TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(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
(1) JAMES BRUDVIG........................................................................ CHAIRMAN	2.0 .......................	X				0	0	0
(2) DENISE GEORGE........................................................................ PRESIDENT	1.0 .......................63.0	X	X			0	434,005	44,124
(3) SUE CRANE........................................................................ LIFE MEMBER	1.0 .......................	X				0	0	0
(4) DRAYTON GRANT........................................................................ MEMBER	1.0 .......................	X				0	0	0
(5) LEWIS RUGE........................................................................ LIFE MEMBER AND SECRETARY	1.0 .......................	X				0	0	0
(6) GEORGE VERRILLI MD........................................................................ LIFE MEMBER	1.0 .......................	X				0	0	0
(7) M NADER KAYAL JR MD........................................................................ LIFE MEMBER	1.0 .......................	X				0	0	0
(8) EVAN MELTZER........................................................................ FIRST VICE CHAIRMAN	2.0 .......................	X				0	0	0
(9) WILLIAM CARROLL........................................................................ MEMBER	1.0 .......................	X				0	0	0
(10) SUSAN KOCHANOWSKI PHD........................................................................ MEMBER	1.0 .......................	X				0	0	0
(11) JOHN HORISZNY MD........................................................................ MEMBER	1.0 .......................	X				0	0	0
(12) KEVIN M SHEEHAN........................................................................ SECOND VICE CHAIRMAN	2.0 .......................	X				0	0	0
(13) MICHAEL T WEBER........................................................................ CEO	1.0 .......................65.0	X	X			0	1,006,627	53,723
(14) RUSSELL TIGGES MD........................................................................ MEDICAL STAFF PRESIDENT	1.0 .......................	X				0	0	0
(15) MARYANN KEPPLE........................................................................ TREASURER	0.0 .......................60.0		X			0	506,786	20,505
(16) JOHN SABIA MD........................................................................ CMO	0.0 .......................55.0			X		0	226,511	40,083
(17) CONNIE REGAN........................................................................ PHARMACY CLINICAL COORDINATOR	39.0 .......................				X	161,511	0	11,008

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	0	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0	0
4	Benefits paid to or for members	0	0
5	Compensation of current officers, directors, trustees, and key employees ....	0	0	0	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0	0	0	0
7	Other salaries and wages	22,192,479	19,827,718	2,364,761	0
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,096,137	979,336	116,801	0
9	Other employee benefits .......	4,783,351	4,273,652	509,699	0
10	Payroll taxes ...........	1,783,271	1,593,251	190,020	0
11	Fees for services (non-employees):
a	Management ......	0	0	0	0
b	Legal .........	0	0	0	0
c	Accounting ...........	0	0	0	0
d	Lobbying ...........	3,355	0	3,355	0
e	Professional fundraising services. See Part IV, line 17	0			0
f	Investment management fees ......	0	0	0	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	75,029	75,029
12	Advertising and promotion ....	0	0	0	0
13	Office expenses .......	1,857,739	1,012,874	844,865	0
14	Information technology ......	73,661	42,505	31,156	0
15	Royalties ..	0	0	0	0
16	Occupancy ...........	1,304,075	1,069,180	234,895	0
17	Travel ............	39,312	32,314	6,998	0
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0	0	0	0
19	Conferences, conventions, and meetings ....	239	239	0	0
20	Interest ...........	677,448	555,423	122,025	0
21	Payments to affiliates .......	0	0	0	0
22	Depreciation, depletion, and amortization .....	3,890,100	3,189,400	700,700	0
23	Insurance ..............	855,352	701,283	154,069	0
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES	10,491,960	10,461,898	30,062
b	PURCHASED SERVICES	12,578,180	2,766,349	9,811,831
c	PHYSICIAN FEES	1,994,728	1,994,728
d	BAD DEBT	2,022,373	2,022,373
e	All other expenses	1,959,414	1,204,735	754,679
25	Total functional expenses. Add lines 1 through 24e	67,678,203	51,802,287	15,875,916	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).	0	0	0	0

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	65,065	1	4,661,604
2	Savings and temporary cash investments .........	1,604,378	2	0
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	7,703,568	4	7,353,967
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	2,877	7	36,336
8	Inventories for sale or use ..............	1,058,035	8	1,151,031
9	Prepaid expenses and deferred charges ..........	693,636	9	667,733
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	85,538,028
b	Less: accumulated depreciation .....	10b	52,407,503	34,535,099	10c	33,130,525
11	Investments—publicly traded securities ..........	3,367,675	11	3,764,129
12	Investments—other securities. See Part IV, line 11 .....	0	12	0
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	18,056,539	15	18,868,347
16	Total assets. Add lines 1 through 15 (must equal line 34)......	67,086,872	16	69,633,672
	17	Accounts payable and accrued expenses .........	6,060,469	17	6,400,749
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	13,220,195	20	12,432,324
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	873,622	23	437,126
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	9,420,042	25	9,298,010
26	Total liabilities. Add lines 17 through 25.........	29,574,328	26	28,568,209
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	33,664,710	27	37,166,689
28	Temporarily restricted net assets ...........	2,352,430	28	2,403,370
29	Permanently restricted net assets ...........	1,495,404	29	1,495,404
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........	37,512,544	33	41,065,463
34	Total liabilities and net assets/fund balances ........	67,086,872	34	69,633,672

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

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 described in 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. See section 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 - Non-functionally integrated

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 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 monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. 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—2011. If the organization did not check a 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—2012. 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—2011. 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) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

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 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. 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—2011. 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) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

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

2012

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization NORTHERN DUTCHESS HOSPITAL

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization NORTHERN DUTCHESS HOSPITAL

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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

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) (2012)

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

2012

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

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 SchCMd Bullet

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 SchCMd Bullet

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) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable 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) 2012

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

3,355

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

3,355

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, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
SCHEDULE C, PART II-B, LINE 1I	LOBBYING ACTIVITIES	14.6% OF NORMET ASSOCIATION DUES WERE ALLOCATED TO POLITICAL ACTIVITIES, RELATED TO LOBBYING.

Schedule C (Form 990 or 990EZ) 2012

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

2012

Open to Public Inspection

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

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 section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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 XIII, 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

Using the organization’s acquisition, 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 XIII.

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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........

Part V

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

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	1,495,404	1,495,404	1,495,400	1,495,000	1,495,000
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 ......	1,495,404	1,495,404	1,495,400	1,495,000	1,495,000

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

100.000 %

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 XIII 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 .................	109,930		109,930
b	Buildings ................	44,659,481	21,108,796	23,550,685
c	Leasehold improvements ............
d	Equipment ................	38,860,799	30,305,590	8,555,209
e	Other .................	1,907,818	993,116	914,702
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				33,130,526

Schedule D (Form 990) 2012

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				7,569,461
(2) DEFERRED COMPENSATION ASSET				177,268
(3) DEFERRED FINANCING				435,832
(4) 2007 SERIES B BONDS PREMIUM				720,008
(5) 2007 DSRF SERIES B BONDS				1,632,104
(6) MISC RECEIVABLES				520,877
(7) ESTIMATED THIRD PARTY ADJMNTS				336,068
(8) DSRF TELP LOAN TDBANK GENERAL				139,850
(9) INTEREST IN NDH FOUNDATION LT				2,088,545
(10) DUE FROM AFFILIATE LT				5,248,334
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				18,868,347

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes		0
HITNY LIABILITY		623,244
DEFERRED COMP LIABILITY		177,268
FIN 47 LIABILITY		257,499
RETRO PAYABLE TO 3RD PARTY PAY		2,627,549
DUE TO AFFILIATES		65,554
DUE TO HQ L/T		298,562
MED MALPRACTICE INSURANCE LIAB		5,248,334


Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		9,298,010
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	71,180,158
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	304,492
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	-3,356,133
e	Add lines 2a through 2d .....................			2e	-3,051,641
3	Subtract line 2e from line 1.....................			3	74,231,799
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 XIII.) ...........	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	74,231,799

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1	67,678,203
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 XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3	67,678,203
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 XIII.) ............	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	67,678,203

Part XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
TRANSFER OF EQUITY	SCHEDULE D PART XI LINE 2D	TRANSFER OF EQUITY - ($3,356,133)
ENDOWMENT FUNDS	SCHEDULE D, PART V, LINE 4	THE ORIGINAL CONTRIBUTION IS BEING HELD FOR THE BENEFIT OF THE HOSPITAL.

Schedule D (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

Part I

Financial Assistance 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) as a factor in determining eligibility for providing free care?

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

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

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

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining 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, as a factor in determining eligibility for free or discounted care.

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..			1,722,640	986,480	736,160	1.090 %
b	Medicaid (from Worksheet 3, column a) ....			5,601,188	3,801,322	1,799,866	2.660 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .			7,323,828	4,787,802	2,536,026	3.750 %
Other Benefits		6	347	15,140		15,140	0.020 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	6	347	15,140		15,140	0.020 %
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)
j	Total. Other Benefits ..	6	347	15,140		15,140	0.020 %
k	Total. Add lines 7d and 7j .	6	347	7,338,968	4,787,802	2,551,166	3.770 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

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	1	2,824	32,140	150	31,990	0.050 %
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	1	2,824	32,140	150	31,990	0.050 %

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. Explain in Part VI the methodology used by the organization to estimate this amount. ......

1,443,178

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

721,589

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

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

23,142,421

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

28,681,543

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

-5,539,122

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—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) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?3 Name, address, and primary website address				Facility reporting group
1	NORTHERN DUTCHESS HOSPITAL 6511 SPRINGBROOK AVENUE RHINEBECK,NY12572 WWW.HEALTH-QUEST.ORG	X		A
2	HYDE PARK SATELLITE HEALTH CENTER 11 CRUM ELBOW ROAD HYDE PARK,NY12538 WWW.HEALTH-QUEST.ORG		X	A
3	STANDFORDVILLE COMM HEALTH CLINIC 3 GRISTMILL LANE STANDFORD,NY12581 WWW.HEALTH-QUEST.ORG		X	A

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	NORTHERN DUTCHESS HOSPITAL
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Did the hospital facility make its CHNA report widely available to the public? .............

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	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 website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	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?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	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?..........	17	Yes
	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)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

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.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

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?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2012

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; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
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.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
PART I, LINE 3C	PART I, LINE 3C	N/A
PART I, LINE 6A	PART I, LINE 6A	NORTHERN DUTCHESS HOSPITAL PREPARES A COUNTY WIDE COMMUNITY SERVICE REPORT.
PART I, LINE 7 COLUMN F	PART I, LINE 7, COLUMN F	TOTAL BAD DEBT EXPENSE EXCLUDED FROM COLUMN F PERCENTAGE - $2,022,373
PART I, LINE 7	PART I, LINE 7	COST TO RATIO PERCENTAGE WAS USED AS THE COSTING METHODOLOGY. WORKSHEET #2 WAS USED TO DERIVE THE PERCENTAGE.
PART III, LINE 4	PART III, LINE 4	BAD DEBT EXPENSE WAS GROSSED UP TO GROSS CHARGES AND THEN THE COST TO CHARGE RATIO PERCENTAGE DERIVED FROM WORKSHEET #2 WAS USED TO CALCULATE THE VALUE AT COST. SELF PAY ACCOUNTS, ONCE DETERMINED A LACK OF INSUFFICIENCY OF INSURANCE AND ONCE THE PATIENT HAS RECEIVED GOVERNMENT PAYOR DENIAL, THE ACCOUNTS ARE ADJUSTED DOWN TO THE HIGHEST VOLUME COMMERCIAL PAYOR RATE. AFTER THE ACCOUNT IS DEEMED UNCOLLECTIBLE, THE ACCOUNT IS WRITTEN OFF TO BAD DEBT EXPENSE AT ADJUSTED CHARGES LESS ANY PAYMENTS MADE ON THE ACCOUNT. 50% OF THESE PATIENTS WOULD MOST LIKELY QUALIFY FOR CHARITY CARE IF THEY WERE COOPERATIVE IN FILING THE PAPERWORK, ASSOCIATED WITH GOVERNMENT ASSISTANCE. FOOTNOTE ON AUDITED FINANCIALS - FEDERAL AND STATE LAW REQUIRES THE HOSPITALS TO PROVIDE EMERGENCY SERVICES REGARDLESS OF A PATIENT'S ABILITY TO PAY. UNINSURED PATIENTS SEEN IN THE EMERGENCY DEPARTMENT, INCLUDING PATIENTS SUBSEQUENTLY ADMITTED FOR INPATIENT SERVICES, OFTEN DO NOT PROVIDE INFORMATION NECESSARY TO ALLOW THE HOSPITAL TO QUALIFY SUCH PATIENTS FOR CHARITY CARE. UNCOLLECTIBLE AMOUNTS DUE FROM SUCH UNINSURED PATIENTS REPRESENT THE SUBSTANTIAL PORTION OF THE PROVISION FOR BAD DEBTS REFLECTED IN THE ACCOMPANYING STATEMENT OF OPERATIONS.
PART III, LINE 8	PART III, LINE 8	THE MEDICARE SHORTFALL SHOULD BE INCLUDED IN OUR COMMUNITY BENEFIT PERCENTAGE BECAUSE WE ARE INCURRING THE FULL COST OF CARE FOR THE PATIENTS IN OUR COMMUNITY AND OUR REIMBURSEMENT FROM GOVERNMENT PROGRAMS, INCLUDING MEDICARE, DOES NOT COVER THE HOSPITALS COST TO PROVIDE HIGH QUALITY PATIENT CARE. THE COSTING METHODOLOGY TO CALCULATE THE SHORTFALL IS COST TO CHARGE RATIO AND WORKSHEET #2 WAS USED. COST TO CHARGE RATIO - USED WORKSHEET #2
PART III, LINE 9B	PART III, LINE 9B	HEALTH QUEST MAY CHOOSE TO SEND ANY DELIQUENT ACCOUNT TO A COLLECTION AGENCY, HOWEVER, BEFORE REFERRING A DELIQUENT ACCOUNT TO A COLLECTION AGENCY, HEALTH QUEST WILL REVIEW THE ACCOUNT TO DETERMINE WHETHER THE PATIENT HAS APPLIED FOR A DISCOUNT UNDER THE CHARITY CARE POLICY AND THE STATUS OF THE APPLICATION. IF THE PATIENT HAS APPLIED FOR A DISCOUNT, THE ACCOUNT MAY NOT BE REFERRED TO A COLLECTION AGENCY UNTIL A FINAL DETERMINATION OF SUCH APPLICATION IS MADE AND IF ANY APPEAL OF SUCH DETERMINATION IS PROVIDED FOR IN THE CHARITY CARE POLICY, A FINAL DETERMINATION HAS BEEN MADE WITH RESPECT TO SUCH APPEAL. PATIENTS MAY STILL APPLY FOR A DISCOUNT UNDER THE CHARITY CARE POLICY EVEN AFTER THE ACCOUNT HAS BEEN SENT TO A COLLECTION AGENCY.
PART V, LINE 20D	PART V, LINE 20D	THE HOSPITAL FACILITY USES THE HIGHEST VOLUME COMMERCIAL PAYOR RATE TO BILL INDIVIDUALS WHO DO NOT HAVE INSURANCE.
PART VI, LINE 2	PART VI, LINE 2 NEEDS ASSESSMENT	The Community Health Needs Assessment Process Northern Dutchess Hospital participated in a CHNA with the Dutchess County Department of Health. The Integrated Community Assessment Workgroup (ICA) was established in 2008 by the Integrated Community Planning Workgroup (ICP) to implement a countywide integrated assessment. Its goal is to examine the local health and human services system including all aspects of the local environment - i.e. physical, legal, social, economic, and health. The assessment was achieved by conducting a survey reaching out to a representative sample of Dutchess County residents. The ICP consists of health and human services public agency representatives, and the ICA consists of a smaller group of individuals from the lead agencies - Dutchess County Department of Health, Dutchess County Community and Family Services, Dutchess County Department of Mental Hygiene, Dutchess County Department of Probation, Dutchess County Department of Planning & Development; Dutchess County Office for Aging, Dutchess County Veterans Services; as well as the Mental Health Association, the Dyson Foundation, the Foundation for Community Health, Health Quest, and St Francis Hospital. The ICP has been building upon other community assessment data, including the Many Voices One Valley Report, a project of the Dyson Foundation and the Marist College Institute for Public Opinion to examine residents' priorities for the Mid-Hudson Region (http://www.manyvoicesonevalley.org/). Several independent assessments have been conducted over the years, notably: o An annual countywide data document capturing available economic, educational and health data that impact children, youth, families and adults o A community health assessment report issued every three years for selected indicators In 2009, the County issued its first systematic and integrated assessment, accomplished via survey administration to a representative sample of Dutchess County residents. The results of the 2009 integrated assessment have fed the strategic planning process of each department involved, as well as the ICP. It also ensures that the Health and Human Services planning process is responsive to community strengths and needs and results in a plan that can be implemented successfully, where clear indicators can be tracked and benchmarked. In 2012, members of the ICA reviewed the questions from the 2009 survey. While some questions were discarded or added, care was taken to insure that survey results would be compatible with the 2009 results for trending purposes. Once the survey questions were finalized, the group issued an RFP and retained a firm to conduct the survey. The firm made 11,227 calls between November 31, 2012 and January 18, 2013. They achieved a 10% response rate, including both land lines and cell phones. The raw data was submitted to the Dutchess Department of Health, where it was analyzed and compiled by their epidemiologist. On September 17, 2013, the Dutchess County Department of Health hosted a county-wide Community Health Improvement Plan Design Forum. The purpose of the forum was to review the results of the recent survey and develop a locally relevant, comprehensive action plan to improve the health and lives of the residents of Dutchess County. Representatives from various agencies attended, including staff, management and physician representation from Health Quest, VBMC and NDH. As a result of the survey and subsequent analysis, Dutchess County identified the following four priority areas: 1. Reduce Childhood and Adult Obesity 2. Increase Access to preventative healthcare and improve management of chronic disease 3. Reduce Tick and Insect-related Diseases 4. Reduce Substance Abuse While insect-related disease does not appear to fit into any of the Preventive Agenda's categories, it was by far the biggest health concern for Dutchess County residents who responded to the survey. We have, in order to be consistent with the Prevention Agenda structure, considered it to be in the Safe and Healthy Environment category. Northern Dutchess Hospital: Three Year Plans of Action 1. Vaccinate Preventable Diseases - Decrease the Burden of Influenza: In choosing its first initiative, Northern Dutchess Hospital deviated slightly from the DCDOH priorities. NDH is a small hospital (68 beds) with limited resources. In NDH's service area, 18% of its population is over 65, a number projected to rise to 23% in the next 10 years. NDH has a strong focus on caring for the senior community, with its affiliated 100-bed skilled nursing facility, its Center for Healthy Aging, and its commitment to orthopedic and rehabilitative services. The hospital itself is a hub for senior activity and a natural location for outreach to the senior population. While the most recent rates of immunization available meet the NYS 2017 objective, the county lags behind the statewide rate. NDH's implementation plan is designed to build on its existing policy of screening and immunizing all inpatients by expanding screening efforts to the emergency department. It will also gauge the need for community flu clinics, which appear to be less in demand due to inexpensive vaccines being offered by pharmacies. Priority Area: Vaccinate Preventable Diseases Goal: Decrease the burden of influenza disease Increase flu immunization rates by 10%. Disparity: Increase flu immunization rates among residents 65 and older by 10%. Performance Measures Objective 1: Increase screening and vaccination of NDH patients by targeting outpatients Indicator Source Percentage of NDH patients vaccinated for influenza will increase by 20% over three years Internal data Objective 2: Increase community awareness of benefits of vaccine and community resources to receive vaccinations Indicator Source Attendance at community flu clinics will rise 10% over baseline (dependent on community need) over three years Internal data, Regional pharmacy data Action Plan Objective 1 Activity Target Date Partners Determine baseline % of NDH patients who have received the flu vaccine 4/31/2014 None required Enact protocols to screen all ED admits for vaccination and provide vaccine according to state recommendations 12/31/2013 VBMC, PHC, DCDOH Increase the percentage of patients who receive the vaccine by 8% 12/31/2014 DCDOH Increase the percentage of patients who receive the vaccine by 14% over baseline (cumulative) 12/31/2015 DCDOH Increase the percentage of patients who receive the vaccine by 20% over baseline (cumulative) 12/31/2016 DCDOH Objective 2 Activity Target Date Partners Develop at least one patient education campaign in year one 12/31/2014 DCDOH Develop at least one patient education campaign in year two 12/31/2015 DCDOH Develop at least one patient education campaign in year three 12/31/2016 DCDOH Provide outreach to senior groups through lectures, mailings and other forums. Ongoing DCDOH, Office of the Aging, Dutchess Connect Hold at least one community flu clinic in year one (determine baseline attendance) 12/31/2014 DCDOH Collaborate with community partners to offer flu clinics focused on the elderly. 12/31/2014 DCDOH, Office of the Aging, Dutchess Connect Hold at least one community flu clinic in year two, with attendance = 5% over baseline 12/31/2015 DCDOH Hold at least one community flu clinic in year three, with attendance = 10% over baseline 12/31/2016 DCDOH 2. Lyme and Other Insect-Borne Diseases: Dutchess County residents have significantly higher rates of tick-borne diseases than NYS residents overall. In both the 2009 and 2012 Dutchess Community Surveys, Lyme disease and other insect-related diseases were identified by two thirds of respondents as the top environmental concern. While VBMC's initiative focuses on education of providers, NDH will focus on education of the patient. This two-pronged approach is hoped to have a positive impact on awareness and treatment. 2011 Tick-borne Illness Rates per 100,000 Population Disease Dutchess County New York State Lyme disease 147.9 64.9 Anaplasmosis 23.9 2.8 Erlichiosis 0.7 0.4 Babesiosis 17.8 3.2 Source: DCDOH, NYSDOH Priority Area: Promote a Healthy and Safe Environment Goal: Prevent Tick-Borne Diseases in Dutchess County. Promote Use of Evidence-based Care to Manage Insect-borne Disease. Performance Measures Objective 1: Educate NDH patients on tick attachment prevention and treatment options Indicator Source 90% of people attending educational events will demonstrate increased knowledge of subject matter Pre and post testing Action Plan Objective 1 Activity Target Date Partners Collaborate with DCDOH staff to create or adopt informational pamphlet for patients 12/31/2014 DCDOH, Tick Task Force Develop protocol to disseminate information to all ED patients during tick season 12/31/2013 DCDOH, Tick Task Force Conduct at least one patient education event in year one 12/31/2014 DCDOH, Tick Task Force Conduct at least one patient education event in year two 12/31/2015 DCDOH,
PART VI, LINE 3	PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	FINANCIAL ASSISTANCE POSTERS ARE HUNG UP IN VARIOUS AREAS OF THE HOSPITAL. FOR PATIENTS THAT INQUIRE ABOUT FINANCIAL ASSISTANCE, THE POLICY IS PROVIDED TO THE PATIENT ALONG WITH ASSISTANCE IN COMPLETING THE APPLICATIONS.
PART IV, LINE 4	PART IV, LINE 4 COMMUNITY INFORMATION	NORTHERN DUTCHESS HOSPITAL'S PRIMARY SERVICE AREA COVERS HYDE PARK AND NORTHERN DUTCHESS COUNTY. IT ALSO INCLUDES SEVERAL ADJACENT ZIP CODES IN ULSTER COUNTY AND SOME OF THE SOUTHERNMOST TOWNS IN COLUMBIA COUNTY WHICH RESIDES TO THE NORTH OF THE HOSPITAL. THE HOSPITAL'S SERVICE AREAS ARE PREDOMINATELY WHITE AND SKEWING SLIGHTLY OLDER THAN THE NATIONAL AVERAGES. HIGHER PERCENTAGE OF COLLEGE DEGREES THAN THE NATIONAL AVERAGE, WITH AVERAGE HOUSEHOLD INCOMES SIGNIFICANTLY HIGHER THAN NATIONAL INCOME.
PART IV, LINE 5	PART IV, LINE 5 PROMOTION OF COMMUNITY HEALTH	ALL HOSPITALS SERVE AS COMMUNITY LEADERS IN HEALTH RELATED FUNDRAISERS, SUCH AS RELAY FOR LIFE AND THE MARCH OF DIMES. EXECUTIVES AND EMPLOYEES VOLUNTEER AND SERVE ON THE BOARDS OF MANY COMMUNITY ORGANIZATIONS AND USE HOSPITAL RESOURCES TO ASSIST COALITIONS AND MEET A BROAD DEFINITION FOR HEALTH WHICH INCLUDES EDUCATION AND HOUSING. ALL HOSPITALS OFFER SCREENING AND LECTURES TO EDUCATE THE COMMUNITY AND ENCOURAGE PREVENTATIVE MEDICINE.
PART VI, LINE 6	PART VI, LINE 6 AFFILIATE HEALTH CARE SYSTEM	HEALTH QUEST SYSTEMS, INC (DBA HEALTH QUEST) IS THE ACTIVE PARENT COMPANY TO ALL AFFILIATED HOSPITALS. HEALTH QUEST ACTS ON BEHALF OF THE HOSPITALS IN SOME COMMUNITY ASSESSMENT ACTIVITIES. HEALTH QUEST HAS TRANSITIONED TO A MODEL IN WHICH IT WILL SUPERVISE BOARD COMMITTEES AT EACH HOSPITAL AS THEY ASSESS COMMUNITY NEEDS, PLAN APPROPRIATE PROGRAMS AND MONITOR THEM FOR EFFECTIVENESS.
PART VI, LINE 7	PART VI, LINE 7 STATE FILING OF COMMUNITY BENEFIT REPORT	NORTHERN DUTCHESS HOSPITAL FILES A COUNTY-WIDE COMMUNITY SERVICE PLAN WITH NYS DEPARTMENT OF HEALTH
PART V, LINE 14G	PART V, LINE 14G	FINANCIAL ASSISTANCE POSTERS ARE HUNG UP IN VARIOUS AREAS OF THE HOSPITAL STATING WHO TO CONTACT REGARDING THE POLICY. FOR PATIENTS THAT INQUIRE ABOUT FINANCIAL ASSISTANCE, THE POLICY IS PROVIDED TO THE PATIENT ALONG WITH ASSISTANCE IN COMPLETING THE APPLICATIONS.
PART II	PART II	N/A

Schedule H (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

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 of the expenses described above? If "No," complete Part III to explain....

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2012

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 (E) amounts for that individual.

(A) Name and Title		(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 and Title		(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)DENISE GEORGEPRESIDENT	(i) (ii)	0 296,879	0 112,892	0 24,234	0 15,000	0 29,124	0 478,129	0 14,700
(2)JOHN SABIA MDCMO	(i) (ii)	0 211,303	0 15,208	0 0	0 15,000	0 25,083	0 266,594	0 14,700
(3)CONNIE REGANPHARMACY CLINICAL COORDINATOR	(i) (ii)	160,462 0	0 0	1,049 0	10,430 0	578 0	172,519 0	10,585 0
(4)BOGUMILA LANGPHARMACIST	(i) (ii)	127,823 0	0 0	0 0	8,414 0	23,455 0	159,692 0	8,203 0
(5)MICHAEL T WEBERCEO	(i) (ii)	0 685,867	0 206,535	0 114,225	0 15,000	0 38,723	0 1,060,350	0 0
(6)MARYANN KEPPLETREASURER	(i) (ii)	0 395,910	0 68,741	0 42,135	0 15,000	0 5,505	0 527,291	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
NORTHERN DUTCHESS HOSPITAL

Employer identification number
14-1338467

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	DORMITORY AUTHORITY - STATE OF NEW YORK	14-6000293	649903UK5	09-06-2007	15,718,408	PURCHASE OF EQUIPMENT		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .	1,589,913
2 Amount of bonds legally defeased . . . . . . . . . . .	0
3 Total proceeds of issue . . . . . . . . . . . . . .	16,419,184
4 Gross proceeds in reserve funds . . . . . . . . . . . .	1,126,871
5 Capitalized interest from proceeds . . . . . . . . . . .	319,526
6 Proceeds in refunding escrows . . . . . . . . . . . .	0
7 Issuance costs from proceeds . . . . . . . . . . . .	216,413
8 Credit enhancement from proceeds . . . . . . . . . . .	247,657
9 Working capital expenditures from proceeds . . . . . . . . .	0
10 Capital expenditures from proceeds . . . . . . . . . . .	13,176,836
11 Other spent proceeds . . . . . . . . . . . . . .	0
12 Other unspent proceeds . . . . . . . . . . . . . .	1,331,881
13 Year of substantial completion . . . . . . . . . . . .	2008
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .		X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X
16 Has the final allocation of proceeds been made? . . . . . . . .		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .		X

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

Cat. No. 50193E

Schedule K (Form 990) 2012

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . .	0%		%		%		%
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . .	%		%		%		%
6 Total of lines 4 and 5 . . . . . . . . . . . . . . .	%		%		%		%
7 Does the bond issue meet the private security or payment test? . . . . .
8a Has there been a sale or disposition of any of the bond financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of.	%		%		%		%
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2?

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T? . . . . .		X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .		X
b Exception to rebate? . . . . . . . .		X
c No rebate due? . . . . . . . . . .	X
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . .		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider . . . . . . . . .	0
c Term of hedge . . . . . . . . . .
d Was the hedge superintegrated? . . . . . .
e Was a hedge terminated? . . . . . . .

Schedule K (Form 990) 2012

Page 3

Part IV

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .		X
b Name of provider . . . . . . . . .	0
c Term of GIC . . . . . . . . . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .	X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X

Part VI

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

Identifier	Return Reference	Explanation
BOND ISSUES	PART I, LINE A, COLUMN E	TOTAL ISSUE PRICE PER IRS FORM 8038 - $61,974,071.30 ALLOCATED BETWEEN THREE ORGANIZATIONS
PROCEEDS	PART II, LINE 3	THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN E DUE TO INVESTMENT EARNINGS.
ARBITRAGE	PART IV, LINE 2C	(A) ISSUER NAME: DORMITORY AUTHORITY - STATE OF NEW YORK DATE THE REBATE COMPUTATION WAS PERFORMED: 12/31/2011
PRIVATE BUSINESS USE	PART III, LINE 9	THE HOSPITAL HAS RETAINED THE SERVICES OF OUTSIDE LEGAL COUNSEL TO ASSIST IN ESTABLISHING WRITTEN PROCEDURES TO ENSURE THAT ALL NONQUALIFIED BONDS OF THE ISSUE ARE REMEDIATED IN ACCORDANCE WITH THE REQUIREMENTS UNDER REGULATIONS SECTIONS 1.141-12 AND 1.145-2.
ARBITRAGE	PART IV, LINE 7	THE HOSPITAL HAS RETAINED THE SERVICES OF OUTSIDE LEGAL COUNSEL TO ASSIST IN ESTABLISHING WRITTEN PROCEDURES TO MONITOR THE REQUIREMENTS OF SECTION 148.

Schedule K (Form 990) 2012

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

2012

Open to Public
Inspection

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

Identifier	Return Reference	Explanation
RELATED TAX EXEMPT ORGANIZATIONS	SCHEDULE R, PART II - RELATED TAX EXEMPT ORGANIZATIONS	Entity Tax ID# Primary Activity Legal Domicile Exempt Code Status Public Charity Status Direct controlling Entity Vassar Brothers Medical Center 14-1338586 Hospital NY 501c3 Box 3 HQ The Foundation for Vassar Brothers Medical Center 14-1736429 Fundraising NY 501c3 Box 9 HQ Riverside Diversified Services, Inc (Parent) 14-1675545 Education NY 501c3 Box 9 HQ Alamo Ambulance Service, Inc 14-1745417 Transport NY 501c3 Box 9 HQ Hudson Valley Home Care, Inc (Certified) 14-1788412 Home Health NY 501c3 Box 9 HQ Hudson Valley Home Care, Inc (Licensed) 14-1788410 Home Health NY 501c3 Box 9 HQ Northern Duchess Hospital 14-1338467 Hospital NY 501c3 Box 3 HQ Northern Dutchess Residential Health Care Facility 22-3129608 Nursing Home NY 501c3 Box 9 HQ NDH Foundation 14-1776208 Fundraising NY 501c3 Box 9 HQ Putnam Hospital Center 14-6019179 Hospital NY 501c3 Box 3 HQ Putnam Hospital Center Foundation 06-1399319 Fundraising NY 501c3 Box 9 HQ Health Quest Medical Practice, PC 56-2669185 Medical Care NY 501c3 Box 3 HQ Health Quest Urgent Medical Practice, PC 80-0152047 Medical Care NY 501c3 Box 3 HQ Health Serve Information Technologies, LLC 14-1797086 IT Support NY 501c3 Box 3 HQ Health Quest Laboratory Support Services, LLC 45-4370644 Medical Laboratory NY 501c3 Box 3 HQ One Columbia Street, LLC 46-1626016 Real Estate Mgmt NY 501c3 Box 3 HQ
GOVERNING	FORM 990 PART VI SECTION A LINE 6, 7A AND 7B	LINE 6 - THE SOLE MEMBER OF NDH IS HEALTH QUEST SYSTEMS, INC. LINE 7A - APPOINTMENT/ELECTION OF DIRECTORS NOMINEES TO THE BOARD OF DIRECTORS OF NDH SHALL BE NOMINATED IN THE FOLLOWING MANNER: NDH'S EXECUTIVE COMMITTEE MAY PREPARE A SLATE OF NOMINEES TO PRESENT TO THE HEALTH QUEST EXECUTIVE COMMITTEE FOR ITS REVIEW AND APPROVAL NOT LESS THAN THIRTY DAYS (30) PRIOR TO THE ANNUAL MEETING OF NDH IN THE CASE OF VACANCIES CREATED BY THE EXPIRATION OF NDH DIRECTORS TERMS OF OFFICE, OR IN THE CASE OF ALL VACANCIES, AS SOON AS REASONABLY POSSIBLE. THE EXECUTIVE COMMITTEE OF HEALTH QUEST MUST APPROVE SLATES OF NOMINEES BY A MAJORITY VOTE OF THE ENTIRE HEALTH QUEST EXECUTIVE COMMITTEE. ONCE HEALTH QUEST'S EXECUTIVE COMMITTEE APPROVES THE SLATE OF NOMINEES BY MAJORITY VOTE, HEALTH QUEST'S EXECUTIVE COMMITTEE SHALL INFORM THE NDH BOARD OF DIRECTORS AND PRESENT THE SLATE OF NOMINEES TO THE BOARD OF TRUSTEES OF HEALTH QUEST FOR APPROVAL. LINE 7B - MANNER OF ACTING/VOTE REQUIRED FOR CERTAIN SPECIFIC ACTIONS EXCEPT AS OTHERWISE SPECIFIED IN THE CERTIFICATE OF INCORPORATION OF NDH, OR THESE BYLAWS, OR THE BYLAWS OF HEALTH QUEST, OR PROVIDED BY LAW, THE ACTS OF A MAJORITY OF THE DIRECTORS PRESENT AND VOTING AT A MEETING AT WHICH A QUORUM IS PRESENT SHALL BE THE ACTS OF THE BOARD OF DIRECTORS. THERE SHALL BE NO VOTING BY PROXY. THE POWERS TO BE EXERCISED BY THE NDH BOARD OF DIRECTORS THAT ARE (I) SUBJECT TO THE SUBSEQUENT APPROVAL OF HEALTH QUEST, OR (II) TO BE UNDERTAKEN IN COLLABORATION WITH HEALTH QUEST,ARE SET FORTH IN PARAGRAPHS (C), (D) AND (E) BELOW. THE POWERS SET FORTH IN PARAGRAPH (F) BELOW REQUIRE THE VOTE OF TWO-THIRDS OF SOLELY THE NDH BOARD OF DIRECTORS. UNLESS OTHERWISE SPECIFIED, ALL OTHER ACTIONS THAT REQUIRE NDH BOARD APPROVAL REQUIRE A MAJORITY VOTE OF SOLELY THE NDH BOARD OF DIRECTORS. PARAGRAPH (C) - ACTIONS REQUIRING HOSPITAL BOARD MAJORITY VOTE & AT LEAST NINE (9) HEALTH QUEST TRUSTEES. THE VOTE OF A MAJORITY OF THE NDH DIRECTORS PRESENT AND VOTING AT A MEETING AT WHICH A QUORUM IS PRESENT SHALL BE REQUIRED TO APPROVE THE FOLLOWING ACTIONS: (I) TERMINATION OF HEALTH QUEST'S RELATIONSHIP TO NDH AS THE SOLE MEMBER OF NDH; (II) APPROVAL OF THE ABANDONMENT OR MATERIAL DIMINUTION OF ANY SERVICE, PROGRAM OR CAMPUS OF NDH; PROVIDED HOWEVER, THAT THE ACTIONS LISTED ABOVE IN THIS ARTICLE V, SECTION 16(C) SHALL REQUIRE THE AFFIRMATIVE VOTE OF AT LEAST NINE (9) OF THE TRUSTEES OF HEALTH QUEST THEN IN OFFICE. PARAGRAPH (D) - ACTIONS REQUIRING TWO-THIRDS OF ENTIRE HOSPITAL BOARD & AT LEAST NINE (9) HEALTH QUEST TRUSTEES. THE TWO-THIRDS (2/3) OF THE ENTIRE BOARD OF NDH ("ENTIRE BOARD" SHALL MEAN THE TOTAL NUMBER OF DIRECTORS ENTITLED TO VOTE WHICH NDH WOULD HAVE IF THERE WERE NOT VACANCIES.) SHALL BE REQUIRED TO APPROVE THE FOLLOWING ACTIONS: (I) REORGANIZATION, MERGER, DISSOLUTION OF NDH; AND (II) THE SALE, LEASE OR MORTGAGE OF SUBSTANTIALLY ALL THE ASSETS OF NDH; PROVIDED HOWEVER, THAT THE ACTIONS LISTED ABOVE IN THIS ARTICLE V, SECTION 16(D) SHALL REQUIRE THE AFFIRMATIVE VOTE OF AT LEAST NINE (9) OF THE TRUSTEES OF HEALTH QUEST THEN IN OFFICE. PARAGRAPH (E) - ACTIONS REQUIRING MAJORITY OF HOSPITAL BOARD & COLLABORATION WITH HEALTH QUEST TRUSTEES. THE VOTE OF A MAJORITY OF THE NDH DIRECTORS PRESENT AND VOTING AT A MEETING AT WHICH A QUORUM IS PRESENT SHALL BE REQUIRED TO APPROVE THE FOLLOWING ACTIONS: (I) OVERSIGHT OF NDH'S QUALITY IMPROVEMENT PROCESSES, INCLUDING, BUT NOT LIMITED TO, POLICIES AND PROCEDURES AND PHYSICIAN CREDENTIALING; (II) DELIVERY OF CLINICAL SERVICES; (III) ESTABLISHMENT AND MAINTENANCE OF A COORDINATED PROGRAM WHICH INTEGRATES THE REVIEW ACTIVITIES OF ALL HOSPITAL SERVICES FOR THE PURPOSE OF ENHANCING THE QUALITY OF PATIENT CARE AND IDENTIFYING AND PREVENTING MALPRACTICE; (IV) OVERSIGHT OF NDH'S CORPORATE COMPLIANCE PROCESSES; AND (V) THE BOARD OF DIRECTORS MAY NOT AUTHORIZE ANY ORGANIZATION OR GROUP TO FUNCTION IN THE NAME OR ON BEHALF OF THE CORPORATION ABSENT THE PRIOR APPROVAL OF HEALTH QUEST; PROVIDED HOWEVER, THE ACTIONS LISTED ABOVE SHALL BE COORDINATED AND UNDERTAKEN IN COLLABORATION WITH, AND AS AN AFFILIATED MEMBER OF, THE HEALTH QUEST SYSTEM. PARAGRAPH (F) - ACTIONS REQUIRING TWO-THIRDS OF ENTIRE HOSPITAL BOARD. THE VOTE OF TWO-THIRDS (2/3) OF THE ENTIRE BOARD OF NDH SHALL BE REQUIRED TO APPROVE THE FOLLOWING: (I) SALE, MORTGAGE OR LEASE OF REAL PROPERTY BY NDH.
POLICIES	PART VI SECTION B LINE 11A, 12C, 15A AND 15B	LINE 11A - A COPY OF THE FORM 990 WAS EMAILED TO ALL MEMBERS OF THE BOARD. THE CHAIR OF THE HQ EXECUTIVE COMPENSATION COMMITTEE REVIEWED ALL SECTIONS RELATED TO EXECUTIVE COMPENSATION. A 3RD PARTY WAS HIRED TO PREPARE SCHEDULE K. PRICEWATERHOUSE COOPERS WAS CONSULTED IN THE PREPARATION OF SCHEDULE H. LINE 12C - ON AN ANNUAL BASIS OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST FILING WHICH IS REVIEWED BY THE HQ VP OF COMPLIANCE AND INTERNAL AUDIT. ALL POTENTIAL CONFLICTS OF INTEREST ARE REVIEWED BY THE HQ BUSINESS ETHICS COMMITTEE ON BEHALF OF NDH. LINE 15 A/B - COMPENSATION OF THE CEO, TOP MANAGEMENT AND OTHER KEY EMPLOYEES IS ESTABLISHED BY THE HQ EXECUTIVE COMPENSATION COMMITTEE BASED ON INFORMATION AND RECOMMENDATIONS OF AN INDEPENDENT THIRD PARTY.
DISCLOSURE	FORM 990 PART VI SECTION C LINE 19	LINE 19 - POLICIES AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE DOCUMENTS ARE PROVIDED EITHER ELECTRONICALLY OR PAPER COPIES. IN ADDITION, CERTAIN FINANCIAL INFORMATION IS AVAILABLE ON VARIOUS WEBSITES DUE TO REGULATORY FILINGS SUCH AS THE 990 AND BOND HOLDER REQUIREMENTS.
SCHEDULE K	PART 1, LINE A, COLUMN E	TOTAL ISSUE PRICE PER IRS FORM 8038 - $61,974,071.30, ALLOCATED AS FOLLOWS NORTHERN DUTCHESS HOSPITAL - $15,718,407.82 PUTNAM HOSPITAL CENTER - $28,161,750.86 VASSAR BROTHERS MEDICAL CENTER - $18,093,912.82
ALLOCATION METHODOLOGY FOR HQ	SCHEDULE R, PART V, LINE 2 (1)	Health Quest Systems, Inc Allocation of Support Services/Shared Expenses/Cash Funding General: The following services are considered shared services for Health Quest affiliates and the cost to provide these services are allocated to each entity which benefits from the service based on a pre defined allocation methodology: 1. Specialty Staffing a. VBMC Surgical b. Radiology c. Oncology d. VBMC Sleep Lab e. PT/OT/ST f. Cardiac Rehab 2. Clinical Management a. Emergency Room b. Pharmacy c. Cardiac d. Oncology 3. Revenue Cycle including health information management, budgets and reimbursement, revenue cycle, system business office, patient access oversight, financial clearance center, managed care and decision support 4. Facilities including courier service, construction, property management, facility operations, food service management and security 5. Business Development including strategic planning, marketing and public relations, answering service and community education 6. Corporate Finance including accounts payable, payroll, general accounting, purchasing, supply chain and mailroom, practice management billing and management engineering 7. Internal Audit and Compliance 8. Practice management operations including physician recruitment, physician management and centralized scheduling 9. Human Resources and learning and development 10. Administrative including Executive office, Hospital Support and risk management 11. Legal Counsel 12. Information Technology and Medical Technology Services (MTS) Description of Services: 1. Specialty staffing a. Provides non union staffing services for various specialties to the hospitals, offsite ancillary locations and the Fishkill Medical Mall 2. Clinical management includes management oversight to system consolidated clinical services 3. Revenue Cycle - a. Health Information Management functions includes coding and transcription of medical records for all 3 hospitals b. Budget functions include preparation of annual budgets, variance reporting and maintenance of the budget module Reimbursement functions include preparation of annual cost reports, analysis of third party rate accounts and third party audits c. Revenue cycle functions include charge master analysis and development of revenue producing charges, compliance with CPT coding and establishment of appropriate charges d. System business office services includes producing claims for third party payers and private pay patients, payment processing, periodic reporting, accounts receivable analysis, charity care application process, denial management, collection and follow up for the hospitals. Patient access and financial clearance center includes oversight of all centralized registration areas at the hospitals and pre-authorization for numerous hospital services to insure compliance with third party regulations e. Managed Care functions include contract negotiations and analysis of contract terms f. Decision Support functions include cost accounting reporting, maintenance of HBI (Horizon Business Insight) reporting and the contract management system 4. Facilities - a. Courier service provides delivery services internally throughout the HQ system and bank deposit drop offs b. Construction and property management functions include contracting services for Health Quest projects and property management of all HQ facilities c. Facility operations include management oversight of the engineering departments for the hospitals d. Food Service management includes management oversight of food and nutrition departments for the hospitals e. Security functions include management oversight of all facilities to ensure the safest environment 5. Business Development - a. Strategic Planning functions include CON submissions, market data analysis and assistance with business plans b. Marketing includes advertising services, coordination of joint Health Quest advertisements and reduction of expenses associated with larger campaigns c. Public relations functions include coordination of Health Quest communication to external customers, patients and media d. Oversight of the outsourced answering services for physicians affiliated with the hospitals and HQMP e. Community education functions include training classes specific to life saving techniques 6. Finance - a. Accounts payable functions include scheduling vendor payments, insuring flow of goods and services, maintaining days cash on hand goals and maintaining days in accounts payable b. Payroll functions include biweekly employee payments and tax filings in accordance with Human Resources and Payroll policies c. General Accounting functions include preparation of financial statements, account analysis, contract reconciliation, tax filings, investment coordination, insurance coordination and coordination of internal and external audit functions d. Purchasing, supply chain and mailroom functions include procurement services, contract negotiations, price negotiations, capital purchase negotiations, management/distribution of hospital inventory, and central mailroom management e. Practice management billing functions include producing all claims for third party payers and private pay patients, payment processing, periodic reporting, accounts receivable analysis, charity care application process, denial management, collection and follow up services for all employed HQ physicians f. Management Engineering functions include evaluating each area within HQ to ensure compliance with various productivity benchmarks optimizing staffing ratios 7. Internal Audit and Compliance includes oversight of the corporate compliance program, internal audit, HIPAA compliance, contract review and compliance 8. Human Resource and learning and development functions include recruitment, compensation, benefit administration and employee training 9. Physician management operations functions include oversight of all HQ physician practices, physician recruitment functions, and the centralized scheduling office 10. Administrative functions include oversight of the Health Quest system, hospital management and risk management 11. Legal Counsel functions include internal legal services for HQ and coordination of all outsourced legal initiatives 12. Information Technology and MTS - a. IT provides information technology support for all applications and telephony support within HQ. In addition provides project management services for all new and upgrades to current IT applications. b. MTS/Biomed includes technical services provided to each hospital for equipment repair and maintenance Shared Expenses: In addition to services provided by support departments, certain insurance policies are consolidated for all Health Quest entities. These include property insurance, travel, crime, environmental, cyber risk and Directors and Officers insurance. Affiliate Cash Shortfalls: Affiliate cash shortfalls are funded by the entity(s) benefiting from the affiliate services. Examples include Health Quest Medical Practice and the Thompson House. The cash shortfall funding is based on the percentage of benefit received (percentage of revenue by division for HQMP and admissions to the Thompson House from the hospitals) Allocation Methodology: Net Revenue - lab management, budgets, revenue cycle, managed care, decision support, all facilities (excluding construction), business development, general accounting, management engineering, internal audit and compliance, executive office, legal, information technology and MTS # of visits/procedures - staffing specialties Historical trends - health information management, clinical management and hospital support Cash collections - patient accounting and the financial clearance center # of FTE's - payroll and human resources Non payroll expenses - accounts payable and purchasing Project based - construction # of FTE's allocated to physician sites - Practice management billing, operations and physician practice management System Benefits: 1. Financial planning 2. Revenue enhancement 3. Improved cash collections 4. Enhanced managed care contract rates 5. Optimized medical records coding 6. Savings for supplies, contracts, insurance and capital purchases 7. Staffing reduction through shared services 8. Enhanced employee benefit programs Health Quest Laboratory Support Services, LLC provides clinical diagnostic services to affiliate hospitals. NDH covers lab services performed for both their inpatient and outpatient services.
RECONCILIATION OF NET ASSETS	990 PART XI LINE 9	TRANSFER OF EQUITY - ($3,356,133); INTEREST IN FOUNDATION - $195,384; NET ASSETS FROM RESTRICTIONS USED FOR OPERATIONS - ($144,443); PERM RESTRICTED MISC $23
OMB CIRCULAR A-133 AUDIT	FORM 990, PART XII LINE 3A	NORTHERN DUTCHESS HOSPITAL DID NOT RECEIVE MORE THAN $500,000 IN FEDERAL AWARDS IN 2012, AND DID NOT QUALIFY FOR AN A-133 AUDIT.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

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

2012

Open to Public Inspection

Name of the organization

NORTHERN DUTCHESS HOSPITAL

Employer identification number

14-1338467

Part I

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

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

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to 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 entity?
(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) HEALTH QUEST SYSTEMS INC 45 READE PLACE POUGHKEEPSIE,NY12601 14-1678068	SUPPORT SERV			BOX 9	HQ
(2) SEE SCHEDULE O					N/A

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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" to 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	(i) Section 512(b)(13) controlled entity?
(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	Yes	No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

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 or (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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

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

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

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

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

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

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

Yes

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

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

s 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-s)	(c) Amount involved	(d) Method of determining amount involved
(1) HEALTH QUEST SYSTEMS INC	P	10,071,181	SEE SCHEDULE O
(2) HEALTH QUEST LABORATORY SUPPORT SERVICES LLC	P	1,612,168	SEE SCHEDULE O

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) 2012

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: TO PROVIDE COMPREHENSIVE PRIMARY HEALTH CARE SERVICES
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	14
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	11
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	598
6	Total number of volunteers (estimate if necessary) .............	6	126
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	86,290
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-61,642

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	706,743	210,414
9	Program service revenue (Part VIII, line 2g) .........	70,063,121	71,839,103
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	201,578	107,579
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,336,128	2,074,703
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	72,307,570	74,231,799
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	28,064,530	29,855,238
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–24e)....	34,356,215	37,822,965
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	62,420,745	67,678,203
19	Revenue less expenses. Subtract line 18 from line 12.......	9,886,825	6,553,596
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	67,086,872	69,633,672
21	Total liabilities (Part X, line 26).............	29,574,328	28,568,209
22	Net assets or fund balances. Subtract line 21 from line 20.....	37,512,544	41,065,463

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 28,608,838 including grants of $ ) (Revenue $ 39,674,566 )
	INPATIENT SERVICES: PATIENTS ADMITTED FOR ACUTE CARE - NUMBER OF PATIENTS 4,199; NUMBER OF PATIENT DAYS 16,468 THE HOSPITAL PROVIDED APPROXIMATELY $469,293 IN UNCOMPENSATED CARE (AT COST) TO THE REGIONS UN-INSURED AND UNDER-INSURED POPULATION

4b	(Code: ) (Expenses $ 23,193,449 including grants of $ ) (Revenue $ 32,164,537 )
	OUTPATIENT SERVICES: EMERGENCY VISITS 13,261; AMBULATORY SURGERY VISITS 2,797 ALL OTHER VISTIS/PROCEDURES 86,397 THE HOSPITAL PROVIDED APPROXIMATELY $771,368 IN UNCOMPENSATED CARE (AT COST) TO THE REGIONS UN-INSURED AND UNDER-INSURED POPULATION

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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses51,802,287

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) BOGUMILA LANG........................................................................ PHARMACIST	40.0 .......................	X	127,823	0	31,869
(19) TIMOTHY GOVEL........................................................................ PHARMACIST	38.0 .......................	X	129,918	0	498
(20) GAIL RICHARDSON........................................................................ DIRECTOR OF SURGICAL SERVICES	50.0 .......................	X	124,705	0	24,322
(21) PAUL KING........................................................................ DIRECTOR OF DIAGNOSTIC SVCS	45.0 .......................	X	137,089	0	12,347

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	681,046	2,173,929	238,479

(A) Name and business address	(B) Description of services	(C) Compensation





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 0

				(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
e	Government grants (contributions)1e		85,414

f	All other contributions, gifts, grants, and similar amounts not included above1f		125,000

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			210,414
			Business Code
2a	NET INPATIENT REVENUE		900099	39,674,566	39,674,566
b	NET OUTPATIENT REVENUE		900099	32,164,537	32,164,537
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			71,839,103
3	Investment income (including dividends, interest, and other similar amounts).......			93,436			93,436
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents	300,692
b	Less: rental expenses
c	Rental income or (loss)	300,692	0
d	Net rental income or (loss).......			300,692			300,692
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss)..........			14,143			14,143
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..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	AFFILIATE REVENUE		900099	709,246	709,246
b	MEANINGFUL USE REVENUE		900099	447,218	447,218
c	MEANINGFUL USE REVENUE		900099	323,036	323,036
d	All other revenue ....			294,511	208,221	86,290
e	Total. Add lines 11a–11d ......			1,774,011
12	Total revenue. See Instructions......			74,231,799	73,526,824	86,290	408,271


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			65,065	1	4,661,604
2	Savings and temporary cash investments .........			1,604,378	2	0
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			7,703,568	4	7,353,967
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			2,877	7	36,336
8	Inventories for sale or use ..............			1,058,035	8	1,151,031
9	Prepaid expenses and deferred charges ..........			693,636	9	667,733
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	85,538,028
b	Less: accumulated depreciation .....	10b	52,407,503	34,535,099	10c	33,130,525
11	Investments—publicly traded securities ..........			3,367,675	11	3,764,129
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			18,056,539	15	18,868,347
16	Total assets. Add lines 1 through 15 (must equal line 34)......			67,086,872	16	69,633,672
17	Accounts payable and accrued expenses .........			6,060,469	17	6,400,749
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			13,220,195	20	12,432,324
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			873,622	23	437,126
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			9,420,042	25	9,298,010
26	Total liabilities. Add lines 17 through 25.........			29,574,328	26	28,568,209
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			33,664,710	27	37,166,689
28	Temporarily restricted net assets ...........			2,352,430	28	2,403,370
29	Permanently restricted net assets ...........			1,495,404	29	1,495,404
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........			37,512,544	33	41,065,463
34	Total liabilities and net assets/fund balances ........			67,086,872	34	69,633,672