TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) GARTH MILLER MD TRUSTEE	.40	X		420,694	27,799
(2) MARK FOURRE MD SECRETARY	.40	X	X	280,228	27,235
(3) ROBERT MCARTOR MD TRUSTEE	.40	X		159,100	40,540
(4) DANIEL FRIEDLAND MD TRUSTEE	.40	X		159,013	25,611
(5) ALAN BARKER MD TRUSTEE	.40	X		150,029	21,410
(6) STEVEN FEDER DO TRUSTEE	.40	X		144,016	21,523
(7) LESLIE BIRD TRUSTEE	.40	X		0	0
(8) WILLIAM LOGAN TRUSTEE	.40	X		0	0
(9) PETER MUNDY CHAIRMAN	.40	X	X	0	0
(10) MICHAEL CLARK MD TRUSTEE	.40	X		0	0
(11) JAMES COSGROVE TRUSTEE	.40	X		0	0
(12) BARBARA MITCHELL TRUSTEE	.40	X		0	0
(13) CATHERINE GREGG TRUSTEE	.40	X		0	0
(14) JANE G SMITH TRUSTEE	.40	X		0	0
(15) JANE HURD TRUSTEE	.40	X		0	0
(16) JEFFREY CURTIS VICE-CHAIRMA	.40	X	X	0	0
(17) JAMES HUNT TRUSTEE	.40	X		0	0

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
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	6,426,112	5,858,731	567,381
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	152,180	138,484	13,696
9	Other employee benefits .......	1,132,962	1,030,995	101,967
10	Payroll taxes ...........	476,768	433,859	42,909
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........	8,852		8,852
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......
g	Other ..........	5,106,233	3,375,496	1,676,121	54,616
12	Advertising and promotion ....	35,412	30,296	5,116
13	Office expenses .......	1,247,206	1,108,129	139,077
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	737,275	726,160	11,115
17	Travel ............	26,852	24,107	2,745
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	505,609	505,527	82
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	1,266,833	1,266,833
23	Insurance ..............
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	HOSPITAL & PROVIDER TAXES	577,841	577,841
b	FOOD	394,486	392,680	1,806
c	BAD DEBTS	345,526	298,698	46,828
d	MISCELLANEOUS	100,572	73,837	26,735
e
f	All other expenses	57,866	23,000	34,866
25	Total functional expenses. Add lines 1 through 24f	18,598,585	15,864,673	2,679,296	54,616
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	443,507	1	381,343
2	Savings and temporary cash investments .......		2
3	Pledges and grants receivable, net .........	152,570	3	188,818
4	Accounts receivable, net .........	2,312,264	4	1,740,671
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	328,267	8	187,079
9	Prepaid expenses and deferred charges ............	95,607	9	78,852
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	31,538,821
b	Less: accumulated depreciation. .....	10b	14,285,747	18,272,814	10c	17,253,074
11	Investments—publicly traded securities ..........	6,136,923	11	6,959,386
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	2,243,494	15	1,631,031
16	Total assets. Add lines 1 through 15 (must equal line 34)...	29,985,446	16	28,420,254
	17	Accounts payable and accrued expenses .	671,280	17	787,474
18	Grants payable ..........		18
19	Deferred revenue ..........	230,590	19	185,938
20	Tax-exempt bond liabilities ..........	7,624,212	20	7,220,776
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	3,671,408	23	3,500,958
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	3,291,560	25	2,319,151
26	Total liabilities. Add lines 17 through 25.....	15,489,050	26	14,014,297
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	13,684,336	27	13,601,259
28	Temporarily restricted net assets .....	180,801	28	121,618
29	Permanently restricted net assets .....	631,259	29	683,080
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	14,496,396	33	14,405,957
34	Total liabilities and net assets/fund balances .....	29,985,446	34	28,420,254

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Other

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2011

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2011

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2011

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2011

Name of organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

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

Page 2

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

Page 3

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

Page 4

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

Name of organization
ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part III

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

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below.
SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

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

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

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

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

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

2a	Lobbying non-taxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

6,108

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

6,108

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Identifier	Return Reference	Explanation
	SCHEDULE C, PART II-B, LINE 1	PORTION OF MEMBERSHIP DUES ATTRIBUTABLE TO LOBBYING ACTIVITIES: LOBBYING PORTION OF MAINE HOSPITAL ASSOCIATION DUES: 3,319 LOBBYING PORTION OF AMERICAN HOSPITAL ASSOCIATION DUES: 1,528 LOBBYING PORTION OF MAINE HEALTH CARE ASSOCIATION: 1,042 LOBBYING PORTION OF AMERICAN HEALTH CARE ASSOCIATION: 219

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2011

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

		(a)Current Year	(b)Prior Year	(c)Two Years Back	(d)Three Years Back
1a	Beginning of year balance ....	4,545,019	4,402,289	3,797,878	3,708,727
b	Contributions ........	900	70,055		77,640
c	Net investment earnings, gains, and losses ...	720,113	91,209	585,966	87,588
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........	-36,580		34,289	-62,499
f	Administrative expenses ....	-18,733	-18,534	-15,844	-13,578
g	End of year balance ......	5,210,719	4,545,019	4,402,289	3,797,878

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

Board designated or quasi-endowment SchDMd Bullet

89.700 %

Permanent endowment SchDMd Bullet

10.300 %

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

Yes

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	669,009		669,009
b	Buildings ................	21,233,380	7,049,427	14,183,953
c	Leasehold improvements ............
d	Equipment ................	7,473,031	5,487,923	1,985,108
e	Other .................	2,163,401	1,748,397	415,004
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				17,253,074

Schedule D (Form 990) 2011

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value
(1) DUE FROM AFFILIATE				1,328,450
(2) PATIENT AND OTHER DEPOSITS				173,690
(3) DEFERRED FINANCING COSTS				89,326
(4) OTHER ASSETS				39,565





Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,631,031

Part X

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

1.(a) Description of Liability		(b) Book value
Federal Income Taxes
AMOUNTS PAYABLE UNDER REIMB. REGS.		1,085,000
DUE TO AFFILIATE		920,294
DEPOSITS PAYABLE		173,690
MALPRATICE INSURANCE RESERVE		68,500
OTHER LIABILITIES		46,667
ASSET RETIREMENT OBLIGATIONS		25,000



Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		2,319,151
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2011

Page 4

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

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

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

Part XIV

Supplemental Information

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

Identifier	Return Reference	Explanation
INTENDED USES FOR ENDOWMENT FUNDS	SCHEDULE D, PAGE 2, PART V, LINE 4	ENDOWMENT FUNDS CONSIST OF A BENEFICIAL INTEREST IN PERPETUAL TRUST, BOARD DESIGNATED FUNDS, AND BEQUESTS THAT HAVE BEEN VOTED ON BY THE BOARD OF TRUSTEES TO BE UNRESTRICTED ENDOWMENT FUNDS.

Schedule D (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other 175.000 %

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

Yes

200% 250% 300% 350% 400% Other 225.000 %

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

	(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) ..	397,165		397,165	2.180 %
b Medicaid (from Worksheet 3, column a) .....	3,384,442	2,356,032	1,028,410	5.630 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .
dTotal Financial Assistance and Means-Tested Government Programs .....	3,781,607	2,356,032	1,425,575	7.810 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	10,890		10,890	0.060 %
f Health professions education (from Worksheet 5) ..	589		589
g Subsidized health services (from Worksheet 6) ..	2,062	550	1,512	0.010 %
h Research (from Worksheet 7)
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	14,320		14,320	0.080 %
jTotal Other Benefits ...	27,861	550	27,311	0.150 %
kTotal. Add lines 7d and 7j. ..	3,809,468	2,356,582	1,452,886	7.960 %

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.

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	5,387	5,387	0.030 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other	5,000	5,000	0.030 %
10	Total	10,387	10,387	0.060 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

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

257,186

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

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

Section B. Medicare

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

6,438,168

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

6,460,010

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

-21,842

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

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

Schedule H (Form 990) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	ST ANDREWS HOSPITAL 6 ST ANDREWS LANE BOOTHBAY HARBOR,ME04538	X	X	X

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

ST ANDREWS 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: 175.0% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

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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: 225.0% 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

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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	Yes
	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

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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?1
Name and address		Type of Facility (describe)
1	ST ANDREWS HOSPITAL DBA ST ANDREWS VILLAGE 145 EMERY LANE BOOTHBAY HARBOR,ME04538	LONG-TERM CARE FACILITY
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2011

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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
SUBSIDIZED HEALTH SERVICES EXPLANATION	PART I LINE 7G	SUBSIDIZED HEALTH SERVICES INCLUDE SCHOOL BASED HEALTH CENTERS WHERE LINCOLN COUNTY HEALTH CARE INC LCH AND ITS SUBSIDIARIES MILES MEMORIAL HOSPITAL MMH AND ST ANDREWS HOSPITAL SAH PROVIDE PHYSICIANS OR NURSE PRACTITIONERS TO CONSULT AND PROVIDE SERVICES WITHIN THE SCHOOL CLINICS ARE ALSO OFFERED THROUGHOUT THE YEAR TO PROVIDE SUBSIDIZED SERVICES SUCH AS MAMMOGRAPHY BLOOD PRESSURE SCREENINGS ETC TO ENCOURAGE ITS RESIDENTS TO OBTAIN THESE HEALTH SERVICES PHYSICIAN PRACTICES OFFERING SERVICES SUCH AS FAMILY MEDICINE INTERNAL MEDICINE AND PEDIATRICS OPERATE AT A LOSS IN ORDER TO ENSURE HEALTHCARE FOR ITS COMMUNITY MEMBERS REGARDLESS OF THEIR ABILITY TO PAY 2062 IN 2011 8862 OF EXPENSES RELATED TO OUTPATIENT CLINICS ARE INCLUDED IN THE SUBSIDIZED HEALTH SERVICES TOTAL IN PART I LINE 7G
EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE	PART I LINE 7 COLUMN F	BAD DEBT EXPENSE OF 345526 IN 2011 500452 WAS REMOVED FROM TOTAL EXPENSES WHEN CALCULATING THE PERCENT OF TOTAL EXPENSES IN COLUMN F
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	CHARITY CARE AND MEANSTESTED GOVERNMENT PROGRAMS UTILIZE A COST TO CHARGE RATIO IN DETERMINING THE COST OF THE ACTUAL CHARITY CARE WRITEOFF THE COST TO CHARGE RATIO IS DERIVED FROM THE ANNUAL COST REPORT SUBMISSIONS
COMMUNITY BUILDING ACTIVITIES	PART II	LINCOLN COUNTY HEALTH CARE INC AND ITS SUBSIDIARY HOSPITAL ORGANIZATIONS MILES MEMORIAL HOSPITAL AND ST ANDREWS HOSPITAL PARTNER WITH VARIOUS COMMUNITY GROUPS SUCH AS THE LINCOLN COUNTY ABUSE TASK FORCE AND THE DOMESTIC ABUSE PREVENTION COUNCIL TO IMPROVE AND PROTECT THE HEALTH OF ITS COMMUNITY MEMBERS MEALS ARE PREPARED BY ITS STAFF AS PART OF THE LOCAL MEALS ON WHEELS PROGRAMS WHICH DELIVERS MEALS TO THE ELDERLY POPULATION TO ASSIST WITH THEIR NUTRITIONAL NEEDS LCH PARTICIPATES IN THE COMMUNITY DISASTER TRAINING HELD ON A REGULAR BASIS THROUGHOUT THE COUNTY PART III LINE 4 BAD DEBT EXPLANATION FROM THE LCH AUDITED FINANCIAL STATEMENTS CHARITY CARE AND BAD DEBTS MMH AND SAH THE HOSPITALS ACCEPT ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY A PATIENT IS CLASSIFIED AS A CHARITY PATIENT BY REFERENCE TO CERTAIN ESTABLISHED POLICIES OF THE HOSPITALS ESSENTIALLY THESE POLICIES DEFINE CHARITY CARE AS THOSE SERVICES FOR WHICH LIMITED OR NO PAYMENT IS ANTICIPATED IN ASSESSING A PATIENTS ABILITY TO PAY THE HOSPITALS UTILIZE GENERALLY RECOGNIZED POVERTY INCOME LEVELS CHARITY CARE IS MEASURED BASED ON THE HOSPITALS ESTABLISHED RATES THE HOSPITALS UTILIZE ANNUAL FEDERAL GUIDELINES AND ADJUST ACCOUNT FOR THOSE WHOSE INCOME IS 225 OF THE POVERTY LEVEL TAKING FAMILY SIZE INTO CONSIDERATION THE COSTS AND EXPENSES INCURRED IN PROVIDING THESE SERVICES ARE INCLUDED IN OPERATING EXPENSES REVENUE FOR SERVICES RENDERED TO INDIVIDUALS FROM WHO PAYMENT IS EXPECTED AND ULTIMATELY NOT RECEIVED IS WRITTEN OFF AND INCLUDED AS PART OF THE ALLOWANCE FOR BAD DEBTS THE COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS REPORTED ON PART III LINE 2 AND 3 FOLLOW THE WORKSHEETS PROVIDED IN THE SCHEDULE H INSTRUCTIONS AND UTILIZES COSTS TO CHARGE INFORMATION DERIVED DIRECTLY OFF THE ANNUAL COST REPORTS BAD DEBT EXPENSE REPRESENTS HEALTHCARE SERVICES ST ANDREWS HOSPITAL HAS PROVIDED WITHOUT COMPENSATION AS A TAXEXEMPT HOSPITAL SAH PROVIDES NECESSARY PATIENT CARE REGARDLESS OF THE PATIENTS ABILITY TO PAY FOR THE SERVICES A PORTION OF SAH BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE THAT FOR A VARIETY OF REASONS DO NOT COMPLETE THE FINANCIAL ASSISTANCE APPLICATION PROCESS SAH CANNOT DETERMINE THE AMOUNT OF BAD DEBT EXPENSE THAT COULD BE REASONABLY ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE SAH FREE CARE POLICY IN ADDITION BAD DEBT EXPENSE ALSO INCLUDES AMOUNTS FOR SERVICES PROVIDED TO INDIVIDUALS EXPERIENCING DIFFICULT PERSONAL OR ECONOMIC CIRCUMSTANCES RELATED TO A PORTION OF OUR COMMUNITY BASED PATIENT POPULATION THEIR MEDICAL BILLS OFTEN PLACE THESE INDIVIDUALS IN UNTENABLE POSITIONS WHERE THEY ARE NOT ABLE TO HANDLE THEIR PERSONAL DEBT AND THEIR NEW MEDICAL DEBT HOWEVER BECAUSE OF THEIR INCOME LEVEL THEY DO NOT QUALIFY FOR FREE CARE BY PROVIDING NECESSARY HEALTHCARE SERVICES TO THOSE INDIVIDUALS EITHER WHO FAIL TO APPLY FOR FINANCIAL ASSISTANCE OR WHO ARE EXPERIENCING DIFFICULT PERSONAL OR ECONOMIC CIRCUMSTANCES SAH BELIEVES THAT BAD DEBT EXPENSE SHOULD BE INCLUDED AS A COMMUNITY BENEFIT
MEDICARE EXPLANATION	PART III LINE 8	MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST TO CHARGE RATIO SAH BELIEVES THAT THE MEDICARE SHORTFALL SHOULD BE INCLUDED AS A COMMUNITY BENEFIT BECAUSE SAH HAS A CLEAR MISSION COMMITMENT TO SERVING ELDERLY PATIENTS AND ADULTS WITH DISABILITIES THROUGH THE PROVISION OF SPECIFIC SUBSIDIZED PROGRAMS DEVELOPED TO HELP IMPROVE THE HEALTH STATUS OF THESE PATIENTS IF THESE CRITICAL SUBSIDIZED PROGRAMS WERE NOT IMPROVED BY SAH THEY WOULD BECOME THE OBLIGATION OF THE FEDERAL GOVERNMENT
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	COLLECTION POLICY EXCERPT REGARDING SELFPAY ACCOUNTS FOR SELFPAY BALANCES PAYMENTS MUST BE ARRANGED BY THE FINANCIAL COUNSELOR OR PATIENT ACCOUNTS STAFF USING THE FOLLOWING CRITERIA BALANCES UNDER 100 25MONTH MINIMUM BALANCES L00500 50MONTH MINIMUM BALANCES OVER 500 100MONTH MINIMUM IF THE PATIENT CANNOT MEET THE GUIDELINES ABOVE THE FINANCIAL COUNSELOR OR PATIENT ACCOUNTS STAFF WILL REQUEST PROOF OF INCOME AND REASON WHY THEY CANNOT MAKE REGULAR PAYMENTS THE PATIENT WILL BE OFFERED FINANCIAL ASSISTANCE IF CRITERIA IS MET WITH FREE CARE GUIDELINES AND OTHER ASSISTANCE THAT IS AVAILABLE WHEN IT IS DETERMINED THAT THE GUARANTOR CANNOT REALISTICALLY MEET THE EXTENDED PAYMENT PLAN TERMS DUE TO INSUFFICIENT INCOME LIMITED OR NEGLIGIBLE ASSETS OR OTHER EXTENUATING CIRCUMSTANCES BEYOND THE GUARANTORS CONTROL THE HOSPITAL MAY REDUCE THE TOTAL INDEBTEDNESS THROUGH FREE CARE UNDER THE SUPERVISION OF THE DIRECTOR OF PATIENT ACCOUNTS THE FINANCIAL COUNSELORS WILL FOLLOW THE FREE CARE GUIDELINES FOR APPROVAL OF FREE CARE A FREE CARE WRITEOFF MAY BE UTILIZED ONLY AFTER ALL THIRD PARTY BENEFIT POSSIBILITIES HAVE BEEN EXHAUSTED AND WHEN IT IS DETERMINED THAT NO OTHER HOSPITAL ASSISTANCE PROGRAMS OR FUNDS ARE APPLICABLE OR AVAILABLE TO THE GUARANTOR ONCE APPROVED THE HOSPITAL WILL ALLOW FULL OR PARTIAL ADJUSTMENTS ON BALANCES UP TO 225 OF THE FREE CARE GUIDELINES SET BY THE STATE OF MAINE
NEEDS ASSESSMENT	PART VI	THE HEALTH NEEDS OF THE COMMUNITY ARE ASSESSED BY UTILIZING THE MAINE STATE HEALTH PLAN AND ASSESSMENT COMMUNITY FORUMS INVOLVEMENT IN COMMUNITY BASED HEALTH STATUS IMPROVEMENT PROGRAMS AND IN CONJUNCTION WITH MAINEHEALTH OUR HEALTH CARE SYSTEM MAINEHEALTH ALSO PARTICIPATES IN VARIOUS INITIATIVES TO HELP SUPPORT AND PROVIDE UPDATES TO COMMUNITY NEEDS ASSESSMENT PLANNING SOME OF THESE INITIATIVES INCLUDE CLINICAL STRATEGIC PLANNING FINANCIAL STRATEGIC PLANNING FACILITY PLANNING MANPOWER PLANNING PHYSICIAN RECRUITMENT STRATEGIC PLANNING EMERGENCY PREPAREDNESS PLANNING ALONG WITH THE INTERNAL ASSESSMENTS MOST MEMBER ORGANIZATIONS ALSO REVIEW AND ACT ON MANY OF THE RECOMMENDATIONS PROVIDED BY EXTERNAL GROUPS SUCH AS THE MAINE CENTER FOR DISEASE CONTROL AND PREVENTION AND THE STATE HEALTH PLAN CREATED BY THE ADVISORY COMMITTEE FOR HEALTH SYSTEMS DEVELOPMENT IN ADDITION MAINEHEALTH AND ITS PARTNERS IN THE ONEMAINE HEALTH COLLABORATIVE EASTERN MAINE HEALTH SYSTEM AND MAINEGENERAL HEALTH RELEASED THE ONEMAINE HEALTH COMMUNITY HEALTH NEEDS ASSESSMENT REPORT IN 2011 THE REPORT IS A COMPREHENSIVE COMPILATION AND ANALYSIS CONTAINING PRIMARY AND SECONDARY HEALTH DATA SOURCES THE REPORT CONTAINS A HEALTH STATUS PROFILE FOR THE STATE AS A WHOLE AND FOR EACH OF MAINES SIXTEEN COUNTIES THE PRIMARY DATA SOURCE WAS A RANDOMIZED TELEPHONE SURVEY THE SAMPLING METHODOLOGY WAS DESIGNED TO PERMIT COMPARISONS AT THE COUNTY LEVEL SECONDARY DATA SOURCES INCLUDE NUMEROUS STATE AND FEDERAL SOURCES THIS REPORT PROVIDES BASELINE DATA ON HUNDREDS OF HEALTH INDICATORS THAT ARE RELEVANT TO HOSPITALS AND COMMUNITIES TO INFORM PLANNING AND EVALUATION ACTIVITIES PLANS CALL FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT TO BE REPLICATED EVERY THREE YEARS MAINEHEALTH HOLDS COMMUNITY FORUMS IN PARTNERSHIP WITH EACH MEMBER AND AFFILIATE HOSPITAL IN ORDER TO INCREASE UNDERSTANDING AND USE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT AND TO INFORM IDENTIFICATION AND ACTION ON LOCAL COMMUNITYBASED HEALTH PRIORITIES
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	PATIENTS AND OTHER PERSONS WHO ARE BILLED FOR PATIENT CARE ARE INFORMED ABOUT ELIGIBILITY CRITERIA FOR FREE CARE GOVERNMENTAL ASSISTANCE IE MEDICAID AND OTHER ASSISTANCE PROGRAMS SUCH NOTIFICATION IS ACCOMPLISHED IN THE FOLLOWING WAYS ALL SELFPAY PATIENTS ARE PROVIDED A PACKET THAT DESCRIBES AVAILABLE PROGRAMS ELIGIBILITY AND THE APPLICATION PROCESS NOTIFICATIONS ARE POSTED AT NUMEROUS LOCATIONS THROUGHOUT THE HOSPITAL IN PATIENT CARE AREAS AS WELL AS THE HOSPITAL ENTRANCE INPATIENTS WITHOUT INSURANCE RECEIVE FINANCIAL COUNSELING AT WHICH TIME FINANCIAL ASSISTANCE OPPORTUNITIES ARE DISCUSSED HOSPITAL STAFF WILL ASSIST PATIENTS IN THE APPLICATION PROCESS PATIENT BILLS AND STATEMENTS PROVIDE A TELEPHONE NUMBER TO CALL FOR INFORMATION ABOUT FINANCIAL ASSISTANCE PROGRAMS AND HELP IN QUALIFYING FOR THEM
COMMUNITY INFORMATION	PART VI	OUR SERVICE AREA IS LINCOLN COUNTY MAINE WHICH WAS INCORPORATED JUNE 19 1760 LINCOLN COUNTY CONTAINS 457 SQUARE MILES OF LAND 451 MILES OF COASTLINE AND SIX RIVERS MARINE INTERESTS SUCH AS COMMERCIAL FISHING LOBSTERING CLAMMING EELING BOAT BUILDING ALONG WITH FORESTRY AND AGRICULTURE CONSTITUTED THE MAJORITY OF OUR EARLY ECONOMIC BASE IN MORE RECENT TIMES SERVICE INDUSTRIES AND TOURISM ALSO SERVE AS OUR ECONOMIC BASE ACCORDING TO 20062008 AMERICAN COMMUNITY SURVEY OF THE US CENSUS BUREAU LINCOLN COUNTY HAS A TOTAL POPULATION OF 34730 THIS POPULATION ALMOST DOUBLES IN THE SUMMER AS WE ARE A VERY BUSY TOURIST DESTINATION ON THE COAST TEN PERCENT OF OUR RESIDENTS ARE BELOW THE POVERTY LEVEL MAINE HAS THE THIRD HIGHEST PERCENTAGE OF RESIDENTS OVER 65 156 VERSUS 129 NATIONALLY WITHIN MAINE LINCOLN COUNTY HAS THE HIGHEST PERCENTAGE OF RESIDENTS OVER 65 200 LINCOLN COUNTY ALSO HAS A HIGHER MEDIAN AGE 456 VS 367 THAN IN THE UNITED STATES AS COMPARED TO THE UNITED STATES 652 A SMALLER PERCENT OF RESIDENTS AT LEAST 16 YEARS OF AGE ARE IN THE LABOR FORCE 642 LINCOLN COUNTY IS AN ECONOMICALLY POOR COUNTY THE US DEPARTMENT OF LABOR REPORTS THAT THE WEEKLY WAGE IN LINCOLN COUNTY DURING THE THIRD QUARTER OF 2009 WAS ONLY 542 AS COMPARED TO THE AVERAGE WEEKLY WAGE OF 840 IN THE UNITED STATES IN FACT LINCOLN COUNTY HAS THE SECOND LOWEST WEEKLY WAGE OF ALL COUNTIES IN MAINE THESE POPULATION AND ECONOMIC DATA POINT OUT THE DEPENDENCE OF MILES MEMORIAL HOSPITAL ON MEDICARE AND MEDICAID AND EXPLAIN THE LARGE AMOUNT OF UNCOMPENSATED CARE PROVIDED MILES MEMORIAL HOSPITAL IS A SOLE COMMUNITY HOSPITAL LOCATED IN DAMARISCOTTA IT IS THE ONLY OTHER HOSPITAL IN LINCOLN COUNTY THE PROVISION OF CARE TO LINCOLN COUNTY RESIDENTS IS COORDINATED BETWEEN MILES AND STANDREWS AND THEY SHARE COMMON GOVERNANCE MANAGEMENT AND ADMINISTRATIVE SERVICES IN AN EFFORT TO CONTROL COSTS PORTIONS OF LINCOLN COUNTY HAVE BEEN DESIGNATED AS MEDICALLY UNDERSERVED
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	THE TAX EXEMPT PURPOSE OF THE ORGANIZATION TO IMPROVE THE HEALTH OF THE COMMUNITY IS PROMOTED AND ENHANCED IN THE FOLLOWING WAYS THE MAJORITY OF THE GOVERNING BODY IS COMPOSED OF PERSONS LIVING WITHIN THE HOSPITAL SERVICE AREA THAT ARE NEITHER EMPLOYED BY NOR HAVE CONTRACTUAL RELATIONSHIPS WITH THE HOSPITAL OR ITS AFFILIATES MEDICAL STAFF PRIVILEGES ARE AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY SOLICITATION OF COMMUNITY INPUT IN THE STRATEGIC PLANNING PROCESS COMMON GOVERNANCE OF THE HOSPITALS LONGTERM CARE HOME HEALTH HOSPICE AND PHYSICIAN SERVICES PROVIDED IN THE COUNTY TO PROMOTE COMMON HEALTH CARE AND IMPROVEMENT PLANNING AND CONTROL COSTS VOLUNTARY CAP ON INCOME FROM OPERATIONS TO RESTRAIN PRICES AND TO FUND HEALTH CARE AND HEALTH IMPROVEMENT ACTIVITIES SURPLUS FUNDS ARE REINVESTED IN CAPITAL EQUIPMENT AND IMPROVEMENTS TO ENSURE HIGH QUALITY CARE EACH YEAR A PORTION OF RETAINED EARNINGS ARE DISTRIBUTED TO OUR PARENT MAINEHEALTH FOR THE SPECIFIC PURPOSE OF HEALTH STATUS IMPROVEMENT PROGRAMS THROUGHOUT THE MAINEHEALTH SERVICE AREA
AFFILIATED HEALTH CARE INFORMATION	PART VI	THE HOSPITAL IS PART OF LINCOLN COUNTY HEALTH CARE INC WHICH INCLUDES THE FOLLOWING SERVICES PROVIDED IN LINCOLN COUNTY A CRITICAL ACCESS HOSPITAL A SOLE COMMUNITY PROVIDER HOSPITAL TWO NURSING FACILITIES TWO ASSISTED LIVING FACILITIES TWO DEMENTIA CARE FACILITIES RURAL HEALTH CLINICS AT SEVERAL SITES GENERAL SURGERY PRACTICE ORTHOPEDIC SURGERY PRACTICE OBGYN PHYSICIAN PRACTICE PEDIATRICS HOME HEALTH CARE AND HOSPICE LINCOLN COUNTY HEALTH CARE LCH IN TURN IS PART OF THE MAINEHEALTH SYSTEM THE ABILITY TO IMPROVE HEALTH CARE AND THE HEALTH STATUS IN LINCOLN COUNTY IS ENHANCED BY THE COMMON GOVERNANCE MANAGEMENT AND ADMINISTRATION OF THESE DIVERSE HEALTH CARE SERVICES THE SYSTEMS COORDINATED APPROACH TO THE FOLLOWING ENHANCES THE RESOURCES THAT CAN BE ALLOCATED TO DIRECT PATIENT CARE AND HEALTH STATUS IMPROVEMENT ACCOUNTING ANALYSIS AND BUDGETING PATIENT BILLING MEDICAL RECORDS SUPPLY CHAIN MANAGEMENTPURCHASING HUMAN RESOURCES INFORMATION SERVICES MEDICAL STAFF EDUCATION COMMUNITY STAFF SHARED CLINICAL DEPARTMENT MANAGEMENT HOSPITALS THE SYSTEM APPROACH PROVIDES A MORE HOLISTIC APPROACH TO COMMUNITY NEEDS ASSESSMENT AND TO THE IMPLEMENTATION OF PROGRAMS TO IMPROVE COMMUNITY HEALTH STRATEGIC PLANNING AND BUDGETING CAN BETTER ALLOCATE RESOURCES ACROSS THE SPECTRUM OF CARE TO ACHIEVE BETTER OVERALL OUTCOMES MAINEHEALTH IS A NOTFORPROFIT FAMILY OF LEADING HIGHQUALITY PROVIDERS AND OTHER HEALTHCARE ORGANIZATIONS WORKING TOGETHER SO THEIR COMMUNITIES ARE THE HEALTHIEST IN AMERICA RANKED AMONG THE NATIONS TOP 100 INTEGRATED HEALTHCARE DELIVERY NETWORKS MAINEHEALTH IS GOVERNED BY A BOARD OF TRUSTEES CONSISTING OF COMMUNITY AND BUSINESS LEADERS FROM ITS SOUTHERN CENTRAL AND WESTERN MAINE REGIONAL SERVICE AREAS THE COLLABORATION OF MAINEHEALTH MEMBERS MAKES IT POSSIBLE TO OFFER AN EXTENSIVE RANGE OF CLINICAL INTEGRATION AND COMMUNITY HEALTH PROGRAMS MANY AIMED AT IMPROVING ACCESS TO PREVENTIVE AND PRIMARY CARE SERVICES MAINEHEALTH INCLUDES THE FOLLOWING MEMBER ORGANIZATIONS LINCOLN COUNTY HEALTH CARE MILES MEMORIAL HOSPITAL AND ST ANDREWS HOSPITAL MAINE MEDICAL CENTER MAINE MENTAL HEALTH PARTNERS SPRING HARBOR HOSPITAL PEN BAY HEALTHCARE PEN BAY MEDICAL CENTER SOUTHERN MAINE MEDICAL CENTER WALDO COUNTY HEALTHCARE WALDO COUNTY GENERAL HOSPITAL WESTERN MAINE HEALTHCARE STEPHENS MEMORIAL HOSPITAL HOMEHEALTH VISITING NURSES MAINE PHYSICIAN HOSPITAL ORGANIZATION NORDX AND SYNERNET AFFILIATES OF MAINEHEALTH INCLUDE MAINEGENERAL MEDICAL CENTER MID COAST HOSPITAL NEW ENGLAND REHABILITATION HOSPITAL AND ST MARYS REGIONAL MEDICAL CENTER
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED	PART VI	MAINE
ADDITIONAL INFORMATION	PART VI	THE COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE REPORT PREPARED BY LINCOLN COUNTY HEALTH CARE INC SEE SCHEDULE O PART I LINE 3B ELIGIBILITY FOR FREE OR DISCOUNTED CARE IS BASED ON INCOME CRITERIA AS OUTLINED BELOW 175 FPL 100 WRITEOFF 200 FPL 50 WRITEOFF 225 FPL 25 WRITEOFF FEDERAL POVERTY LEVELS FPL TAKE INTO ACCOUNT FAMILY SIZE NO ASSET TEST OR OTHER CRITERIA IS EVALUATED FOR ELIGIBILITY THESE LEVELS SURPASS THE MINIMUM STATE REQUIREMENTS FOR FREE CARE ELIGIBILITY AT 150 OF FPL
ST ANDREWS HOSPITAL LINE NUMBER 1 PART V LINE 11H	PART V LINE 11H	PRESUMPTIVE ELIGIBILITY INTENDED FOR THOSE PATIENTS WHO NEVER COMPLETED A FREE CARE APPLICATION BUT THE PATIENT ACCOUNTS DEPARTMENT HAS SUFFICIENT INFORMATION TO DETERMINE THAT THE PATIENT WOULD QUALIFY FOR FREE CARE IF THEY APPLIED EXAMPLES INCLUDE THE FOLLOWING PATIENT IS HOMELESS AND DID NOT COMPLETE AN APPLICATION PATIENT IS COVERED BY AN OUT OF STATE MEDICAID PLAN THAT THE PROVIDER IS NOT CREDENTIALED WITH AND THE PATIENTS BALANCE DOES NOT JUSTIFY COMPLETION OF THE BURDENSOME PAPERWORK ASSOCIATED WITH CREDENTIALING PATIENT HAS BEEN IN THE HOSPITAL WITHOUT INCOME FOR MORE THAN 3 MONTHS AND EXPIRES BEFORE AN APPLICATION CAN BE COMPLETED PATIENT IS INCARCERATED CONSISTENT WITH THE SECTION ON MEDICAL INDIGENCE PRESUMPTIVE ELIGIBILITY PATIENTS WILL BE APPROVED FOR ADJUSTMENT BY SUPERVISORY OR MANAGEMENT STAFF IN THE PATIENT ACCOUNTS DEPARTMENT UPON RECOMMENDATION BY COLLECTION OR CUSTOMER SERVICE STAFF
ST ANDREWS HOSPITAL LINE NUMBER 1 PART V LINE 19D	PART V LINE 19D	THE HOSPITAL FACILITY USED GROSS CHARGES TO CALCULATE DISCOUNTS ITEMS 19AC ARE BEING EVALUATED FOR WHICH IS MOST PRACTICABLE FOR FUTURE IMPLEMENTATION
ST ANDREWS HOSPITAL LINE NUMBER 1 PART V LINE 20	PART V LINE 20	THE HOSPITAL BILLS ALL PATIENTS INSURED OR NOT THE SAME AMOUNT SOME INSURANCE COMPANIES APPLY A NEGOTIATED DISCOUNT AGAINST THESE BILLED AMOUNTS IF PAID PER PROMPT PAYMENT TERMS THE NET IMPACT IS THAT WE ACCEPT LOWER PAYMENT FOR CERTAIN INSURANCE CONTRACTS MEDICARE AND MEDICAID EVEN THOUGH ALL ARE BILLED THE SAME AMOUNT WE ARE CURRENTLY PLANNING TO IMPLEMENT ONE OF THE METHODS DESCRIBED ABOVE IN 19AC FOR FAPELIGIBLE INDIVIDUALS

Schedule H (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2011

Page 2

Part II

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

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

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

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) GARTH MILLER MD	(i) (ii)	331,848		88,846	7,259	20,540	448,493
(2) MARK FOURRE MD	(i) (ii)	280,228			7,963	19,272	307,463
(3) ROBERT MCARTOR MD	(i) (ii)	137,014		22,086	13,524	27,016	199,640
(4) DANIEL FRIEDLAND MD	(i) (ii)	126,608		32,405	5,453	20,158	184,624
(5) ALAN BARKER MD	(i) (ii)	146,696		3,333	4,288	17,122	171,439
(6) STEVEN FEDER DO	(i) (ii)	126,545		17,471	4,649	16,874	165,539
(7) JAMES DONOVAN	(i) (ii)	236,314	45,000	26,485	7,963	20,610	336,372
(8) WAYNE PRINTY	(i) (ii)	184,899			5,686	20,176	210,761

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
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS	SCHEDULE J, PAGE 1, PART I, LINE 4	ROBERT MCARTOR, M.D. 0 17,464 0
OTHER ADDITIONAL INFORMATION	SCHEDULE J, PART III	PART I, LINE 4: THE NONQUALIFIED PAYMENTS ARE FROM RELATED ORGANIZATIONS WHERE THE INDIVIDUAL IS EMPLOYED.

Schedule J (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization
ST ANDREWS HOSPITAL

Employer identification number
01-0153960

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	MHHEFA REVENUE BOND SERIES 2011A	01-0314384	560427LW4	08-31-2011	8,469,460	REFINANCE BONDS		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . .	375,000
2 Amount of bonds legally defeased . . . . . . . . . .
3 Total proceeds of issue . . . . . . . . . . . . .	8,469,460
4 Gross proceeds in reserve funds . . . . . . . .	857,358
5 Capitalized interest from proceeds . . . . . . . . . .
6 Proceeds in refunding escrows . . . . . . . . . . .
7 Issuance costs from proceeds . . . . . . . . . . .	88,736
8 Credit enhancement from proceeds . . . . . . . . . .
9 Working capital expenditures from proceeds . . . . . . .
10 Capital expenditures from proceeds . . . . . . . . . .
11 Other spent proceeds . . . . . . . . . . .	8,380,724
12 Other unspent proceeds . . . . . . . . . . .
13 Year of substantial completion . . . . . . . . . . .	2000
	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

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . .		X
b If ‘Yes’ to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . .		X
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . .		X
d If ‘Yes’ to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .		X
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 . .	%		%		%		%
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . .	%		%		%		%
6 Total of lines 4 and 5 . . .. . . . . . . . .	%		%		%		%
7 Does the bond issue meet the private security or payment test? . . .		X
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 . . . . . . . .
c Term of hedge . . . . . . . .
d Was the hedge superintegrated? . . . .
e Was a hedge terminated? . . . . .
4a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . .		X
b Name of provider . . . . . .
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

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? . . . . . . . . . . . . . . YesNo

Part VI

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Identifier	Return Reference	Explanation
ORGANIZATION'S MISSION	FORM 990 - ORGANIZATION'S MISSION	- TO ESTABLISH, OPERATE, & MAINTAIN FOR SCIENTIFIC, CHARITABLE, EDUCATIONAL & BENEVOLENT PURPOSES A PUBLIC HOSPITAL, CLINIC, INFIRMARY & RETIREMENT COMMUNITY FOR THE CARE & TREATMENT OF SICK, WOUNDED, INFIRM OR AGED PERSONS, A DOCTOR'S OFFICE BUILDING & A SCHOOL FOR THE EDUCATION & TRAINING OF NURSES, ALL WITHOUT DISCRIMINATION AS TO RACE, COLOR, CREED, NATIONAL ORIGIN, AGE, GENDER, SEXUAL ORIENTATION OR FINANCIAL STATUS. - TO BE OPERATED & MAINTAINED AS A CRITICAL ACCESS HOSPITAL IN ACCORDANCE WITH THE STANDARDS ESTABLISHED FROM TIME TO TIME FOR THE MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM. - TO ENCOURAGE & CARRY ON EDUCATIONAL ACTIVITIES PURSUANT TO CONTINUALLY IMPROVING THE QUALITY OF CARE PROVIDED. - TO COOPERATE & PARTICIPATE WITH ALLIED AGENCIES IN ALL ACTIVITIES DESIGNED TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY IN THE AREAS SERVED BY THE HOSPITAL. - THIS CORPORATION SHALL NOT BE CONDUCTED FOR GAIN OR PROFIT, & NO PART OF THE NET EARNINGS SHALL INURE TO THE BENEFIT OF ANY MEMBER.
ANY SIGNIFICANT CHANGES IN CONDUCT FOR PROGRAM SERVICES	FORM 990, PAGE 2, PART III, LINE 3	ST. ANDREWS HOSPITAL CEASED GENERAL SURGERY SERVICES IN APRIL 2012.
FIRST ACCOMPLISHMENT DESCRIPTION	FORM 990, PAGE 2, PART III, LINE 4A	PATIENT DAYS: ADULT & CHILDREN:3,520 NURSING FACILITY: 10,704 DISCHARGES: 277 DEPARTMENT AMOUNT STATISTICS OPERATING ROOM 164 PROCEDURES LABORATORY 26,033 TESTS CARDIOPULMONARY 2,311 PROCEDURES CT SCANS 913 PROCEDURES RADIOLOGY 2,535 PROCEDURES REHABILITATION SERVICES 7,622 VISITS OUTPATIENT DEPARTMENT: EMERGENCY ROOM 4,653 VISITS PLEASE SEE ATTACHED COMMUNITY BENEFITS STATEMENT
CLASSES OF MEMBERS OR STOCKHOLDERS	FORM 990, PAGE 6, PART VI, LINE 6	ST. ANDREWS HOSPITAL AND MILES MEMORIAL HOSPITAL SHARE LINCOLN COUNTY HEALTH CARE INC. (LCH) AS THEIR SOLE CORPORATE MEMBER. MAINEHEALTH (EIN 01-0431680), AS THE SOLE MEMBER OF LCH, HAS THE RIGHT TO APPROVE SIGNIFICANT DECISIONS OF THE GOVERNING BOARD OF LCH AND ITS SUBSIDIARIES.
ELECTION OF MEMBERS AND THEIR RIGHTS	FORM 990, PAGE 6, PART VI, LINE 7A	THE MEMBER ELECTS THE BOARD OF TRUSTEES. ALL OFFICERS OF THE BOARD OF TRUSTEES ARE ELECTED BY THE BOARD, AND EACH MUST BE A TRUSTEE. OFFICERS OF THE CORPORATION ARE ELECTED ANNUALLY BY THE BOARD.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS	FORM 990, PAGE 6, PART VI, LINE 7B	DECISIONS OF THE GOVERNING BODY SUCH AS BUDGETS, BUSINESS STRATEGIES, SIGNIFICANT FINANCIAL COMMITMENTS, AMENDMENTS TO THE ARTICLES OF INCORPORATION, AND ELECTION OF THE PRESIDENT/CEO AMONG OTHER DECISIONS, ARE SUBJECT TO THE APPROVAL OF THE SOLE MEMBER.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	THE FINANCE COMMITTEE PERFORMED A DETAILED REVIEW OF THE FORM 990. THE FORM 990 IS THEN MADE AVAILABLE TO THE FULL BOARD. THE CHIEF FINANCIAL OFFICER ALSO PERFORMS A DETAILED REVIEW OF THE ENTIRE FORM 990 BEFORE SIGNING AND PRIOR TO FILING.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF A TRUSTEE, PHYSICIAN, OFFICER OR MANAGER (E.G., A MEMBER OF LINCOLN COUNTY HEALTHCARE LEADERSHIP TEAM, DIRECTOR, MANAGER OR PERSON RESPONSIBLE FOR PURCHASING) MUST BE DISCLOSED TO THE APPLICABLE BOARD, BOARD COMMITTEE OR, IN THE CASE OF AN ADMINISTRATIVE DECISION THAT IS NOT SUBJECT TO BOARD OR COMMITTEE APPROVAL, TO THE MANAGER'S IMMEDIATE SUPERVISOR. SUCH DISCLOSURES SHALL BE MADE A MATTER OF RECORD. DISCLOSURE WILL BE MADE AT THE TIME OF INITIAL AFFILIATION WITH LINCOLN COUNTY HEALTH CARE ANNUALLY AND WHEN THE INTEREST BECOMES A MATTER FOR BOARD OR COMMITTEE ACTION OR ADMINISTRATIVE DECISION. DISCLOSURE FORMS SHALL BE COMPLETED ANNUALLY BY TRUSTEES AND OFFICERS AT THE TIME OF THE ANNUAL MEETING, AND ANNUALLY BY VICE PRESIDENTS, DIRECTORS, AND MANAGERS IN CONJUNCTION WITH THEIR ANNUAL PERFORMANCE REVIEW.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	IN CONSULTATION WITH SULLIVAN COTTER, THE MAINEHEALTH EXECUTIVE COMMITTEE ESTABLISHES APPROPRIATE COMPENSATION PARAMETERS FOR EACH MEMBER ORGANIZATION'S CEO AND CERTAIN MEMBERS OF THEIR SENIOR MANAGEMENT TEAM. WORKING WITHIN THOSE PARAMETERS, THE LCH COMPENSATION COMMITTEE DETERMINES THE LEVEL OF COMPENSATION FOR ITS CEO. THE FINDINGS OF THE COMPENSATION COMMITTEE ARE MADE TRANSPARENT TO, AND VOTED ON BY, THE FULL GOVERNING BOARD. THIS "TOTAL EXECUTIVE COMPENSATION" IS FILED PUBLICLY BY THE ORGANIZATION, AND INCLUDES "TOTAL CASH COMPENSATION" AND "TOTAL VALUE OF ALL BENEFITS AND PERQUISITES ASSOCIATED WITH POSITION (SUCH AS HOUSING ALLOWANCES, SOCIAL CLUB MEMBERSHIPS, SIGNING BONUSES, ETC.)". THE BOARD TAKES NECESSARY ACTION TO PREVENT THE CEO FROM VOTING OR DIRECTLY PARTICIPATING IN THE FINAL COMMITTEE DETERMINATION OF (HER/HIS) OWN COMPENSATION. THE ORGANIZATION'S EXECUTIVE COMPENSATION PROCEDURE RELIES UPON APPROPRIATE DATA FOR COMPARABILITY (E.G. COMPENSATION LEVELS PAID BY BOTH TAXABLE AND TAX-EXEMPT SIMILARLY SITUATED ORGANIZATIONS AND INDEPENDENT COMPENSATION SURVEYS BY NATIONALLY RECOGNIZED INDEPENDENT FIRMS). FINALLY, THE ORGANIZATION REFRAINS FROM ALLOWING EXECUTIVE COMPENSATION TO EVER BE BASED SOLELY ON LCH'S REVENUES OR OTHER SIMILAR PROFIT-SHARING STRATEGIES.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	IN CONSULTATION WITH SULLIVAN COTTER, THE MAINEHEALTH EXECUTIVE COMMITTEE ESTABLISHES APPROPRIATE COMPENSATION PARAMETERS FOR EACH MEMBER ORGANIZATION'S CEO AND CERTAIN MEMBERS OF THEIR SENIOR MANAGEMENT TEAM. WORKING WITHIN THOSE PARAMETERS, THE LCH COMPENSATION COMMITTEE DETERMINES THE LEVEL OF COMPENSATION FOR ITS CEO. THE FINDINGS OF THE COMPENSATION COMMITTEE ARE MADE TRANSPARENT TO, AND VOTED ON BY, THE FULL GOVERNING BOARD. THIS "TOTAL EXECUTIVE COMPENSATION" IS FILED PUBLICLY BY THE ORGANIZATION, AND INCLUDES "TOTAL CASH COMPENSATION" AND "TOTAL VALUE OF ALL BENEFITS AND PERQUISITES ASSOCIATED WITH POSITION (SUCH AS HOUSING ALLOWANCES, SOCIAL CLUB MEMBERSHIPS, SIGNING BONUSES, ETC.)". THE BOARD TAKES NECESSARY ACTION TO PREVENT THE CEO FROM VOTING OR DIRECTLY PARTICIPATING IN THE FINAL COMMITTEE DETERMINATION OF (HER/HIS) OWN COMPENSATION. THE ORGANIZATION'S EXECUTIVE COMPENSATION PROCEDURE RELIES UPON APPROPRIATE DATA FOR COMPARABILITY (E.G. COMPENSATION LEVELS PAID BY BOTH TAXABLE AND TAX-EXEMPT SIMILARLY SITUATED ORGANIZATIONS AND INDEPENDENT COMPENSATION SURVEYS BY NATIONALLY RECOGNIZED INDEPENDENT FIRMS). FINALLY, THE ORGANIZATION REFRAINS FROM ALLOWING EXECUTIVE COMPENSATION TO EVER BE BASED SOLELY ON LCH'S REVENUES OR OTHER SIMILAR PROFIT-SHARING STRATEGIES.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	DOCUMENTS THAT ARE REQUIRED TO BE OPEN FOR PUBLIC INSPECTION ARE MADE AVAILABLE UPON REQUEST.
RELATED ORGANIZATIONS	FORM 990, PAGE 7, PART VII	FOR EACH OF THE BOARD OF TRUSTEE'S LISTED, 50 HOURS PER WEEK IS TO A RELATED ORGANIZATION - LINCOLN COUNTY MEDICAL GROUP: ALAN BARKER, M.D., MARK FOURRE, M.D., DANIEL FRIEDLAND, M.D., GARTH MILLER, M.D., AND STEVEN FEDER, D.O.. JAMES DONOVAN AND WAYNE PRINTY WORKS AN AVERAGE OF 50 HOURS PER WEEK FOR A RELATED ORGANIZATION - LINCOLN COUNTY HEALTH CARE. ROBERT MCARTOR, M.D. WORKS AN AVERAGE OF 50 HOURS PER WEEK FOR A RELATED ORGANIZATION - MAINEHEALTH.
ADDITIONAL INFORMATION	FORM 990, PART XI	THE FINANCIAL RESULTS OF THE ORGANIZATION WERE PART OF A CONSOLIDATED FINANCIAL STATEMENT AUDIT PREPARED FOR LINCOLN COUNTY HEALTH CARE, INC. (EIN 26-1475629) AND ITS SUBSIDIARIES.
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 5	CHANGE IN UNREALIZED 401,302 EQUITY TRANSFERS TO AFFILIATES (367,739) CHANGE IN PERPETUAL TRUST 50,920 TOTAL OTHER CHANGES IN NET ASSETS 84,483

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

ST ANDREWS HOSPITAL

Employer identification number

01-0153960

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) LINCOLN COUNTY MEDICAL GROUP 6 ST ANDREWS LANE BOOTHBAY HARBOR,ME04538 26-3878235	PHYS SVC	ME	501C3	3	LCH		No
(2) LINCOLN COUNTY HEALTH CARE INC (LCH) 6 ST ANDREWS LANE BOOTHBAY HARBOR,ME04538 26-1475629	HEALTH SVC	ME	501C3	11C	MH		No
(3) MILES MEMORIAL HOSPITAL 35 MILES STREET DAMARISCOTTA,ME04543 01-0211796	HOSP SVC	ME	501C3	3	LCH		No
(4) COVES EDGE INC 26 SCHOONER STREET DAMARISCOTTA,ME04543 01-0382340	LT CARE SV	ME	501C3	3	LCH		No
(5) MAINEHEALTH (MH) 110 FREE STREET PORTLAND,ME04101 01-0431680	HEALTHCARE	ME	501C3	11C	NA		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2011

Page 2

Part III

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

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

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership

Schedule R (Form 990) 2011

Page 3

Part V

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

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

Yes

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2011

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2011

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation
ADDITIONAL INFORMATION	SCHEDULE R	LINCOLN COUNTY MEDICAL GROUP HAS APPLIED FOR PUBLIC CHARITY TAXEXEMPT STATUS WITHIN THE DUE DATE REQUIRED TO RECEIVE IRS APPROVAL RETROACTIVE TO THE LEGAL DATE OF FORMATION

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: - TO ESTABLISH, OPERATE, & MAINTAIN FOR SCIENTIFIC, CHARITABLE, EDUCATIONAL & BENEVOLENT PURPOSES A PUBLIC HOSPITAL, CLINIC, INFIRMARY & RETIREMENT COMMUNITY FOR THE CARE & TREATMENT OF SICK, WOUNDED, INFIRM OR AGED PERSONS, A DOCTOR'S OFFICE BUILDING & A SCHOOL FOR THE EDUCATION & TRAINING OF NURSES, ALL WITHOUT DISCRIMINATION AS TO RACE, COLOR, CREED, NATIONAL ORIGIN, AGE, GENDER, SEXUAL ORIENTATION OR FINANCIAL STATUS. - TO BE OPERATED & MAINTAINED AS A CRITICAL ACCESS HOSPITAL IN ACCORDANCE WITH THE STANDARDS ESTABLISHED FROM TIME TO TIME FOR THE MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM. - TO ENCOURAGE & CARRY ON EDUCATIONAL ACTIVITIES PURSUANT TO CONTINUALLY IMPROVING THE QUALITY OF CARE PROVIDED. - TO COOPERATE & PARTICIPATE WITH ALLIED AGENCIES IN ALL ACTIVITIES DESIGNED TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY IN THE AREAS SERVED BY THE HOSPITAL. - THIS CORPORATION SHALL NOT BE CONDUCTED FOR GAIN OR PROFIT, & NO PART OF THE NET EARNINGS SHALL INURE TO THE BENEFIT OF AN
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	20
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	14
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	229
6	Total number of volunteers (estimate if necessary) ....	6	74
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	166,224
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	-89,394

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	354,360	368,279
9	Program service revenue (Part VIII, line 2g) .........	18,482,299	17,332,784
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	285,969	254,681
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	588,128	467,919
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	19,710,756	18,423,663
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	8,620,981	8,188,022
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 54,616
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	10,250,796	10,410,563
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	18,871,777	18,598,585
19	Revenue less expenses. Subtract line 18 from line 12.......	838,979	-174,922
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	29,985,446	28,420,254
21	Total liabilities (Part X, line 26).............	15,489,050	14,014,297
22	Net assets or fund balances. Subtract line 21 from line 20.....	14,496,396	14,405,957

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 11,452,663 including grants of $ ) (Revenue $ 11,883,374 )
	ST. ANDREWS HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL OPERATIONS PROVIDE BOTH ACUTE CARE AND REHABILITATIVE CARE IN ITS INPATIENT SETTING. OUTPATIENT SERVICES INCLUDE EMERGENCY CARE, GENERAL SURGERY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, CARDIOPULMONARY SERVICES, DIAGNOSTIC IMAGING, LABORATORY, AND PHARMACY. (CONTINUED ON SCHEDULE O) PATIENT DAYS: ADULT & CHILDREN:3,520 NURSING FACILITY: 10,704 DISCHARGES: 277 DEPARTMENT AMOUNT STATISTICS OPERATING ROOM 164 PROCEDURES LABORATORY 26,033 TESTS CARDIOPULMONARY 2,311 PROCEDURES CT SCANS 913 PROCEDURES RADIOLOGY 2,535 PROCEDURES REHABILITATION SERVICES 7,622 VISITS OUTPATIENT DEPARTMENT: EMERGENCY ROOM 4,653 VISITS PLEASE SEE ATTACHED COMMUNITY BENEFITS STATEMENT

4b	(Code: ) (Expenses $ 4,412,010 including grants of $ ) (Revenue $ 5,449,410 )
	ST. ANDREWS HOSPITAL OFFERS LONG TERM CARE SERVICES AT ST. ANDREWS VILLAGE COMMUNITY. IT INCLUDES 13 ASSISTED LIVING UNITS, 28 INDEPENDENT LIVING APARTMENTS, 11 DEMENTIA CARE BEDS, ADULT DAY SERVICES, AND 30 LONG-TERM CARE BEDS. STATISTICS FOR THE YEAR: ASSISTED LIVING 4,083 DAYS, INDEPENDENT LIVING 8,084 DAYS, DEMENTIA CARE 3,661 DAYS, AND ADULT DAY SERVICES 587 HOURS.

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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 15,864,673

(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
(A) Name and Title
(18) NORMAN HOCHGRAF TRUSTEE	.40	X			0	0	0
(19) PATRICK LYDON TREASURER	.40	X	X		0	0	0
(20) REV DR MARY JO ZIMMERLI TRUSTEE	.40	X			0	0	0
(21) JAMES DONOVAN CEO LCH	3.00		X		0	307,799	28,573
(22) WAYNE PRINTY CFO	3.00		X		0	184,899	25,862
(23) CHARLES KIRK PHARMACIST	50.00			X	131,167	0	15,568
(24) PATRICE CARTER PHARMACIST	50.00			X	127,038	0	20,181

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	258,205	1,805,778	254,302

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





2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		72,010

f	All other contributions, gifts, grants, and similar amounts not included above1f		296,269
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			368,279
			Business Code
2a	NET PATIENT REVENUE		623,000	16,907,747	16,907,747
b	RENTAL INCOME		531,390	425,037	425,037
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			17,332,784
3	Investment income (including dividends, interest
	and other similar amounts).....			86,424			86,424
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross rents	15,618
b	Less: rental expenses
c	Rental income or (loss)	15,618
d	Net rental income or (loss).......			15,618		15,618
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	1,490,452	78,397
b	Less: cost or other basis and sales expenses	1,312,076	88,516
c	Gain or (loss)	178,376	-10,119
d	Net gain or (loss)..........			168,257	168,257
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	MISCELLANEOUS INCOME		900,099	301,695	301,695
b	COTTAGE SERVICES		531,310	122,430		122,430
c	MANAGEMENT FEES		531,310	22,660		22,660
d	All other revenue ....			5,516		5,516
e	Total. Add lines 11a–11d ......			452,301
12	Total revenue. See Instructions....			18,423,663	17,802,736	166,224	86,424


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			443,507	1	381,343
2	Savings and temporary cash investments .......				2
3	Pledges and grants receivable, net .........			152,570	3	188,818
4	Accounts receivable, net .........			2,312,264	4	1,740,671
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			328,267	8	187,079
9	Prepaid expenses and deferred charges ............			95,607	9	78,852
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	31,538,821
b	Less: accumulated depreciation. .....	10b	14,285,747	18,272,814	10c	17,253,074
11	Investments—publicly traded securities ..........			6,136,923	11	6,959,386
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			2,243,494	15	1,631,031
16	Total assets. Add lines 1 through 15 (must equal line 34)...			29,985,446	16	28,420,254
17	Accounts payable and accrued expenses .			671,280	17	787,474
18	Grants payable ..........				18
19	Deferred revenue ..........			230,590	19	185,938
20	Tax-exempt bond liabilities ..........			7,624,212	20	7,220,776
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			3,671,408	23	3,500,958
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			3,291,560	25	2,319,151
26	Total liabilities. Add lines 17 through 25.....			15,489,050	26	14,014,297
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			13,684,336	27	13,601,259
28	Temporarily restricted net assets .....			180,801	28	121,618
29	Permanently restricted net assets .....			631,259	29	683,080
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			14,496,396	33	14,405,957
34	Total liabilities and net assets/fund balances .....			29,985,446	34	28,420,254