TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) BRENT WILSON CHAIR	2.00	X	X	0	0
(2) HAROLD HOUSE VICE CHAIR	2.00	X	X	0	0
(3) PATRICK E BURNS SECRETARY/TREASURER	2.00	X	X	0	0
(4) DAVID FREESTONE MD BOARD MEMBER/PHYSICIAN	40.00	X		240,625	13,640
(5) DEBBY CASSADY BOARD MEMBER	2.00	X		0	0
(6) DOUGLAS POFF DO BOARD MEMBER/PHYSICIAN	40.00	X		200,582	14,572
(7) GARY REETZ BOARD MEMBER	2.00	X		0	0
(8) MARK BRETT BOARD MEMBER	2.00	X		0	0
(9) REX A RIMMEL DO BOARD MEMBER	2.00	X		0	0
(10) ROBERT SEALS DO BOARD MEMBER/PHYSICIAN	40.00	X		270,372	12,602
(11) RODERICK COY BOARD MEMBER	2.00	X		0	0
(12) TOM MACDONALD BOARD MEMBER	2.00	X		0	0
(13) TOM OSTRANDER BOARD MEMBER	2.00	X		0	0
(14) BRUCE L TRAVERSE PRESIDENT/CEO	40.00		X	239,392	7,734
(15) DUANE C MILLER CFO	40.00		X	150,658	11,262
(16) MATTHEW J THOMPSON COO	40.00		X	161,307	7,438
(17) NANCY A WEAVER DIRECTOR OF PATIENT SERVICES	40.00		X	143,944	9,374

(A) Name and business address	(B) Description of services	(C) Compensation
PHARMACY SYSTEMS INC PO BOX 71-0716 COLUMBUS,OH43271	PHARMACY CONSULTING SERVICES	239,539
GARY RALPH 400 WILDWOOD DR EAST LANSING,MI48823	PHYSICIAN CONSULTING SERVICES	163,350
PROMED 17197 LAUREL PARK N STE 521 LIVONIA,MI48152	HOME HEALTH CARE BILLING CONSULTING	149,584
LIFE CARE SLEEP AND HEALTH CENTER LLC 7200 W SAGINAW HWY SUITE 2 LANSING,MI48917	SLEEP STUDY CONSULTING	145,825

2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 4

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	19,979	19,979
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	2,030,147	1,342,727	687,420
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	26,402,918	23,491,354	2,911,564
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	789,777	589,803	199,974
9	Other employee benefits .......	1,498,094	1,107,947	390,147
10	Payroll taxes ...........	1,853,570	1,620,200	233,370
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	118,520		118,520
c	Accounting ...........	70,374		70,374
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	40,382		40,382
g	Other ..........	4,083,309	1,575,732	2,507,577
12	Advertising and promotion ....	533,783	8,051	525,732
13	Office expenses .......	2,838,495	2,347,267	491,228
14	Information technology ......	745,207	211,171	534,036
15	Royalties ..	0
16	Occupancy ...........	2,923,965	1,544,985	1,378,980
17	Travel ............	117,110	114,838	2,272
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	419,059	419,059
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	1,859,186	1,859,186
23	Insurance ..............	833,937	81,714	752,223
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	DIRECT PATIENT CARE SUPPLIES & EXPENSES	8,309,383	8,309,383
b	BAD DEBT EXPENSE	2,333,022	2,333,022
c	PROVIDER/OTHER TAXES	1,725,486	1,689,854	35,632
d	RECRUITING	238,633	218,072	20,561
e
f	All other expenses	286,661	147,145	138,464	1,052
25	Total functional expenses. Add lines 1 through 24f	60,070,997	49,031,489	11,038,456	1,052
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).	0

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	4,202	1	4,633
2	Savings and temporary cash investments .......	6,202,651	2	3,996,424
3	Pledges and grants receivable, net .........	50,900	3	28,207
4	Accounts receivable, net .........	8,138,330	4	10,007,350
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 .............	59,492	7	43,588
8	Inventories for sale or use ..............	1,065,956	8	987,209
9	Prepaid expenses and deferred charges ............	1,230,733	9	2,136,643
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	45,885,042
b	Less: accumulated depreciation. .....	10b	22,577,244	23,913,240	10c	23,307,798
11	Investments—publicly traded securities ..........	5,100,698	11	5,065,752
12	Investments—other securities. See Part IV, line 11 ......	0	12	0
13	Investments—program-related. See Part IV, line 11 ..	0	13	0
14	Intangible assets .........	239,804	14	239,804
15	Other assets. See Part IV, line 11 ...........	627,987	15	610,940
16	Total assets. Add lines 1 through 15 (must equal line 34)...	46,633,993	16	46,428,348
	17	Accounts payable and accrued expenses .	4,213,919	17	6,029,100
18	Grants payable ..........		18
19	Deferred revenue ..........	0	19
20	Tax-exempt bond liabilities ..........	15,904,911	20	15,147,534
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 ..	1,492,963	23	1,318,003
24	Unsecured notes and loans payable to unrelated third parties ....	25,010	24	22,510
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	1,649,023	25	710,902
26	Total liabilities. Add lines 17 through 25.....	23,285,826	26	23,228,049
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	23,141,058	27	22,936,749
28	Temporarily restricted net assets .....	207,109	28	263,550
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	23,348,167	33	23,200,299
34	Total liabilities and net assets/fund balances .....	46,633,993	34	46,428,348

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Other

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2011

Page 2

Part II

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

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3..
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public Support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

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

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

Section C. Computation of Public Support Percentage

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

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

16a

33 1/3% support test—2011. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2010. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

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

Schedule A (Form 990 or 990-EZ) 2011

Page 3

Part III

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

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public Support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f)) .........

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

Section D. Computation of Investment Income Percentage

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

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

19a

33 1/3% support tests—2011. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

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

Schedule A (Form 990 or 990-EZ) 2011

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2011

Name of organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2

Name of organization CARSON CITY HOSPITAL
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part I	Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3

Name of organization CARSON CITY HOSPITAL
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part II	Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4

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

Name of organization
CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part III

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

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

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

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

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SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below.
SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part I-A

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

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

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

A Check if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check if the filing organization checked box A and "limited control" provisions apply.

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

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

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) Total

2a	Lobbying non-taxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

Other activities? ..........................

Yes

3,234

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

3,234

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Identifier	Return Reference	Explanation
Description of the activities reported on Lines 1a through 1i	Schedule C, Part II-B, Line 1	THE ORGANIZATION INDIRECTLY INFLUENCED LEGISLATION THOUGH ITS ANNUAL DUES PAID TO THE MICHIGAN HEALTH AND HOSPITAL ASSOCIATION; 13.92% OF DUES PAID WERE USED FOR SPECIFIC LOBBYING PURPOSES.

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

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

(ii)

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

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2011

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

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

Provide the estimated percentage of the year end balance (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	731,643		731,643
b	Buildings ................	31,154,525	13,250,793	17,903,732
c	Leasehold improvements ............	1,471,761	532,525	939,236
d	Equipment ................	12,287,183	8,793,926	3,493,257
e	Other .................	239,930		239,930
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				23,307,798

Schedule D (Form 990) 2011

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value









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

Part X

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

1.(a) Description of Liability		(b) Book value
Federal Income Taxes		0
DEFINED BENEFIT PENSION LIABILITY		710,902








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		710,902
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2011

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1	60,809,630
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	60,070,997
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	738,633
4	Net unrealized gains (losses) on investments ..........................	4
5	Donated services and use of facilities .............................	5	-200,065
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV.) .................................	8	-686,436
9	Total adjustments (net). Add lines 4 through 8 .........................	9	-886,501
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	-147,868

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	59,885,652
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	-200,065
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV.) ............	2d	2,905
e	Add lines 2a through 2d .....................			2e	-197,160
3	Subtract line 2e from line 1.....................			3	60,082,812
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	40,382
b	Other (Describe in Part XIV.) ...........	4b	686,436
c	Add lines 4a and 4b.......................			4c	726,818
5	Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	60,809,630

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............			1	60,033,520
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	2,905
e	Add lines 2a through 2d......................			2e	2,905
3	Subtract line 2e from line 1.....................			3	60,030,615
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	40,382
b	Other (Describe in Part XIV.) ............	4b	0
c	Add lines 4a and 4b.......................			4c	40,382
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	60,070,997

Part XIV

Supplemental Information

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

Identifier	Return Reference	Explanation
FIN 48 (ASC 740) footnote	Schedule D, Part X, Line 2	CARSON CITY HOSPITAL IS A NONPROFIT, TAX-EXEMPT ORGANIZATION PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM INCOME TAXES ON RELATED INCOMES PURSUANT TO SECTION 501(A). ACCORDINGLY, NO TAX PROVISION IS REFLECTED IN THE FINANCIAL STATEMENTS. HOWEVER, INCOME NOT DIRECTLY RELATED TO THE HOSPITAL'S TAX-EXEMPT PURPOSE IS SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME. A TAX POSITION IS RECOGNIZED AS A BENEFIT ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WOULD BE SUSTAINED IN A TAX EXAMINATION, WITH A TAX EXAMINATION BEING PRESUMED TO OCCUR. THE AMOUNT RECOGNIZED IS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS GREATER THAN 50% LIKELY OF BEING REALIZED ON EXAMINATION. FOR TAX POSITIONS NOT MEETING THE MORE LIKELY THAN NOT TEST, NO TAX BENEFIT IS RECORDED. THE HOSPITAL RECOGNIZES INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX LIABILITIES AND INCLUDES THESE IN INTEREST AND INCOME TAX EXPENSE. THE HOSPITAL HAS NO AMOUNTS ACCRUED FOR INTEREST AND PENALTIES AS OF DECEMBER 31, 2011 OR 2010. THE HOSPITAL DOES NOT EXPECT THE TOTAL AMOUNT OF UNRECOGNIZED TAX LIABILITIES TO SIGNIFICANTLY CHANGE OVER THE NEXT TWELVE MONTHS. THE HOSPITAL IS NO LONGER SUBJECT TO EXAMINATION BY TAXING AUTHORITIES FOR YEARS BEFORE 2008.

Schedule D (Form 990) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

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

2011

Open to Public Inspection

Name of the organization
CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and e-mail solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

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?

Yes

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
	(ii) Activity	Yes	No	(iv) Gross receipts from activity		(vi) Amount paid to (or retained by) organization
Total .................

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) 2011

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 SUMMER DANCE (event type)	(b) Event #2 (event type)	(c) Other Events (total number)	(d) Total Events (Add col. (a) through col. (c))
1	Gross receipts . . .	68,284			68,284
2	Less: Charitable contributions . . .	51,800			51,800
3	Gross income (line 1 minus line 2) . . .	16,484	0	0	16,484
4	Cash prizes . . .				0
5	Non-cash prizes . .				0
6	Rent/facility costs . .				0
7	Food and beverages . .	2,905			2,905
8	Entertainment . . .				0
9	Other direct expenses .				0
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........				2,905
11	Net income summary. Combine lines 3 and 10 in column (d)............				13,579

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.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (Add col. (a) through col. (c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," Explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," Explain:

Does the organization operate gaming activities with nonmembers? .................

YesNo

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? ..........................

YesNo

Schedule G (Form 990 or 990-EZ) 2011

Page 3

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Provide the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

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

$ .

If "Yes," enter name and address:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

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) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other

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

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

Yes

200% 250% 300% 350% 400% Other

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

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

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

	(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 Financial Assistance at cost (from Worksheet 1) ..	0	0	2,162,964	0	2,162,964	3.750 %
b Medicaid (from Worksheet 3, column a) .....	22	30,157	11,714,532	7,895,636	3,818,896	6.610 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .	0	0	0	0	0	0 %
dTotal Financial Assistance and Means-Tested Government Programs .....	22	30,157	13,877,496	7,895,636	5,981,860	10.360 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	84	3,275	2,281,433	0	2,281,433	3.950 %
f Health professions education (from Worksheet 5) ..	4	19	218,126	16,262	201,864	0.350 %
g Subsidized health services (from Worksheet 6) ..	13	88,440	11,488,220	9,616,313	1,871,907	3.240 %
h Research (from Worksheet 7)	0	0	0	0	0	0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	97	150	19,979	0	19,979	0.030 %
jTotal Other Benefits ...	198	91,884	14,007,758	9,632,575	4,375,183	7.570 %
kTotal. Add lines 7d and 7j. ..	220	122,041	27,885,254	17,528,211	10,357,043	17.930 %

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

Schedule H (Form 990) 2011

Page

Part II

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

		(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	0	0	0	0	0	0 %
2	Economic development	0	0	0	0	0	0 %
3	Community support	0	0	0	0	0	0 %
4	Environmental improvements	0	0	0	0	0	0 %
5	Leadership development and training for community members	0	0	0	0	0	0 %
6	Coalition building	0	0	0	0	0	0 %
7	Community health improvement advocacy	0	0	0	0	0	0 %
8	Workforce development	0	0	0	0	0	0 %
9	Other	0	0	0	0	0	0 %
10	Total	0	0	0	0	0	0 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

Enter the amount of the organization's bad debt expense........

2,333,022

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

45,599

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

Section B. Medicare

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

10,152,773

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

12,475,165

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

-2,322,392

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

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

Schedule H (Form 990) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	CARSON CITY HOSPITAL 406 E ELM STREET CARSON CITY,MI48811	X	X	X	X

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Name of Hospital Facility:

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

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet the community health needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. ....		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?.......		9
	If “Yes,” indicate the FPG family income limit for eligibility for free care: %

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: % If "No," explain in Part VI the criteria the hospital facility used.
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 on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......		14
15	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	DDid the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

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 why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?14
Name and address		Type of Facility (describe)
1	CARSON PAIN MANAGEMENT 102 S THIRD STREET SUITE 300 CARSON CITY,MI48811	OUTPATIENT PAIN MANAGEMENT OFFICE
2	CARSON CITY HOSPITAL ORTHOPEDICS AND GENERAL SURGERY 102 S THIRD ST STE 400 BOX 326 CARSON CITY,MI48811	GENERAL MEDICAL/SURGICAL OUTPATIENT CLINIC
3	PHYSICAL REHABILITATION CARE CENTER 602 E ELM STREET CARSON CITY,MI48811	OUTPATIENT REHABILITATION CLINIC
4	ITHACA FAMILY CARE CENTER 114 N MAIN ST ITHACA,MI48847	GENERAL MEDICAL OUTPATIENT CLINIC
5	CARSON FAMILY CARE CENTER 102 S THIRD ST STE 100 BOX 277 CARSON CITY,MI48811	GENERAL MEDICAL OUTPATIENT CLINIC
6	CARSON HOME CARE 406 E ELM ST CARSON CITY,MI48811	HOME HEALTH CARE
7	GREENVILLE FAMILY CARE CENTER 1014 E WASHINGTON GREENVILLE,MI48838	GENERAL MEDICAL OUTPATIENT CLINIC
8	PEDIATRIC & ADOLESCENT SPECIALISTS 245 S SECOND ST BOX 847 CARSON CITY,MI48811	GENERAL MEDICAL OUTPATIENT CLINIC
9	STANTON FAMILY CARE CENTER 545 N STATE ST BOX 638 STANTON,MI48888	GENERAL MEDICAL OUTPATIENT CLINIC
10	ASHLEY FAMILY CARE CENTER 320 S STERLING ST BOX 96 ASHLEY,MI48806	GENERAL MEDICAL OUTPATIENT CLINIC
11	HOSPITALISTS 406 E ELM ST CARSON CITY,MI48811	GENERAL MEDICAL INPATIENT CLINIC
12	CARSON BEHAVIORAL HEALTH CENTER 102 S THIRD ST STE 500 BOX 417 CARSON CITY,MI48811	BEHAVIORAL HEALTH CLINIC
13	FOWLER FAMILY CARE CENTER 11017 W THIRD ST BOX 19 FOWLER,MI48835	GENERAL MEDICAL OUTPATIENT CLINIC
14	LYONS FAMILY CARE CENTER 505 E BRIDGE ST BOX 186 LYONS,MI48851	GENERAL MEDICAL OUTPATIENT CLINIC

Schedule H (Form 990) 2011

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
Costing Methodology used to calculate financial assistance	Schedule H, Part I, Line 7	THE DEFINITION OF A COMMUNITY BENEFIT IS A SERVICE OR PROGRAM THAT THE HOSPITAL PROVIDES TO PROMOTE HEALTH AND HEALING AS A RESPONSE TO COMMUNITY NEEDS. COMMUNITY BENEFITS USUALLY GENERATE A LOW OR NEGATIVE FINANCIAL RETURN, RESPOND TO PUBLIC HEALTH NEEDS, INVOLVE EDUATION OR RESEARCH THAT IMPROVES THE OVERALL COMMUNITY HEALTH, AND RESPOND TO THE NEEDS OF SPECIAL POPULATIONS SUCH AS PERSONS LIVING IN POVERTY AND OTHER DISENFRANCHISED PERSONS. THE COSTING METHODOLOGY USED IS COST TO CHARGE RATIO. THE COST TO CHARGE RATIO IS FIGURED BY TAKING THE TOTAL EXPENSES EXCLUSIVE OF BAD DEBT AND DIVIDING THAT BY GROSS PATIENT REVENUE AND OTHER OPERATING REVENUE.
Bad Debt Expense excluded from financial assistance calculation	Schedule H, Part I, Line 7, column(f)	2,333,022
Subsidized Health Services	Schedule H, Part I, Line 7g	THE COMMUNITY BENEFITS REPORT TAKES THE WHOLE HOSPITAL, WHICH ALSO TAKES THE MEDICAL SERVICES GROUP PHYSICIAN CLINICS INTO CONSIDERATION. SOME ITEMS CAN ONLY BE DONE IN THE HOSPITAL WHILE MANY OTHERS CAN BE DONE IN A PHYSICIAN CLINIC SETTING. OF THE $9.6 MILLION IN REVENUE THAT IS BROUGHT IN FROM THE PHYSICIAN CLINIC SETTING, $100 FROM BLOOD PRESSURE CHECKS, $5,300 FROM CHILD IMMUNIZATIONS, AND $230 FROM CHOLESTEROL TESTING.
Bad debt expense - financial statement footnote	Schedule H, Part III, Line 4	ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. THE HOSPITAL DOES NOT ACCRUE INTEREST ON ANY OF ITS ACCOUNTS RECEIVABLE. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVELY CALCULATED ADJUSTMENTS ARISING UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS, AS FINAL SETTLEMENTS ARE DETERMINED. BAD DEBT REPORTED IN PART III, LINE 2 IS REPORTED AT THE ESTIMATED NET REALIZABLE VALUE, THE SAME METHODOLOGY USED TO REPORT BAD DEBT IN THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS. THE AMOUNT OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY REPORTED IN PART III, LINE 3 IS DETERMINED BY USING A PERCENTAGE (2.6%) OF THE ORGANIZATION'S TOTAL BAD DEBT EXPENSE AT COST. THIS PERCENTAGE IS DETERMINED BY ANALYZING THE HOSPITAL'S WRITE-OFFS COMPARED TO ITS TOTAL GROSS REVENUE.
Community benefit & methodology for determining medicare costs	Schedule H, Part III, Line 8	THE COSTING METHODOLOGY USED IS COST TO CHARGE RATIO. THE COST TO CHARGE RATIO IS FIGURED BY TAKING THE TOTAL EXPENSES EXCLUSIVE OF BAD DEBT AND DIVIDING THAT BY GROSS PATIENT REVENUE AND OTHER OPERATING REVENUE. ANY SHORTFALLS THAT RESULT FROM MEDICARE ALLOWABLE COSTS EXCEEDING MEDICARE REVENUE CAN BE CONSIDERED A COMMUNITY BENEFIT IF THE ACTIVITY IS SOMETHING THAT CARSON CITY HOSPITAL IS DOING TO CREATE THE AWARENESS AND WELL-BEING OF THE HOSPITAL COMMUNITY.
Collection practices for patients eligible for financial assistance	Schedule H, Part III, Line 9b	CARSON CITY HOSPITAL INITIATES COLLECTION AT THE POINT OF SERVICE THROUGH THE PATIENT ACCESS DEPARTMENT. PATIENTS ARE ADVISED OF THEIR CO-PAY AND DEDUCTIBLE AND ASKED FOR A DEPOSIT ON THESE SELF-PAY CONTRIBUTIONS. PATIENTS WHO DO NOT HAVE INSURANCE ARE ADVISED OF ESTIMATED COST, AND ASSISTANCE PROGRAMS ARE OFFERED ALONG WITH CONTACT INFORMATION TO OBTAIN FURTHER INFORMATION. THE PATIENT'S BILL IS CHARGED, CODED, AND PROCESSED WITH THE APPROPRIATE PAYORS, IF APPLICABLE, AND AT THE POINT ALL THIRD PARTY PAYORS HAVE MADE PAYMENT, THE REMAINING BALANCE IS BILLED ON A STATEMENT TO THE PATIENT. AT THE POINT THAT THE PATIENT RECEIVES THE STATEMENT, THEY MAY CHOOSE TO MAKE PAYMENT ARRANGEMENTS THROUGH A PAYMENT PLAN, OR MAY CHOOSE TO APPLY FOR ASSISTANCE. THE PATIENT WHO DOES NOT MAKE PAYMENT ARRANGEMENTS OR DOES NOT APPLY FOR ASSISTANCE, WILL RECEIVE THREE STATEMENTS OVER A 90-DAY PERIOD. IF NO RESOLUTION IS ACHIEVED THE ACCOUNT WILL BE REFERRED TO AN OUTSIDE AGENCY FOR COLLECTION. THE PATIENT HAS 60 DAYS AT THE AGENCY BEFORE THEIR ACCOUNT IS RECORDED AS BAD DEBT. THE PATIENT STILL HAS THE OPTION OF APPLYING FOR ASSISTANCE OR MAKING PAYMENT ARRANGEMENTS WITH THE AGENCY.
FINANCIAL ASSISTANCE POLICY: BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS	SCHEDULE H, PART V, SECTION B, LINE 11	ALTHOUGH NOT SPECIFICALLY OUTLINED IN THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL USES THE FOLLOWING FACTORS IN DETERMINING THE AMOUNTS CHARGED TO PATIENTS: - INCOME LEVEL - ASSET LEVEL - MEDICAL INDIGENCY - INSURANCE STATUS - UNINSURED DISCOUNT - MEDICAID/MEDICARE THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS CURRENTLY UNDER REVIEW, AND THE HOSPITAL IS CONSIDERING ADDING SPECIFIC INFORMATION RELATED THE FACTORS USED IN DETERMINING THE BASIS FOR AMOUNTS CHARGED TO PATIENTS.
FINANCIAL ASSISTANCE POLICY: MEASURES TO PUBLICIZE THE POLICY WITHIN THE COMMUNITY SERVED	SCHEDULE H, PART V, SECTION B, LINE 13	ALTHOUGH NOT SPECIFICALLY OUTLINED IN THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY, THE HOSPITAL USES THE FOLLOWING METHODS TO PUBLICIZE ITS FINANCIAL ASSISTANCE POLICY WITHIN THE COMMUNITY SERVED: - THE POLICY WAS POSTED ON THE HOSPITAL FACILITY'S WEBSITE. - THE POLICY WAS POSTED IN THE HOSPITAL FACILITY'S EMERGENCY ROOMS OR WAITING ROOMS. - THE POLICY WAS POSTED IN THE HOSPITAL FACILITY'S ADMISSIONS OFFICE. - THE POLICY WAS AVAILABLE UPON REQUEST. - PATIENTS WERE MADE AWARE OF THE POLICY UPON ADMISSION. THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS CURRENTLY UNDER REVIEW, AND THE HOSPITAL IS CONSIDERING ADDING SPECIFIC INFORMATION RELATED THE METHODS USED TO PUBLICIZE ITS FINANCIAL ASSISTANCE POLICY WITHIN THE COMMUNITY SERVED.
Other collection actions permitted	Schedule H, Part V Section B, Line 15e	(1) CARSON CITY HOSPITAL - IF AN ACCOUNT IS DELINQUENT BY 90 DAYS, AND THERE HAS BEEN NO PLAN FOR PAYMENT MADE OR FOLLOWED, THE ACCOUNT WILL BE CONSIDERED FOR FURTHER ACTION WHICH MAY INCLUDE: AN OUTSIDE COLLECTION AGENCY, SMALL CLAIMS COURT, OR OTHER ACTION. ALL REASONABLE EFFORTS MUST BE MADE BEFORE SENDING AN ACCOUNT TO A COLLECTION AGENCY, AND NO ACCOUNT SHALL BE SENT TO AN OUTSIDE COLLECTION AGENCY WITHOUT APPROVAL FROM AN AUTHORIZED ASSOCIATE OR OTHER APPROVED INDIVIDUAL. IF AN ACCOUNT PLACED IN A COLLECTION AGENCY HAS BEEN DETERMINED TO NEED LEGAL ACTION TO COLLECT THE BALANCE, THE ACCOUNT MUST BE REVIEWED BY AN ADMINISTRATOR BEFORE SUIT CAN BE FILED.;
Means used to determine amounts billed	Schedule H, Part V Section B, Line 19d	(1) CARSON CITY HOSPITAL - DURING 2011, THE HOSPITAL FACILITY USED THE HIGHEST COMMERCIAL RATE WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. DURING 2012, THE HOSPITAL FACILITY HAS CHANGED ITS PRACTICE AND USES THE AVERAGE OF THE THREE HIGHEST COMMERCIAL RATES WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE.;
Needs assessment.	Schedule H, Part VI, Line 2	CARSON CITY HOSPITAL RESPONDS TO THE HEALTHCARE NEEDS OF ITS ENTIRE SERVICE AREA. ITS DOORS ARE OPEN TO ALL THOSE WHO NEED HEALTHCARE SERVICES. INFORMATION ABOUT HEALTHCARE NEEDS IS RECEIVED THROUGH PARTNERSHIPS WITH LOCAL NON-PROFITS, GOVERNMENT AGENCIES AND OTHER HEALTHCARE ORGANIZATIONS, SUCH AS THE MID-MICHIGAN DISTRICT HEALTH DEPARTMENT AND THE IONIA COUNTY HEALTH DEPARTMENT - WHICH, TOGETHER, MONITOR THE MORTALITY RATES AND CAUSES IN CLINTON, GRATIOT, IONIA AND MONTCALM COUNTIES. HOSPITAL SERVICE RECORDS AND PATIENT SATISFACTION SURVEYS - MANAGED BY PRESS GANEY - ALSO PROVIDE FEEDBACK TO HOSPITAL STAFF ABOUT THE NEEDS OF THE COMMUNITY.
Patient education of eligibility for assistance.	Schedule H, Part VI, Line 3	CARSON CITY HOSPITAL OFFERS SEVERAL OPTIONS FOR ASSISTING PATIENTS WITH THEIR BILLS; THIS ASSISTANCE INFORMATION IS OFFERED AT THE TIME OF REGISTRATION, THROUGH PHONE CONTACT, AND IS ADVISED ON THE PATIENTS STATEMENTS. A TOLL FREE NUMBER IS PROVIDED FOR PATIENTS TO CALL AND INQUIRE ABOUT ASSISTANCE IF PERSONAL CONTACT WAS NOT AVAILABLE AT THE TIME THE PATIENT RECEIVED SERVICES. CARSON CITY HOSPITAL, THROUGH A PARTNERSHIP WITH MONTCALM COUNTY DEPARTMENT OF HUMAN SERVICES, PROVIDES DIRECT ON-SITE ACCESS TO A MARA (MEDICAID ASSISTANCE REVIEW AGREEMENT) WORKER (DHS TRAINED STAFF MEMBER) WHO ASSISTS THE PATIENT WITH THE APPLICATION PROCESS FOR STATE OR COUNTY PROGRAMS, AND IF THE PATIENT DOES NOT MEET THE REQUIREMENTS FOR THESE TYPES OF ASSISTANCE, PROVIDES THE PATIENT WITH THE CHARITY CARE APPLICATION. THIS APPLICATION IS PROCESSED BY THE HOSPITAL BILLING DEPARTMENT AND IF APPROVED FOR ASSISTANCE PROVIDES CHARITY CARE AT 200% OF THE FEDERAL POVERTY GUIDELINES. THE ASSISTANCE PROGRAM INFORMATION FOR PATIENTS IS HANDED OUT AT THEIR TIME OF SERVICE BY THE RESPECTED DEPARTMENTS (RADIOLOGY, LABORATORY, PRE-ADMISSION TESTING, ETC). AN ON-SITE MARA (MEDICAID ASSISTANCE REVIEW AGREEMENT) WORKER IS ON-SITE FOR INDIVIDUALS THAT DO SEEK ASSISTANCE. THE FINANCIAL ASSISTANCE POLICY IS ALSO POSTED ON THE HOSPITAL'S WEBSITE, IS AVAILABLE TO ANYONE UPON REQUEST, AND IS POSTED IN THE EMERGENCY/WAITING ROOMS AND ADMISSIONS OFFICE.
Community information.	Schedule H, Part VI, Line 4	CARSON CITY HOSPITAL (CCH) IS A 77-BED, ACUTE CARE HOSPITAL LOCATED IN CENTRAL MICHIGAN. IT IS THE OLDEST OSTEOPATHIC HOSPITAL IN MICHIGAN, FOUNDED IN 1936 BY EMMETT BINKERT, DO. SINCE THIS TIME CCH HAS BEEN COMMITTED TO SERVING THE RESIDENTS OF COMMUNITIES IN A FOUR-COUNTY AREA. THE HOSPITALS GOVERNING BODY CONSISTS PRIMARILY OF VOLUNTEER MEMBERS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA. IN THE FALL OF 1996, CARSON BECAME A PART OF CARSON HEALTH NETWORK (CHN). CHN WAS INTRODUCED TO WORK AS AN UMBRELLA UNDER WHICH ALL THE INDIVIDUAL HEALTHCARE ENTITIES ARE CONTAINED. CHN INCLUDES CARSON CITY HOSPITAL, FAMILY MEDICINE PRACTICES AND SEVERAL SPECIALTY CLINICS OFFERING A WIDE VARIETY OF SERVICES. THE FAMILY MEDICINE PROFESSIONAL MEDICAL STAFF, IN COOPERATION WITH HOSPITAL BASED SPECIALISTS, SERVES PATIENTS IN ASHLEY, CARSON CITY, FOWLER, GREENVILLE, ITHACA, LYONS, MAPLE RAPIDS AND STANTON. THESE OFFICES FALL INTO 4 COUNTIES WHICH INCLUDE MONTCALM, IONIA, CLINTON AND GRATIOT COUNTIES. ALL AREAS ARE DESIGNATED AS RURAL BASED WITH AN AVERAGE OF 21,750 HOUSEHOLDS WITH AN AVERAGE HOUSEHOLD SIZE OF 2.7 PEOPLE. THE AVERAGE INCOME PER HOUSEHOLD IS $47,355 WHILE 13.75% OF ALL FAMILIES ARE BELOW THE POVERTY LEVEL. ALSO INCLUDED IN THIS GEOGRAPHIC AREA ARE 5 OTHER HOSPITALS, SPARROW CLINTON HOSPITAL, SPARROW IONIA HOSPITAL, SPECTRUM HEALTH UNITED CAMPUS, SHERIDAN COMMUNITY HOSPITAL, AND GRATIOT MEDICAL CENTER. IN ADDITION TO ACUTE HOSPITAL CARE, CCH PROVIDES A VARIETY OF ADVANCED SERVICES, RANGING FROM AN INTENSIVE/CORONARY CARE UNIT TO A BEHAVIORAL HEALTH UNIT AND MULTIPLE OUTPATIENT SERVICES. CCH ALSO PROVIDES 24-HOUR EMERGENCY ROOM CARE. PHYSICIANS ARE AVAILABLE TO YOU ANY TIME AT THE HOSPITAL, DAY OR NIGHT FOR EMERGENCY OR NON-EMERGENCY MEDICAL ASSISTANCE. ANY SURPLUS FUNDS AVAILABLE TO THE HOSPITAL ARE USED FOR FACILITY AND EQUIPMENT IMPROVEMENTS IN ORDER TO PROVIDE BETTER PATIENT CARE. THE AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009 INCLUDED PROVISIONS FOR IMPLEMENTING HEALTH INFORMATION TECHNOLOGY UNDER THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT ("HITECH"). THESE PROVISIONS WERE DESIGNED TO INCREASE THE USE OF ELECTRONIC HEALTH RECORDS ("EHR") TECHNOLOGY AND ESTABLISH REQUIREMENTS FOR A MEDICARE AND MEDICAID INCENTIVE PAYMENTS PROGRAM BEGINNING IN 2011 FOR ELIGIBLE HOSPITALS AND PROVIDERS THAT ADOPT AND MEANINGFULLY USE CERTIFIED EHR TECHNOLOGY. ELIGIBILITY FOR ANNUAL MEDICARE INCENTIVE PAYMENTS IS DEPENDENT ON PROVIDERS DEMONSTRATING MEANINGFUL USE OF EHR TECHNOLOGY IN EACH PERIOD OVER A FOUR-YEAR PERIOD. INITIAL MEDICAID INCENTIVE PAYMENTS ARE AVAILABLE TO PROVIDERS THAT ADOPT, IMPLEMENT, OR UPGRADE CERTIFIED EHR TECHNOLOGY, BUT PROVIDERS MUST DEMONSTRATE MEANINGFUL USE OF SUCH TECHNOLOGY IN SUBSEQUENT YEARS TO QUALIFY FOR ADDITIONAL INCENTIVE PAYMENTS. DURING 2011, CARSON CITY HOSPITAL DEMONSTRATED THE MEANINGFUL USE OF ITS CERTIFIED EHR TECHNOLOGY AND WAS ABLE TO RECOGNIZE APPROXIMATELY $2.1 MILLION IN REVENUE FOR HITECH INCENTIVES FROM MEDICARE AND MEDICAID. THESE INCENTIVE PAYMENTS ALLOW THE HOSPITAL TO PROVIDE ADDITIONAL QUALITY SERVICES TO THOSE IN THE COMMUNITY.
Promotion of community health	Schedule H, Part VI, Line 5	CARSON CITY HOSPITAL PROVIDES A SPEAKERS BUREAU LIST OF PHYSICIANS AND STAFF MEMBERS WHO ARE WILLING TO GO OUT INTO THE COMMUNITY AND SPEAK ON A VARIETY OF HEALTHCARE, QUALITY-OF-LIFE, AND GENERAL-INTEREST TOPICS TO SCHOOLCHILDREN, BUSINESS CLUBS, AND OTHER NON-PROFIT ORGANIZATIONS. THE HOSPITAL ALSO MAINTAINS A MONTHLY BROWN BAG LUNCH SERIES FEATURING SIMILAR TOPICS, WHICH IS HELD INSIDE THE HOSPITAL AND OPEN TO THE COMMUNITY. CARSON CITY HOSPITAL'S ACTIVITIES PROMOTE THE HEALTHCARE OF THE COMMUNITY BY EDUCATING AND PROVIDING EASY ACCESSIBLE HEALTHCARE WITH A 24-HOUR EMERGENCY DEPARTMENT. OUTSIDE PHYSICIANS CAN APPLY FOR PRIVILEGES AT CARSON CITY HOSPITAL THROUGH A PROCESS TO TREAT AND PROVIDE MEDICAL CARE AT THE HOSPITAL. IN ADDITION, CARSON CITY HOSPITAL IS COMPRISED OF SEVEN HOSPITAL-OWNED PHYSICIAN CLINICS IN A RURAL SETTING. FREE AND REDUCED RATE SPORTS PHYSICALS ARE PROVIDED AT SELECTED CLINICS.
Affiliated health care system	Schedule H, Part VI, Line 6	IN JANUARY 1997, CHN BECAME AFFILIATED WITH THE SPARROW HEALTH SYSTEM OF LANSING, MICHIGAN. THIS AFFILIATION HAS MANY BENEFITS INCLUDING HOLDING DOWN HEALTH CARE COSTS, IMPROVED ACCESS TO SPECIALIZED SERVICES, ACCESS TO INFORMATION SYSTEMS, MANAGED CARE CONTRACTS AND NEW PHYSICIAN RECRUITMENT. CCH IS A MEMBER OF THE MICHIGAN HEALTH AND HOSPITAL ASSOCIATION, AMERICAN HOSPITAL ASSOCIATION, AND THE MICHIGAN OSTEOPATHIC ASSOCIATION.
State filing of community benefit report	Schedule H, Part VI, Line 7	MI

Schedule H (Form 990) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization
CARSON CITY HOSPITAL

Employer identification number
38-1490180

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance
(1) CARSON CITY FRONTIER DAYS INC123 MAIN STREET PO BOX 340 CARSON CITY,MI48811	38-6111280	501(C)(4)	7,519	0	N/A	N/A	N/A

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

Enter total number of other organizations listed in the line 1 table ......................... . Bullet Image

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

Cat. No. 50055P

Schedule I (Form 990) 2011

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
Procedures for monitoring use of grant funds	Schedule I, Part I, Line 2	THE HOSPITAL MAKES GRANTS TO VARIOUS COMMUNITY ORGANIZATIONS. GRANTS MADE ARE UNRESTRICTED AND CAN BE USED IN ANY WAY THE DONEE ORGANIZATION SEES FIT TO FURTHER ITS MISSION.

Schedule I (Form 990) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Yes

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

Yes

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2011

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

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

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) ROBERT SEALS DO	(i) (ii)	215,738 0	49,871 0	4,763 0	7,350 0	5,252 0	282,974 0	0 0
(2) JANMEET SAHOTA	(i) (ii)	447,464 0	0 0	145 0	7,350 0	7,366 0	462,325 0	0 0
(3) MICHAEL H MULLINS	(i) (ii)	345,835 0	0 0	336 0	7,350 0	273 0	353,794 0	0 0
(4) ADAM Z COTE	(i) (ii)	346,684 0	0 0	0 0	0 0	4,811 0	351,495 0	0 0
(5) CHRISTOPHER E HERALD	(i) (ii)	300,200 0	600 0	675 0	7,350 0	7,153 0	315,978 0	0 0
(6) MATTHEW J THOMPSON	(i) (ii)	158,962 0	0 0	2,345 0	4,860 0	2,578 0	168,745 0	0 0
(7) BRUCE L TRAVERSE	(i) (ii)	187,471 0	10,100 0	41,821 0	7,209 0	525 0	247,126 0	0 0
(8) DOUGLAS POFF DO	(i) (ii)	172,401 0	28,181 0	0 0	6,116 0	8,456 0	215,154 0	0 0
(9) DAVID FREESTONE MD	(i) (ii)	189,510 0	50,485 0	630 0	7,350 0	6,290 0	254,265 0	0 0
(10) DUANE C MILLER	(i) (ii)	147,584 0	600 0	2,474 0	4,710 0	6,552 0	161,920 0	0 0
(11) BRUCE MURRAY	(i) (ii)	317,524 0	600 0	307 0	7,350 0	6,811 0	332,592 0	0 0
(12) PARUTAPPA R BHIMALLI	(i) (ii)	474,774 0	0 0	14,719 0	7,350 0	10,725 0	507,568 0	0 0
(13) NANCY A WEAVER	(i) (ii)	138,808 0	2,670 0	2,466 0	4,477 0	4,897 0	153,318 0	0 0

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
Housing allowance or residence for personal use	Schedule J, Part I, Line 1a	MATTHEW J. THOMSON (COO) RECEIVED A HOUSING ALLOWANCE IN THE AMOUNT OF $300 DURING 2011. THE AMOUNT WAS INCLUDED IN HIS 2011 FORM W-2 AS TAXABLE COMPENSATION.
Non-fixed payments	Schedule J, Part I, Line 7	BRUCE L. TRAVERSE (PRESIDENT/CEO) RECEIVED A DISCRETIONARY QUARTERLY STIPEND IN THE AMOUNT OF $9,500 DURING 2011. THE AMOUNT WAS INCLUDED IN HIS 2011 FORM W-2 AS TAXABLE COMPENSATION.

Schedule J (Form 990) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization
CARSON CITY HOSPITAL

Employer identification number
38-1490180

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	MICHIGAN STATE HOSPITAL FINANCE AUTHORITY	38-2889417	54965HKS4	02-01-2006	18,000,000	HOSPITAL EQUIPMENT LOAN PROGRAM (HELP)		X		X	X
B	MICHIGAN STATE HOSPITAL FINANCE AUTHORITY	38-2889417	594654HG5	12-18-2007	455,937	HOSPITAL EQUIPMENT LOAN PROGRAM (HELP)		X		X	X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . .	3,601,603		85,488
2 Amount of bonds legally defeased . . . . . . . . . .	0		0
3 Total proceeds of issue . . . . . . . . . . . . .	18,000,000		455,937
4 Gross proceeds in reserve funds . . . . . . . .	0		0
5 Capitalized interest from proceeds . . . . . . . . . .	0		0
6 Proceeds in refunding escrows . . . . . . . . . . .	0		0
7 Issuance costs from proceeds . . . . . . . . . . .	133,000		0
8 Credit enhancement from proceeds . . . . . . . . . .	0		0
9 Working capital expenditures from proceeds . . . . . . .	0		0
10 Capital expenditures from proceeds . . . . . . . . . .	14,012,600		0
11 Other spent proceeds . . . . . . . . . . .	3,854,400		455,937
12 Other unspent proceeds . . . . . . . . . . .	0		0
13 Year of substantial completion . . . . . . . . . . .	2009		2007
	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) 2011

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . .		X		X
b If ‘Yes’ to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . .
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . .		X		X
d If ‘Yes’ to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . .	0.0000%		0.0000%		%		%
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . .	0.0000%		0.0000%		%		%
6 Total of lines 4 and 5 . . .. . . . . . . . .	0.0000%		0.0000%		%		%
7 Does the bond issue meet the private security or payment test? . . .	X		X
8 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2?	X		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 qualified hedge with respect to the bond issue?		X		X
b Name of provider . . . . . . . .
c Term of hedge . . . . . . . .
d Was the hedge superintegrated? . . . .
e Was a hedge terminated? . . . . .
4a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . .		X		X
b Name of provider . . . . . .
c Term of GIC . . . . . . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . . .
5 Were any gross proceeds invested beyond an available temporary period? . . . . . .		X		X
6 Did the bond issue qualify for an exception to rebate? .	X		X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .	X		X

Schedule K (Form 990) 2011

Page 3

Part V

Procedures To Undertake Corrective Action

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

Part VI

Supplemental Information

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

Identifier	Return Reference	Explanation
TOTAL PROCEEDS OF ISSUE	PART II, LINE 3	THE ORGANIZATION SPENT ITS OWN OPERATING FUNDS AND IN TURN WAS REIMBURSED WITH THE BOND PROCEEDS; THEREFORE THERE ARE NO INTEREST EARNINGS ON THE PROCEEDS.
Procedures to take corrective action	Schedule K, Part V	THE ORGANIZATION WORKS DIRECTLY WITH THE MICHIGAN HOSPITAL ASSOCIATION (MHA) TO ENSURE COMPLIANCE, AS THE BONDS ARE PART OF A POOLED FINANCING AND ARE ISSUED TO MHA.

Schedule K (Form 990) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

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?
1(a) Name of disqualified person	(b) Description of transaction	Yes	No

Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image

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?
(a) Name of interested person and purpose	To	From	(c)Original principal amount	(d)Balance due	Yes	No	Yes	No	Yes	No






Total ............... $

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) 2011

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?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) SPARROW HEALTH SYSTEM	M. BRETT, T. OSTRANDER AND G. REETZ ARE CCH BOARD MEMBERS AND SPARROW OFFICERS	466,097	MARK BRETT, TOM OSTRANDER AND GARY REETZ, CARSON CITY HOSPITAL BOARD MEMBERS, SERVE AS THE SENIOR VICE PRESIDENT, AFFILIATE OPERATIONS; VICE PRESIDENT, PROFESSIONAL SERVICES; AND CONTROLLER, RESPECTIVELY, FOR SPARROW HEALTH SYSTEM, AN UNRELATED ORGANIZATION. FOR THE YEAR ENDED DECEMBER 31, 2011, CARSON CITY HOSPITAL MADE PAYMENTS TO SPARROW HEALTH SYSTEM IN THE AMOUNT OF $406,135 FOR REIMBURSEMENT OF SUPPLIES AND PHARMACEUTICALS, LABORATORY AND OTHER PATIENT CARE SERVICES, SOFTWARE SUPPORT, EQUIPMENT RENTAL, AND PHYSICIAN RECRUITING.		No
(2) SPARROW HEALTH SYSTEM	M. BRETT, T. OSTRANDER AND G. REETZ ARE CCH BOARD MEMBERS AND SPARROW OFFICERS	204,784	MARK BRETT, TOM OSTRANDER AND GARY REETZ, CARSON CITY HOSPITAL BOARD MEMBERS, SERVE AS THE SENIOR VICE PRESIDENT, AFFILIATE OPERATIONS; VICE PRESIDENT, PROFESSIONAL SERVICES; AND CONTROLLER, RESPECTIVELY, FOR SPARROW HEALTH SYSTEM, AN UNRELATED ORGANIZATION. FOR THE YEAR ENDED DECEMBER 31, 2011, CARSON CITY HOSPITAL RECEIVED PAYMENTS FROM SPARROW HEALTH SYSTEM IN THE AMOUNT OF $204,784 FOR REIMBURSEMENT OF SUPPLIES AND PHARMACEUTICALS, OFFICE RENT, AND SUPPORT FOR PSYCHIATRIC MEDICAL EDUCATION.		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

Schedule L (Form 990 or 990-EZ) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

CARSON CITY HOSPITAL

Employer identification number

38-1490180

Identifier	Return Reference	Explanation
Description of other program services	Form 990, Part III, Line 4d	OTHER PROGRAM SERVICES INCLUDE THE OPERATION OF THE FOLLOWING FACILITIES: ASHLEY FAMILY CARE CENTER CARSON BEHAVIORAL CARE CENTER CARSON CITY HOSPITAL ORTHOPEDICS AND GENERAL SURGERY PHYSICAL REHABILITATION CENTER FOWLER FAMILY CARE CENTER GREENVILLE FAMILY CARE CENTER HOSPITALISTS LYONS FAMILY CARE CENTER PEDIATRIC AND ADOLESCENT SPECIALISTS STANTON FAMILY CARE CENTER CARSON HOME CARE CARSON PAIN MANAGEMENT
Delegate broad authority to a committee	Form 990, Part VI, Section A, Line 1a	THE EXECUTIVE COMMITTEE OF THE BOARD SHALL CONSIST OF THE CHAIRPERSON OF THE BOARD, THE PRESIDENT, THE VICE-CHAIRPERSON, THE SECRETARY/TREASURER AND THE MEDICAL DIRECTOR. A SIXTH MEMBER SHALL BE APPOINTED BY THE CHAIRPERSON AND CHOSEN FROM ONE OF THE CLASS B MEMBERS OF THE BOARD. THE CHAIRPERSON SHALL APPOINT REPLACEMENTS WHEN NECESSARY. A MAJORITY OF THE EXECUTIVE COMMITTEE SHALL CONSTITUTE A QUORUM. IT SHALL HAVE THE AUTHORITY TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERVAL BETWEEN MEETINGS OF THE BOARD OF DIRECTORS. THE COMMITTEE SHALL MAKE A FULL REPORT OF ITS ACTIONS, IF ANY, AT THE NEXT REGULAR MEETING OF THE BOARD. MEETINGS OF THE COMMITTEE MAY BE HELD AT ANY TIME ON CALL BY THE CHAIRPERSON OF THE BOARD.
Classes of members or stockholders	Form 990, Part VI, Section A, Line 6	CARSON CITY HOSPITAL (CCH) IS ORGANIZED ON A MEMBERSHIP BASIS. THERE ARE TWO CLASSES OF MEMBERS: CLASS A MEMBERSHIP CONSISTS OF THE ORIGINAL DIRECTORS OF CCH, EXCLUDING THOSE DIRECTORS WHO ARE ELECTED OR APPOINTED BY THE CLASS B MEMBER; THE CLASS B MEMBER IS SPARROW HEALTH SYSTEM (SPARROW), AN UNRELATED MICHIGAN NONPROFIT CORPORATION. OTHER THAN SPARROW, THERE SHALL BE NO ADDITIONAL CLASS B MEMBERSHIP INTERESTS WITHOUT THE CONSENT OF SPARROW.
Members or stockholders electing members of governing body	Form 990, Part VI, Section A, Line 7a	CLASS A MEMBERS EACH HAVE ONE VOTE FOR PURPOSES OF VOTING BY MEMBERS; THE NUMBER OF VOTES HELD BY THE CLASS B MEMBER (SPARROW) IS PROPORTIONATE TO THE SPARROW PERCENTAGE INTEREST MULTIPLIED BY THE VOTES HELD IN THE AGGREGATE BY BOTH CLASS A AND CLASS B MEMBERS. AT THE ANNUAL MEETING OF THE MEMBERS, THE CLASS A MEMBERS ELECT 9 DIRECTORS OF THE BOARD OF DIRECTORS BY MAJORITY VOTE OF THE CLASS A MEMBERS, AND THE CLASS B MEMBER (SPARROW) ELECTS A NUMBER OF DIRECTORS OF THE BOARD OF DIRECTORS THAT IS CONSISTENT WITH THE CURRENT SPARROW PERCENTAGE INTEREST.
Decisions requiring approval by members or stockholders	Form 990, Part VI, Section A, Line 7b	THE FOLLOWING ACTIVITIES REQUIRE THE AFFIRMATIVE VOTE OF THE CLASS B MEMBER (SPARROW): 1. AMENDMENTS TO THE ARTICLES OF INCORPORATION AND THE BYLAWS; 2. THE DISSOLUTION, MERGER, SALE, SALE OF SUBSTANTIALLY ALL OF THE ASSETS, LEASE, OR TRANSFER OF CONTROL; 3. THE SALE OF A MAJORITY OWNERSHIP INTEREST IN CCH; 4. THE PUBLICLY RECOGNIZED "AFFILIATION" WITH ANY ORGANIZATION OTHER THAN THE CLASS B MEMBER (SPARROW); 5. APPROVAL OF CCH'S ANNUAL OPERATING BUDGET, WHEN SUCH BUDGET REFLECTS A TOTAL MARGIN OF LESS THAN 2% OF NET REVENUE; 6. APPROVAL OF CCH'S ANNUAL CAPITAL BUDGET, WHEN SUCH BUDGET ANTICIPATES AN ADDITIONAL CAPITAL CONTRIBUTION FROM THE CLASS B MEMBER (SPARROW) BEYOND ITS ORIGINAL CAPITAL CONTRIBUTION; 7. THE INCURRENCE OF ANY DEBT OBLIGATION IN THE AGGREGATE GREATER THAN $500,000; 8. THE APPROVAL OF CAPITAL EXPENDITURES IN EXCESS OF $500,000 (EXCEPT AS TO REPLACE EQUIPMENT); AND 9. ANY ACTION THAT ALLOWS OR FACILITATES THE CREATION OF A NEW CLASS OF MEMBERS OR CREATION OF A MEMBERSHIP INTEREST IN CCH.
Review of form 990 by governing body	Form 990, Part VI, Section B, Line 11b	THE FORM 990 IS REVIEWED IN DETAIL BY THE ORGANIZATION'S MANAGEMENT. A BOARD MEETING IS HELD WITH OUR TAX ADVISORS WHERE A COPY OF THE FULL FORM 990, INCLUDING ALL APPLICABLE SCHEDULES, IS PROVIDED TO EACH MEMBER OF THE GOVERNING BODY FOR REVIEW BEFORE THE RETURN IS FILED WITH THE IRS. THE BOARD IS GIVEN A SUMMARY OF KEY POINTS REGARDING THE FORM 990, AND IS ALLOWED TO ASK ANY QUESTIONS THEY MAY HAVE. ONCE ALL BOARD MEMBERS HAVE REVIEWED THE RETURN, IT IS THEN SUBMITTED TO THE IRS.
Conflict of interest policy	Form 990, Part VI, Section B, Line 12c	CONFLICT OF INTEREST QUESTIONNAIRES ARE DISTRIBUTED TO ALL OFFICERS, DIRECTORS, AND KEY EMPLOYEES TO DETERMINE WHETHER ANY POTENTIAL CONFLICTS OF INTEREST EXIST. THE HOSPITAL EXECUTIVE COMMITTEE, WHICH INCLUDES THE PRESIDENT OF THE BOARD OF DIRECTORS, DISCUSSES THE CONFLICT OF INTEREST QUESTIONNAIRES TO DETERMINE WHETHER AN ACTUAL CONFLICT EXISTS. IF A CONFLICT IS DETERMINED TO EXIST, THE PERSON WITH THE CONFLICT IS RECUSED FROM TAKING PART IN ANY DECISIONS CONCERNING THE CONFLICTING ISSUE.
Process used to establish compensation of top management official	Form 990, Part VI, Section B, Line 15a	THE ORGANIZATION'S BOARD OF DIRECTORS ANNUALLY REVIEWS AND APPROVES THE COMPENSATION FOR THE ORGANIZATION'S PRESIDENT/CEO. THE BOARD PRESIDENT/CEO IS REMOVED FROM THE BOARD DISCUSSIONS TO PREVENT HIM FROM DISCUSSING AND DETERMINING HIS OWN COMPENSATION. THE BOARD OF DIRECTORS USES COMPENSATION STUDIES AND WAGE SURVEYS IN DETERMINING THE AMOUNT OF COMPENSATION FOR THE CEO, AND THEIR DISCUSSIONS ARE DOCUMENTED IN THE BOARD MEETING MINUTES. COMPENSATION FOR THE CURRENT YEAR IS DISCUSSED AND APPROVED IN THE PREVIOUS YEAR DURING THE BUDGET APPROVAL PROCESS. THE 2011 COMPENSATION WAS REVIEWED AND APPROVED DURING NOVEMBER/DECEMBER 2010 DURING THE ANNUAL BUDGETING PROCESS; THE 2012 COMPENSATION WAS REVIEWED AND APPROVED DURING NOVEMBER/DECEMBER 2011 DURING THE ANNUAL BUDGETING PROCESS.
Process used to establish compensation of other officers/key employees	Form 990, Part VI, Section B, Line 15b	THE ORGANIZATION'S BOARD OF DIRECTORS ANNUALLY REVIEWS AND APPROVES THE COMPENSATION FOR ALL POSITIONS, INCLUDING OTHER OFFICERS AND KEY EMPLOYEES. THE BOARD OF DIRECTORS USES COMPENSATION STUDIES AND WAGE SURVEYS IN DETERMINING THE AMOUNT OF COMPENSATION FOR ALL POSITIONS, AND THEIR DISCUSSIONS ARE DOCUMENTED IN THE BOARD MEETING MINUTES. THE 2011 COMPENSATION WAS REVIEWED AND APPROVED AT THE END OF 2010 DURING THE ANNUAL BUDGETING PROCESS.
Governing documents, conflict of interest policy and financial statements available to the public	Form 990, Part VI, Section C, Line 19	AN ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104. THESE DOCUMENTS ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. AS A HOSPITAL, THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC AS AN ATTACHMENT TO ITS FORM 990, WHICH IS A REQUIRED DISCLOSURE PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104.
Other changes in net assets or fund balances	Form 990, Part XI, Line 5	NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - -200065; CHANGE IN PENSION LIABILITY - -686436;

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:	11000230
Software Version:	v2011.1.0

1	Briefly describe the organization’s mission or most significant activities: THE MISSION OF CARSON CITY HOSPITAL (CCH) IS TO PROVIDE HIGH QUALITY & ACCESSIBLE HEALTH CARE SERVICES TO COMMUNITIES WE SERVE. IN CONJUNCTION, CCH PROVIDES CHARITY CARE TO PATIENTS WHO MEET CERTAIN CRITERIA.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	13
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	7
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	718
6	Total number of volunteers (estimate if necessary) ....	6	145
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	173,923	179,222
9	Program service revenue (Part VIII, line 2g) .........	56,098,857	59,862,979
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	268,368	164,770
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	544,801	602,659
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	57,085,949	60,809,630
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	19,979
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)	29,805,940	32,574,506
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 1,052
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	25,973,959	27,476,512
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	55,779,899	60,070,997
19	Revenue less expenses. Subtract line 18 from line 12.......	1,306,050	738,633
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	46,633,993	46,428,348
21	Total liabilities (Part X, line 26).............	23,285,826	23,228,049
22	Net assets or fund balances. Subtract line 21 from line 20.....	23,348,167	23,200,299

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 45,201,899 including grants of $ 19,979 ) (Revenue $ 52,532,051 )
	CCH IS A 77-BED, ACUTE CARE HOSPITAL LOCATED IN CENTRAL MICHIGAN. IT IS THE OLDEST OSTEOPATHIC HOSPITAL IN MICHIGAN, FOUNDED IN 1936 BY EMMETT BINKERT, DO. SINCE THIS TIME, CCH HAS BEEN COMMITTED TO SERVING THE RESIDENTS IN A FOUR-COUNTY AREA. CCH CURRENTLY OPERATES A SHORT-TERM, ACUTE-CARE FACILITY AND SEVERAL SATELLITE CLINICS OFFERING INPATIENT AND OUTPATIENT HEALTHCARE SERVICES, PSYCHIATRIC SERVICES, PHYSICIAN SERVICES, AND HOME HEALTH CARE, PRIMARILY TO PATIENTS IN THE CARSON CITY, MICHIGAN AREA, INCLUDING GRATIOT, MONTCALM, CLINTON, AND IONIA COUNTIES. CCH PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. BECAUSE CCH DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. UNDER ARRANGEMENTS WITH VARIOUS GOVERNMENTAL INSURANCE PROGRAMS, CCH PROVIDES SIGNIFICANT CARE TO THE LOCAL INDIGENT POPULATION FOR WHICH REIMBURSEMENT FOR SERVICES RENDERED IS GENERALLY LESS THAN THE COST OF PROVIDING SUCH SERVICES. AS PART OF ITS OBLIGATION TO THE LOCAL COMMUNITY, CCH ALSO PROVIDES NUMEROUS OTHER SERVICES, WHICH BENEFIT THE COMMUNITY AND ARE GENERALLY PERFORMED AT NO CHARGE AND PROVIDES SERVICES TO INDIGENT PATIENTS UNDER THE MEDICAID PROGRAM AT PAYMENT AMOUNTS LESS THAN THE COST OF THE SERVICES PROVIDED. FOR THE YEAR ENDED DECEMBER 31, 2011, CCH PROVIDED OVER $2 MILLION IN UNCOMPENSATED CARE. DURING THE YEAR ENDED DECEMBER 31, 2011, CCH PROVIDED 6,564 PATIENT DAYS, WITH AN AVERAGE LENGTH OF STAY OF 3.02 DAYS. THERE WERE ALSO 12,497 EMERGENCY ROOM VISITS, 67,245 OUTPATIENT HOSPITAL VISITS, 1,874 HOSPITAL ADMISSIONS, AND 319 BIRTHS DURING THE YEAR. CCH PERFORMED 5,940 SURGERIES, 193,874 LAB TESTS, 13,323 DIAGNOSTIC IMAGING EXAMS, 4,102 CT SCANS, AND 2,947 M.R.I. SCANS. THE ESTIMATED TOTAL LOCAL ECONOMIC IMPACT FOR THE YEAR WAS $30,139,891.

4b	(Code: ) (Expenses $ 1,504,356 including grants of $ 0 ) (Revenue $ 1,729,023 )
	ITHACA FAMILY CARE CENTER (IFCC) IS AN OFFICE WITH 3 PHYSICIANS AND 1 PHYSICIAN ASSISTANT THAT FOCUSES ON FAMILY PRACTICE FOR GRATIOT COUNTY. IFCC PROVIDES OUTPATIENT SERVICES SUCH AS AUDIOMETRY, BLOOD PRESSURE CHECK, EAR EXAMINATION, EKG, EXCISION, FOREIGN BODY REMOVAL, GYNECOLOGICAL EXAMINATIONS, HEALTH EDUCATION, HEMOCCULT, IMMUNIZATION, LACERATION, OFFICE VISITS, OSTEOPATHIC MANIPULATIVE THERAPY, PATIENT COUNSELING, PHYSICAL EXAMINATIONS AND PREMARITAL COUNSELING. THEY ALSO PROVIDE LABORATORY SERVICES SUCH AS BLOOD SUGAR, HEMOGLOBIN, PREGNANCY TESTING, UA (DIPSTICK) AND WET PREP.

4c	(Code: ) (Expenses $ 1,192,853 including grants of $ 0 ) (Revenue $ 1,400,611 )
	CARSON FAMILY CARE CENTER (CFCC) IS AN OFFICE WITH 2 PHYSICIANS AND 1 NURSE PRACTITIONER THAT FOCUSES ON FAMILY PRACTICE FOR MONTCALM COUNTY. CFCC PROVIDES OUTPATIENT SERVICES SUCH AS ASTHMA SERVICES, AUDIOMETRY, BLOOD PRESSURE CHECKS, DISABILITY/IMPAIRMENT EVALUATIONS, DRUG AND ALCOHOL SCREENING, EAR EXAMINATION, EKG, EMPLOYEE SCREENING, EXCISION, FOREIGN BODY REMOVAL, GYNECOLOGICAL EXAMINATION, HEALTH EDUCATION, IMMUNIZATION, IMMUNOTHERAPY, INJURY MANAGEMENT WORK RELATED INJURIES, LACERATION, LASER COSMETICS, OFFICE VISITS, OSTEPATHIC MANIPULATIVE THERAPY, PATIENT COUNSELING, PHYSICAL EXAMINATIONS, PRE-EMPLOYMENT PHYSICALS, PREMARITAL COUNSELING, SAFETY PROGRAMS AND WORK SITE VISITS. THEY ALSO PROVIDE LABORATORY SERVICES SUCH AS BLOOD SUGAR, HEMOCCULT, HEMOGLOBIN, PREGNANCY TESTING, UA (DIPSTICK) AND WET PREP.

	(Code: ) (Expenses $ 1,132,381 including grants of $ 0 ) (Revenue $ 4,201,294 )
	OTHER PROGRAM SERVICES INCLUDE THE OPERATION OF THE FOLLOWING FACILITIES: ASHLEY FAMILY CARE CENTER CARSON BEHAVIORAL CARE CENTER CARSON CITY HOSPITAL ORTHOPEDICS AND GENERAL SURGERY PHYSICAL REHABILITATION CENTER FOWLER FAMILY CARE CENTER GREENVILLE FAMILY CARE CENTER HOSPITALISTS LYONS FAMILY CARE CENTER PEDIATRIC AND ADOLESCENT SPECIALISTS STANTON FAMILY CARE CENTER CARSON HOME CARE CARSON PAIN MANAGEMENT

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 1,132,381 including grants of $ 0 ) (Revenue $ 4,201,294 )
4e	Total program service expenses$ 49,031,489

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)				(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) NATALIE W BUSLEPP DIRECTOR OF MEDICAL SERVICES GROUP	40.00	X			110,535	0	10,503
(19) RICHARD D TERRY CIO	40.00	X			103,289	0	6,340
(20) CHRISTOPHER E HERALD ER DIRECTOR	40.00		X		301,475	0	14,503
(21) ADAM Z COTE PHYSICIAN	40.00			X	346,684	0	4,811
(22) BRUCE MURRAY PHYSICIAN	40.00			X	318,431	0	14,161
(23) JANMEET SAHOTA PHYSICIAN	40.00			X	447,609	0	14,716
(24) MICHAEL H MULLINS PHYSICIAN	40.00			X	346,171	0	7,623
(25) PARUTAPPA R BHIMALLI PHYSICIAN	40.00			X	489,493	0	18,075

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	3,870,567	0	167,354

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c		51,800
d	Related organizations...1d
e	Government grants (contributions)1e		6,720

f	All other contributions, gifts, grants, and similar amounts not included above1f		120,702
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			179,222
			Business Code
2a	NET PATIENT SERVICE REVENUE		621,300	57,765,950	57,765,950
b	MEDICARE/MEDICAID "HITECH" REVENUE		900,099	2,097,029	2,097,029
c
d
e
f	All other program service revenue .			0	0	0	0
g	Total. Add lines 2a–2f........			59,862,979
3	Investment income (including dividends, interest
	and other similar amounts).....			263,679			263,679
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross rents	591,282
b	Less: rental expenses	441,006
c	Rental income or (loss)	150,276	0
d	Net rental income or (loss).......			150,276			150,276
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		0
b	Less: cost or other basis and sales expenses		98,909
c	Gain or (loss)	0	-98,909
d	Net gain or (loss)..........			-98,909			-98,909
8a	Gross income from fundraising events (not including $ 51,800 of contributions reported on line 1c). See Part IV, line 18 ...
	a		16,484
b	Less: direct expenses ...b		2,905
c	Net income or (loss) from fundraising events..			13,579			13,579
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a		1,582
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			1,582			1,582
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	CAFETERIA/COFFEE SHOP/VENDING		722,219	323,974			323,974
b	MISCELLANEOUS		900,099	113,248			113,248
c
d	All other revenue ....			0	0	0	0
e	Total. Add lines 11a–11d ......			437,222
12	Total revenue. See Instructions....			60,809,630	59,862,979	0	767,429


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			4,202	1	4,633
2	Savings and temporary cash investments .......			6,202,651	2	3,996,424
3	Pledges and grants receivable, net .........			50,900	3	28,207
4	Accounts receivable, net .........			8,138,330	4	10,007,350
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 .............			59,492	7	43,588
8	Inventories for sale or use ..............			1,065,956	8	987,209
9	Prepaid expenses and deferred charges ............			1,230,733	9	2,136,643
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	45,885,042
b	Less: accumulated depreciation. .....	10b	22,577,244	23,913,240	10c	23,307,798
11	Investments—publicly traded securities ..........			5,100,698	11	5,065,752
12	Investments—other securities. See Part IV, line 11 ......			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets .........			239,804	14	239,804
15	Other assets. See Part IV, line 11 ...........			627,987	15	610,940
16	Total assets. Add lines 1 through 15 (must equal line 34)...			46,633,993	16	46,428,348
17	Accounts payable and accrued expenses .			4,213,919	17	6,029,100
18	Grants payable ..........				18
19	Deferred revenue ..........			0	19
20	Tax-exempt bond liabilities ..........			15,904,911	20	15,147,534
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 ..			1,492,963	23	1,318,003
24	Unsecured notes and loans payable to unrelated third parties ....			25,010	24	22,510
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			1,649,023	25	710,902
26	Total liabilities. Add lines 17 through 25.....			23,285,826	26	23,228,049
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			23,141,058	27	22,936,749
28	Temporarily restricted net assets .....			207,109	28	263,550
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			23,348,167	33	23,200,299
34	Total liabilities and net assets/fund balances .....			46,633,993	34	46,428,348