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)
(1) JAMES E CULLUM........................................................................ CHAIRMAN	1.0 .......................	X	X
(2) MICHAEL B CLARKE........................................................................ VICE CHAIRMAN	1.0 .......................	X	X
(3) JOHN C BIENIEK........................................................................ DIRECTOR	1.0 .......................	X
(4) DANIEL J BURKE........................................................................ DIRECTOR	1.0 .......................	X
(5) KATHIE L DUNCAN........................................................................ DIRECTOR	1.0 .......................	X
(6) KEVIN J HERLIHY MD........................................................................ DIRECTOR	1.0 .......................	X
(7) GARY R HICKS........................................................................ DIRECTOR	1.0 .......................	X
(8) DAVID CUNNINGHAM MD........................................................................ DIRECTOR	1.0 .......................	X
(9) JOHN B KELLEHER........................................................................ DIRECTOR	1.0 .......................	X
(10) GLENDA KELMAN........................................................................ SECRETARY	1.0 .......................	X	X
(11) JOANNE DAVIDSON........................................................................ DIRECTOR	1.0 .......................	X
(12) MICHAEL F MASSIANO........................................................................ DIRECTOR	1.0 .......................	X
(13) JOSEPH F RACCUIA........................................................................ DIRECTOR	1.0 .......................	X
(14) WILLIAM H REYNOLDS MD........................................................................ DIRECTOR	1.0 .......................	X
(15) SHARON RUGGI........................................................................ DIRECTOR	1.0 .......................	X
(16) MICHAEL T BITTEL........................................................................ DIRECTOR	1.0 .......................	X
(17) THOMAS J MURPHY........................................................................ DIRECTOR	1.0 .......................	X

(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
(18) DAVID WESTFALL MD........................................................................ DIRECTOR	1.0 .......................	X				0	0
(19) DAVID G KRUCZLNICKI........................................................................ PRESIDENT & CEO	40.0 .......................		X			521,545	20,547
(20) ROBERT PICKOFF MD........................................................................ VP MEDICAL AFFAIRS	40.0 .......................			X		327,916	14,338
(21) JOAN MCFAUL........................................................................ CIO	40.0 .......................			X		263,820	16,226
(22) JEFF TREASURE........................................................................ CFO	40.0 .......................			X		308,982	18,399
(23) DONNA KIRKER........................................................................ VP PATIENT SERVICES	40.0 .......................			X		208,115	9,546
(24) DIANNE SHUGRUE........................................................................ COO	40.0 .......................			X		322,740	11,276
(25) PAUL SCIMECA........................................................................ VP PHYSICIAN PRACTICES	40.0 .......................			X		226,087	22,636
(26) ROBERT W SPONZO MD........................................................................ CANCER CTR PHYS	40.0 .......................				X	579,146	20,547
(27) JOHN P STOUTENBURG MD........................................................................ CANCER CTR PHYS	40.0 .......................				X	552,325	23,328
(28) AQEEL A GILLANI MD........................................................................ CANCER CTR PHYS	40.0 .......................				X	500,726	23,328
(29) ERIC A PILLEMER MD........................................................................ CANCER CTR PHYS	40.0 .......................				X	508,434	23,328
(30) John Layden MD........................................................................ CARDIAC PHYSICIAN	40.0 .......................				X	478,539	1,197

(A) Name and business address	(B) Description of services	(C) Compensation
Portal Healthcare Solutions, 5585 Trinity ParkwayCENTERVILLEVA20120	Transcription Servic	1,096,000
Clarient Diagnostic Services, PO Box 748188LOS ANGELOSCA90074	Lab services	644,939
Hudson Energy Services, PO Box 29193NEW YORKNY10087	Energy services	470,152
Adirondack Pathology, PO Box 761LATHAMNY12110	Pathology services	420,565
Adirondack Neurology, 454 Glen StreetGLENS FALLSNY12801	Neurology services	417,251
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 24

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
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	2,292,173		2,292,173
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	150,393,272	131,091,418	19,050,028	251,826
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	3,877,418	3,331,506	539,512	6,400
9	Other employee benefits .......	18,520,931	16,010,386	2,479,789	30,756
10	Payroll taxes ...........	10,262,366	8,817,502	1,427,925	16,939
11	Fees for services (non-employees):
a	Management ......	1,432,100	868,286	563,814
b	Legal .........	457,363		457,363
c	Accounting ...........	134,330		129,690	4,640
d	Lobbying ...........	150,754		150,754
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	18,658,077	9,875,264	8,756,756	26,057
12	Advertising and promotion ....	446,072	41,986	404,086
13	Office expenses .......	69,697,568	62,820,370	6,850,618	26,580
14	Information technology ......	5,211,385	222,320	4,989,065
15	Royalties ..	0
16	Occupancy ...........	4,108,857	1,492,289	2,616,568
17	Travel ............	283,640	191,632	91,785	223
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	263,313	174,781	88,532
20	Interest ...........	3,653,847	3,145,443	508,404
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	12,585,194	10,834,065	1,751,129
23	Insurance ..............	857,925	440,208	417,717
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	OTHER EXPENSES	3,323,283	1,492,256	1,729,993	101,034
b
c
d
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	306,609,868	250,849,712	55,295,701	464,455
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	7,906,149	1	7,540,967
2	Savings and temporary cash investments .........	15,519,693	2	5,669,138
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	33,119,717	4	30,030,383
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 .............	273,063	7	243,605
8	Inventories for sale or use ..............	3,205,184	8	3,196,935
9	Prepaid expenses and deferred charges ..........	1,505,424	9	1,762,217
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	275,720,226
b	Less: accumulated depreciation .....	10b	172,903,062	96,095,543	10c	102,817,164
11	Investments—publicly traded securities ..........	58,978,729	11	67,948,324
12	Investments—other securities. See Part IV, line 11 .....	3,757,898	12	1,961,569
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 ...........	10,381,741	15	10,985,268
16	Total assets. Add lines 1 through 15 (must equal line 34)......	230,743,141	16	232,155,570
	17	Accounts payable and accrued expenses .........	42,460,592	17	35,402,581
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	59,849,504	20	58,430,905
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 ..	9,225,662	23	8,389,921
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....................	12,299,750	25	13,380,848
26	Total liabilities. Add lines 17 through 25.........	123,835,508	26	115,604,255
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	102,408,618	27	110,677,442
28	Temporarily restricted net assets ...........	2,992,343	28	4,367,201
29	Permanently restricted net assets ...........	1,506,672	29	1,506,672
	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 ...........	106,907,633	33	116,551,315
34	Total liabilities and net assets/fund balances ........	230,743,141	34	232,155,570

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

Glens Falls Hospital

Employer identification number

14-1338413

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

Glens Falls Hospital

Employer identification number

14-1338413

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 Glens Falls 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 Glens Falls 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
Glens Falls Hospital

Employer identification number

14-1338413

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

Glens Falls Hospital

Employer identification number

14-1338413

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

150,754

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

150,754

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
Part IIB, Line 1i		In 2012, Glens Falls Hospital retained a technical consultant to pursue a change in the Medicare Wage Index. The hospital contracted with a firm that is well versed in government relations in order to communicate to elected officials the financial impact that proposed state and federal legislation will have on the hospital, and to pursue additional funding streams for community services. In 2012, Glens Falls Hospital paid dues to the American Hospital Association of New York, a portion of which went towards lobbying expenses, as determined by the associations.

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

Glens Falls Hospital

Employer identification number

14-1338413

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 ....	1,506,672	1,506,672	1,506,672	1,506,672	1,506,672
b	Contributions ........	0	0	0	0	26,920
c	Net investment earnings, gains, and losses	114,227	44,224	90,709	39,660	127,098
d	Grants or scholarships .....	12,000	16,900	12,000	9,900	15,800
e	Other expenditures for facilities and programs ........	20,545		6,333	19,096	7,675
f	Administrative expenses ....	81,682	27,324	72,376	10,664	130,543
g	End of year balance ......	1,506,672	1,506,672	1,506,672	1,506,672	1,506,672

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 .................	7,462,431		7,462,431
b	Buildings ................	160,235,911	94,599,381	65,636,530
c	Leasehold improvements ............
d	Equipment ................	108,021,884	78,303,681	29,718,203
e	Other .................	0	0
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				102,817,164

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









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

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes		0
DEFERRED COMP PAYABLE		6,316,848
SELF INSURED LIABILITY RESERVE		6,530,000
ASSET RETIREMENT OBLIGATION		534,000






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		13,380,848
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	316,253,550
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	4,046,827
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c	2,268,610
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................			2e	6,315,437
3	Subtract line 2e from line 1.....................			3	309,938,113
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	309,938,113

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1	306,609,868
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	306,609,868
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	306,609,868

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
Part V, Line 4		Permanently restricted net assets are investments to be held in perpetuity, the income from which is expendable to support the following: Dental Free Care 1,053,285 Indigent Care 148,927 Gen. Operating Expenses 169,975 Health Education 134,485 Total 1,506,672
Part XI, Line 2d		Additional net actuarial loss on accrued post retirement benefit obligations $ (71,825) Net Assets released from restrictions used for purchases of property and equipment $ 1,163,780 Restricted gifts and distributions from GFH Foundation $ 1,413,482 Change in interest in net assets of GFH Foundation $ 1,205,767 Restricted gain income $ 65,605 Net assets released from restrictions $(1,508,199) Line 2d Total = $ 2,268,610
Part X, Line 2		The Hospital recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than fifty percent likely of being realized upon settlement. Changes in recognition in measurement are reflected in the period in which the change in judgement occurs. The hospital did not recognize the effect of any uncertain tax positions in either 2012 or 2011.

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

Glens Falls Hospital

Employer identification number

14-1338413

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 130 %

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 330 %

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? ......

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		(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) ..	2,342,914	1,265,869	1,077,045	0.350 %
b	Medicaid (from Worksheet 3, column a) ....	33,253,305	23,392,101	9,861,204	3.220 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	35,596,219	24,657,970	10,938,249	3.570 %
Other Benefits		1,236,654		1,236,654	0.400 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	1,236,654		1,236,654	0.400 %
f	Health professions education (from Worksheet 5) ..	262,976	103,976	159,000	0.050 %
g	Subsidized health services (from Worksheet 6) ..	30,600,827	27,173,708	3,427,119	1.120 %
h	Research (from Worksheet 7)	146,714	67,657	79,057	0.030 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8)
j	Total. Other Benefits ..	32,247,171	27,345,341	4,901,830	1.600 %
k	Total. Add lines 7d and 7j .	67,843,390	52,003,311	15,840,079	5.170 %

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.

		(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other	103,243	3,207	100,036
10	Total	103,243	3,207	100,036

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. ......

2,027,349

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. ......

1,192,081

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).....

65,899,595

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

76,145,323

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

-10,245,728

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Part IV

Management Companies and Joint Ventures(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 %
1Imaging Serv NENY	Diagnostic Radiology	50.000 %	50.000 %	50.000 %
2Adk Hlth Info Exch	Electronic medical records	50.000 %	50.000 %	50.000 %
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?1 Name, address, and primary website address
1	Glens Falls Hospital 100 Park Street Glens Falls,NY12801 glensfallshospital.org	X

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)

	Glens Falls 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: 130.% 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: 330.% 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		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

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?27
Name and address		Type of Facility (describe)
1	Advanced Imaging at Baybrook 22 Willowbrook Road Queensbury,NY12804	Hosp. Extension Clinic - Diagnostic OP Radiology CT Scanner
2	Behavioral Health ServicesRidge Commons 1 Lawrence Street Glens Falls,NY12801	Hosp. Extension Clinic - O/P Mental Health Services
3	Cambridge Family Health Clinic 35 Gilbert Street Cambridge,NY12816	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology, MHU, PT
4	Center for Recovery 101 Ridge Street Glens Falls,NY12801	Hosp. Extension Clinic - Chemical dependence, O/P Rehab
5	Evergreen Health Center Evergreen Plaza 13 Palmer Avenue Corinth,NY12822	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology, PT
6	Fort Edward Family Medicine 327 Broadway Fort Edward,NY12828	HOsp. Extension Clinic - Primary Medical Care O/P
7	GFH Outpatient Renal Dialysis Center 3 Broad Street Glens Falls,NY12801	HOsp. Extension Clinic - O/P Renal Dialysis, Home Dialysis training
8	GFH Sleep Lab 92 Broad Street Glens Falls,NY12801	Hosp. Extension Clinic - Primary Medical Care, Sleep studies
9	GFH Broad Street Campus 2 Broad Street Glens Falls,NY12801	HOsp. Extension Clinic - Primary Medical Care
10	GFH Neurosurgery & Spine 454 Glen Street Glens Falls,NY12801	Hosp. Extension Clinic - Primary Medical Care
11	Granville Health Center 79 North Street Granville,NY12832	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology,Lab, Rehab
12	Greenwich Family Health Center 200 Main Street Greenwich,NY12834	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology, PT
13	Hoosick Falls Family Health Center 16 Danforth Street Hoosick Falls,NY12090	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology, PT
14	Hudson Falls Internal Medicine 325 Main Street Hudson Falls,NY12893	HOsp. Extension Clinic - Primary Medical Care
15	Main Street Physical Therapy 17 Main Street Glens Falls,NY12801	Hosp. Extension Clinic - Physical Therapy O/P
16	Mobile Pediatric Dental Van 100 Park Street Glens Falls,NY12801	Hosp. Extension Clinic - O/P Dental Services
17	Moreau Health Center 10154 Territorial Park Fort Edward,NY12828	Hosp. Extension Clinic - O/P Lab, O/P Radiology
18	Salem Family Health Center 213 Main Street Salem,NY12865	Hosp. Extension Clinic - Primary Medical Care, O/P Physical Therapy
19	Saratoga Physicians Practice 1 West Medical Plaza Saratoga Springs,NY12866	HOsp. Extension Clinic - Primary Medical Care
20	The Center for Recovery 340 Main Street Glens Falls,NY12801	Hosp. Extension Clinic - Chemical dependency O/P Rehab
21	The Medical Center at Wilton 135 North Road Gansevoort,NY12831	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology,Lab, PT
22	The Rehab Center & Hearing Center 2 Country Club Road Queensbury,NY12804	Hosp. Extension Clinic - PT, OT, Speech, Audiology
23	West Avenue Family Practice 19 West Avenue Saratoga Springs,NY12866	Hosp. Extension Clinic - Primary Medical Care, Lab Services
24	Whitehall Health Center 65 Poultney Street Whitehall,NY12887	Hosp. Extension Clinic - Primary Medical Care, O/P Radiology, Rehab
25	Wilton Health Center 11 Carpenter Lane Wilton,NY12866	HOsp. Extension Clinic - Primary Medical Care, Lab Services
26	Stuart M Townsend Middle School 27 Hyland Drive Lake Luzerne,NY12846	School Based HOsp. Ext.Clinic- Health Ed, Immunology, Screenings
27	Whitehall Elementary School Buckley Road Whitehall,NY12887	School Based HOsp. Ext.Clinic- Health Ed, Immunology, Screenings

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 1, Line 6a		Glens Falls Hospital provides an annual report to the community which includes a comprehensive overview of our community benefit program descriptions. The report is mailed to donors and Board Members, and is published as a PDF on the Hospital web site(http://www.glensfallshosp.org/Give-to-Glens-Falis-Hospital/publicatio ns.cfm). In addition, hard copies of the report are available at various locations throughout the community.
Part 1, Line 7		The costing methodology used to calculate the amounts reported in the table was a cost-to-charge ratio as derived from Worksheet 2, Ratio of Patient Care Cost-tocharges.
Part II, Community Building Activities		Glens Falls Hospital regularly assesses the makeup of the region's physician population, paying particular attention to physicians who may be approaching retirement age and specialties that may have a physician shortage due to retirement or relocation. To insure that there is never a shortage of physicians across all specialties the hospital now employs a physician recruiter. The position actively recruits for vacancies and shortages among hospital employed physicians, and partners with independent practices to help them keep a full complement of physicians across specialties. The hospital also monitors and actively engages in preventing the spread of infectious disease through School Based Health and the hospital's infection control program. This includes vaccinations for children, and access to flu vaccine for the residents of our service area (free or at a significantly reduced cost), including an annual HPODS drill.
Part III, Section A, Line 2		Glens Falls Hospital considers 100% of the amount reported in Part III, line 2 a community benefit. Glens Falls Hospital is the only comprehensive acute-care hospital serving a predominately rural, 3,000-square mile area of upstate New York that encompasses Warren, Washington, Hamilton, Essex and northern Saratoga counties. In a very real sense, it is the safety-net hospital for the patients in these communities. The Hospital provides services to all patients regardless of their ability to pay and grants credit to all patients regardless of creditworthiness and without collateral. While the hospital prusues collections of amounts owed including the use of collection agencies, it does so in a manner that is respectful of the needs of our patients, in adherence with all applicable laws and is reflective of our values and public mission. We entertain reasonable settlement offers, including providing discounts for payment and offering payment plans where we accept reasonable monthly installments based on the individual's means. Litigation is commenced selectively and only as a last resort. Approximately 60% of the amounts written off as bad debt are for patients who have no insurance coverage for the services provided. The Hospital approves 98% of applications it recieves for patient assistance.
Part III, Section A; Line 4		The hospital grants credit without collateral to patients, most of whom are local residents and are insured under third-party agreements. Additions to the allowance for estimated uncollectible accounts are made by means of the provision for bad debts. Accounts written off as uncollectible are deducted from the allowance. The amount of the provision for bad debt is based upon management's assessment of historical expected net collections, business and economic conditions, trends in Federal and State governmental health care coverage, and other collection indicators. Services rendered to individuals when payment is expected and ultimately not received are written off to the allowance for estimated uncollectible account.
Part III, Section B, Lines 5,6.7		In addition to the amount included in the Medicare Cost Report and reported on lines 5,6 & 7, the hospital incurred losses on services provided to Medicare patients and paid for under the Part B fee schedule and not reportable on the Medicare Cost Report. A complete reconciliation of amounts reportable in Section B. Total revenues included on the Medicare Cost Report, reported on line 5 $65,899,595 Total revenues from Medicare Part B services, not reported on line 5 $3,186,374 ---------------------------------------------------------------- Total revenues for Medicare services $69,085,969 Total costs included on the Medicare Cost report, reported on line 6 $76,145,323 Total costs from Medicare Part B services, not reported on line 6 $ 4,021,363 ----------------------------------------------------------------- Total costs from Medicare services $ 80,166,686 Total (shortfall) included on the Medicare Cost Report, reported on line 7 $ 10,245,728 Total (shortfall) from Medicare Part B services, not reported on line 7 $ 834,989 ------------------------------------------------------------------ Total costs for Medicare services $ 11,080,717
Part III, Line 8		The costing methodology used to determine the Medicare allowable costs reported in the organization's Medicare Cost Report, as reflected on line 6, is the methodology prescribed by Medicare in the completion for Form CMS-2552-96 and conforms to the requirements and principals set forth in 42 CFR, Part 412, 42 CFR, Part 413 and in the Provider Reimbursement manual, Part 1. Glens Falls Hospital considers 100% of the amount reported in Part III, line 7 a community benefit. Glens Falls Hospital is the only comprehensive acute-care hospital serving a predominately rural, 3,000 square mile area of upstate New York that encompasses Warren, Washington, Hamilton, Essex and northern Saratoga counties. In a very real sense, it is the safety net hospital for the Medicare patients in these communities. Despite the fact that the payments received from Medicare for the services provided are generally below the rates that the hospital receives from managed care payers and private insurers the hospital remains committed to serving elderly patients and improving the health status of the elderly. Part III, Line 9b It is Glens Falls Hospital policy to delay final collections efforts while a patient financial assistance application is in process. A final determination is required before outside collection efforts are initiated.
Part VI, Line 2	Needs Assessment	Glens Falls Hospital completes a NY State Department of Health required Community Needs Assessment in partnership with the Public Health Departments of the counties we serve (Warren, Washington, Hamilton, Saratoga and Essex)and the NY State Department of Health. This assessment is available via PDF (http://www.arhn.org/regional-health-assessment.php), through the county public health departments, or by contacting Glens Falls Hospital.
Part VI, Line 3		Patient education of eligibility for assistance - Brochures are given at the point of service. All patient's statements advertise charity care programs. Customer Service reps are trained to outline and encourage participation in the program. Vender Medicaid eligibility process includes charity care screening step for all inpatient and outpatient. Website contains information on charity care programs and web portal give the ability to complete an online appliation.
Part VI, Line 4	Community Information	Community information - The Glens Falls Hospital healthcare system serves a large area of upstate New York that includes all or portions of the following counties: Warren, Washington, Saratoga, Essex, and Hamilton. The service area covers approximately 400,000 people; the population is largely white, non-Hispanic (93.5%). Approximately 40% of the female population is of child-bearing age. People over the age of 65 constitute 13.9% of the population; children under the age of 15 make up 16.8% of the population. The average household income is $67,708, essentially equal to the national average of $67,918. One in four people has obtained a Bachelor's degree or higher level of education (25.7%). By 2013 the population of this area is expected to grow by 3.4%. Two age groups that will see the greatest growth are people aged 55 to 65 years and older.It is estimated that these two segments of the population together will constitute 29.1 % of the total population by 2013.
Part VI, Line 5	Promotion of community health	GFH is governed by an 17 member board of Governors, all of whom live in the Hospital's service area. Any and all physicians living in the service area who are qualified, and who meet requirements as documented in the medical staff bylaws, are extended privileges. Fund in excess of expenses are allocated for capital projects, medical research and clinical trials, patient care improvements and system improvements. Capital projects are prioritized by an interdisciplinary committee, consisting of physician from different specialties, as well as hospital management.
Part VI, Line 6		Not Applicable
Part VI, Line 7	State in which the organization files a community benefit report	New York State

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

Glens Falls Hospital

Employer identification number

14-1338413

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? .........

Yes

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

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

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

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

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

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

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

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

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

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

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

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

Yes

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

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

For 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)DAVID G KRUCZLNICKIPRESIDENT & CEO	(i) (ii)	433,655 0	86,000 0	1,890 0	10,000 0	10,547 0	542,092 0	0 0
(2)ROBERT PICKOFF MDVP MEDICAL AFFAIRS	(i) (ii)	292,452 0	32,692 0	2,772 0	1,010 0	13,328 0	342,254 0	0 0
(3)JOAN MCFAULCIO	(i) (ii)	226,129 0	34,627 0	3,064 0	9,554 0	6,672 0	280,046 0	0 0
(4)JEFF TREASURECFO	(i) (ii)	268,586 0	38,454 0	1,942 0	5,071 0	13,328 0	327,381 0	0 0
(5)DONNA KIRKERVP PATIENT SERVICES	(i) (ii)	181,884 0	25,665 0	566 0	8,318 0	1,228 0	217,661 0	0 0
(6)DIANNE SHUGRUECOO	(i) (ii)	281,884 0	39,890 0	966 0	10,000 0	1,276 0	334,016 0	0 0
(7)PAUL SCIMECAVP PHYSICIAN PRACTICES	(i) (ii)	196,590 0	27,900 0	1,597 0	9,308 0	13,328 0	248,723 0	0 0
(8)ROBERT W SPONZO MDCANCER CTR PHYS	(i) (ii)	573,812 0	0 0	5,334 0	10,000 0	10,547 0	599,693 0	0 0
(9)JOHN P STOUTENBURG MDCANCER CTR PHYS	(i) (ii)	551,707 0	0 0	618 0	10,000 0	13,328 0	575,653 0	0 0
(10)AQEEL A GILLANI MDCANCER CTR PHYS	(i) (ii)	500,306 0	0 0	420 0	10,000 0	13,328 0	524,054 0	0 0
(11)ERIC A PILLEMER MDCANCER CTR PHYS	(i) (ii)	505,662 0	0 0	2,772 0	10,000 0	13,328 0	531,762 0	0 0
(12)John Layden MDCARDIAC PHYSICIAN	(i) (ii)	382,608 0	94,469 0	1,462 0	0 0	1,197 0	479,736 0	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
Part 1, Line 4b		GLENS FALLS HOSPITAL OFFERS A 457B PLAN PRIMARILY FO THE PURPOSES OF PROVIDING DEFERRED COMPENSATION FOR A SELECT GROUP OF MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES. IN ADDITION, THE HOSPITAL ESTABLISHED A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN FOR IT'S CEO IN 2009.
Part 1, Line 7		Physicians are eligible and did receive additional compensation through participation in an incentive program that addressed quality, patient satisfaction and their personal productivity.

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
Glens Falls Hospital

Employer identification number
14-1338413

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	Warren Washington Cty IDA series A	14-4085209	934651AS9	10-16-2003	35,871,377	Hospital expansion & equipment		X		X		X
B	Warren Washington Cty IDA series B	14-4085209	934651AZ3	10-16-2003	20,038,436	Hospital expansion & equipment		X		X		X
C	Warren Washington Cty IDA series C	14-4085209	934651BRO	10-16-2003	12,393,178	Hospital expansion & equipment		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .	3,165,000		6,415,000		3,115,000
2 Amount of bonds legally defeased . . . . . . . . . . .	0		0		0
3 Total proceeds of issue . . . . . . . . . . . . . .	36,988,121		20,603,485		12,711,601
4 Gross proceeds in reserve funds . . . . . . . . . . . .	2,433,352		1,480,382		775,481
5 Capitalized interest from proceeds . . . . . . . . . . .	0		0		0
6 Proceeds in refunding escrows . . . . . . . . . . . .	0		0		0
7 Issuance costs from proceeds . . . . . . . . . . . .	714,428		400,770		247,684
8 Credit enhancement from proceeds . . . . . . . . . . .	3,527,563		1,856,320		972,412
9 Working capital expenditures from proceeds . . . . . . . . .	0		0		0
10 Capital expenditures from proceeds . . . . . . . . . . .	29,715,852		16,454,529		10,500,082
11 Other spent proceeds . . . . . . . . . . . . . .	0		0		0
12 Other unspent proceeds . . . . . . . . . . . . . .	0		0		0
13 Year of substantial completion . . . . . . . . . . . .	2005		2005		2005
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .		X		X		X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X		X		X
16 Has the final allocation of proceeds been made? . . . . . . . .	X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X		X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .		X		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .		X		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		X		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .		X		X		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%		0%		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? . . . . .	X		X		X
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?. . . . . . . . . . . . . . . . .		X		X		X
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? . . . . . . . . . . . . .		X		X		X
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?		X		X		X

Part IV

Arbitrage

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

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		X		X
b Name of provider . . . . . . . . .	0		0		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		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .	X		X		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		X		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
During Sept 2003, the counties of Warren and Washington INDUSTRIAL	0	development agency (issuer) issued civic facility revenue bonds. Series A 2003, $36,200,000; Series B 2003, $20,000,000; and series C 2003, $12,435,000 for the purpose of financing the hospital's expansion and renovation construction of the northwest tower, refinancing the hospital's series 1975 and 1979 bonds issued by the dormitory authority of the state of new york, fund a debt service reserve and provide the funding for the financing expenses. the final maturity date is 12/01/35. The remaining balance of the bonds that were refinanced from the dormitory authority were $5,387,352.

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

Glens Falls Hospital

Employer identification number

14-1338413

Identifier	Return Reference	Explanation
Part I, Line 1 & Part III, Line 1		Glens Falls Hospital is an acute care facility and is the largest hospital between Albany and Montreal. It serves 6 counties and operates 24 regional care facilities. We have more than 225 board certified physicians, ranging from primary care to surgical specialties. Glens Falls hospital provides access to primary care and preventative health education and outreach activities, services offered to the community for free or reduced costs including patient financial assistance and charity care. The purpose of Glens Falls Hospital is to improve the health and wellbeing of the people and communities in our region. Our fundamental values are a) respect by treating each individual with courtesy and compassion b) responsiveness through innovation and continuous improvement and c) responsibility to assure a wide range of high quality healthcare services to all. Our vision is that we will be a great hospital, preferred by patients, physicians and staff throughout our 6 county region because of our passion for and excellence in quality and service. We will achieve this through a process of emphasizing a culture that inspires continuous improvement of our performance, our results and ourselves.
Part VI, Section A, Line 11		A copy of Form 990 was given to the Hospital's audit and compliance committee to review and comment on at their regular meeting. The form was approved by the committee and filed on a timely basis. The form was also given to the VP of finance to review and comment on. In addition, the form was reviewed by an independent accountant, KPMG, to make sure it was filled out completely and accurately.
Part VI, Section B, Line 12B		Each director, principal officer and member of a committee with board delegated powers shall annually sign a statement which affirms that such person a) has received a copy of the conflicts of interest policy, b) has read and understands the policy, c) has agreed to comply with the policy and d) understands that the corporation is a charitable organization and that in order to maintain its Federal exemption it must engage primarily in activities which accomplish one or more of its tax exempt purposes. To ensure that the corporation operates in a manner consistent with its charitable purposes and that it does not engage in activiites that could jeopardize its status as an organization exempt from federal income tax, periodic reviews shall be conducted. Reviews shall include the following subjects: A) whether compensation arrangements and benefits are reasonable and are the result of arm's length bargaining. B) whether acquisitions of physician practices and other provider services result in inurement or impermissible private benefit. C) whether partnership and joint venture arrangements and arrangements with management service organizations and physician hospital organizations conform to written policies, are properly recorded, reflect reasonable payments for goods and services, further the corporation's charitable purposes and do not result in inurement or impermissible private benefit. In conducting reviews, the corporation may use outside advisors.
Part VI, Section B, Line 15b		Glens Falls Hospital is committed to developing and maintaining a total compensation program that is competitive with programs offered by other health care organizations that are comparable to Glens Falls Hospital in revenue, structure, mission and scope of services. The compensation philosophy includes: base salary ranges positioned in the 50th percentile of a national and regional peer group, annual incentive opportunities tied to performance goals established by the Board, benefits delivered in the 50th percentile of a national peer group and total compensation positioned at approximately the 50th percentile for expected performance and somewhat about that for exceptional performance. Executive pay is reviewed annually by a third party consultant. This review includes comparison of Glens Falls Hospital executive pay practices with national and regional benchmark studies as appropriate. The consultant is engaged directly by the Glens Falls Hospital Board of Governors and reports their findings to the Board Personnel Committee for review and action.
Part VI, Section C, Line 19		The organization makes its governing documents, conflicts of interest policy and financial statements available upon request.
Part XI, Line 5		Unrestricted Net Assets: Net assets released from restrictions 1,163,780 Net actuarial (loss) on accrued post retirement benefits (71,825) Temporary Restricted Net Assets: Restricted gifts & distributions from GFH Foundation 1,413,482 Change in interest in net assets of GFH Foundation 1,205,767 Restricted income 65,605 Net Assets released from restrictions (1,508,199) Change in unrealized (losses) on investments 198,203 Net change in unrealized losses on trading investments 3,848,624; ---------------- Total 6,315,437
Part VI, Section A, Line 9		Dave Kruczlnicki, 32 Oakvalley Way, Queensbury,NY 12804; Robert Pickoff MD, 17 Schoolhouse Lane, Morristown, NJ 07960; Jeffrey Treasure, CFO, Kings Daughters Medical Center, 2201 Lexington Ave, Ashland, KY 41101

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

Glens Falls Hospital

Employer identification number

14-1338413

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) Glens Falls Hopital Foundation 100 Park Street Glens Falls,NY12801 14-1790805	Support Org	NY	501(c)(3)	11,Type III	NA		No
(2) Adirondack Health Services Inc 100 Park Street Glens Falls,NY12801 14-1667492	Parent Org.	NY	501(c)(3)	11, Type I	NA		No
(3) McGregor Realty Corporation 100 Park Street Glens Falls,NY12801 14-1560380	Property rent	NY	501(c)(2)		GFH	Yes
(4) Greater Adirondack Home Aides 100 Park Street Glens Falls,NY12801 14-1491972	Home Health	NY	501(c)(3)	7	NA		No
(5) Lower Adirondack Wilderness Rescue 100 Park Street Glens Falls,NY12801 54-2082693	Wildrnes res.	NY	501(c)(3)	7	NA		No
(6) Adirondack Health Information Exchange 100 Park Street Glens Falls,NY12801 02-0752148	Elec med recs	NY	501(c)(3)	3	NA		No

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	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Imaging Services of NENY 100 Park Street Glens Falls,NY12801 14-1820955	Diag.radiolog	NY	NA	Related	462,262	236,591		No			No	50.000 %

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) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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

Yes

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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
(1) McGregor Realty	k	166,581
(2) McGregor Realty	l	21,606

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: SEE SCHEDULE O
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	17
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	17
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	3,839
6	Total number of volunteers (estimate if necessary) .............	6	631
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	1,200,833
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	513,974

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,768,995	3,120,087
9	Program service revenue (Part VIII, line 2g) .........	294,171,160	301,415,480
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	903,692	3,090,286
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	2,669,981	2,312,260
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	300,513,828	309,938,113
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)	173,560,798	185,346,160
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 464,455
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	119,678,374	121,263,708
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	293,239,172	306,609,868
19	Revenue less expenses. Subtract line 18 from line 12.......	7,274,656	3,328,245
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	230,743,141	232,155,570
21	Total liabilities (Part X, line 26).............	123,835,508	115,604,255
22	Net assets or fund balances. Subtract line 21 from line 20.....	106,907,633	116,551,315

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 250,849,712 including grants of $ ) (Revenue $ 301,416,527 )
	Glens Falls Hospital provides a comprehensive health care system that stretches across 3,000 square miles in upstate NY. We provide high quality care to people, regardless of their ability to pay. We are a 410 bed facility with more than 225 certified physicians in over 25 specialties. Our services include, but are not limited to, emergency care, surgical services, mental health, cancer care, primary care and preventative health education. In 2012, we had 77,831 patient days and 15,702 discharges. The Emergency Care Center provided care to over 53,000 patients. Our Mental Health department provided 58,098 outpatient treatments and 7,701 inpatient days. Our Surgery Center performed 14,706 procedures.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses250,849,712

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	4,798,375	0	204,696

				(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		344,419
e	Government grants (contributions)1e		2,775,668

f	All other contributions, gifts, grants, and similar amounts not included above1f		0

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			3,120,087
			Business Code
2a	PATIENT SERVICE REVENUE		900099	291,771,274	291,771,274
b	OUTPATIENT PHARMACY		900099	2,705,730	2,705,730
c	CTR FOR OCCUPATIONAL HEALTH		900099	1,409,892	1,409,892
d	HOSPITAL LAB SERVICES		621500	671,376		671,376
e	PHYSICIAN ANSWERING SERVICE		900099	67,472		67,472
f	All other program service revenue .			4,789,736	4,789,736
g	Total. Add lines 2a–2f........			301,415,480
3	Investment income (including dividends, interest, and other similar amounts).......			1,452,747			1,452,747
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	32,840,833	60,480
b	Less: cost or other basis and sales expenses	31,209,664	54,110
c	Gain or (loss)	1,631,169	6,370
d	Net gain or (loss)..........			1,637,539			1,637,539
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	GAIN ON INVENTORY IN ISNENY		621990	468,090	454,047	14,043
b	INVESTMENT IN YANKEE ALLIANCE		900099	447,942		447,942
c	INVESTMENT IN AHIE		900099	-453,000	-453,000
d	All other revenue ....			1,849,228			1,849,228
e	Total. Add lines 11a–11d ......			2,312,260
12	Total revenue. See Instructions......			309,938,113	300,677,679	1,200,833	4,939,514


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			7,906,149	1	7,540,967
2	Savings and temporary cash investments .........			15,519,693	2	5,669,138
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			33,119,717	4	30,030,383
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 .............			273,063	7	243,605
8	Inventories for sale or use ..............			3,205,184	8	3,196,935
9	Prepaid expenses and deferred charges ..........			1,505,424	9	1,762,217
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	275,720,226
b	Less: accumulated depreciation .....	10b	172,903,062	96,095,543	10c	102,817,164
11	Investments—publicly traded securities ..........			58,978,729	11	67,948,324
12	Investments—other securities. See Part IV, line 11 .....			3,757,898	12	1,961,569
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 ...........			10,381,741	15	10,985,268
16	Total assets. Add lines 1 through 15 (must equal line 34)......			230,743,141	16	232,155,570
17	Accounts payable and accrued expenses .........			42,460,592	17	35,402,581
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			59,849,504	20	58,430,905
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 ..			9,225,662	23	8,389,921
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....................			12,299,750	25	13,380,848
26	Total liabilities. Add lines 17 through 25.........			123,835,508	26	115,604,255
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			102,408,618	27	110,677,442
28	Temporarily restricted net assets ...........			2,992,343	28	4,367,201
29	Permanently restricted net assets ...........			1,506,672	29	1,506,672
	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 ...........			106,907,633	33	116,551,315
34	Total liabilities and net assets/fund balances ........			230,743,141	34	232,155,570