (Form 990 or 990EZ) 2011

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, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

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 can 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 education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 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, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax 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 (ASC 958), 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 (ASC 958), 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 (ASC 958), 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) 2011

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	Net investment earnings, gains, and 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 (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

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

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	257,796		257,796
b	Buildings ................	37,821,039	25,551,679	12,269,360
c	Leasehold improvements ............	134,846	95,261	39,585
d	Equipment ................	40,812,717	32,982,856	7,829,861
e	Other .................	12,727,047		12,727,047
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				33,123,649

Schedule D (Form 990) 2011

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) must 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) must 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) DUE FROM RELATED PARTIES				9,853,057
(2) DEFERRED FINANCING COST				417,142
(3) COST REPORT SETTLEMENT				-882,938






Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				9,387,261

Part X

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

1.(a) Description of Liability		(b) Book value
Federal Income Taxes









Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)
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) 2011

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 through 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 must 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 must 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
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	CRH HEALTH CARE, INC., EXCLUDING CRH VENTURES, INC. AND SOUTHEASTERN MANAGED CARE, INC. IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE.

Schedule D (Form 990) 2011

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

2011

Open to Public Inspection

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....

Yes

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

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

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

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

Yes

100% 150% 200% Other 125.000 %

Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the

following was the family income limit for eligibility for discounted care: ............

Yes

200% 250% 300% 350% 400% Other

If the organization did 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 used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance 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 discountedcare to a patient who was eligibile for free or discounted care?...............

Did the organization prepare a community benefit report during the tax year?...........

Yes

If "Yes," did 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.

Financial Assistance and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Financial Assistance at cost (from Worksheet 1) ..	2,651,223		2,651,223	3.530 %
b Medicaid (from Worksheet 3, column a) .....	15,164,720	14,734,127	430,593	0.570 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .
dTotal Financial Assistance and Means-Tested Government Programs .....	17,815,943	14,734,127	3,081,816	4.100 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	19,385		19,385	0.030 %
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..
h Research (from Worksheet 7)
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	4,400		4,400	0.010 %
jTotal Other Benefits ...	23,785		23,785	0.040 %
kTotal. Add lines 7d and 7j. ..	17,839,728	14,734,127	3,105,601	4.140 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011

Schedule H (Form 990) 2011

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support		1,500	1,500
4	Environmental improvements
5	Leadership development and training for community members	2	3,840	3,840	0.010 %
6	Coalition building
7	Community health improvement advocacy
8	Workforce development	12	1,200	1,200
9	Other
10	Total	14	6,540	6,540	0.010 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did 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........

18,208,960

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....

13,656,720

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).....

18,594,668

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

20,966,599

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

-2,371,931

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

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

(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) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	COFFEE REGIONAL MEDICAL CENTER 1101 OCILLA ROAD P O BOX 1287 DOUGLAS,GA31533	X	X	X	PHYS OFCS, RURAL HLTH CLINIC

Schedule H (Form 990) 2011

Page

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)

COFFEE REGIONAL MEDICAL CENTER

Name of Hospital Facility:

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 2011)
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 the community health 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 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	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a 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 Needs Assessment
	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 and 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	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 125.0% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

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Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted 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 (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 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 patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

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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	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	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)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	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		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

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Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care 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) 2011

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Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions 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, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any 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
EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE	PART I LINE 7 COLUMN F	IN DERIVING THE DENOMINATOR TO BE USED FOR COLUMN F THE FOLLOWING ADJUSTMENTS WERE MADE TO THE TOTAL EXPENSES REPORTED ON FORM 990 PART IX LINE 25 FORM 990 PART IX LINE 25 93278017 LESS BAD DEBTS IN PART IX 18208960 DENOMINATOR FOR COLUMN F 75069057
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	THE DATA REPORTED IN THIS AREA IS REPORTED AS INSTRUCTED BY CATHOLIC HEALTH ASSOCIATIONS A GUIDE FOR PLANNING AND REPORTING COMMUNITY BENEFITS 2008 SEE ALSO THE DESCRIPTION FOR PART III LINE 4
COMMUNITY BUILDING ACTIVITIES	PART II	5K RUN NOVEMBER 5 2011 COFFEE REGIONALS ANNUAL FALL FITNESS 5K RUNFUN WALK WAS HELD NOVEMBER 5 2011 WITH OVER 115 PARTICIPANTS IN ADDITION TO THE 5K EVENT A ONE MILE FUN RUN WAS HELD FOR THE YOUTH IN OUR COMMUNITY A CHECK FOR 1725 PROCEEDS FROM THE EVENT WAS DONATED TO THE CARDIAC REHAB AWARENESS PROGRAM APPROXIMATELY 40 MAN HOURS AT A COST OF800 HEALTH FAIR OCTOBER 2 2011 THE ANNUAL HEALTH SAFETY FESTIVAL HELD OCTOBER 2 2011 ATTRACTED NEARLY 1008 VISITORS WITH OVER 80 EXHIBITORS DEMONSTRATIONS AND HEALTH SCREENS THE FESTIVAL OFFERED WONDERFUL INTERACTIVE WAYS TO PROMOTE A HEALTHY LIFESTYLE 466 VISITORS TOOK ADVANTAGE OF THE COMPLETE BIOCHEMICAL BLOOD PROFILES OFFERED AT A REDUCED FEE OF 30 ACTUAL CHARGE OF 535 RESULTING IN A COMMUNITY SAVINGS OF 238610 APPROXIMATELY 100 MAN HOURS AT A COST OF 2000 PROSTATE CANCER SCREENING OCTOBER 13 15 2011 THE EARLIER PROSTATE CANCER IS DISCOVERED THE BETTER THE CHANCES ARE THAT IT CAN BE TREATED EFFECTIVELY WHEN PROSTATE CANCER IS IN ITS EARLIEST STAGES STILL CONFINED TO THE PROSTATE GLAND IT USUALLY CAUSES NO PAIN OR OTHER SYMPTOMS THATS WHY EACH YEAR COFFEE REGIONAL MEDICAL CENTER OFFERS LOW COST PROSTATE CANCER SCREENINGS ORE AND PSA BLOOD TEST TO OUR COMMUNITY FOR A REDUCED LAB FEE OF ONLY 10 ACTUAL CHARGE 147 RESULTING IN A COMMUNITY SAVINGS OF 17116 IN 2011 128 MEN TOOK ADVANTAGE OF THIS LIFESAVING SCREEN APPROXIMATELY 135 PHYSICIAN HOURS AND 36 STAFF HOURS AT A COST OF 2745 SPORTS PHYSICALS APRI1 24 2011 ATHLETIC PHYSICALS ARE REQUIRED BY BOTH THE GEORGIA HIGH SCHOOL AND GEORGIA INDEPENDENT SCHOOL ASSOCIATION FOR STUDENTS PLANNING ON PARTICIPATING IN SCHOOL ATHLETIC PROGRAMS EACH YEAR COFFEE REGIONAL PROVIDES OVER 600 SPORTS PHYSICALS TO STUDENTS PARTICIPATING IN INTERSCHOLASTIC SPORTS DURING THE SUMMER AND THROUGHOUT THE FOLLOWING YEAR THIS EVENT RESULTED IN A TOTAL COST SAVINGS TO THE COMMUNITY OF OVER 15000 APPROXIMATELY 40 PHYSICIAN HOURS AND 32 STAFF HOURS AT A COST OF 6640 PROJECT SEARCH PROJECT SEARCH IS A ONEYEAR EDUCATIONAL PROGRAM FOR STUDENTS WITH DISABILITIES IN THEIR LAST YEAR OF HIGH SCHOOL IT IS TARGETED FOR STUDENTS WHOSE MAIN GOAL IS COMPETITIVE EMPLOYMENT COFFEE REGIONAL MEDICAL CENTER PROVIDES THE SETTING FOR TWELVE PROJECT SEARCH STUDENTS THUS ALLOWING TOTAL IMMERSION IN THE WORKPLACE TO FACILITATE THE TEACHING AND LEARNING PROCESS THROUGH CONTINUOUS FEEDBACK AND APPLICATION OF NEW SKILLS INDIVIDUALIZED JOB DEVELOPMENT AND PLACEMENT BEGINS AFTER ROTATIONS AT ONE OR MORE WORKSTATIONS ARE COMPLETED STUDENTS RECEIVE SUPPORT THROUGH ON THEJOB COACHING AND WORKSITE ACCOMMODATIONS PROVIDED BY COFFEE REGIONAL THE PROGRAM IS DEDICATED TO WORKFORCE DEVELOPMENT THAT BENEFITS THE INDIVIDUAL COMMUNITY AND WORKPLACE CLASSROOM SPACE AT 300MONTH TOTAL OF 2700 AND APPROXIMATELY 60 STAFF HOURS OF TRAINING MENTORING AND EDUCATION OF 12 STUDENTSYEAR AT A COST OF 1200 BREAST CANCER SUPPORT GROUP MONTHLY 2011 IN 2011 COFFEE REGIONAL OFFERED A FREE MONTHLY BREAST CANCER SUPPORT GROUP FOR WOMEN IN THE COMMUNITY RECENTLY DIAGNOSED WITH BREAST CANCER THOSE UNDERGOING TREATMENT AND THOSE WHO HAVE COMPLETED TREATMENT CRMCS CLINICAL EDUCATION DEPARTMENT LEADS AND ORGANIZES EACH MEETING PROVIDING SUPPORT EDUCATION RESOURCES AND EXPERT SPEAKERS AT EACH MEETING APPROXIMATELY 1015 PEOPLE ATTEND EACH MONTHLY MEETING 144 MAN HOURS PER YEAR AT A COST OF 2800 DIABETES SUPPORT GROUP MONTHLY 2011 COFFEE REGIONAL OFFERS A FREE MONTHLY DIABETES SUPPORT GROUP FOR THE GENERAL PUBLIC CRMCS CLINICAL EDUCATION DEPARTMENT LEADS AND ORGANIZES EACH MEETING PROVIDING SUPPORT EDUCATION RESOURCES AND EXPERT SPEAKERS AT EACH MEETING EXPERTS SUCH AS DIETICIANS PODIATRISTS AND PHYSICIANS PROVIDE VALUABLE EDUCATION TO OUR COMMUNITY REGARDING DIABETES APPROXIMATELY 30 PEOPLE ATTEND EACH MONTHLY MEETING 144 MAN HOURS PER YEAR AT A COST OF 2800 AMERICAN CANCER SOCIETY RELAY FOR LIFE APRI1 2011 CRMC PROVIDES A CORPORATE SPONSOR OF 1000 ANNUALLY TO THE AMERICAN CANCER SOCIETY FOR CANCER RESEARCH TREATMENT AND RESOURCES EACH YEAR MANY OF COFFEE REGIONAL EMPLOYEES PROVIDE NUMEROUS MAN HOURS FOR THE COMMUNITY WIDE RELAY FOR LIFE EVENT IN EFFORT TO RAISE MONEY AND AWARENESS APPROXIMATELY 180 MAN HOURS AT A COST OF 3600 COFFEE COUNTY CHILDHOOD CANCER SUPPORT GROUP 2011 CRMC PROVIDES SPACE MONTHLY FOR THE COFFEE COUNTY CHILDHOOD CANCER SUPPORT GROUP AT NO COST TO THEM THE CHILDHOOD CANCER SUPPORT GROUP IS A NON PROFIT ORGANIZATION THAT PROVIDES FAMILIES AND PATIENTS WITH CHILDHOOD CANCER SUPPORT EDUCATION RESOURCES AND EXPERT SPEAKERS AT EACH MONTHLY MEETING CLASSROOM SPACE 100 PER MONTH FOR A TOTAL OF 1200 ANNUALLY AUTISM SUPPORT GROUP OF COFFEE COUNTY 2011 CRMC PROVIDES SPACE MONTHLY FOR THE AUTISM SUPPORT GROUP OF COFFEE COUNTY AT NO COST TO THEM THE AUTISM SUPPORT GROUP IS NONPROFIT ORGANIZATION THAT PROVIDES FAMILIES AND CHILDREN SUPPORT EDUCATION RESOURCES AND EXPERT SPEAKERS AT EACH MONTHLY MEETING CLASSROOM SPACE 100 PER MONTH FOR A TOTAL OF 1200 ANNUALLY SIDELINE SERVICE 2011 CRMC PROVIDES SIDELINE SERVICE FOR EACH HIGH SCHOOL FOOTBALL GAME IN COFFEE COUNTY A FULLY EQUIPPED AMBULANCE EMT AND PARAMEDIC ARE PROVIDED FOR EACH HOME FOOTBALL GAME AS A COURTESY TO THE SCHOOL SYSTEM AND SPECTATORS AT A COST OF 250 PER GAME AND 1500YEAR COFFEE COUNTY CHAMBER OF COMMERCE NEW CENTURY LEADERS 2011 PARTICIPANTS IN NEW CENTURY LEADERS COMMIT TO AN EIGHTMONTH PROJECT THAT ALLOWS THEM TO TAKE A CLOSE LOOK AT GOVERNMENT EDUCATION ECONOMIC DEVELOPMENT AND ALL ISSUES DEALING WITH QUALITY OF LIFE ON A LOCAL AND STATE LEVEL THE PROGRAM IS DESIGNED TO HELP PARTICIPANTS DEVELOP LEADERSHIP SKILLS FOR THE WORKPLACE AND THE COMMUNITY CRMC SPONSORED 2 EMPLOYEES IN 2011 FOR THE NEW CENTURY LEADER PROGRAM STAFF TIME TRAVEL AND EXPENSES FOR THE PROGRAM IS APPROXIMATELY 3840 2 EMPLOYEES 12 DAYS OF TRAINING AT 8 HOURS PER DAY 192 STAFF HOURS203840
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	AMOUNTS ON PART III LINES 2 AND 3 REPRESENT CHARGES WRITTEN OFF AS UNCOLLECTIBLE LINE 3 IS ESTIMATED AT 75 OF THE AMOUNT ON LINE 2 EXCERPT FROM AUDITED FINANCIAL STATEMENTS ALLOWANCE FOR DOUBTFUL ACCOUNTS THE CORPORATION PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON AN EVALUATION OF THE OVERALL COLLECTIBILITY OF THE ACCOUNTS RECEIVABLE AS ACCOUNTS ARE KNOWN TO BE UNCOLLECTIBLE THE ACCOUNT IS CHARGED AGAINST THE ALLOWANCE
MEDICARE EXPLANATION	PART III LINE 8	MEDICARE ALLOWABLE COSTS ARE COMPUTED IN ACCORDANCE WITH COST REPORTING METHODOLOGIES UTILIZED ON THE MEDICARE COST REPORT AND IN ACCORDANCE WITH RELATED REGULATIONS INDIRECT COSTS ARE ALLOCATED TO DIRECT SERVICE AREAS USING THE MOST APPROPRIATE STATISTICAL BASIS
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	THE ORGANIZATION WRITES OFF PATIENT ACCOUNTS RECEIVABLE BALANCES FOR PATIENTS QUALIFYING FOR CHARITY CARE OR FINANCIAL ASSISTANCE AND DOES NOT MAKE FURTHER COLLECTION EFFORTS
NEEDS ASSESSMENT	PART VI	THE ORGANIZATION EVALUATES THE NEEDS OF THEIR PATIENT BASE THROUGH THE NUMBER OF PATIENTS REFERRED TO OTHER FACILITIES FOR SERVICES NOT PROVIDED BY THE FACILITY ITSELF AND THROUGH OTHER INDICATORS
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	FINANCIAL COUNSELING DEPARTMENT WILL PROVIDE INFORMATION AND APPLICATIONS TO ALL PATIENTSGUARANTORS SEEKING FINANCIAL ASSISTANCE FOR SERVICES RENDERED AT COFFEE REGIONAL MEDICAL CENTER THAT ARE DEEMED MEDICALLY NECESSARY FINANCIAL COUNSELORS WILL DISCUSS ELIGIBILITY FOR MEDICAL ASSISTANCE PROGRAMS THROUGH THE DEPARTMENT OF FAMILY CHILDREN SERVICES AND SOCIAL SECURITY ADMINISTRATION IF ELIGIBILITY IS NOT MET FOR ANY MEDICAL ASSISTANCE PROGRAM THE FINANCIAL COUNSELING DEPARTMENT WILL SEEK ELIGIBILITY THROUGH COFFEE REGIONAL MEDICAL CENTERS INDIGENT CARE TRUST FUND PROGRAM PATIENTSGUARANTORS REQUESTING FINANCIAL ASSISTANCE ARE REFERRED TO THE FINANCIAL COUNSELORS FC OR BENEFIT SPECIALIST AT THE TIME OF REGISTRATION FOR OUTPATIENT SERVICES AND EMERGENCY DEPARTMENT AFTER MEDICAL SCREENING HAS BEEN COMPLETED SOCIAL SERVICES REQUEST PHYSICIAN OFFICES REQUEST OR FROM THE PATIENT FINANCIAL SERVICES DEPARTMENT PATIENTS ADMITTED FOR INPATIENT OR OBSERVATION SERVICES MAY BE VISITED BY THE FC AFTER THE PATIENT HAS BEEN PLACED IN A ROOM AND STABILIZED FC WILL DISCUSS WITH THE PATIENTGUARANTOR THE INDIGENT CARE TRUST FUND PROGRAM REQUIREMENTS AND APPLICATION PROCESS THE PATIENTGUARANTOR WILL BE REQUIRED TO COMPLETE AN INDIGENT APPLICATION PROVIDE PROOF OF IDENTITY PROVIDE BIRTH CERTIFICATES OR PROOF OF DEPENDENCY FOR CHILDREN WITH NO IDENTITY AND PROVIDE VERIFICATION OF INCOME IE W2S FEDERAL TAX RETURN PAY STUBS ETC IF VERIFICATION IS NOT PROVIDED AT THE TIME OF THE INTERVIEW THE PATIENTGUARANTOR WILL BE REQUIRED TO PROVIDE WITHIN 30 DAYS APPLICATIONS MADE ON BEHALF OF DECEASED PATIENTS MUST HAVE VERIFICATION OF INCOME AND INFORMATION CONCERNING THE VALUE OF THE PATIENTS ESTATE PATIENTS WHO CHOOSE NOT TO UTILIZE CURRENT BENEFITS THEY ARE ELIGIBLE FOR IE VETERANS BENEFITS MEDICARE AND COMMERCIAL INSURANCE WILL NOT BE CONSIDERED FOR THE INDIGENT PROGRAM UPON RECEIPT OF THE COMPLETED APPLICATION INCLUDING NECESSARY DOCUMENTATION CALCULATION OF THE HOUSEHOLD SIZE AND ANNUAL HOUSEHOLD INCOME IS COMPUTED AND COMPARED TO THE FEDERAL POVERTY GUIDELINES FPG TO DETERMINE THE PERCENTAGE OF ASSISTANCE A PATIENTGUARANTOR IS ELIGIBLE TO RECEIVE PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS BELOW THE GROSS INCOME CEILING FOR POTENTIAL MEDICAID ELIGIBILITY ARE REQUIRED TO APPLY FOR MEDICAID ASSISTANCE IS PROVIDED TO PATIENTS IN FILING FOR OTHER BENEFITS AND COMPLETING MEDICAID APPLICATIONS PATIENTS WHO CHOOSE NOT TO APPLY FOR OTHER BENEFITS TO WHICH THEY MAY BE ENTITLED IE MEDICAID APPLICATIONS WILL NOT BE CONSIDERED FOR THE INDIGENT PROGRAM PATIENTS WHO CHOOSE TO APPLY COFFEE REGIONAL MEDICAL CENTERS ACCOUNTS FOR THE PURPOSE OF MEETING MEDICALLY NEEDY SPEND DOWN TO RECEIVE ONGOING MEDICAID WILL NOT BE ALLOWED TO APPLY FOR THE INDIGENT PROGRAM FOR THAT ACCOUNT PATIENTSGUARANTORS OVER 18 YEARS OF AGE BUT CLASSIFIED AS DEPENDENTS FOR TAX PURPOSES DUE TO STUDENT ELIGIBILITY WILL HAVE A TOTAL HOUSEHOLD SIZE INCLUDING PARENTS AND SUBSEQUENT INCOME PATIENTSGUARANTORS NOT ELIGIBLE FOR OTHER MEDICAL ASSISTANCE PROGRAMS WILL BE PROCESSED UNDER THE INDIGENT CARE TRUST FUND GUIDELINES USING THE FOLLOWING CATEGORIES INDIGENT PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS BELOW 125 OF THE FPG THE APPLICABLE ACCOUNTS WILL BE ADJUSTED TO ZERO BALANCES CHARITY PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS GREATER THAN OR EQUAL TO 125 BUT NOT GREATER THAN 200 OF THE FPG THE APPLICABLE ACCOUNTS WILL BE ADJUSTED BY THE APPROPRIATE PERCENTAGES AN ADJUSTMENT OF 85 OF APPLICABLE CHARGES FOR PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS BETWEEN 125 AND 150 OF FPG AN ADJUSTMENT OF 70 OF APPLICABLE CHARGES FOR PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS BETWEEN 150 AND 175 OF FPG AN ADJUSTMENT OF 55 OF APPLICABLE CHARGES FOR PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS BETWEEN 175 AND 200 OF FPG CATASTROPHIC PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME IS GREATER THAN 200 FPG MAY QUALIFY FOR CHARITY ADJUSTMENTS ON APPLICABLE ACCOUNTS IF CONSIDERATION OF CRMC PATIENT OBLIGATIONS REDUCES THE ANNUAL HOUSEHOLD INCOME TO THE APPROPRIATE FPG NOTIFICATION OF STATUS OF COMPLETED APPLICATION IS PROVIDED TO THE PATIENTGUARANTOR WITHIN 5 WORKING DAYS OF RECEIPT OF NEEDED INFORMATION APPROVED APPLICATIONS ARE VALID FOR 30 DAYS FROM DATE OF SIGNATURE INCOMPLETE APPLICATIONS ARE HELD FOR 30 DAYS IF NO DOCUMENTATION IS PROVIDED TO COMPLETE THE APPLICATION A DENIAL LETTER IS SENT TO THE PATIENTGUARANTOR THE APPLICATION MAY BE COMPLETED IF THE PATIENTGUARANTOR PROVIDES THE REQUESTED INFORMATION WITHIN 15 WORKING DAYS OF THE DENIAL NOTIFICATION OF STATUS OF COMPLETED APPLICATION WILL BE MAILED WITHIN 15 WORKING DAYS OF RECEIPT OF NEEDED INFORMATION NO CONSIDERATION FOR ELIGIBILITY WILL BE REVIEWED FOR ACCOUNTS REFERRED TO OUTSIDE COLLECTION AGENCIES THE APPLICATION AND DOCUMENTATION WILL BECOME PROPERTY OF COFFEE REGIONAL MEDICAL CENTER AND IS TO BE KEPT CONFIDENTIAL IN THE SAME MANNER AS MEDICAL RECORDS HOWEVER THIS INFORMATION WILL BE USED FOR AGGREGATE REPORTING PURPOSES ONLY
COMMUNITY INFORMATION	PART VI	COFFEE REGIONAL MEDICAL CENTERS PRIMARY SERVICE AREA IS COFFEE COUNTY THE COUNTY HAD A POPULATION OF 42864 CITIZENS IN DECEMBER OF 2011 OF WHICH APPROXIMATELY 213 FALL BELOW GOVERNMENTAL DEFINED POVERTY GUIDELINES COFFEE COUNTYS UNEMPLOYMENT RATE AT YEAREND WAS 131
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	COFFEE REGIONAL MEDICAL CENTER IS GOVERNED BY A BOARD OF DIRECTORS CONSISTING OF 11 MEMBERS THE COFFEE COUNTY HOSPITAL AUTHORITY NOMINATES POTENTIAL BOARD MEMBERS AS OPENINGS ARISE THE BOARDS MAKEUP IS NINE COMMUNITY MEMBERS REFLECTING THE DIVERSITY OF THE COMMUNITY THE REMAINING TWO MEMBERS ARE THE CHIEF OF STAFF AND CHIEF OF STAFF ELECT IT IS THE PHILOSOPHY OF COFFEE REGIONAL MEDICAL CENTER TO ASSURE THE CONTINUATION AND ENHANCEMENT OF PATIENT CARE BY REINVESTING EXCESS FUNDS BACK INTO THE OPERATIONS OF THE FACILITY THIS INCLUDES GREATER ACCESSIBILITY OF CARE THROUGH THE CREATION OF A RURAL HEALTH CENTER IMPLEMENTATION OF A TELEMEDICINE PROGRAM AND RECRUITMENT OF PHYSICIANS TO THE UNDERSERVED ENVIRONMENT ENHANCEMENT OF TECHNOLOGY IS ALSO IMPERATIVE TO ASSURE APPROPRIATE DIAGNOSTIC AND THERAPEUTIC OPTIONS FOR THE COMMUNITY UPDATING THE AMBULANCE FLEET IS CONSISTENTLY HIGH ON THE FUNDING PRIORITY LIST TO ASSURE SERVICE TO THE MOST REMOTE AREAS OF THE COUNTY WHICH IN SQUARE MILES IS THE SECOND LARGEST COUNTY IN THE STATE OF GEORGIA
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED	PART VI	GEORGIA
COFFEE REGIONAL MEDICAL CENTER LINE NUMBER 1 PART V LINE 19D	PART V LINE 19D	THE HOSPITAL FACILITY DISCOUNTS CHARGES BASED ON A SLIDING FEE SCALE WHICH COMPARES THE APPLICANTS ANNUAL HOUSEHOLD INCOME TO FEDERAL POVERTY GUIDELINES CHARGES ARE REDUCED AS MUCH AS 55 IN ACCORDANCE WITH THE FACILITYS FINANCIAL ASSISTANCE POLICY

Schedule H (Form 990) 2011

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

2011

Open to Public Inspection

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

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 or provision of all the expenses described above? If "No," complete Part III to explain....

Yes

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. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

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 Regulations 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) 2011

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.

(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 as deferred in prior Form 990
(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)	(F) Compensation reported as deferred in prior Form 990
(1) DREW BAGWELL MD	(i) (ii)	298,124	52,824		12,250	783	363,981
(2) GEORGE HECK	(i) (ii)	364,405		5,824	12,250	20,370	402,849
(3) DONALD C LEWIS	(i) (ii)	253,606		2,659	12,250	10,505	279,020
(4) SHERRY THOMAS	(i) (ii)	214,189		69	10,949	798	226,005
(5) EDDY N DUNCAN MD	(i) (ii)	496,507		24	12,250	798	509,579
(6) THOMAS C HENRIS MD	(i) (ii)	480,501		37	12,250	798	493,586
(7) GEORGE EGOLF	(i) (ii)	223,842		88	11,405	648	235,983
(8) PATRICIA COLLINS	(i) (ii)	217,263		69	11,195	798	229,325
(9) STUART O'STEEN	(i) (ii)	215,611		14	11,024	798	227,447

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
FRINGE OR EXPENSE EXPLANATION	SCHEDULE J, PAGE 1, PART I, LINE 1A	EXECUTIVE AND KEY PERSONNEL WERE PROVIDED COUNTRY CLUB MEMBERSHIPS TO AID IN MARKETING AND FOR REWARD AND RECOGNITION.

Schedule J (Form 990) 2011

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 Part VI.
SchKMediumBullet

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization
COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number
65-0543088

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	COFFEE COUNTY HOSPITAL AUTHORITY	58-6003116	192137DJ3	11-16-2004	39,213,858	DEFEASEMENT OF PREVIOUS BONDS		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . .	6,165,089
2 Amount of bonds legally defeased . . . . . . . . . .
3 Total proceeds of issue . . . . . . . . . . . . .	39,213,858
4 Gross proceeds in reserve funds . . . . . . . .
5 Capitalized interest from proceeds . . . . . . . . . .
6 Proceeds in refunding escrows . . . . . . . . . . .
7 Issuance costs from proceeds . . . . . . . . . . .	767,435
8 Credit enhancement from proceeds . . . . . . . . . .
9 Working capital expenditures from proceeds . . . . . . .
10 Capital expenditures from proceeds . . . . . . . . . .
11 Other spent proceeds . . . . . . . . . . .	38,446,423
12 Other unspent proceeds . . . . . . . . . . .
13 Year of substantial completion . . . . . . . . . . .	2004
	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) 2011

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 of bond-financed property? . . . . . . . . .		X
b If ‘Yes’ to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . .		X
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . .		X
d If ‘Yes’ to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any 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 . .	%		%		%		%
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 . . . . . . .	%		%		%		%
6 Total of lines 4 and 5 . . .. . . . . . . . .	%		%		%		%
7 Does the bond issue meet the private security or payment test? . . .	X
8 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2?	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 qualified 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 guaranteed investment contract (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
7 Has the organization established written procedures to monitor the requirements of section 148? . . .		X

Schedule K (Form 990) 2011

Page 3

Part V

Procedures To Undertake Corrective Action

Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? . . . . . . . . . . . . . . YesNo

Part VI

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2011

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

2011

Open to Public
Inspection

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

Identifier	Return Reference	Explanation
FINANCIAL ACCOUNTS IN FOREIGN COUNTRIES	FORM 990, PART V, LINE 4B	CAYMAN ISLANDS
ELECTION OF MEMBERS AND THEIR RIGHTS	FORM 990, PAGE 6, PART VI, LINE 7A	BOARD MEMBERS OF THE ORGANIZATION ARE APPOINTED, AND CAN BE REMOVED, BY CRH HEALTH CARE, INC., THE PARENT ORGANIZATION.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS	FORM 990, PAGE 6, PART VI, LINE 7B	DECISIONS OF THE BOARD ARE SUBJECT TO APPROVAL BY CRH HEALTH CARE, INC., THE PARENT ORGANIZATION.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	FORM 990 IS PROVIDED TO THE BOARD FOR THEIR REVIEW AFTER FILING WITH THE IRS. MANAGEMENT'S REVIEW OF FORM 990 IS PERFORMED BEFORE THE FILING DATE AND INCLUDES A REVIEW OF FINANCIAL DATA AND OTHER DETAILS.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS ANNUALLY. THIS IS REVIEWED BY THE CEO AND BOARD CHAIRMAN, IF NEEDED. MEMBERS HAVE EXCUSED THEMSELVES FROM CERTAIN DISCUSSIONS/DECISIONS AS A RESULT OF CONFLICTS.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	THE BOARD'S COMPENSATION COMMITTEE REVIEWS COMPENSATION DATA FROM SEVERAL SOURCES. IN 2011, YAFFE AND ASSOCIATES WAS ENGAGED TO PROVIDE THE CEO/VP'S COMPENSATION ANALYSIS.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	SEE RESPONSE FOR LINE 15A ABOVE.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS OF THE ORGANIZATION ARE ALL AVAILABLE TO THE PUBLIC UPON REQUEST AT THE ORGANIZATION'S CORPORATE OFFICE.
RELATED ORGANIZATIONS	FORM 990, PAGE 7, PART VII	AVERAGE WEEKLY HOURS DEVOTED TO RELATED ORGANIZATIONS: GEORGE HECK 2 HOURS DON LEWIS 2 HOURS COLIN TOOGOOD 1 HOUR DAVID ARNETT MD 1 HOUR GUY MOORMAN 1 HOUR GABE EVANS 1 HOUR
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 5	UNREALIZED LOSS ON INVESTMENTS (459,906)

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

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

2011

Open to Public Inspection

Name of the organization

COFFEE REGIONAL MEDICAL CENTER INC

Employer identification number

65-0543088

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
(1) CRH PHYSICIAN PRACTICES 1101 OCILLA ROAD DOUGLAS,GA31533 20-5778734	PHY OFC	GA	7,714,208	2,728,650	CRMC COFFEE REGIONAL MEDICAL CENTER

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) CRH HEALTH CARE INC 1101 OCILLA ROAD P O BOX 1287 DOUGLAS,GA31533 58-2163724	MGMT SVC	GA	501C3	11D	NA		No
(2) CRH HEALTH SERVICES INC 1101 OCILLA ROAD P O BOX 1287 DOUGLAS,GA31533 58-2165827	FOUNDATION	GA	501C3	11D	NA		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2011

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
(1) CRH VENTURES INC 1101 OCILLA ROAD P O BOX 1287 DOUGLAS,GA31533 58-2165279	OFC RENTAL	GA	N/A
(2) SOUTHEASTERN MANAGED CARE INC 1101 OCILLA ROAD P O BOX 1287 DOUGALS,GA31533 58-2236627	MNGD CARE	GA	N/A

Schedule R (Form 990) 2011

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 related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

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

h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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

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

Yes

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

m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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	(d) Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2011

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)	(e) Are all partners section 501(c)(3) organizations?		(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 entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(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

Schedule R (Form 990) 2011

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: HOSPITAL SERVICES FOR COFFEE COUNTY & SURROUNDING AREAS
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	10
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	9
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	786
6	Total number of volunteers (estimate if necessary) ....	6	77
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	229,367	284,969
9	Program service revenue (Part VIII, line 2g) .........	86,218,316	89,470,431
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,091,750	649,630
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	2,080,693	1,837,315
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	89,620,126	92,242,345
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	43,630,186	42,678,559
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	46,271,984	50,599,458
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	89,902,170	93,278,017
19	Revenue less expenses. Subtract line 18 from line 12.......	-282,044	-1,035,672
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	89,941,653	92,333,662
21	Total liabilities (Part X, line 26).............	47,414,624	51,302,211
22	Net assets or fund balances. Subtract line 21 from line 20.....	42,527,029	41,031,451

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 82,388,544 including grants of $ ) (Revenue $ 89,472,991 )
	HOSPITAL SERVICES - SHORT TERM CARE FOR INPATIENT AND OUTPATIENT SERVICES FOR DOUGLAS AND COFFEE COUNTY. COFFEE REGIONAL MEDICAL CENTER SERVED 5,846 PATIENTS FOR A TOTAL OF 19,733 DAYS IN 2011. NURSERY DAYS WERE 975 IN 2011. COFFEE REGIONAL MEDICAL CENTER PROVIDED APPROXIMATELY 6,942,000 OF INDIGENT AND CHARITY SERVICES IN 2011.

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$ 82,388,544

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	2,825,656	142,119

(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) STUART O'STEEN CRNA	40.00	X	215,625	0	11,822

				(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
e	Government grants (contributions)1e		275,000

f	All other contributions, gifts, grants, and similar amounts not included above1f		9,969
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			284,969
			Business Code
2a	PATIENT SERVICE REVENUE		621,990	89,470,431	89,470,431
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			89,470,431
3	Investment income (including dividends, interest
	and other similar amounts).....			575,262			575,262
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross rents	176,258
b	Less: rental expenses
c	Rental income or (loss)	176,258
d	Net rental income or (loss).......			176,258			176,258
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	457,735	347,442
b	Less: cost or other basis and sales expenses	403,143	327,666
c	Gain or (loss)	54,592	19,776
d	Net gain or (loss)..........			74,368			74,368
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..
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...
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..
Miscellaneous Revenue			Business Code
11a	PHARMACY REVENUE		621,990	946,779			946,779
b	CAFETERIA		561,000	294,747			294,747
c	WELLNESS CENTER		561,439	223,039			223,039
d	All other revenue ....			196,492	2,560		193,932
e	Total. Add lines 11a–11d ......			1,661,057
12	Total revenue. See Instructions....			92,242,345	89,472,991		2,484,385


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........				1
2	Savings and temporary cash investments .......			3,845,201	2	3,394,014
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			8,069,070	4	8,211,976
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 .............			76	7	240
8	Inventories for sale or use ..............			640,037	8	741,718
9	Prepaid expenses and deferred charges ............			2,581,612	9	920,654
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	91,753,445
b	Less: accumulated depreciation. .....	10b	58,629,796	31,960,968	10c	33,123,649
11	Investments—publicly traded securities ..........			33,603,163	11	36,554,150
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........			302,953	14
15	Other assets. See Part IV, line 11 ...........			8,938,573	15	9,387,261
16	Total assets. Add lines 1 through 15 (must equal line 34)...			89,941,653	16	92,333,662
17	Accounts payable and accrued expenses .			12,937,858	17	14,468,214
18	Grants payable ..........				18
19	Deferred revenue ..........			20,695	19
20	Tax-exempt bond liabilities ..........			33,771,282	20	33,048,769
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 ..			684,789	23	3,785,228
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....				25
26	Total liabilities. Add lines 17 through 25.....			47,414,624	26	51,302,211
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			42,527,029	27	41,031,451
28	Temporarily restricted net assets .....				28
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 .....			42,527,029	33	41,031,451
34	Total liabilities and net assets/fund balances .....			89,941,653	34	92,333,662