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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
DOUGLAS HOSPITAL INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
805 Sandy Plains Road
 
Room/suite
City or town, state or country, and ZIP + 4
Marietta, GA300666340
D Employer identification number

58-2026750
E Telephone number

G Gross receipts $ 107,200,563
F Name and address of principal officer:
Reynold J Jennings
805 Sandy Plains Road
Marietta,GA300666340
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.wellstar.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1992
M State of legal domicile: GA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: To provide world class charitable healthcare to the community
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 14
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 844
6 Total number of volunteers (estimate if necessary) .... 6 100
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 0
9 Program service revenue (Part VIII, line 2g) ......... 94,854,673 106,423,008
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 0 -9,202
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 737,359 777,555
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 95,592,032 107,191,361
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 43,038,270 46,291,528
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 43,492,307 47,845,015
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 86,530,577 94,136,543
19 Revenue less expenses. Subtract line 18 from line 12....... 9,061,455 13,054,818
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 58,798,093 61,790,253
21 Total liabilities (Part X, line 26)............. 45,809,603 42,659,885
22 Net assets or fund balances. Subtract line 21 from line 20..... 12,988,490 19,130,368
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

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



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: TO CREATE AND DELIVER HIGH QUALITY HOSPITAL, PHYSICIAN AND OTHER HEALTHCARE RELATED SERVICES THAT IMPROVE THE HEALTH AND WELL-BEING OF THE INDIVIDUALS AND COMMUNITIES WE SERVE
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 80,006,148 including grants of $   ) (Revenue $ 106,423,008 )
As discussed herein, Douglas Hospital, Inc (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of Internal Revenue Code section 501 (c) (3) and the "community benefit standard" of IRS Revenue Ruling 69-545. In this regard, the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualified physicians in the area consistent with the size and nature of the facility; the hospital operates a full-time emergency room open to all regardless of ability to pay; the hospital provides care to the needy members of the community consistent with its charity care policy regardless of their ability to pay for these services. The hospital's excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement of patient care, community benefit activities, and charity care. Douglas Hospital committed approximately $4.6 million in capital expenditures for the year to meet the technology and program needs of the community we serve. Douglas Hospital, Inc. was organized in 1992. The hospital affiliated with the Northwest Georgia Health System in 1993. In 1994 Northwest Georgia Health System helped form the PROMINA Health System and changed its name to Promina Northwest Health System. In 1998 Promina Northwest changed its name to Wellstar Health System and is now totally independent of PROMINA. Douglas Hospital is subordinate to, and subject to the authority of Wellstar Health System and its governing boards including the Hospital Authority of Douglas County. Wellstar Douglas provides a full range of inpatient and outpatient services characteristic of a community hospital. The hospital is licensed to operate 108 beds and is presently staffed to operate 102 beds. The original hospital was constructed in 1974 and had one major structural addition in 1985. The following stats constitute the overall program services provided during the reporting period ended June 30, 2012: Adult Discharges 6,826 Med & Surgical Short Stay Cases 147 Emergency Room Visits 58,581 Outpatient Surgical Cases 4,336 Inpatient Surgical Cases 1,260 Outpatient Procedures Non-ED OP Radiology 44,278 GI Laboratory 1,317 Total FTEs Paid 659 Community Benefit Reporting Community Outreach $ 401,114 Unreimbursed Charity Care (at cost) $10,843,010 Medicaid Shortfalls (at cost) $2,703,151 Total Community Benefit $13,546,161 As an affiliate of Wellstar Health System, Douglas Hospital participates in many community and educational programs for the overall health and benefit of the area that we serve. Some examples of those programs are: Community Health/Education--screenings and educational opportunities such as defensive driving for teens (offered at a minimal cost), smoking cessation, heart smart school, CPR and others. Community Activities--sponsors blood drives, provides funding to school health programs for medical and dental care for the underserved population. Community Events--Latino Day for the community Hispanics to have a variety of screenings for health related issues. In all a total of over 200,000 area residents participated in some type of education or screening in health issues. Over 2,000 couples participated in prenatal educational offerings sponsored by WellStar. Sponorships-- Wellstar's Laundry services Department partnered with a local homeless shelter, MUST Ministries, to donate retired and faded scrubs to new arrivals at the shelter. MUST has integrated housing programs in Cobb, Cherokee, and Douglas counties (the heart of Wellstar"s service area). Recognition and Accomplishments- Douglas Hospital continues to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). All of the Wellstar system hospitals (including Douglas) have been awarded "Accreditation with Distinction" by the Commission on Laboratory Accreditation of the College of American Pathologists (CAP). CAP awards are considered one of the most stringent in laboratory quality assurance in the industry. The Wellstar Cancer Program is accredited by the American College of Surgeons. The expansion of the cancer program has resulted in an increase in the services provided for cancer patients at both Douglas and Paulding Hospitals. The Wellstar Respiratory Care is accredited by the American Association for Respiratory Care with its "Recognition for Quality". Wellstar Health System is number five in the Top 100 Integrated Healthcare Networks as published by SDI. It is also the highest ranked integrated network in the state. Wellstar is named in the 100 Best Companies List by "Working Mothers" magazine and as a National Employer Team Member by AARP for its work on behalf of more mature workers within the organization. Wellstar was also named for a fifth year in a row to the Companies that Care Honor Roll. This distinction represents employers who create positive work environments for its employees and who are also active community partners. Douglas Hospital received a Partnership for Health and Accountability Quality and Patient Safety Award from Georgia Hospital Association related to the reduction of healthcare associated infections. For the last several years Wellstar Douglas Hospital has sponsored classes for patients who are scheduled to have some type of joint replacement surgery. These twice a month classes prepare the patients for not only surgery and the risk involved but post-operative realities and their new "pain free" activities and rehabilitation that is involved. This program has educated approximately 250 patients over a four year period. Wellstar continues to expand its participation in the annual American Heart Association-Heart Walk as a major sponsor (the Wellstar Cardiac Network). For the past several years Wellstar has participated with walkers and donations now totalling more than $100,000 per year. Wellstar was named one of America's Best Adoption-Friendly Workplaces on a list released by the Dave Thomas Foundation for Adoption. Wellstar ranked fifth in the hospital and health industry. The rankings are based on a survey of companies to analyze their adoption benefits. Wellstar's policy includes a $5,000 per finalized adoption (and a $10,000 lifetime maximum) for employees with at least six months of continuous employment to assist in the adoption process. Douglas Hospital initiated a new patient experience called "Zero Sleepless Nights" in its Diagnostic services department for mammography patients. The service is intended to provide screening results to patients within 24 hours of their procedure to reduce and hopefully eliminate the stress associated with unknown diagnoses. As a system Wellstar performs more than 73,000 mammograms each year and this new service has proven to be very well received by those patients including patients at Douglas Hospital. Cobb, Douglas, Kennestone, and Paulding hospitals continue to meet the Appropriate Care Measures (ACM) of 93 percent thresholds in quality for the Presidental Level of Quality Honor Roll as reported by the Georgia Hospital Association. Wellstar has progressed in this area from an 81.4 percent threshold to 94.6 percent. Wellstar (including Cobb, Douglas, and Kennestone hospitals) received a "3 STAR" rating from the Society of Thoracic Surgeons (STS) for the quality of its cardiac surgery (only 12-15 percent of hospitals across the country receive this rating). This rating helps validate that quality cardiovascular care will remain a priority of the system's program. WellStar Douglas Hospital Birthing Center became the first hospital in the system to implement a perinatal surveillance/documentation system. The system allows a full hospital monitoring for mothers and their newborns and is one step closer to the ultimate goal of a completely electronic medical record and the elimination of at least 10 paper forms. All five of WellStar's hospitals have earned Quality Respiratory Care Recognition (QRCR) for the ninth year in a row under a national program that attempts to help patients make informed decisions about quality respiratory services available in hospitals. Only about 15 percent of hospitals have applied and received this recognition. The designation ensures patient safety by agreeing to adhere to a strict set of criteria for quality respiratory services. WellStar implemented a new Enterprise Master Patient Index (EMPI) during the year. The project was activated at all of the system hospitals as well as the physician offices in an effort to enhance the patient experience and improve safety. The system provides more patient-centered care and helps eliminate duplicate medical records as the information gathered at registration is shared throughout WellStar. Wellstar Health System donated approximately $1.0 million in funds to the Georgia Highlands College Nur
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 80,006,148
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? ........
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements. Click to see list of attachments
20b
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
844
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
18
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
14
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
GA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
JAMES M SWARTZ
805 SANDY PLAINS ROAD
Marietta,GA300666340
(770) 792-5023
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Randall Bentley
Board Member-Chairman
 1.0 X           0 16,769 0
(2) Robert N Cross MD
Board Member
 1.0 X           0 4,272 0
(3) T E Durham
Board Member
 1.0 X           0 36,443 1,430
(4) Thomas E Gearhard
Board Member
 1.0 X           0 441,387 30,593
(5) David Hafner MD
Board Member
 1.0 X           0 17,769 0
(6) Charles J Jones
Board Member
 1.0 X           0 12,580 0
(7) Connie Kirk
Board Member
 1.0 X           0 4,675 0
(8) Janie Maddox
Board Member- Vice Chair
 1.0 X           0 15,634 0
(9) Gary A Miller
Board Member
 1.0 X           0 1,742 0
(10) Steven W Oweida MD
Board Member
 1.0 X           0 16,946 0
(11) Tom Phillips
Board Member
 1.0 X           0 6,165 0
(12) Walter G Robinson
Board Member
 1.0 X           0 3,954 0
(13) Otis Brumby III
Board Member
 1.0 X           0 2,374 0
(14) W Allen Separk
Board Member
 1.0 X           0 8,095 0
(15) T Fitz Johnson
Board Member
 1.0 X           0 3,730 0
(16) Jeffrey Tharp MD
Board Member
 1.0 X           0 508,542 31,417
(17) Charles Pete Wood
Board Member
 1.0 X           0 13,025 0
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Avril Beckford MD
Board Member
 1.0 X           0 398,842 21,377
(19) A James Budzinski
Exec VP and CFO & Acting CEO
 2.0     X       0 932,621 48,453
(20) David W Anderson
Exec VP HR/OL/CCO
 2.0     X       0 503,600 29,075
(21) Donald Campbell MD
Sr VP Physician Educ
 2.0     X       0 599,439 33,540
(22) Barbara B Corey
Sr VP Managed Care
 2.0     X       0 345,736 22,861
(23) Bruce Dean
VP & Real Estate/Asst Gen Coun
 2.0     X       0 282,753 22,320
(24) Marcia Delk MD
Sr VP Med Affairs & CQO
 2.0     X       0 420,637 32,831
(25) Reynold J Jennings
President & CEO
 2.0     X       0 348,685 14,385
(26) Clarence H Evins
VP Revenue Cycle Mgmt
 2.0     X       0 250,193 18,352
(27) Christopher M Kane
Sr VP Strategic Planning
 2.0     X       0 396,107 27,207
(28) Kenneth C Kunze MD
Sr VP Chief Med Officer
 2.0     X       0 698,966 35,591
(29) Kimberly W Menefee
Sr VP Public & Govt Affairs
 2.0     X       0 325,382 22,343
(30) Ronald J Strachan
Sr VP Chief Info Officer
 2.0     X       0 492,358 24,507
(31) Robert Mandler
VP Diagnostic Outreach
 2.0     X       0 266,979 18,768
(32) Jonathan B Morris
VP & Chief Med Info Officer
 2.0     X       0 416,394 27,823
(33) MICHAEL GRAUE
EXEC VP COO
 2.0     X       0 680,247 43,271
(34) Robin Wilson MD
VP Performance Innovation
 2.0     X       0 506,787 32,116
(35) ELLEN LANGFORD
VP & COO MED GROUP
 2.0     X       0 275,321 14,655
(36) CRAIG OWENS
SR VP & ADMIN
 50.0     X       317,578 0 22,294
(37) Anthony M Trupiano
Sr VP Supply Chain
 2.0     X       0 284,073 16,516
(38) Joseph L Brywczynski
Sr VP Health Parks Admin
 2.0     X       0 311,785 19,612
(39) Elizabeth A Hoffmann
VP Budget & Anaysis
 2.0     X       0 233,775 11,530
(40) Richard T Lopes MD
Sr VP & Pres Wellstar Phy Grp
 2.0     X       0 757,815 36,938
(41) James M Swartz
VP Accounting
 2.0     X       0 217,871 14,937
(42) Mary L Wesley
Sr VP Nursing Srvcs & CNE
 2.0     X       0 457,717 21,831
(43) Barbara Ballard
VP Homecare and Hospice
 2.0     X       0 259,113 22,697
(44) Robert Jansen MD
VP Medical Affairs
 2.0     X       0 509,124 26,667
(45) Beth Kost
VP Compliance/Chief Privacy Of
 2.0     X       0 269,763 17,725
(46) Carol S Edwards
VP Cardiac Services
 2.0     X       0 325,593 20,146
(47) C Brett Scullen
VP Pulmonology Operations
 2.0     X       0 188,627 8,053
(48) Adam C Thompson
VP Surgery
 2.0     X       0 185,584 10,535
(49) Leo E Reichert
Exec VP General Counsel
 2.0     X       0 623,353 36,099
(50) Deborah DeVita Roegge
VP Women's and Newborn Srvs
 2.0     X       0 170,369 7,541
(51) Melissa L Box
VP/CNO Pat Care Srv
 50.0     X       171,147 0 17,376
(52) Mary L Tavernaro
VP Human Resources Operations
 2.0     X       0 224,515 15,552
(53) Robert W Hamilton MD
VP Medical Affairs
 50.0     X       366,759 0 15,220
(54) Carol B Maxwell
VP Talent Acquistion
 2.0     X       0 86,518 4,350
(55) Chester Zborowski
VP Health Park Operations
 2.0     X       0 0 0
(56) Valery Akopov
VP Chief Hospitalists Services
 2.0     X       0 0 0
(57) Christopher S Green
Dir Financial Planning & Oper
 50.0         X   149,674 0 8,139
(58) Margaret W Chastain
Dir Pharmacy
 50.0         X   156,290 0 9,910
(59) Beverly Bates
RN
 50.0         X   144,489 0 14,653
(60) Linitra Montgomery
RN
 50.0         X   130,611 0 11,533
(61) Peggy Tyndall
Dir Nursing
 50.0         X   138,704 0 15,892
(62) Gregory L Simone MD
President & CEO
             X 0 248,936 13,892
(63) Bonnie Wilson
Exec VP & Gen Counsel
             X 0 244,138 13,763
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 1,575,252 14,853,818 986,316
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet32
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Batchelor Kimball
PO Box 70
LITHONIA,GA30058 		Maintenance 639,469
Inglett and Stubbs Inc
PO Box 932506
ATLANTA,GA311932506 		General Contractor 641,620
RCC Marietta
PO Box 101518
ATLANTA,GA303921518 		Medical 344,500
Quest Diagnostics
PO Box 740736
ATLANTA,GA303740736 		Medical Lab 265,250
Urology Associates Lithrotripsy LLC
9825 Spectrum Drive Bldg 3
AUSTIN,TX78717 		Medical 343,600
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet11
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 0
Program Service Revenue Business Code
2a HOSPITAL PATIENT REVENUE 621,990 106,028,035 106,028,035    
b MEDICAL RECORDS REVENUE 621,990 24 24    
c PATIENT EDUCATION 621,990 10,328 10,328    
d MEDICAID REIMB (MEANINGFUL USE) 621,990 384,621 384,621    
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 106,423,008
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 0      
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 74,311  
b Less: rental expenses    
c Rental income or (loss) 74,311  
d Net rental income or (loss).......MediumBullet 74,311     74,311
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses   9,202
c Gain or (loss)   -9,202
d Net gain or (loss)..........MediumBullet -9,202     -9,202
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a GROUND LEASE REVENUE   84,804     84,804
b CAFETERIA SALES   459,205     459,205
c LACTATION/IMMUNIZATIONS   25,756     25,756
d All other revenue .... 133,479     133,479
e Total. Add lines 11a–11d ......MediumBullet 703,244
12 Total revenue. See Instructions....MediumBullet 107,191,361 106,423,008   768,353
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 488,724 428,269 60,455  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 38,453,205 33,697,255 4,755,950  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 2,050,583 1,796,926 253,657  
9 Other employee benefits ....... 2,520,944 2,209,103 311,841  
10 Payroll taxes ........... 2,778,072 2,434,424 343,648  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 3,974   3,974  
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 4,277,912 3,943,101 334,811  
12 Advertising and promotion .... 144 144    
13 Office expenses ....... 4,679,816 4,133,651 546,165  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 1,365,311 101,734 1,263,577  
17 Travel ............ 42,673 28,944 13,729  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 35,517 24,937 10,580  
20 Interest ........... 15,973   15,973  
21 Payments to affiliates ....... 19,218,679 16,841,328 2,377,351  
22 Depreciation, depletion, and amortization ..... 4,758,478 2,107,035 2,651,443  
23 Insurance .............. 680,069   680,069  
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 REPAIRS & MAINT 1,822,567 1,442,376 380,191  
b MEDICAL SUPPLIES 10,810,713 10,809,335 1,378  
c OTHER EXPENSES 133,189 7,586 125,603  
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 94,136,543 80,006,148 14,130,395 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 2,150 1 2,495
2 Savings and temporary cash investments ....... 6,294 2 11,610
3 Pledges and grants receivable, net ......... 0 3 0
4 Accounts receivable, net ......... 16,052,926 4 17,991,997
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 0 5 0
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L .......... 0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 1,609,493 8 1,914,134
9 Prepaid expenses and deferred charges ............ 371,288 9 432,590
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 93,042,169
b Less: accumulated depreciation. ..... 10b 53,293,726 38,784,564 10c 39,748,443
11 Investments—publicly traded securities .......... 0 11 0
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 1,971,378 15 1,688,984
16 Total assets. Add lines 1 through 15 (must equal line 34)... 58,798,093 16 61,790,253
Liabilities 17 Accounts payable and accrued expenses . 6,303,534 17 6,720,207
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 39,506,069 25 35,939,678
26 Total liabilities. Add lines 17 through 25..... 45,809,603 26 42,659,885
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 12,988,490 27 19,130,368
28 Temporarily restricted net assets ..... 0 28 0
29 Permanently restricted net assets ..... 0 29 0
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 12,988,490 33 19,130,368
34 Total liabilities and net assets/fund balances ..... 58,798,093 34 61,790,253
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
107,191,361
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
94,136,543
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
13,054,818
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
12,988,490
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-6,912,940
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
19,130,368
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


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

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

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

58-2026750
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

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

Additional Data


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

58-2026750
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

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

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   59,570 59,570
b Buildings ................   42,322,219 20,062,049 22,260,170
c Leasehold improvements ............   1,343,121 832,082 511,039
d Equipment ................   48,457,601 32,399,595 16,058,006
e Other .................   859,658   859,658
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 39,748,443
Schedule D (Form 990) 2011

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








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








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








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
DUE TO AFFILIATIES 4,774,742
ASSET RETIREMENT OBLIGATION LT 598,491
TAX EXEMPT BOND LIAB-DUE TO WH 30,566,445






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 35,939,678
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
SCHEDULE D PART X, LINE 2 FIN 48 FOOTNOTE   The following footnote is related to the organization's application of FIN 48 (ASC 740). "Wellstar (including Douglas Hospital) and all but one of its affiliates have been recognized as exempt from Federal income tax under Internal Revenue Code Section 501 (a) as organizations described in Section 501 (c)(3) and, therefore, related income is generally not subject to Federal or state income taxes. CAC is a controlled foreign corporation not subject to Federal tax. Wellstar applies FASB ASC 740, Income Taxes, which addresses accounting for uncertainties in income tax positions. It also provides guidance on when tax positions are recognized in an entity's financial statements and how the values of these positions are determined. There is no impact on Wellstar's combined financial statements as a result of the application of ASC 740."
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




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

58-2026750
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

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

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    10,843,010   10,843,010 11.520 %
b Medicaid (from Worksheet 3, column a) .....     14,499,842 11,796,691 2,703,151 2.870 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .            
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		    25,342,852 11,796,691 13,546,161 14.390 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    396,859   396,859 0.420 %
f Health professions education
(from Worksheet 5) .. 		           
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....            
jTotal Other Benefits ...     396,859   396,859 0.420 %
kTotal. Add lines 7d and 7j. ..     25,739,711 11,796,691 13,943,020 14.810 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense........
2
5,295,347
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
1,070,850
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
35,073,519
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
39,107,464
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-4,033,945
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 Douglas Hospital Inc
8954 Hospital Drive
Douglasville,GA30134 		X X         X    
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 125.%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

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

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

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?  
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
Publication of Annual Community Benefit Report Part I Line 6a Douglas Hospital, Inc. is an affiliate of Wellstar Health System, Inc. which on an annual basis issues a community benefit report. This report is subsequently distributed in and around the five county service area of the health system.
Cost to Charge Ratio Schedule H Part 1 Line 7 For purposes of the IRS Form 990 Schedule H, Wellstar Health System and Affiliates (including Douglas Hospital) have estimated the current year cost to charge ratio for each hospital as it is reported in the annual community benefit report and as it will be reported in the state's Annual Hospital Financial Survey.
Footnote on Bad Debts and Rationale for Community Benefit Schedule H Part III Line 4 The following footnote is detailed in the Wellstar Health System, Inc. and Affiliates Financial Statements related to bad debt or uncollectible accounts: "During 2011, Wellstar adopted the provisions of FASB Accounting Standards Update (2011-07), Healthcare Entities (Topic 954). ASU 2011-07 requires the reclassification of the provision for uncollectible accounts associated with patient service revenue from an operating expense to a deduction from patient service revenue (net of contractual allowances and discounts). "Wellstar recognizes patient service revenue associated with services provided to patients with third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for community financial aid, Wellstar recognizes revenue on the basis of its discounted rates for services provided. On the basis of historical experience, a significant portion of Wellstar's uninsured patients are unable or unwilling to pay for the services provided. Thus, Wellstar records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided." Subsequent to the end of the reporting period a propensity to pay review of patient accounts often results in prior year bad debt accounts which are deemed eligible for the organization's financial assistance policy. Those bad debt accounts are reclassified as charity and thus our rationale for including as community benefit.
Medicare Shortfalls Part III Line 8 Douglas Hospital is a provider of inpatient and outpatient services to Medicare program beneficiaries at determined rates. Without the participation in the Medicare program these patients may not have had convenient access to those services. The Medicare shortfall on line 7 represents the uncompensated difference between the expected reimbursement and the Medicare charges for those services stated at cost. We determine a cost to charge ratio for Medicare patients as part of the annual filing of the Medicare cost report.
Collection Practices Part III Sec C Line 9b The policy written for collection practices that applies to all Wellstar Health System entities incorporates guidelines for personnel in the admissions and patient access areas to be trained in identifying patients that might qualify for financial assistance. It is also the policy of all Wellstar facilities to have at least one employee or contractor available at all times, especially in the hospitals with emergency rooms, who can provide assistance with the paperwork necessary to help patients who would qualify for governmental and other assistance programs.
Hospital Description Schedule H Part V Douglas Hospital is a general acute care hospital providing a full range of services, is licensed to operate 108 beds, and is presently staffed to operate 102 beds. It is located on an approximately 50-acre campus in Douglasville, Georgia and is housed within a complex of connected buildings which contain a total square footage of over 174,000 square feet. The original hospital was constructed in 1974 and three major structural additions were made in 1985, 2004, and 2005. Wellstar Douglas Hospital provides medical, surgical, and obstetrical inpatient care and outpatient care, including emergency services.
Needs Assessment Schedule H Part VI Line 2 Wellstar Health System (and affiliates) is a key stakeholder in MAPP, Mobilizing for Action through Planning and Partnerships. MAPP, developed by the National Association of County and City Health Officials (NACCHO) in collaboration with the CDC, provides a structured guidance on creating and implementing a community-wide strategic planning process focused on improving the health and safety of our population. Through MAPP, a broad collection of community partners and residents come together to identify and prioritize health and safety issues and to identify resources for addressing them. The process results in an actionable community health improvement plan (CHIP) for measurable improvements in the community's health and quality of life as well as a scorecard for implementation and evaluation. The resulting community plan does not focus on one agency or community health challenge; rather, MAPP provides a long-term strategy that addresses the multiple factors that affect health in the community. Community involvement throughout the creation and the implementation of a health improvement plan results in creative solutions to community health problems with an improved focus on priorities, reduced duplication of services, increased collaboration on projects and activities, and increased capacity to garner additional resources. Moreover, continous community involvement leads to community ownership of the process. Community ownership, in turn, increases the credibility and sustainability of the health improvement efforts.
Patient Education of Eligibility for Assistance Part VI Line 3 Douglas Hospital provides its patients with hospital personnel or contracted personnel who are trained in all aspects of governmental programs, payments plans, charity discounts, and other financial assistance offered to assist them in their hospital bills. If the patient is eligible for federal or state assistance programs, a staff member is knowledgeable in the steps necessary to qualify those individuals. If a patient is indigent or charity eligible they will be offered assistance through the hospital's charity and indigent care policy including the state's indigent care trust fund. If the patient has no other insurance and fails to qualify for indigent care assistance, the financial counselor can then offer the patient an opportunity to accept a payment plan with discounted payment options based on their ability to pay immediately or over time. All patient are afforded these opportunities.
Community Information Part VI Line 4 Douglas Hospital is one of five hospitals that are affiliated with the parent corporation, Wellstar Health System. The primary service area of the system is located in the Northwest Georgia area and receives the majority of its patients from one of five counties (Cherokee, Cobb, Douglas, Bartow and Paulding). Generally about 85% to 90% of the patient volume comes from this service area although other health systems have a presence in the area as well. Demographically the region is one of the fastest growing in the state as well as the country and the expansion of the services for the patient population reflects a desire to offer healthcare "closer to home" since Wellstar is considered a part of a larger metropolitan Atlanta market. Economically the region is strong in per capita income but given recent trends a rise in the uninsured and indigent population has occured.
Affiliated Health Care System Roles Part VI Line 7 As stated in the Wellstar Health System, Inc and Affiliates audited financial statments for the period ended June 30, 2011, Douglas Hospital (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of Internal Revenue Code Sect 501 (c) (3) and the "community benefit standard" of IRS Ruling 69-545. In this regard the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualifed physicians in the area consistent with the size and nature of the facility; the hospital operates a full-time emergency room open to all regardless of ability to pay; and the hospital provides care to the needy members of the community consistent with its charity care policy. The hospital's excess funds are genrally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement fo patient care, community benefit activities, and charity care. Douglas Hospital committed approximately $4.7 million in capital expenditures for the year to meet those needs.
Publication of Financial Assistance Policy Part V Line 13g In addition to the posting of the financial assistance policy in various locations throughout the hospital, the patient financial servies and patient access service departments provide a brochure which includes frequently asked questions about the terms and conditions associated with the policy.
Schedule H (Form 990) 2011
Additional Data


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

58-2026750
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
No
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
Yes
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
Yes
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

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

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) Thomas E Gearhard (i)
(ii)		 0
249,303 		0
184,230 		0
7,854 		0
23,371 		0
7,222 		0
471,980 		0
0
(2) Jeffrey Tharp MD (i)
(ii)		 0
308,337 		0
89,305 		0
110,900 		0
26,140 		0
5,277 		0
539,959 		0
0
(3) A James Budzinski (i)
(ii)		 0
464,491 		0
454,394 		0
13,736 		0
43,675 		0
4,778 		0
981,074 		0
0
(4) Avril Beckford MD (i)
(ii)		 0
261,712 		0
49,363 		0
87,767 		0
21,377 		0
  		0
420,219 		0
0
(5) Gregory L Simone MD (i)
(ii)		 0
248,936 		0
0 		0
0 		0
10,168 		0
3,724 		0
262,828 		0
0
(6) Bonnie Wilson (i)
(ii)		 0
244,138 		0
0 		0
0 		0
10,168 		0
3,595 		0
257,901 		0
0
(7) David W Anderson (i)
(ii)		 0
388,078 		0
100,027 		0
15,495 		0
25,522 		0
3,553 		0
532,675 		0
0
(8) Donald Campbell MD (i)
(ii)		 0
314,601 		0
64,127 		0
220,711 		0
29,646 		0
3,894 		0
632,979 		0
0
(9) Barbara B Corey (i)
(ii)		 0
276,741 		0
58,195 		0
10,800 		0
19,361 		0
3,500 		0
368,597 		0
0
(10) Bruce Dean (i)
(ii)		 0
201,641 		0
72,017 		0
9,095 		0
16,148 		0
6,172 		0
305,073 		0
0
(11) Marcia Delk MD (i)
(ii)		 0
337,360 		0
71,529 		0
11,748 		0
22,572 		0
10,259 		0
453,468 		0
0
(12) Reynold J Jennings (i)
(ii)		 0
339,346 		0
0 		0
9,339 		0
14,385 		0
0 		0
363,070 		0
0
(13) Clarence H Evins (i)
(ii)		 0
191,938 		0
29,473 		0
28,782 		0
14,197 		0
4,155 		0
268,545 		0
0
(14) Christopher M Kane (i)
(ii)		 0
318,290 		0
66,617 		0
11,200 		0
21,485 		0
5,722 		0
423,314 		0
0
(15) Kenneth C Kunze MD (i)
(ii)		 0
569,002 		0
118,114 		0
11,850 		0
33,824 		0
1,767 		0
734,557 		0
0
(16) Kimberly W Menefee (i)
(ii)		 0
258,803 		0
54,544 		0
12,035 		0
18,482 		0
3,861 		0
347,725 		0
0
(17) Ronald J Strachan (i)
(ii)		 0
287,145 		0
49,464 		0
155,749 		0
22,279 		0
2,228 		0
516,865 		0
0
(18) Christopher S Green (i)
(ii)		 133,697
0 		15,977
0 		0
0 		7,511
0 		628
0 		157,813
0 		0
0
(19) Margaret W Chastain (i)
(ii)		 143,113
0 		13,177
0 		0
0 		9,301
0 		609
0 		166,200
0 		0
0
(20) Beverly Bates (i)
(ii)		 141,098
0 		3,391
0 		0
0 		8,812
0 		5,841
0 		159,142
0 		0
0
(21) Peggy Tyndall (i)
(ii)		 126,777
0 		11,927
0 		0
0 		8,018
0 		7,874
0 		154,596
0 		0
0
(22) Robert Mandler (i)
(ii)		 0
206,312 		0
31,122 		0
29,545 		0
14,907 		0
3,861 		0
285,747 		0
0
(23) Jonathan B Morris (i)
(ii)		 0
267,997 		0
136,358 		0
12,039 		0
22,332 		0
5,491 		0
444,217 		0
0
(24) MICHAEL GRAUE (i)
(ii)		 0
527,427 		0
138,784 		0
14,036 		0
33,360 		0
9,911 		0
723,518 		0
0
(25) Robin Wilson MD (i)
(ii)		 0
290,890 		0
205,797 		0
10,100 		0
21,394 		0
10,722 		0
538,903 		0
0
(26) ELLEN LANGFORD (i)
(ii)		 0
186,452 		0
80,169 		0
8,700 		0
11,975 		0
2,680 		0
289,976 		0
0
(27) CRAIG OWENS (i)
(ii)		 247,215
0 		59,113
0 		11,250
0 		18,219
0 		4,075
0 		339,872
0 		0
0
(28) Anthony M Trupiano (i)
(ii)		 0
237,972 		0
36,641 		0
9,460 		0
16,516 		0
0 		0
300,589 		0
0
(29) Joseph L Brywczynski (i)
(ii)		 0
249,445 		0
51,540 		0
10,800 		0
17,759 		0
1,853 		0
331,397 		0
0
(30) Elizabeth A Hoffmann (i)
(ii)		 0
194,472 		0
30,603 		0
8,700 		0
9,763 		0
1,767 		0
245,305 		0
0
(31) Richard T Lopes MD (i)
(ii)		 0
563,490 		0
98,330 		0
95,995 		0
35,223 		0
1,715 		0
794,753 		0
0
(32) James M Swartz (i)
(ii)		 0
180,180 		0
28,991 		0
8,700 		0
9,268 		0
5,669 		0
232,808 		0
0
(33) Mary L Wesley (i)
(ii)		 0
295,174 		0
151,203 		0
11,340 		0
18,920 		0
2,911 		0
479,548 		0
0
(34) Barbara Ballard (i)
(ii)		 0
218,870 		0
31,523 		0
8,720 		0
14,225 		0
8,472 		0
281,810 		0
0
(35) Robert Jansen MD (i)
(ii)		 0
346,951 		0
98,895 		0
63,278 		0
21,176 		0
5,491 		0
535,791 		0
0
(36) Beth Kost (i)
(ii)		 0
225,630 		0
35,433 		0
8,700 		0
15,958 		0
1,767 		0
287,488 		0
0
(37) Carol S Edwards (i)
(ii)		 0
260,780 		0
29,770 		0
35,043 		0
18,289 		0
1,857 		0
345,739 		0
0
(38) C Brett Scullen (i)
(ii)		 0
159,623 		0
20,304 		0
8,700 		0
7,837 		0
216 		0
196,680 		0
0
(39) Adam C Thompson (i)
(ii)		 0
152,126 		0
24,158 		0
9,300 		0
7,783 		0
2,752 		0
196,119 		0
0
(40) Leo E Reichert (i)
(ii)		 0
438,716 		0
168,080 		0
16,557 		0
28,317 		0
7,782 		0
659,452 		0
0
(41) Deborah DeVita Roegge (i)
(ii)		 0
119,681 		0
0 		0
50,688 		0
7,048 		0
493 		0
177,910 		0
0
(42) Melissa L Box (i)
(ii)		 144,981
0 		15,895
0 		10,271
0 		10,465
0 		6,911
0 		188,523
0 		0
0
(43) Mary L Tavernaro (i)
(ii)		 0
191,015 		0
27,108 		0
6,392 		0
13,871 		0
1,681 		0
240,067 		0
0
(44) Robert W Hamilton MD (i)
(ii)		 254,276
0 		15,050
0 		97,433
0 		15,220
0 		0
0 		381,979
0 		0
0
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Severance Benefits Schedule J Pursuant to their respective employment agreements, the following groups of officers are entitled to severance payments based on their base salary and wages at that time in the event of certain identified circumstances. The officers with a severance payment period of 24 months as per their contractual agreement are: David Anderson Reynold Jennings The officers with a severance payment period of 18 months as per their respective agreements are: Joseph Brywczynski A James Budzinski Donald Campbell MD Barbara Corey Marcia Delk MD Michael Graue T Mark Haney Robert Jansen MD Christopher Kane Kenneth Kunze MD Lou Little Richard Lopes MD Kimberly Menefee Craig Owens Jonathan Morris MD Leo E Reichert Ron Strachan Anthony Trupiano Mary L Wesley Robin Wilson, MD The officers with a severance payment period of 12 months as per their agreement: Barbara Ballard Bruce Dean Carol Edwards Darold Etheridge Lee Evins Robert Hamilton Elizabeth Hoffmann Beth Kost Ellen Langford Robert Mandler Deborah Roegge DeVita C Brett Scullen James Swartz Mary L Tavernaro Adam Thompson Anthony Trupiano Robin Wilson MD Melissa Box During the calendar year, the following individuals received a payout in the amounts listed in accordance with their severance agreements as set forth above: Gregory L Simone $248,936 Bonnie Wilson $244,138 Bruce Harrison $21,897
Non-Fixed Payments to Officers Form 990 Schedule J Part 1 Line 7 Wellstar has instituted an annual incentive plan for key leaders in the company. On an annual basis performance measures are proposed by management and subsequently approved by the Compensation Committee of the Board. The plan is designed to retain and reward leaders with incentives that keep them competitive with the market and comparably sized health systems. The criteria used to measure the performance consists of weighted factors in the areas of financial performance, customer service, employee engagement and quality and growth indicators. Upon successful achievement up to various targeted levels for each factor the performance payout is recommended and approved by the board after the annual financial audit is finalized and approved. Additionally the system has implemented an incentive program for all eligible non-management team members based on a less strigent application of the aforementioned management performance payout plan.
Other Compensation Form 990 Schedule J Part 1 Line 1b and 2 While Wellstar Health System does not have a written policy regarding payment or reimbursement of the items listed in Part 1 Line 1a, the organization follows IRS guidelines in the payment of any items to individuals listed in Form 990 Part VII Section A. All of these items are added as taxable wages on the individual's W-2 as appropriate.
Compensation Exceptions Schedule J Part III On Schedule J of Form 990 the following individuals were employed as officers with Wellstar Health System Inc. during the reporting period but did not have compensation during the calendar year for which salary and benefits totals apply: Chester Zborowski and Valery Akopov.
Schedule J (Form 990) 2011

Additional Data


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

58-2026750
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Pamela Etheridge Wife of Officer 55,003 Employee of Wellstar   No
(2) Greg Fortgang Son-in-Law of Trustee 92,895 Employee of Wellstar   No
(3) Greg Separk Son of Board Member 59,724 Employee of Wellstar   No
(4) George Fleming Brother of Officer 60,969 Employee of Wellstar   No
(5) Greystone Power Board Member - Pres of Co 739,493 Electric Services   No
(6) Bonnie Miller Wife of Board Member 31,510 Employee of Wellstar   No
(7) Matthew Maddox Son of Board Member 39,776 Employee of Wellstar   No
(8) Jessica Haney Daughter of Officer 54,545 Employee of Wellstar   No
(9) Greg Kost Brother-in-Law of Officer 25,034 Employee of Wellstar   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Business Transactions with Interested Parties Form 990 Sch L Part The business transactions listed on Schedule L Part IV are for interested parties (family members) of either a trustee or officer of Douglas Hospital or a related organization. All transaction with the exception of Greystone Power are for employment services with Wellstar Health System and its Affiliates. The transaction with Greystone Power is for utility services provided to Douglas Hospital by a company whose CEO is also a trustee of Wellstar Health System
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

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

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

58-2026750
Identifier Return Reference Explanation
Filing of 990 T Part V Line 3 a & b Douglas Hospital, Inc. has elected to file a blank 990-T for the reporting period as there is no known unrelated business income. However in the event a subsequent disclosure of any unrelated business income is made we will amend the currently filed return.
Conflict of Interest Policy Form 990 Part VI Section B Line 12 Our Conflict of Interest Policy requires all covered persons to annually review the policy and then complete, sign and return the Conflicts of Interest Survey and Attestation to the Compliance Office. The following is our process to regularly and consistently monitor and enforce the policy: Compliance identifies all covered persons who must complete the Survey and Attestation annually. Compliance verifies that the Survey and Attestation is distributed to these persons. Compliance verifies that these persons return a fully completed and signed Survey and Attestation. Compliance reviews each completed and signed Survey and Attestation to identify all conflicts listed in the document. All conflicts, potential conflicts and incidences of non-compliance are referred to the Chief Compliance Officer. The CCO takes appropriate action to completely resolve all identified conflicts and incidences of non-compliance.
Process for Determining Compensation for Top Execs Form 990 Part VI Section B Line 15 Wellstar engages the Hay Group to work with the governing board to review and recommend executive compensation. The executive compensation process at Wellstar is overseen by a committee of independent trustees, which follows a board-approved executive compensation philosophy. The compensation committee consists of three board members and the Chief Executive Officer. In committtee discussions about the compensation for the Chief Executive Officer, the CEO will recuse himself from that process but is a non-voting committee member for discussions on all other officers. The executive compensation philosophy empowers the committee to oversee the executive compensation process and administer the executive compensation program on behalf of the full board of trustee of Wellstar; provided, however, the full Board of Trustees evaluates and approves the compensation of the Chief Executive Officer. The philosophy requires annual disclosure of the committee's actions and decisions to the full board, which it has done. The committee is guided by the board-approved philosophy. Overall, the philosophy is intended to reward for organizational and individual performance. When performance is at a predetermined targeted level, the compensation is intended to be at or around the median of compensation paid to similar positions at similar organizations (the "market"). Wellstar's executive compensation philosophy defines the market as being comprised of comparable not-for-profit health care delivery systems, i.e., not-for-profit organizations similar in complexity and scale to Wellstar. To assist the committee in fulfilling its duties, the committee engaged the Hay Group to provide market compensation data to compare to the Wellstar positions whose compensation the committee oversees. The committee uses this data to provide context when making decisions in administering the compensation program. Accurate minutes of the committee's discussion and decisions are recorded during each committee meeting, and reviewed and approved at the following committee meeting.
Process for Public Disclosure of Important Documents Form 990 Part VI Section C Line 19 The organization and its subsidiaries are subject to the Open Records Law in the State of Georgia. Therefore, by law, citizens are permitted to inspect and copy its governing documents, policies and financial statements as may be requested from time to time. Additionally, the organization's Form 990 is made readily available on the Guidestar website for charitable organizations. Periodically, the organization publishes its financial performance in the local newspaper for citizens to review, and it also publishes a community benefit report once a year for distribution to the public.
Audited Financial Statements Form 990 Part IV Line 12 Douglas Hospital, Inc. is audited on an annual basis by an outside auditing firm, KPMG, and as part of that audit a consolidated financial statement is issued for all of WellStar Health System, Inc and its Affiliates. "The independent auditors report includes the accounts of Wellstar and its controlled affiliates, Kennestone Hospital, Inc., Cobb Hospital, Inc., Douglas Hospital, Inc., Paulding Medical Center, Inc., Wellstar Foundation, Inc. CHS Foundation, Inc., Community Assurance Company, Ltd., various Wellstar owned physician practices, a hospice facility, a nursing facility, home health business, and entities for infusion therapy and durable medical equipment. All significant intercompany accounts and transactions have been eliminated in combination. The Board of Trustees of Wellstar has the authority to approve appointments of the members of the board of trustees of all affiliate corporations."
Tax Exempt Bond Reporting Form 990 Part IV Line 24a For purposes of the Form 990 reporting, Wellstar Health System, Inc EIN 58-1649541 will list all tax-exempt bonds issued since January 1, 2003 on Schedule K as it typically allocates the proceeds of the bonds to members of the Obligated Group (including the hospitals and physician group). Douglas Hospital, Inc. will report this tax exempt bond liability on Part X, Line 25 Other Liabilities.
Current Officers/Directors Relationships Form 990 Part VI Section A Line 2 Two of the current officers and trustees for Wellstar Health System, Inc. --EIN 58-1649541 are related to each other through family. Gregory Simone, Former President and CEO is the brother-in-law of Lou Little, Sr VP Post Acute Services and Administrator of Windy Hill Hospital.
Organizational Structure Form 990 Part VI Section A Lines 6, 7a & 7b As per the articles of incorporation, the sole member of the organization is Wellstar Health System, Inc., a GA nonprofit corporation. As sole member, Wellstar Health System holds certain powers of elections and approval in connection with the governing body of the organization. These powers are presented in detail in the governing documents which the company makes available to the public upon request.
Officers Hours Worked Form 990 General Statement and Schedule J The officers devote their time to all of the organizations within Wellstar Health System that are listed in Schedule R, Part II. As such, the total hours worked by the officers across all organizations exceeds 40 hours a week.
Compensation Schedule J, Part II All compensation amounts reported on Form 990 Part V, Part VII, and Part IX as well as Schedule J represent compensation provided to individuals that provide services to the organization. Likewise, the number of employees reported on Form 990 represent the number of individuals providing services to the organization. All Federal employment tax responsibilities for these individuals (including Federal Employment Tax reporting responsibilities) are handled by Wellstar Health System, Inc (EIN 58-1649541).
990 Board Review Form 990 Part VI Line 11A Internal staff prepare the organization's Form 990. Before filing the return with the Internal Revenue Service an external accounting firm, PricewaterhouseCoopers, reviews and sign-offs on the completed return of each organization. The current year Form 990 is then reviewed by the Finance Committee along with a question and answer session. A motion is then made by the Finance committee to approve the returns and present to the full board copies of the forms in an electronic (pdf. format) version as well as a hard copy. The organization's CFO or designee subsequently signs the return for either manual or electronic filing by the appropriate due date.
Changes in Net Assets Form 990 Part XI Line 5 For the reporting period Douglas Hospital, Inc. had a change in net assets of ($9,509,577) related to transfers to affiliates as part of the allocation of income statement and balance sheet transactions over the year.
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Randall Bentley TITLE:Board Member-Chairman HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert N Cross, MD TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:T. E. Durham TITLE:Board Member HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Thomas E Gearhard TITLE:Board Member HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:David Hafner, MD TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Charles J. Jones TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Connie Kirk TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Janie Maddox TITLE:Board Member- Vice Chair HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Gary A Miller TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Steven W. Oweida, MD TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Tom Phillips TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Walter G. Robinson TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Otis Brumby, III TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:W. Allen Separk TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:T. Fitz Johnson TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Jeffrey Tharp, MD TITLE:Board Member HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Charles "Pete" Wood TITLE:Board Member HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Avril Beckford, MD TITLE:Board Member HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:A James Budzinski TITLE:Exec VP and CFO & Acting CEO HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:David W Anderson TITLE:Exec VP HR/OL/CCO HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Donald Campbell, MD TITLE:Sr VP Physician Educ HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Barbara B Corey TITLE:Sr VP Managed Care HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Bruce Dean TITLE:VP & Real Estate/Asst Gen Coun HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Marcia Delk, MD. TITLE:Sr VP Med Affairs & CQO HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Reynold J Jennings TITLE:President & CEO HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Clarence H Evins TITLE:VP Revenue Cycle Mgmt HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Christopher M. Kane TITLE:Sr VP Strategic Planning HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Kenneth C Kunze, MD TITLE:Sr VP Chief Med Officer HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Kimberly W. Menefee TITLE:Sr VP Public & Govt Affairs HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Ronald J Strachan TITLE:Sr VP Chief Info Officer HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert Mandler TITLE:VP Diagnostic Outreach HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Jonathan B Morris TITLE:VP & Chief Med Info Officer HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL GRAUE TITLE:EXEC VP COO HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robin Wilson MD TITLE:VP Performance Innovation HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ELLEN LANGFORD TITLE:VP & COO MED GROUP HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Anthony M Trupiano TITLE:Sr VP Supply Chain HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Joseph L Brywczynski TITLE:Sr VP Health Parks Admin HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Elizabeth A Hoffmann TITLE:VP Budget & Anaysis HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Richard T Lopes, MD TITLE:Sr VP & Pres Wellstar Phy Grp HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:James M Swartz TITLE:VP Accounting HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary L Wesley TITLE:Sr VP Nursing Srvcs & CNE HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Barbara Ballard TITLE:VP Homecare and Hospice HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert Jansen, MD TITLE:VP Medical Affairs HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Beth Kost TITLE:VP Compliance/Chief Privacy Of HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Carol S Edwards TITLE:VP Cardiac Services HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:C Brett Scullen TITLE:VP Pulmonology Operations HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Adam C Thompson TITLE:VP Surgery HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Leo E Reichert TITLE:Exec VP General Counsel HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Deborah DeVita Roegge TITLE:VP Women's and Newborn Srvs HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary L Tavernaro TITLE:VP Human Resources Operations HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Carol B Maxwell TITLE:VP Talent Acquistion HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Chester Zborowski TITLE:VP Health Park Operations HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Valery Akopov TITLE:VP Chief Hospitalists Services HOURS:50
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


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

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
DOUGLAS HOSPITAL INC
 
Employer identification number

58-2026750
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
Yes No
(1) CHS Foundation

805 Sandy Plains Road

Marietta,GA30066
58-1649540 		Foundation GA 501 (c) (3) 11 WHS
 
Yes
 
(2) Cobb Hospital Inc

805 Sandy Plains Road

Marietta,GA30066
58-0968382 		Healthcare GA 501 (c) (3) 3 WHS
 
Yes
 
(3) Kennestone Hospital Inc

805 Sandy Plains Road

Marietta,GA30066
58-2032904 		Healthcare GA 501 (c) (3) 3 WHS
 
Yes
 
(4) Paulding Medical Center Inc

805 Sandy Plains Road

Marietta,GA30066
58-2095884 		Healthcare GA 501 (c) (3) 3 WHS
 
Yes
 
(5) Wellstar Foundation

805 Sandy Plains Road

Marietta,GA30066
58-1627413 		Foundation GA 501 (c) (3) 11 Type 2 WHS
 
Yes
 
(6) Wellstar Health System

805 Sandy Plains Road

Marietta,GA30066
58-1649541 		Healthcare GA 501 (c) (3) 11 Type 2 NA
 
 
No


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



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No
(1) Cobb Hospital Parking Company LLC

805 Sandy Plains Road
Marietta,GA300666340
75-2999669 		PARKING GA NA
  		INVESTMENT 75,069 783,098   No     No  
(2) Kennestone East Parking Deck LLC

805 Sandy Plains Road
Marietta,GA300666340
20-0537100 		PARKING GA NA
  		INVESTMENT -48,320 2,644,650   No     No  










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



 		(b)
Primary activity



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


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

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) Community Assurance Co
805 Sandy Plains Road
Marietta,GA300666340
58-1649541 		Insurance CJ WHS Inc
  		C   60,018,602 100.000 %












Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

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




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






























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


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