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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
Frederick Memorial Hospital Inc
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
400 WEST SEVENTH STREET
 
Room/suite
City or town, state or country, and ZIP + 4
FREDERICK, MD21701
D Employer identification number

52-0591612
E Telephone number

G Gross receipts $ 398,441,099
F Name and address of principal officer:
THOMAS A KLEINHANZL
400 WEST 7TH STREET
FREDERICK,MD21701
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.FMH.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1897
M State of legal domicile: MD
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: TO CONTRIBUTE TO THE HEALTH AND WELL-BEING OF AREA RESIDENTS BY PROVIDING QUALITY HEALTHCARE IN A CARING, COST EFFICIENT, SAFE AND CONVENIENT MANNER.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 13
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 3,233
6 Total number of volunteers (estimate if necessary) .... 6 790
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 9,843
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b  
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 1,975,386 1,544,404
9 Program service revenue (Part VIII, line 2g) ......... 340,072,234 349,642,033
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 7,459,520 5,813,060
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -876,778 -454,399
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 348,630,362 356,545,098
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 100,000 100,000
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) 167,577,086 178,059,458
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet760,292    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 164,986,730 171,529,894
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 332,663,816 349,689,352
19 Revenue less expenses. Subtract line 18 from line 12....... 15,966,546 6,855,746
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 406,175,936 415,327,620
21 Total liabilities (Part X, line 26)............. 228,526,672 253,045,947
22 Net assets or fund balances. Subtract line 21 from line 20..... 177,649,264 162,281,673
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

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



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: SEE SCHEDULE O.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 40,119,017 including grants of $ 100,000 ) (Revenue $ 62,184,089 )
In FY2012, Frederick Memorial Hospital's Inpatient Medical-Surgical Departments provided quality, patient-centered care, regardless of ability to pay, to approximately 22,758 inpatients and observation patients. Major Medical and Surgical Services include Cardiology, Congestive Heart Failure, Post-Cardiac Catheterization, Center for Chest Pain, Hemodialysis, Peritoneal Dialysis, Neurology, Neurosurgery, Pulmonology, Oncology, Orthopedics, General Medicine and Surgical Care. Inpatient care is supported by a team of Board-Certified Physician Hospitalists. In 2012 FMH opened a brand new 12-bed inpatient unit specializing in the care of patients requiring Medical and Surgical Oncology, Thoracic Surgery, and Inpatient Hospice Care. This unit was designed with the patient and family at the center of thought in all planning activities. The FMH Joint Works Program received the UnitedHealth Premium Total Joint Replacement Specialty Center Designation in recognition of quality care, serving approximately 2,150 patients in 2012. In addition, FMH is designated as a Primary Stroke Center by the Maryland Institute of Emergency Medical Service Systems (MIEMSS) and we pursued and achieved the Stroke Center Gold Performance Award by the American Heart Association in 2012. In addition to the program services expense listed here, FMH incurred $37.7 million of general and administrative expenses in meeting the health needs of our primary service area.
4b (Code:   ) (Expenses $ 20,819,263 including grants of $   ) (Revenue $ 28,512,457 )
FMH's Oncology Program provides integrated, multidisciplinary, patient centered cancer care for patients with malignancies, regardless of ability to pay. Services include medical oncology consultations, chemotherapy, radiation oncology consultations and treatment, and surgical oncology consultations and treatment. FMH offers coordinated multidisciplinary clinics for patients with cancers of the lung, breast and prostate. Integrated palliative care and hospice services, both inpatient and outpatient are available for patients with advanced malignancies. Support services include nutrition, patient navigation and social work, as well as other forms of psychosocial support. For those with additional financial need, financial counselors and a patient assistance fund are available. The program treats approximately 800 newly diagnosed cancers per year and also has a community outreach program that includes education and screening. This past year, educational seminars were held for the community on breast and prostate cancer, as well as a community screening event for prostate cancer. The program is accredited by the American College of Surgeons Commission on Cancer, and in 2013, received an award of exceptional achievement from the commission, meriting commendation in all 8 of the 8 assessed competencies.
4c (Code:   ) (Expenses $ 36,101,543 including grants of $   ) (Revenue $ 50,478,801 )
PMH's Perioperative Services provided high quality care to 13,800 surgical and endoscopy patients in fiscal year 2012. Procedures were performed in our state of the art facility which includes a dedicated imaging room for vascular and other procedures. Our total joint replacement patients participate in a program deemed as a Center of Excellence. In FY2012 we performed thoracic and GYN robotics cases as our robotics program began. We have participated in the SCIP Quality improvement project for continual improvements in care following evidence based medicine.
4d Other program services (Describe in Schedule O.)
(Expenses $ 214,145,953 including grants of $   ) (Revenue $ 208,466,686 )
4e Total program service expensesMediumBullet$ 311,185,776
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part IIIClick to see attachment........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
Yes
 
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II.. Click to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III.. Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see list of attachments
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
Yes
 
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
301
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
3,233
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
18
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
13
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
Yes
 
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
No
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
No
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
MD
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
MICHELLE MAHAN
400 WEST 7TH STREET
FREDERICK,MD21701
(240) 566-3300
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Thomas A Kleinhanzl
President and CEO
 40.0 X   X       700,823 0 155,432
(2) Neil Waravdekar MD
Chief Of Staff
 10.0 X   X       42,319 0 0
(3) Ravi Yalamanchili
Vice Chief Of Staff
 6.0 X   X       66,499 0 0
(4) Adriane Wodey
Chairman
 6.0 X   X       0 0 0
(5) Anne Herbert Rollins
Vice Chairman
 6.0 X   X       0 0 0
(6) E James Reinsch
Secretary And Treasurer
 2.0 X   X       0 0 0
(7) Marvin Ausherman
Director
 2.0 X           0 0 0
(8) James R Dixon
Director (End 10/1/11)
 2.0 X           0 0 0
(9) Gregory P Dormitzer
Director
 2.0 X           0 0 0
(10) Bernard Gouin
Director
 2.0 X           0 0 0
(11) Theodore Luck
Director
 2.0 X           0 0 0
(12) J Frederick Manning
Director
 2.0 X           0 0 0
(13) Joann Ramsburg
Director
 2.0 X           0 0 0
(14) Adriana Roa BSN
Director
 2.0 X           0 0 0
(15) Rev Roger W Wilmer Jr
Director
 2.0 X           0 0 0
(16) Gerald Winnan MD
Director
 2.0 X           0 0 0
(17) Shawn Wolf
Director
 2.0 X           0 0 0
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Saeed Zaidi Md
Past Chief Of Staff
 2.0 X           1,000 0 0
(19) P Gregory Rausch MD
Chair, FMH Devlopment Council
 6.0 X           12,883 0 0
(20) Greg Powell PhD
Past Chairman Of The Board
 8.0 X           0 0 0
(21) John Molesworth DO
Past Chief Of Staff
 10.0 X           38,997 0 0
(22) Michelle Mahan
Sr VP and CFO
 40.0     X       375,640 0 64,944
(23) John Verbus
Sr VP and COO
 40.0     X       372,760 0 39,123
(24) Manuel A Casiano
VP Medical Staff
 40.0       X     337,731 0 68,322
(25) Kenneth R Coffey II
VP Chief Development Officer
 40.0       X     186,802 0 28,691
(26) Hannah R Jacobs
VP Finance
 40.0       X     149,903 0 8,115
(27) Rose A Labriola
Sr VP Patient Care
 40.0       X     272,122 0 25,410
(28) Terry P O'Malley
VP Human Resources
 40.0       X     199,161 0 40,867
(29) David Quike
VP Chief Information Officer
 40.0       X     247,732 0 41,398
(30) Craig F Rosendale
VP Ancillary Services
 40.0       X     187,752 0 26,913
(31) Donald R Schilling
VP Ambulatory Services
 40.0       X     192,473 0 22,629
(32) Lucy A Shamash
VP Srvc Line Dev & Ops
 40.0       X     230,036 0 16,722
(33) Jennifer G Teeter
AVP Payor Contracting
 40.0       X     157,935 0 20,774
(34) Jim R Williams
VP Bus Dev and Prof Srvcs
 40.0       X     194,547 0 27,217
(35) Jared R Berkowitz
Physician
 40.0         X   355,730 0 19,782
(36) Paul N Chomiak
Physician
 40.0         X   438,131 0 24,624
(37) Elhamy D Eskander
Physician
 40.0         X   382,593 0 33,609
(38) Brian M O'Connor
Physician
 40.0         X   383,987 0 33,976
(39) Brian T Tully
Physician
 40.0         X   354,437 0 20,064
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 5,881,993 0 718,612
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet141
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
TXTEAM REHAB INC
4625 East Stop 11 Road
INDIANAPOLIS,IN46237 		  7,390,414
PRIME DOC OF FREDERICK PA
PO Box 7568
ASHEVILLE,NC28802 		  2,133,254
ALLIANCE RADIOSURGERY LLC
PO Box 6600
NEWPORT BEACH,CA92658 		  1,945,320
SLEEPMED DIGITRACE CARE SERVICES
200 Corporate Place
PEABODY,MA01960 		  1,051,980
FIRST COLONIES ANESTHESIA ASSOCIATE
7490 New Technology Way
FREDERICK,MD21703 		  1,051,094
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet23
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		1,544,404
g Noncash contributions included in lines 1a-1f:$ 26,592
h Total. Add lines 1a-1f.......MediumBullet 1,544,404
Program Service Revenue Business Code
2a Inpatient Revenue 624,100 168,299,302 168,299,302    
b Outpatient Revenue 621,400 173,056,704 173,056,704    
c Transcription Services 561,000 460,187 460,187    
d Group Purchasing (Premier) 525,990 778,773 768,930 9,843  
e Hitech and Medical Home Revenues 621,610 4,818,644 4,818,644    
f All other program service revenue . 2,228,423 2,228,423    
g Total. Add lines 2a–2f........MediumBullet 349,642,033
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 3,632,188     3,632,188
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 572,964  
b Less: rental expenses    
c Rental income or (loss) 572,964  
d Net rental income or (loss).......MediumBullet 572,964     572,964
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 44,020,960 55,913
b Less: cost or other basis and sales expenses 41,773,753 122,248
c Gain or (loss) 2,247,207 -66,335
d Net gain or (loss)..........MediumBullet 2,180,872     2,180,872
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a Cafeteria and Coffee Shop 722,210 1,257,794     1,257,794
b Mt. Airy Joint Venture management fee 541,610 302,669     302,669
c Realized losses on interest rate swap 900,099 -2,587,826     -2,587,826
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet -1,027,363
12 Total revenue. See Instructions....MediumBullet 356,545,098 349,632,190 9,843 5,358,661
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 100,000 100,000
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 .... 5,642,767   5,642,767  
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 135,501,022 125,137,898 10,060,358 302,766
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 7,014,470 6,486,956 521,513 6,001
9 Other employee benefits ....... 20,089,058 18,507,510 1,514,512 67,036
10 Payroll taxes ........... 9,812,141 9,074,231 729,515 8,395
11 Fees for services (non-employees):        
a Management ...... 12,841,423 11,612,907 1,220,516 8,000
b Legal ......... 811,300 200 810,200 900
c Accounting ........... 312,280   312,280  
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 399,680   399,680  
g Other .......... 36,944,735 31,826,779 5,055,581 62,375
12 Advertising and promotion .... 931,776 27,152 742,351 162,273
13 Office expenses ....... 5,306,668 4,620,298 575,751 110,619
14 Information technology ...... 3,292,475 3,292,475    
15 Royalties .. 0      
16 Occupancy ........... 4,317,171 3,682,515 634,656  
17 Travel ............ 121,425 74,436 46,590 399
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 283,324 173,685 108,709 930
20 Interest ........... 4,569,501 4,281,644 278,719 9,138
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 19,949,560 16,003,920 3,933,990 11,650
23 Insurance .............. 5,136,180 361,055 4,775,125  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a SUPPLIES AND COGS 62,471,742 62,081,461 380,471 9,810
b Bad debt expense 13,840,654 13,840,654    
c
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 349,689,352 311,185,776 37,743,284 760,292
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 0 1 0
2 Savings and temporary cash investments ....... 25,713,868 2 29,890,405
3 Pledges and grants receivable, net ......... 3,277,527 3 3,136,826
4 Accounts receivable, net ......... 45,891,896 4 50,427,786
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 135,316 5 81,190
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L .......... 0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 4,355,878 8 4,648,660
9 Prepaid expenses and deferred charges ............ 2,357,935 9 2,430,944
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 392,792,936
b Less: accumulated depreciation. ..... 10b 203,755,335 174,734,246 10c 189,037,601
11 Investments—publicly traded securities .......... 107,206,670 11 99,649,453
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. 36,930,641 13 28,573,661
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 5,571,959 15 7,451,094
16 Total assets. Add lines 1 through 15 (must equal line 34)... 406,175,936 16 415,327,620
Liabilities 17 Accounts payable and accrued expenses . 35,316,086 17 41,374,475
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 138,926,650 20 137,149,099
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 372,575 23 278,511
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..... 53,911,361 25 74,243,862
26 Total liabilities. Add lines 17 through 25..... 228,526,672 26 253,045,947
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 171,475,327 27 156,164,358
28 Temporarily restricted net assets ..... 5,197,760 28 5,141,138
29 Permanently restricted net assets ..... 976,177 29 976,177
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 177,649,264 33 162,281,673
34 Total liabilities and net assets/fund balances ..... 406,175,936 34 415,327,620
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
356,545,098
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
349,689,352
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
6,855,746
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
177,649,264
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-22,223,337
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
162,281,673
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


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

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

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

52-0591612
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

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

Additional Data


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

52-0591612
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




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

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Frederick Memorial Hospital Inc
  		Employer identification number

52-0591612
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

     
 
   

$  




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

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Frederick Memorial Hospital Inc
  		Employer identification number

52-0591612
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
Frederick Memorial Hospital Inc
  		Employer identification number

52-0591612
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


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

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

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

52-0591612
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

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

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

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

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










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

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

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


Schedule C (Form 990 or 990-EZ) 2011
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
 
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
 
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
24,666
j
Total. Add lines 1c through 1i ...............................
24,666
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Description of lobbying activities Schedule C Part II-B line 1i The expense of $24,666 is a portion of dues paid to the American Hospital Association, Maryland Hospital Association, National Association for Home Care, and National Hospice and Palliative Care Organization.
Schedule C (Form 990 or 990EZ) 2011

Additional Data


Software ID:  
Software Version:  

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

52-0591612
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 976,177 976,177 976,177 976,177
b Contributions ........        
c Net investment earnings, gains, and losses ...        
d Grants or scholarships .....        
e Other expenditures for facilities
and programs ........ 		       
f Administrative expenses ....        
g End of year balance ...... 976,177 976,177 976,177 976,177
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet100.000 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   2,421,745 2,421,745
b Buildings ................   173,584,497 57,203,764 116,380,733
c Leasehold improvements ............   18,776,137 14,200,767 4,575,370
d Equipment ................   184,504,575 132,350,804 52,153,771
e Other .................   13,505,982   13,505,982
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 189,037,601
Schedule D (Form 990) 2011

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








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1) Assets limited as to use 11,097,224 F
(2) Investments in subsidiaries 17,476,437 F







Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet 28,573,661
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
Advances from third parties 10,065,289
Interest rate swap contract 16,512,477
Pension liability 26,368,362
Malpractice insurance liability 7,510,975
Capital lease obligations 7,416,649
Other liabilities 6,370,110



Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 74,243,862
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
INTENDED USE OF ENDOWMENT FUNDS FORM 990, SCHEDULE D, PART V, LINE 4 ENDOWMENT FUNDS ARE USED FOR HEALTH CARE SERVICES. ASC 740 FOOTNOTE DISCLOSURE FORM 990, SCHEDULE D, PART X, LINE 2 THERE WAS NO ASC 740 FOOTNOTE IN THE AUDITED FINANCIAL STATEMENTS BECAUSE THERE WERE NO MATERIAL UNCERTAIN TAX POSITIONS AS OF JUNE 30, 2012.
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




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

52-0591612
Part I
General Information on Activities Outside the United States. Complete if the organization answered
“Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of its grants
and other assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used
to award the grants or assistance? ..............................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other
assistance outside the United States.
3
Activites per Region. (Use Part V if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees or agents in region or independent contractors (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total
expenditures for region/investments
in region
Central America and the Caribbean 1   Investments   6,574,661
Central America and the Caribbean 1   Program Services Self-insurance 2,347,614
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total ..... 2   8,922,275
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b) 2   8,922,275
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2011
Schedule F (Form 990) 2011
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990,
Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 ........ MediumBullet
Use Part V if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2
Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .....MediumBullet
 
3
Enter total number of other organizations or entities ........................MediumBullet
 
Schedule F (Form 990) 2011
Schedule F (Form 990) 2011Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Use Part V if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2011
Schedule F (Form 990) 2011
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926 (see instructions for Form 926).................
2 Did the organization have an interest in a foreign trust during the tax year? If " Yes," the organization may be required to file Form 3520 and/or Form 3520-A. (see instructions for Forms 3520 and 3520-A)..........
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see instructions for Form 5713)................................................
Schedule F (Form 990) 2011
Schedule F (Form 990) 2011
Page 5
Part V
Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
Identifier ReturnReference Explanation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2011
Additional Data


Software ID:  
Software Version:  



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

52-0591612
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

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

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    6,928,711   6,928,711 2.060 %
b Medicaid (from Worksheet 3, column a) .....     31,120,266 21,965,939 9,154,327 2.730 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .            
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		    38,048,977 21,965,939 16,083,038 4.790 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    2,464,195 871,460 1,592,735 0.470 %
f Health professions education
(from Worksheet 5) .. 		    115,495   115,495 0.030 %
g Subsidized health services
(from Worksheet 6) .. 		    15,424,981 1,968,152 13,456,829 4.010 %
h Research (from Worksheet 7)            
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....     174,700   174,700 0.050 %
jTotal Other Benefits ...     18,179,371 2,839,612 15,339,759 4.560 %
kTotal. Add lines 7d and 7j. ..     56,228,348 24,805,551 31,422,797 9.350 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense........
2
13,840,654
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
1,384,065
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
124,665,018
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
112,121,288
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
12,543,730
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 FREDERICK MEMORIAL HOSPITAL
400 WEST SEVENTH STREET
FREDERICK,MD21701 		X X         X    
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

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

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 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)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

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

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?17
Name and address Type of Facility (describe)
1 FMH KLINE HOSPICE HOUSE
7000 KIMMEL ROAD
mt airy,MD21771 		INPATIENT HOSPICE PATIENT FACILITY
2 MT AIRY HEALTH SERVICES
1502 SOUTH MAIN STREET
MT AIRY,MD21771 		OUTPATIENT HLTH SRVC FACILITY
3 PARKVIEW MEDICAL GROUP
1502 SOUTH MAIN STREET
MT AIRY,MD21771 		PHYSICIAN PRACTICE
4 PARKVIEW MEDICAL GROUP
3000-D VENTRIE COURT
MYERSVILLE,MD21773 		PHYSICIAN PRACTICE
5 PARKVIEW MEDICAL GROUP
1564 OPPOSSUMTOWN PIKE
FREDERICK,MD21702 		PHYSICIAN PRACTICE
6 FMH REGIONAL CANCER CARE THERAPY CENTER
501 WEST SEVENTH STREET
FREDERICK,MD21701 		OUTPATIENT CANCER TREATMENT CENTER
7 FMH ROSE HILL
1562 OPPOSSUMTOWN PIKE
FREDERICK,MD21701 		OUTPATIENT HLTH SRVC FACILITY
8 UNION BRIDGE FAMILY PRACTICE
104 NORTH MAIN STREET
UNION BRIDGE,MD21791 		PHYSICIAN PRACTICE
9 FMH Home Medical Equipment and Supplies
605 East Church Street
FREDERICK,MD21701 		DURABLE MEDICAL GOODS ORGANIZATION
10 FMH Home Health Services
605 East Church Street Suite 2
FREDERICK,MD21701 		HOME HEALTH NURSING ORG
11 Hospice of Frederick County
PO Box 1799 516 Trail Ave
FREDERICK,MD21702 		HOSPICE CARE ORGANIZATION
12 FMH Rose Hill Rehab Services
1562 Opossumtown Pike
FREDERICK,MD21702 		REHABILITATION CLINIC
13 FMH CRESTWOOD
7211 Bank Court
FREDERICK,MD21703 		OUTPATIENT HLTH SRVC FACILITY
14 FMH WELLNESS CENTER
5500 BUCKEYSTOWN PIKE
FREDERICK,MD21702 		HEALTH SERVICE CENTER
15 FMH ECHO AND VASCULAR LAB
1560 OPPOSSUMTOWN PIKE
FREDERICK,MD21702 		HEALTH SERVICE CENTER
16 FMH URBANA
3430 WORHTINGTON BLVD
FREDERICK,MD21704 		OUTPATIENT HLTH SRVC FACILITY
17 FMH IMMEDIATE CARE
850 OAK STREET
FREDERICK,MD21702 		WALK-IN CLINIC
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
SUPPLEMENTAL INFORMATION   PART I, LINE 7B For the last 30 years, Maryland hospitals have met their community benefit obligations in a unique manner that builds the costs of uncompensated care (charity care and patient bad debt) and graduate medical education into the rates that hospitals are reimbursed by all payors. The system is based in federal and state law and benefits all Maryland residents, including those in need of financial assistance to pay their hospital bills. Maryland is the only state in which all payors (governmentally-insured, commercially-insured, or self-pay) are charged the same price for services at any given hospital. Under this system, Maryland hospitals are regulated by a state agency -the Health Services Cost Review Commission (HSCRC)-that is required to: -Publicly disclose information on the cost and financial position of hospitals; -Review and approve hospital rates; -Collect information detailing transactions between hospitals and firms with which their trustees have a financial interest; and, -Maintain the solvency of efficient and effective hospitals. Since 2000, the rate setting commission has had its own framework for reporting hospitals' community benefits and issuing a report annually regarding hospitals' community benefit totals. That report is available on http://www.hscrc.state.md.us/ Because of this unique structure Maryland hospitals' community benefits numbers will not compare with the rest of the nation's hospitals. However, Maryland hospitals meet or exceed the community benefit standard established by the IRS in 1969. Additional detail illustrating this can be found within this Schedule H report. PART I, LINE 7, COLUMN (F) Our total expense from Form 990, Part IX, Line 25, Column (A) is $349,689,352. The bad debt expense included in this amount is $13,840,654. This left a total expense of $335,848,698 for purposes of calculating Line 7, Column (F). PART I, LINE 7 Amounts were calculated using the cost-to-charge ratio derived from Worksheet 2. PART III, Line 4 The amount included in part III, line 2 is the amount of charges written off of patient accounts after pursuing payment and other alternatives such as qualifying the patient for charity care or for state and federal government programs. The charges are reduced to approximate cost using the cost to charge ratio computed in schedule h, worksheet 2. Any adjustments or payments received on accounts previously written off to bad debt have the impact of reducing the reported bad debt cost. fmh adopted FASB-issued ASU 2011-07 which provided guidance on the presentation and disclosure of patient service revenue, provisions for bad debts, and the allowance for doubtful accounts for certain health care entities effective for the fiscal year ending June 30, 2012. The Hospital's policy is to write off all patient accounts that have been identified as uncollectible. An allowance for doubtful accounts is recorded for accounts not yet written off that are anticipated to become uncollectible in future periods. Insurance coverage and credit information are obtained from patients when available. No collateral is obtained for accounts receivable. Accounts receivable from third-party payors have been adjusted to reflect the difference between charges and the estimated reimbursable amounts. Recoveries of previously written off patient receivables are recorded when received. PART III, LINE 8 AMOUNTS WERE CALCULATED USING THE COST-TO-CHARGE RATIO CALCULATED USING WORKSHEET 2. PART III, LINE 9B Patients who qualify for charity care or financial assistance are specifically excluded from the collection process. Part V, Sec B, Line 19d Maryland's HSCRC determines rates charged. NEEDS ASSESSMENT IN 2011, THE COMMUNITY FOUNDATION OF FREDERICK COUNTY COMMISSIONED A FREDERICK COUNTY HUMAN NEEDS ASSESSMENT. ONE OF THE PRIORITY AREAS COVERED IN THE ASSESSMENT WAS THE COUNTY'S HEALTH NEEDS. THREE AREAS WERE IDENTIFIED IN THE ASSESSMENT AS REQUIRING SPECIAL ATTENTION: 1. AFFORDABLE HEALTH CARE 2. A "MEDICAL HOME" FOR LOW-INCOME FAMILIES AND INDIVIDUALS 3. THE NEED FOR AFFORDABLE MENTAL HEALTH SERVICES LOCAL HEALTH IMPROVEMENT PRIORITY SETTING SUMMIT FREDERICK MEMORIAL HOSPITAL PARTNERED WITH THE FREDERICK COUNTY HEALTH DEPARTMENT AND THE FREDERICK COUNTY HEALTH CARE COALITION TO SPONSOR AND PARTICIPATE IN THE LOCAL HEALTH IMPROVEMENT PRIORITY (LHIP) SETTING SUMMIT. THE PURPOSE OF THE DAY-LONG SUMMIT WAS TO ESTABLISH THE PRIORITIES FOR HEALTH IMPROVEMENT IN FREDERICK COUNTY AND TO DEVELOP GOALS AND ACTION PLANS TO ACHIEVE IMPROVEMENT IN THOSE PRIORITY AREAS THROUGH COMMUNITY ENGAGEMENT. FREDERICK COUNTY LOCAL HEALTH IMPROVEMENT PLAN (LHIP) THE FREDERICK HEALTH IMPROVEMENT PLAN SETS FREDERICK-SPECIFIC OBJECTIVES FOR IMPROVING THE HEALTH OF FREDERICK COUNTY RESIDENTS. IN ADDITION, THE LHIP PRESENTS ACTION STEPS FOR HOW TO ACHIEVE THESE OBJECTIVES. THE PRIORITY AREAS INCLUDED IN THE DOCUMENT WERE CHOSEN BY THE OCTOBER 2011 SUMMIT ATTENDEES. ATTENDEES THEN MET IN WORKGROUPS TO CLARIFY AND DEFINE THE TOP 5 PRIORITIES FOR LOCAL HEALTH IMPROVEMENT. THOSE AREAS ARE: 1. MENTAL HEALTH 2. AFFORDABLE DENTAL CARE 3. WELLNESS & PREVENTION 4. HEALTH INEQUITIES AWARENESS 5. ACCESS TO CARE WHAT IS THE RELATIONSHIP OF THE LHIP TO HEALTHY PEOPLE 2020? HEALTHY PEOPLE 2020 PROVIDES SCIENCE-BASED, 10-YEAR NATIONAL OBJECTIVES FOR IMPROVING THE HEALTH OF ALL AMERICANS. FOR THREE DECADES, HEALTHY PEOPLE HAS ESTABLISHED BENCHMARKS AND MONITORED PROGRESS OVER TIME IN ORDER TO ENCOURAGE COLLABORATIONS ACROSS SECTORS; GUIDE INDIVIDUALS TOWARD MAKING INFORMED HEALTH DECISIONS; AND MEASURE THE IMPACT OF PREVENTION ACTIVITIES. THE FREDERICK COUNTY LOCAL HEALTH IMPROVEMENT PLAN FOCUSES ON A SMALL SUBSET OF THE CDC'S HEALTHY PEOPLE 2020 OBJECTIVES SO THAT (1) WE CAN FOCUS ON FACTORS THAT ARE MOST CRITICAL TO HEALTH EQUITY AND IMPROVING THE HEALTH OF ALL FREDERICK COUNTY RESIDENTS, (2) AND WE CAN MEASURE OUR SUCCESS AND IMPROVE OUR LEADERSHIP IF OUR PLANS AREN'T MEETING OUR GOALS. FREDERICK REGIONAL HEALTH SYSTEM'S COMMUNITY BENEFITS PROGRAM THE FINDINGS OF THE SURVEY TOOLS DESCRIBED ABOVE COINCIDE REMARKABLY WELL WITH THE HEALTH SYSTEM'S INTERNAL DATA THAT CLEARLY INDICATES THAT RESOURCES NEED TO FOCUS UPON THE SAME 5 AREAS OF NEED IDENTIFIED BY THE LOCAL HEALTH IMPROVEMENT PLAN AND THE HUMAN NEEDS ASSESSMENT. THESE DOCUMENTS AND OUR CLOSE WORKING RELATIONSHIP WITH THE FREDERICK COUNTY HEALTH DEPARTMENT AND THE FREDERICK COUNTY HEALTH CARE COALITION WILL HELP TO FOCUS THE HEALTH SYSTEM'S COMMUNITY BENEFITS PROGRAM MOVING FORWARD. FMH WILL ALLOCATE RESOURCES TO ADDRESS MORE SPECIFICALLY THOSE IDENTIFIED COMMUNITY NEEDS, WHILE CONTINUING TO PROVIDE EDUCATIONAL AND SUPPORT PROGRAMS, EARLY DETECTION SCREENINGS AND WELLNESS CLASSES, COUNSELING AND DEMONSTRATIONS TO A BROADER AUDIENCE IN OUR COMMUNITY. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE Frederick Memorial Hospital posts its charity care policy and financial assistance contact information in admission areas, the FMH Emergency Department, and in all of our satellite facilities in areas where eligible patients are likely to present. FMH provides a summary of the Charity Care Policy and financial assistance contact information to all patients at the time of admission to the hospital. FMH admissions personnel discuss the availability of various government benefits such as Medicaid or state programs with patients and/or their family members, and they assist patients with qualification for the programs. Frederick Memorial Hospital increased its efforts to provide financial assistance to its patients through a variety of initiatives. FMH increased ITS financial assistance for catastrophic situations. In our program, patients may receive financial assistance if their bill is 25% or more of their annual income. In FY11 a financial counselor met with patients who had no insurance the day after admission to explain our financial assistance program and the state's medical assistance program. Because the meeting with the patient was early in their stay, the patient's accumulated charges typically did not reach a catastrophic stage. Therefore, we had patients who left the hospital without a detailed catastrophic financial assistance discussion and without a Financial Assistance application. Now, every inpatient or outpatient who accumulates $10,000 or more in charges will receive a second visit from a financial counselor along with a financial assistance application. Also, we mail these patients another financial assistance application with a cover letter stating that due to the balance of their bill, they may qualify for financial assistance. FREDERICK MEMORIAL HOSPITAL ATTEMPTS TO IDENTIFY AND NOTIFY ALL PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE. ALL PATIENTS ARE NOTIFIED AT THE TIME OF REGISTRATION OF OUR FINANCIAL ASSISTANCE POLICY. DESPITE OUR EFFORTS, WE ESTIMATE AS MUCH AS 10% OF OUR BAD DEBT EXPENSE COULD BE THE RESULT OF A LACK OF INFORMATION ON PATIENTS THAT WOULD OTHERWIS
Schedule H (Form 990) 2011
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Frederick Memorial Hospital Inc
 
Employer identification number
52-0591612
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) Frederick Community College7932 Opossumtown pike
Frederick,MD21702 		52-0743590 501(c)(3) 100,000 0 CASH N/A Support of Allied Health Education Program






















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

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













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
Form 990, Schedule I Description of Organization's Procedures for Monitoring the Use of Grants THE HOSPITAL PROVIDES FUNDING TO A LOCAL COMMUNITY COLLEGE (501(C)(3)) IN AN EFFORT TO ENHANCE ITS ALLIED HEALTH PROGRAM. THROUGH THIS PROGRAM, A FORMAL EDUCATION FORUM IS ESTABLISHED RESULTING IN FULLY ACCREDITED PROGRAMS THAT MEET THE HOSPITAL'S NEEDS.
Schedule I (Form 990) 2011


Additional Data


Software ID:  
Software Version:  


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

52-0591612
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
Yes
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
Yes
 
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

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

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) Thomas A Kleinhanzl (i)
(ii)		 538,976
0 		158,508
0 		3,339
0 		140,143
0 		15,289
0 		856,255
0 		0
0
(2) Manuel A Casiano (i)
(ii)		 301,303
0 		34,106
0 		2,322
0 		53,297
0 		15,025
0 		406,053
0 		0
0
(3) Kenneth R Coffey II (i)
(ii)		 166,646
0 		17,834
0 		2,322
0 		14,033
0 		14,658
0 		215,493
0 		0
0
(4) Hannah R Jacobs (i)
(ii)		 149,797
0 		0
0 		106
0 		6,968
0 		1,147
0 		158,018
0 		0
0
(5) Rose A Labriola (i)
(ii)		 247,013
0 		22,787
0 		2,322
0 		12,907
0 		12,503
0 		297,532
0 		0
0
(6) Michelle Mahan (i)
(ii)		 306,947
0 		66,371
0 		2,322
0 		52,758
0 		12,186
0 		440,584
0 		0
0
(7) Terry P O'Malley (i)
(ii)		 175,134
0 		20,463
0 		3,564
0 		28,959
0 		11,908
0 		240,028
0 		0
0
(8) David Quike (i)
(ii)		 222,503
0 		24,689
0 		540
0 		31,378
0 		10,020
0 		289,130
0 		0
0
(9) Craig F Rosendale (i)
(ii)		 166,508
0 		17,680
0 		3,564
0 		15,075
0 		11,838
0 		214,665
0 		0
0
(10) Donald R Schilling (i)
(ii)		 172,429
0 		17,722
0 		2,322
0 		10,762
0 		11,867
0 		215,102
0 		0
0
(11) Lucy A Shamash (i)
(ii)		 194,576
0 		34,650
0 		810
0 		4,809
0 		11,913
0 		246,758
0 		0
0
(12) Jennifer G Teeter (i)
(ii)		 139,821
0 		16,872
0 		1,242
0 		9,118
0 		11,656
0 		178,709
0 		0
0
(13) John Verbus (i)
(ii)		 314,939
0 		55,499
0 		2,322
0 		31,436
0 		7,687
0 		411,883
0 		0
0
(14) Jim R Williams (i)
(ii)		 173,541
0 		18,684
0 		2,322
0 		15,337
0 		11,880
0 		221,764
0 		0
0
(15) Jared R Berkowitz (i)
(ii)		 355,514
0 		0
0 		216
0 		5,638
0 		14,144
0 		375,512
0 		0
0
(16) Paul N Chomiak (i)
(ii)		 437,771
0 		0
0 		360
0 		10,216
0 		14,408
0 		462,755
0 		0
0
(17) Elhamy D Eskander (i)
(ii)		 381,561
0 		0
0 		1,032
0 		19,201
0 		14,408
0 		416,202
0 		0
0
(18) Brian M O'Connor (i)
(ii)		 382,403
0 		0
0 		1,584
0 		19,568
0 		14,408
0 		417,963
0 		0
0
(19) Brian T Tully (i)
(ii)		 354,245
0 		0
0 		192
0 		5,656
0 		14,408
0 		374,501
0 		0
0
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Supplemental Compensation Information SCHEDULE J, PART I, LINE 1 FREDERICK MEMORIAL HOSPITAL HOLDS TWO CORPORATE MEMBERSHIPS TO A LOCAL GOLF/COUNTRY CLUB THAT ARE USED BY THE CHIEF EXECUTIVE OFFICER AND THE CHIEF FUND DEVELOPMENT OFFICER OF THE HOSPITAL. WHILE THE MAJORITY OF THE FEES ASSOCIATED WITH THE CLUB DUES, ETC. IS BUSINESS RELATED, GENERAL PERSONAL USE EXPENSES ARE REIMBURSED BACK TO THE HOSPITAL BY THESE INDIVIDUALS AS NEEDED. SCHEDULE J, PART I, LINE 4B Frederick Memorial Hospital has one 457(f) non-qualified deferred compensation plan for certain members of senior management. Under the plan, they may contribute amounts from their compensation to the plan and may receive a discretionary employer contribution. Employees are fully vested in all employee contributions to the plan. Vesting in employer contributions occurs in accordance with the underlying plan documents. All assets of the plan are held in a separate trust. Total Hospital contributions to this plan were $191,707 and there were no payments from the Plan during the year. SCHEDULE J, PART I, LINE 6A THE EXECUTIVE COMPENSATION PROGRAM IS DESIGNED TO CARRY OUT THE HEALTH SYSTEM MISSION, TO ACHIEVE THE CHARITABLE PURPOSE, TO ATTRACT, RETAIN, MOTIVATE AND REWARD EXECUTIVE MANAGEMENT, AND TO MAINTAIN A COMPETITIVE POSITION WITH PEER ORGANIZATIONS IN THE REGION. OVERSIGHT OF THE EXECUTIVE COMPENSATION PROGRAM IS PROVIDED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD, COMPOSED OF THE BOARD CHAIR, VICE CHAIR, IMMEDIATE PRECEDING CHAIR, CHAIR OF THE FINANCE COMMITTEE AND CHAIR OF THE GOVERNANCE COMMITTEE. ANNUALLY, THE COMMITTEE REVIEWS AND RECOMMENDS TO THE BOARD VARIABLE PAY GOALS FOR THE COMING YEAR, AND PAYMENT LEVELS BASED ON PERFORMANCE FOR THE CURRENT YEAR. THE EXECUTIVE COMPENSATION PHILOSOPHY OF THE BOARD PROVIDES FOR BASE COMPENSATION AT THE 50TH TO 60TH PERCENTILE WITH VARIABLE PAY DESIGNED TO PROVIDE A TARGET OPPORTUNITY FOR TOTAL COMPENSATION TO REACH THE 75TH PERCENTILE. VARIABLE PAY CRITERIA ARE CLINICAL QUALITY (33%), CUSTOMER SERVICE (11%), PEOPLE (11%), FINANCIAL VIABILITY (28%), AND GROWTH (17%). GOALS USING THE VARIABLE PAY CRITERIA ARE ESTABLISHED AT BOTH THE CORPORATE AND INDIVIDUAL LEVEL. INDIVIDUAL PAYMENTS ARE BASED ON PERFORMANCE AGAINST CORPORATE GOALS, INDIVIDUALS GOALS, AND DISCRETION OF THE BOARD.
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
Frederick Memorial Hospital Inc
 
Employer identification number
52-0591612
Part I
Bond Issues
(a) Issuer Name (b) Issuer EIN (c) CUSIP # (d) Date Issued (e) Issue Price (f) Description of Purpose (g) Defeased (h) On
Behalf of
Issuer 		(i) Pool
financing
Yes No Yes No Yes No
A MARYLAND HEALTH & HIGHER EDUC FACILITIES AUTHORITY
  		52-0936091 574217Y25 07-09-2008 72,160,000 SEE PART VI   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . 0      
2 Amount of bonds legally defeased . . . . . . . . . . 0      
3 Total proceeds of issue . . . . . . . . . . . . . 72,160,000      
4 Gross proceeds in reserve funds . . . . . . . . 0      
5 Capitalized interest from proceeds . . . . . . . . . . 0      
6 Proceeds in refunding escrows . . . . . . . . . . . 0      
7 Issuance costs from proceeds . . . . . . . . . . . 975,844      
8 Credit enhancement from proceeds . . . . . . . . . . 166,621      
9 Working capital expenditures from proceeds . . . . . . . 0      
10 Capital expenditures from proceeds . . . . . . . . . . 0      
11 Other spent proceeds . . . . . . . . . . . 71,017,535      
12 Other unspent proceeds . . . . . . . . . . . 0      
13 Year of substantial completion . . . . . . . . . . . 2008
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . X              
15 Were the bonds issued as part of an advance refunding issue? . . . .   X            
16 Has the final allocation of proceeds been made? . . . . . . X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . X              
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . . X              
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2011
Schedule K (Form 990) 2011
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . .   X            
b If ‘Yes’ to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . .                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . .   X            
d If ‘Yes’ to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0%   %   %   %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet 0.00000%   %   %   %
6 Total of lines 4 and 5 . . .. . . . . . . . . 0%   %   %   %
7 Does the bond issue meet the private security or payment test? . . .   X            
8 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
  X            
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .   X            
2 Is the bond issue a variable rate issue? X              
3a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue? X              
b Name of provider . . . . . . . . UBS AG STAMFORD
  		 
  		 
  		 
 
c Term of hedge . . . . . . . . 3.8      
d Was the hedge superintegrated? . . . .   X            
e Was a hedge terminated? . . . . .   X            
4a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . .   X            
b Name of provider . . . . . . 0
  		 
  		 
  		 
 
c Term of GIC . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . . .                
5 Were any gross proceeds invested beyond an available temporary period? . . . . . .   X            
6 Did the bond issue qualify for an exception to rebate? . X              
7 Has the organization established written procedures to monitor the requirements of section 148? . . . X              
Schedule K (Form 990) 2011

Schedule K (Form 990) 2011
Page 3
Part V
Procedures To Undertake Corrective Action
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? . . . . . . . . . . . . . .
Part VI
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
DESCRIPTION OF TAX-EXEMPT BONDS 0 SCHEDULE K, PART I, COLUMN F THE MHHEFA SERIES 2008 REVENUE BONDS, ISSUED ON JULY 9, 2008 WERE A REFUNDING OF THE SERIES 2006 BONDS, WHICH WERE ISSUED ON MAY 23, 2006. MANAGEMENT PRACTICES AND PROCEDURES SCHEDULE K, PART III, LINE 7 THE ORGANIZATION HAS POLICIES AND PROCEDURES IN PLACE TO ENSURE TAX-EXEMPT BOND POST ISSUANCE COMPLIANCE, BUT WRITTEN POLICIES ARE BEING CREATED AND EVALUATED AND WILL BE ADOPTED BY THE FMH BOARD PRIOR TO JUNE 30, 2013.
Schedule K (Form 990) 2011

Additional Data


Software ID:  
Software Version:  

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

52-0591612
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
(1) PAUL CHOMIAK
SEE SCH L, PART V 		  X 649,518 81,190   No   No Yes  
Total ...............Small Bullet $ 81,190
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
LOANS TO AND FROM INTERESTED PERSONS SCHEDULE L, PART II PURPOSE OF LOAN: PHYSICIAN RECRUITMENT AND INCOME GUARANTEE AGREEMENT.
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Frederick Memorial Hospital Inc
 
Employer identification number

52-0591612
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 1 26,592 FMV
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2011
Schedule M (Form 990) 2011
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33 and whether the organization is reporting in Part I, column (b) the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Identifier Return Reference Explanation
Schedule M (Form 990) 2011
Additional Data


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

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

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

52-0591612
Identifier Return Reference Explanation
ORGANIZATION'S MISSION STATEMENT FORM 990, PART III, LINE 1 The mission of Frederick Memorial Hospital, Inc. is to contribute to the health and well-being of area residents by providing quality healthcare in a caring, cost efficient, safe and convenient manner through a coordinated program of prevention, diagnosis and treatment, rehabilitation, and support.
DESCRIPTION OF RELATIONSHIPS FORM 990, PART VI, QUESTION 2 MARVIN AUSHERMAN, DIRECTOR OF FMH, INC. IS ENGAGED IN AN INDIRECT BUSINESS RELATIONSHIP WITH THOMAS KLEINHANZL, JOHN VERBUS, KENNETH COFFEY, JAMES REINSCH AND ANNE HERBERT ROLLINS. FORM 990, PART VI, QUESTION 6 The sole member of the organization is Frederick Regional Health System. FORM 990, PART VI, QUESTION 7A The sole member, Frederick Regional Health System, has the power to appoint the president/CEO and the directors of Frederick Memorial Hospital. FORM 990, PART VI, QUESTION 7B The sole member, Frederick Regional Health System, must approve the incurrence of debt if such debt exceeds a certain amount to be designated by the member, capital expenditures exceeding a certain amount to be designated by the member, the decision to dissolve or liquidate, the creation of a subsidiary, and amendments to the bylaws. DESCRIBE THE PROCESS USED BY MANAGEMENT/GOVERNING BODY TO REVIEW 990 FORM 990, PART VI, QUESTION 11B FORM 990 IS PREPARED IN CONJUNCTION WITH OUTSIDE TAX ACCOUNTANTS AND REVIEWED BY UPPER MANAGEMENT PRIOR TO PROVIDING A COPY TO THE BOARD. A COPY OF FORM 990 WILL BE PROVIDED TO ALL MEMBERS OF THE BOARD PRIOR TO FILING. DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST FORM 990, PART VI, QUESTION 12C THE FREDERICK MEMORIAL HOSPITAL, INC. BOARD OF DIRECTORS IS COMMITTED TO MEETING ITS FIDUCIARY RESPONSIBILITIES AND MAINTAINING ITS DUTY OF LOYALTY TO THE HOSPITAL AND THE COMMUNITY IT SERVES. TO THIS END, THE BOARD WILL EXERCISE VIGILANCE IN IDENTIFYING ANY CONFLICTS OF INTEREST. THE BOARD WILL ALSO MAINTAIN TRANSPARENCY AND OBJECTIVITY IN MAKING DECISIONS ABOUT CONFLICTS OF INTEREST SO THAT THE ORGANIZATION'S MISSION IS ALWAYS THE FIRST PRIORITY. THE CHAIRPERSON (OR VICE CHAIRPERSON IF THE CHAIR IS INVOLVED) WILL NOTIFY ALL DIRECTORS OF A REPORTED CONFLICT OF INTEREST AND DECIDE WHETHER TO TAKE THE MATTER TO THE FULL BOARD TO DECIDE WHETHER A CONFLICT EXISTS AND, IF SO, WHAT ACTION TO TAKE, OR WILL REFER THE MATTER TO THE GOVERNANCE COMMITTEE FOR AN IN-DEPTH EXAMINATION, SUMMARY, AND RECOMMENDATION PRIOR TO A FULL BOARD DISCUSSION AND DECISION. IF TIME IS OF THE ESSENCE, THE CHAIRPERSON OR VICE CHAIRPERSON WILL TAKE THE MATTER TO THE EXECUTIVE COMMITTEE FOR DISCUSSION AND A DECISION, AND WILL THEN NOTIFY THE FULL BOARD. WHERE A CONFLICT OF INTEREST HAS BEEN IDENTIFIED, THE BOARD MEMBER SHALL NOT VOTE OR BE PRESENT FOR THE DISCUSSION OR THE VOTE REGARDING THE TRANSACTION AT EITHER THE FULL BOARD, EXECUTIVE COMMITTEE, OR GOVERNANCE COMMITTEE MEETINGS, EXCEPT TO ANSWER QUESTIONS THAT MAY BE ASKED OF HIM OR HER. TO PREVENT ACTUAL OR PERCEIVED INFLUENCE ON THE BOARD'S DECISION, THE CONFLICTED MEMBER IS PROHIBITED, AFTER INITIAL DISCLOSURE, FROM DISCUSSING THE CONFLICT OF INTEREST EITHER FORMALLY OR INFORMALLY WITH FELLOW DIRECTORS OR WITH MEMBERS OF THE MANAGEMENT. THERE WILL BE AN ANNUAL REVIEW OF ALL BOARD MEMBERS' AND OFFICERS' TRANSACTIONS PREPARED BY THE ADMINISTRATION AND REVIEWED BY THE GOVERNANCE COMMITTEE AND THE FULL BOARD OF DIRECTORS. AT THAT TIME, ALL DIRECTORS WILL BE REMINDED OF THE IRS INTERMEDIATE SANCTIONS REGULATION THAT ESTABLISHES EXCISE TAXES AS A SANCTION AGAINST ADMINISTRATORS AND DIRECTORS OF TAX-EXEMPT ORGANIZATIONS WHO PARTICIPATE IN "EXCESS BENEFIT TRANSACTIONS" (E.G., UNREASONABLY HIGH EMPLOYMENT COMPENSATION OR BUSINESS DEALS). The President and CEO shall be responsible for monitoring transactions or arrangements in which a director or officer may have a conflict of interest and for assuring that the director or officer serves the organization's best interests. OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN FORM 990, PART VI, QUESTIONS 15A & 15B THE EXECUTIVE COMPENSATION PROGRAM IS DESIGNED TO CARRY OUT THE HEALTH SYSTEM MISSION, TO ACHIEVE THE CHARITABLE PURPOSE, TO ATTRACT, RETAIN, MOTIVATE AND REWARD EXECUTIVE MANAGEMENT, AND TO MAINTAIN A COMPETITIVE POSITION WITH PEER ORGANIZATIONS IN THE REGION. OVERSIGHT OF THE EXECUTIVE COMPENSATION PROGRAM IS PROVIDED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD, COMPOSED OF THE BOARD CHAIRMAN, VICE CHAIRMAN, IMMEDIATE PRECEDING CHAIRMAN, CHAIRMAN OF THE FINANCE COMMITTEE AND THE CHAIRMAN OF THE GOVERNANCE COMMITTEE. THE EXECUTIVE COMPENSATION PHILOSOPHY OF THE BOARD PROVIDES FOR BASE COMPENSATION AT THE 50TH TO 60TH PERCENTILE OF OUR PEER GROUP. IN ADDITION TO THE BOARD'S COMPENSATION COMMITTEE, WE UTILIZED AN EXTERNAL INDEPENDENT CONSULTANT AND MARKET SURVEYS FOR ALL EXECUTIVE MANAGEMENT COMPENSATION. THE PRESIDENT AND CEO HAS A WRITTEN EMPLOYMENT CONTRACT. WRITTEN POLICIES AND PROCEDURES FOR JOINT VENTURES FORM 990, PART VI, QUESTION 16B FREDERICK MEMORIAL HOSPITAL USES LEGAL COUNSEL WHEN EVALUATING ANY POTENTIAL JOINT VENTURES WITH FOR-PROFIT ENTITIES. IN ADDITION, TAX EXPOSURES RELATED TO THESE ENTITIES ARE CONSIDERED ANNUALLY IN THE PREPARATION OF THE FIN 48 MEMO REQUIRED AS PART OF THE AUDIT OF THE CONSOLIDATED FINANCIAL STATEMENTS. FMH IS IN THE PROCESS OF COMPILING A FORMAL POLICY IN THIS AREA AND WRITTEN POLICIES WILL BE ADOPTED PRIOR TO 6/30/13. AVAIL OF GOV DOCS, CONFL. OF INTEREST POLICY & FIN STMTS TO GEN PUBLIC FORM 990, PART VI, QUESTION 19 GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FREDERICK MEMORIAL HOSPITAL, INC. CONSOLIDATED ANNUAL AUDITED FINANCIAL STATEMENTS ARE AVAILABLE AT WWW.FMH.ORG. OTHER CHANGES IN NET ASSETS OR FUND BALANCES FORM 990, PART XI, LINE 5 UNREALIZED LOSS ON INVESTMENT SECURITIES AND EBURG ($4,038,143) UNREALIZED LOSS ON INTEREST RATE SWAP ($6,797,708) PENSION ADJUSTMENT ($10,303,587) TRANSFER TO FMH FROM EMMITSBURG, NET ($1,227,876) CHANGE IN TEMP RESTRICTED NET ASSETS ($56,622) RELEASES FROM RESTRICTION $198,171 OTHER $2,428 ----------- TOTAL ($22,223,337)
AVERAGE HOURS WORKED FOR A RELATED ORGANIZATION FORM 990, PART VII, SECTION A, COLUMN B THE FOLLOWING INDIVIDUALS ALSO WORK FOR HOSPICE OF FREDERICK, INC., A RELATED ORGANIZATION. THOMAS KLEINHANZL 1 HOUR JOHN VERBUS 4 HOURS MICHELLE MAHAN 1 HOUR
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


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

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Frederick Memorial Hospital Inc
 
Employer identification number

52-0591612
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity







(1) EMMITSBURG PROPERTIES LLC
 
 
52-1910823 		Holding Invts MD 105,439 406,796 NA
 










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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) Hospice of Frederick County Inc

 
 
52-1164513 		HOSPICE CARE MD 501(c)(3) 7  
Yes
 
(2) Frederick Regional Health System

 
 
45-4133096 		Health System MD 501(c)(3) 11b  
 
No
(3) Monocacy Health Partners LLC

 
 
45-3007639 		Physician Org MD 501(c)(3) 7  
 
No








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



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No












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



 		(b)
Primary activity



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


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

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) Frederick Health Services Corporation
 
 
52-1851661 		MANAGEMENT CO. MD N/A
 C Corp 868,572 10,054,214 100.000 %
(2) Frederick Surgical Services Corporation
 
 
52-1642334 		Holding Company MD FHSC
  		C CORP 336,446 1,964,454 100.000 %
(3) Monocacy Insurance Ltd
 
 
98-1011570 		Insurance MD NA
  		C Corp      








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

 n 799,634 FMV
(2) Frederick Health Services Corporation

 n 192,388 FMV
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

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




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






























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


Software ID:  
Software Version: