TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) BAREFOOTSAMUAL TRUSTEE	2.00	X		0	0	0
(2) CARROLLJOE TRUSTEE	2.00	X		0	0	0
(3) COLONNADAVID TRUSTEE	2.00	X		0	10,500	0
(4) EDWARDSJOEL LYNN TRUSTEE	2.00	X		414,293	0	49,527
(5) EGGERSGERALD TRUSTEE	2.00	X		0	0	0
(6) ELYJOSEPH SEC	2.00	X	X	0	0	0
(7) FORIESTBRYANT TRUSTEE	2.00	X		0	0	0
(8) FULLERSTANLEY BRIAN TRUSTEE	2.00	X		0	419,851	41,829
(9) GREENGARY TREASURER	2.00	X	X	0	0	0
(10) HAULSEEHADA EE VARONA VICE CHAIR	2.00	X	X	0	0	0
(11) JOHNSONJOIA TRUSTEE	2.00	X		0	0	0
(12) JONESBRUCE TRUSTEE	2.00	X		0	0	0
(13) LAMBECLARENCE TRUSTEE	2.00	X		0	0	0
(14) LEAVITTROBERT TRUSTEE	2.00	X		0	0	0
(15) LOGANJOSEPH TRUSTEE	2.00	X		0	0	0
(16) MCNEIL-MILLERKAREN CHAIR	2.00	X	X	0	0	0
(17) POLLARDHAROLD TRUSTEE	2.00	X		0	0	0

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) POLONSKYSHERRY TRUSTEE	2.00	X					0	0	0
(19) REAVESDONALD TRUSTEE	2.00	X					0	0	0
(20) WOLFE IIIJOHN TRUSTEE	2.00	X					0	0	0
(21) LINDSAYJEFFERY T PRESIDENT FMC/COO WS MARKET	60.00		X				757,410	0	352,308
(22) MCGEELAWRENCE UPCHURCH SVP & GC	2.00		X				0	1,088,209	423,765
(23) MORRISJOHN BENTON ASST SEC	2.00		X				0	277,977	35,153
(24) ALLENJOANNE PRES-KVILLE	60.00			X			207,683	0	23,483
(25) HAMMESPAUL H SVP & COO FMC	60.00			X			476,027	0	44,491
(26) WALLEYBRUCE DOUGLAS SVP MED AFFRS	60.00			X			460,555	0	13,381
(27) BRAVOJULIO R RHEUMATOLOGIST	40.00				X		498,779	0	44,354
(28) CANNONTHOMAS B FAMILY PRACTITIONER	40.00				X		464,265	0	63,972
(29) CHASECHERE MONIQUE MEDICAL DIRECTOR	40.00				X		503,865	0	27,298
(30) EBERLEROBERT A INTERNIST	40.00				X		467,927	0	47,972
(31) STURGILLWILLIAM H DERMATOLOGIST	40.00				X		466,529	0	42,948
(32) ALLENELMS LEACH FORMER SVP MED AFFRS	0.00					X	284,398	0	26,795

(A) Name and business address	(B) Description of services	(C) Compensation
MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA,GA30368	FOOD SERVICE	6,467,291
NURSEFINDERS INC PO BOX 910738 DALLAS,TX75391	STAFFING	5,520,854
AMERICAN RED CROSS PO 905890 CHARLOTTE,NC28290	BLOOD PROCESSING	4,390,536
LABORATORY CORPORATION OF AMERICA PO BOX 12140 BURLINGTON,NC27216	LAB SERVICES	3,150,737
PIEDMONT TRIAD ANESTHESIA PO BOX 602365 CHARLOTTE,NC28260	ANESTHESIA SERVICES	2,830,589
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 76

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	265,060	265,060
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	107,714	107,714
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	2,991,927		2,991,927
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	339,058,603	326,106,564	12,952,039
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	16,437,506	15,809,593	627,913
9	Other employee benefits .......	43,559,352	41,895,385	1,663,967
10	Payroll taxes ...........	23,054,258	22,173,585	880,673
11	Fees for services (non-employees):
a	Management ......	179,313		179,313
b	Legal .........	297		297
c	Accounting ...........	3,150		3,150
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......
g	Other ..........	51,669,673	42,827,996	8,841,677
12	Advertising and promotion ....	4,654,489	4,476,688	177,801
13	Office expenses .......	5,852,682	5,629,110	223,572
14	Information technology ......	6,440,453	6,194,428	246,025
15	Royalties ..	5,269	5,068	201
16	Occupancy ...........	30,326,092	29,167,635	1,158,457
17	Travel ............	417,343	401,400	15,943
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....	551,559	530,489	21,070
20	Interest ...........	16,320,498	15,697,055	623,443
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	22,494,927	21,635,621	859,306
23	Insurance ..............	1,680,250	1,616,064	64,186
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	CORPORATE ALLOCATION	107,614,747		107,614,747
b	MEDICAL SUPPLIES	94,851,393	94,851,393
c	DRUGS	79,491,551	79,491,551
d	INCOME TAXES	62,933		62,933
e
f	All other expenses	54,682,214	53,806,136	876,078
25	Total functional expenses. Add lines 1 through 24f	902,773,253	762,688,535	140,084,718	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	2,350,739	1	3,529,739
2	Savings and temporary cash investments .......		2
3	Pledges and grants receivable, net .........	230,565	3	167,577
4	Accounts receivable, net .........	125,995,888	4	98,613,263
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........	47,685	5	30,685
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............	6,556,006	7	7,792,203
8	Inventories for sale or use ..............	11,035,044	8	14,946,588
9	Prepaid expenses and deferred charges ............	1,084,525	9	368,711
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	370,511,852
b	Less: accumulated depreciation. .....	10b	214,086,433	77,148,221	10c	156,425,419
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........	29,563,796	14	31,510,968
15	Other assets. See Part IV, line 11 ...........	596,822,061	15	575,740,529
16	Total assets. Add lines 1 through 15 (must equal line 34)...	850,834,530	16	889,125,682
	17	Accounts payable and accrued expenses .	43,941,007	17	38,342,075
18	Grants payable ..........		18
19	Deferred revenue ..........	191,829	19	189,281
20	Tax-exempt bond liabilities ..........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	5,409,069	25	7,720,048
26	Total liabilities. Add lines 17 through 25.....	49,541,905	26	46,251,404
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	801,292,625	27	842,874,278
28	Temporarily restricted net assets .....		28
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	801,292,625	33	842,874,278
34	Total liabilities and net assets/fund balances .....	850,834,530	34	889,125,682

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Other

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2011

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2011

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2011

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2011

Name of organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

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

Page 2

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

Page 3

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

Page 4

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

Name of organization
FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part III

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

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below.
SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

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

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

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

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

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

2a	Lobbying non-taxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

68,388

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

68,388

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Identifier	Return Reference	Explanation
PART IV, SUPPLEMENTAL INFORMATION:		SCHEDULE C, PART II-B, LINE 1I DUES PAID TO CERTAIN ORGANIZATIONS WHICH INCLUDE A PORTION RELATED TO LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2011

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	4,082,278		4,082,278
b	Buildings ................	73,660,088	2,451,212	71,208,876
c	Leasehold improvements ............	9,634,929	5,887,380	3,747,549
d	Equipment ................	272,812,936	205,495,368	67,317,568
e	Other .................	10,321,621	252,473	10,069,148
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				156,425,419

Schedule D (Form 990) 2011

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value
(1) DUE FROM AFFILIATES				575,671,064
(2) INCOME TAX RECEIVABLE				69,465







Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				575,740,529

Part X

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

1.(a) Description of Liability		(b) Book value
Federal Income Taxes		0
CAPITAL LEASE PAYABLE		224,344
THIRD PARTY PAYABLE		7,495,704







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		7,720,048
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2011

Page 4

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

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

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

Part XIV

Supplemental Information

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

Identifier	Return Reference	Explanation
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:	PART X:	LIABILITY UNDER FIN 48 (ASC 740) FOOTNOTE THE AUDIT FOR NOVANT HEALTH AND ITS AFFILIATES IS PREPARED ON A CONSOLIDATED BASIS. THE COMPANY WAS REQUIRED TO EVALUATE UNCERTAIN TAX POSITIONS. THIS EVALUATION INCLUDES A QUANTIFICATION OF TAX RISK IN AREAS SUCH AS UNRELATED BUSINESS TAXABLE INCOME AND THE TAXATION OF OUR FOR-PROFIT SUBSIDIARIES. THIS EVALUATION DID NOT HAVE A MATERIAL EFFECT ON THE COMPANY'S STATEMENT OF OPERATIONS FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010.

Schedule D (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other 30000.0000000000 %

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: ............

200% 250% 300% 350% 400% Other

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

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

Yes

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

Yes

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

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Financial Assistance at cost (from Worksheet 1) ..	33,858,393	0	33,858,393	3.750 %
b Medicaid (from Worksheet 3, column a) .....	85,980,574	56,472,700	29,507,874	3.270 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .	9,288,255	6,092,030	3,196,225	0.350 %
dTotal Financial Assistance and Means-Tested Government Programs .....	129,127,222	62,564,730	66,562,492	7.370 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	13,896,288	1,728,074	12,168,214	1.350 %
f Health professions education (from Worksheet 5) ..	1,461,062	871,585	589,477	0.070 %
g Subsidized health services (from Worksheet 6) ..	37,331,212	28,729,811	8,601,401	0.950 %
h Research (from Worksheet 7)	649,382	0	649,382	0.070 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	372,774	0	372,774	0.040 %
jTotal Other Benefits ...	53,710,718	31,329,470	22,381,248	2.480 %
kTotal. Add lines 7d and 7j. ..	182,837,940	93,894,200	88,943,740	9.850 %

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

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

31,748,242

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

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

Section B. Medicare

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

167,011,768

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

190,392,325

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

-23,380,557

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Part IV

Management Companies and Joint Ventures

(see instructions)

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

Schedule H (Form 990) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?2 Name and address		Other (Describe)
1	FORSYTH MEMORIAL HOSPITAL INC 3333 SILAS CREEK PARKWAY WINSTON SALEM,NC27103	X	X	X
2	FMH DBA KERNERSVILLE MEDICAL CENTER 1750 KERNERSVILLE MEDICAL PARKWAY KERNERSVILLE,NC27284	X	X	X

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

FORSYTH MEMORIAL HOSPITAL INC

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: 300.000000000000% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

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

Schedule H (Form 990) 2011

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

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)

FMH DBA KERNERSVILLE MEDICAL CENTER

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):2

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 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: 300.000000000000% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

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

Schedule H (Form 990) 2011

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

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?52
Name and address		Type of Facility (describe)
1	WINSTON-SALEM HEALTH CARE 250 CHARLOIS BOULEVARD WINSTON SALEM,NC27103	PHYSICIAN CLINIC
2	FMCIMAPLEWOOD 3155 MAPLEWOOD AVENUE WINSTON SALEM,NC27103	IMAGING CENTER
3	FMCIBREAST CLINIC 2025 FRONTIS PLAZA BLVD SUITE 300 WINSTON SALEM,NC27103	IMAGING CENTER
4	MAPLEWOOD FAMILY PRACTICE ROBINHOOD MEDICAL PLAZA BLDG 100 WINSTON SALEM,NC27106	PHYSICIAN CLINIC
5	INPATIENT PHYSICIANS OF FORSYTH 3333 SILAS CREEK PARKWAY WINSTON SALEM,NC27103	PHYSICIAN CLINIC
6	FMCIWSHC RADIOLOGY 250 CHARLOIS BOULEVARD WINSTON SALEM,NC27103	IMAGING CENTER
7	SALEM FAMILY PRACTICE 105 VEST MILL CIRCLE WINSTON SALEM,NC27103	PHYSICIAN CLINIC
8	FORSYTH INTERNAL MEDICINE 1381 WESTGATE CENTER DRIVE WINSTON SALEM,NC27103	PHYSICIAN CLINIC
9	MOUNTAINVIEW MEDICAL 216 MOORE ROAD KING,NC27021	PHYSICIAN CLINIC
10	KERNERSVILLE FAMILY PRACTICE 291 BROAD STREET KERNERSVILLE,NC27284	PHYSICIAN CLINIC
11	FMCIKERNERSVILLE IMAGING CENTER 445 PINEVIEW DRIVE SUITE 100 KERNERSVILLE,NC27284	IMAGING CENTER
12	MEDICAL ASSOCIATES OF SURRY 865 WESTLAKE DRIVE MOUNT AIRY,NC27030	PHYSICIAN CLINIC
13	MEDICAL ASSOCIATES OF DAVIE 485 VALLEY ROAD MOCKSVILLE,NC27028	PHYSICIAN CLINIC
14	PHOA KERNERSVILLE 445 PINEVIEW DRIVE KERNERSVILLE,NC27284	PHYSICIAN CLINIC
15	CHAIR CITY FAMILY PRACTICEMEDZONE 903 RANDOLPH STREET THOMASVILLE,NC27360	PHYSICIAN CLINIC
16	UROLOGY PARTNERS 180 KIMEL PARK DRIVE SUITE 110 WINSTON SALEM,NC27103	PHYSICIAN CLINIC
17	PHOA LEXINGTON 1370 PIEDMONT DRIVE SUITE 202 LEXINGTON,NC272952053	PHYSICIAN CLINIC
18	PHOA MT AIRY 865 WEST LAKE DRIVE MT AIRY,NC270302157	PHYSICIAN CLINIC
19	YADKIN MEDICAL ASSOCIATES 305 EAST LEE AVENUE YADKINVILLE,NC27055	PHYSICIAN CLINIC
20	PREMIER MEDICAL ASSOCIATES 3333 BROOKVIEW HILLS BLVD STE 204 WINSTON SALEM,NC27103	PHYSICIAN CLINIC
21	FAMILY MEDICAL ASSO OF LEWISVILLE 1225 LEWISVILLE-CLEMMONS ROAD LEWISVILLE,NC27023	PHYSICIAN CLINIC
22	THOMASVILLE MEDICAL ASSOCIATES 309 PINEYWOOD ROAD THOMASVILLE,NC27360	PHYSICIAN CLINIC
23	KING HEALTHCARE PHARMACY 212 MOORE ROAD KING,NC27021	PHARMACY
24	WINSTON-SALEM HEALTH CARE DERMATOLOGY 175 KIMEL PARK DRIVE WINSTON SALEM,NC27103	PHYSICIAN CLINIC
25	FORSYTH ENDOCRINE CONSULTANTS 755 HIGHLAND OAKS DRIVE SUITE 201 WINSTON SALEM,NC27103	PHYSICIAN CLINIC
26	FORSYTH HEALTHCARE PHARMACY 3333 SILAS CREEK PARKWAY WINSTON SALEM,NC27103	PHARMACY
27	CLEMMONS FAMILY PRACTICE 6301 STADIUM DRIVE CLEMMONS,NC27012	PHYSICIAN CLINIC
28	ARCADIA FAMILY PRACTICE 12208 HWY 150 NORTH WINSTON SALEM,NC27127	PHYSICIAN CLINIC
29	NORTH POINT MEDICAL ASSOCIATES 1995 BETHABARA ROAD WINSTON SALEM,NC27106	PHYSICIAN CLINIC
30	INFECTIOUS DISEASE SPECIALISTS 1381 WESTGATE CENTER DRIVE WINSTON SALEM,NC27103	PHYSICIAN CLINIC
31	RHEUMATOLOGY & ARTHRITIS ASSOCIATES 1995 BETHABARA ROAD WINSTON SALEM,NC27106	PHYSICIAN CLINIC
32	MAPLEWOOD FAMILY PRACTICE 5110 ROBINHOOD VILLAGE DRIVE STE C-1 WINSTON SALEM,NC27106	PHYSICIAN CLINIC
33	WEST FORSYTH FAMILY MEDICINE 105 STADIUM OAKS DRIVE CLEMMONS,NC27012	PHYSICIAN CLINIC
34	NEW GARDEN MEDICAL ASSOCIATES 1941 NEW GARDEN ROAD GREENSBORO,NC27410	PHYSICIAN CLINIC
35	GATEWAY FAMILY PRACTICE 390 SALEM AVENUE WINSTON SALEM,NC27101	PHYSICIAN CLINIC
36	FORSYTH INTERNAL MEDICINE K'VILLE 445 PINEVIEW DRIVE SUITE 240 KERNERSVILLE,NC27284	PHYSICIAN CLINIC
37	SALEM HEALTHCARE PHARMACY 105 VEST MILL CIRCLE WINSTON SALEM,NC27103	PHARMACY
38	PILOT MOUNTAIN FAMILY MEDICINE 207 MEDICAL STREET PILOT MOUNTAIN,NC27041	PHYSICIAN CLINIC
39	WINSTON-SALEM HEALTH CARE PSYCHIATRY 280 CHARLOIS BOULEVARD WINSTON SALEM,NC27103	PHYSICIAN CLINIC
40	PHOA ELKIN 505 SAMARITANS RIDGE COURT ELKIN,NC28621	PHYSICIAN CLINIC
41	INPATIENT PHYSICIANS OF DAVIDSON 207 OLD LEXINGTON ROAD THOMASVILLE,NC27360	PHYSICIAN CLINIC
42	MEDICAL ASSOCIATES OF DAVIE HILLSDALE 121 MEDICAL DRIVE ADVANCE,NC27006	PHYSICIAN CLINIC
43	FORSYTH COMPREHENSIVE NEUROLOGY 2025 FRONTIS PLAZA BLVD STE 120 WINSTON SALEM,NC27103	PHYSICIAN CLINIC
44	PALLIATIVE CARE SERVICES 3333 SILAS CREEK PARKWAY WINSTON SALEM,NC27103	PHYSICIAN CLINIC
45	PHOA STATESVILLE 276 OLD MOCKSVILLE ROAD STATESVILLE,NC286251949	PHYSICIAN CLINIC
46	LEXINGTON PRIMARY CARE 110 WEST MEDICAL PARK DRIVE LEXINGTON,NC272926773	PHYSICIAN CLINIC
47	FOOTHILLS FAMILY MEDICINE 600 CHATHAM MEDICAL PARK ELKIN,NC28621	PHYSICIAN CLINIC
48	TRIAD ENDOCRINE CONSULTANTS 500 PINEVIEW DRIVE SUITE 101 KERNERSVILLE,NC27284	PHYSICIAN CLINIC
49	STROKE BRIDGE CLINIC 3333 SILAS CREEK PARKWAY WINSTON SALEM,NC27103	PHYSICIAN CLINIC
50	WINSTON SALEM CARDIOLOGY 186 KIMEL PARK DRIVE WINSTON SALEM,NC27103	PHYSICIAN CLINIC
51	WALKERTOWN FAMILY PRACTICE 2800 DARROW ROAD WALKERTOWN,NC27051	PHYSICIAN CLINIC
52	FRIEDBERG FAMILY MEDICINE 5010 PETERS CREEK PARKWAY WINSTON SALEM,NC27127	PHYSICIAN CLINIC

Schedule H (Form 990) 2011

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

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

Identifier	ReturnReference	Explanation
		PART I, LINE 3C: ALL UNINSURED PATIENTS RECEIVE A STANDARD DISCOUNT REGARDLESS OF THEIR ABILITY TO PAY. THIS DISCOUNT MIRRORS OUR AVERAGE MANAGED CARE RATE. PATIENTS BELOW 300% OF THE FEDERAL POVERTY GUIDELINES ARE DISCOUNTED AT 100% (3A: FREE CARE). OTHER PATIENTS MAY ALSO BE ELIGIBLE FOR DISCOUNTS FOR BALANCES ABOVE $5,000 (CATASTROPHIC DISCOUNT).
		PART I, LINE 6A: THE ORGANIZATION IS PART OF THE NOVANT HEALTH CARE SYSTEM AND THE COMMUNITY BENEFIT REPORT IS PREPARED BY A RELATED ORGANIZATION. NOVANT HEALTH, INC. PRODUCES ITS OWN COMMUNITY BENEFIT REPORT, WHICH REPRESENTS THE HEALTH SYSTEM AS A WHOLE AND CAN BE FOUND ATHTTP://WWW.NOVANTHEALTH.ORG/GIVEBACK/COMMUNITYBENEFITREPORT.ASPX.PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES.
		PART I, LINE 7: COSTS REPORTED IN THE TABLE OF CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AMOUNTS ARE CALCULATED USING AN ENTITY SPECIFIC COST TO CHARGE RATIO BASED ON WORKSHEET 2 (RCC).
		PART I, L7 COL(F): THE AMOUNT OF BAD DEBT REMOVED FROM TOTAL EXPENSES (DENOMINATOR) WAS $31,748,242.
		PART II: ALTHOUGH PART II FOR SCHEDULE H HAS BEEN LEFT BLANK, THE ORGANIZATION DOES ENGAGE IN MANY COMMUNITY BUILDING ACTIVITIES, WHICH SUPPORT AND STRENGTHEN THE COMMUNITY IT SERVES. THESE ACTIVITIES ARE IMPORTANT TO THE ORGANIZATION'S MISSION TO IMPROVE THE HEALTH OF THE COMMUNITY. HOWEVER, THE ORGANIZATION HAS NOT TRADITIONALLY MAINTAINED AN INFRASTRUCTURE TO TRACK, MONITOR AND REPORT THESE ACTIVITIES. THE ORGANIZATION IS PART OF THE NOVANT HEALTH CARE SYSTEM, WHICH HAS A COMMUNITY BENEFIT COMMITTEE. THE COMMUNITY BENEFIT COMMITTEE IS CURRENTLY IN THE PROCESS OF ESTABLISHING THE APPROPRIATE INTERNAL MECHANISMS TO TRACK, MONITOR AND REPORT THESE ACTIVITIES. THE ORGANIZATION IS COMMITTED TO CONTINUING TO PROVIDE THE COMMUNITY BUILDING ACTIVITIES NECESSARY TO MAINTAIN A HEALTHY, PRODUCTIVE AND VIABLE COMMUNITY.
		PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE (AT COST) ON LINE 2 IS CALCULATED USING THE SAME METHODOLOGY AS CHARITY CARE AND OTHER COMMUNITY BENEFITS USING AN ENTITY SPECIFIC COST TO CHARGE RATIO (RCC).BAD DEBT EXPENSE ONLY REPRESENTS ACCOUNTS FOR WHICH COLLECTION EFFORTS HAVE BEEN MADE BUT NO PAYMENTS HAVE BEEN RECEIVED. DISCOUNTS ARE RECORDED AS EITHER CONTRACTUALS (FOR PATIENTS WHO DO NOT QUALIFY FOR CHARITY) OR AS CHARITY (FOR PATIENTS WHO DO QUALIFY FOR CHARITY). THE TEXT OF THE NOVANT HEALTH, INC. CONSOLIDATED FINANCIAL STATEMENTS READS: "THE PROVISION FOR BAD DEBTS IS DETERMINED BASED ON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, BUSINESS AND ECONOMIC CONDITIONS, THE AGE OF THE ACCOUNTS, TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS."
		PART III, LINE 8: THE METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT AS REFLECTED IN THE AMOUNT REPORTED IN PART III, LINE 6 IS DETERMINED BY FOLLOWING THE MEDICARE PRINCIPLES OF ALLOWABLE COSTS. COST FOR THE OVERHEAD DEPARTMENTS ARE STEPPED DOWN TO THE REMAINING COST CENTERS BASED ON STATISTICS FOR EACH OVERHEAD COST CENTER. ONCE THE STEP-DOWN PROCESS IS COMPLETE, A RATIO OF COST TO CHARGES IS DEVELOPED FOR EACH COST CENTER. THE RCC IS THEN APPLIED TO THE MEDICARE REVENUE BY COST CENTER AND TOTALED.IT SHOULD BE NOTED THAT THE MEDICARE COST REPORTS DO NOT ADDRESS ANY MANAGED CARE MEDICARE REVENUES, COSTS, OR RELATED SHORTFALL. THE TOTAL REVENUES REPORTED AS RECEIVED FROM MEDICARE IN LINE 5 OF SECTION B ARE ONLY REPRESENTATIVE OF MEDICARE FEE FOR SERVICE PAYMENTS RECEIVED. THE ALLOWABLE COSTS ON LINE 6 ARE SIGNIFICANTLY LOWER THAN THE ACTUAL EXPENDITURES. AS SUCH, THE SHORTFALL IS UNDERESTIMATED. EVERY HOSPITAL TREATS MEDICARE PATIENTS. SOME HOSPITALS ARE LOCATED IN HIGH MEDICARE POPULATION AREAS OR OFFER SERVICES DISPROPORTIONATELY USED BY MEDICARE PATIENTS. MEDICARE RATES AND NUMBERS OF MEDICARE PATIENTS ARE NOT NEGOTIATED. AS REIMBURSEMENT RATES DECLINE RELATIVE TO COSTS OF CARE, HOSPITALS CONTINUE TO SERVE THE MEDICARE POPULATION. WITHOUT THIS SERVICE THESE PATIENTS WOULD BECOME AN OBLIGATION TO THE GOVERNMENT. ANY UNREIMBURSED COSTS OF THIS CARE ARE A COMMUNITY BENEFIT PROVIDED BY THE HOSPITAL TO THE COMMUNITY AND GOVERNMENT.
FORSYTH MEMORIAL HOSPITAL, INC		PART V, SECTION B, LINE 10: ALL UNINSURED PATIENTS RECEIVE A STANDARD DISCOUNT REGARDLESS OF THEIR ABILITY TO PAY. THIS DISCOUNT MIRRORS OUR AVERAGE MANAGED CARE RATE. PATIENTS BELOW 300% OF THE FEDERAL POVERTY GUIDELINES ARE DISCOUNTED AT 100% (3A: FREE CARE). OTHER PATIENTS MAY ALSO BE ELIGIBLE FOR DISCOUNTS FOR BALANCES ABOVE $5,000 (CATASTROPHIC DISCOUNT).
FMH DBA KERNERSVILLE MEDICAL CENTER		PART V, SECTION B, LINE 10: ALL UNINSURED PATIENTS RECEIVE A STANDARD DISCOUNT REGARDLESS OF THEIR ABILITY TO PAY. THIS DISCOUNT MIRRORS OUR AVERAGE MANAGED CARE RATE. PATIENTS BELOW 300% OF THE FEDERAL POVERTY GUIDELINES ARE DISCOUNTED AT 100% (3A: FREE CARE). OTHER PATIENTS MAY ALSO BE ELIGIBLE FOR DISCOUNTS FOR BALANCES ABOVE $5,000 (CATASTROPHIC DISCOUNT).
FORSYTH MEMORIAL HOSPITAL, INC		PART V, SECTION B, LINE 17E: FORSYTH MEMORIAL HOSPITAL, INC:PART V, SECTION B, LINES 15, 16 AND 17:WE DID NOT CHECK ANYTHING FOR QUESTION 15, 16 AND 17 BECAUSE WE PROCEED WITH ALL REASONABLE EFFORTS TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE PRIOR TO INITIATING ANY COLLECTION ACTIONS.
FMH DBA KERNERSVILLE MEDICAL CENTER		PART V, SECTION B, LINE 17E: FMH DBA KERNERSVILLE MEDICAL CENTER:PART V, SECTION B, LINES 15, 16 AND 17:WE DID NOT CHECK ANYTHING FOR QUESTION 15, 16 AND 17 BECAUSE WE PROCEED WITH ALL REASONABLE EFFORTS TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE PRIOR TO INITIATING ANY COLLECTION ACTIONS.
FORSYTH MEMORIAL HOSPITAL, INC		PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED THE AVERAGE OF ITS NEGOTIATED COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED.
FMH DBA KERNERSVILLE MEDICAL CENTER		PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USED THE AVERAGE OF ITS NEGOTIATED COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNTS THAT CAN BE CHARGED.
		PART VI, LINE 2: NEEDS ASSESSMENTTHE ORGANIZATION IS PART OF THE NOVANT HEALTH CARE SYSTEM, WHICH HAS A COMMUNITY BENEFIT COMMITTEE. THE COMMUNITY BENEFIT COMMITTEE IS RESPONSIBLE FOR ASSISTING THE HOSPITALS WITHIN THE HEALTH CARE SYSTEM WITH PREPARING COMMUNITY NEEDS ASSESSMENTS. THE COMMUNITY BENEFIT COMMITTEE IS MADE OF INDIVIDUALS REPRESENTING CORPORATE-WIDE DEPARTMENTS, SUCH AS COMMUNITY RELATIONS, LEGAL, TAX, INTERNAL AUDIT, MARKETING/COMMUNICATIONS, AS WELL AS INDIVIDUALS FROM VARIOUS DEPARTMENTS OF HOSPITAL OPERATIONS AND THE HEALTH CARE SYSTEM'S HOSPITAL FOUNDATIONS. EACH HOSPITAL, WITH THE ASSISTANCE OF THE COMMUNITY BENEFIT COMMITTEE, WILL IDENTIFY ORGANIZATIONS AND RESOURCES WITHIN ITS COMMUNITY TO CONTRIBUTE TO THE HOSPITAL'S COMMUNITY NEEDS ASSESSMENT. THESE ORGANIZATIONS AND RESOURCES INCLUDE LOCAL HEALTH DEPARTMENTS, UNITED WAY, UNIVERSITIES, PUBLIC HEALTH DEPARTMENTS, ETC. THE EXISTING COMMUNITY HEALTH ASSESSMENTS PREPARED BY OTHER ORGANIZATIONS IN THE COMMUNITY WILL BE COMBINED WITH INTERNAL HOSPITAL DATA AND INFORMATION COLLECTED FROM LOCAL AGENCIES TO BECOME THE HOSPITAL'S COMMUNITY NEEDS ASSESSMENT. EACH HOSPITAL HAS ALSO TRADITIONALLY RESPONDED TO REQUESTS FOR CERTAIN COMMUNITY BENEFIT ACTIVITIES OR PROGRAMS FROM PUBLIC AGENCIES OR COMMUNITY GROUPS AND THIS WILL ALSO BE INCLUDED IN THE HOSPITAL'S COMMUNITY NEEDS ASSESSMENT. ONCE THE COMMUNITY NEEDS ASSESSMENT IS COMPLETED, WHICH WILL BE EVERY THREE YEARS, THE HOSPITAL WILL PRIORITIZE THE NEEDS BY DETERMINING WHAT HOSPITAL RESOURCES ARE AVAILABLE TO MEET THE NEEDS AND WHAT OTHER COMMUNITY RESOURCES ARE BEING USED TO MEET A PARTICULAR NEED. THE HOSPITAL WILL DEVELOP A COMMUNITY BENEFIT PLAN, WHICH WILL BE REVIEWED AND UPDATED AS NECESSARY, AT LEAST EVERY THREE YEARS. ALL HOSPITALS' COMMUNITY NEEDS ASSESSMENTS WILL BE MADE AVAILABLE TO THE PUBLIC.
		PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCEAS A NOT-FOR-PROFIT ORGANIZATION, NOVANT HEALTH IS COMMITTED TO PROVIDING OUTSTANDING HEALTH CARE TO ALL MEMBERS OF OUR COMMUNITIES, REGARDLESS OF THEIR ABILITY TO PAY. OUR ACUTE CARE FACILITIES PROVIDE CARE IN 35 COUNTIES ACROSS THREE STATES. ADDITIONALLY, OUR PHYSICIANS AND ACUTE CARE FACILITIES OFFER CARE TO NATIONAL AND INTERNATIONAL MISSION PATIENTS. OUR FINANCIAL COUNSELING TEAMS ARE CONSTANTLY WORKING WITH THE PATIENTS WITHIN OUR COMMUNITIES TO UNDERSTAND THEIR NEEDS AND ENSURE THAT OUR POLICIES AND PROCESSES ADDRESS THESE NEEDS. WE ALSO MAINTAIN CONTRACTS WITH MEDICAID ELIGIBILITY VENDORS AND LOCAL DEPARTMENT OF SOCIAL SERVICES TEAMS TO HAVE EMBEDDED CASE WORKERS WITHIN OUR FACILITIES. THESE TEAMS OFFER ADDITIONAL SUPPORT IN PROCESSING AND ASSESSING HOW WE SERVE THE FINANCIAL NEEDS OF OUR PATIENTS. BASED ON THE ASSESSMENTS OF OUR COMMUNITIES, NOVANT HEALTH HAS DEVELOPED FINANCIAL ASSISTANCE POLICIES AND PROGRAMS THAT ADDRESS THE FINANCIAL NEEDS OR OUR PATIENTS. - UNINSURED PATIENTS WITH INCOMES OF UP TO 300% OF THE FEDERAL POVERTY LEVEL ARE ELIGIBLE FOR 100% WRITE-OFF. - UNINSURED PATIENTS WITH INCOME OVER 300% OF THE FEDERAL POVERTY LEVEL ARE ELIGIBLE FOR SELF-PAY DISCOUNTS BASED ON THE PATIENT'S ANNUAL INCOME AND OUTSTANDING MEDICAL BILLS / COSTS. - ANY PATIENT (EVEN WITH HEALTH INSURANCE) WITH A BALANCE OVER $5,000 AND / OR INCOME OVER 300% OF THE FEDERAL POVERTY LEVEL IS ELIGIBLE FOR A CATASTROPHIC DISCOUNT. OUR CATASTROPHIC DISCOUNTS ARE ALSO BASED ON THE PATIENT'S ANNUAL INCOME AND OUTSTANDING MEDICAL BILLS / COSTS.- ANY PATIENT IS ELIGIBLE FOR AN INDIVIDUALIZED PAYMENT PLAN BASED ON THE AMOUNT DUE AND THE PATIENT'S FINANCIAL STATUS, WITH TERMS EXTENDING UP TO FIVE YEARS. NO INTEREST IS CHARGED, UNLESS APPROPRIATE. WE PRIDE OURSELVES IN THE TRANSPARENCY OF OUR PROGRAMS AND THE EDUCATION WE OFFER OUR PATIENTS AROUND OUR FINANCIAL ASSISTANCE POLICIES. OUR PROGRAMS ARE DOCUMENTED ON OUR CORPORATE WEBSITE AS WELL AS EACH INDIVIDUAL FACILITY'S WEBSITE, ALONG WITH CONTACT INFORMATION FOR OUR FINANCIAL COUNSELORS. ADDITIONALLY, OUR PROGRAMS ARE DOCUMENTED ON PATIENT FLYERS THROUGHOUT THE NOVANT AFFILIATED FACILITIES AND PHYSICIAN OFFICES. OUR PATIENT ACCESS SPECIALISTS, FINANCIAL COUNSELORS AND BUSINESS OFFICE TEAMS WORK WITH ALL SELF-PAY PATIENTS AND INSURED PATIENTS WITH HIGH DEDUCTIBLES TO EDUCATE THEM ON THE VARIOUS OPTIONS AVAILABLE VIA OUR FINANCIAL ASSISTANCE PROGRAMS OR GOVERNMENT SPONSORED CARE. FINALLY, WE WORK WITH LOCAL AREA FREE HEALTH CLINICS AND OTHER CHARITABLE ORGANIZATIONS TO PROVIDE CONTINUATION OF CARE FOR THEIR PATIENTS. IN ADDITION TO OUR FINANCIAL COUNSELING PROCESSES USED TO IDENTIFY CHARITY CARE PATIENTS, OUR COLLECTIONS PROCESSES WITHIN OUR BUSINESS OFFICES ALSO HELP IDENTIFY PATIENTS WHO ARE ALREADY ELIGIBLE FOR CHARITY OR WHO MAY BE ELIGIBLE BASED ON THEIR STATUS WITHIN THE FEDERAL POVERTY GUIDELINES ("FPG"). WE UTILIZE PREVIOUSLY SUBMITTED PATIENT DOCUMENTATION AND CREDIT AGENCY REPORTED FPG FOR DETERMINATION. SUPPORTING DOCUMENTS ARE VALID 6 MONTHS FROM THE DATE OF SUBMISSION. OUR POLICIES ARE CONSIDERED FLUID AND ARE UPDATED FREQUENTLY BASED ON LOCAL AND NATIONAL MARKET STANDARDS AND NATIONAL ECONOMIC CONDITIONS. ANY UPDATES TO OUR POLICIES REQUIRE MULTI-LEVEL LEADERSHIP APPROVAL AND ARE ULTIMATELY APPROVED BY THE NOVANT EXECUTIVE TEAM.
		PART VI, LINE 4: COMMUNITY INFORMATIONTHE FORSYTH MEMORIAL HOSPITAL, INC. FORM 990 INCLUDES THE OPERATIONS OF TWO HOSPITALS. FORSYTH MEMORIAL HOSPITAL, INC. DBA FORSYTH MEDICAL CENTER AND AS KERNERSVILLE MEDICAL CENTERTHE ORGANIZATION DEFINES ITS COMMUNITY BY ITS PRIMARY SERVICE AREA, WHICH IS FORSYTH COUNTY, NORTH CAROLINA. THIS IS AN URBAN AREA.THERE ARE THREE NONPROFIT ACUTE CARE HOSPITALS IN THE COMMUNITY, TWO OF WHICH ARE THE ORGANIZATION AND ONE OF WHICH IS PART OF THE NOVANT HEALTH CARE SYSTEM. THERE IS ALSO ONE ACADEMIC, TEACHING HOSPITAL. ACCORDING TO TRUVEN HEALTH DATA, THE SPECIFIC POPULATION GROUPS (ETHNIC AND CULTURAL) ARE AS FOLLOWS: WHITE NON-HISPANIC (226,127) 59.5%; BLACK NON-HISPANIC (92,351) 24.3%; HISPANIC (46,602) 12.3%; ASIAN AND PACIFIC ISLAND (7,543) 2.0%; OTHERS (7,705) 2.0%; FOR A TOTAL POPULATION OF 380,328. ACCORDING TO TRUVEN HEALTH DATA, THE MEDIAN HOUSEHOLD INCOME LEVEL WAS $47,132.ACCORDING TO TRUVEN HEALTH DATA, THE AGE BREAKDOWN IS AS FOLLOWS: 0-17 YEARS (94,003) 24.7%; 18-64 YEARS (237,335) 62.4%; 65+ YEARS (48,990) 12.9%
		PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTHTHE ORGANIZATION FURTHERS ITS EXEMPT PURPOSES BY DOING THE FOLLOWING:1. ADOPTING A CHARITY CARE POLICY, WHICH PROVIDES FREE CARE TO INDIVIDUALS WHOSE INCOME IS AT OR BELOW 300% OF THE FEDERAL POVERTY LEVEL;2. REMAINING CERTIFIED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES TO PROVIDE SERVICES TO ALL BENEFICIARIES OF MEDICARE, MEDICAID, AND OTHER GOVERNMENT PAYMENT PROGRAMS, AND PROVIDING SERVICES IN A NONDISCRIMINATORY MANNER TO SUCH BENEFICIARIES;3. OPERATING A FULL-TIME EMERGENCY ROOM WHICH IS OPEN TO AND ACCEPTS ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY; 4. MAINTAINING AN OPEN MEDICAL STAFF, SUBJECT TO EXCLUSIVE CONTRACTS FOR HOSPITAL-BASED SERVICES SUCH AS ANESTHESIOLOGY, RADIOLOGY, PATHOLOGY, HOSPITALIST, AND EMERGENCY DEPARTMENT SERVICES, TO THE EXTENT AN EXCLUSIVE CONTRACT FOR THOSE SERVICES IS REQUIRED TO OBTAIN PROPER STAFFING COVERAGE OR TO PERMIT A MORE EFFICIENT DELIVERY OF THOSE SERVICES WITHIN THE HOSPITAL FACILITY;5. MAINTAINING A GOVERNING BOARD CONSISTING PRIMARILY OF A BROAD CROSS-SECTION OF LEADERS IN THE COMMUNITY;6. ADOPTING AND APPLYING A CONFLICT OF INTEREST POLICY, WHICH APPLIES TO THE GOVERNING BOARD AND ORGANIZATION OFFICERS;7. PROVIDING HEALTH EDUCATION LECTURES AND WORKSHOPS;8. PROVIDING HEALTH FAIRS, EDUCATION ON SPECIFIC DISEASES OR CONDITIONS, AND HEALTH PROMOTION AND WELLNESS PROGRAMS TO THE COMMUNITIES IT SERVES; 9. PROVIDING SUPPORT GROUPS AND SELF HELP PROGRAMS TO THE COMMUNITIES IT SERVES;10. PROVIDING COMMUNITY-BASED CLINICAL SERVICES, INCLUDING WITHOUT LIMITATION, HEALTH SCREENINGS AND CLINICS FOR UNINSURED OR UNDERINSURED PERSONS TO THE COMMUNITIES IT SERVES; 11. PROVIDING HEALTH CARE SUPPORT SERVICES, INCLUDING WITHOUT LIMITATION, INFORMATION AND REFERRAL TO COMMUNITY SERVICES, CASE MANAGEMENT OF UNDERINSURED AND UNINSURED PERSONS, TELEPHONE INFORMATION SERVICES AND ASSISTANCE TO ENROLL IN PUBLIC PROGRAMS, SUCH AS SCHIP AND MEDICAID TO THE COMMUNITIES IT SERVES; 12. PROVIDING SUBSIDIZED HEALTH SERVICES AND CLINICAL PROGRAMS TO THE COMMUNITIES IT SERVES; 13. PROVIDING CASH AND IN-KIND CONTRIBUTIONS TO NONPROFIT COMMUNITY HEALTH CARE ORGANIZATIONS IN THE COMMUNITIES IT SERVES; AND14. GENERALLY PROMOTING THE HEALTH, WELLNESS, AND WELFARE OF THE COMMUNITIES IT SERVES BY PROVIDING QUALITY HEALTH CARE SERVICES AT REASONABLE COST.FOR SPECIFIC EXAMPLES OF THIS ORGANIZATION'S COMMUNITY BENEFIT ACTIVITIES, WHICH FURTHER THE ORGANIZATION'S EXEMPT PURPOSES (AND THOSE OF ALL HOSPITALS AND HEALTH CARE FACILITIES IN THE SAME HEALTH CARE SYSTEM), PLEASE SEE THE NOVANT HEALTH COMMUNITY BENEFIT REPORT, LOCATED AT HTTP://WWW.NOVANTHEALTH.ORG/GIVEBACK/COMMUNITYBENEFITREPORT.ASPX.PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES.
		PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEMTHE ORGANIZATION IS ONE OF TEN TAX-EXEMPT HOSPITALS IN THE NOVANT HEALTH CARE SYSTEM IN NORTH CAROLINA AND VIRGINIA. EACH HOSPITAL PROVIDES SUBSTANTIAL COMMUNITY BENEFIT TO THE COMMUNITY IT SERVES, AS REPORTED INDIVIDUALLY ON EACH HOSPITAL'S FORM 990, SCHEDULE H. THE COMMUNITY BENEFIT OF THE HEALTH CARE SYSTEM AS A WHOLE IS DOCUMENTED IN A SYSTEM-WIDE COMMUNITY BENEFIT REPORT, LOCATED AT HTTP://WWW.NOVANTHEALTH.ORG/GIVEBACK/COMMUNITYBENEFITREPORT.ASPX.PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. THE NOVANT HEALTH CARE SYSTEM ALSO INCLUDES AN ORGANIZATION THAT OWNS PHYSICIAN PRACTICES IN VIRGINIA, SOUTH CAROLINA, AND NORTH CAROLINA, WHICH PROVIDE ADDITIONAL COMMUNITY BENEFIT TO THEIR COMMUNITIES, AND FIVE HOSPITAL FOUNDATIONS, WHICH SUPPORT AND ENHANCE THE COMMUNITY BENEFIT ACTIVITIES IN THOSE HOSPITAL'S COMMUNITIES. FURTHER, THE NOVANT HEALTH CARE SYSTEM INCLUDES AMBULATORY SURGERY CENTERS, SKILLED NURSING FACILITIES, REHABILITATION PROGRAMS, AND OTHER OUTPATIENT FACILITIES, WHICH ALSO PROVIDE COMMUNITY BENEFIT TO THEIR COMMUNITIES. THERE ARE SIGNIFICANT COMMUNITY BENEFIT ACTIVITIES WITHIN THE NOVANT HEALTH SYSTEM, WHICH MAY NOT BE REPORTABLE ON A SCHEDULE H BECAUSE THEY ARE NOT CONDUCTED BY AN ENTITY WHICH OWNS OR OPERATES A HOSPITAL. THE HEALTH CARE SYSTEM HAS A COMMUNITY BENEFIT COMMITTEE, WHICH WILL OVERSEE AND ASSIST ALL TAX-EXEMPT HOSPITALS WITHIN NOVANT IN PREPARING THEIR COMMUNITY NEEDS ASSESSMENTS AND COMMUNITY BENEFIT PLANS. THE GOAL OF HAVING A SYSTEM-WIDE COMMITTEE IS TO IDENTIFY COMMUNITY BENEFIT ACTIVITIES THAT ARE DUPLICATIVE IN COMMUNITIES AND TO STREAMLINE AND COORDINATE EFFORTS TO RESULT IN BETTER AND MORE EFFICIENT USES OF RESOURCES, WHICH COULD LEAD TO ADDITIONAL RESOURCES TO BE ALLOCATED TO MEET OTHER COMMUNITY NEEDS, AND TO REPLICATE SUCCESSFUL PROGRAMS AND ACTIVITIES IN COMMUNITIES WHERE A SIMILAR NEED IS INDICATED. ALL OF THE TAX-EXEMPT HOSPITALS WITHIN THE NOVANT HEALTH CARE SYSTEM ARE COMMITTED TO IMPROVING THE HEALTH OF THEIR COMMUNITIES AND PROVIDING COMMUNITY BENEFIT ACTIVITIES TO SUPPORT THEIR MISSION.
	PART VI, LINE 7, STATE FILING OF COMMUNITY BENEFIT REPORT	NOVANT HEALTH, INC. FILES A SYSTEM-WIDE COMMUNITY BENEFIT REPORT PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES WITH THE NORTH CAROLINA MEDICAL CARE COMMISSION AS PART OF THE DOCUMENTATION REQUIRED FOR THE ISSUANCE OF TAX EXEMPT BOND FINANCING.

Schedule H (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization
FORSYTH MEMORIAL HOSPITAL

Employer identification number
56-0928089

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) STATE EMPLOYEES CREDIT UNION FOUNDATION1000 WADE AVE RALEIGH,NC27605	56-2255292	501(C)(3)	250,000	TO BUILD A HOSPITALITY GUEST HOUSE FOR PATIENTS AND/OR THEIR FAMILY MEMBERS/CAREGIVERS.

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2011

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant
(1) DISCOUNTED PRESCRIPTION DRUG PROGRAM	1640	107,714

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
		PART I, LINE 2 - PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS THE ORGANIZATION IS AN AFFILIATE IN AN INTEGRATED HEALTH CARE SYSTEM AND FOLLOWS A SYSTEM-WIDE CORPORATE POLICY WITH STANDARDIZED GUIDELINES THAT ARE TO BE USED IN REVIEWING THE ELIGIBILITY AND SELECTION OF GRANTEES RECEIVING CERTAIN EXEMPT PURPOSE FUNDS. THE ORGANIZATION MAINTAINS DOCUMENTATION OF THE ELIGIBILITY AND SELECTION CRITERIA AND RECORDS OF THE AMOUNTS ARE MAINTAINED VIA THE GENERAL LEDGER. FUNDS ARE GENERALLY NOT TRACKED AFTER BEING GRANTED, AS THE ORIGINAL ELIGIBILITY AND SELECTION CRITERIA HAVE ALREADY BEEN MET.

Schedule I (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Yes

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

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2011

Page 2

Part II

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

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

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

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) EDWARDSJOEL LYNN	(i) (ii)	403,303 0	175 0	10,815 0	31,746 0	17,781 0	463,820 0	0 0
(2) FULLERSTANLEY BRIAN	(i) (ii)	0 359,937	0 47,018	0 12,896	0 14,700	0 27,129	0 461,680	0 16,901
(3) LINDSAYJEFFERY T	(i) (ii)	472,588 0	245,365 0	39,457 0	333,573 0	18,735 0	1,109,718 0	245,365 0
(4) MCGEELAWRENCE UPCHURCH	(i) (ii)	0 394,252	0 277,860	0 416,097	0 400,397	0 23,368	0 1,511,974	0 673,197
(5) MORRISJOHN BENTON	(i) (ii)	0 220,277	0 42,900	0 14,800	0 13,650	0 21,503	0 313,130	0 42,900
(6) ALLENJOANNE	(i) (ii)	167,005 0	24,212 0	16,466 0	16,066 0	7,418 0	231,167 0	24,212 0
(7) HAMMESPAUL H	(i) (ii)	297,703 0	156,080 0	22,244 0	22,200 0	22,291 0	520,518 0	156,080 0
(8) WALLEYBRUCE DOUGLAS	(i) (ii)	324,221 0	110,229 0	26,105 0	4,912 0	8,469 0	473,936 0	110,229 0
(9) BRAVOJULIO R	(i) (ii)	363,673 0	133,780 0	1,326 0	22,200 0	22,154 0	543,133 0	0 0
(10) CANNONTHOMAS B	(i) (ii)	423,164 0	0 0	41,101 0	47,203 0	16,769 0	528,237 0	0 0
(11) CHASECHERE MONIQUE	(i) (ii)	403,608 0	17,255 0	83,002 0	14,700 0	12,598 0	531,163 0	17,255 0
(12) EBERLEROBERT A	(i) (ii)	459,265 0	675 0	7,987 0	27,086 0	20,886 0	515,899 0	0 0
(13) STURGILLWILLIAM H	(i) (ii)	461,765 0	4,222 0	542 0	22,200 0	20,748 0	509,477 0	0 0
(14) ALLENELMS LEACH	(i) (ii)	65,625 0	218,492 0	281 0	11,845 0	14,949 0	311,192 0	218,492 0

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
	PART I, LINE 1A	PART I, LINE 1A - FRINGE OR EXPENSE EXPLANATION FIRST-CLASS OR CHARTER TRAVEL: FIRST-CLASS OR CHARTER TRAVEL IS NOT A COVERED TRAVEL EXPENSE FOR EXECUTIVES; THEY ARE LIMITED TO BUSINESS OR COACH CLASS FARES FOR COMMERCIAL FLIGHTS. HOWEVER, CHARTER TRAVEL IS AVAILABLE TO CERTAIN EXECUTIVES, BOARD MEMBERS, AND APPROVED BUSINESS PERSONNEL IN LIMITED CIRCUMSTANCES DEEMED TO INVOLVE BUSINESS NECESSITY. TRAVEL FOR COMPANIONS: COMPANIONS ARE ALLOWED ON CERTAIN CHARTER FLIGHTS PAID FOR BY THE ORGANIZATION. IN THAT CASE, THE VALUE OF THE COMPANION'S FLIGHT IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. TAX INDEMNIFICATION AND GROSS-UP PAYMENTS: EXECUTIVES WHO PURCHASE SPLIT DOLLAR INSURANCE THROUGH THEIR DISCRETIONARY SPENDING ACCOUNT MAY HAVE THE ADDITIONAL INCOME TAX OWED ON THE PS-58 COSTS PAID BY THE ORGANIZATION. EXECUTIVES WHO RECEIVE TAXABLE RELOCATION INCOME MAY HAVE THE ADDITIONAL INCOME TAX OWED ON THE INCOME PAID BY THE ORGANIZATION. EXECUTIVES MAY RECEIVE AS SEVERANCE BENEFITS CASH PAYMENTS IN LIEU OF PREMIUMS PAID FOR COVERAGE OF CERTAIN GROUP BENEFITS THAT ENDED WITH THE EXECUTIVE'S TERMINATION. THE ORGANIZATION MAY PAY THE ADDITIONAL TAX OWED ON ACCOUNT OF THESE PAYMENTS. DISCRETIONARY SPENDING ACCOUNT: CERTAIN EXECUTIVES RECEIVE A DISCRETIONARY SPENDING ACCOUNT. THE DOLLAR AMOUNT IN THE ACCOUNT IS PRE-APPROVED BY THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD. THE ACCOUNT CAN BE USED ONLY FOR AN APPROVED LIST OF EXPENDITURES. ALL OPTIONS OTHER THAN A DEFERRED, AT-RISK, COMPENSATION OPTION ARE CONSIDERED TAXABLE AND ARE INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE: WE PROVIDE TEMPORARY HOUSING ALLOWANCES IN CERTAIN EXECUTIVE RECRUITMENT AND RELOCATION PACKAGES. IN THE CASE THAT SUCH EXPENSE IS NOT REIMBURSABLE UNDER THE ACCOUNTABLE PLAN RULES, THE VALUE IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. THE ORGANIZATION PROVIDES A TEMPORARY RESIDENCE FOR LIMITED EXECUTIVE USE THAT AT TIMES MAY INCLUDE INCIDENTAL PERSONAL USE. IN THAT CASE, THE VALUE IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES: IN CASES WHERE CORPORATE MEMBERSHIPS ARE NOT AVAILABLE, A MEMBERSHIP MAY BE OBTAINED IN AN EXECUTIVE'S NAME WITH A "BUSINESS USE ONLY" RESTRICTION. AT THIS TIME NOVANT HAS ONE SUCH MEMBERSHIP.
	PART I, LINE 3	THE FILING ORGANIZATION IS AN AFFILIATE IN AN INTEGRATED HEALTHCARE SYSTEM AND IS SUPPORTED BY A PARENT ORGANIZATION THAT USES THE PROCESS DESCRIBED IN PART VI, LINE 15A OF THIS RETURN TO ESTABLISH THE COMPENSATION OF THE TOP MANAGEMENT OFFICIAL OF THE FILING ORGANIZATION. THIS PROCESS ADHERES TO THE REQUIREMENTS SET FORTH TO SECURE THE REBUTTABLE PRESUMPTION OF REASONABLENESS AND INCLUDES A REVIEW AND APPROVAL BY INDEPENDENT AND DISINTERESTED MEMBERS OF A COMPENSATION COMMITTEE, CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, THE UTILIZATION OF THIRD-PARTY COMPARABILITY DATA SUCH AS PUBLISHED COMPENSATION SURVEYS, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION.
	PART I, LINE 4B	SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SEVERANCE NONQUALIFIED EQUITY-BASED MCGEE, LAWRENCE UPCHURCH 0 395,337 0
SUPPLEMENTAL INFORMATION	PART III	PART III - OTHER ADDITIONAL INFORMATION DESCRIPTIONS OF SUPPLEMENTAL EXECUTIVE BENEFITS INCLUDED IN PART VII AND SCHEDULE J: EXECUTIVE ANNUAL INCENTIVE PLAN: AS PART OF THE REPORTED COMPENSATION AMOUNTS, THE REPORTING ORGANIZATION PROVIDES ANNUAL INCENTIVE COMPENSATION TO OFFICERS AND KEY EMPLOYEES UNDER AN EXECUTIVE ANNUAL INCENTIVE PLAN. THE INCENTIVE PLAN IS DESIGNED TO OFFER OPPORTUNITIES FOR ADDITIONAL COMPENSATION, BUT ONLY TO THE EXTENT THAT ELIGIBLE EXECUTIVES HAVE PROVIDED EXTRAORDINARY SERVICES AND ACHIEVED EXTRAORDINARY RESULTS THAT MEET OR EXCEED PREDETERMINED GOALS IN THE AREAS OF QUALITY, PATIENT SATISFACTION, EMPLOYEE SATISFACTION AND FINANCIAL VITALITY. THESE GOALS ARE ESTABLISHED AND APPROVED BY INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD). THESE GOALS ARE WEIGHTED EQUALLY. THE ADDITIONAL COMPENSATION CAN RANGE ANYWHERE FROM ZERO TO A MAXIMUM PERCENTAGE OF BASE SALARY THAT DIFFERS BY THE CLASS OF EXECUTIVE; THIS MAXIMUM PERCENTAGE RANGES FROM 30% TO 70% OF BASE SALARY. IN ADDITION, THE INDEPENDENT MEMBERS OF THE BOARD OF TRUSTEES WHO OVERSEE THE INCENTIVE COMPENSATION PROGRAM APPLY TWO "CIRCUIT BREAKERS," WHICH ARE SUBSTANTIAL LEVELS OF ORGANIZATION-WIDE ACHIEVEMENT THAT MUST BE SATISFIED BEFORE ANY AWARDS ARE PAID TO ANY EXECUTIVE UNDER THE PROGRAM. THE INCENTIVE COMPENSATION AWARDS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(II) OF SCHEDULE J. THEY ARE REPORTED IN THE YEAR PAID. INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS ANNUAL INCENTIVE PLAN. LONG-TERM INCENTIVE PLAN: THE REPORTING ORGANIZATION OFFERS A LONG-TERM INCENTIVE PLAN (THE "PLAN") TO CERTAIN KEY EXECUTIVES. THE PLAN TIES A KEY EXECUTIVE'S COMPENSATION TO THE ORGANIZATION'S LONG-TERM STRATEGIC PERFORMANCE, PROVIDES A RETENTION INCENTIVE FOR KEY EXECUTIVES, AND ALLOWS THE ORGANIZATION TO COMPETE IN THE MARKETPLACE FOR TOP LEADERSHIP TALENT. THE PLAN OPERATES ON THREE-YEAR PERFORMANCE CYCLES THAT BEGIN EACH YEAR. LONG-TERM STRATEGIC GOALS (IN THE PRINCIPAL AREAS OF QUALITY OF PATIENT CARE AND LONG-TERM FINANCIAL STRENGTH) ARE ESTABLISHED AND APPROVED FOR EACH CYCLE, IN ADVANCE, BY INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD). A MINIMUM LEVEL OF COMMUNITY BENEFIT AND CHARITY CARE, AS WELL AS A MINIMUM LEVEL OF FINANCIAL PERFORMANCE, IS REQUIRED BEFORE ANY AWARD CAN BE PAID UNDER THE PLAN. NOVANT HEALTH'S INTERNAL AUDIT DEPARTMENT REVIEWS THE METHODOLOGY AND PROCESS USED TO DETERMINE ACHIEVEMENT OF THE QUALITY METRICS. AWARDS ARE PAYABLE FOR A PARTICULAR THREE-YEAR PERFORMANCE CYCLE ONLY IF THE REQUISITE LEVEL OF COMMUNITY BENEFIT AND CHARITY CARE, ALONG WITH THE REQUIRED LEVEL OF FINANCIAL PERFORMANCE TO DEMONSTRATE LONG-TERM FINANCIAL STRENGTH, HAVE BEEN MET FOR THAT RESPECTIVE THREE-YEAR PERFORMANCE PERIOD. IF AN AWARD IS EARNED AT THE END OF A PERFORMANCE CYCLE, THEN THE INCENTIVE AWARD IS PAID OUT AND IS INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(II) OF SCHEDULE J. THEY ARE REPORTED IN THE YEAR PAID. INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS LONG-TERM INCENTIVE PLAN. SCHEDULE J PART I LINE 4A - SEVERANCE PLAN: ELIGIBLE EXECUTIVES MAY RECEIVE SEVERANCE PAY THAT IS A SPECIFIED MULTIPLE OF ANNUAL COMPENSATION. THE SEVERANCE PAY WOULD BE PAID ONLY IN THE EVENT OF CERTAIN TYPES OF EMPLOYMENT TERMINATION, AND IS FURTHER CONTINGENT ON THE SATISFACTION OF OTHER CONDITIONS SUCH AS COMPLIANCE WITH A NON-COMPETITION COVENANT. ANY CURRENT YEAR PAYMENTS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(III) OF SCHEDULE J. INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS SEVERANCE PLAN. SCHEDULE J PART I LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS: SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN: THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("SERP") IS INTENDED TO SUPPORT RETENTION OF KEY EXECUTIVES, AND TO OFFER COMPETITIVE TOTAL COMPENSATION. THESE SERP BENEFITS ARE CALCULATED WITH REFERENCE TO A FORMULA THAT TAKES INTO CONSIDERATION THE EXECUTIVE'S TOTAL YEARS OF SERVICE WITH THE ORGANIZATION AND OTHER RETIREMENT INCOME. THESE BENEFITS ARE FULLY AT RISK AND WILL NOT BE PAID UNLESS THE EXECUTIVE PROVIDES SUBSTANTIAL FUTURE SERVICES TO THE ORGANIZATION. UNTIL THOSE REQUIREMENTS ARE SATISFIED, IF EVER, THE EXECUTIVE IS NOT ENTITLED TO ANY SERP BENEFIT. IF THE EXECUTIVE WERE TO HAVE LEFT THE ORGANIZATION VOLUNTARILY DURING THE YEAR FOR WHICH THESE AMOUNTS ARE BEING REPORTED (BEFORE REACHING BOTH AGE 55 AND HAVING FIVE YEARS OF SERVICE WITH THE ORGANIZATION), THE EXECUTIVE'S SERP BENEFIT WOULD HAVE BEEN ENTIRELY FORFEITED. THE SERP BENEFIT IS REDUCED AT THE RATE OF 2 PERCENTAGE POINTS PER YEAR FOR PAYMENTS RECEIVED BETWEEN THE AGES OF 55 AND 62. CURRENT YEAR PAYMENTS OF SERP BENEFITS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(III) OF SCHEDULE J. AN ESTIMATE OF THE ANNUAL INCREASE IN ACTUARIAL VALUE IS REPORTED AS DEFERRED COMPENSATION IN PART VII AND IN COLUMN (C) OF SCHEDULE J FOR ELIGIBLE EXECUTIVES. INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS SUPPLEMENTAL RETIREMENT PLAN.

Schedule J (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

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

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

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.

(a) Name of interested person and purpose	(b) Loan to or from the organization?		(c)Original principal amount	(d)Balance due	(e) In default?		(f) Approved by board or committee?		(g)Written agreement?
(a) Name of interested person and purpose	To	From	(c)Original principal amount	(d)Balance due	Yes	No	Yes	No	Yes	No
(1) CHERE CHASE		X	75,000	30,685		No	Yes		Yes





Total ............... $				30,685

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b)Relationship between interested person and the organization	(c)Amount of grant or type of assistance

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2011

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) ELIZABETH WALLEY	FAMILY MEMBER OF BRUCE WALLEY, KEY EMPLOYEE	95,071	COMPENSATION GREATER THAN $10,000 WAS PAID BY THE FILING ORGANIZATION TO A FAMILY MEMBER OF A CURRENT OFFICER, BOARD MEMBER OR KEY EMPLOYEE.		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, PART II, LOANS TO AND FROM INTERESTED PERSONS:		(A) NAME OF PERSON: CHERE CHASE(A) PURPOSE OF LOAN: EMPLOYMENT RELATED

Schedule L (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Identifier	Return Reference	Explanation
ACTIVITIES	FORM 990, PART I, LINE 1: ORGANIZATION'S MISSION OR MOST SIGNIFICANT	IN 2011, FORSYTH MEDICAL CENTER (FMC), A 921-BED NOVANT HEALTH TERTIARY CARE HOSPITAL LOCATED IN WINSTON-SALEM, NC, FOCUSED ON PROVIDING COMMUNITY SUPPORT, CONSISTENT QUALITY, EXCELLENT SERVICE AND A REMARKABLE WORK ENVIRONMENT FOR STAFF. IT IS AN INTEGRAL PART OF THE NOVANT HEALTH SYSTEM (COLLECTIVELY KNOWN AS "NOVANT"), A NOT-FOR-PROFIT INTEGRATED GROUP OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS AND OTHER HEALTHCARE SERVICE PROVIDERS. NOVANT IS RANKED AS ONE OF OUR NATION'S TOP 25 HEALTHCARE SYSTEMS - CARING FOR PATIENTS AND COMMUNITIES IN NORTH CAROLINA, VIRGINIA AND SOUTH CAROLINA. THE NOVANT HEALTH SYSTEM REPORTED $3.453 BILLION IN REVENUES IN 2011. OUR HOSPITAL IS COMMITTED TO MEETING THE HEALTHCARE NEEDS OF RESIDENTS OF THE PIEDMONT TRIAD REGION OF NORTH CAROLINA, ONE PERSON AT A TIME. QUALITY WE ARE PROUD OF THE ACHIEVEMENTS IN QUALITY THIS YEAR AS WE RANK WELL ABOVE STATE AVERAGES IN HEART ATTACK, HEART FAILURE AND PNEUMONIA CARE. IN ADDITION, FORSYTH MEDICAL CENTER'S BREAST CANCER CENTER PROGRAM IS NATIONALLY CERTIFIED. OUR STROKE AND NEUROSCIENCES INSTITUTE AND CARDIAC & VASCULAR CENTER HEART FAILURE PROGRAM AND STROKE REHABILITATION PROGRAM ARE ALL NATIONALLY ACCREDITED AS WELL AS ITS TOTAL HIP AND KNEE JOINT REPLACEMENT PROGRAM. OUR HEART FAILURE PROGRAM RECEIVED ADVANCED HEART FAILURE CERTIFICATION FOR EXCEPTIONAL EFFORTS TO IMPROVE HEART FAILURE PATIENT OUTCOMES AND THE AMERICAN COLLEGE OF SURGEONS (ACS) NAMED FORSYTH MEDICAL CENTER WITHIN ITS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM. DURING 2011, FORSYTH MEDICAL CENTER ("FMC") EARNED THE VHA HONOR OF THE LEADERSHIP AWARD FOR CLINICAL EXCELLENCE, HONORING THE HOSPITAL FOR MEETING OR EXCEEDING NATIONAL PERFORMANCE STANDARDS FOR CLINICAL CARE AND IMPROVING THE PATIENT EXPERIENCE WHILE ACHIEVING TOP PERFORMANCE IN CLINICAL CORE MEASURES. FORSYTH MEDICAL CENTER HAS BEEN RECOGNIZED FOR ACHIEVING THE TOP 10% OF HOSPITALS NATIONALLY FOR PATIENT SATISFACTION BASED ON HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (HCAHPS) DATA AS WELL AS IN THE TOP 10% IN THE NATION FOR CUSTOMER SATISFACTION, EARNING THE HEALTHGRADES OUTSTANDING PATIENT EXPERIENCE AWARD. OUR COMMITMENT TO EXCELLENCE IN PATIENT CARE, INCLUDING NURSING CARE, CONTINUED DURING THE YEAR. FORSYTH MEDICAL CENTER IS AMONG ONLY FIVE PERCENT OF HOSPITALS IN THE UNITED STATES TO BE DESIGNATED BY THE AMERICAN NURSES CREDENTIALING CENTER AS A MAGNET FACILITY, CONFIRMING THE EXCEPTIONAL QUALITY OF CARE THAT OUR NURSES PROVIDE. AT THE STATE LEVEL, TWO NURSES FROM FORSYTH MEDICAL CENTER WERE SELECTED BY THE NORTH CAROLINA NURSES' ASSOCIATION TO BE AMONG THE "GREAT 100 NURSES." TO FURTHER ADVANCE THE QUALITY OF ITS NURSING, FORSYTH MEDICAL CENTER PLANS TO ADOPT A NEW NURSING PROFESSIONAL PRACTICE MODEL IN 2012 THE DUFFY'S QUALITY-CARING MODEL WHICH WILL SOONAFTER, BE ADOPTED BY NOVANT HEALTH'S ENTIRE ACUTE NURSING SYSTEM. FORSYTH MEDICAL CENTER IS ALSO AN AWARD-WINNER FOR ITS AESTHETIC BEAUTY IN TOUR COMMUNITY. FMC HAS BEEN HONORED BY THE COMMUNITY APPEARANCE COMMISSION OF FORSYTH COUNTY/WINSTON-SALEM FOR THE WONDERFUL APPEARANCE OF THE LANDSCAPING ACROSS THE HOSPITAL CAMPUS GROUNDS. ON MARCH 16, 2011, FORSYTH MEDICAL CENTER OPENED A NEW AFFILIATE HOSPITAL, KERNERSVILLE MEDICAL CENTER (KMC) AS A 50-BED NOVANT HEALTH COMMUNITY HOSPITAL LOCATED IN KERNERSVILLE, NC. THE HOSPITAL FOCUSES ON PROVIDING A FAST-ACCESS EMERGENCY DEPARTMENT, GENERAL, ORTHOPAEDIC AND EYE SURGICAL SERVICES, CONSISTENT QUALITY, EXCELLENT SERVICE AND A REMARKABLE WORK ENVIRONMENT FOR STAFF TO RESIDENTS IN THE KERNERSVILLE AREA, WESTERN GUILFORD AND ROCKINGHAM COUNTIES, AS WELL AS EASTERN STOKES AND FORSYTH COUNTIES. SAFETY THE VHA RECOGNIZED FMC AS A LEADER IN CENTRAL ATLANTIC COMPARATIVE SAFETY MEASUREMENTS FOR FALLS WITH INJURY REDUCTION NOTING A 50% REDUCTION IN FALLS WITH INJURY RATE JULY - DECEMBER 2011 COMPARED TO JANUARY - JUNE 2011. FORSYTH MEDICAL CENTER'S SERIOUS SAFETY EVENTS RATE DROPPED TO .21 BASED ON A ROLLING 12-MONTH RATE OF SERIOUS SAFETY EVENTS PER 10,000 ADJUSTED PATIENT DAYS. FMC ALSO CELEBRATED A STREAK OF 177 DAYS WITHOUT A SERIOUS SAFETY EVENT IN 2011. FORSYTH MEDICAL CENTER PRACTICES HAVE BEEN SELECTED AS A VHA LEADING PRACTICE BLUEPRINT FOR DEMONSTRATED NATIONAL EXCELLENCE IN PN2 PNEUMOCOCCAL SCREENING AND/OR VACCINATION AND PN7 INFLUENZA VACCINE (DURING FLU SEASON ONLY). TO EARN THIS HONOR, FORSYTH MEDICAL CENTER EXHIBITED SUPERIOR PERFORMANCE AS A LEADING PRACTICE IN THESE TWO INDICATORS FOR THE LAST EIGHT QUARTERS AND HAS EVEN ATTAINED 100% FOR AT LEAST 10 QUARTERS. AS A VHA LEADING PRACTICE BLUEPRINT, FMC'S BEST PRACTICES IN THESE CATEGORIES WILL BE SHARED WITH OTHER LIKE FACILITIES TRYING TO IMPROVE THEIR OWN BENCHMARKS. DURING 2011, THE MEDICAL CENTER RECEIVED A NUMBER OF ACCREDITATIONS AND AWARDS FOR ITS HIGH LEVEL OF PATIENT CARE IN SPECIFIC CATEGORIES, INCLUDING THESE ACCOMPLISHMENTS: - FORSYTH MEDICAL CENTER RANKS WELL ABOVE THE STATE AVERAGE IN APPROPRIATE CARE MEASURE (ACM), A PATIENT-CENTERED COMPOSITE SCORE THAT CAPTURES WHETHER OR NOT A PATIENT RECEIVED ALL OF THE RECOMMENDED TREATMENTS IN THE FOLLOWING MEASURES: HEART ATTACK (100%) HEART FAILURE (100%) PNEUMONIA CARE (100%) SURGICAL CARE IMPROVEMENT PROJECT (99%) - FORSYTH MEDICAL CENTER'S STROKE & NEUROSCIENCES INSTITUTE EARNED THE DISTINCTION AS THE ONLY MEDICAL CENTER IN NORTH CAROLINA AND SOUTH CAROLINA RECOGNIZED BY THE AMERICAN HEART ASSOCIATION (AHA) AND AMERICAN STROKE ASSOCIATION (ASA) FOR IMPROVING STROKE CARE BY CONSISTENTLY ADMINISTERING THE CLOT DISSOLVING DRUG RT-PA TO VICTIMS OF ISCHEMIC STROKE WITHIN 60 MINUTES OF ARRIVING FOR CARE. THE RECOGNITION IS PART OF THE ASSOCIATIONS' NATIONAL QUALITY IMPROVEMENT CAMPAIGN, TARGET: STROKE AND TARGET: STROKE HONOR ROLL, TO IMPROVE OUTCOMES FOR ISCHEMIC STROKE PATIENTS BY RECOGNIZING THOSE MEDICAL CENTERS THAT CONSISTENTLY DELIVER THE FASTEST CARE FOR STROKE VICTIMS. - THE DIRECTOR FOR NEUROSCIENCES AND NEUROCRITICAL CARE AT FORSYTH MEDICAL CENTER, PRESENTED AND PARTICIPATED IN A PANEL DISCUSSION ON THE CHALLENGES OF RURAL WOMEN: UNITED STATES AND AFRICA AT THE 56TH SESSION OF THE INTERNATIONAL COMMISSION ON THE STATUS OF WOMEN AT UNITED NATIONS HEADQUARTERS IN NEW YORK. - FORSYTH REHAB PARTNERED WITH LOWE'S FOODS (BASED IN WINSTON-SALEM, NC) TO OPEN THE "LOWES LEARNING LAB" WITHIN FMC'S WHITAKER REHABILITATION CENTER. THE LOWES LEARNING LAB IS A MOCK GROCERY STORE SET UP WITHIN THE REHAB CENTER WHERE PATIENTS ARE ABLE TO RE-DEVELOP AND REFINE THE MANY COGNITIVE AND PHYSICAL ABILITIES ASSOCIATED WITH SHOPPING, WHILE IN A SAFE ENVIRONMENT. - THE DERRICK L. DAVIS FORSYTH REGIONAL CANCER CENTER IS THE ONLY CANCER CENTER IN NORTH CAROLINA, AND ONE OF ONLY SIX ONCOLOGY PRACTICES IN THE NATION, RECOGNIZED FOR IMPROVING ACCESS TO CLINICAL TRIALS FOR PATIENTS AS AWARDED BY THE CONQUER CANCER FOUNDATION OF THE ASCO. - FORSYTH MEDICAL CENTER IMAGING - THE BREAST CLINIC HAS EARNED A THREE-YEAR ACCREDITATION IN BREAST MAGNETIC RESONANCE IMAGING (MRI) BY THE AMERICAN COLLEGE OF RADIOLOGY (ACR), MAKING IT WINSTON-SALEM'S ONLY ACR-ACCREDITED BREAST MRI FACILITY. - FORSYTH CARDIAC AND VASCULAR CENTER ANNOUNCED ITS AFFILIATION WITH THE CLEVELAND CLINIC HEART & VASCULAR INSTITUTE, THE NATION'S NUMBER ONE HEART CARE PROGRAM IN SEPTEMBER 2011. THE AFFILIATION GIVES OUR PATIENTS NOT ONLY ACCESS TO OUR NATIONALLY RECOGNIZED CARDIAC CARE, BUT TO WORLD-CLASS, LEADING-EDGE CARDIOVASCULAR PREVENTION PROGRAMS AND TREATMENT OPTIONS AVAILABLE AT THE CLEVELAND CLINIC. - FORSYTH CARDIAC AND VASCULAR CENTER IS ALSO THE RECIPIENT OF THE ACTION REGISTRY-GWTG GOLD PERFORMANCE ACHIEVEMENT AWARD. THIS NCDR PERFORMANCE ACHIEVEMENT AWARD RECOGNIZES PARTICIPATING HOSPITALS THAT HAVE MAINTAINED A RATE OF PERFORMANCE OF 85% OR BETTER FOR EIGHT CONSECUTIVE QUARTERS, ENDING QUARTER FOUR 2010. - FOR THE FOURTH CONSECUTIVE YEAR, FORSYTH CARDIAC AND VASCULAR CENTER HAS EARNED THE SOCIETY OF THORACIC SURGEONS (STS) 3-STAR RATING, REPRESENTING THE HIGHEST QUALITY RATING AWARDED FOR HEART SURGERY. - FMC'S WOMEN'S HEART CENTER HAS SCREENED APPROXIMATELY 400 PEOPLE SINCE ITS LAUNCH IN FEBRUARY 2011, AND THIS YEAR HAS EXPANDED TO OFFER WOMEN'S CARDIAC SCREENING SERVICES AT KERNERSVILLE MEDICAL CENTER AND THOMASVILLE MEDICAL CENTER. - FMC'S LABORATORY COMPLETED A SUCCESSFUL BIENNIAL REVIEW BY THE COLLEGE OF AMERICAN PATHOLOGISTS (CAP) AND EARNED THE INTER-SOCIETAL COMMISSION FOR THE ACCREDITATION OF ECHOCARDIOGRAPHY LABORATORIES.
	COMMUNITY BENEFIT REPORT:	HTTP://WWW.NOVANTHEALTH.ORG/GIVEBACK/COMMUNITYBENEFITREPORT.ASPX THE COMMUNITY BENEFIT REPORT PREPARED BY NOVANT HEALTH IS A SYSTEM-WIDE REPORT THAT INCLUDES QUALITATIVE AND QUANTITATIVE INFORMATION. IN THIS REPORT, THE NOVANT HEALTH SYSTEM'S COMMUNITY BENEFIT WAS APPROXIMATELY $567,000,000 IN 2011. PLEASE NOTE THAT THE NUMERIC DATA IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT.
	FORM 990, PART III, LINE 1: MISSION, VISION, AND VALUES	MISSION: NOVANT HEALTH EXISTS TO IMPROVE THE HEALTH OF COMMUNITIES, ONE PERSON AT A TIME. VISION: WE, THE EMPLOYEES OF NOVANT AND OUR PHYSICIAN PARTNERS, WILL DELIVER THE MOST REMARKABLE PATIENT EXPERIENCE, IN EVERY DIMENSION, EVERY TIME. VALUES: COMPASSION: WE TREAT OUR CUSTOMERS AND THEIR FAMILIES, STAFF AND OTHER HEALTHCARE PROVIDERS AS FAMILY MEMBERS BY SHOWING THEM KINDNESS, PATIENCE, EMPATHY AND RESPECT. DIVERSITY: WE RECOGNIZE THAT EVERY PERSON IS DIFFERENT, EACH SHAPED BY UNIQUE LIFE EXPERIENCES. THIS ENABLES US TO BETTER UNDERSTAND ONE ANOTHER AND OUR CUSTOMERS. PERSONAL EXCELLENCE: WE STRIVE TO GROW PERSONALLY AND PROFESSIONALLY, AND WE APPROACH EACH SERVICE OPPORTUNITY WITH A POSITIVE, FLEXIBLE ATTITUDE. HONESTY AND PERSONAL INTEGRITY GUIDE ALL THAT WE DO. TEAMWORK: THE NEEDS AND EXPECTATIONS OF ANY ONE CUSTOMER ARE GREATER THAN THAT WHICH ONE PERSON'S SERVICE EFFORTS CAN SATISFY. WE SUPPORT EACH OTHER SO THAT TOGETHER AS A TEAM, WE CAN BE SUCCESSFUL IN THE EYE OF THE CUSTOMER AS A QUALITY SERVICE PROVIDER.
	FORM 990, PART I, LINE 6:	THE NUMBER OF VOLUNTEERS REPORTED INCLUDES THOSE VOLUNTEERS SERVING AS BOARD MEMBERS.
		- THE AMERICAN DIABETES ASSOCIATION CERTIFIED FMC'S DIABETES CENTER AS WELL AS ITS SELF MANAGEMENT EDUCATION PROGRAM. - FORSYTH MEDICAL CENTER MOST RECENTLY ANNOUNCED IT IS ADVANCING WOMEN'S HEALTH ONCE AGAIN BY CELEBRATING THE BIRTH OF THE MAYA ANGELOU CENTER FOR WOMEN'S HEALTH AND WELLNESS AT FORSYTH MEDICAL CENTER, WHICH WILL OPEN IN MID-JUNE, 2012. THIS NEW CENTER WILL ENHANCE NOVANT HEALTH'S VISION OF PROVIDING A REMARKABLE EXPERIENCE TO WOMEN WITH SERVICES WHICH FOCUS ON THEIR UNIQUE NEEDS, AND WILL BE COORDINATED IN WAYS THAT ARE EASY AND CONVENIENT FOR WOMEN TO ACCESS. IN BOTH THE INPATIENT AND OUTPATIENT COMMUNITY SETTINGS, OUR HOSPITAL-WIDE STAFF OF PHYSICIANS AND MEDICAL PROFESSIONALS WILL WORK TOGETHER TO PROVIDE THE MOST ADVANCED CARE AVAILABLE TO WOMEN TODAY, CUSTOMIZED TO MEET THE NEEDS OF EACH PATIENT, AND ENSURING THAT WOMEN AND GIRLS THROUGHOUT OUR COMMUNITY CAN ACHIEVE BETTER HEALTH FOR THEMSELVES. - THE EMERGENCY DEPARTMENT AT FMC HAS TRANSFORMED ITS OPERATIONS IN THE PAST TWO YEARS TO ACHIEVE ITS LOWEST DOOR-TO-PROVIDER WAIT TIMES ALONG WITH PROVIDING NEW SERVICES. - 39 MINUTES FOR THE AVERAGE PATIENT. UPON ARRIVAL, EVERY PERSON IS GREETED AND EVALUATED BY A NURSE PRACTITIONER WHO, IN MOST CASES, CAN BEGIN THEIR PLAN OF CARE RIGHT AWAY - INCLUDING ORDERING DIAGNOSTIC TESTS BEFORE A PATIENT GOES BACK TO A TREATMENT ROOM. - 58 MINUTES AVERAGE DOOR-TO-TPA TIME TO BEGIN ADMINISTERING TPA TO STROKE PATIENTS TO BEGIN TO DISSOLVE THE BLOOD CLOT IN THEIR BRAIN. A NEW PRACTICE ALSO BRINGS POTENTIAL STROKE PATIENTS DIRECTLY TO A CT SCANNER, SKIPPING VALUABLE TIME THAT HAS BEEN WASTED IN A TREATMENT ROOM. - ADDING A CLINICAL SERVICE NAVIGATOR WHO IS A CLINICAL NURSE THAT CALLS PATIENTS AFTER DISCHARGE ABOUT LAB RESULTS AND FOLLOW-UP NEEDS. THE MEDICAL CENTER ALSO MADE SIGNIFICANT CONTRIBUTIONS TOWARD IMPROVING THE HEALTH OF THE COMMUNITIES WE SERVE. THE HIGHLIGHTS FOR 2011 INCLUDE THE FOLLOWING: - VASCULAR CLINIC/PAD SCREENINGS COMBINE FREE EDUCATION AND SCREENINGS ON CARDIOVASCULAR DISEASE RISK FACTORS WITH AN EMPHASIS ON PREVENTING PERIPHERAL ARTERIAL DISEASE (PAD) IN THE COMMUNITY. - BEHAVIORAL HEALTH COMMUNITY OUTREACH WHICH PROVIDES A 24/7 BEHAVIORAL HEALTH CALL CENTER, DEPRESSIONS AND BIPOLAR SUPPORT GROUP, DIALECTIC BEHAVIORAL THERAPY SKILLS TRAINING, A FAMILY RECOVERY PROGRAM AND A MOBILE CRISIS RESPONSE TEAM. - THE DERRICK L. DAVIS FORSYTH REGIONAL CANCER CENTER'S COMMUNITY SERVICES INCLUDE COMMUNITY EDUCATION FORUMS, A PALLIATIVE CARE SYMPOSIUM, AN EMPLOYEE MAMMOGRAM PROGRAM AS WELL AS PUBLIC SUPPORT GROUPS AND LEARNING SESSIONS FOR CAREGIVERS AND THOSE WITH LEUKEMIA AND LYMPHOMA, GASTROINTESTINAL CANCER, GYNECOLOGIC CANCER AS WELL AS TEACHING ABOUT SPIRITUALITY AND CANCER. - CARDIAC COMMUNITY SERVICES INCLUDE COMMUNITY HEALTH & NUTRITION EDUCATION AND SCREENINGS, A HEART FAILURE CLINIC AND LIPID CLINIC, AN OPEN HEART CLINIC, STRESS MANAGEMENT PROGRAMS AS WELL AS TOBACCO AND SMOKING CESSATION PROGRAMS. - DIABETES SERVICES FEATURE CONTINUOUS GLUCOSE MONITORING, DIABETES PREVENTION AND SCREENINGS SESSIONS, DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT GROUPS AS WELL AS INSULIN PUMP TRAINING. - REHABILITATION SERVICES TO THE COMMUNITY INCLUDE AN APHASIA SUPPORT GROUP, AUDIOLOGY AND POSTURE SCREENINGS. - STROKE AND NEUROSCIENCES COMMUNITY SUPPORT INCLUDES A SLEEP MEDICINE SYMPOSIUM, A STROKE SYMPOSIUM AS WELL AS STROKE EDUCATION AND SUPPORT GROUPS. - WOMEN'S SERVICES COMMUNITY OUTREACH INCLUDE BABY BOOT CAMP, BIRTH AND BEGINNING CLASSES, BREASTFEEDING EDUCATION AND SUPPORT GROUPS, FORSYTH AND DAVIE COUNTY SCHOOL BMI PROGRAMS, A FREE ON-LINE HEALTH RISK ASSESSMENT, GIRLS ON THE RUN AND GIRLS ON TRACK WHICH PROMOTE YOUTH TO LEAD ACTIVE, HEALTHY LIFESTYLES, AND THE HANESBRAND HEALTH LEARNING LIBRARY WHICH PROVIDES SCREENINGS, HEALTH CHECKS AND EDUCATION SERVICES. IN ADDITION TO OUR QUALITY AND COMPREHENSIVE CATEGORIES OF SERVICES, WE'RE VERY PROUD OF OUR PATIENT FINANCIAL ASSISTANCE PROGRAM. WE WORK WITH CUSTOMERS TO HELP QUALIFY THEM FOR PUBLIC ASSISTANCE, ESTABLISH A REASONABLE PAYMENT PLAN, DISCOUNT THEIR BILL TO REFLECT THEIR PERSONAL RESOURCES OR PROVIDE THEM WITH FREE CHARITY CARE.
	FORM 990, PART VI, SECTION A, LINE 2	FAMILY AND/OR BUSINESS RELATIONSHIPS: BUSINESS RELATIONSHIP GARY GREEN PAUL HAMMES
	FORM 990, PART VI, SECTION A, LINE 6	CLASSES OF MEMBERS OR STOCKHOLDERS THE CORPORATION IS A NONPROFIT CORPORATION WITH MEMBERS (OR A MEMBER).
	FORM 990, PART VI, SECTION A, LINE 7A	ELECTION OF MEMBERS AND THEIR RIGHTS NOVANT HEALTH, INC. ELECTS ALL MEMBERS OF THE GOVERNING BODY OF FORSYTH MEMORIAL HOSPITAL,INC.
	FORM 990, PART VI, SECTION A, LINE 7B	DECISIONS SUBJECT TO APPROVAL OF MEMBERS NOVANT HEALTH, INC. HAS CERTAIN RESERVED POWERS, SUCH AS APPROVAL OF AMENDEMNTS TO THE ARTICLES AND BYLAWS OF THE CORPORATION, AND TO ADOPT CERTAIN POLICIES WHICH SHALL BE IMPLEMENTED BY THE CORPORATION BOARD.
	FORM 990, PART VI, SECTION B, LINE 11	ORGANIZATION'S PROCESS TO REVIEW FORM 990 THE BOARD HAS DELEGATED REVIEW OF THE FORM 990 TO NOVANT HEALTH'S AUDIT AND COMPLIANCE COMMITTEE, WHICH OVERSEES TAX MATTERS FOR NOVANT HEALTH. THE AUDIT AND COMPLIANCE COMMITTEE IS THE REVIEW BODY FOR ALL OF THE FORM 990S FILED FOR ORGANIZATIONS WITHIN THE NOVANT HEALTH SYSTEM. THE AUDIT AND COMPLIANCE COMMITTEE MEETS BEFORE THE FORM 990S ARE FILED WITH THE IRS AND AFTER ALL BOARD MEMBERS HAVE RECEIVED A COPY OF THE FORM 990 AND A SUMMARY OF ITS CONTENTS. THE SENIOR DIRECTOR OF TAX AND LEGAL COUNSEL FOR NOVANT HEALTH ATTEND THE MEETING TO ANSWER ANY QUESTIONS AND ADDRESS ANY SIGNIFICANT DISCLOSURES WITHIN THE FORM 990.
	FORM 990, PART VI, SECTION B, LINE 12C	MONITORING AND ENFORCEMENT OF COI THE ORGANIZATION'S TRUSTEE CONFLICT OF INTEREST POLICY APPLIES TO ALL TRUSTEES, PRINCIPAL OFFICERS OR MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS INCLUDING ANY APPLICABLE DISREGARDED ENTITIES. ALL TRUSTEES ARE SENT AN ANNUAL DISCLOSURE FORM. ANY POSITIVE ANSWERS ON THE TRUSTEE ANNUAL DISCLOSURE FORM ARE REVIEWED BY THE GENERAL COUNSEL. IF THE RELATIONSHIP DISCLOSED IS DETERMINED NOT TO POSE A POTENTIAL CONFLICT OF INTEREST GENERALLY, THEN NO ACTION IS TAKEN. WITH RESPECT TO PARTICULAR TRANSACTIONS THAT COME BEFORE THE BOARD, THE CONFLICT OF INTEREST POLICY WOULD BE FOLLOWED. THE POTENTIAL CONFLICT OF INTEREST WOULD BE DISCLOSED BY THE BOARD MEMBER BEFORE A VOTE ON THE TRANSACTION AND THE REST OF THE BOARD WOULD DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF THE REST OF THE BOARD DETERMINED THAT A CONFLICT OF INTEREST EXISTED THEN THE BOARD MEMBER WITH THE CONFLICT OF INTEREST WOULD NOT PARTICIPATE IN THE DELIBERATIONS AND VOTE.
	FORM 990, PART VI, SECTION B, LINE 15	FORM 990, PART VI, SECTION B, LINE 15A: COMPENSATION PROCESS FOR TOP OFFICIAL INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS OF COMPENSATION AND BENEFITS FOR CERTAIN LEADERS AND EXECUTIVES ("EXECUTIVES") SERVING RELATED OR DISREGARDED ENTITIES. THE COMMITTEE WORKS WITH AN INDEPENDENT COMPENSATION CONSULTANT, USES THIRD PARTY COMPARABILITY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS, AND MAKES SURE THAT TOTAL COMPENSATION AND BENEFITS FOR EACH EXECUTIVE DO NOT EXCEED FAIR MARKET VALUE WHEN COMPARED TO THE MARKET DATA FOR SIMILAR POSITIONS. THE COMMITTEE REVIEWS AND APPROVES EXECUTIVE COMPENSATION AND BENEFITS ANNUALLY, CONSISTENT WITH THE WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY OF NOVANT HEALTH, AND IN A MANNER THAT QUALIFIES FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, THEREBY ASSURING THAT TOTAL COMPENSATION AND BENEFITS PROVIDED TO EACH EXECUTIVE IS REASONABLE. THE COMMITTEE REVIEWS AND APPROVES EACH ITEM OF THE NOVANT HEALTH SYSTEM CEO'S COMPENSATION AND BENEFITS. FORM 990, PART VI, SECTION B, LINE 15B: COMPENSATION PROCESS FOR OFFICERS INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS OF COMPENSATION AND BENEFITS FOR CERTAIN LEADERS AND EXECUTIVES ("EXECUTIVES") SERVING RELATED OR DISREGARDED ENTITIES. THE COMMITTEE WORKS WITH AN INDEPENDENT COMPENSATION CONSULTANT, USES THIRD PARTY COMPARABILITY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS, AND MAKES SURE THAT TOTAL COMPENSATION AND BENEFITS FOR EACH EXECUTIVE DO NOT EXCEED FAIR MARKET VALUE WHEN COMPARED TO THE MARKET DATA FOR SIMILAR POSITIONS. THE COMMITTEE REVIEWS AND APPROVES EXECUTIVE COMPENSATION AND BENEFITS ANNUALLY, CONSISTENT WITH THE WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY OF NOVANT HEALTH, AND IN A MANNER THAT QUALIFIES FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, THEREBY ASSURING THAT TOTAL COMPENSATION AND BENEFITS PROVIDED TO EACH EXECUTIVE IS REASONABLE. LASTLY, IT REVIEWS AND APPROVES ALL OF THE ELEMENTS AND SPECIFICATIONS INCLUDED IN ALL OTHER EXECUTIVE AND LEADER COMPENSATION PLANS AND PROGRAMS (E.G., INCENTIVE PLAN DESIGN, AWARD OPPORTUNITIES, ETC.).
	FORM 990, PART VI, SECTION C, LINE 19	GOVERNING DOCUMENTS DISCLOSURE THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS CONTAINING ALL ORGANIZATIONS IN THE NOVANT HEALTH SYSTEM ARE POSTED TO THE NOVANT HEALTH WEBSITE. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC.
	FORM 990, PART VII, SECTION A, COLUMN B: RELATED ORGANIZATIONS	THE ORGANIZATION EMPLOYS CERTAIN EXECUTIVES WHOSE ROLES ARE SUCH THAT THEY PROVIDE SERVICES TO NOT ONLY THE ORGANIZATION, BUT ALSO TO SOME OR ALL OF THE OTHER TAX-EXEMPT ORGANIZATIONS WITHIN THE NOVANT HEALTH CARE SYSTEM. FOR EXAMPLE, MANY OF THESE EXECUTIVES' ROLES FOCUS ON PARTICULAR SERVICE LINES WHICH CROSS THE VARIOUS GEOGRAPHIC MARKETS OUR ORGANIZATIONS SERVE, THUS THE SERVICES PROVIDED BY THESE EXECUTIVES MAY BENEFIT AND BE RECEIVED BY MULTIPLE ORGANIZATIONS WITHIN THE SYSTEM. THE EXECUTIVES DO NOT ALLOCATE THEIR HOURS BETWEEN THE VARIOUS ORGANIZATIONS, BUT RATHER THEIR TIME SPENT ON SERVICES TO THE ORGANIZATION IS INCLUSIVE OF SERVICES TO ALL OF THE ORGANIZATIONS THEY SERVE WITHIN THE SYSTEM.
CHANGES IN NET ASSETS OR FUND BALANCES:	FORM 990, PART XI, LINE 5:	FMCF AND AUXILIARY OF FMC CONTRIBUTION: -2,336,014. AFFILIATE TRANSFERS: -3,871,104. MALPRACTICE INSURANCE: -4,933,800. PRESENT VALUE OF FTCC GRANT: 8,643. TOTAL TO FORM 990, PART XI, LINE 5: -11,132,275.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL

Employer identification number

56-0928089

Part I

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

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity
(1) EXCEL IMAGING LLC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 20-4253946	INACTIVE	NC	0	0	FORSYTH MEMORIAL HOSPITAL
(2) SALEM MRI LLC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103	INACTIVE	NC	0	0	FORSYTH MEMORIAL HOSPITAL
(3) THE BREAST CLINIC MRI LLC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103	INACTIVE	NC	0	0	FORSYTH MEMORIAL HOSPITAL

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) AUXILIARY OF FORSYTH MEMORIAL HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0862112	HEALTHCARE	NC	501(C)(3)	LINE 9	FORSYTH MEMORIAL HOSPITAL	Yes
(2) BRUNSWICK NOVANT MEDICAL CENTER FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 27-4616751	HEALTHCARE	NC	501(C)(3)	LINE 7	BRUNSWICK COMMUNITY HOSPITAL LLC		No
(3) CAROLINA MEDICORP ENTERPRISES 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1466368	HEALTHCARE	NC	501(C)(3)	LINE 11B, II	NOVANT MEDICAL GROUP		No
(4) COMMUNITY GENERAL HEALTH PARTNERS 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0636250	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH TRIAD REGION		No
(5) COMMUNITY GENERAL HOSPITAL FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1828629	HEALTHCARE	NC	501(C)(3)	LINE 7	COMMUNITY GENERAL HEALTH PARTNERS		No
(6) CONTINUING CARE SERVICES 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1288473	HEALTHCARE	VA	501(C)(3)	LINE 9	PRINCE WILLIAM HEALTH SYSTEM		No
(7) FORSYTH MEDICAL CENTER FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-2120959	HEALTHCARE	NC	501(C)(3)	LINE 7	FORSYTH MEMORIAL HOSPITAL	Yes
(8) FOUNDATION HEALTH SYSTEMS CORP 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1373175	HEALTHCARE	NC	501(C)(3)	LINE 9	NOVANT HEALTH TRIAD REGION		No
(9) MEDICAL PARK HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1340424	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH TRIAD REGION		No
(10) NOVANT HEALTH INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1376950	HEALTHCARE	NC	501(C)(3)	LINE 11C, III-FI	N/A		No
(11) NOVANT MEDICAL GROUP 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1728803	HEALTHCARE	NC	501(C)(3)	LINE 3	NMG SERVICES INC		No
(12) PERSONAL CARE SERVICES 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1291284	HEALTHCARE	VA	501(C)(3)	LINE 9	PRINCE WILLIAM HEALTH SYSTEM		No
(13) PRESBYTERIAN HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0554230	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH SOUTHERN PIEDMONT REGION		No
(14) PRESBYTERIAN HOSPITAL FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1413074	HEALTHCARE	NC	501(C)(3)	LINE 7	NOVANT HEALTH SOUTHERN PIEDMONT REGION		No
(15) PRESBYTERIAN MEDICAL CARE CORPORATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1376368	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH SOUTHERN PIEDMONT REGION		No
(16) PRINCE WILLIAM HEALTH SYSTEM 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1278944	HEALTHCARE	VA	501(C)(3)	LINE 11C, III-FI	NOVANT HEALTH		No
(17) PRINCE WILLIAM HEALTH SYSTEM FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1307595	HEALTHCARE	VA	501(C)(3)	LINE 11A, I	PRINCE WILLIAM HEALTH SYSTEM		No
(18) PRINCE WILLIAM HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-0696355	HEALTHCARE	VA	501(C)(3)	LINE 3	PRINCE WILLIAM HEALTH SYSTEM		No
(19) ROWAN HEALTH SERVICES CORP 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1424814	HEALTHCARE	NC	501(C)(3)	LINE 11C, III-FI	NOVANT HEALTH		No
(20) NMG SERVICES INC (FKA ROWAN MEDICAL PRACTICES) 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-2098809	HEALTHCARE	NC	501(C)(3)	LINE 9	NOVANT HEALTH		No
(21) ROWAN REGIONAL MEDICAL CENTER AUXILIARY 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 23-7022472	HEALTHCARE	NC	501(C)(3)	LINE 9	ROWAN REGIONAL MEDICAL CENTER		No
(22) ROWAN REGIONAL MEDICAL CENTER FOUNDATION INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1424818	HEALTHCARE	NC	501(C)(3)	LINE 7	ROWAN REGIONAL MEDICAL CENTER		No
(23) ROWAN REGIONAL MEDICAL CENTER INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0547479	HEALTHCARE	NC	501(C)(3)	LINE 3	ROWAN HEALTH SERVICES CORP		No
(24) SELF INSURANCE FUND - NOVANT HEALTH INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1867242	HEALTHCARE	NC	501(C)(3)	LINE 11C, III-FI	NOVANT HEALTH		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2011

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(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

Schedule R (Form 990) 2011

Page 3

Part V

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

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

Yes

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

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

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

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

Yes

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

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

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

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

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

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

Yes

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

Yes

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

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

Yes

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

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

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

Yes

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

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

Yes

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

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

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1) FORSYTH MEDICAL CENTER FOUNDATION	Q	3,871,104	CASH
(2) FORSYTH MEDICAL CENTER FOUNDATION	C	2,316,720	CASH
(3) AUXILIARY OF FORSYTH MEMORIAL HOSPITAL	C	19,294	CASH
(4)
(5)
(6)

Schedule R (Form 990) 2011

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2011

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: SEE SCHEDULE O
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	20
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	16
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	7,584
6	Total number of volunteers (estimate if necessary) ....	6	986
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	500,673
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	109,574

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	3,414,624	2,577,799
9	Program service revenue (Part VIII, line 2g) .........	835,247,712	887,587,244
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	-12,263	-244,870
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	62,398,310	65,567,008
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	901,048,383	955,487,181
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	180,878	372,774
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)	386,412,199	425,101,646
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	421,385,517	477,298,833
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	807,978,594	902,773,253
19	Revenue less expenses. Subtract line 18 from line 12.......	93,069,789	52,713,928
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	850,834,530	889,125,682
21	Total liabilities (Part X, line 26).............	49,541,905	46,251,404
22	Net assets or fund balances. Subtract line 21 from line 20.....	801,292,625	842,874,278

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 762,688,535 including grants of $ 372,774 ) (Revenue $ 947,540,011 )
	FORSYTH MEMORIAL HOSPITAL, INC. (FMH) AND KERNERSVILLE MEDICAL CENTER (KMC) CARRY OUT THE PURPOSE OF THE FORSYTH COUNTY BOARD OF COMMISSIONERS BY ADVANCING AND SUPPORTING THE PROMOTION OF THE HEALTH OF THE INHABITANTS OF FORSYTH COUNTY AND THE KERNERSVILLE AREA. FMH AND KMC MAINTAIN AN OPEN DOOR POLICY, ACCEPTING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. FMH HAS 921 LICENSED BEDS. DURING 2011 THERE WERE 228,862 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 5.78 DAYS, AN AVERAGE DAILY CENSUS OF 627, AND 39,629 DISCHARGES. THERE WERE 25,479 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 1,054,801 OUTPATIENT ENCOUNTERS AND 95,146 EMERGENCY DEPARTMENT VISITS. (CONTINUED ON SCHDULE 0)KMC HAS 50 LICENSED BEDS. DURING 2011 THERE WERE 4,175 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 3.19 DAYS, AND AVERAGE DAILY CENSUS OF 14, AND 1,309 DISCHARGES. THERE WERE 1,429 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 15,535 OUTPATIENT ENCOUNTERS AND 14,893 EMERGENCY DEPARTMENT VISITS.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 762,688,535

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	5,001,731	1,796,537	1,237,276

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		2,336,014
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f		241,785
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			2,577,799
			Business Code
2a	NET PATIENT REVENUE		621,990	887,587,244	887,587,244
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			887,587,244
3	Investment income (including dividends, interest
	and other similar amounts).....			5,560			5,560
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross rents	3,581,121
b	Less: rental expenses	0
c	Rental income or (loss)	3,581,121
d	Net rental income or (loss).......			3,581,121			3,581,121
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		66,199
b	Less: cost or other basis and sales expenses		316,629
c	Gain or (loss)		-250,430
d	Net gain or (loss)..........			-250,430			-250,430
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	PHARMACY		446,110	50,635,665	50,183,374	452,291
b	MISCELLANEOUS REVENUE		621,990	5,776,865	5,728,483	48,382
c	CAFETERIA		722,210	3,334,964	3,334,964
d	All other revenue ....			2,238,393	705,946		1,532,447
e	Total. Add lines 11a–11d ......			61,985,887
12	Total revenue. See Instructions....			955,487,181	947,540,011	500,673	4,868,698


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			2,350,739	1	3,529,739
2	Savings and temporary cash investments .......				2
3	Pledges and grants receivable, net .........			230,565	3	167,577
4	Accounts receivable, net .........			125,995,888	4	98,613,263
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........			47,685	5	30,685
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............			6,556,006	7	7,792,203
8	Inventories for sale or use ..............			11,035,044	8	14,946,588
9	Prepaid expenses and deferred charges ............			1,084,525	9	368,711
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	370,511,852
b	Less: accumulated depreciation. .....	10b	214,086,433	77,148,221	10c	156,425,419
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........			29,563,796	14	31,510,968
15	Other assets. See Part IV, line 11 ...........			596,822,061	15	575,740,529
16	Total assets. Add lines 1 through 15 (must equal line 34)...			850,834,530	16	889,125,682
17	Accounts payable and accrued expenses .			43,941,007	17	38,342,075
18	Grants payable ..........				18
19	Deferred revenue ..........			191,829	19	189,281
20	Tax-exempt bond liabilities ..........				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			5,409,069	25	7,720,048
26	Total liabilities. Add lines 17 through 25.....			49,541,905	26	46,251,404
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			801,292,625	27	842,874,278
28	Temporarily restricted net assets .....				28
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			801,292,625	33	842,874,278
34	Total liabilities and net assets/fund balances .....			850,834,530	34	889,125,682