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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2011 and ending 12-31-2011
BCheck if applicable:
CName of organization
Upper Valley Medical Center
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
3130 North County Road 25A
 
Room/suite
City or town, state or country, and ZIP + 4
Troy, OH45373
D Employer identification number

31-0537095
E Telephone number

G Gross receipts $ 223,119,622
F Name and address of principal officer:
Thomas Parker
3130 North County Road 25A
Troy,OH45373
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.uvmc.com
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1926
M State of legal domicile: OH
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: The primary exempt purpose is to provide comprehensive inpatient, outpatient and emergency health care services to area residents. The Hospital furthers its exempt purpose by promoting community health.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 17
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 13
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 1,628
6 Total number of volunteers (estimate if necessary) .... 6 180
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 192,858
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b -42,161
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 26,332 63,258
9 Program service revenue (Part VIII, line 2g) ......... 140,499,574 147,412,296
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 2,760,318 2,719,969
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,414,283 1,433,718
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 144,700,507 151,629,241
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 140,741 242,433
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) 73,405,112 79,119,649
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 62,537,181 65,994,730
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 136,083,034 145,356,812
19 Revenue less expenses. Subtract line 18 from line 12....... 8,617,473 6,272,429
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 160,660,248 154,457,885
21 Total liabilities (Part X, line 26)............. 106,955,964 117,307,199
22 Net assets or fund balances. Subtract line 21 from line 20..... 53,704,284 37,150,686
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: SEE SCHEDULE O
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 113,469,223 including grants of $ 242,433 ) (Revenue $ 147,860,671 )
See Schedules H and O.
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 expensesMediumBullet$ 113,469,223
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part IIIClick to see attachment........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II.. Click to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III.. Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see list of attachments
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
Yes
 
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
Yes
 
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
Yes
 
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
93
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
1,628
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
17
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
13
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
OH
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
TIMOTHY SNIDER
3130 NORTH COUNTY RD 25A
Troy,OH45373
(937) 440-7853
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Douglas R Murray
Chair
 .5 X   X            
(2) Rowan R Nickol MD
First Vice Chair
 40.0 X   X         332,731 88,007
(3) Craig C Bundschuh
Second Vice Chair/Secretary
 .5 X   X            
(4) Cliff R Alexander
Director
 .5 X                
(5) Arthur R Disbrow
Director
 .5 X                
(6) Ronald R Fox
Director
 .5 X                
(7) Daniel P French
Director
 .5 X                
(8) Gail Haddad RN
Director
 .5 X                
(9) R Douglas Haines
Director
 .5 X                
(10) L Stewart Lowry MD
Director
 40.0 X             329,401 23,845
(11) William E Lukens
Director
 .5 X                
(12) Peter E Nims MD
Director
 .5 X                
(13) P Naga Maddireddy MD
Director
 .5 X           13,317    
(14) James Pancoast
Director
 .5 X                
(15) Michael R Tinkler DDS
Director
 .5 X                
(16) Joel H Walker
Director
 .5 X                
(17) Mary Patricia Wampler RN
Director
 .5 X                
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Thomas Parker
President/CEO
 40.0     X       362,894   52,290
(19) Timothy Snider
Vice President/CFO
 40.0     X       251,661   27,768
(20) Judith Snyder
Vice President
 40.0       X     226,578   66,446
(21) Rebecca Rice
Vice President
 40.0       X     205,063   64,923
(22) James Hurak
Vice President
 40.0       X     193,119   53,058
(23) Barbara Evert MD
Former Vice President
 40.0       X     171,342   9,885
(24) Mary M Clancy
VP-CIO (PHP)
 40.0       X       467,688 55,146
(25) WILLIAM E LINESCH
VP - HR & OE (PHP)
 40.0       X       424,338 41,137
(26) THOMAS J ARQUILLA
VP-BUSINESS DEV (PHP)
 40.0       X       203,967 28,003
(27) MARK W SHAW
VP-MANAGED CARE (PHP)
 40.0       X       349,386 84,013
(28) J NICHOLAS LAIR
VP-CHF PURCH OFFICER (PHP)
 40.0       X       295,289 34,887
(29) RENEE P GEORGE
VP-REVENUE CYCLE (PHP)
 40.0       X       269,407 33,415
(30) Shakil Rahman MD
Physician
 40.0         X   392,449   26,255
(31) Rafay Atiq MD
Physician
 40.0         X   248,056   24,216
(32) William Watercutter
Director of IT
 40.0         X   149,158   24,601
(33) Thomas Bigley
Director of Pharmacy
 40.0         X   169,174   24,896
(34) Tracy Moser
Director of Human Resources
 40.0         X   138,417   26,783
(35) Michael J Maiberger
Former President/CEO
             X   495,480 26,597
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 2,521,228 3,167,687 816,171
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet22
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Brackett Builders
185 Marybill Dr
TROY,OH45373 		Construction 4,323,228
Valley Anesthesia Inc
3130 North County Rd 25A
TROY,OH45373 		Anesthesiology 1,639,358
North Dayton Pathologist Inc
2222 Philadelphia Dr
DAYTON,OH45406 		Pathology 998,585
Premier Health Care Services Inc
332 Congress Park Dr
DAYTON,OH45459 		Occupational Health 444,662
Quest Diagnostics
3 Giralda Farms
MADISON,NJ07940 		Lab/Healthcare 439,509
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet20
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		63,258
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 63,258
Program Service Revenue Business Code
2a NET MEDICARE / MEDICAID 621,300 65,161,268 65,161,268    
b NET PATIENT CARE SERVICES 212,000 81,376,260 81,376,260    
c JOINT HOSPITAL SERVICES - LAUNDRY 812,300 611,250 601,602 9,648  
d TRAINING & EDUCATION 561,499 115,878 115,878    
e RENTAL FROM AFFILIATES 532,000 23,940 23,940    
f All other program service revenue . 123,700 123,700    
g Total. Add lines 2a–2f........MediumBullet 147,412,296
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 2,092,929     2,092,929
4 Income from investment of tax-exempt bond proceeds..MediumBullet 303,678     303,678
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 195,527  
b Less: rental expenses 131,989  
c Rental income or (loss) 63,538  
d Net rental income or (loss).......MediumBullet 63,538     63,538
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 71,445,370 236,384
b Less: cost or other basis and sales expenses 71,297,256 61,136
c Gain or (loss) 148,114 175,248
d Net gain or (loss)..........MediumBullet 323,362     323,362
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..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a NUTRITION SERVICES 722,210 811,667 73,072   738,595
b PHYSICIAN LABORATORY SERVICES 621,500 137,654   137,654  
c MEDICAL RECORDS FEES 541,800 47,856 47,856    
d All other revenue .... 373,003 327,447 45,556  
e Total. Add lines 11a–11d ......MediumBullet 1,370,180
12 Total revenue. See Instructions....MediumBullet 151,629,241 147,851,023 192,858 3,522,102
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 242,433 242,433
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 2,073,851 57,061 2,016,790  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 59,138,291 46,973,327 12,164,964  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 4,676,107 4,002,047 674,060  
9 Other employee benefits ....... 9,070,495 6,784,531 2,285,964  
10 Payroll taxes ........... 4,160,905 3,469,280 691,625  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 72,966   72,966  
c Accounting ........... 176,938   176,938  
d Lobbying ........... 15,403   15,403  
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 111,981   111,981  
g Other .......... 7,147,210 6,588,491 558,719  
12 Advertising and promotion .... 478,597 52,046 426,551  
13 Office expenses ....... 3,456,024 2,368,732 1,087,292  
14 Information technology ...... 4,714,902 57,817 4,657,085  
15 Royalties .. 0      
16 Occupancy ........... 3,118,666 2,740,462 378,204  
17 Travel ............ 160,901 124,340 36,561  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 1,492,678 1,463,887 28,791  
20 Interest ........... 2,678,813 2,196,627 482,186  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 7,265,994 5,607,050 1,658,944  
23 Insurance .............. 1,246,389   1,246,389  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a OPERATING SUPPLIES/EQUIP 14,706,075 14,697,922 8,153  
b JOINT OPERATING AGREEMENT 7,223,000 7,223,000    
c PURCHASED SERVICES 6,854,500 3,964,218 2,890,282  
d BAD DEBTS 3,648,419 3,648,419    
e
f All other expenses 1,425,274 1,207,533 217,741  
25 Total functional expenses. Add lines 1 through 24f 145,356,812 113,469,223 31,887,589 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 3,395 1 3,518
2 Savings and temporary cash investments ....... 2,562,716 2 1,340,748
3 Pledges and grants receivable, net ......... 0 3 0
4 Accounts receivable, net ......... 11,001,086 4 16,363,312
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 45,177 5 28,995
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 .......... 0 6 0
7 Notes and loans receivable, net ............. 478,548 7 487,223
8 Inventories for sale or use .............. 534,319 8 633,671
9 Prepaid expenses and deferred charges ............ 1,337,541 9 1,891,735
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 142,590,916
b Less: accumulated depreciation. ..... 10b 79,179,660 56,242,584 10c 63,411,256
11 Investments—publicly traded securities .......... 86,868,834 11 68,986,819
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 1,586,047 15 1,310,608
16 Total assets. Add lines 1 through 15 (must equal line 34)... 160,660,248 16 154,457,885
Liabilities 17 Accounts payable and accrued expenses . 51,319,938 17 62,253,136
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 53,190,064 20 51,180,950
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 2,445,962 25 3,873,113
26 Total liabilities. Add lines 17 through 25..... 106,955,964 26 117,307,199
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 51,123,204 27 34,468,919
28 Temporarily restricted net assets ..... 1,507,638 28 1,592,465
29 Permanently restricted net assets ..... 1,073,441 29 1,089,302
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 53,704,283 33 37,150,686
34 Total liabilities and net assets/fund balances ..... 160,660,248 34 154,457,885
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
151,629,241
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
145,356,812
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
6,272,429
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
53,704,283
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-22,826,026
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
37,150,686
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Upper Valley Medical Center
  		Employer identification number

31-0537095
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Upper Valley Medical Center
  		Employer identification number

31-0537095
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Upper Valley Medical Center
  		Employer identification number

31-0537095
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


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

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

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

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

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

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










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2011

Schedule C (Form 990 or 990-EZ) 2011
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check expenses, and share of excess lobbying expenditures).
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2011


Schedule C (Form 990 or 990-EZ) 2011
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
8,653
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
6,750
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
 
No
 
j
Total. Add lines 1c through 1i ...............................
15,403
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Schedule C, Part II-B, Lines 1f & 1g   Amounts include a portion of membership dues paid to Ohio Hospital Association and Greater Dayton Area Hospital Association that were used for lobbying purposes. Also includes payments to a contracted lobbyist for health care related issues.
Schedule C (Form 990 or 990EZ) 2011

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 1,253,294 1,013,866 974,642 946,469
b Contributions ........ 85,008 213,180 161,508 74,844
c Net investment earnings, gains, and losses ... 121,433 62,404 -80,688 -2,389
d Grants or scholarships ..... 45,284 24,999 30,895 16,333
e Other expenditures for facilities
and programs ........ 		7,898 11,157 10,701 27,949
f Administrative expenses ....        
g End of year balance ...... 1,406,553 1,253,294 1,013,866 974,642
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet77.440 %
c
Temporarily restricted endowment SchDMd Bullet22.560 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
Yes
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   409,459 409,459
b Buildings ................   65,088,429 33,023,264 32,065,165
c Leasehold improvements ............   78,425 78,425  
d Equipment ................   70,102,287 44,871,109 25,231,178
e Other .................   6,912,316 1,206,862 5,705,454
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 63,411,256
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








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








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
DUE TO MEDICARE / MEDICAID 3,873,113








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 3,873,113
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Intended uses of the organization's endowment funds Schedule D, Part V, Line 4 The permanent and term endowment funds are to be used to provide building/equipment and program related needs for the UVMC Health System, to provide support to the Upper Valley Medical Center Cancer Care Center, and to provide healthcare scholarships. In addition, the term endowment funds are to be used to provide financial support for indigent patient bills, to provide health education programs, and to provide benefits to enhance a child's well being while spending time in the hospital.
Income Taxes Schedule D, Part X, Line 2 UVMC is tax-exempt under Section 501(c)(3) of the Internal Revenue Code. As such, there is no income tax liability recorded at December 31, 2011 and 2010. In addition, Management annually reviews its tax positions and has determined that there are no material uncertain tax positions that require recognition in the combined financial statements. UVMC and its respective subsidiaries are a group of corporations that are tax-exempt corporations under Section 501(c)(3) of the Internal Revenue Code except for the following subsidiaries: - UVMC Management Corporation - For-profit corporation subject to federal income taxes - After Hours Family Care, Inc. - For-profit corporation subject to federal income taxes - Med-Terra, Inc. - Tax-exempt corporation under Section 501(c)(2) of the Internal Revenue Code
Schedule D (Form 990) 2011

Additional Data


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SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16.Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I
General Information on Activities Outside the United States. Complete if the organization answered
“Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of its grants
and other assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used
to award the grants or assistance? ..............................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other
assistance outside the United States.
3
Activites per Region. (Use Part V if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees or agents in region or independent contractors (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total
expenditures for region/investments
in region
North America     Investments   464,435
Europe (Including Iceland and Greenland)     Investments   3,576,097
East Asia and the Pacific     Investments   788,366
Central America and the Caribbean     Investments   7,500,000
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total .....     12,328,898
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b)     12,328,898
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2011
Schedule F (Form 990) 2011
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990,
Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 ........ MediumBullet
Use Part V if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2
Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .....MediumBullet
 
3
Enter total number of other organizations or entities ........................MediumBullet
 
Schedule F (Form 990) 2011
Schedule F (Form 990) 2011Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Use Part V if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2011
Schedule F (Form 990) 2011
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926 (see instructions for Form 926).................
2 Did the organization have an interest in a foreign trust during the tax year? If " Yes," the organization may be required to file Form 3520 and/or Form 3520-A. (see instructions for Forms 3520 and 3520-A)..........
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see instructions for Form 5713)................................................
Schedule F (Form 990) 2011
Schedule F (Form 990) 2011
Page 5
Part V
Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
Identifier ReturnReference Explanation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2011
Additional Data


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Software Version:  



SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    8,776,234 1,877,661 6,898,573 4.870 %
b Medicaid (from Worksheet 3, column a) .....     15,661,841 11,067,403 4,594,438 3.240 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .     425,742 333,510 92,232 0.070 %
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		    24,863,817 13,278,574 11,585,243 8.180 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    1,069,932 99,907 970,025 0.680 %
f Health professions education
(from Worksheet 5) .. 		    54,280   54,280 0.040 %
g Subsidized health services
(from Worksheet 6) .. 		    3,516,441 783,279 2,733,162 1.930 %
h Research (from Worksheet 7)            
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....     214,430   214,430 0.150 %
jTotal Other Benefits ...     4,855,083 883,186 3,971,897 2.800 %
kTotal. Add lines 7d and 7j. ..     29,718,900 14,161,760 15,557,140 10.980 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development     632   632  
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members     1,200   1,200  
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development     12,970   12,970 0.010 %
9 Other     18,361   18,361 0.010 %
10 Total     33,163   33,163 0.020 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense........
2
802,643
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
 
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
34,935,883
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
40,058,840
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-5,122,957
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 UPPER VALLEY MEDICAL CENTER
3130 NORTH COUNTY ROAD 25A
TROY,OH45373 		X X         X   BEHAVIORAL HEALTH
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
UPPER VALLEY MEDICAL CENTER
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 200.%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16    
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?7
Name and address Type of Facility (describe)
1 DIALYSIS SERVICES
3130 N COUNTY RD 25A
TROY,OH45373 		DIALYSIS
2 HYATT CENTER
450 HYATT STREET
TIPP CITY,OH45371 		LABORATORY, IMAGING, SPORTS MEDICINE, SURGERY
3 OUTPATIENT CARE CENTER NORTH
280 LOONEY RD
PIQUA,OH45356 		LABORATORY, IMAGING, REHABILITATIVE THERAPY
4 OUTPATIENT CARE CENTER SOUTH
998 SOUTH DORSET ROAD
TROY,OH45373 		LABORATORY, IMAGING OCCUPATIONAL HEALTH REHABILITATIVE THERAPY
5 STANFIELD PLACE
31 STANFIELD ROAD
TROY,OH45373 		LABORATORY, IMAGING
6 JACOB DETTMER BUILDING
3130 N COUNTY RD 25A
TROY,OH45373 		SLEEP DISORDER
7 VERSAILLES CENTER
471 MARKER ROAD
VERSAILLES,OH45380 		LABORATORY
8
9
10
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
SUPPLEMENTAL INFORMATION Part I, line 3c Not applicable. Upper Valley Medical Center uses the Federal Poverty Guidelines for determining eligibility for free or discounted care under the organization's charity care policy.
SUPPLEMENTAL INFORMATION Part I, line 6a An annual written community benefit report is prepared by the organization directly. In addition, Upper Valley Medical Center's community benefit information is included in an annual written community benefit report with Premier Health Partners, a related organization. Both of these reports are made available to the public via publications in local newspapers, as well as on the organizations' websites.
SUPPLEMENTAL INFORMATION Part I, line 7g Included in subsidized health services are revenues and expenses related to an obstetrics clinic which is subsidized by both the Miami County Health Department and Upper Valley Medical Center. This clinic serves the prenatal, delivery and postnatal medical needs of women in the hospital's Miami County service area. Also included in subsidized health services are revenues and expenses related to an outpatient behavioral health clinic which serves the mental and behavioral health needs of area residents. The clients in both of these clinics include those who either have no medical insurance or qualify for Medicaid services. The total community benefit expense for these clinics in 2011 was $1,105,770, with direct offsetting revenues of $783,279. The net community benefit expense was $322,491.
SUPPLEMENTAL INFORMATION Part I, line 7, column (f) Bad debt expenses of $3,648,419, which are included on Form 990, Part IX, line 25, column (A), have been removed from the denominator prior to the calculation of the percent of total expense.
SUPPLEMENTAL INFORMATION Part I, line 7 A cost-to-charge ratio methodology was used to calculate the community benefit expenses which appear in the table in Schedule H, Part I, Sections 7a-c. This cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The community benefits expenses which appear in the table under Sections 7e-j are calculated based on actual costs.
SUPPLEMENTAL INFORMATION - Community Building Activities Part II To aid in the leadership development and training for community members, Upper Valley Medical Center participates in the Leadership Piqua and Leadership Troy programs. These programs consist of annual sessions, whereby participants learn leadership and interpersonal skills to be informed civic-oriented leaders who are interested in helping to direct the future of the Miami County communities. Upper Valley Medical Center is a member of the local area chambers of commerce. Through this membership and the various chamber activities, the organization participates in the economic development of the Miami County area. In 2011, Upper Valley Medical Center participated in the Project Search Program. Project Search is a high school transition program which provides training and education leading to employment for individuals with disabilities. It is a collaborative program between Upper Valley Medical Center, Upper Valley Joint Vocational School, Rehabilitation Services Commission, the Miami and Shelby County Boards of Developmental Disabilities, and Capabilities. Eight individuals were selected to gain employable skills working in various departments within the hospital performing various tasks. The goal of this program is to have the individuals gain more independence and an ability to work in gainful employment. A Project Search Coordinator and a Job Coach supervise the students on a daily basis. Other community building activities include cash donations made to other organizations throughout the Miami County area. Upper Valley Medical Center makes several direct charitable donations to other not-for-profit organizations throughout Miami County. These organizations include area schools, chambers of commerce, churches, etc. These donations are given in the spirit of aiding in the overall well-being of the community.
SUPPLEMENTAL INFORMATION - BAD DEBTS Part III, line 4 Upper Valley Medical Center uses Worksheet A and the cost-to-charge ratio methodology from Worksheet 2, Ratio of Patient Care Cost-to-Charges to determine the amounts reported as the organization's bad debt expense (at cost) on Part III, Section A., lines 2-3. The Medical Center does not have a footnote in the audited financial statements that describes bad debt expense. Bad debt expense is incurred when an account is taken out of accounts receivable and turned over to a collection agency. This is done immediately if a patient refuses payment arrangements, refuses to apply for charitable assistance and there is no insurance balance being contended. An account is written off to bad debt after 120 days if an attempt to collect from the patient is made within the organization's collection policy and the patient has not returned phone calls, set up a payment plan, applied for charitable assistance and there is no insurance balance being contended. The collection agency attempts to collect the account in accordance with established guidelines. Collection attempts are immediately ceased and the account returned back to the organization if the patient applies for charitable assistance. Any amounts collected from these accounts are credited back against bad debt. Upper Valley Medical Center recognizes that there are accounts written off to bad debt that may have qualified for charity care if the patient provided the necessary financial information. In order to resolve this, the organization has engaged a third party vendor to analyze data based on credit scores to reallocate some of this expense to charity care. The policy is as follows: The collection agency pursues all bad-debt accounts until they exhaust their efforts of until 9 months after the placement date, whichever occurs earlier. If the collection agency has not been able to resolve the account, the account is returned to the organization for final close-back. These accounts are then sent to the third party vendor who gathers external credit data that presents the account as less than 200% Federal Poverty Level or not enough information (typically indicative of indigent). These accounts are reclassified from bad debt expense to charity expense on our income statement. Any credit score that presents the accounts as greater than 200% Federal Poverty Level remains in bad debt expense. Due to this process, Upper Valley Medical Center does not feel it has reported bad debt expense for patients eligible under the organization's charity care policy.
SUPPLEMENTAL INFORMATION - MEDICARE SHORTFALL Part III, line 8 The Medicare shortfall of $5,122,957 should be treated as community benefit because the organization is providing high-quality care in excess of the cost to those in its community who need care. The Medicare population at the organization is approximately 30% of net patient revenue. The Medicare advantage plans and Medicare managed care plans are excluded from this percentage. Upper Valley Medical Center uses the Medicare Allowable Costing Methodology (Medicare Cost Report 2552-96) to determine Medicare allowable costs reported.
SUPPLEMENTAL INFORMATION Part III, line 9b Upper Valley Medical Center makes reasonable efforts to determine whether or not an individual is eligible for assistance under the state's or hospital's financial assistance policy before engaging in extraordinary collective actions against that individual. Patients who are known to qualify for financial assistance are not subjected to extraordinary collections actions. Any third party collecting self pay receivables on our behalf is required to make reasonable efforts to determine if the individual meets the qualifications of the state or of our hospital's financial assistance programs. Reasonable efforts include: 1) Validating that the patient owes the unpaid bills and that all sources of third party payment have been identified and billed by the hospital. 2) Documenting that the organization has or has attempted to offer the patient the opportunity to apply for charity care under its financial assistance policy. 3) Documenting that the patient does not qualify for financial assistance. 4) Documenting that the patient has been offered a payment plan, but has not honored the terms of that plan. The Financial Counselors meet with both inpatient and outpatient self-pay and other patients upon request, who may need financial assistance. In addition to assisting patients who want to apply for assistance through the Medicaid program, the Financial Counselor will provide the patient with a financial assistance application.
SUPPLEMENTAL INFORMATION - FACILITY INFORMATION Part V, Section B Part V, Section B, line 9 Not applicable. Upper Valley Medical Center uses the Federal Poverty Guidelines for determining eligibility for free care under the organization's charity care policy. Part V, Section B, line 10 Not applicable. Upper Valley Medical Center uses the Federal Poverty Guidelines for determining eligibility for discounted care under the organization's charity care policy. Part V, Section B, line 11 If the patient's family income falls within 400% of the federal poverty guidelines, the patient qualifies for assistance under the hospital's financial assistance policy and all or part of the account will be written off to charity care, based upon a sliding fee schedule. The amount charged to patients who are eligible for financial assistance are not more than the amounts generally billed to individuals who have insurance covering such care. Patients who qualify for financial assistance are not charged gross charges for emergency or medically necessary care. Patients may also qualify for charity care discounts due to a medically-based catastrophic event which have occurred in their life. If a patient qualifies for this discount, he/she would only be held responsible for payment of his/her medical expenses up to 25% of their annual income. Part V, Section B, line 13 Upper Valley Medical Center widely distributes information about its financial assistance policy within the Miami County area and surrounding communities that it serves. This information includes the method of applying for and accessing financial assistance. Notices are publicized in patient's bills and are posted in the emergency room, admitting and registration areas, hospital business offices and patient financial services offices, as well as other public areas. A summary of the financial assistance policy is published on the UVMC website, in brochures available in patient areas and in other places within the community. Financial counselors, patient advocates and customer service representatives discuss the financial assistance policy with all uninsured patients and any patient who express financial hardship with paying their bill. Information regarding the financial assistance policy is available in both English and Spanish. Part V, Section B, line 15 Upper Valley Medical Center does not impose extraordinary collection actions such as wage garnishments, liens on primary residences or other legal actions for any patient without first making reasonable efforts to determine whether the patient is eligible for charity care under its financial assistance policy. Reasonable efforts include: a. Validating that the patient owes the unpaid bills and that all sources of third party payment have been indentified and billed by the hospital, b. Documenting that Upper Valley Medical Center has or has attempted to offer the patient the opportunity to apply for charity care under its financial assistance policy, c. Document that the patient does not qualify for financial assistance, d. Document that the patient has been offered a payment plan but has not honored the terms of that plan. Part V, Section B, line 16 Upper Valley Medical Center engages the services of third party collection agencies to assist in its collection efforts. These collection agencies may engage in similar collection actions allowed by the hospital under its billing and collections policy after first making reasonable efforts to determine whether the patient is eligible for charity care under its financial assistance policy. Part V, Section B, line 17 Before initiating collections actions, Upper Valley Medical Center notifies patients of its financial assistance policy. Notices of the policy are publicized in patient's bills and are also posted in the emergency room, admitting and registration areas, hospital business offices and patient financial services offices, as well as other public areas. A summary of the financial assistance policy is published on the UVMC website, in brochures available in patient areas and in other places within the community. Patient advocates discuss the financial assistance policy directly with all uninsured patients in the emergency department and those who are admitted to the hospital. The patient advocates also contact uninsured outpatients who are scheduled to have major procedures and all inpatients who are covered by Medicare only. In any instance where a patient calls the hospital and expresses a concern about their ability to pay, the financial assistance policy is explained. For all accounts with balances over $500, the patient advocate attempts to contact the patient three times prior to turning the account over for collections. Part V, Section B, line 18 Upper Valley Medical Center's financial assistance policy ensures that the financial capacity of people who require health care services does not prevent them from seeking or receiving care. Upper Valley Medical Center provides, without discrimination, care for emergency medical conditions, consistent with Section 1867 of the Social Security Act (EMTALA), to individuals regardless of their eligibility for financial assistance or for government assistance. Part V, Section B, lines 19 & 20 Upper Valley Medical Center does not have a discount program for all uninsured patients. However, for those uninsured or underinsured patients who apply for and meet the eligibility criteria for financial assistance under the financial assistance policy, the hospital uses the lowest negotiated commercial insurance rate for the services received by the patient. Part V, Section B, line 21 Upper Valley Medical Center does not have a discount program for all uninsured patients. Uninsured or underinsured patients who do not apply for financial assistance or those who do not qualify for financial assistance are charged the gross charges for any services provided to the patient.
SUPPLEMENTAL INFORMATION - Needs assessment: Part VI, Question 2: The primary purpose of the UVMC Community Benefit Plan is to work toward improved health in the communities that we serve by responding to community needs with programs that increase access to health care. This is accomplished through identifying community needs, making prudent choices for the use of resources, building and strengthening relationships in the community, and demonstrating accountability and transparency. UVMC works with the community on programs that address the underlying causes of persistent health problems, as part of a comprehensive strategy to improve the health status and quality of life for identified members of the community who are economically disadvantaged, disenfranchised and/or who have disproportionate unmet health needs. UVMC strives to work with Premier Health Partners, the UVMC Board of Directors, executive management, managers, staff members, community groups, and individuals to provide a collaborative approach to the governance and management of community benefit activities.
SUPPLEMENTAL INFORMATION - Patient education of eligibility for assistance Part VI, Question 3: There are several ways in which Upper Valley Medical Center informs and educates patients who may be billed for services about their eligibility for assistance under federal, state, or local government programs or under the Medical Center's financial assistance policy. First, notification of such available assistance is clearly posted in registration areas, as well as the maternity and emergency departments. Next, patient advocates, patient access staff members and financial advocates in the inpatient and emergency departments meet with uninsured and under-insured patients, as well as those with just Medicare coverage, to discuss eligibility for assistance. Financial counselors also discuss options to resolve unpaid account balances with uninsured and under-insured patients. A summary of the financial assistance policy is posted on the hospital's website, along with information on how to obtain an application. When a patient receives a bill from Upper Valley Medical Center, the reverse side of the bill contains information about the State of Ohio Free Care Program (Care Assurance). The patient statement offers a summary of the financial assistance options available and the contact information for assistance.
SUPPLEMENTAL INFORMATION - Community information Part VI, Question 4: Upper Valley Medical Center serves the northern Miami Valley area with acute care services, community health and wellness programs and more. Upper Valley Medical Center is located in Miami County, Ohio and is the sole hospital system operating within the county. The population of Upper Valley Medical Center's primary service area is approximately 130,000 people. Including the adjacent counties, which are also served (Shelby, Darke, and Champaign Counties), Upper Valley Medical Center's total primary and secondary service area population approaches 300,000 residents. The overall service area is categorized as having relatively slow growth with an aging population, consistent with current trends throughout Ohio. The median household income of Miami County and the surrounding area is slightly above $50,000 per year, with approximately 10% of its citizens living below the federal poverty level. Approximately 48% of the hospital's gross revenues are generated from Medicare patients, while another 19% of the revenues are generated from either uninsured patients or Medicaid recipients. The current unemployment rate of Miami County is approximately 9%. Recent job growth has been negative.
SUPPLEMENTAL INFORMATION - Promotion of Community Health Part VI, Question 5 The primary exempt purpose of Upper Valley Medical Center is to provide comprehensive inpatient, outpatient and emergency health care services to the residents of Miami and surrounding counties. The hospital furthers it tax-exempt purpose by promoting the health of the community in many ways. A principal financial contribution to the community is the provision of acute health services to patients regardless of their ability to pay. In addition to charity care services provided, Upper Valley Medical Center experienced bad debt expenses and also incurred costs from providing care for patients covered by government programs such as Medicare and Medicaid, where reimbursement is limited. Upper Valley Medical Center also subsidizes an obstetrics clinic and a behavioral health clinic and provides a comprehensive continuum of psychiatric and chemical dependency programs. These services are provided at a reduced cost or no cost for those who are uninsured or unable to pay. Thousands of individuals throughout Miami and surrounding counties benefited from Upper Valley Medical Center's health-focused programs during 2011, including health fairs, screenings, immunizations, support groups and other services. Many of these programs are free to the public or offered at a reduced price. Free presentations are available to area civic, service and social groups, professional organizations, schools, churches, and industries through the UVMC speaker's bureau. Speakers are available on a wide variety of medical/health care topics and are able to provide accurate up-to-date information to the community. Upper Valley Medical Center's use of surplus funds includes the purchase of property, plant and equipment of approximately $16 million. Highlights include: -Epic (Electronic Medical Record) Implementation -Cancer Care Center Expansion -CT Scanner for Cancer Care -Hemodialysis Machines -Emergency Room Renovation for Behavioral Health Assessments -Information Systems Upgrades. The UVMC board of directors consists of 18 members of the community. The majority of the board members are neither employees nor contractors of the organization. None of these board members receive compensation from the organization for services provided in the role of board member. The Medical Center extends medical staff privileges to all qualified physicians in its community for the majority of its departments. See Schedule O, Part III for more comprehensive details about how the Medical Center promotes the health of the community.
SUPPLEMENTAL INFORMATION - Affiliated Health Care System Part VI, Question 6 Upper Valley Medical Center is affiliated with Miami Valley Hospital, Good Samaritan Hospital, and Atrium Medical Center. The agreement between the systems provides for the creation of Premier Health Partners (PHP), an Ohio non-profit corporation. Each hospital system has the authority to determine the amounts it contributes to community building and other indigent programs.
Schedule H (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number
31-0537095
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) UVMC FOUNDATION3130 N COUNTY ROAD 25A
TROY,OH45373 		31-1581859 501(C)(3) 36,000       SCHOLARSHIP
(2) AMERICAN CANCER SOCIETY5555 FRANTZ ROAD
DUBLIN,OH43017 		34-0726080 501(C)(3) 7,500       SPONSORSHIP MIAMI CO RELAY FOR LIFE
(3) EDISON FOUNDATION1973 EDISON DRIVE
PIQUA,OH45356 		31-1379781 501(C)(3) 124,200       CAPITAL, EVENT SPONSORSHIP & GENERAL FUND
(4) Health Partners Free Clinic1300 North County Rd 25A
Troy,OH45373 		31-1596731 501(C)(3) 61,000       Operations
(5) Troy City Schools151 Staunton Rd
Troy,OH45373 		31-6000985   75,000       Equipment & Sponsorship
(6) AMERICAN HEART ASSOCIATION1313 W Dorothy Lane
Kettering,OH45409 		13-5613797 501(c)(3) 6,000       GO RED NORTH SPONSORSHIP












2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
6
3
Enter total number of other organizations listed in the line 1 table ......................... . Bullet Image
0
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2011

Schedule I (Form 990) 2011
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
Form 990, Schedule I, Part I, Line 2 Description of Organization's Procedures for Monitoring the Use of Grants UPPER VALLEY MEDICAL CENTER MONITORS THE USE OF GRANT FUNDS IN THE UNITED STATES BY VERIFYING THAT THE ORGANIZATIONS REQUESTING ASSISTANCE ARE 501(C)(3) TAX EXEMPT ORGANIZATIONS. THE GRANTS THAT ARE GIVEN ARE USUALLY SMALL IN NATURE AND LARGER ONES ARE APPROVED BY THE UVMC BOARD OF DIRECTORS. THEY ARE USUALLY GIVEN FOR A SPECIFIC PURPOSE, SUCH AS ONGOING OPERATIONS OR A CAPITAL PROJECT, AND ARE RELATED TO HEALTHCARE IN THE COMMUNITY.
Schedule I (Form 990) 2011


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
Yes
 
b
Any related organization? .........................
6b
Yes
 
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) Rowan R Nickol MD (i)
(ii)		  
258,350 		 
54,829 		 
19,552 		 
66,483 		 
21,524 		 
420,738 		 
 
(2) L Stewart Lowry MD (i)
(ii)		  
302,724 		 
8,839 		 
17,838 		 
2,450 		 
21,395 		 
353,246 		 
 
(3) Michael J Maiberger (i)
(ii)		  
294,532 		 
103,295 		 
97,653 		 
14,700 		 
11,897 		 
522,077 		 
20,993
(4) Thomas Parker (i)
(ii)		 258,307
  		66,488
  		38,099
  		43,710
  		8,580
  		415,184
  		 
 
(5) Timothy Snider (i)
(ii)		 196,471
  		37,691
  		17,499
  		14,700
  		13,068
  		279,429
  		 
 
(6) Judith Snyder (i)
(ii)		 152,010
  		42,542
  		32,026
  		60,205
  		6,241
  		293,024
  		 
 
(7) Rebecca Rice (i)
(ii)		 146,617
  		32,400
  		26,046
  		58,249
  		6,674
  		269,986
  		 
 
(8) James Hurak (i)
(ii)		 133,704
  		33,843
  		25,572
  		39,899
  		13,159
  		246,177
  		 
 
(9) Shakil Rahman MD (i)
(ii)		 287,924
  		103,488
  		1,037
  		2,450
  		23,805
  		418,704
  		 
 
(10) Rafay Atiq MD (i)
(ii)		 222,093
  		25,000
  		963
  		2,450
  		21,766
  		272,272
  		 
 
(11) William Watercutter (i)
(ii)		 126,384
  		13,080
  		9,694
  		9,135
  		15,466
  		173,759
  		 
 
(12) Thomas Bigley (i)
(ii)		 141,342
  		20,632
  		7,200
  		10,321
  		14,575
  		194,070
  		 
 
(13) Tracy Moser (i)
(ii)		 117,714
  		15,560
  		5,143
  		8,696
  		18,087
  		165,200
  		 
 
(14) Barbara Evert MD (i)
(ii)		 70,304
  		58,239
  		42,799
  		4,652
  		5,233
  		181,227
  		 
 
(15) Mary M Clancy (i)
(ii)		  
313,530 		 
126,634 		 
27,524 		 
41,787 		 
13,359 		 
522,834 		 
151,055
(16) WILLIAM E LINESCH (i)
(ii)		  
300,256 		 
103,880 		 
20,202 		 
33,815 		 
7,322 		 
465,475 		 
118,246
(17) THOMAS J ARQUILLA (i)
(ii)		  
126,756 		 
67,633 		 
9,578 		 
6,832 		 
21,171 		 
231,970 		 
75,243
(18) MARK W SHAW (i)
(ii)		  
255,244 		 
86,405 		 
7,737 		 
62,595 		 
21,418 		 
433,399 		 
86,405
(19) J NICHOLAS LAIR (i)
(ii)		  
199,671 		 
94,873 		 
745 		 
14,638 		 
20,249 		 
330,176 		 
94,873
(20) RENEE P GEORGE (i)
(ii)		  
202,151 		 
66,675 		 
581 		 
9,394 		 
24,021 		 
302,822 		 
66,675
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
SCHEDULE J, PART I, LINE 4B:   Due to restrictions imposed by the Internal Revenue Code, certain persons are limited in the amount of benefit that can be earned under a qualified retirement plan. Like many employers, UVMC Management Corporation (related organization) compensates for this limitation and supplements the affected executives' qualified pension through certain nonqualified plans. UVMC Management Corporation supplements through a Supplemental Executive Retirement Plan or "SERP". The benefits under the SERP are subject to multi-year vesting and a participant can forfeit benefits earned if vesting requirements are not satisfied. The SERP is a non-qualified deferred compensation plan subject to the requirements of the Internal Revenue Code Section 409A. The 2011 Participant in the SERP with a vested amount is: Michael Maiberger, and his vested amount of SERP for 2011 is $20,993. Additionally, the 451 Deferred Compensation Plan is offered to a select group of key management or highly compensated employees. This plan is intended to be a nonqualified deferred compensation arrangement which complies with the requirements of the Internal Revenue Code Section 409A. This plan is funded solely by the plan participants and maintained by a related organization. The 2011 participant is Michael Maiberger. The amount of his deferral under the Plan for 2011 is $56,488. All or parts of these payments were also properly reported on prior years' filed IRS Form 990 returns disclosing compensation earned by these individuals under the plans for each such year. However, based on the guidance provided in the instructions to the Form 990, any payments to the participants related to these plans that were made within 2-1/2 months after the end of the organization's tax year are not treated as deferred compensation for purposes of Schedule J. Such amounts are properly reported as compensation for Form 990 purposes when included in the participants' Form W-2 wages, which in this situation is 2012.
Schedule J, Part I, Lines 6a & 6b:   PREMIER HEALTH PARTNERS (PHP), OF WHICH UPPER VALLEY MEDICAL CENTER IS A PART, HAS AN INCENTIVE COMPONENT FOR ALL EXECUTIVE AND DIRECTOR LEVEL EMPLOYEES THAT TIES A PORTION OF THEIR TOTAL COMPENSATION TO ORGANIZATIONAL AND INDIVIDUAL OBJECTIVES AND OUTCOMES. THE ORGANIZATIONAL CRITERION IS WEIGHTED ACCORDING TO BALANCED SCORECARD CATEGORIES: POSITIVE WORK ENVIRONMENT (15%), QUALITY (30%), PATIENT SATISFACTION (15%), PHYSICIAN PARTNERSHIP, (15%), FINANCIAL (20%) AND MAJOR PROJECTS (5%). THE FINANCIAL CATEGORY OF THE SCORECARD IS BASED ON NET EARNINGS OF THE INDIVIDUAL HOSPITAL AND THE NET EARNINGS OF THE SYSTEM OF A WHOLE. THIS FINANCIAL TARGET IS SET BASED ON THE OPERATING AND CASH FLOW MARGINS REQUIRED TO MAINTAIN THE SYSTEM AA CREDIT RATINGS. DIRECTORS, VICE PRESIDENTS AND ABOVE INCENTIVE OBJECTIVES ARE WEIGHTED 45% ON ORGANIZATIONAL CRITERIA AND 45% ON INDIVIDUAL CRITERIA, AND 10% ON ORGANIZATIONAL EFFECTIVENESS. THE 2011 INCENTIVE PLAN AMOUNTS WERE PAID TO THE PARTICIPANTS IN 2012. THESE ARE NOT REPORTED AS DEFERRED COMPENSATION ON THE 2011 FORM 990 BASED ON THE DEFINITION OF DEFERRED COMPENSATION CONTAINED IN THE FORM 990 INSTRUCTIONS. PER THE INSTRUCTIONS, "DEFERRED COMPENSATION IS GENERALLY TREATED AS EARNED OR ACCRUED IN THE YEAR THAT SERVICES ARE RENDERED, EXCEPT WHEN ENTITLEMENT TO PAYMENT IS CONTINGENT ON SATISFACTION OF ORGANIZATIONAL GOALS OR SPECIFIED PERFORMANCE CRITERIA (OTHER THAN MERE LONGEVITY OF SERVICE) UNDER THE DEFERRED COMPENSATION PLAN." BASED ON THE INCENTIVE PROGRAM'S CRITERIA OUTLINED ABOVE, WE BELIEVE THE INCENTIVE PAYMENTS MEET THE EXCEPTION NOTED IN THE INSTRUCTIONS. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES, WHICH IN THIS SITUATION IS 2012.
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number
31-0537095
Part I
Bond Issues
(a) Issuer Name (b) Issuer EIN (c) CUSIP # (d) Date Issued (e) Issue Price (f) Description of Purpose (g) Defeased (h) On
Behalf of
Issuer 		(i) Pool
financing
Yes No Yes No Yes No
A County of Miami Ohio
  		31-6000055 593328EV5 06-29-2006 57,502,248 See Part VI   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . 5,855,000      
2 Amount of bonds legally defeased . . . . . . . . . . 0      
3 Total proceeds of issue . . . . . . . . . . . . . 61,109,249      
4 Gross proceeds in reserve funds . . . . . . . . 5,240,175      
5 Capitalized interest from proceeds . . . . . . . . . . 0      
6 Proceeds in refunding escrows . . . . . . . . . . . 0      
7 Issuance costs from proceeds . . . . . . . . . . . 663,253      
8 Credit enhancement from proceeds . . . . . . . . . . 0      
9 Working capital expenditures from proceeds . . . . . . . 0      
10 Capital expenditures from proceeds . . . . . . . . . . 19,589,170      
11 Other spent proceeds . . . . . . . . . . . 35,616,651      
12 Other unspent proceeds . . . . . . . . . . . 0      
13 Year of substantial completion . . . . . . . . . . . 2009
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . X              
15 Were the bonds issued as part of an advance refunding issue? . . . .   X            
16 Has the final allocation of proceeds been made? . . . . . . X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . X              
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . . X              
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2011
Schedule K (Form 990) 2011
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . X              
b If ‘Yes’ to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . X              
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . .   X            
d If ‘Yes’ to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0%   %   %   %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet 0%   %   %   %
6 Total of lines 4 and 5 . . .. . . . . . . . . 0%   %   %   %
7 Does the bond issue meet the private security or payment test? . . . X              
8 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
X              
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .   X            
2 Is the bond issue a variable rate issue?   X            
3a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X            
b Name of provider . . . . . . . . 0
  		 
  		 
  		 
 
c Term of hedge . . . . . . . .        
d Was the hedge superintegrated? . . . .                
e Was a hedge terminated? . . . . .                
4a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . .   X            
b Name of provider . . . . . . 0
  		 
  		 
  		 
 
c Term of GIC . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . . .                
5 Were any gross proceeds invested beyond an available temporary period? . . . . . . X              
6 Did the bond issue qualify for an exception to rebate? .   X            
7 Has the organization established written procedures to monitor the requirements of section 148? . . .   X            
Schedule K (Form 990) 2011

Schedule K (Form 990) 2011
Page 3
Part V
Procedures To Undertake Corrective Action
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? . . . . . . . . . . . . . .
Part VI
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
See Schedule O 0  
Schedule K (Form 990) 2011

Additional Data


Software ID:  
Software Version:  

Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
(1) DIGESTIVE SPECIALTY
LINE OF CREDIT 		  X 52,847 28,995   No Yes   Yes  
Total ...............Small Bullet $ 28,995
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Digestive Specialty Care >35% OWNED-ABBOUD (FORM.) 300,000 GASTROENTEROLOGY SERVICES   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

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

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
Identifier Return Reference Explanation
MISSION STATEMENT PART III, LINE 1 Upper Valley Medical Center, as a subsidiary of UVMC, serves as an integral part in achieving UVMC's mission: UVMC will strive to provide quality care that upholds the dignity of all individuals. Care will be given in a holistic manner without regard to race, religion, creed, national origin or social status. Our health care delivery system is structured to optimize the delivery of safe, efficient and cost-effective health care.
PROGRAM SERVICES PART III, LINE 4A Upper Valley Medical Center (UVMC) was founded in 1986 as the umbrella corporation for the merger of Miami County's three independent & competing hospitals. In 1998, acute care services were consolidated into a centrally located facility. Currently, the hospital is licensed for 139 acute care beds and 39 behavioral health beds. UVMC's vision is committed to preserving long-term access to quality health care services for Miami County and the surrounding area. Quality customer service is a priority at UVMC. Our culture is defined by "Caring Plus" which is UVMC's commitment to quality, kindness, and compassion for our patients, their families, visitors, physicians, and co-workers. It is an important part of the basic foundation of UVMC's patient-centered approach to care. UVMC also uses AIDET -- a powerful, proven communication tool designed to reinforce our Caring Plus customer service. AIDET is an acronym that represents how we can gain trust and communicate with patients who are nervous, anxious, and feeling vulnerable about their illness by remembering these key words: Acknowledge, Introduce, Duration, Explanation, and Thank-you. In January 2009, a joint operating agreement was implemented in which Upper Valley Medical Center became a part of the Premier Health Partners (PHP), a comprehensive health system serving southwestern Ohio through member and affiliate organizations in seven counties. The association with PHP, a not-for-profit corporation, allows for more flexibility in accessing specialty services not provided locally. It also gives local residents more access to community health services such as expanded wellness programs provided in conjunction with Premier Community Health and the CareFinders physician referral network. Upper Valley Medical Center is a member of PHP along with three other hospitals. Each hospital has the authority to determine the amounts it contributes to community building and other indigent programs. The policies for bad debts and charity collections are established by PHP. The hospital was granted tax exempt status as a hospital in February of 1935.
PROGRAM SERVICES - CONTINUED PART III, LINE 4A The primary exempt purpose of Upper Valley Medical Center is to provide comprehensive inpatient, outpatient, and emergency health care services to the residents of Miami and the surrounding counties. The hospital furthers its tax-exempt purpose by promoting the health of the community in many ways. Upper Valley Medical Center, as a subsidiary of UVMC, serves as an integral part in achieving UVMC's mission: UVMC will strive to provide quality care that upholds the dignity of all individuals. Care will be given in a holistic manner without regard to race, religion, creed, national origin or social status. Our health care delivery system is structured to optimize the delivery of safe, efficient, and cost-effective health care. As a part of the PHP system of providers, UVMC also shares the PHP mission of building healthier communities with others who share our commitment to provide high quality cost-competitive health care services. A principal financial contribution that Upper Valley Medical Center makes to the community is its provision of acute health care services to patients regardless of their ability to pay. The hospital operates a 24-hour emergency room 365 days per year that is open to all individuals. It also participates in government-sponsored health care programs such as Medicare, Medicaid, TRICARE, and has an active charity care program. The Board of Directors for Upper Valley Medical Center consists of 18 members of the community. The majority of them are neither employees nor contractors of the organization. No board member receives compensation from the organization for services provided in the role of board member. The Medical Center extends medical staff privileges to all qualified physicians in its community for the majority of its departments. The medical staff consists of 215 physicians and the health system continues to actively recruit new doctors to Miami County in important primary and specialty areas of medicine.
PROGRAM SERVICES - CONTINUED PART III, LINE 4A COMMUNITY BENEFIT APPROACH Upper Valley Medical Center is located between Troy and Piqua, Ohio and serves the northern Miami Valley area with acute care services, community health and wellness programs, and more. It is the sole hospital system operating within Miami County. The hospital also offers easy access to quality care by providing outpatient services throughout the Miami County area. Satellite locations provide Laboratory, Radiology, Surgical, Sports Medicine, Occupational Health, Dialysis, and Rehabilitative services. Upper Valley Medical Center also provided Home Health/Home Care visits to community residents in their homes for part of the year. 2011 operating statistics for Upper Valley Medical Center follow: Patient Days: -Acute Care (Excluding Newborns) 30,096 -Behavioral Health 8,282 Other Volume Indicators: -Laboratory Tests 571,308 -Radiology/Imaging Exams 110,554 -Cardiopulmonary Procedures 122,760 -Rehabilitation Services Visits 50,410 -Emergency Room Visits 42,693 -Occupational Health Procedures 35,387 -Cancer Care Visits 11,281 -Home Care Services Visits 12,097 -Dialysis Treatments 10,085 -Outpatient Surgeries 7,353 -Inpatient Surgeries 1,798 -Behavioral Health Outpatient Visits 9,876 -Births 689 Approximately 48% of the hospital's gross revenues are generated from Medicare patients, while another 19% of the revenues are generated from either uninsured patients or Medicaid recipients. The primary purpose of the UVMC Community Benefit Plan is to work toward improved health in the communities that we serve by responding to community needs with programs that increase access to health care. This is accomplished through identifying community needs, making prudent choices for the use of resources, building and strengthening relationships in the community, and demonstrating accountability and transparency. UVMC works with the community on programs that address the underlying causes of persistent health problems as part of a comprehensive strategy to improve the health status and quality of life for members of the community who may be economically disadvantaged, disenfranchised, and/or have disproportionate unmet health needs. UVMC strives to work with Premier Health Partners, the UVMC Board of Directors, executive management, managers, staff members, community groups, and individuals to provide a collaborative approach to the governance and management of community benefit activities.
PROGRAM SERVICES - CONTINUED PART III, LINE 4A COMMUNITY OUTREACH FOR THE BROADER COMMUNITY During 2011, thousands of individuals throughout Miami and surrounding counties benefited from Upper Valley Medical Center's health-focused programs, such as health fairs, screenings, immunizations, support groups, and other services. Many of these programs are free to the public or offered at a reduced price. Free presentations are available to area civic, service and social groups, professional organizations, schools, churches, and industries through the UVMC Speaker's Bureau. Speakers are available on a wide variety of medical/healthcare topics and are able to provide accurate, up-to-date information to the community. UVMC, along with other PHP hospitals, began Target Zero, an important safety initiative that ensures all staff members are committed to safety first in every aspect of their work. The outcome of this initiative is to create the safest environment for all patients, visitors, and employees with the goal of zero preventable accidents. This is achieved by a daily check-in, which is a 15-minute standup meeting, led by a senior executive and attended by directors/managers to identify any safety issues from the last shift or 24 hours. Upper Valley Medical Center participated in STate Action on Avoidable Readmissions (STAAR), a statewide initiative. The goal of the pilot project is to reduce costly, avoidable hospital readmissions by improving patient care and the transition from hospital care to home or extended care facility. In the spring of 2011, UVMC introduced Quiet Time in the patient care setting daily from 2:00 p.m. to 4:00 p.m. Among the goals of Quiet Time is to enhance the patient experience by reducing environmental stimuli and promoting patient rest and/or sleep during those hours. Evidence-based research suggests that this timeframe is when the body is most ready for rest due to natural lows in the body's circadian rhythm. Upper Valley Medical Center subsidizes the outpatient services for Behavioral Health. It provides traditional private outpatient therapy and medication management for adults, adolescents, and children. Clients include those who either have no insurance or qualify for Medicaid services. Also included in subsidized health services are revenues and expenses related to an obstetrics clinic which is subsidized by both the Miami County Health Department and Upper Valley Medical Center. The obstetrics clinic serves the prenatal, delivery, and postnatal medical needs of women in the hospital's Miami County service area who either have no medical insurance or qualify for Medicaid services. The net community benefit expense for 2011 was $322,000 for these services. UVMC increased support of the local Health Partners Free Clinic in the form of contributions totaling $61,000 as part of both organizations' common mission to assure access to needed health care services in our communities.
PROGRAM SERVICES - CONTINUED PART III, LINE 4A A Heart Month Health Fair was held in February. With heart disease being the leading cause of death for American adults, people should be aware of their risks. The event was open to the community and included free screenings for total cholesterol, HDL, blood sugar, as well as blood pressure testing. UVMC programs and Cardiology professionals also provided health testing and helpful information. The second Go Red for Women/North Expo was held at Edison Community College in September. The event was presented by UVMC in conjunction with the American Heart Association's "Go Red" initiatives focusing on promoting women's heart health. UVMC provided more than 300 free health tests/screenings and counseling. The keynote speaker used humor to emphasize the need for women to lighten up and get a handle on stress that surrounds them. Other activities at the event included mini-makeovers, hand/chair massages, heart healthy cooking demonstrations, and more. The annual McGraw Cancer Awareness Symposium was also held in September. The keynote speaker presented the topic "Genetics and Cancer: How Your Genes Influence Your Cancer Risk." The symposium also included a panel discussion. This event was sponsored by the UVMC Cancer Care Center and the UMVC Foundation along with a gift from the McGraw Family Fund of the Troy Foundation and support from Myriad Labs. The symposium was free and open to the public. The Nutrition Services Department encompasses all components of food production for patient meals, cafeteria services, vending foods, and internal catering. The clinical team of dietitians and diet technicians accommodate inpatient and outpatient as well as community nutrition therapy and education. Nutrition Services also prepares meals for the Altrusa Mobile Meals and Piqua Meals on Wheels programs. The number of meals prepared was 12,736 and 12,825 respectively. The hospital subsidizes these programs. People of different ages have the opportunity to contribute their time and skills to various departments within the hospital such as the gift shop, emergency services, escort services, surgical services, chaplaincy, reception, etc. During 2011, 180 UVMC volunteers provided over 28,000 hours of service throughout the hospital system. These volunteers generously give of their time to perform services that benefit our patients, visitors, and staff. The UVMC Auxiliary also sponsors an important community program called Lifeline, a low-cost medical alert service designed to reduce the risk of living alone. Lifeline began in 1985 with 25 clients and now serves over 500 clients in a seven county area. The hospital offers this program office and storage space. The Department of Pastoral Care has staff chaplains and community clergy volunteers who provide spiritual care at all UVMC facilities 24 hours a day. In addition, nondenominational worship services are provided for patients, their family members, visitors, and staff. There is no fee to patients for the services that the UVMC Pastoral Care staff provides. Teams from UVMC participated in the Miami County Relay for Life held in May. The event celebrates cancer survivorship, helps increase awareness of cancer prevention and treatment, and raises funds for important cancer research and programs. UVMC Center for Sports Medicine offers many services and programs throughout the year to the community. In February, it held its annual Symposium. The Sportsmetrics Knee Injury Reduction Program is designed to reduce the risk of injury and enhance performance for female athletes. Also, offered for the ninth year, was Explosive Speed & Power for local athletes who want to improve speed, agility, vertical jump, strength, and flexibility. These are just a few of the specialized programs that are offered.
PROGRAM SERVICES - CONTINUED Part III, Line 4a The caring professionals of Upper Valley Medical Center have shown their commitment to the needs of the community through the annual United Way Fund campaign for many years. Employees demonstrate their commitment to the community by contributing to the local chapters of the United Way Fund in order to benefit the many important services provided by local agencies. The 2011 fund drive brought in over $15,000 in contributions. Food pantries around the area reported an increase in requests. The Caring Plus Holiday Food Drive collected a record 657 food items for its annual event. Items were donated to the Bethany Center in Piqua and St. Patrick Soup Kitchen in Troy, both of which provide food and other assistance for those in need in our communities. The hospital offers interpreters, at no cost to the patient, to serve hearing-impaired or non-English speaking patients. EDUCATION Both the Ohio Board of Nursing and the Ohio Counselor/Social Worker Board approved Upper Valley Medical Center as a provider of continuing education credits. This distinction enables the Education and Development Department to meet its responsibility to assist in the maintenance and improvement of healthcare education. This is significant for those in search of opportunities to maintain and improve their professional skills and fulfill educational needs and requirements. The department coordinates education programs, provides resources, satellite teleconferences, and provides continuing education credits for a variety of disciplines. The scope of the department's services includes coordination of: Advanced Cardiac Life Support Education Fair Continuing Education In-Services CPR Nursing Orientation Education on managing diabetes is available for inpatients and outpatients who have the disease. This department also teaches community diabetes classes and coordinates a support group. The subsidy for offering all of the above programs was $426,000 in 2011. The Health Sciences Library, located on the Lower Level, is open to the public during normal business hours, or by making special arrangements with the librarian. A Health Education Center, adjacent to the Library, offers educational materials to help promote wellness and understanding about diseases. Information is available via computer, videos, and pamphlets. The subsidy for offering this service was $67,000 in 2011. EMS Education provides initial training and continuing education that local EMS providers require. First Responder is a 40-hour program designed to fit the needs of those who are often "first-on-the-scene", such as police officers and industrial health personnel. A 130-hour class provides the foundation for pre-hospital care for a basic Emergency Medical Technician. Refresher classes are also offered for EMS levels. This program was subsidized by the hospital in the amount of $96,000 in 2011. During 2011, Upper Valley Medical Center participated in the Project SEARCH program. This is a high school transition program, designed to provide training and education leading to employment for individuals with disabilities. Local Project SEARCH partners include UVMC, Upper Valley Career Center, Capabilities Inc., the Board of Developmental Disabilities in Miami and Shelby counties, and the state Bureau of Vocational Rehabilitation. RESEARCH PROGRAMS UVMC Cancer Care Center partners with the Dayton Clinical Oncology Program (DCOP). Clinical trials investigate cancer prevention and evaluate agents and drugs for the prevention of cancer. One type of study is a "chemo-prevention trial." This type of study is conducted by recruiting healthy, cancer-free individuals who are at risk for developing cancer. Chemo-prevention trials use medications, vitamins, and other substances which have been tested for preventing the development of a specific type of cancer. DCOP develops and investigates new drugs and new combinations of surgery, chemotherapy, and radiation treatments for cancer. UVMC is an active partner in these new treatment protocols. UVMC surgeons, oncologists, and radiation oncologists are active participants in DCOP trials both in patient recruitment and treatment. Our affiliation with DCOP provides cancer patients access to clinical trial protocols. As a result of this affiliation, our patients can receive the latest in cancer treatments and participate in clinical trials from several research bases such as NSABP Foundation, Southwest Oncology Group (SWOG), Radiation Therapy Oncology Group (RTOG), and M.D. Anderson Cancer Center. Through participation in clinical trials, cancer patients benefit from, as well as contribute to, how this disease is treated. AWARDS AND RECOGNITION UVMC has received many awards and recognitions that demonstrate our commitment to excellence, to our patients, and to our employees. The Department of Health and Human Services, Centers for Medicare & Medicaid Services issued a preview performance score report for the UVMC Dialysis Unit. The purpose of the End Stage Renal Disease Quality Incentive report is to improve patient care by setting quality of care performance standards. Facilities failing to meet the quality of care performance standards may be subject to a payment reduction of up to two percent. The UVMC Dialysis Unit total performance score was 30 out of 30 possible points, meaning the unit will not incur any payment reduction in the next year. GROWTH AND ENHANCEMENTS Upper Valley Medical Center invested over $16 million in important technological advancements to enhance the range of services offered. Highlights include: Implementation of EPIC (Electronic Medical Record) Expansion of Cancer Care Center Purchase of equipment such as CT Scanner and Hemodialysis Machines Renovation of Emergency Department for Behavioral Health Assessments Upgrades to Information Systems. See Schedule H for more information.
DID THE ORGANIZATION HAVE MEMBERS OR STOCKHOLDERS? PART VI, QUESTION 6 Upper Valley Medical Center has two members. One member is UVMC, the parent company of the hospital. The second member is Premier Health Partners, an Ohio nonprofit corporation, formed pursuant to the Joint Operating Agreement. UVMC has the sole authority to elect the Board of Trustees of the corporation. Premier Health Partners has the general authority to operate and manage the operations of the Premier Health Partners activities of the corporation.
MEMBERS/STOCKHOLDERS WHO MAY ELECT GOVERNING BODY MEMBERS PART VI, QUESTION 7A UVMC has the sole authority to elect the board of trustees for Upper Valley Medical Center (hospital.) UVMC has the authority to remove trustees at any regular or special board meeting or by written consent. In addition to removal by UVMC, a trustee may be removed from office with approval by UVMC, by the affirmative vote of not less than two-thirds of the entire board of trustees. Premier Health Partners (PHP) has the right to request that UVMC remove a trustee of the corporation if PHP has determined that such trustee is frustrating the goals and purposes of the Premier Health Partners network. Such request shall not be unreasonably refused by UVMC.
APPROVAL OF GOVERNING BODY DECISIONS PART VI, QUESTION 7B Premier Health Partners (PHP) develops and oversees the implementation of the strategic plan for Upper Valley Medical Center (hospital), which addresses such matters as location of clinical and administrative services and the consolidation of such services. Hospital shall comply with and implement this plan and shall not take any action that materially departs from this plan without PHP approval. Hospital develops and submits an annual capital and operating budget to PHP for approval. Hospital shall adopt and implement the capital and operating budget so approved and/or revised for it by PHP. Hospital periodically develops and submits a business plan to PHP for approval. Hospital shall implement the business plan approved by PHP. PHP is the sole agent to negotiate all relationships with payors on behalf of hospital with all third party payors and alternative delivery systems including, but not limited to insurers. Hospital must have approval from PHP to borrow in any fiscal year, guarantee in any year, or incur any lien or other encumbrance on any property in an amount equal to or greater than $500,000. Hospital must seek PHP approval for any acquisitions, sale or transfer of any material asset used in PHP activities.
REVIEW OF FORM 990 PART VI, SECTION B, LINE 11B The 990 tax return and attached schedules are prepared by staff members of the UVMC Finance department. Draft returns are reviewed by the Budget and Reimbursement Manager, Controller and Chief Financial Officer. After revisions are made, the draft returns are sent to Ernst & Young (E&Y) for review and evaluation. Review notes are made available by E&Y, changes are made, and then the returns are reviewed again by the finance management team. An electronic version of the return is provided to the UVMC Board of Directors at least one week prior to the board meeting. At that meeting, the Chief Financial Officer of UVMC presents detailed information on compensation and community benefits, as well as addresses questions from the board. The board then approves the return and associated schedules for filing. In addition, an electronic version is sent out at least one week prior to the Premier Health Partners (PHP) audit committee meeting. At the meeting, the Vice President/Controller of PHP shares detailed information on compensation and community benefits, as well as addresses any questions from the committee. The Audit Committee then approves the return and schedules for filing.
CONFLICTS OF INTEREST PROCESS PART VI, LINE 12C Premier Health Partners (PHP), of which Upper Valley Medical Center is included, requires all board members, officers, executives and management personnel to annually review the PHP Comprehensive Conflict of Interest Statement, an explanatory memorandum, the Antitrust Compliance Policy and complete an individual questionnaire disclosing any potential conflicts as defined in the Conflicts of Interest Policy. This is accomplished with a memo sent out annually from the Chairman of the Board and Chief Executive Officer of PHP to all board members, executive directors, management directors and above personnel, purchasing department staff and authorized purchasers. It also includes an explanatory memorandum of specific activities that might give cause to a conflict and an individual questionnaire to disclose all such activities. This questionnaire must be completed and signed by the individual. Last, this memo includes a copy of the Antitrust Compliance Policy that must be signed by the individual. All of these documents are sent to the Corporate Compliance Officer. The Corporate Compliance Department ensures all forms are returned and retains the documents for five years. In addition, at each meeting of the Board or any Board committee, following approval of the minutes, the Board Committee Chair shall request any board member who perceives a potential conflict of interest on any of the meeting's agenda items to disclose such conflict. Additionally, any Board or Board Committee meeting where the subject of conflicts of interest is discussed, the normally taken minutes shall contain the name of the party discussing a potential conflict of interest, the nature of the potential conflict of interest and whether a conflict of interest was found to exist. If a conflict of interest does exist, the board member will be excused from participating in any discussion or voting on the particular agenda item. The Corporate Compliance Officer reports the results of the PHP Conflicts of Interest questionnaires no less than annually to the Board of Trustees by way of the Compliance and Audit Committee. This review is documented in the minutes of the meeting. Periodically, the Internal Audit department will review a sample of completed Conflict of Interest questionnaires and report the results to the Compliance and Audit Committee. The annual conflicts of interest questionnaires are summarized by person in a word document and sent electronically to the Finance department for any necessary disclosures required on the 990 tax return.
OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN PART VI, SECTION B, LINE 15A & 15B Premier Health Partners, of which UVMC is a part, follows a market-based compensation philosophy designed to attract and retain the executive talent required to meet the high performance standards of our board and our community. PHP annually reviews executive compensation survey data for a regional peer group of systems and hospitals that are similar in size and complexity to PHP and its subsidiaries. The data for the survey is provided by a third party consultant group that is independent of PHP. The report includes comparability for key executives, vice presidents and director level positions. The independent comparability data is reviewed by the executive compensation committee on an annual basis. This committee is comprised of three members, all of which are independent. This committee reviews in detail the compensation for the PHP CEO, COO, CFO, Chief Strategy Officer and the hospital CEOs. Other positions are reviewed at a high level for reasonableness. All the meeting minutes are documented and kept on file along with any comparability data and the consultant report. After the compensation committee reviews and approves the compensation actions, the process is audited by the internal audit department. The executive compensation committee presents the compensation actions to the PHP board annually.
AVAILABILITY OF DOCUMENTS PART VI, LINE 19 The governing documents, conflict of interest policy, and financial statements are made available to the public when required by law or for accreditation purposes.
Other Changes in Net Assets Part XI, Line 5 Pension Adjustment (12,690,391) Net Transfers with Affiliates (8,787,781) Unrealized Gain/(Loss) on Investments (907,395) Amortization of Investment Premiums/Discounts (383,222) Change in Foundation General Funds (184,915) Change in Foundation Restricted Funds 86,550 Change in Foundation Endowment Funds 15,861 Change in Temporarily Restricted Funds (1,723) Other Changes 26,990 Total (22,826,026)
Supplemental Information on Tax-Exempt Bonds Schedule K Schedule K, Part I, Line A, Column F - Purpose of Bond The bond issue of 06/29/2006 was used to currently refund the 1996A, 1996B and 1996C series bonds and to provide capital for hospital improvements and equipment purchases. Schedule K, Part II, Line 3 - Total Proceeds of Issue Includes sale proceeds of $57,502,248 plus $1,473,860 earnings on Debt Service Reserve Fund and $2,133,141 earnings on Project Fund. Schedule K, Part II, Line 11 - Other Spent Proceeds Includes $34,109,391 sale proceeds used to currently refund the 1996A, 1996B and 1996C bonds and $1,507,260 of earnings on the Debt Service Reserve Fund used to pay debt service on the 2006 series bonds. Schedule K, Part IV, Line 1 - Arbitrage An arbitrage rebate calculation and a yield restriction calculation were performed by a rebate analyst and it was determined that no arbitrage rebate or yield restriction liability were owed. Therefore, Form 8038-T was not required to be filed. Schedule K, Part IV, Line 5 - Gross Proceeds Invested Beyond an Available Temporary Period A portion of the proceeds received from the sale of the 2006 series bonds, and the earnings thereon, which were held in the Project Fund were not expended prior to June 29, 2009, the end of the three-year temporary period described in Treas. Reg. 1.148-2(e)(2). Those amounts were fully spent as of December 24, 2009. A yield restriction calculation was performed by a rebate analyst on the five-year anniversary date of the issuance of the 2006 series bonds and it was determined that no yield reduction payments were owed. Schedule K, Part V - Procedures To Undertake Corrective Action While the organization does not have written procedures, the organization does have procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations.
AVERAGE HOURS PER WEEK PART VII, SECTION A, COLUMN B HOURS REPORTED FOR OFFICERS ARE SPREAD AMONG THE ENTITIES LISTED IN SCHEDULE R, PARTS II AND IV. HOURS REPORTED FOR VICE PRESIDENTS OF PREMIER HEALTH PARTNERS (PHP) ARE SPREAD AMONG THE FOUR HOSPITALS IN PHP OF WHICH UPPER VALLEY MEDICAL CENTER IS A PART.
Statement Pertaining to Form 5471:   UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(a) AND (b), THE TAXPAYER IS REQUIRED TO FILE FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, AS A CATEGORY 5 FILER WITH RESPECT TO CERTAIN CONTROLLED FOREIGN CORPORATIONS (CFCs). THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 5471 FOR THESE CFCs BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. Samaritan Health Partners 110 North Main St, Suite 500 Dayton, OH 45402 EIN: 31-1107411 THE FILING ORGANIZATION, UPPER VALLEY MEDICAL CENTER, IS NOT FILING A SEPARATE FORM 5471 - SCHEDULE I BECAUSE IT HAS NO INCOME FROM THE FOREIGN CORPORATION.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


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

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Upper Valley Medical Center
 
Employer identification number

31-0537095
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
Yes No
(1) UVMC

3130 NORTH COUNTY ROAD 25A

TROY,OH45373
34-1850683 		PARENT OH 501(c)(3) 11, I NA
 
 
No
(2) UVMC Foundation

3130 North County Road 25A

Troy,OH45373
31-1581859 		Foundation OH 501(c)(3) 11, III-O NA
 
 
No
(3) Miami County Mental Health Center

3130 North County Road 25A

Troy,OH45373
26-0841036 		MENTAL HEALTH OH 501(c)(3) 9 UVMC
 
Yes
 
(4) Med-Terra Inc

3130 North County Road 25A

Troy,OH45373
31-1232074 		HOLDING CO OH 501(c)(2) N/A UVMC
 
Yes
 
(5) Premier Health Partners

40 West Fourth Street

Dayton,OH45402
31-1446699 		JOA Parent OH 501(c)(3) 11, I NA
 
 
No
(6) Upper Valley Professional Corporation

3130 North County Road 25A

Troy,OH45373
31-1400963 		Health Care OH 501(c)(3) 9 UVMC
 
Yes
 
(7) UVPC Specialists Inc

3130 North County Road 25A

Troy,OH45373
20-3687536 		Health Care OH 501(c)(3) 9 UVPC
 
Yes
 
(8) UVMC NURSING CARE INC

3130 NORTH COUNTY ROAD 25A

TROY,OH45373
31-1224064 		NURSING HOME OH 501(c)(3) 9 UVMC
 
Yes
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No












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



 		(b)
Primary activity



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


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

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) UVMC MANAGEMENT CORPORATION
3130 NORTH COUNTY ROAD 25A
TROY,OH45373
31-1360489 		MGT COMPANY OH UVMC
  		C CORP      
(2) After Hours Family Care Inc
31 Stanfield Rd
Troy,OH45373
31-1269483 		Health Care OH UVPC
  		C Corp      










Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
Yes
 
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) Med-Terra Inc

 a (iv 2,085 FMV
(2) Med-Terra Inc

 b 1,800,000 Cash
(3) Med-Terra Inc

 f 1,653,400 FMV
(4) Med-Terra Inc

 j 767,515 FMV
(5) Med-Terra Inc

 o 235,878 CASH
(6) Med-Terra Inc

 p 212,880 FMV
(7) UVMC Nursing Care Inc

 P 57,771 fmv
(8) Upper Valley Professional Corporation

 a(iv) 16,000 FMV
(9) Upper Valley Professional Corporation

 b 7,100,000 Cash
(10) Upper Valley Professional Corporation

 e 3,650,000 Cash
(11) Upper Valley Professional Corporation

 p 1,688,144 FMV
(12) Upper Valley Professional Corporation

 q 303,452 Cash
(13) Upper Valley Professional Corporation

 r 1,750,000 Cash
(14) UVPC Specialists Inc

 l 104,000 FMV
(15) UVPC Specialists Inc

 p 67,210 FMV
(16) UVMC

 c 61,000 CASH
(17) Miami County Mental Health Center

 a(iv) 5,770 FMV
(18) Miami County Mental Health Center

 l 161,023 FMV
(19) Miami County Mental Health Center

 p 57,061 pmv
(20) UVMC Management Corporation

 l 683,785 fmv
(21) UVMC Management Corporation

 r 54,923 cash
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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