Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 10-01-2010 and ending 09-30-2011
BCheck if applicable:
CName of organization
MARTHA JEFFERSON HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
500 MARTHA JEFFERSON DRIVE
 
Room/suite
City or town, state or country, and ZIP + 4
CHARLOTTESVILLE, VA22911
D Employer identification number

54-0261840
E Telephone number

G Gross receipts $ 249,593,737
F Name and address of principal officer:
JAMES HADEN
500 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.MARTHAJEFFERSON.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1929
M State of legal domicile: VA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: IMPROVE HLTH STATUS OF COMMUNITY BY MAINTAINING, ENHANCING & RESTORING PERSONAL HEALTH & WELL BEING.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 15
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 12
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 1,761
6 Total number of volunteers (estimate if necessary) .... 6 813
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 140,823
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 5,875,354 4,176,406
9 Program service revenue (Part VIII, line 2g) ......... 224,324,967 233,790,096
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 739,801 719,922
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 2,617,942 3,681,439
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 233,558,064 242,367,863
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 317,500
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 101,044,888 105,001,460
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 125,600,436 116,397,603
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 226,645,324 221,716,563
19 Revenue less expenses. Subtract line 18 from line 12...... 6,912,740 20,651,300
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 485,162,429 317,788,638
21 Total liabilities (Part X, line 26)............ 349,759,822 359,534,902
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 135,402,607 -41,746,264
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: THE ORGANIZATION'S MISSION IS TO IMPROVE THE HEALTH STATUS OF OUR COMMUNITY AND SET THE STANDARD FOR CLINICAL QUALITY AND PERSONALIZED HEALTHCARE SERVICES. IT IS DEDICATED TO PROVIDING THE BEST CLINICAL QUALITY WHILE MAINTAINING EXTRAORDINARY CUSTOMER SERVICE.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 189,163,348 including grants of $   ) (Revenue $ 235,459,537 )
AT THE HEART OF MARTHA JEFFERSON'S MISSION AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL IS OUR ROLE AND RESPONSIBILITY TO ADDRESS THE HEALTH NEEDS OF OUR COMMUNITY. MARTHA JEFFERSON IS ENTRUSTED WITH RESOURCES AND SKILLS THAT CAN HELP THE PEOPLE OF OUR COMMUNITY ACHIEVE AND MAINTAIN THEIR BEST POSSIBLE HEALTH. THE HOSPITAL'S BOARD OF TRUSTEES IN 2011 REAFFIRMED THE FOLLOWING COMMITMENTS THAT ARE FUNDAMENTAL TO OUR ABILITY TO MEET THESE CHALLENGES: AS AN INTEGRAL PART OF THE STRATEGIC PLANNING PROCESS, THE MISSION OF MARTHA JEFFERSON HOSPITAL WILL BE REVIEWED ALONG WITH SPECIFIC INITIATIVES, GOALS AND OBJECTIVES TO CONSIDER INCORPORATING SPECIFIC STATEMENTS AIMED AT HELPING TO RESOLVE COMMUNITY PROBLEMS ADVERSELY AFFECTING THE HEALTH STATUS OF THE COMMUNITIES WE SERVE. MARTHA JEFFERSON WILL CONDUCT, OR GAIN ACCESS TO, COMMUNITY-NEEDS ASSESSMENTS TO IDENTIFY PROBLEMS ADVERSELY AFFECTING OUR COMMUNITIES' HEALTH STATUS. MARTHA JEFFERSON WILL REGULARLY INVENTORY HOSPITAL-SPONSORED AND COMMUNITY PROGRAMS WORKING TO MEET THE IDENTIFIED NEEDS OF MEDICALLY UNDERSERVED OR DISADVANTAGED POPULATIONS. AS APPROPRIATE, THESE PROGRAMS WILL BE TRACKED AND EVALUATED FOR THEIR IMPACT ON IDENTIFIED HEALTH STATUS ISSUES. MARTHA JEFFERSON WILL REGULARLY ASSESS ITS ABILITY TO COMMIT RESOURCES, FINANCIAL AND HUMAN, TOWARD HELPING MEET IDENTIFIED NEEDS. ACCESS TO HEALTHCARE: MARTHA JEFFERSON ACCEPTS PATIENTS REGARDLESS OF THEIR ABILITY TO PAY FOR HEALTHCARE SERVICES. THE HOSPITAL ASSISTS PATIENTS WITH FINANCIAL NEEDS THROUGH THE MARTHA JEFFERSON HEALTHTRUST, A PROGRAM THAT PROVIDES A SLIDING FEE SCALE FOR HOSPITAL PATIENTS WHO QUALIFY BASED ON FAMILY INCOME UP TO 300 PERCENT OF POVERTY LEVEL. FINANCIAL ASSISTANCE IS BASED ON A REVIEW OF THE PATIENT'S FINANCIAL CIRCUMSTANCES UPON ADMISSION OR THE SERVICE DATE. BECAUSE MARTHA JEFFERSON DOES NOT PURSUE COLLECTION OF THE AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, SUCH AMOUNTS ARE NOT REPORTED AS A COMPONENT OF PATIENT SERVICE REVENUES. MARTHA JEFFERSON DEFINES CHARITY CARE AS CARE FOR WHICH COLLECTION IS NOT ATTEMPTED (I.E. INDIGENT CARE) AND OPERATING COSTS FOR SERVICES RENDERED FOR MEDICAID PATIENTS THAT ARE IN EXCESS OF REIMBURSEMENT FROM STATE AGENCIES. THE PERCENTAGE OF PATIENTS RECEIVING SOME FORM OF CHARITY ASSISTANCE 14.67%. ADDITIONAL CHARITY CARE INFORMATION IS PROVIDED ON SCHEDULE H. IN ADDITION TO PROVIDING UNCOMPENSATED CARE, MARTHA JEFFERSON HAS ESTABLISHED SPECIAL ACCOUNTS TO PROVIDE FREE DIAGNOSTIC SERVICES FOR PATIENTS REFERRED BY THE CHARLOTTESVILLE FREE CLINIC AND THE FREE CLINIC OF GREENE COUNTY. THROUGHOUT THE YEAR, COMMUNITY HEALTH SCREENINGS AND REDUCED-FEE SERVICES PROVIDED OTHER MEANS OF ACCESS TO HEALTHCARE FOR PEOPLE ACROSS CENTRAL VIRGINIA. PHYSICIANS EMPLOYED BY MARTHA JEFFERSON HOSPITAL HAVE OFFICES THROUGHOUT CHARLOTTESVILLE AND IN SEVEN SURROUNDING COUNTIES INCLUDING ALBEMARLE, BUCKINGHAM, LOUISA, MADISON, GREENE, FLUVANNA AND NELSON, WHICH PROVIDE ACCESS TO HEALTHCARE IN MANY RURAL AREAS WITHOUT REGARD TO ONE'S ABILITY TO PAY. DURING 2011, THE MEDICAL STAFF CONSISTED OF JUST OVER 400 PHYSICIANS REPRESENTING 35 MEDICAL SPECIALTIES. MARTHA JEFFERSON HOSPITAL ALSO OPERATES AN EMERGENCY DEPARTMENT, WHICH IS STAFFED 24-HOURS A DAY/7 DAYS A WEEK BY BOARD-CERTIFIED PHYSICIANS AND SPECIALLY TRAINED NURSES AND SUPPORT STAFF. ADDITIONALLY, THE HOSPITAL OPERATES A FREE-STANDING EMERGENCY DEPARTMENT. IN FISCAL YEAR 2011, MARTHA JEFFERSON HOSPITAL SERVED THE COMMUNITY BY WAY OF 10,982 INPATIENT ADMISSIONS; 223,229 OUTPATIENT ACCOUNTS; 51,189 EMERGENCY DEPARTMENT VISITS; 6,194 OPERATING ROOM VISITS; AND 152,079 PHYSICIAN OFFICE VISITS. IN ADDITION, MARTHA JEFFERSON OFFERED OR SUPPORTED MANY PROGRAMS AND SERVICES IN OUR COMMUNITY, WHICH ARE DETAILED BELOW.EDUCATIONAL PROGRAMS: AN IMPORTANT PART OF OUR COMMUNITY OUTREACH IS CENTERED ON EDUCATIONAL PROGRAMS AND TRAINING. WHEN A FAMILY IS PREPARING TO DELIVER A BABY AT MARTHA JEFFERSON, SIBLING TOURS, BREASTFEEDING CLASSES AND PEDIATRIC CPR ARE OFFERED AS WELL AS CLASSES CENTERED ON PREPARING FOR CHILDBIRTH AND BECOMING A PARENT. ONCE THE BABY HAS BEEN DELIVERED HOWEVER, THE EDUCATION DOESN'T STOP. A BRUNCH IS HELD DAILY FOR NEW FAMILIES BEFORE THEY ARE DISCHARGED. DURING THIS TIME FAMILIES LEARN HOW TO CALM THEIR CRYING BABY, THE DANGERS OF SUDDEN INFANT DEATH SYNDROME AND HOW TO GET A BIG BROTHER OR SISTER WARMED UP TO THE IDEA OF SHARING MOM AND DAD. OTHER EDUCATIONAL CLASS OFFERINGS AT MARTHA JEFFERSON INCLUDE; POSTOPERATIVE BREAST REHABILITATION, PREPARING FOR A HYSTERECTOMY, POST-HYSTERECTOMY REHAB, ADVANCED MEDICAL PLANNING, STRESS MANAGEMENT, UNDERSTANDING VASCULAR DISEASE, CARDIAC REHABILITATION AND PULMONARY REHABILITATION.CONTINUED IN PROGRAM SERVICE TWO
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
CONTINUED FROM PROGRAM SERVICE ONESCHOOL PROGRAMS: MARTHA JEFFERSON HOSPITAL UNDERSTANDS MANY OF THE HEALTH DECISIONS WE MAKE AS ADULTS ARE A RESULT OF THE SITUATIONS WE EXPERIENCE AS CHILDREN. THROUGH OUR SCHOOL PROGRAMS WE ARE ABLE TO TEACH CHILDREN AND LEAVE AN IMPRESSION THAT WILL HOPEFULLY STAY WITH THEM AS THEY GROW UP.IN OUR ELEMENTARY SCHOOL OUTREACH, AN EMPLOYEE OF MARTHA JEFFERSON ENGAGES STUDENTS IN THEIR CLASSROOM IN LESSONS ON HEALTH AND WELLNESS THAT DIRECTLY RELATE TO THE VIRGINIA STANDARDS OF LEARNING TEST. PROFESSIONAL EDUCATION SUPPORT: AS A WAY TO PROVIDE CONTINUED PROFESSIONAL EDUCATION, MARTHA JEFFERSON SUPPORTS THE PIEDMONT VIRGINIA COMMUNITY COLLEGE SONOGRAPHY PROGRAM AND PROVIDES CLINICAL PLACEMENTS FOR NURSING STUDENTS OF UVA, JMU, PVCC, BLUE RIDGE COMMUNITY COLLEGE, BRYANT AND STRATTON SCHOOL OF NURSING, WALDEN UNIVERSITY AND GERMANNA COMMUNITY COLLEGE.HOSPITAL SERVICES: MARTHA JEFFERSON HOSPITAL OFFERS MANY PROGRAMS THAT HELP PATIENTS BOTH GET ACCLIMATED WITH OUR SYSTEM, AND ALSO NAVIGATE THE HOSPITAL AS NEEDS ARISE.HEALTH CONNECTION, OUR PHYSICIAN REFERRAL, PATIENT EDUCATION AND INFORMATION SERVICE TAKES 120 CALLS ON A DAILY BASIS. THEY'RE ABLE TO HELP NEW MEMBERS OF THE COMMUNITY FIND A PHYSICIAN, ENROLL PEOPLE IN THE VARIOUS CLASSES THE HOSPITAL OFFERS AND PROVIDE SUPPORT FOR SPECIFIC MEDICAL NEEDS.FOR PEOPLE UNDERGOING CANCER TREATMENTS AT MARTHA JEFFERSON HOSPITAL, WE PROVIDE A CANCER CARE CENTER. THE CENTER SERVES AS A RESOURCE FOR PATIENTS FROM THE MOMENT THEY ARE DIAGNOSED THROUGH THEIR ENTIRE LINE OF INTERACTIONS AT THE HOSPITAL, AND IN MANY CASES EVEN CONTINUES AFTER THEY ARE ARE NO LONGER COMING FOR VISITS. STAFF MEMBERS ARE DEDICATED TO HELPING PATIENTS DEAL WITH THE EMOTIONS THAT GO ALONG WITH BEING DIAGNOSED WITH CANCER, FITTING THEM WITH COMPLIMENTARY WIGS AND SCARVES TO USE DURING TREATMENT AND JUST BEING FRIENDS THROUGHOUT THE PROCESS.MARTHA JEFFERSON HOSPITAL ALSO OFFERS A PALLIATIVE CARE PROGRAM. WHEN A PERSON IS FACING A SERIOUS OR ADVANCING ILLNESS, THE ACCOMPANYING PHYSICAL, EMOTIONAL AND SPIRITUAL ISSUES CAN DRAMATICALLY AFFECT THE EXPERIENCE AND OFTEN QUALITY OF LIFE FOR PATIENTS AND LOVED ONES. OVER THE PAST FIVE YEARS MORE THAN 1,000 LOCAL FAMILIES HAVE BENEFITTED FROM CONSULTATIONS BY A MULTIDISCIPLINARY TEAM PROVIDING PALLIATIVE CARE AT MARTHA JEFFERSON HOSPITAL. THE CAREGIVERS FOCUS ON DELIVERING A UNIQUE COMBINATION OF SPECIAL EXPERTISE IN PAIN AND SYMPTOM MANAGEMENT AND COORDINATE CARE AMONG A MULTIPLICITY OF PHYSICIANS INVOLVED WHEN AN INDIVIDUAL IS SERIOUSLY ILL AND DEDICATE THE TIME NEEDED FOR PATIENT-FAMILY COMMUNICATION ABOUT GOALS OF CARE AND THE EMOTIONAL AND SPIRITUAL STRUGGLES THAT OFTEN ACCOMPANY A LIFE-CHANGING ILLNESS. IN ADDITION TO THE ABOVE MENTIONED PROGRAMS, MARTHA JEFFERSON HOSPITAL ALSO OFFERS THE FOLLOWING: CHAPLAINCY PROGRAM, PATIENT ADVOCATE PROGRAM, WEBSITE WITH INTEGRATED HEALTH INFORMATION (WWW.MARTHAJEFFERSON.ORG), A HEALTH SOURCE LIBRARY AND A WOMEN'S MIDLFE RESOURCE CENTER. MARTHA JEFFERSON HOSPITAL HELD 'UNWANTED MEDICATION TAKE BACK DAY' WHICH WAS A DRIVE-THROUGH EVENT ALLOWING ANY AND ALL IN OUR COMMUNITY TO DROP OFF UNWANTED MEDICATIONS AND MEDICAL SHARPS FOR PROPER DISPOSAL.COMMUNITY EVENTS AND HEALTH SCREENINGS: HEALTH SCREENINGS ARE AN IMPORTANT SERVICE OFFERED BY MARTHA JEFFERSON. THE FOLLOWING SCREENINGS ARE HELD ANNUALLY: SKIN CANCER SCREENING, BREAST HEALTH SCREENING, DIABETES SCREENING.IN ADDITION TO THE SCREENING EVENTS, WE ALSO HOST EVENTS FOR THE COMMUNITY THAT PROMOTE WELLNESS. EACH SPRING THE CELEBRATION OF LIFE IS HELD FOR CANCER PATIENTS, SURVIVORS AND THEIR FAMILIES. THE AFTERNOON IS FILLED WITH FOOD, SALSA DANCING, GAMES AND MUSIC AND PROVIDES A CHANCE FOR MEMBERS OF THE COMMUNITY TO CELEBRATE THEIR LIFE. WE ALSO HOLD FOOD AND SHOE DRIVES TO HELP PROVIDE MUCH NEEDED ITEMS TO PEOPLE IN OUR COMMUNITY. ANNUALLY, WE HOST THE MJ8K RUN AND WALK TO BENEFIT COMMUNITY EDUCATION SERVICES AND MARTHA'S MARKET, WHICH HELPS FUND CANCER SERVICES AND SUPPORT WELLNESS INITIATIVES.NUTRITION PROGRAMS: AS HEALTHCARE PROVIDERS, OUR GOAL IS TO KEEP THE MEMBERS OF OUR COMMUNITY HEALTHY AND FEELING WELL. AT MARTHA JEFFERSON HOSPITAL WE OFFER A VARIETY OF PROGRAMS THAT ALLOW PEOPLE ACCESS TO INFORMATION THAT THEN HELPS THEM MAKE EDUCATED NUTRITION CHOICES.FOR STARTERS, ONE OF OUR REGISTERED DIETICIANS TAKES LEARNING ON LOCATION THROUGH OUR SUPERMARKET SMARTS CLASSES. THROUGH A PARTNERSHIP WITH GIANT FOOD, PEOPLE ARE ABLE TO GET HANDS-ON EXPERIENCE WHEN IT COMES TO MAKING HEALTHY DECISIONS AT THE GROCERY. WE ALSO PROVIDE HEART HEALTHY NUTRITION, DIABETES NUTRITION AND NUTRITION TIPS FOR INDIVIDUALS WITH CANCER.IN ADDITION TO OUR CLASSES, MARTHA JEFFERSON HAS A PRESENCE ACROSS THE LOCAL MEDIA AIRWAVES. NUTRITION TIPS AND TIMELY INFORMATION IS GIVEN BY ONE OF OUR REGISTERED DIETICIANS THROUGH DAILY RADIO SPOTS, A WEEKLY TELEVISION SEGMENT, AND VARIOUS PRINT OPPORTUNITIES.SUPPORT GROUPS: MARTHA JEFFERSON HOSPITAL OFFERS SUPPORT GROUPS OF A WIDE VARIETY TO OUR PATIENTS AND MEMBERS OF THE COMMUNITY. GROUPS MEET ON A REGULAR BASIS AND HELP PROVIDE A SAFE COMMUNITY WHERE PEOPLE CAN SHARE STORIES, REFLECT ON THEIR EXPERIENCES, AND GAIN KNOWLEDGE FROM WHAT OTHERS ARE GOING THROUGH. THE FOLLOWING ARE JUST SOME OF THE TOPICS WE OFFER: WELCOME TO MOTHERHOOD, BREAST CANCER SUPPORT, FAMILY CANCER SUPPORT, HODGKIN'S AND LYMPHOMA SUPPORT, CARDIAC REHAB SUPPORT AND SLEEP APNEA SUPPORT.PROGRAM SUPPORT/UNDERWRITING: MARTHA JEFFERSON PROVIDES MEDICAL IMAGING, LABORATORY SERVICE AND OUTPATIENT DIAGNOSTIC SERVICE ACCESS TO THE CLIENTS OF THE CHARLOTTESVILLE FREE CLINIC (CFC) AND GREENE FREE CLINIC (GFC). THIS ACCESS SUPPORTS PRIMARY CARE SERVICES FOR THE WORKING UNINSURED MEMBERS OF OUR COMMUNITIES. THE HOSPITAL IS ALSO DEDICATED TO SUPPORTING HEADSTART WHICH FOCUSES ON CHILD DENTAL SERVICES AND GIVES IN-KIND DONATIONS TO THE WOMEN'S INITIATIVE, PACEM (PEOPLE AND CONGREGATIONS ENGAGED IN MINISTRY) AND EMT TRAINING THROUGH THE THOMAS JEFFERSON EMERGENCY MEDICAL COUNCIL.
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 189,163,348
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II.. Click to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III.. Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II........................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III............... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I........................... Click to see attachment
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
Yes
 
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
178
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
1,761
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
Yes
 
b
If "Yes," enter the name of the foreign country: MediumBulletCJ
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
15
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
12
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
 
No
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
No
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
VA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
J MICHAEL BURRIS CHIEF FINANCIAL
500 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911
(434) 654-7304
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(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
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) JOHN P CHAMALES
BOARD MEMBER
 2.00 X           0 0 0
(2) JAMES P CRAIG
BOARD MEMBER
 2.00 X           0 0 0
(3) DR GREGORY G DEGNAN
BOARD MEMBER
 2.00 X           0 0 0
(4) MARK GILES
BOARD MEMBER
 2.00 X           0 0 0
(5) CAROL B HURT
CHAIR
 2.50 X   X       0 0 0
(6) ARTHUR KISER
BOARD MEMBER
 2.00 X           0 0 0
(7) Dr JOHN LIGUSH
VICE CHAIR
 2.00 X   X       0 0 0
(8) DR JOHN M CARPENTER
BOARD MEMBER
 2.00 X           0 0 0
(9) DR JOSEPH ORLICK
BOARD MEMBER
 2.00 X           0 0 0
(10) KATHRYN B PARKER
BOARD MEMBER
 2.00 X           0 0 0
(11) DR JOSH FISCHER
BOARD MEMBER
 2.00 X           0 0 0
(12) DR BURKHARD SPIEKERMANN
BOARD MEMBER
 2.00 X           0 0 0
(13) DR R HUNT MACMILLAN
BOARD MEMBER & CHAIR
 2.00 X           0 0 0
(14) DR KEVIN R MCCONNELL
BOARD MEMBER
 2.00 X           0 0 0
(15) DR TIMOTHY B SHORT
BOARD MEMBER
 2.00 X           0 0 0
(16) WILLIAM L ACHENBACH
BOARD MEMBER
 2.00 X           0 0 0
(17) DAVID BERND
BOARD MEMBER
 2.00 X           0 0 0
Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(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
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) LILLIAN R BEVIER
BOARD MEMBER
 2.00 X           0 0 0
(19) PETER BROOKS
BOARD MEMBER
 2.00 X           0 0 0
(20) GREGORY DOULL MD
BOARD MEMBER
 2.00 X           0 0 0
(21) EARNEST EDWARDS
BOARD MEMBER
 2.00 X           0 0 0
(22) RICHARD GILLIAM
BOARD MEMBER
 2.00 X           0 0 0
(23) HOWARD KERN
BOARD MEMBER
 2.00 X           0 0 0
(24) KENNETH KRAKAUR
BOARD MEMBER
 2.00 X           0 0 0
(25) E RAY MURPHY
BOARD MEMBER
 2.00 X           0 0 0
(26) BRUCE MURRAY
BOARD MEMBER
 2.00 X           0 0 0
(27) CHARLES ROTGIN JR
BOARD MEMBER
 2.00 X           0 0 0
(28) DAVID G SUTTON
BOARD MEMBER
 2.00 X           0 0 0
(29) JAMES E HADEN
PRESIDENT (NON-VOTING)
 50.00     X       615,116 0 195,462
(30) AMY BLACK
SECRETARY (NON-VOTING)
 65.00     X       231,437 0 27,742
(31) J MICHAEL BURRIS
TREASURER (NON-VOTING)
 54.00     X       277,357 0 76,539
(32) ELLIOT H KUIDA
VP, COO
 63.00       X     325,286 0 26,915
(33) MARIJO LECKER
VP, CLINICAL SUPPORT SVS/I
 65.00       X     245,167 0 28,626
(34) RONALD J COTTRELL
VP, PLANNING, MKTG, CORP D
 65.00       X     236,620 0 58,649
(35) FINLAY M ASHBY
VP, MEDICAL AFFAIRS
 65.00       X     238,872 0 21,111
(36) SUSAN CABELL MAINS
VP, HR, RETAIL, COMPLIANCE
 65.00       X     226,588 0 100,054
(37) RAY R MISHLER
VP, DEVELOPMENT
 65.00       X     180,865 0 60,718
(38) DEBORAH L THEXTON
FINANCE DIRECTOR
 65.00       X     163,661 0 12,357
(39) JOHN Z EDWARDS
PHYSICIAN
 40.00         X   483,201 0 24,342
(40) CHRISTOPHER D WILLMS
PHYSICIAN
 40.00         X   477,508 0 27,717
(41) TEJA SANDEEP
PHYSICIAN
 40.00         X   475,247 0 19,760
(42) JACOB N YOUNG
PHYSICIAN
 40.00         X   445,631 0 14,499
(43) GORDON L MORRIS
PHYSICIAN
 40.00         X   376,029 0 17,209
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 4,998,585 0 711,700
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet111
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
MA MORTENSON COMPANY
17975 WEST SARAH LANE
BROOKFIELD,WI53045 		CONSTRUCTION 64,223,672
KAHLERSLATER
111 W WISCONSIN AVENUE
MILWAUKEE,WI532032501 		ARCHITECTS 2,057,584
QUEST DIAGNOSTICS
12436 COLLECTIONS CENTER DRIVE
CHICAGO,IL606932436 		LAB SERVICES 1,268,392
INSCRIBE LLC
PO BOX 1427
MURRAY,KY42071 		TRANSCRIPTION SERVICE 938,572
MCCANDLISH HOLTON PC
PO BOX 796
RICHMOND,VA232180796 		LEGAL SERVICES 778,377
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet43
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 286,304
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		3,890,102
g Noncash contributions included in lines 1a-1f:$ 108,168
h Total. Add lines 1a-1f.......MediumBullet 4,176,406
Program Service Revenue Business Code
2a PATIENT SERVICES 621,500 233,790,096 233,711,046 79,050  
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 233,790,096
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 338,943   61,773 277,170
4 Income from investment of tax-exempt bond proceeds..MediumBullet 312,326     312,326
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross Rents 1,486,834  
b Less: rental expenses 873,205  
c Rental income or (loss) 613,629  
d Net rental income or (loss).......MediumBullet 613,629     613,629
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   6,317,601
b Less: cost or other basis and sales expenses   6,248,948
c Gain or (loss)   68,653
d Net gain or (loss)..........MediumBullet 68,653     68,653
8a Gross income from fundraising events (not including
$ 286,304
of contributions reported on line 1c). See Part IV, line 18 ...
a 153,208
b Less: direct expenses ...b 103,721
c Net income or (loss) from fundraising events..MediumBullet 49,487   49,487
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...MediumBullet        
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..MediumBullet        
Miscellaneous Revenue Business Code
11a CAFETERIA & GIFT SHOP 722,210 1,162,439     1,162,439
b PHYSICIAN TELEPHONE SV 621,110 105,072 105,072    
c NETWORK ACCESS FEES 561,000 96,364 96,364    
d All other revenue .... 1,654,448 1,547,055   107,393
e Total. Add lines 11a–11d ......MediumBullet 3,018,323
12 Total revenue. See Instructions....MediumBullet 242,367,863 235,459,537 140,823 2,591,097
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 317,500 317,500
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 2,859,602   2,859,602  
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 77,691,944 72,635,848 5,056,096  
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 5,288,992 4,747,143 541,849  
9 Other employee benefits ....... 13,283,965 12,112,502 1,171,463  
10 Payroll taxes ........... 5,876,957 5,380,940 496,017  
11 Fees for services (non-employees):        
a Management ...... 1,087,895 1,087,895    
b Legal ......... 1,125,722 -14,846 1,140,568  
c Accounting ........... 246,304 66,774 179,530  
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ......        
g Other .......... 17,873,510 12,186,160 5,687,350  
12 Advertising and promotion .... 591,155 561,650 29,505  
13 Office expenses ....... 45,784,791 44,270,747 1,514,044  
14 Information technology ...... 4,802,020 3,742,661 1,059,359  
15 Royalties ..        
16 Occupancy ........... 6,250,808 5,021,368 1,229,440  
17 Travel ............ 195,730 159,206 36,524  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 118,033 93,073 24,960  
20 Interest ........... 6,791,725   6,791,725  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 9,110,468 7,941,835 1,168,633  
23 Insurance .............. 738,386 799,172 -60,786  
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a PROV FOR BAD DEBT 13,433,514 13,437,406 -3,892  
b EQUIPMENT MAINTENANCE 4,394,318 4,009,275 385,043  
c DUES & SUBSCRIPTIONS 1,040,629 334,650 705,979  
d RECRUITMENT 499,783 265,207 234,576  
e
f All other expenses 2,312,812 7,182 2,305,630  
25 Total functional expenses. Add lines 1 through 24f 221,716,563 189,163,348 32,553,215 0
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 93,355,036 1 23,184,335
2 Savings and temporary cash investments .......   2  
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 21,315,310 4 24,830,779
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 ............. 2,417,703 7 1,819,634
8 Inventories for sale or use .............. 3,422,784 8 3,627,267
9 Prepaid expenses and deferred charges ............ 2,843,927 9 3,228,468
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 189,090,363
b Less: accumulated depreciation. ..... 10b 2,701,067 297,162,443 10c 186,389,296
11 Investments—publicly traded securities ..........   11 54,656,615
12 Investments—other securities. See Part IV, line 11 ......   12  
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 64,645,226 15 20,052,244
16 Total assets. Add lines 1 through 15 (must equal line 34)... 485,162,429 16 317,788,638
Liabilities 17 Accounts payable and accrued expenses . 88,869,316 17 42,471,418
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities .......... 230,148,275 20 230,137,799
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 ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 30,742,231 25 86,925,685
26 Total liabilities. Add lines 17 through 25..... 349,759,822 26 359,534,902
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 131,166,311 27 -46,106,689
28 Temporarily restricted net assets ..... 3,696,776 28 3,849,557
29 Permanently restricted net assets ..... 539,520 29 510,868
Organizations that do not follow SFAS 117, check here MediumBullet 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 ..... 135,402,607 33 -41,746,264
34 Total liabilities and net assets/fund balances ..... 485,162,429 34 317,788,638
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
242,367,863
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
221,716,563
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
20,651,300
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
135,402,607
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
-197,800,171
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
-41,746,264
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
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.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
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.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
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)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(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?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




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—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
MARTHA JEFFERSON HOSPITAL
  		Employer identification number

54-0261840
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
MARTHA JEFFERSON HOSPITAL
  		Employer identification number

54-0261840
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
MARTHA JEFFERSON HOSPITAL
  		Employer identification number

54-0261840
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use 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		 (c)
Use 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		 (c)
Use 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		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities ....................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2010

Schedule C (Form 990 or 990-EZ) 2010
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
Organization's
Totals 		(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? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots non-taxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2010


Schedule C (Form 990 or 990-EZ) 2010
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
(a)
Yes
No
(b)
Amount
1
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:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
35
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? If "Yes," describe in Part IV ..........................
Yes
 
11,014
j
Total. lines 1c through 1i ...................................
11,049
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
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
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
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? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Explanation of Other Lobbying Activities: Part II-B, Line 1i: $9,014 REPRESENTS A PORTION OF MJH'S DUES PAID TO VIRGINIA HOSPITAL AND HEALTHCARE ASSOCIATION (VHHA) ALLOCABLE TO LOBBYING ACTIVITIES CONDUCTED BY VHHA. DUES TO VHHA TOTALED $92,923. THE REMAINING $2,000 REPRESENTS THE LOBBYING PORTION OF DUES PAID TO MEDICAL ASSOCIATIONS ON BEHALF OF MJH EMPLOYEES.
Schedule C (Form 990 or 990EZ) 2010

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
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 .......    
5
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? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
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)? ....................................
9
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.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
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):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
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?........
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
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 ........ 29,368,803    
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ...... 29,368,803    
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet100.000 %
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
Yes
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   30,248,829 30,248,829
b Buildings ................   109,988,770 317,406 109,671,364
c Leasehold improvements ............   434,239 11,074 423,165
d Equipment ................   48,199,786 2,372,587 45,827,199
e Other .................   218,739   218,739
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 186,389,296
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) MISCELLANEOUS ACCOUNTS RECEIVABLE 1,101,929
(2) DEPOSITS 778,363
(3) OTHER ASSETS 5,292,802
(4) ASSETS HELD FOR SALE 11,583,150
(5) DUE FROM AFFILIATE 1,296,000




Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 20,052,244
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes  
CLAIMS ACCRUAL 750,000
PENSION LIABILITY 29,149,071
CAPITAL LEASE OBLIGATIONS 1,623,707
LONG TERM LIABILITIES 7,607,733
INTEREST RATE SWAP LIABILITY 47,795,174




Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 86,925,685
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8  
9 Total adjustments (net). Add lines 4 - 8 ............................. 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Description of Uncertain Tax Positions Under FIN 48: Part X: THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. THERE WERE NO UNCERTAIN TAX POSITIONS RECORDED AT SEPTEMBER 30, 2011.
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE F
(Form 990)

Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,
Part IV, line 14b, 15, or 16.
Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I
General Information on Activities Outside the United States. Complete if the organization answered
“Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of the grants or
assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award
the grants or assistance? ...................................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside the
United States.
3
Activites per Region. (Use Part V if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees or agents in region or independent contractors (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total
expenditures for region/investments
in region
CENTRAL AMERICA AND THE CARIBBEAN     PROGRAM SERVICES INSURANCE CAPTIVE 0
EUROPE     PROGRAM SERVICE INVESTMENTS   38,702,000
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total .....   0 38,702,000
b Total from continuation sheets to Part I ...   0 0
c Totals (add lines 3a and 3b)   0 38,702,000
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990,
Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 ........ MediumBullet
Use Part V if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2
Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .....MediumBullet
 
3
Enter total number of other organizations or entities ........................MediumBullet
 
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Use Part V if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926 (see instructions for Form 926).................
2 Did the organization have an interest in a foreign trust during the tax year? If " Yes," the organization may be required to file Form 3520 and/or Form 3520-A. (see instructions for Forms 3520 and 3520-A)..........
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see instructions for Form 5713)................................................
Schedule F (Form 990) 2010
Schedule F (Form 990) 2010
Page 5
Part V
Supplemental Information
Complete this part to provide the information (see instructions) required in Part I, line 2, and any additional information.
Identifier ReturnReference Explanation
Other Information Schedule F, Part V AS OF SEPTEMBER 30, 2011 MARTHA JEFFERSON HOSPITAL HAS A 17% OWNERSHIP IN VIRGINIA SOLUTION SPC LTD, AN INSURANCE CAPTIVE, WHICH OPERATES IN THE CAYMAN ISLANDS. IN ACCORDANCE WITH MARTHA JEFFERSON HOSPITAL'S INTEREST RATE SWAP AGREEMENTS WITH UBS, MARTHA JEFFERSON HOSPITAL IS REQUIRED TO PROVIDE COLLATERAL WHEN THE FAIR VALUE OF THE SWAP AGREEMENTS EXCEEDS A PREDETERMINED THRESHOLD AMOUNT. WHEN MARTHA JEFFERSON IS REQUIRED TO PROVIDE COLLATERAL, IT IS HELD BY UBS AND EARNS INTEREST.
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2010
Additional Data


Software ID:  
Software Version:  



SCHEDULE G
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

MARTHA'S MARKET
(event type) 		(b) Event #2

IN THE PINK
(event type) 		(c) Other Events

  
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 410,561 28,951   439,512
2 Less: Charitable
contributions . . . 		257,353 28,951   286,304
3 Gross income (line 1
minus line 2) . . . 		153,208     153,208
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . .        
7 Food and beverages . .        
8 Entertainment . . .        
9 Other direct expenses . 102,973 748   103,721
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 103,721
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 49,487
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ...........................
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2010
Additional Data


Software ID:  
Software Version:  
SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
Yes
 
c
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Charity care at cost (from
Worksheets 1 and 2) .. 		    5,079,059   5,079,059 2.310 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		    11,073,225 7,689,127 3,384,098 1.540 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....     220   220 0 %
dTotal Charity Care and
Means-Tested Government Programs ..... 		    16,152,504 7,689,127 8,463,377 3.850 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    722,516   722,516 0.330 %
f Health professions education
(from Worksheet 5) .. 		    581,959 297,842 284,117 0.130 %
g Subsidized health services
(from Worksheet 6) .. 		    18,386,040 10,028,091 8,357,949 3.800 %
h Research (from Worksheet 7)     0 0    
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		    338,392   338,392 0.150 %
jTotal Other Benefits ...     20,028,907 10,325,933 9,702,974 4.410 %
kTotal. Add lines 7d and 7j. ..     36,181,411 18,015,060 18,166,351 8.260 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support     9,280   9,280 0 %
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other     28,463   28,463 0.010 %
10 Total     37,743   37,743 0.010 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense (at cost).....
2
6,058,949
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
1,098,483
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
61,927,928
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
70,302,878
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-8,374,950
8
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:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
11 MARTHA JEFFERSON OUTPATIENT SURGERY CENTER LLC
  		FREESTANDING AMBULATORY SURGERY CENTER 50.000 % 0 % 50.000 %
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many hospital facilities did the organization operate during the tax year?2
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 MARTHA JEFFERSON HOSPITAL
500 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		X X         X    
2 MARTHA JEFFERSON OUTPATIENT SURGERY CENT
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		X               AMBULATORY SURGERY CENTER
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:NOT REQUIRED
Line Number of Hospital Facility (from Schedule H, Part V, Section A):2

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?19
Name and address Type of Facility (Describe)
1 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
2 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
3 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
4 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
5 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
6 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
7 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
8 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
9 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
10 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
11 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
12 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
13 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
14 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
15 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
16 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
17 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
18 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
19 MARTHA JEFFERSON OUTPATIENT CARE CENTER
595 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911 		DIAGNOSTIC CENTER
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
    Part I, Line 7: A COMBINATION OF A RATIO OF COSTS TO CHARGES AND A COST ACCOUNTING PROCESS WHICH ADDRESSES ALL PATIENT SEGMENTS (INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICARE, MEDICAID, UNINSURED AND SELF PAY) WAS USED TO DETERMINE ALL AMOUNTS REPORTED ON LINE 7.
    Part I, Line 7g: INCLUDES PRIMARY CARE PRACTICES COSTS OF $8,357,949.
    Part I, L7 Col(f): THE AMOUNT OF BAD DEBT EXPENSE SUBTRACTED FROM THE DENOMINATOR WHEN CALCULATING COLUMN F PERCENTAGES IS $13,433,514.
    Part II: WE OFFER A VARIETY OF COMMUNITY BUILDING ACTIVITIES INCLUDING THOSE DESIGNED TO HELP MEET THE BASIC NEEDS OF OUR COMMUNITY SUCH AS FOOD DRIVES AND OUR SHOES FOR THE HOMELESS ANNUAL CAMPAIGN. WE OFFER AN ANNUAL CELEBRATION OF LIFE EVENT FOR CANCER SURVIVORS TO GIVE THEM THE OPPORTUNITY TO INTERACT WITH THE PHYSICIANS AND STAFF WHO WERE RESPONSIBLE FOR THEIR CARE. WE HAVE HAD FOUR ANNUAL UNWANTED MEDICATION AND SHARPS DROP-OFF EVENTS. WE HAVE STEADILY INCREASED THE AMOUNT OF MEDICATIONS AND SHARPS WE ARE TAKING OUT OF HOMES IN OUR COMMUNITY AT EACH EVENT.
    Part III, Line 4: WORKSHEET A IN THE INSTRUCTIONS WAS USED TO COMPUTE THE AMOUNT REPORTED ON LINE 2.IN COMPUTING LINE 3, THE ORGANIZATION USES PRESUMPTIVE CRITERIA FOR ACCOUNTS IN BAD DEBT, BASED ON PREVIOUS QUALIFICATIONS FOR MEDICAID, EXISTENCE OF INSURANCE, EMPLOYMENT STATUS, AND HISTORY OF BAD DEBT WRITE-OFFS. BAD DEBT SHOULD BE INCLUDED IN COMMUNITY BENEFIT AS HOSPITALS OFTEN FACE A BARRIER TO CLASSIFYING A PATIENT ACCOUNT AS CHARITY CARE DUE TO THEIR ABILITY TO OBTAIN FROM PATIENTS THE NECESSARY INFORMATION TO EVALUATE THEIR ELIGIBILITY FOR CHARITY CARE. AS SUCH, SOME PORTION OF BAD DEBT EXPENSE MAY, IN FACT, MORE ACCURATELY BE CONSIDERED TO BE CHARITY CARE.THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE DESCRIBING BAD DEBT EXPENSE. THE FINANCIAL STATEMENTS ACCOUNT FOR BAD DEBT BY RESERVING 72% OF THE SELF PAY A/R BALANCES. BAD DEBT EXPENSE IS REPORTED NET OF ANY DISCOUNTS OR COLLECTIONS ON ACCOUNTS THAT WERE PREVIOUSLY WRITTEN-OFF (I.E. BAD DEBT WRITE-OFFS - DISCOUNTS - PAYMENTS RECEIVED).
    Part III, Line 8: THE MEDICARE COST REPORT WAS USED TO DETERMINE THE MEDICARE COSTS REPORTED ON LINE 6. MEDICARE MARGINS HAVE BEEN DECLINING AT THE SAME TIME THAT HOSPITALS HAVE BEEN ENGAGED IN CONCERTED EFFORTS TO IMPROVE EFFICIENCY, WHICH POINTS TO THE FACT THAT THE LOSSES ARE MOST LIKELY THE RESULT OF INADEQUATE REIMBURSEMENT BY THE FEDERAL GOVERNMENT, THUS, SHOULD BE INCLUDED IN COMMUNITY BENEFIT.
    Part III, Line 9b: COLLECTION PRACTICES ARE GEARED TOWARDS PATIENTS THAT HAVE A HIGH PROBABILITY OF BEING ABLE TO PAY FOR SERVICES BASED ON INCOME LEVEL AND INELIGIBILITY FOR CHARITY PROGRAMS. IT IS THE POLICY OF MARTHA JEFFERSON HOSPITAL TO REVIEW ACCOUNTS TO ENSURE ALL POSSIBLE METHODS OF PAYMENT HAVE BEEN EXHAUSTED, I.E. MEDICAL ASSISTANCE, FINANCIAL ASSISTANCE, PAYMENT PLANS AND SELF-PAY DISCOUNTS, PRIOR TO AN ACCOUNT BEING DEEMED AS "BAD DEBT". THE ORGANIZATION USES OUTSIDE COLLECTION AGENCIES ON A PRIMARY PLACEMENT BASIS. THE ORGANIZATION DETERMINES WHICH PATIENTS ARE SENT TO OUTSIDE AGENCIES AND GUIDES THE AGENCIES IN PERFORMING REASONABLE COLLECTION EFFORTS.
    Part VI, Line 2: MARTHA JEFFERSON WAS INVITED BY THE THOMAS JEFFERSON HEALTH DISTRICT TO PARTICIPATE ON THE STEERING COMMITTEE OF THE CITY OF CHARLOTTESVILLE/ALBEMARLE COUNTY COMMUNITY HEALTH STATUS ASSESSMENT. THE STEERING COMMITTEE WAS INCLUSIVE, WITH REPRESENTATIVES FROM ALL LOCAL AGENCIES AND ORGANIZATIONS THAT IMPACT THE OVERALL HEALTH OF OUR COMMUNITY. THE PURPOSE OF COMMUNITY HEALTH STATUS ASSESSMENT WAS TO ANSWER THREE MAIN QUESTIONS: 1) WHO COMPRISES THE COMMUNITY, AND WHAT DO THE COMMUNITY MEMBERS BRING TO THE TABLE? 2) WHAT ARE THE STRENGTHS AND RISK FACTORS IN THE COMMUNITY THAT CONTRIBUTE TO HEALTH? 3) WHAT IS THE STATUS OF THE COMMUNITY?THIS ASSESSMENT WAS PUBLISHED IN 2008 AND CAN BE FOUND ON THE THOMAS JEFFERSON HEALTH DISTRICT'S WEBSITE LOCATED AT WWW.VDH.STATE.VA.US/LHD/THOMASJEFFERSON.WE ARE CURRENTLY PLANNING A SIMILAR COLLABORATIVE EFFORT TO MEET THE REQUIREMENTS FOR A NEW ASSESSMENT BY OCTOBER 2013.
    Part VI, Line 3: THE HOSPITAL PROVIDES PAMPHLETS AT REGISTRATION AREAS, PAYMENT AREAS AND WAITING ROOMS DESCRIBING THE HOSPITAL'S BILLING PROCESS AND FINANCIAL ASSISTANCE. IN ADDITION, INFORMATION IS AVAILABLE ON THE HOSPITAL'S WEBSITE DISCUSSING ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE, THE FULL FINANCIAL ASSISTANCE POLICY, AS WELL AS INFORMATION ON THE APPLICATION PROCESS. FINANCIAL COUNSELORS AT THE HOSPITAL MAY REACH OUT TO PATIENTS TO DETERMINE IF THEY WOULD LIKE TO APPLY FOR ASSISTANCE, WHICH APPLICATION MAY BE MADE PRIOR TO, DURING OR SUBSEQUENT TO RECEIVING SERVICES.
    Part VI, Line 4: MARTHA JEFFERSON HOSPITAL SERVES THE THOMAS JEFFERSON AREA PLANNING DISTRICT (PD10), INCLUDING THE CITY OF CHARLOTTESVILLE, AND THE COUNTIES OF ALBEMARLE, FLUVANNA, GREENE, LOUISA, AND NELSON, ALL OF WHICH ARE FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREAS. THIS DISTRICT INCLUDES URBAN, RURAL AND SUBURBAN GEOGRAPHIC AREAS. PD10 CONSISTS OF APPROXIMATELY 230,000 PEOPLE (U.S. CENSUS BUREAU 2009), WITH ALBEMARLE COUNTY BY FAR THE MOST HIGHLY POPULATED AREA, DISTANTLY FOLLOWED BY THE CITY OF CHARLOTTESVILLE AND THE OTHER COUNTIES. IN GENERAL, THE PLANNING DISTRICT IS GROWING IN POPULATION, WITH AN INCREASE OF OVER 30,000 PEOPLE FROM 2000-2009 (U.S. CENSUS BUREAU 2009). APPROXIMATELY 75 PERCENT OF CITY RESIDENTS AND 90 PERCENT OF ALBEMARLE COUNTY RESIDENTS LIVE ABOVE THE FEDERAL POVERTY LEVEL, WITH CHILDREN BEING THE MOST AFFECTED GROUP BY AGE OF PERSONS LIVING IN POVERTY. WHILE ABOUT 10 PERCENT OF CITY HOUSEHOLDS RECEIVE ASSISTANCE THROUGH FOOD STAMPS, OVER 50 PERCENT OF CITY SCHOOL CHILDREN QUALIFY FOR FREE OR REDUCED-COST LUNCH PROGRAMS (2008 CITY OF CHARLOTTESVILLE/ALBEMARLE COUNTY COMMUNITY HEALTH STATUS ASSESSMENT). MEDICAID AND SELF PAY PATIENTS COMPRISE APPROXIMATELY 9% OF THE HOSPITAL'S PATIENTS. THE COMMUNITY IS SERVED BY TWO HOSPITALS.
    Part VI, Line 6: MARTHA JEFFERSON FURTHERS ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY THROUGH WORKPLACE HEALTHY INITIATIVES, AN OPEN MEDICAL STAFF, BOARDS OF DIRECTORS COMPRISED OF COMMUNITY MEMBERS AND PHYSICIANS, CHARITY CARE POLICIES AND OUTREACH, AND USE OF SURPLUS FUND DISPERSAL. WORKFORCE DEVELOPMENT PROGRAMS CONTINUE AS DOES OUR SUPPORT OF ORGANIZATIONS CHAMPIONING CHILD DENTAL, INDIGENT PRESCRIPTION DRUG, COMMUNITY MENTAL HEALTH SERVICES AND FREE CLINIC ACCESS EFFORTS.MARTHA JEFFERSON HOSPITAL STAFF SERVE ON COMMITTEES AND BOARDS RELATED TO COMMUNITY HEALTH INCLUDING THE CHARLOTTESVILLE FREE CLINIC, JEFFERSON AREA BOARD FOR AGING, THE SENIOR CENTER, THE CHARLOTTESVILLE OBESITY TASK FORCE, HOSPICE OF THE PIEDMONT, AND THE WOMEN'S INITIATIVE. PARTNERSHIPS ARE IMPORTANT TO US. WE PARTNER WITH ORGANIZATIONS THAT HAVE A TRACK RECORD OF IMPROVING HEALTH IN OUR COMMUNITY INCLUDING BUT NOT LIMITED TO THE CHARLOTTESVILLE FREE CLINIC, GREENE FREE CLINIC, CHARLOTTESVILLE/ALBEMARLE RESCUE SQUAD, THE UNITED WAY, AND THE WOMEN'S INITIATIVE (MENTAL HEALTH SERVICES). WE MAXIMIZE OUR REACH THROUGH FINANCIAL AND IN-KIND DONATIONS TO ORGANIZATIONS SUCH AS THE CHARLOTTESVILLE CITY SCHOOLS, HOSPICE OF THE PIEDMONT, JEFFERSON AREA BOARD FOR AGING AND HEAD START PROGRAMS IN SEVERAL SURROUNDING COUNTIES. OUR PARTNERSHIPS HELP BUILD AND STRENGTHEN EXISTING PROGRAMS, AS WELL AS LEADING TO THE DEVELOPMENT OF NEW PROGRAMS. OUR PARTNERSHIPS WITH OTHER NON-PROFITS IN THE COMMUNITY ALSO HELP US STAY ABREAST OF COMMUNITY NEEDS.MARTHA JEFFERSON HOSPITAL WELCOMES AND ENCOURAGES SIGNIFICANT COMMUNITY INVOLVEMENT THROUGH THE ESTABLISHMENT OF NUMEROUS GOVERNING COMMITTEES AND A COMMUNITY LEADERSHIP COUNCIL. THERE ARE 100 COMMUNITY MEMBERS ANNUALLY INVOLVED DIRECTLY WITH THESE COMMITTEES.MARTHA JEFFERSON HOSPITAL MAINTAINS AN OPEN MEDICAL STAFF TO ALL WHO SEEK PRIVILEGES HERE. THERE ARE OVER 450 PHYSICIANS AND ALLIED STAFF ON THE MARTHA JEFFERSON HOSPITAL MEDICAL STAFF.MARTHA JEFFERSON HOSPITAL UTILIZES SURPLUS FUNDS TO PURCHASE MEDICAL EQUIPMENT AND FACILITIES DESIGNED TO MEET THE NEEDS OF THE COMMUNITY IT SERVES.
    Part VI, Line 7: IN ORDER TO INCREASE ITS ABILITY TO PROVIDE HIGH QUALITY, COMPREHENSIVE HELATH CARE SERVICES TO PATIENTS, THE ORGANIZATION AFFILIATED WITH SENTARA HEALTHCARE SYSTEM EFFECTIVE JUNE 1, 2011. SENTARA, A NOT-FOR-PROFIT HEALTH SYSTEM, OPERATES MORE THAN 100 SITES OF CARE SERVING RESIDENTS ACROSS VIRGINIA AND NORTHEASTERN NORTH CAROLINA. THE SYSTEM IS COMPRISED OF 10 ACUTE CARE HOSPITALS, INCLUDING SEVEN IN HAMPTON ROADS, ONE IN NORTHERN VIRGINIA AND TWO IN THE BLUE RIDGE REGION, ADVANCED IMAGING CENTERS, NURSING AND ASSISTED LIVING CENTERS, OUTPATIENT CAMPUSES, TWO HOME HEALTH AND HOSPICE AGENCIES, A 3,680-PROVIDE MEDICAL STAFF, AND THREE MEDICAL GROUPS WITH 618 PROVIDERS.THE ORGANIZATION, ALONG WITH ITS SUBSIDIARIES, HAS JOINED WITH SENTARA IN ORDER TO ENHANCE ITS ABILITY TO ACHIEVE BEST PRACTICES IN HEALTHCARE DELIVERY; ACQUIRE CUTTING EDGE TECHNOLOGY AND INTEGRATED INFORMATION SYSTEMS, AND PROVIDE A HIGHER LEVEL OF MEDICAL CARE TO VIRGINIA'S BLUE RIDGE REGION COMMUNITY. COMBINED, THESE ATTRIBUTES BETTER POSITION THE ORGANIZATION TO ADDRESS HELATH CARE REFORM AND OTHER PROFOUND CHANGES AFFECTING THE HEALTHCARE ENVIRONMENT.
Schedule H (Form 990) 2010
Additional Data


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Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number
54-0261840
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) VIRGINIA HEALTH CARE FOUNDATION707 EAST MAIN STREET STE 1350
RICHMOND,VA23219 		54-1639924 501(c)(3) 60,000       COMMUNITY HEALTH
(2) BLUE RIDGE MEDICAL CENTER4038 THOMAS NELSON HWY
ARRINGTON,VA22922 		54-1222147 501(c)(3) 25,000       DENTAL SERVICES
(3) BOYS & GIRLS CLUB OF CENTRAL VIRGINIAPO BOX 707
CHARLOTTESVILLE,VA22902 		54-1602004 501(c)(3) 7,500       NUTRITIONAL PROGRAMS
(4) CHARLOTTESVILLE CITY SCHOOLS1562 DAILY ROAD
CHARLOTTESVILLE,VA22903 		54-6001203   15,000       SPECIAL EDUCATION, STUDENT SERVICES
(5) CHARLOTTESVILLE FREE CLINIC1138 ROSE HILL DRIVE
CHARLOTTESVILLE,VA22903 		54-1610405 501(c)(3) 40,000       RX RELIEF PROGRAM
(6) COUNTY OF ALBEMARLE401 MCINTIRE ROAD
CHARLOTTESVILLE,VA22903 		54-6001102   12,000       BRIGHT STARS PROGRAM, DEPT OF SOCIAL SERVICES, PRESCHOOL NETWORK
(7) GREENE CARE CLINIC39 STANDARD STREET
STANDARDSVILLE,VA22973 		72-1602744 501(c)(3) 15,000       COMMUNITY HEALTH
(8) MADISON FREE CLINIC410 NORTH MAIN STREET
MADISON,VA22727 		31-1654015 501(c)(3) 15,000       COMMUNITY HEALTH
(9) MONTICELLO AREA COMMUNITY ACTION AGENCY1025 PARK STREET
CHARLOTTESVILLE,VA22901 		54-0799964 501(c)(3) 21,000       DENTAL SERVICES FOR UNDERSERVED CHILDREN
(10) ORANGE COUNTY FREE CLINIC13296-A JAMES MADISON HWY
ORANGE,VA22960 		25-1922019 501(c)(3) 15,000       COMMUNITY HEALTH
(11) REGION TEN COMMUNITY SERVICES BOARD502 OLD LYNCHBURG ROAD
CHARLOTTESVILLE,VA22902 		54-1625290 501(c)(3) 40,000       PHYCHIATRIC SERVICES
(12) THE WOMEN'S INITIATIVE1101 EAST HIGH STREET STE A
CHARLOTTESVILLE,VA22902 		20-5913090 501(c)(3) 20,000       MENTAL HEALTH SERVICES
(13) THOMAS JEFFERSON PARTNERSHIP FOR ECONOMIC DEVELOPMENT2211 HYDRAULIC ROAD STE 104
CHARLOTTESVILLE,VA22901 		26-3895424 501(c)(3) 5,000       COMMUNITY HEALTH
(14) AMERICAN HEART ASSOCIATION4217 PARK PLACE COURT
GLEN ALLEN,VA23060 		13-5613797 501(c)(3) 6,000       COMMUNITY HEALTH
(15) FIRST TEE CHARLOTTESVILLE1400 PEN PARK ROAD
CHARLOTTESVILLE,VA22901 		54-6001202 501(c)(3) 5,000       COMMUNITY HEALTH
(16) UNITED WAY806 EAST HIGH STREET
CHARLOTTESVILLE,VA22902 		54-0505882 501(c)(3) 15,000       COMMUNITY HEALTH
2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
16
3
Enter total number of other organizations ................................ . Bullet Image
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: MARTHA JEFFERSON HOSPITAL DONATES FUNDS IN FURTHERANCE OF THE HOSPITAL'S MISSION TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY BY MAINTAINING, ENHANCING AND RESTORING PERSONAL HEALTH AND WELL BEING. ASSISTANCE IS GIVEN BASED ON DIRECTION FROM THE BOARD OF DIRECTORS AND COMMUNITY NEED.
Schedule I (Form 990) 2010


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Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
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? ....
2
Yes
 
3
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.
4
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:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
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.
5
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:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
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:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
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 ............
7
Yes
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) JAMES E HADEN (i)
(ii)		 487,616
0 		127,500
0 		0
0 		182,914
0 		12,548
0 		810,578
0 		0
0
(2) AMY BLACK (i)
(ii)		 187,916
0 		43,521
0 		0
0 		16,321
0 		11,421
0 		259,179
0 		0
0
(3) J MICHAEL BURRIS (i)
(ii)		 225,091
0 		52,266
0 		0
0 		64,925
0 		11,614
0 		353,896
0 		0
0
(4) ELLIOT H KUIDA (i)
(ii)		 262,731
0 		62,555
0 		0
0 		17,150
0 		9,765
0 		352,201
0 		0
0
(5) MARIJO LECKER (i)
(ii)		 200,424
0 		44,743
0 		0
0 		17,150
0 		11,476
0 		273,793
0 		0
0
(6) RONALD J COTTRELL (i)
(ii)		 191,490
0 		45,130
0 		0
0 		47,172
0 		11,477
0 		295,269
0 		0
0
(7) FINLAY M ASHBY (i)
(ii)		 199,869
0 		39,003
0 		0
0 		16,721
0 		4,390
0 		259,983
0 		0
0
(8) SUSAN CABELL MAINS (i)
(ii)		 185,824
0 		40,764
0 		0
0 		88,763
0 		11,291
0 		326,642
0 		0
0
(9) RAY R MISHLER (i)
(ii)		 146,932
0 		33,933
0 		0
0 		49,510
0 		11,208
0 		241,583
0 		0
0
(10) DEBORAH L THEXTON (i)
(ii)		 142,857
0 		20,804
0 		0
0 		11,456
0 		901
0 		176,018
0 		0
0
(11) JOHN Z EDWARDS (i)
(ii)		 483,201
0 		0
0 		0
0 		17,150
0 		7,192
0 		507,543
0 		0
0
(12) CHRISTOPHER D WILLMS (i)
(ii)		 477,508
0 		0
0 		0
0 		17,150
0 		10,567
0 		505,225
0 		0
0
(13) TEJA SANDEEP (i)
(ii)		 475,247
0 		0
0 		0
0 		9,800
0 		9,960
0 		495,007
0 		0
0
(14) JACOB N YOUNG (i)
(ii)		 445,631
0 		0
0 		0
0 		7,350
0 		7,149
0 		460,130
0 		0
0
(15) GORDON L MORRIS (i)
(ii)		 376,029
0 		0
0 		0
0 		7,350
0 		9,859
0 		393,238
0 		0
0

Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
  Part I, Line 1a THE INDICATED BENEFITS ARE PROVIDED TO CERTAIN SENIOR EXECUTIVES OF THE ORGANIZATION AS PART OF OVERALL COMPENSATION PACKAGES AND ARE CONSIDERED IN EVALUATING THE REASONABLENESS OF COMPENSATION (SEE FORM 990, PART VI, LINE 15, FOR A DESCRIPTION OF THE PROCESS USED TO DETERMINE EXECUTIVE COMPENSATION). COUNTRY CLUB MEMBERSHIP FEES AND DUES: PROVIDED FOR CEO, COO AND VICE PRESIDENT, DEVELOPMENT ONLY. SOCIAL CLUB DUES PAID ON BEHALF OF THE ORGANIZATION'S SENIOR EXECUTIVES ARE ALLOCATED BETWEEN BUSINESS AND PERSONAL USE, THE PERSONAL USE OF WHICH IS TREATED AS ADDITIONAL COMPENSATION AND REPORTED ON FORM W-2 AS TAXABLE WAGES. PERSONAL SERVICES: FINANCIAL PLANNING - THE CEO RECEIVES ANNUAL PAYMENTS UP TO $4,000, VICE PRESIDENTS RECEIVE UP TO $2,500 EVERY FOUR YEARS AT THE DISCRETION OF THE PRESIDENT/CEO. FINANCIAL PLANNING (I.E. PERSONAL SERVICES) EXPENSES PAID BY OR ON BEHALF OF THE ORGANIZATION'S SENIOR EXECUTIVES ARE TREATED AS ADDITIONAL COMPENSATION AND REPORTED ON FORM W-2 AS TAXABLE WAGES.
  Part I, Line 7 THE MANAGEMENT AND SENIOR MANAGEMENT INCENTIVE PLANS RECOGNIZE INDIVIDUALS BASED ON SPECIFIC CRITERIA AND DEFINED ORGANIZATION PERFORMANCE STANDARDS. THOSE PLANS ARE NOT ANNUALLY GUARANTEED AND IMPLEMENTATION WILL DEPEND ON ORGANIZATION-WIDE PERFORMANCE. IF ORGANIZATION-WIDE GOALS ARE NOT MET, THE PRESIDENT/CEO WILL HAVE THE DISCRETION TO DETERMINE ANY VARIATIONS TO THE PLAN.
Supplemental Information Part III PART 1, LINE 4b: SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN 457(f): JAMES HADEN PARTICIPATES IN THE MARTHA JEFFERSON HEALTH SERVICES CORPORATION NONQUALIFIED RETIREMENT PLAN. THIS IS A SERP WITH TARGET BENEFIT OFFSET BY THE QUALIFIED PENSION PLAN AND SOCIAL SECURITY. ELLIOT KUIDA, FINLAY ASHBY, MICHAEL BURRIS, MARIJO LECKER, AMELIA BLACK, RONALD COTTRELL, SUSAN CABELL MAINS, RAY MISHLER AND DEBORAH THEXTON PARTICIPATE IN THE MARTHA JEFFERSON HEALTH SERVICES CORPORATION NONQUALIFIED DEFERRED COMPENSATION ARRANGEMENT. THIS PLAN REWARDS THE INDIVIDUALS LISTED FOR MEETING TARGET FINANCIAL GOALS ESTABLISHED FOR EACH OF THEM BY THE CEO WITH THE APPROVAL OF THE BOARD, AND AS AN INCENTIVE FOR THE EMPLOYEES TO REMAIN WITH THE EMPLOYER UNTIL THEIR VESTING DATE.
Schedule J (Form 990) 2010

Additional Data


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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number
54-0261840
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
Yes No Yes No Yes No
A INDUSTRIAL DEVELOPMENT AUTHORITY OF ALBEMARLE COUNTY VIRGINIA
  		52-1297503 012677CE8 09-25-2003 34,192,283 REFUNDED BONDS ISSUED JULY 1993   X   X   X
B ECONOMIC DEVELOPMENT AUTHORITY OF ALBEMARLE COUNTY VIRGINIA
  		52-1297503 012663AD2 10-30-2008 160,795,000 FINANCING FOR REPLACEMENT HOSPITAL CONSTRUCTION   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired. . . . .        
2 Amount of bonds defeased . . . .        
3 Total proceeds of issue . . . . 35,257,603 160,910,173    
4 Gross proceeds in reserve funds . . 4,093,857      
5 Capitalized interest from proceeds. 20,817,708 20,817,708    
6 Proceeds in refunding escrow. . . . . 30,758,484      
7 Issuance costs from proceeds . . . 405,262 1,424,688    
8 Credit enhancement from proceeds. 199,290 199,290    
9 Working capital expenditures from proceeds . .        
10 Capital expenditures from proceeds . . 137,812,586 137,812,586    
11 Other spent proceeds . .        
12 Other unspent proceeds. . . 655,901 655,901    
13 Year of substantial completion . . . 2003 2011
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? X     X        
15 Were the bonds issued as part of an advance refunding issue?   X   X        
16 Has the final allocation of proceeds been made? . . X     X        
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . X   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   X        
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .   X   X        
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2010
Schedule K (Form 990) 2010
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use?   X   X        
b Are there any research agreements that may result in private business use of bond-financed property? . .   X   X        
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? . X   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 . . . . . . . . . . . . . SchKMediumBullet 0 % 0 %    
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . SchKMediumBullet 0 % 0 %    
6 Total of lines 4 and 5 . . .. . . . . . 0 % 0 %    
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?   X 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   X        
2 Is the bond issue a variable rate issue?   X X          
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?   X X          
b Name of provider . UBS AG STAMFORD
BRANCH 		UBS AG STAMFORD
BRANCH 		 
  		 
 
c Term of hedge . . 40.000000000000 40.000000000000    
d Was the hedge superintegrated? . X   X          
e Was a hedge terminated? .   X   X        
4a Were gross proceeds invested in a GIC? . X     X        
b Name of provider . WACHOVIA BANK
  		NA
  		 
  		 
 
c Term of GIC . . 16.500000000000      
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . X              
5 Were any gross proceeds invested beyond an available temporary period? .   X   X        
6 Did the bond issue qualify for an exception to rebate? . . . X     X        
Schedule K (Form 990) 2010

Schedule K (Form 990) 2010
Page 3
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
PART II, LINE 3, COLUMN A   TOTAL PROCEEDS INCLUDES DSRF EARNINGS SINCE 2003 OF $1,063,168 INTEREST FUND EARNINGS OF $1,454, AND RESIDUAL COI RESERVE TRANSFER FOR DSRF OF $67,410
PART II, LINE 3, COLUMN B   TOTAL PROCEEDS FROM ISSUANCE INCLUDES $115,173 OF EARNINGS ON THE COI, PROJECT AND INTEREST FUNDS FROM 2009; THERE WERE NO EARNINGS IN 2010/2011.
PART III, COLUMN A   N/A: POST 12/31/2002 REFUNDING ISSUE OF AN ORIGINAL ISSUANCE PRIOR TO 1/1/2003. TAX PREPARATION SOFTWARE WOULD NOT ACCOMODATE LEAVING THIS SECTION BLANK AND ANSWERED ALL QUESTIONS "NO".
Schedule K (Form 990) 2010

Additional Data


Software ID:  
Software Version:  

Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2010
Schedule L (Form 990 or 990-EZ) 2010
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) MARTHA JEFFERSON PHYSICIAN HOSPITAL ORGANIZATION INC
  		SEE BELOW 144,813 ACCOUNTING SERVICE   No
(2) MARTHA JEFFERSON OUTPATIENT SURGERY CENTER LLC
  		SEE BELOW 465,719 RENT AND CLEANING SERVICE   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
PART IV (b)   TRANSACTIONS WITH INTERESTED PERSONS - BOARD/OFFICER/KEY EMPLOYEE OVERLAP WITH TAXABLE ENTITIESBOARD MEMBERS CAROL HURT AND CHARLES ROTGIN, JR. AND OFFICERS JAMES HADEN AND J. MICHAEL BURRIS ALSO SERVE AS BOARD MEMBERS AND/OR OFFICERS OF MARTHA JEFFERSON PHYSICIAN HOSPITAL ORGANIZATION, INC., A JOINT VENTURE OF THE ORGANIZATION.BOARD MEMBERS LILLIAN BEVIER AND PETER BROOKS, OFFICER J. MICHAEL BURRIS, AND KEY EMPLOYEE RONALD COTTRELL SERVE AS BOARD MEMBERS OF MARTHA JEFFERSON OUTPATIENT SURGERY CENTER, LLC, A JOINT VENTURE OF THE ORGANIZATION.DIRECTORS/OFFICERS/KEY EMPLOYEES OF THE ORGANIZATION MAY ALSO SERVE AS DIRECTORS/OFFICERS/KEY EMPLOYEES OF RELATED TAXABLE ENTITIES WITHIN THE SENTARA HEALTHCARE SYSTEM. SEE FORM 990 SCHEDULE R FOR A LISTING OF TRANSACTIONS THE ORGANIZATION HAD WITH THESE RELATED TAXABLE ENTITIES.
Schedule L (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
contribution amounts
1 Art—Works of art .... X 3 21,999 APPRAISAL
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 15 49,596 COST OR SELLING PRICE
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( GIFTS IN KIND ) X 113 36,573 COST OR SELLING PRICE OF DONATED PROPERTY
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
3
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell non-cash
contributions? ............................
32a
Yes
 
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2010
Schedule M (Form 990) 2010
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33. Also complete this part for any additional information.
Identifier Return Reference Explanation
Method for Determining Number of Contributors: Part I, Column (b): THE NUMBER OF CONTRIBUTIONS FOR EACH TYPE OF PROPERTY RECEIVED IS CALCULATED USING THE NUMBER OF CONTRIBUTIONS RECORDED, WHICH MAY INCLUDE MULTIPLE ITEMS RECEIVED. CONTRIBUTIONS FROM DONORS WHO GIVE ITEMS THROUGHOUT THE YEAR ARE COUNTED AS SEPARATE CONTRIBUTIONS ON EACH NEW DATE RECEIVED.
Third Party Use: Part I, Line 32b: MARTHA JEFFERSON HOSPITAL USES EXTERNAL PARTIES TO COORDINATE AN ARMS-LENGTH SALE OF NON-CASH CONTRIBUTIONS. FOR EXAMPLE, A LICENSED STOCK BROKER WAS USED THIS YEAR TO SELL GIFTS OF STOCK.
Schedule M (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
Identifier Return Reference Explanation
Form 990, Part VI, Section A, line 2   THE ORGANIZATION'S OFFICERS AND DIRECTORS SERVE TOGETHER ON THE BOARDS OF OTHER TAXABLE ORGANIZATIONS WITHIN THE SENTARA HEALTHCARE SYSTEM ("THE SYSTEM"), AS WELL AS JOINT VENTURES IN WHICH THE SYSTEM HAS AN OWNERSHIP INTEREST. SEE SCHEDULE R FOR A LISTING OF SUCH ENTITIES.
Form 990, Part VI, Section A, line 4   ON APRIL 1, 2011, THE ORGANIZATION ENTERED INTO AN AFFILIATION AGREEMENT WITH SENTARA HEALTHCARE, A 501(c)(3) ORGANIZATION ("SENTARA"), WHEREBY SENTARA REPLACED MARTHA JEFFERSON HEALTH SERVICES CORPORATION ("MJHSC") AS THE SOLE MEMBER OF THE ORGANIZATION EFFECTIVE JUNE 1, 2011. AS A RESULT OF THE AFFILIATION, THE ORGANIZING AND GOVERNING DOCUMENTS WERE CHANGED IN THE FOLLOWING MANNER: - MJHSC WAS REPLACED BY SENTARA AS SOLE MEMBER OF THE ORGANIZATION. - THE TWELVE-MEMBER BOARD OF TRUSTEES, WHICH WAS SELECTED BY MJHSC AS SOLE MEMBER AND WAS COMPRISED OF SIX ACTIVE MEDICAL STAFF MEMBERS AND SIX LAY PERSONS, WAS REPLACED WITH A FIFTEEN-MEMBER BOARD OF DIRECTORS, TWELVE SELECTED BY MJHSC AND THREE APPOINTED BY SENTARA. THOSE SELECTED BY MJHSC SHALL ALSO SERVE AS DIRECTORS OF MJHSC DURING THE COVENANT PERIOD DEFINED IN THE AFFILIATION AGREEMENT AND SHALL ULTIMATELY BE REDUCED TO SIX THROUGH TERM EXPIRATIONS. - SENTARA, AS SOLE MEMBER, SHALL HAVE EXCLUSIVE AUTHORITY TO DIRECT AND MANAGE THE OPERATIONS AND AFFAIRS OF THE ORGANIZATION AND TO MAKE ALL DECISIONS REGARDING THE BUSINESS OF THE ORGANIZATION, SUBJECT TO BOARD OVERSIGHT TO THE EXTENT AND IN THE MANNER SET FORTH IN THE ORGANIZATION'S BYLAWS. THE BOARD OF DIRECTORS SHALL FUNCTION IN AN ADVISORY CAPACITY, PROVIDING RECOMMENDATIONS TO SENTARA REGARDING THE ESTABLISHMENT OF ORGANIZATION POLICIES, THE MAINTENANCE OF QUALITY PATIENT CARE, AND THE PROVISION OF INSTITUTIONAL PLANNING IN A MANNER RESPONSIVE TO LOCAL COMMUNITY NEEDS. - UPON ANY LIQUIDATION OR DISSOLUTION OF THE ORGANIZATION, ITS REMAINING ASSETS SHALL BE DISTRIBUTED TO SENTARA. - DURING THE COVENANT PERIOD DEFINED IN THE AFFILIATION AGREEMENT, ORGANIZING OR ENABLING DOCUMENTS OR BYLAWS MAY ONLY BE ALTERED, AMENDED, RESTATED OR REPEALED THROUGH APPROVAL OF A MAJORITY OF THE BOARD MEMBERS SELECTED BY MJHSC VOTING AS A SEPARATE CLASS, AND SENTARA.
Form 990, Part VI, Section A, line 6   SENTARA HEALTHCARE, A 501(c)(3) TAX EXEMPT ORGANIZATION, IS THE SOLE MEMBER OF MARTHA JEFFERSON HOSPITAL.
Form 990, Part VI, Section A, line 7a   BOARD CANDIDATES IDENTIFIED BY THE ORGANIZATION'S NOMINATION COMMITTEE MUST BE RATIFIED BY THE BOARD OF DIRECTORS OF THE ORGANIZATION'S SOLE MEMBER, SENTARA HEALTHCARE, PRIOR TO ELECTION.
Form 990, Part VI, Section A, line 7b   THE ORGANIZATION MAY NOT TAKE OR ALLOW ANY OF THE FOLLOWING GOVERNANCE ACTIONS WITHOUT THE CONSENT OF ITS 501(c)(3) SOLE MEMBER, SENTARA HEALTHCARE: APPROVAL OR ADOPTION OF ANY PLAN OR MERGER OR CONSOLIDATION, ANY SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, THE PROPERTY AND ASSETS OF THE ORGANIZATION, THE VOLUNTARY DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION, REVOCATION OF ANY SUCH VOLUNTARY DISSOLUTION PROCEEDINGS, OR ANY DECISION TO FILE A PETITION REQUESTING OR CONSENTING TO AN ORDER FOR RELIEF UNDER THE FEDERAL BANKRUPTCY LAWS OR SIMILAR STATE LAWS FOR THE ORGANIZATION; ELECTION OF NEW BOARD MEMBERS; OR ALTERATION, AMENDMENT, RESTATEMENT OR REPEAL OF ANY ORGANIZING OR ENABLING DOCUMENTS OR BYLAWS. THE APPROVAL OF THE SOLE MEMBER IS ALSO REQUIRED FOR CERTAIN OPERATIONAL ACTIONS, AS OUTLINED IN THE ORGANIZATION'S BYLAWS. SUCH ACTIONS INCLUDE, BUT ARE NOT LIMITED TO, APPROVAL OF LONG-RANGE AND STRATEGIC PLANS AND ANNUAL OPERATING AND CAPITAL BUDGETS; TRANSACTIONS WITH INTERESTED PERSONS; CREATION OR ACQUISITION OF SUBSIDIARIES OR INTERESTS IN WHICH THE ORGANIZATION WILL BE A MEMBER; ENTRANCE INTO JOINT VENTURE OR OTHER SIMILAR ARRANGEMENTS; EMPLOYMENT MATTERS CONCERNING THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER; AND THE COMMENCEMENT OR SETTLEMENT OF LITIGATION. SENTARA HEALTHCARE HAS EXCLUSIVE AUTHORITY TO DIRECT AND MANAGE THE OPERATIONS AND AFFAIRS OF THE HOSPITAL AND TO MAKE ALL DECISIONS REGARDING THE BUSINESS OF THE ORGANIZATION, SUBJECT TO BOARD OVERSIGHT TO THE EXTENT AND IN THE MANNER SET FORTH IN THE ORGANIZATION'S BYLAWS.
Form 990, Part VI, Section B, line 11   THE ANNUAL AUDITED FINANCIALS OF MARTHA JEFFERSON HOSPITAL ARE REVIEWED BY SENTARA HEALTHCARE IN ADDITION TO THE MARTHA JEFFERSON HOSPITAL BOARD'S REVIEW. PRIOR TO FILING THE FORM 990 WITH THE IRS, IT IS REVIEWED BY THE FINANCE TEAM, INCLUDING THE CHIEF FINANCIAL OFFICER. IT IS ALSO REVIEWED BY SENTARA HEALTHCARE'S TAX DIRECTOR. MARTHA JEFFERSON HOSPITAL WILL SUBMIT THE INTERNAL REVENUE SERVICE FORM 990 FOR THE PRECEEDING FISCAL YEAR TO THE CEO EVALUATION COMMITTEE OF THE MARTHA JEFFERSON HOSPITAL BOARD OF DIRECTORS IN THE RESPECTIVE MEETING FOLLOWING THE FILING OF THE FORM 990. IN ADDITION, THE FORM 990 WILL BE PROVIDED TO THE MARTHA JEFFERSON HOSPITAL BOARD OF DIRECTORS AT THE MEETING FOLLOWING THE FILING OF THE FORM 990. MARTHA JEFFERSON HOSPITAL WILL ALSO ADVISE BOARD MEMBERS OF THE WEBSITE ADDRESS AT WHICH THE FILED FORM 990 WILL BE POSTED (WWW.GUIDESTAR.ORG/990).
  Form 990, Part VI, Section B, line 12c MARTHA JEFFERSON HOSPITAL'S CONFLICT OF INTEREST POLICY IS ADMINISTERED BY THE CORPORATE COMPLIANCE OFFICER. ON AN ANNUAL BASIS ALL DIRECTORS, TRUSTEES, OFFICERS, KEY EMPLOYEES, MEDICAL STAFF MEMBERS WITH ADMINISTRATIVE RESPONSIBILITIES AND OTHER EMPLOYEES COMPLETE A DETAILED CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING ANY REPORTABLE ACTIVITIES AND INVESTMENTS. THESE QUESTIONNAIRES ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER. IN ADDITION, ALL PERSONS LISTED ABOVE ARE ANNUALLY PROVIDED A COPY OF THE CONFLICT OF INTEREST POLICY. IF CHANGES TO PERSONNEL OCCUR BETWEEN ANNUAL COMPLETION OF THE CONFLICT OF INTEREST QUESTIONNAIRE, NEW PERSONNEL ARE ALSO REQUIRED TO COMPLETE THE QUESTIONNAIRE. ALL DISCLOSURE STATEMENTS ARE REVIEWED FOR REPORTABLE TRANSACTIONS.
  Form 990, Part VI, Section B, line 15 THE ORGANIZATION HAS AN ESTABLISHED CEO EVALUATION COMMITTEE MADE UP OF HOSPITAL BOARD MEMBERS AND COMMITTEE MEMBERS. ON AN ANNUAL BASIS, A THIRD PARTY COMPENSATION CONSULTING FIRM PROVIDES AN INDEPENDENT REVIEW AND ANALYSIS OF BASE AND TOTAL COMPENSATION AND EXECUTIVE PERQUISITES USING MARKET COMPARABILITY DATA. THE CONSULTING FIRM RENDERS AN OPINION ON THE FAIR MARKET VALUE OF COMPENSATION PAID AND BENEFITS PROVIDED WITH RESPECT TO THE IRS INTERMEDIATE SANCTIONS REGULATIONS. THE PROCESS IS FOLLOWED FOR THE FOLLOWING POSITIONS: CEO, VICE PRESIDENTS, EMPLOYED PHYSICIANS. FORM 990, PART VI, SECTION B, LINE 16b AT SEPTEMBER 30, 2011 MARTHA JEFFERSON HOSPITAL DID NOT HAVE A SPECIFIC JOINT VENTURE POLICY. ANY PROPOSED JOINT VENTURE PARTICIPATION IS EVALUATED WITHIN THE CONTEXT OF THE ADMINISTRATIVE POLICY ENTITLED "AUTHORITY TO COMMIT AND EXPEND FUNDS". THIS POLICY DEPICTS THE TYPES AND LEVELS OF EXPENDITURES AND COMMITMENTS THAT MANAGEMENT CAN UNDERTAKE. ALL PROPOSED JOINT VENTURES ARE REVIEWED BY EXTERNAL LEGAL COUNSEL TO ENSURE COMPLIANCE WITH THE APPROPRIATE FEDERAL, STATE AND REGULATORY LAW. ANY JOINT VENTURE PARTICIPATION MUST BE EVALUATED AND APPROVED BY THE MARTHA JEFFERSON HOSPITAL BOARD OF DIRECTORS. A SPECIFIC JOINT VENTURE PARTICIPATION POLICY IS CURRENTLY IN PROCESS OF DEVELOPMENT.
  Form 990, Part VI, Section C, line 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A JAMES HADEN DEVOTED AN AVERAGE OF 15 HOURS PER WEEK TO RELATED ORGANIZATIONS. J. MICHAEL BURRIS DEVOTED AN AVERAGE OF 11 HOURS PER WEEK TO RELATED ORGANIZATIONS. ELLIOT KUIDA DEVOTED AN AVERAGE OF 2 HOURS PER WEEK TO RELATED ORGANIZATIONS.
  FORM 990, PART VII, SECTION A THE EFFECTIVE DATE OF THE ORGANIZATION'S AFFILIATION WITH SENTARA HEALTHCARE, ITS NEW 501(c)(3) SOLE MEMBER, WAS JUNE 1, 2011. SINCE THE COMPENSATION REQUIRED TO BE REPORTED IN PART VII SECTION A IS FROM THE 2010 CALENDAR YEAR, AND SENTARA HEALTHCARE WAS NOT RELATED TO THE ORGANIZATION AT ANY TIME DURING 2010, NO RELATED COMPENSATION HAS BEEN REPORTED IN PART VII SECTION A FOR VICE CHAIRMAN HOWARD KERN AND BOARD MEMBERS DAVID BERND AND KENNETH KRAKAUR, WHO ARE EMPLOYED OFFICERS OF SENTARA HEALTHCARE.
  FORM 990, PART X CERTAIN BALANCE SHEET ITEMS WERE RECLASSIFIED IN THE CURRENT YEAR DUE TO AFFILIATION WITH SENTARA HEALTHCARE.
Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: TRANSFER FROM MJH FOUNDATION 3007292. INCREASE IN ADDITIONAL MINIMUM PENSION LIABILITY -5870375. NET UNREALIZED GAINS ON CHARITABLE TRUSTS -43422. NET UNREALIZED GAINS ON INVESTMENTS 899. ASU 2010-07 FAIR MARKET VALUE ADJUSTMENTS -XXX-XX-XXXX. NET PLEDGE ACTIVITY 25130. FY10 CAPITALIZED INTEREST RESTATED -11423820. DEEMED DISTRIBUTION FROM CFC NOT ON BOOKS -33850. INTEREST RATE SWAP VALUATION -11631070. Total to Form 990, Part XI, Line 5: -XXX-XX-XXXX.
  FORM 990, PART XII, LINE 2C DURING THE YEAR, MARTHA JEFFERSON HOSPITAL AFFILIATED WITH SENTARA HEALTHCARE WHO ASSUMED RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTED THE INDEPENDENT ACCOUNTANT.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MARTHA JEFFERSON HOSPITAL
 
Employer identification number

54-0261840
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) MARTHA JEFFERSON MEDICAL GROUP LLC
500 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911
26-1126956 		PHYSICIAN PRACTICES VA 18,747,398 2,810,673 N/A










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
Yes No
(1) MARTHA JEFFERSON HEALTH SERVICES CORPORATION

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
54-1401355 		COMMUNITY HEALTHCARE VA 501(C)(3) 11 TYPE I N/A
 
No
(2) MJH FOUNDATION

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
54-1401357 		INVESTMENT & MANAGEMENT SERVICES FOR MARTHA JEFFERSON HOSPITAL VA 501(C)(3) 11 TYPE I MARTHA JEFFERSON HOSPITAL
 
Yes
 
(3) MARTHA JEFFERSON HOSPITAL FOUNDATION

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
30-0041113 		FUNDRAISING VA 501(C)(3) 11 TYPE I MARTHA JEFFERSON HOSPITAL
 
Yes
 
(4) MJH ENTERPRISES

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
54-1403114 		NON-HOSPITAL PATIENT CARE SERVICES VA 501(C)(3) 11 TYPE I MARTHA JEFFERSON HOSPITAL
 
Yes
 
(5) SENTARA HEALTHCARE

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
52-1271901 		HEALTH CARE VA 501(C)(3) 7 N/A
 
No
(6) SENTARA PRINCESS ANNE HOSPITAL

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
52-1277419 		HEALTH CARE VA 501(C)(3) 3 SENTARA HOSPITALS
 
Yes
 
(7) SENTARA HOSPITALS

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1547408 		HEALTH CARE VA 501(C)(3) 3 SENTARA HEALTHCARE
 
Yes
 
(8) SENTARA MEDICAL GROUP

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1217184 		HEALTH CARE VA 501(C)(3) 9 SENTARA HEALTHCARE
 
Yes
 
(9) SENTARA LIFE CARE CORP

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1217183 		HEALTH CARE VA 501(C)(3) 9 SENTARA HEALTHCARE
 
Yes
 
(10) MPB INC

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1346393 		TITLE HOLDING COMPANY VA 501(C)(2)   SENTARA ENTERPRISES
 
Yes
 
(11) OPTIMA HEALTH PLAN

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1283337 		HMO VA 501(C)(3) 11A - I SENTARA HEALTHCARE
 
Yes
 
(12) POTOMAC HOSPITAL CORP OF PRINCE WILLIAM

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-0853898 		HEALTH CARE VA 501(C)(3) 3 SENTARA HEALTHCARE
 
Yes
 
(13) ROCKINGHAM MEMORIAL HOSPITAL

2010 HEALTH CAMPUS DRIVE

HARRISONBURG,VA22801
54-0506331 		HEALTH CARE VA 501(C)(3) 3 SENTARA HEALTHCARE
 
Yes
 
(14) VALLEY WELLNESS CENTER

501 STONE SPRING ROAD

HARRISONBURG,VA22801
52-1309257 		PREVENTATIVE HEALTH/REHAB VA 501(C)(3) 9 ROCKINGHAM MEMORIAL HOSPITAL
 
Yes
 
(15) SENTARA ENTERPRISES

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1917649 		HEALTH CARE VA 501(C)(3) 9 SENTARA HEALTHCARE
 
Yes
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) MARTHA JEFFERSON OUTPATIENT SURGERY CENTER LLC

595 PETER JEFFERSON PARKWAY
CHARLOTTESVILLE,VA22911
11-3656095 		OUTPATIENT SURGERY CENTER VA N/A
 RELATED 1,002,232 1,555,092   No   Yes   51.950 %
(2) PHYSICAL THERAPY ACAC LLC

501 ALBEMARLE SQUARE
CHARLOTTESVILLE,VA22901
26-0080717 		PHYSICAL THERAPY VA N/A
 N/A       No   Yes    
(3) MANAGEMENT SERVICES

814 GREENBRIER CIR
CHESAPEAKE,VA23320
54-1365012 		HEALTH MANAGEMENT SERVICES VA N/A
 N/A       No     No  
(4) OBICI REAL ESTATE HOLDINGS LLC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
26-1749881 		REAL ESTATE RENTAL VA N/A
 N/A       No     No  
(5) PRINCESS ANNE AMB SURG CENTER

1975 GLENN MITCHELL DRIVE
VA BEACH,VA23456
20-4920880 		HEALTH CARE VA N/A
 N/A       No     No  
(6) VA BEACH AMBULATORY SURG CENTER

1700 WILL O WISP DR
VA BEACH,VA23454
54-1448218 		HEALTH CARE VA N/A
 N/A       No     No  
(7) AMER HEALTH EVAL CTR - WMSBG

PO BOX 3508
WILLIAMSBURG,VA23187
26-3761741 		HEALTH CARE VA N/A
 N/A       No     No  
(8) CANCER CENTERS OF VA LLC

5900 LAKE WRIGHT DR
NORFOLK,VA23502
20-1338518 		HEALTH CARE VA N/A
 N/A       No     No  
(9) HAMPTON ROADS LITHOTRIPSY LLC

225 CLEARFIELD AVE
VA BEACH,VA23502
20-0942600 		HEALTH CARE VA N/A
 N/A       No     No  
(10) HEALTHCARE PERFORMANCE IMPROVEMENT LLC

5041 CORPORATE WOODS DR
VA BEACH,VA23462
20-4024074 		CONSULTING VA N/A
 N/A       No     No  
(11) RADIOLOGY SERVICES OF HAMPTON ROADS LC

814 GREENBRIER CIR
CHESAPEAKE,VA23320
54-1774472 		HEALTH CARE VA N/A
 N/A       No   Yes    
(12) CAREPLEX ORTHO ASC LLC

3000 COLISEUM DRIVE
HAMPTON,VA23666
27-1867311 		HEALTH CARE VA N/A
 N/A       No     No  
(13) SENTARA OBICI AMBULATORY SURGERY LLC

2750 GODWIN BLVD
SUFFOLK,VA23434
26-0144898 		HEALTH CARE VA N/A
 N/A       No     No  
(14) ST LUKES PROPERTIES LLC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
27-2774684 		MOB RENTAL VA N/A
 N/A       No   Yes    
(15) POTOMAC INOVA HEALCARE ALLIANCE LLC

8110 GATEHOUSE ROAD
FALLS CHURCH,VA22042
54-1802733 		HEALTH CARE VA N/A
 N/A       No     No  
(16) CAREPLEX WEST LLC

18000 W SARAH LANE
BROOKFIELD,WI53045
20-2738977 		RENTAL RE WI N/A
 N/A       No     No  
(17) PORT WARWICK II LLC

18000 W SARAH LANE
BROOKFIELD,WI53045
20-2739075 		RENTAL RE WI N/A
 N/A       No     No  
(18) ORTHOPAEDIC HOSPITAL MGT LLC

3000 COLISEUM DRIVE
HAMPTON,VA23666
27-4185117 		MGT SVCS VA N/A
 N/A       No     No  
(19) PORT WARWICK III LLC

18000 W SARAH LANE
BROOKFIELD,WI53045
61-1499371 		RENTAL RE WI N/A
 N/A       No     No  
(20) VALIANCE HEALTH LLC

3190 PEOPLES DR
HARRISONBURG,VA22801
54-1866081 		HEALTH CARE VA N/A
 N/A       No     No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) MARTHA JEFFERSON MEDICAL ENTERPRISES INC
630 PETER JEFFERSON PARKWAY
CHARLOTTESVILLE,VA22911
54-1841528 		MEDICAL BILLING SERVICE VA N/A
 C 3,700,395 387,434 100.000 %
(2) SENTARA HOLDINGS INC
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1555638 		HOLDING COMPANY VA N/A
 C      
(3) SENTARA HEALTH PLANS INC
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
52-2368125 		TPA VA N/A
 C      
(4) OPTIMA HEALTH GROUP
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1473382 		HMO VA N/A
 C      
(5) OPTIMA HEALTH INSURANCE COMPANY
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1642752 		HEALTH INSURANCE VA N/A
 C      
(6) OPTIMA BEHAVIORAL HEALTH SERVICES
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
62-1382666 		MENTAL HEALTH SVCS VA N/A
 C      
(7) SENTARA VENTURES INC
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1688615 		HOLDING COMPANY VA N/A
 C      
(8) SMG INNOVATIONS INC
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
20-3730331 		HEALTH CARE VA N/A
 C      
(9) SENTARA OBICI PROFESSIONAL CENTER
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1445865 		RE RENTAL VA N/A
 C      
(10) SENTARA OBICI MED MGT SERVICES
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1020941 		HEALTH CARE VA N/A
 C      
(11) ROCKINGHAM HEALTH SERVICES INC
2010 HEALTH CAMPUS DRIVE
HARRISONBURG,VA22801
54-1721387 		CONTRACTING SERVICES VA N/A
 C      
(12) POTOMAC VENTURES CORP
6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1441420 		PHARMACY VA N/A
 C      
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
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 . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
Yes
 
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
2
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) MARTHA JEFFERSON MEDICAL ENTERPRISES

 A 61,773 CORP BOOKS/RECORDS
(2) MARTHA JEFFERSON MEDICAL ENTERPRISES

 D 2,019,889 CORP BOOKS/RECORDS
(3) MARTHA JEFFERSON MEDICAL ENTERPRISES

 P 276,173 CORP BOOKS/RECORDS
(4) MJH FOUNDATION

 P 178,632 CORP BOOKS/RECORDS
(5) MJH FOUNDATION

 R 3,007,292 CORP BOOKS/RECORDS
(6) MARTHA JEFFERSON OUTPATIENT SURGERY CENTER

 A 465,719 CORP BOOKS/RECORDS
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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