TY 2010 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Steve Gregory President/Chairman	1.00	X	X	0	0	0
(2) Tod Lambert Sch O Director	1.00	X		323,392	0	25,892
(3) Neil Jobe Secretary/Treasurer	1.00	X	X	0	0	0
(4) Clark Baker Director	1.00	X		0	0	0
(5) Sister Sherry Barrett Director	1.00	X		0	0	0
(6) James Bearden Director	1.00	X		0	0	0
(7) Tom Blankenship Sch O Director	1.00	X		0	254,827	43,652
(8) William Coltharp MD Director	1.00	X		0	0	0
(9) R Seth Cooper MD Director	1.00	X		0	0	0
(10) Michael Curb Director	1.00	X		0	0	0
(11) Dana Dye Director	1.00	X		0	0	0
(12) Webb Earthman Director	1.00	X		0	0	0
(13) Mary Falls Esq Director	1.00	X		0	0	0
(14) Anthony Heard Director	1.00	X		0	0	0
(15) Scott Jenkins Director	1.00	X		0	0	0
(16) Sally Killian MD Director	1.00	X		0	0	0
(17) Randy Laszewski Director	1.00	X		0	0	0

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(18) Bill McDonald Director	1.00	X			0	0	0
(19) Matt Murfree Esq Director	1.00	X			0	0	0
(20) Wayne Qualls Director	1.00	X			0	0	0
(21) Sean Ryan Director	1.00	X			0	0	0
(22) Mike Schatzlein MD Sch O Director	1.00	X			0	565,713	11,549
(23) Sheila Sffrella Sch O Director	1.00	X			0	257,640	20,601
(24) Sister Dinah White DC Director	1.00	X			0	0	0
(25) Brian Wilcox MD Director	1.00	X			0	0	0
(26) Shirley Zeitlin Director	1.00	X			0	0	0
(27) Jana Buckles Chief Nursing Officer	40.00		X		88,250	0	4,530
(28) Marek Durakiewicz MD Physician	40.00			X	294,139	0	6,480
(29) Zachary Hutchens MD Physician	40.00			X	149,104	0	3,156
(30) Muhammad Mirza MD Physician	40.00			X	187,572	0	5,266
(31) Elyas Safar MD Physician	40.00			X	129,504	0	12,217
(32) John Sexton MD Physician	40.00			X	136,637	0	12,752

(A) Name and business address	(B) Description of services	(C) Compensation
Millennium Medical Trust Inc 2000 Glen Echo Rd Suite 200 Nashville,TN37215	Operational & Financial Management	1,233,428
Kenneth Poag MD 1111 Mooresville Pike Columbia,TN38401	Emergency Room Physician Coverage	139,910
Medical Doctor Associates 145 Technology Parkway Norcross,GA30092	Emergency Room Physician Coverage	134,091


2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 3

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	92,780		92,780
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	7,108,583	5,407,175	1,701,408
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	392,775	294,974	97,801
9	Other employee benefits .......	1,370,602	1,029,322	341,280
10	Payroll taxes ...........	437,868	328,839	109,029
11	Fees for services (non-employees):
a	Management ......	427,968		427,968
b	Legal .........	16,656		16,656
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......
g	Other ..........	1,198,064	959,412	238,652
12	Advertising and promotion ....
13	Office expenses .......	83,578		83,578
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	451,214	451,214
17	Travel ............	31,150	15,243	15,907
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	304,509	304,509
23	Insurance ..............	31,319		31,319
24	Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a	Supplies	1,124,245	832,624	291,621
b	Corporate Allocations	1,054,340		1,054,340
c	Bad Debt Expense	1,014,909	1,014,909
d	Equipment Rental	663,123	259,400	403,723
e	Nursing Home License	90,290	90,290
f	All other expenses	249,054	131,395	117,659
25	Total functional expenses. Add lines 1 through 24f	16,143,027	11,119,306	5,023,721	0
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	4,623,803	1	7,702,323
2	Savings and temporary cash investments .......	61,988	2	62,245
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	1,900,831	4	2,256,993
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 .............	753,575	7	605,528
8	Inventories for sale or use ..............	185,546	8	232,237
9	Prepaid expenses and deferred charges ............	30,667	9	27,415
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	10,007,553
b	Less: accumulated depreciation. .....	10b	4,795,832	2,297,735	10c	5,211,721
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	17,946	15	18,289
16	Total assets. Add lines 1 through 15 (must equal line 34)...	9,872,091	16	16,116,751
	17	Accounts payable and accrued expenses .	17,250,671	17	22,304,465
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities. Complete Part X of Schedule D.....	43,929	25	43,578
26	Total liabilities. Add lines 17 through 25.....	17,294,600	26	22,348,043
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	-7,422,509	27	-6,231,292
28	Temporarily restricted net assets .....		28
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	-7,422,509	33	-6,231,292
34	Total liabilities and net assets/fund balances .....	9,872,091	34	16,116,751

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Other

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2010

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2010

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2010

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2010

Name of organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

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

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

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

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

Page 1 of 1 of Part III

Name of organization
Hickman Community Health Services Inc

Employer identification number

58-1737573

Part III

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

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

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

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

Term endowment: SchDMd Bullet

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of investment		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	15,326		15,326
b	Buildings ................	5,350,425	1,707,081	3,643,344
c	Leasehold improvements ............	141,510	117,957	23,553
d	Equipment ................	4,500,292	2,970,794	1,529,498
e	Other .................
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				5,211,721

Schedule D (Form 990) 2010

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value









Total. (Column (b) should 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) Amount
Federal Income Taxes
Patient Trust Funds		17,989
Self Insurance Liability		25,589







Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		43,578
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2010

Page 4

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

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

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

Part XIV

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other

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

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

Yes

200% 250% 300% 350% 400% Other

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Charity Care and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Charity care at cost (from Worksheets 1 and 2) ..	518,395	173,677	344,718	2.280 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	3,409,859	3,820,679	-410,820	0 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....	3,928,254	3,994,356	-66,102	2.280 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	2,625		2,625	0.020 %
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	20,414		20,414	0.130 %
jTotal Other Benefits ...	23,039		23,039	0.150 %
kTotal. Add lines 7d and 7j. ..	3,951,293	3,994,356	-43,063	2.430 %

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

Schedule H (Form 990) 2010

Page 2

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

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

578,978

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

386,932

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).....

4,521,521

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

4,899,889

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

-378,368

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures

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

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?4 Name and address		Other (Describe)
1	Hickman Community Hospital 135 East Swan St Centerville,TN370331417	X	X	X	X
2	Hickman Community Nursing Home 135 East Swan St Centerville,TN370331417					Intermediate Care Nursing Home
3	Hickman Medical Clinic-Centerville 150 East Swan St Centerville,TN370331417					Rural Health Clinic
4	Hickman Medical Clinic-Lyles 5047 Highway 100 Lyles,TN37098					Rural Health Clinic

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Name of Hospital Facility:NA

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

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

Schedule H (Form 990) 2010

Page 5

Part VFacility Information (continued)

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

Schedule H (Form 990) 2010

Page 6

Part VFacility Information (continued)

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

Schedule H (Form 990) 2010

Page 7

Part VFacility Information (continued)

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

Schedule H (Form 990) 2010

Page 8

Part VI

Supplemental Information

Complete this part to provide the following information.

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

Identifier	ReturnReference	Explanation
		Part I, Line 7: The cost of providing charity care, means tested government programs, and community benefit programs is estimated using internal cost data, and is calculated in compliance with Catholic Health Association ("CHA") guidelines. HCHS uses a cost accounting system that addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self pay). The best available data was used to calculate the amounts reported in the table. For certain categories in the table, this was a cost accounting system; in other categories, a specific cost-to-charge ratio was applied.
		Part I, Line 7g: HCHS employs its physicians in its emergency room and at physician clinics, thus the associated costs and charges relating to the physician services are included in all relevant categories in Part I.
		Part I, L7 Col(f): The amount of bad debt expense reported on Form 990, Part IX, Line 25, column (A), but subtracted for purposes of calculating the percentages in Part I, Line 7, column (f) is $1,014,909.
		Part II: HCHS strives to promote the health of the communities it serves through various community outreach activities. These activities are not provided as a marketing tool for the organization or to increase referrals of patients, but to improve the health of the community. Some examples include providing wellness programs on the local radio station and providing articles on various topics to the local newspaper. HCHS also provided seminars and classes to the community covering such topics as suicide prevention, depression, diabetes education, and smoking cessation. HCHS believes that it is important to educate the community regarding the types of behavior that improve their chances of living a health life. HCHS has also worked with others in the community to address health concerns through the Hickman Alzheimer Support Group, Hickman Suicide Prevention Task Force, and the Dispensary of Hope.
		Part III, Line 4: HCHS is part of the Ascension Health consolidated audit. The footnote that references bad debt expense in the 2010 consolidated audit is as follows: The provision for bad debts is based upon management's assessment of expected new collections considering economic conditions, historical experience, trends in health care coverage, and other collections indicators. Periodically throughout the year, management assesses the adequacy of allowance for uncollectible accounts based upon historical write off experience by payor category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for bad debts to establish an appropriate allowance for uncollectible accounts. After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have bee exhausted, the organization follows established guidelines for placing certain past due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by the organization. Accounts receivable are written off after collection efforts have been followed in accordance with the organization's policies.The HCHS share of bad debt expense in 2010 was $1,879,830 at charges ($1,157,795 at cost).
		Part III, Line 8: Ascension Health and related health ministries follow the Catholic Health Association (CHA) guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit.
		Part III, Line 9b: HCHS has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance certain collection practices do not apply.
		HCHS is a licensed hospital in the state of Tennessee which serves as a general medical and surgical hospital. It is also a Critical Access Hospital for the purposes of Medicare and TennCare reimbursement which operates a 24-hour emergency room.
		Part VI, Line 2: HCHS contracted with an outside research company to conduct a focused needs assessment with different community groups. Three groups were assembled. One group consisted of individuals from the business or education sectors of the community, and the other two consisted of randomly selected individuals from throughout the community. Hospital representatives attempted to learn what the organization does well, where the facility could improve, and additional services the organization could provide.
		Part VI, Line 3: Education of eligibility for assistance at HCHS begins at registration with signage displayed at all registration points notifying patients that we have a Financial Assistance program, as well as contact information for the patient to use should they need assistance. Brochures containing this information are also available for patients at all registration points. HCHS registration associates discuss the estimated balance that will be due with both insured and self-pay patients. Should the associate identify that the patient may need assistance with that balance he/she will provide the patient with a Financial Assistance application and help them complete it, if needed. All self-pay and underinsured patients are screened by HCHS for alternative coverage including Medicaid, SSI/SSD, Cobra, student coverage, and crime victims' compensation. If no alternative is identified then an associate will work with the patient to complete a Financial Assistance application. Also, contact information is listed on HCHS billing statements for the patient to use in the event they need assistance with their balances, and collections associates have been trained to offer patients a Financial Assistance application if needed by the patient. HCHS works with third party collection vendors who are required to follow the hospital's Financial Assistance policy.
		Part VI, Line 4: HCHS is a 25 bed Critical Access Hospital and 40 bed Intermediate Care Nursing Facility, with two provider-based Rural Health Clinics. Hickman Community Healthcare Services serves Hickman County, Tennessee and portions of the surrounding counties of Lewis, Perry, Humphreys, Maury, and Dickson. HCHS seeks to improve the physical, mental, social and spiritual health status of its surrounding community. Approximately 70% of the patients served are dependent on public health programs such as Medicare and TennCare, 18% are covered through commercial insurance, and 12% are not covered by any type of insurance.
		Part VI, Line 6: Other ways in which HCHS strives to further its exempt purpose through community involvement include comprising a majority of the organization's governing body with residents of the local community and extending medical staff privileges to all qualified physicians in the community. HCHS also partners with the Hickman County Health Department and the Hickman County Health Foundation to improve community health and well-being. HCHS is designated as a Critical Access Hospital by the State of Tennessee, also providing a 24-hour emergency room to the community. HCHS participates in the government sponsored health care programs of Medicare, TennCare, CHAMPUS, and Tricare and provides financial assistance and sliding scale discounts to those not covered by health insurance.
		Part VI, Line 7: Hickman Community Health Services, Inc. (HCHS) is a wholly owned subsidiary of Saint Thomas Health Services, which is a member of Ascension Health. Ascension Health is a Catholic, national health system consisting primarily of nonprofit corporations that own and operate local health care facilities, or Health Ministries, located in 20 of the United States and the District of Columbia. Ascension Health is sponsored by the Northeast, Southeast, East Central, and West Central Provinces of the Daughters of Charity of St. Vincent de Paul, the Congregation of St. Joseph, and the Sisters of St. Joseph of Carondelet (CSJ).HCHS, located in Centerville, TN is a nonprofit acute care hospital. HCHS provides inpatient, outpatient, and emergency care services for the residents of Centerville, TN. Admitting physicians are primarily practitioners in the local area. The Medical Center is related to Ascension Health's other sponsored organizations through common control. Substantially all expenses of Ascension Health and its sponsored organizations are related to providing health care services.Mission:Ascension Health directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing and dedicates its resources to spiritually centered care which sustains and improves the health of the individuals and communities it serves. In accordance with Ascension Health's mission of service to those who are poor and vulnerable, each Health Ministry accepts patients regardless of their ability to pay. Ascension Health uses four categories to identify the resources utilized for the care of persons who are poor and community benefit programs:-Traditional charity care includes the cost of services provided to persons who cannot afford health care because of inadequate resources and/or who are uninsured or underinsured.-Unpaid cost of public programs represents the unpaid cost of services provided to persons covered by public programs for the poor.-Cost of other programs for the poor includes unreimbursed costs of programs intentionally designed to serve the poor and vulnerable of the community, including substance abusers, the homeless, victims of child abuse, and persons with acquired immune deficiency syndrome.-Community benefit consists of the unreimbursed costs of community benefit programs and services for the general community, not solely for the poor, including health promotion and education, health clinics and screenings, and medical research.Discounts are provided to all uninsured patients, including those with the means to pay. Discounts provided to those patients who did not qualify for assistance under charity care guidelines are not included in the cost of providing care of persons who are poor and community benefit programs. The cost of providing care of persons who are poor and community benefit programs is estimated using internal cost data.

Schedule H (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

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

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

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

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported in prior Form 990 or Form 990-EZ
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) Tod Lambert Sch O	(i) (ii)	263,444 0	18,943 0	41,005 0	4,900 0	20,992 0	349,284 0	0 0
(2) Tom Blankenship Sch O	(i) (ii)	0 210,830	0 15,378	0 28,619	0 23,510	0 20,142	0 298,479	0 0
(3) Mike Schatzlein MD Sch O	(i) (ii)	0 352,812	0 150,000	0 62,901	0 0	0 11,549	0 577,262	0 0
(4) Sheila Sffrella Sch O	(i) (ii)	0 214,407	0 15,285	0 27,948	0 11,235	0 9,366	0 278,241	0 0
(5) Marek Durakiewicz MD	(i) (ii)	277,355 0	0 0	16,784 0	4,900 0	1,580 0	300,619 0	0 0
(6) Zachary Hutchens MD	(i) (ii)	140,620 0	1,478 0	7,006 0	2,964 0	192 0	152,260 0	0 0
(7) Muhammad Mirza MD	(i) (ii)	187,492 0	0 0	80 0	0 0	5,266 0	192,838 0	0 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
	Part I, Line 4b	Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. Amounts Paid: Sheila Sferrella - $6,335 Thomas Blankenship - $18,786

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Identifier	Return Reference	Explanation
Explanation of Attached Audited Financial Statements:	Form 990, Part IV, Line 20b:	The financial statements of Saint Thomas Health, which included the activity of Hickman Community Health Services, Inc. D/B/A Hickman Community Hospital, fall under the specific scope audit. The activity of Hickman Community Health Services, Inc. and other members of Saint Thomas Health are reported in the consolidated financial statements of Ascension Health. No individual audit of Hickman Community Health Services, Inc. D/B/A Hickman Community Hospital is completed. Therefore, the attached audited financial statements are of Ascension Health and Affiliates (which include the activity of Hickman Community Health Services, Inc.).
Form 990, Part VI, Section A, line 3		Operational and financial management is provided by Millennium Medical Trust, Inc.
Form 990, Part VI, Section A, line 6		Hickman Community Health Services, Inc. has a single corporate member, Baptist Health Care Affiliates, Inc.
Form 990, Part VI, Section A, line 7a		Hickman Community Health Services, Inc. has a single corporate member, Baptist Health Care Affiliates, Inc., who has the ability to elect members to the governing body of the Hickman Community Health Services, Inc.
Form 990, Part VI, Section A, line 7b		All decisions that have a material impact to Hickman Community Health Services, Inc. financial information or corporation as a whole are subject to approval by its sole corporate member, Baptist Health Care Affiliates, Inc. (a member of the Saint Thomas Health). Ascension Health, the sole corporation member of Saint Thomas Health, has designed a system authority matrix which assigns authority for key decisions that are necessary in the operation of the System. Specific areas that are identified in the authority matrix are: new organizations & major transactions; governing documents; appointments/removals; evaluation; debt limits; strategic & financial plans; assets; system policies & procedures. These areas are subject to certain levels of approval by Ascension per the system authority matrix.
Form 990, Part VI, Section B, line 11		Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form 990 to the Board, or a designated committee, to review and answer any questions. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members questions.
	Form 990, Part VI, Section B, line 12c	The organization regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflict of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose.
	Form 990, Part VI, Section B, line 15b	This question is more appropriately answered "not applicable" as Hickman Community Health Services, Inc. does not compensate a CEO, Executive Director, or top management official. In determining the compensation of other officers of the organization, the process performed by Saint Thomas Health Services, a related organization of Hickman Community Health Services, Inc., included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The executive committee reviewed and approved the compensation. In the review of the compensation, the other officers of the organization were compared to other organizations' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the executive committee minutes.
	Form 990, Part VI, Section C, line 19	The organization will provide any documents open to public inspection upon request.
Changes in Net Assets or Fund Balances:	Form 990, Part XI, line 5:	Deferred Pension Cost 183,516. Transfer of Assets 450,028. Total to Form 990, Part XI, Line 5: 633,544.
Explanation of Board Member Compensation:	Form 990, Part VII, Section A:	Tom Blankenship and Mike Schatzlein receive compensation from Saint Thomas Health, a related organization of Hickman Community Hospital. The compensation they receive is for their role at Saint Thomas Health, and not for their role as a director of Hickman Community Hospital.
Explanation of Board of Directors Listing:	Form 990, Part VII, Section A:	Baptist Health Care Affiliates, Inc. (a member of the Saint Thomas Health) is the sole corporate member of Hickman Community Hospital. As a member of Saint Thomas Health, Saint Thomas Health retains reserved authority over certain activity of Hickman Community Hospital. Therefore, Saint Thomas Health's board of directors is listed on Form 990, Part VII.
		Hickman Community Healthcare Services, Inc. COMMUNITY BENEFIT REPORT For the year ended June 30, 2011 This report illustrates the significant degree to which Hickman Community Healthcare Services, Inc. contributes to the positive health status of the communities it serves. As a member of Ascension Health, the nation's largest Catholic healthcare system, Hickman Community Healthcare Services, Inc. continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. Ascension Health directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing and dedicates its resources to spiritually centered care which sustains and improves the health of the individuals and communities it serves. In accordance with Ascension Health's mission of service to those who are poor and vulnerable, each Health Ministry accepts patients regardless of their ability to pay. Hickman Community Healthcare Services, Inc. has engaged in the following activities to ensure that our mission is accomplished: Unreimbursed Services Provided to the Elderly and the Poor Hickman Community Healthcare Services, Inc. provides a substantial portion of its services to the elderly and poor. During the fiscal year ending June 30, 2011, approximately 44% of the value of services rendered were to elderly patients under the Medicare program, and approximately 22% of the services were provided to patients who were deemed indigent under state, county, or Medical Center Guidelines. In the spirit of principles adopted by Ascension Health, Hickman Community Healthcare Services, Inc. has taken proactive steps to address those issues that will affect accessibility, the financing, and the delivery of healthcare to all persons, especially the uninsured, underinsured, and the underserved. During the fiscal year ending June 30, 2011, the estimated unreimbursed cost of services provided to the elderly, uninsured, and underinsured totaled $344,718. Patient Services Hickman Community Healthcare Services, Inc. provides the following in-patient and out-patient medical services to the community: Inpatient Acute Beds Swing Beds Intermediate Care Nursing Home Facility Rural Health Clinics (2) Respiratory Therapy Physical Therapy Laboratory Services Radiology Services Social Services Surgical Services Pharmacy Some of the services listed above operate at a loss in order to ensure that all services are available to meet community health care needs. During the fiscal year ending June 30, 2011, our Medical Center treated 406 adults and children in the community for a total of 1,157 hospital patient days of service and 11,639 ICF nursing facility patient days of service. The Medical Center also provided services to 30,402 outpatients, including 268 outpatient surgery patients, 4,904 emergency care visits, and 19,802 rural health clinic visits. Community Outreach activities Hickman Community Healthcare Services, Inc. seeks to improve the physical, mental, social and spiritual health status of its surrounding community. In addition to providing health care services to all individuals who require medical attention, Hickman Community Healthcare Services, Inc. has developed the following programs to help achieve its mission: Expanding Awareness, Education, and Health Promotion Hickman Community Healthcare Services, Inc. believes that it is essential to educate people regarding the types of behavior that improve their chances of living a healthy life. Hickman Community Healthcare Services, Inc. has invested significantly in unique, top quality health education and materials to accomplish its goals. Hickman Community Healthcare Services, Inc. has provided throughout the year various wellness programs twice weekly on the local radio station, articles on various health topics to the local Hickman County Times newspaper, and other seminars provided to the community covering topics such as suicide prevention, diabetes education to individuals and groups, CPR training, depression recognition, hypothermia, and smoking cessation. Hickman Community Healthcare Services, Inc. has provided charitable contributions to several community organizations during the year including the Hickman Civitan Club, the Hickman County Library, the Centerville Lions Club, the Hickman County Education Foundation, the Hickman County Humane Society, the Middle Tennessee Council of the Boy Scouts of America, the National Child Safety Council, and the Tennessee Kidney Foundation. Hickman Community Healthcare Services, Inc. also participated in other charitable programs this year which included providing sports physicals for Hickman County High School and the local middle schools athletes, providing physicals for the local Department of Transportation school bus drivers, assistance to local Adult Protective Services, providing books to the local elementary schools, the Hickman Alzheimer Support Group, and the Hickman Suicide Prevention Task Force. Hickman has also collaborated with other community organizations to improve community health that include the Hickman County Health Department, the Hickman County Health Foundation, and the Dispensary of Hope. Medical Education Hickman Community Healthcare Services, Inc. believes that, in order to provide the best health care to the community, its clinical personnel must receive ongoing medical education. Hickman Community Healthcare Services, Inc. has provided seminars during the year to its medical staff on topics such as dementia, CPR-Heartsavers classes, ACLS classes, pericare, back safety in lifting and turning patients, infection control, and food and drug interaction. Summary Hickman Community Healthcare Services, Inc. furthers its charitable purposes by providing a broad array of services to meet the healthcare needs of patients and organizations in the community. We provide essential medical services to the community, train and recruit healthcare professionals to serve the needs of the broader community, provide appropriate charity services to those patients who are not able to pay for their own healthcare needs, provide services to other organizations that allow them to provide quality services to their patients or constituents, and present education information classes and activities to the community in order to improve its overall health status.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Hickman Community Health Services Inc

Employer identification number

58-1737573

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) Ascension Health PO Box 45998 St Louis,MO63134 31-1662309	National Health System	MO	Section 501(c)(3)	Schedule A, Line 11a	N/A		No
(2) Saint Thomas Health 4220 Harding Rd Nashville,TN37205 58-1716804	Health System Parent Company	TN	Section 501(c)(3)	Schedule A, Line 11c	Ascension Health		No
(3) Saint Thomas Hospital Inc 4220 Harding Road Nashville,TN37205 62-0347580	Hospital	TN	Section 501(c)(3)	Schedule A, Line 3	Saint Thomas Health		No
(4) Saint Thomas Network 4220 Harding Road Nashville,TN37205 62-1284994	Health Investment Entity	TN	Section 501(c)(3)	Schedule A, Line 9	Saint Thomas Health		No
(5) Saint Thomas Health Foundations FKA Saint Thomas Health Services Fund 4220 Harding Road Nashville,TN37205 58-1663055	Operates Foundation	TN	Section 501(c)(3)	Schedule A, Line 7	Saint Thomas Network		No
(6) Middle Tennessee Medical Center Inc 400 N Highland Avenue Murfreesboro,TN37219 62-0475842	Hospital	TN	Section 501(c)(3)	Schedule A, Line 3	Saint Thomas Health		No
(7) Middle Tennessee Medical Center Development Foundation 400 N Highland Avenue Murfreesboro,TN37219 62-1167917	Foundation	TN	Section 501(c)(3)	Schedule A, Line 11a	Middle Tennessee Medical Center Inc		No
(8) Seton Corporation 4220 Harding Road Nashville,TN37205 62-1869474	Acute Care Hospital	TN	Section 501(c)(3)	Schedule A, Line 3	Saint Thomas Health		No
(9) Baptist Health Care Group 2000 Church Street Nashville,TN37236 62-1529858	Healthcare Provider	TN	Section 501(c)(3)	Schedule A, Line 3	Seton Corporation		No
(10) Baptist Saint Thomas Home Care 2000 Church Street Nashville,TN37236 51-0172298	Home Health Care	TN	Section 501(c)(3)	Schedule A, Line 9	Seton Corporation		No
(11) Baptist Hospital Foundation of Nashville Inc 2000 Church Street Nashville,TN37236 58-1861378	Inactive	TN	Section 501(c)(3)	Schedule A, Line 11a	Seton Corporation		No
(12) Baptist Health Care Affiliates Inc 2000 Church Street Nashville,TN37236 58-1509251	Community Health Promotion	TN	Section 501(c)(3)	Schedule A, Line 11a	Seton Corporation		No
(13) Hickman Community Home Care Inc 135 East Swan St Centerville,TN37033 62-1836937	Home Health Care	TN	Section 501(c)(3)	Schedule A, Line 9	Hickman Community Health Care Services Inc	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2010

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Baptist Womens Health Center LLC dba The Center For Spinal Surgery 2011 Murphy Avenue Nashville,TN37203 62-1772195	Owns and Operates Specialty Hospital	TN	N/A
(2) Middle Tennessee Ambulatory Surgery Center LP 500 N Highland Avenue Murfreesboro,TN37130	Operates Outpatient Surgery Center	TN	N/A
(3) Middle Tennessee Imaging LLC 400 N Highland Avenue Murfreesboro,TN37219 01-0570490	Diagnostic Imaging Center	TN	N/A
(4) Murfreesboro Diagnostic Imaging LLC 400 N Highland Avenue Murfreesboro,TN37219 20-0291952	Diagnostic Imaging Center	TN	N/A
(5) Nashville Diagnostic Imaging LLC 30 Burton Hills Blvd Suite 165 Nashville,TN37215	Inactive	TN	N/A
(6) STHS Sleep Center LLC 618 Church Street Suite 520 Nashville,TN37219 20-3664894	Operates a Sleep Center	TN	N/A

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)
(1) Mid-State Properties Inc 2000 Church Street Nashville,TN37236 62-1232018	Pharmacy	TN	N/A	C
(2) Sova Inc 102 Woodmont Blvd Suite 700 Nashville,TN37205 26-1319638	Health Services	TN	N/A	C
(3) Vincentian Ventures Inc 4220 Harding Road Nashville,TN37205 62-1331896	Health Services	TN	N/A	C
(4) Comp Plus Inc 2000 Church Street Nashville,TN37236 62-1626010	Healthcare	TN	N/A	C
(5) Manaco Management Services Inc 400 North Highland Avenue Murfreesboro,TN37130 62-1718479	Health Services	TN	N/A	C
(6) St Thomas Medical Clinic 4220 Harding Road Nashville,TN37205 62-1583605	Health Services	TN	N/A	C
(7) Baptist Health Care Ventures Inc 2000 Church Street Nashville,TN37236 62-0469214	Holding Company	TN	N/A	C
(8) Middle Tennessee Network Inc 2000 Church Street Nashville,TN37236 62-1570989	Health Services	TN	N/A	C
(9) Health Net Reserve Inc 44 Vantage Way Suite 300 Nashville,TN37202 62-1540604	Health Management	TN	N/A	C

Schedule R (Form 990) 2010

Page 3

Part V

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

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

Yes

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

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

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

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

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

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

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

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

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

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

Yes

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

Yes

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

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

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

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

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

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

Yes

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

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

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

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1) Baptist Real Estate Services	J	70,089	Actual Amount Paid
(2) Hickman Community Home Care	P	331,371	Actual Amount Paid
(3) Saint Thomas Foundations	C	1,731,394	FMV
(4)
(5)
(6)

Schedule R (Form 990) 2010

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2010

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: High quality acute care hospital, intermediate care nursing home & physician services.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	25
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	22
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	196
6	Total number of volunteers (estimate if necessary) ....	6	21
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) .........	334,609	1,829,611
9	Program service revenue (Part VIII, line 2g) .........	13,541,198	14,710,488
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	3,946	6,256
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	125,569	154,345
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	14,005,322	16,700,700
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
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)	8,531,299	9,402,608
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	7,511,037	6,740,419
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	16,042,336	16,143,027
19	Revenue less expenses. Subtract line 18 from line 12......	-2,037,014	557,673
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	9,872,091	16,116,751
21	Total liabilities (Part X, line 26)............	17,294,600	22,348,043
22	Net assets or fund balances. Subtract line 21 from line 20 .....	-7,422,509	-6,231,292

Sign Here

	Signature of officer	Date

	Type or print name and title.

Paid Preparer's Use Only	Preparer's signature	Date	Check if self- employed	Preparer’s taxpayer identification number (see instructions)
	Firm’s name (or yours if self-employed), address, and ZIP + 4			EIN
				Phone no.


4a	(Code: ) (Expenses $ 11,119,306 including grants of $ ) (Revenue $ 14,710,488 )
	Hickman Community Hospital operates a hospital and nursing home. It provides quality health care services to the residents of Hickman County, Tennessee. See Schedule O for Community Benefit Report.

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












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












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 11,119,306

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,308,598	1,078,180	146,095

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		1,731,394
e	Government grants (contributions)1e		88,669

f	All other contributions, gifts, grants, and similar amounts not included above1f		9,548
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			1,829,611
			Business Code
2a	Hospital		621,990	10,335,835	10,335,835
b	Rural Health Clinic		621,990	2,291,864	2,291,864
c	Nursing Home		621,990	2,082,789	2,082,789
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			14,710,488
3	Investment income (including dividends, interest
	and other similar amounts).....			6,256			6,256
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross Rents	31,165
b	Less: rental expenses
c	Rental income or (loss)	31,165
d	Net rental income or (loss).......			31,165			31,165
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss)..........
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	Home Health - PT/OT		621,990	29,850			29,850
b	Cafeteria Sales		722,320	16,465			16,465
c	Transcription Fees		621,990	5,511			5,511
d	All other revenue ....			71,354			71,354
e	Total. Add lines 11a–11d ......			123,180
12	Total revenue. See Instructions....			16,700,700	14,710,488	0	160,601


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			4,623,803	1	7,702,323
2	Savings and temporary cash investments .......			61,988	2	62,245
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			1,900,831	4	2,256,993
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 .............			753,575	7	605,528
8	Inventories for sale or use ..............			185,546	8	232,237
9	Prepaid expenses and deferred charges ............			30,667	9	27,415
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	10,007,553
b	Less: accumulated depreciation. .....	10b	4,795,832	2,297,735	10c	5,211,721
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			17,946	15	18,289
16	Total assets. Add lines 1 through 15 (must equal line 34)...			9,872,091	16	16,116,751
17	Accounts payable and accrued expenses .			17,250,671	17	22,304,465
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities. Complete Part X of Schedule D.....			43,929	25	43,578
26	Total liabilities. Add lines 17 through 25.....			17,294,600	26	22,348,043
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			-7,422,509	27	-6,231,292
28	Temporarily restricted net assets .....				28
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			-7,422,509	33	-6,231,292
34	Total liabilities and net assets/fund balances .....			9,872,091	34	16,116,751