TY 2012 Form 990

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	985	985
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........
d	Lobbying ...........	2,058		2,058
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	5,678,018	3,997,677	1,680,341
12	Advertising and promotion ....
13	Office expenses .......	38,098	26,340	11,758
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	278,509	248,490	30,019
17	Travel ............
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	15,036	10,395	4,641
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	287,619	198,852	88,767
23	Insurance ..............	28,478	19,689	8,789
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	BAD DEBT	1,050,058	1,050,058
b	DRUGS AND REAGENTS	226,382	226,382
c	PATIENT CARE SUPPLIES	164,873	164,873
d	RENTAL/LEASE EQUIPMENT	139,904	96,726	43,178
e	All other expenses	176,679	155,362	21,317
25	Total functional expenses. Add lines 1 through 24e	8,086,697	6,195,829	1,890,868	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	228,770	1	395,077
2	Savings and temporary cash investments .........	751,932	2	653,296
3	Pledges and grants receivable, net ...........	138,595	3	142,822
4	Accounts receivable, net .............	697,449	4	700,063
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
			6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	65,019	8	42,987
9	Prepaid expenses and deferred charges ..........	28,688	9	24,073
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	2,758,546
b	Less: accumulated depreciation .....	10b	1,268,447	1,466,853	10c	1,490,099
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 .....		12
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........	15,302	15	61,240
16	Total assets. Add lines 1 through 15 (must equal line 34)......	3,392,608	16	3,509,657
	17	Accounts payable and accrued expenses .........	523,521	17	645,082
18	Grants payable .................		18
19	Deferred revenue ................	58,266	19	43,699
20	Tax-exempt bond liabilities .............		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....	1,563,215	24	1,178,251
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....................	67,347	25	16,213
26	Total liabilities. Add lines 17 through 25.........	2,212,349	26	1,883,245
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	1,156,020	27	1,414,818
28	Temporarily restricted net assets ...........	24,239	28	211,594
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	1,180,259	33	1,626,412
34	Total liabilities and net assets/fund balances ........	3,392,608	34	3,509,657

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part I

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

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

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

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

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

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

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

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

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

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

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

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

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

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

16a

33 1/3% support test—2012. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

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

Section D. Computation of Investment Income Percentage

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

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

19a

33 1/3% support tests—2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

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

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

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

Page 2

Name of organization TRI TOWN REGIONAL HEALTHCARE DBA TRI TOWN REGIONAL HOSPITAL

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

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

Page 3

Name of organization TRI TOWN REGIONAL HEALTHCARE DBA TRI TOWN REGIONAL HOSPITAL

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

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

Page 4

Name of organization
TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part III

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

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below. SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

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

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

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

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

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

2,058

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

2,058

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
	SCHEDULE C, PART II-B, LINE 1	HANYS MEMBERSHIP DUES ALLOCATE 28.6% TOWARDS GENERAL LOBBYING ACTIVITIES. TOTAL DUES PAID IN 2012 WAS 1,427 IROQUIOS HEALTHCARE ALLIANCE MEMBERSHIP DUES ALLOCATE 33.0% TOWARDS GENERAL LOBBYING ACTIVITIES. TOTAL DUES PAID IN 2012 WAS 5000

Schedule C (Form 990 or 990EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................
c	Leasehold improvements ............	1,714,812	562,047	1,152,765
d	Equipment ................	1,043,734	706,400	337,334
e	Other .................
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				1,490,099

Schedule D (Form 990) 2012

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value









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

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes
ESTIMATED PAYABLE, 3RD PARTY VENDORS		16,213








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		16,213
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	7,393,608
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 XIII.) ............	2d	-1,139,242
e	Add lines 2a through 2d .....................			2e	-1,139,242
3	Subtract line 2e from line 1.....................			3	8,532,850
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................			4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	8,532,850

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........			1	6,947,455
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d......................			2e
3	Subtract line 2e from line 1.....................			3	6,947,455
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b	1,139,242
c	Add lines 4a and 4b.......................			4c	1,139,242
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	8,086,697

Part XIII

Supplemental Information

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

Identifier	Return Reference	Explanation
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	THE HOSPITAL IS A NOT FOR PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL RECOGNIZES INCOME TAX POSITIONS WHEN IT IS MORE-LIKELY-THAN-NOT THAT THE POSITION WILL BE SUSTAINABLE BASED ON THE MERITS OF THE POSITION. MANAGEMENT HAS CONCLUDED THAT THERE ARE NO MATERIAL TAX LIABILITIES OR UNCERTAIN TAX POSITIONS THAT NEED TO BE RECORDED.
REVENUE AMOUNTS INCLUDED IN FINANCIALS - OTHER	SCHEDULE D, PAGE 4, PART XI, LINE 2D	BAD DEBT -1,050,058 CHARITY CARE -89,184
EXPENSE AMOUNTS INCLUDED ON RETURN - OTHER	SCHEDULE D, PAGE 4, PART XII, LINE 4B	BAD DEBT 1,050,058 CHARITY CARE 89,184

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

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

Yes

100% 150% 200% Other 300.000 %

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

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

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

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) ..	57,658	12,348	45,310	0.650 %
b	Medicaid (from Worksheet 3, column a) ....	1,320,939	1,088,128	232,811	3.350 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	1,378,597	1,100,476	278,121	4.000 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4) ..
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)	175,631		175,631	2.530 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	1,139		1,139	0.020 %
j	Total. Other Benefits ..	176,770		176,770	2.550 %
k	Total. Add lines 7d and 7j .	1,555,367	1,100,476	454,891	6.550 %

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

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
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

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

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

334,683

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

9,576

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

Section B. Medicare

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

645,359

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

1,039,288

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

-393,929

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address					Other (Describe)
1	TRI TOWN REGIONAL HEALTHCARE 43 PEARL STREET SIDNEY,NY13838 WWWTRITOWNHOSPORG	X	X	X	LABORATORY, RADIOLOGY SERVICES

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	TRI TOWN REGIONAL HEALTHCARE
Name of hospital facility or facility reporting group

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

Yes

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

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

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

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

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ....................

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

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

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 300.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11		No
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: % If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12		No
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........

Yes

If “No,” indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

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

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

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

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
OTHER TESTING METHODS FOR FREE OR DISCOUNTED CARE	PART I LINE 3C	THE CSP COMMUNITY SERVICES PROGRAM APPLICATION SPECIFIES FAMILY INCOME LIMITS AND OTHER REQUIREMENTS FOR SERVICES TO BE ELIGIBLE FOR TRI TOWN REGIONAL HOSPITALS CSPFREE CARE PROGRAM
RELATED ORGANIZATION INFORMATION	PART I LINE 6A	TRI TOWN REGIONAL HEALTHCARES DBA TRI TOWN REGIONAL HOSPITAL COMPREHENSIVE COMMUNITY SERVICE PLAN IS SUMMARIZED IN AN ANNUAL REPORT AND POSTED ON THE TRI TOWN REGIONAL HEALTHCARE TRH WEBSITE WWWTRITOWNHOSPITALORG PRINTED COPIES ARE AVAILABLE TO THE PUBLIC IN PATIENT WAITING ROOMS OR UPON REQUEST
EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE	PART I LINE 7 COLUMN F	THE PERCENT OF TOTAL EXPENSE IN PART 1 LINE 7 COLUMN F IS CALCULATED BY DIVIDING COLUMN E NET COMMUNITY BENEFIT EXPENSE BY TOTAL EXPENSE THE BAD DEBT EXPENSE OF 1050058 WAS SUBTRACTED FROM THE TOTAL EXPENSE VALUE USED TO CALCULATE THE PERCENTAGES IN PART 1 LINE 7 COLUMN F
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	WORKSHEET 2 WAS USED TO DEVELOP A COSTTOCHARGE RATIO IT WAS USED FOR PATIENT CARE SERVICES FOR NON PATIENT CARE SERVICES CHARGES WERE REDUCED TO COST FOR THOSE SERVICES TO NON PATIENTS WHERE A MARK UP IS READILY IDENTIFIABLE
COMMUNITY BUILDING ACTIVITIES	PART II	ALL TRI TOWN REGIONAL HOSPITAL COMMUNITY BUILDING ACTIVITES ARE INCLUDED IN PART I AND DESCRIBED BELOW
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	THE RATIO OF APPROVED APPLICATIONS FOR FINANCIAL ASSISTANCE TO TOTAL APPLICATIONS WAS APPLIED TO ARRIVE AT CHARGES PRESUMED ELIGIBLE FOR FINANCIAL ASSISTANCE THE COSTTOCHARGE RATIO WAS THEN APPLIED TO CHARGES TO ARRIVE AT COST FINANCIAL STATEMENTS FOOTNOTE I CHARITY AND UNCOMPENSATED CARE THE HOSPITALS GENERAL POLICY STATEMENT ON CHARITY CARE REQUIRES THAT MEDICAL CARE BE RENDERED TO ALL PERSONS IN NEED OF SUCH CARE REGARDLESS OF THEIR ABILITY TO PAY BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE THEY ARE NOT REPORTED AS REVENUE THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FORGONE FOR SERVICES FURNISHED UNDER ITS CHARITY CARE POLICY THE HOSPITALS CHARITY CARE POLICY HAS NOT CHANGED DURING FISCAL YEARS 2011 OR 2012 FINANCIAL STATEMENTS FOOTNOTE H PROVISION FOR UNCOLLECTIBLE PATIENT ACCOUNTS RECEIVABLE THE HOSPITAL GRANTS CREDIT WITHOUT COLLATERAL TO PATIENTS MOST OF WHO ARE LOCAL RESIDENTS AND ARE INSURED UNDER THIRD PARTY AGREEMENTS SERVICES RENDERED TO INDIVIDUALS WHEN PAYMENT IS EXPECTED AND ULTIMATELY NOT RECEIVED ARE WRITTEN OFF TO THE ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE ACCOUNT ADDITIONS TO THE ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS ARE MADE BY MEANS OF THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE ARE DEDUCTED FROM THE ALLOWANCE AND SUBSEQUENT RECOVERIES ARE ADDED THE AMOUNT OF THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENTS ASSESSMENT OF HISTORICAL EXPECTED NET COLLECTIONS BUSINESS AND ECONOMIC CONDITIONS TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTHCARE COVERAGE AND OTHER COLLECTION INDICATORS
MEDICARE EXPLANATION	PART III LINE 8	TRI TOWN REGIONAL HOSPITAL IS A UNIQUE HEALTH CARE FACILITY IT DOES NOT QUALIFY FOR ANY PAYMENT ENHANCEMENTS THAT WOULD MAKE SERVING A MEDICARE POPULATION PROFITABLE IT IS A PHYSICIAN STAFFED EMERGENCY DEPARTMENT WITH THE CAPACITY TO HOLD OBSERVATION PATIENTS AND AS SUCH THE LOSS THAT TRI TOWN REGIONAL HOSPITAL INCURS ON THE BOTTOM LINE SHOULD BE CONSIDERED A COMMUNITY BENEFIT THE COSTING TO DETERMINE THE BOTTOM LINE AMOUNT WAS DERIVED AS FOLLOWS CHARGES TIMES COSTTOCHARGE RATIO VERSUS REIMBURSEMENT ON THE MEDICARE PSR
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	FOR PATIENTS OR GUARANTORS WHO DO NOT QUALIFY FOR FINANCIAL ASSISTANCE TRI TOWN REGIONAL HOSPITAL MUST UNDERTAKE TO ENSURE AN ADEQUATE UNDERSTANDING ON THE PART OF THE PATIENTS AND THOSE RESPONSIBLE FOR THE CARE OF THEIR FINANCIAL OBLIGATIONS TO TRI TOWN REGIONAL HOSPITAL TRI TOWN REGIONAL HOSPITAL WILL IN COMPLIANCE WITH ALL EXISTING LAWS AND REGULATIONS TAKE THE STEPS NECESSARY TO RECOVER SELFPAY ACCOUNTS RECEIVABLE AS WELL AS PRESERVE THE PATIENTPROVIDER RELATIONSHIP AND KEEP THE NECESSITY OF REFERRING ACCOUNTS TO THIRD PARTY BAD DEBT COLLECTION AGENCIES OR LAW FIRMS TO A MINIMUM IT IS EXPECTED THAT ANY THIRD PARTY COLLECTION AGENCY OR LAW FIRM RETAINED BY TRI TOWN REGIONAL HOSPITAL WILL REFRAIN FROM ANY CONDUCT THAT VIOLATES THE FAIR DEBT COLLECTION PRACTICES ACT THE FAIR CREDIT REPORTING ACT AS WELL AS ANY APPLICABLE STATE LAW OR REGULATIONS THE ARREST OR BODY ATTACHMENT OF A JUDGEMENT DEBTOR ON CONTEMPT PROCEEDINGS OR FORECLOSURE OF A JUDGEMENT DEBTORS PRINCIPAL RESIDENCE WILL NEVER BE CONSIDERED APPROPRIATE PURSUIT OF AN OPEN BALANCE IN THE NAME OF TRI TOWN REGIONAL HOSPITAL LIENS OR GARNISHMENTS UPON THE PERSONAL ASSETS OF A JUDGEMENT DEBTOR WILL BE PURSUED ONLY AFTER INDIVIDUAL CASE REVIEW BY COUNSEL TO ENSURE THAT SUCH ACTION IS NOT ONLY CONSISTENT WITH TRI TOWN REGIONAL HOSPITALS INTERESTS BUT ALSO THE ONLY FEASIBLE RECOVERY MECHANISM FROM A JUDGEMENT DEBTOR CAPABLE OF RESPONDING TO HIS OR HER OBLIGATIONS BUT OTHERWISE UNWILLING TO DO SO
NEEDS ASSESSMENT	PART VI	IN ADDITION TO PUBLIC AND AGENCY INPUT A VARIETY OF DATA FROM THE NYS DEPARTMENT OF HEALTH DELAWARE CO BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM DELAWARE COUNTY PUBLIC HEALTH NURSING SERVICES COMMUNITY HEALTH ASSESSMENT AND OTHER SOURCES WERE USED TO ASSESS PRIORITIES INCLUDING THE RISING PERCENTAGE OF ADULTS WITH DIABETES AND RISING OBESITY RATE BASED ON THE PRIORITY ITEMS THE FOLLOWING STRATEGIES WERE IDENTIFIED 1ACCESS TO QUALITY HEALTHCARE AND PREVENTIVE CARE SERVICES A RECRUITMENT OF PRIMARY CARE PROVIDERS FOR COMMUNITY BASED HEALTH CENTERS BY BASSETT MEDICAL CENTER IN AREAS OF THE COUNTY WHERE ACCESS TO PRIMARY CARE IS AN ISSUE B TRI TOWN REGIONAL HOSPITAL OCONNOR HOSPITAL AND BASSETT MEDICAL CENTER WILL CONTINUE TO IDENTIFY GRANT OPPORTUNITIES TO ASSIST IN ATTRACTING PHYSICIANS TO DELAWARE CO PHYSICIANS TO DELAWARE CO C TRI TOWN REGIONAL HOSPITAL AND OCONNOR HOSPITAL WILL CONTINUE TO EVALUATE THE NEED FOR SPECIALTY SERVICES AND EXPAND OR DEVELOP SPECIALTY CLINICS AS NEEDED TO INCREASE ACCESS D TRI TOWN REGIONAL HOSPITAL AND OCONNOR HOSPITAL WILL WORK WITH BASSETTS CANCER SERVICES PROGRAM AND COMMUNITY PARTNERS TO INCREASE ACCESS TO PREVENTIVE CANCER SCREENING SERVICES THROUGHOUT THE COUNTY E TRI TOWN REGIONAL HOSPITAL AND OCONNOR HOSPITAL WILL CONTINUE TO PROVIDE AND EXPAND SMOKING CESSATION CLASSES TO AREA RESIDENTS AS WELL AS TO OFFER SUPPORT TO INDIVIDUALS WHO HAVE RECENTLY BECOME NONTOBACCO USERS 2PHYSICAL ACTIVITY AND NUTRITION A TRI TOWN REGIONAL HOSPITAL AND THE TRITOWN WELLNESS NETWORK WILL EXPAND DIABETES EDUCATION AND PREVENTION THROUGH MONTHLY THIRD THURSDAYS EDUCATION SESSIONS TO IMPROVE UNDERSTANDING OF NUTRITION DIABETES MEDICATIONS AND ISSUES IMPORTANT TO DIABETICS AND THOSE AT RISK OF BECOMING DIABETIC B TRI TOWN REGIONAL HOSPITAL OCONNOR HOSPITAL AND THE TRITOWN WELLNESS NETWORK WILL PROMOTE ADOPTION OF HEALTHY LIFESTYLE BEHAVIORS THROUGH GROUP SESSIONS TO IMPROVE UNDERSTANDING OF NUTRITION DIABETES MEDICATIONS AND ISSUES IMPORTANT TO DIABETICS AND THOSE AT RISK OF BECOMING DIABETIC C TRI TOWN REGIONAL HOSPITAL AND OCONNOR HOSPITAL WILL COLLABORATE WITH THE DELAWARE CO PUBLIC HEALTH NURSING SERVICES TO ENCOURAGE AREA RESIDENTS TO INCREASE THEIR PERSONAL PHYSICAL ACTIVITY VIA INFORMATION ABOUT AVAILABLE PROGRAMS IN THE REGION AND ENCOURAGEMENT TO PARTICIPATE IN THESE PROGRAMS 3OVERALL GOALS A INCREASE ACCESS TO PREVENTIVE HEALTH CARE BY RECRUITING PRIMARY CARE PROVIDERS EXPANDING WORKPLACE AND COMMUNITYBASED WELLNESS PROGRAMS AND PROVIDING CANCER SCREENING SERVICES IN UNDERSERVED AREAS OF THE COUNTY B IMPROVE COMMUNITY WORKSITE ACCESS TO SMOKING CESSATION PROGRAMS THROUGH ADDITIONAL CLASS OFFERINGS AND FOLLOWUP SESSIONS C ESTABLISH FORMAL DIABETES SUPPORT AND EDUCATIONAL SESSIONS ON PREVENTION AND WELLNESS TOPICS OF PARTICULAR INTEREST TO DIABETICS AND THOSE WHO CARE FOR AND ABOUT THEM D PROMOTE PHYSICAL ACTIVITY BY RAISING AWARENESS OF EXISTING OPPORTUNITIES IN THE AREA AND BY OFFERING ADDITIONAL ACTIVITIES AND REWARDS PROGRAMS FOR PARTICIPATION TRI TOWN REGIONAL HOSPITAL WILL CONTINUE TO OFFER FREE EDUCATIONAL PROGRAMMING HEALTH SCREENINGS AND EVENTS TO INCREASE KNOWLEDGE ABOUT CHRONIC DISEASES WOMENS HEALTH AGING OCCUPATIONAL HEALTH AND OTHER TOPICSPREVENTION PRIORITIES THESE INCLUDE LECTURES PRESENTATIONS SUPPORT GROUPS AND PARTICIPATION IN COMMUNITY WELLNESS EVENTS
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	A MAJOR COMPONENT OF THE TRI TOWN REGIONAL HOSPITALS COMMUNITY SERVICES PROGRAM IS TO ACTIVELY IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR CHARITY CARE THE PROCESS BEGINS WITH AN ORGANIZATIONAL POLICY AND PROCEDURE THAT DEFINES THE PROGRAM AND SERVES AS AN EDUCATION TOOL FOR ALL TRITOWN REGIONAL HOSPITALS EMPLOYEES THE POLICY IS UPDATED ANNUALLY DISTRIBUTED TO KEY PERSONNEL AND POSTED IN THE ONLINE POLICY AND PROCEDURE MANUAL THAT IS ACCESSIBLE TO ALL EMPLOYEES THE PROGRAM IS SUPPORTED BY A FOUR PAGE PLAIN LANGUAGE BROCHURE THAT INCLUDES AN APPLICATION BROCHURES ARE PROMINENTLY DISPLAYED AND AVAILABLE AT THE FACILITY CLINICAL AND SUPPORT STAFF ARE MADE AWARE OF THE PROGRAM AND ABLE TO DIRECT PATIENTS TO SPECIALISTS WHO CAN ASSIST IN THE APPLICATION PROCESS ALL PATIENTS WHO ARE REGISTERED AS SELF PAY ARE PROVIDED A BROCHURE EITHER IN PERSON OR BY MAIL PATIENTS WHO ARE IN THE HOSPITAL RECEIVE INFORMATION AS PART OF A PERSONAL VISIT GEARED TO HELP THE PATIENT NAVIGATE FINANCIAL ASSISTANCE INCLUDING BUT NOT LIMITED TO THE COMMUNITY SERVICES PROGRAM GOVERNMENT PROGRAM OPPORTUNITIES ARE ALSO REFERENCED AND A DIRECTORY OF LOCAL SOCIAL SERVICES AGENCIES IS PROVIDED BASED ON THE PATIENTS COUNTY OF RESIDENCE A LISTING OF ALL SELFPAY ACCOUNTS IS PRODUCED AND REVIEWED DAILY TO INSURE THAT A COMMUNITY SERVICES BROCHURE HAS BEEN PROVIDED THE SELFPAY BILLING OFFICE IDENTIFIES PATIENTS DURING THE BILLING AND COLLECTIONS PROCESS THAT MAY REQUIRE ADDITIONAL HELP UNDERSTANDING THE PROGRAM SELFPAY ACCOUNTS FOR PATIENTS WHO HAVE BEEN APPROVED FOR COMMUNITY SERVICES WITHIN THE PRIOR 120 DAYS ARE AUTOMATICALLY INCLUDED WITH THE PRIOR APPROVAL
COMMUNITY INFORMATION	PART VI	ACCORDING TO THE 2012 UNITED STATES CENSUS ESTIMATE DELAWARE COUNTY NEW YORK HAS A POPULATION OF 47276 AND IS APPROXIMATELY THE SIZE OF THE STATE OF RHODE ISLAND THE COUNTY HAS FOUR HOSPITALS COVERING AN AREA OF 144244 SQUARE MILES WITH 333 PEOPLE PER SQUARE MILE TRI TOWN REGIONAL HOSPITALS SERVICE AREA INCLUDES SIDNEY UNADILLA AND BAINBRIDGE AS WELL AS MORE THAN A DOZEN SURROUNDING COMMUNITIES IN DELAWARE CHENANGO AND OTSEGO COUNTIES THESE INCLUDE AFTON MOUNT UPTON GILBERTSVILLE MASONVILLE TROUT CREEK FRANKLIN GUILFORD WELLS BRIDGE OTEGO OXFORD SIDNEY CENTER TREADWELL AND ROCKDALE
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	TRI TOWN REGIONAL HOSPITAL IS A PHYSICIANSTAFFED EMERGENCY DEPARTMENT WITH THE CAPACITY TO HOLD OBSERVATION PATIENTS LOCATED IN SIDNEY NEW YORK IN ADDITION TO EMERGENCY SERVICES TRH PROVIDES DIAGNOSTIC XRAY DIAGNOSTIC ULTRASOUND VASCULAR ULTRASOUND CT IMAGING DIGITAL MAMMOGRAPHY AND CLINICAL LABORATORY SERVICES ALSO AVAILABLE ON THE TRI TOWN REGIONAL HOSPITAL IS ACCESS TO DENTAL SERVICES OUTPATIENT ORTHOPEDIC SERVICES AND ACCESS TO PRIME CARE SERVICES IT IS GOVERNED BY A BOARD OF TRUSTEES CONSISTING OF COMMUNITY VOLUNTEERS TRH PROGRAMS ADDRESS CHRONIC DISEASE MANAGEMENT AND PREVENTION WOMENS HEALTH AGING TOBACCO AND UNINTENTIONAL INJURY THEY INCLUDE A CANCER SERVICES PROGRAM OF DELAWARE OTSEGO AND SCHOHARIE COUNTIES B BASSETT CANCER INSTITUTE MEDICAL SCREENING COACH EQUIPPED WITH DIGITAL TECHNOLOGY FOR MAMMOGRAPHY AND OTHER CANCER SCREENINGS FOR MEN AND WOMEN C TRITOWN WELLNESS NETWORK OFFERS EDUCATION AND ASSISTANCE FOR DIABETES SMOKING CESSATION OBESITY AND NUTRITION PHYSICAL ACTIVITY LIVING A HEALTHY LIFESTLYE ALONG WITH OTHER COMMUNITY WELLNESS AND PREVENTION PROGRAMS D MISSION MELTAWAY IS A COLLABORATIVE EFFORT BETWEEN TRITOWN WELLNESS NETWORK BROOME COUNTY HEALTH DEPARTMENT AND DELAWARE COUNTY PUBLIC HEALTH NURSING SERVICE THAT IS FUNDED BY A NYS DEPARTMENT OF HEALTH GRANT TO THE SOUTHERN TIER DIABETES COALITION E TRITOWN WELLNESS NETWORK IS PILOTING A LONGTERM WORKSITE WELLNESS PROGRAM AT AMPHENOL CORPORATION IN SIDNEY NEW YORK WHICH EMPLOYS 1500 PEOPLE F TRITOWN WELLNESS NETWORK HAS AN ONGOING EFFORT TO DESIGN AND IMPLEMENT WELLNESS PROGRAMMING FOCUSING FOR THE AGING POPULATION ON PREVENTIVE CARE AND EARLY DETECTION G TELEHEALTH INHOME MONITORING IS AN ONGOING INITIATIVE OF THE TRITOWN WELLNESS NETWORK THROUGH WHICH AT HOME CARE INC WILL INSTALL TELEHEALTH UNITS IN THE HOMES OF PATIENTS DISCHARGED FROM TRI TOWN REGIONAL HOSPITAL OR REFERRED BY THEIR PRIMARY CARE PHYSICIAN WHO NEED HELP MANAGING CONDITIONS SUCH AS CONGESTIVE HEART FAILURE DIABETES AND HIGH BLOOD PRESSURE THE TELEHEALTH UNIT ENABLES A REGISTERED NURSE TO REMOTELY CONNECT WITH EACH PATIENT ON A DAILY BASIS TO MONITOR VITAL SIGNS AND PROVIDE HEALTH EDUCATION TO BETTER MANAGE THEIR CHRONIC DISEASE TRI TOWN REGIONAL HOSPITAL IS CONTINUALLY ENGAGING IN QUALITY IMPROVEMENT ACTIVITIES TO ENSURE HIGH QUALITY HEALTH CARE AND PROGRAMS ARE AVAILABLE IN DELAWARE COUNTY TRH HAS A COMMUNITY BOARD WHO ARE ACTIVELY ENGAGED IN THE HOSPITAL BOTH SUPPORTING THE GROWTH AND THE INVESTMENT IN PROGRAMS THAT BRING HEALTH AND WELLNESS BENEFITS TO THE COMMUNITY TRH CONTINUALLY INVESTS IN PROGRAMS EQUIPMENT AND PEOPLE TO ENSURE HIGH QUALITY SERVICE IS AVAILABLE IN THE COMMUNITY THEY SERVE
AFFILIATED HEALTH CARE INFORMATION	PART VI	TRI TOWN REGIONAL HOSPITAL IS A PART OF THE BASSETT HEALTHCARE NETWORK THAT PROVIDES HEALTH SERVICES IN MORE THAN 20 COMMUNITIES SPANNING 5600 SQUARE MILES AND EIGHT COUNTIES THE NETWORK FOCUSES ITS COMMUNITY SERVICES PROGRAMS IN THE COUNTIES WHERE THE SIX AFFILIATED HOSPITALS AND GREATEST PATIENT POPULATIONS ARE LOCATED OTSEGO COUNTY POPULATION 61709 DELAWARE COUNTY POPULATION 47276 HERKIMER COUNTY POPULATION 64508 SCHOHARIE COUNTY POPULATION 32099 ACCORDING TO THE 2012 US CENSUS ESTIMATES AOCONNOR HOSPITAL A CRITICAL ACCESS HOSPITAL IN DELHI DELAWARE COUNTY BTHE MARY IMOGENE BASSETT HOSPITAL AN ACUTE CARE INPATIENT TEACHING FACILITY THE BASSETT CLINIC AN OUTPATIENT PRIMARY AND SPECIALTY CARE CENTER A REGIONAL NETWORK OF 26 COMMUNITY BASED OUTPATIENT HEALTH CENTERS 19 SCHOOL BASED HEALTH CENTERS TWO AMBULATORY SURGERY CENTERS AND A FULLY SALARIED MEDICAL STAFF IN COOPERSTOWN OTSEGO COUNTY CCOBLESKILL REGIONAL HOSPITAL AN ACUTE CARE FACILITY IN COBLESKILL SCHOHARIE COUNTY DLITTLE FALLS HOSPITAL A CRITICAL ACCESS HOSPITAL IN LITTLE FALLS HERKIMER COUNTY E TRITOWN REGIONAL HOSPITAL A 247 EMERGENCY CARE FACILITY IN SIDNEY DELAWARE COUNTY FAO FOX MEMORIAL HOSPITAL AN ACUTE CARE FACILITY IN ONEONTA OTSEGO COUNTY GVALLEY HEALTH SERVICES A RESIDENTIAL HEALTH CARE AND REHABILITATION FACILITY HAT HOME CARE A CERTIFIED HOME CARE AGENCY IFIRST COMMUNITY CARE OF BASSETT A MEDICAL SUPPLY COMPANY ALL THE ABOVE MAKE UP THE BASSETT HEALTHCARE NETWORK AND PROVIDE HEALTH SERVICES TO THIS EIGHT COUNTY REGION IN CENTRAL NEW YORK
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED	PART VI	NEW YORK
ADDITIONAL INFORMATION	PART VI	PART V SECTION B LINE 11 TRI TOWN REGIONAL HOSPITAL DOES NOT PROVIDE DISCOUNTED CARE
TRI TOWN REGIONAL HEALTHCARE LINE NUMBER 1 PART V LINE 20D	PART V LINE 20D	TRI TOWN REGIONAL HOSPITAL RECOGNIZES THAT SERVICES WILL BE PROVIDED EQUALLY TO ALL PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY FOR SUCH SERVICES CHARGE SCHEDULES ARE THEREFORE UNIFORM BILLINGS TO PATIENTS ARE BASED ON THESE CHARGE SCHEDULES ALL CHARGES TO INDIVIDUALS THAT QUALIFY FOR CHARITY CARE ARE WRITTEN OFF COMPLETELY

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

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

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)NICHOLAS J NICOLETTATREASURER	(i) (ii)	376,575	107,000		23,096	3,436	510,107
(2)JEFFREY J WOEPPELVICE CHAIRPERSON	(i) (ii)	197,600			17,596	4,481	219,677
(3)DANIEL AYRESCEO	(i) (ii)	191,234			12,662	5,323	209,219
(4)SUE E ANDREWSASSISTANT TREASURER	(i) (ii)	183,547			15,946	2,830	202,323

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Identifier	Return Reference	Explanation
ORGANIZATION'S MISSION	FORM 990 - ORGANIZATION'S MISSION	TRI TOWN REGIONAL HOSPITAL EXISTS TO SERVE THE TRI TOWN AREA BY PROVIDING HIGH QUALITY, PATIENT FOCUSED EMERGENCY AND CLINICAL SUPPORT SERVICES IN PARTNERSHIP WITH BASSETT MEDICAL CENTER. IN ADDITION TO EMERGENCY CARE, THEY OFFER RADIOLOGY AND CLINICAL LAB SERVICES.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	EACH MEMBER OF THE BOARD RECEIVES A DRAFT COPY OF THE 990; THE TREASURER OF THE BOARD PRESENTS THE 990 DRAFT TO THE OFFICERS OF THE BOARD PRIOR TO FILING. ANY MEMBER OF THE BOARD WHO WISHES TO ATTEND THIS PRESENTATION MAY. ANY QUESTIONS ARE RAISED AND ANSWERED. ONCE APPROVED, THE 990 CAN BE FILED. A COMPLETE COPY OF THE ORGANIZATION'S FINAL FORM 990, INCLUDING ALL REQUIRED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, IS AVAILABLE TO EACH MEMBER OF THE BOARD BEFORE IT'S FILING WITH THE IRS.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLIES TO THE BOARD OF DIRECTORS, BOARD MEMBERS, OFFICERS, AND KEY PERSONS SUCH AS THE CHIEF EXECUTIVE OFFICER. EACH BOARD MEMBER, OFFICER, OR KEY PERSON OF THE HOSPITAL SHALL COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY. ALL COMPLETED QUESTIONNAIRES ARE REVIEWED AND ALL DISCLOSURES OF POTENTIAL CONFLICTS WILL BE BROUGHT TO THE CHIEF EXECUTIVE OFFICER. THE CEO OF HIS/HER DESIGNEE WILL TAKE ACTION TO ELIMINATE THE POTENTIAL CONFLICT OF INTEREST. ALL DISCLOSURES OF POTENTIAL CONFLICT OF INTEREST IN COMPLETED QUESTIONNAIRES SHALL BE COMPILED AND REPORTED BY THE ASSISTANT TREASURER TO THE OFFICERS OF THE BOARD TO DETERMINE IF THE REPORTED DISCLOSURE AND RESOLUTION IS SATISFACTORY. IF THE ACTIONS TAKEN ARE NOT CONSIDERED SATISFACTORY, THE OFFICERS OF THE BOARD SHALL DETERMINE FURTHER ACTION AS IT DEEMS APPROPRIATE.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	THE CHIEF EXECUTIVE OFFICER'S SALARY IS PAID BY A RELATED ORGANIZATION UNDER A MANAGEMENT SERVICES AGREEMENT. TRI TOWN REGIONAL HOSPITAL REVIEWS THE FORMAL PROCESS THAT IS USED TO DETERMINE THE BASE COMPENSATION OF THE CEO. THE CEO WORK PLAN AND ACCOMPLISHMENTS FOR THE YEAR ARE REVIEWED. SALARY CHANGES ARE BASED ON MARKET, WORK PLAN AND ACCOMPLISHMENTS. THE CEO'S SALARY IS SUBMITTED AS PART OF THE MANAGEMENT SERVICES AGREEMENT, WHICH IS APPROVED BY THE BOARD.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	TRI TOWN REGIONAL HOSPITAL MAKES IT GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. PARTIES DESIRING TO OBTAIN COPIES OF SUCH MUST PRESENT THEMSELVES AT THE ADMINISTRATIVE OFFICES OF TRH OR BY SENDING A SELF ADDRESSED STAMPED ENVELOPE AND PAYMENT FOR COPYING REQUESTED MATERIAL TO TRH ADMINISTRATIVE OFFICES. THE COST OF COPYING SHALL BE EQUAL TO THE COSTS IMPOSED BY THE IRS FOR THE COPYING OF PUBLIC DOCUMENTS.
OTHER FEES FOR SERVICES	FORM 990, PART IX, LINE 11G	CONTRACT SERVICES 3,997,677 1,680,341 0
RECONCILIATION OF CHANGES - OTHER	FORM 990, PART XI, LINE 9	BAD DEBT -1,050,058 CHARITY CARE -89,184 BAD DEBT 1,050,058 CHARITY CARE 89,184

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

TRI TOWN REGIONAL HEALTHCARE
DBA TRI TOWN REGIONAL HOSPITAL

Employer identification number

26-0169584

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) THURSTON CORPORATION ONE ATWELL ROAD COOPERSTOWN,NY13326 13-3218680	SUPPORT	NY	501C3	11C	NONE		No
(2) BASSETT REGIONAL CORPORATION (BRC) ONE ATWELL ROAD COOPERSTOWN,NY13326 13-3522783	SUPPORT	NY	501C3	11B	THURSTON		No
(3) MARY IMOGENE BASSETT HOSPITAL ONE ATWELL ROAD COOPERSTOWN,NY13326 13-5596796	HEALTHCARE	NY	501C3	3	THURSTON		No
(4) TEMPLETON FOUNDATION ONE ATWELL ROAD COOPERSTOWN,NY13326 13-3317084	LANDLORD	NY	501C3	9	THURSTON		No
(5) FRIENDS OF BASSETT ONE ATWELL ROAD COOPERSTOWN,NY13326 23-7041610	FUNDRAISE	NY	501C3	7	THURSTON		No
(6) AO FOX MEMORIAL HOSPITAL ONE NORTON AVENUE ONEONTA,NY13820 15-0539039	HEALTHCARE	NY	501C3	3	THURSTON		No
(7) BASSETT HOSPITAL SCHOHARIE COUNTY 178 GRANDVIEW DRIVE COBLESKILL,NY12043 14-1772971	HEALTHCARE	NY	501C3	3	BRC		No
(8) LITTLE FALLS HOSPITAL 140 BURWELL STREET LITTLE FALLS,NY13365 15-0533578	HEALTHCARE	NY	501C3	3	BRC		No
(9) O'CONNOR HOSPITAL 460 ANDES ROAD DELHI,NY13753 16-1540394	HEALTHCARE	NY	501C3	3	BRC		No
(10) VALLEY HEALTH SERVICES 690 WEST GERMAN STREET HERKIMER,NY13350 22-2511614	ELDER CARE	NY	501C3	3	BRC		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

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

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

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

Yes

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

Yes

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

Yes

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

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

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

Yes

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

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

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

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) BASSETT REGIONAL CORPORATION	C	100,000	CASH

Schedule R (Form 990) 2012

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TRI TOWN REGIONAL HOSPITAL EXISTS TO SERVE THE TRI TOWN AREA BY PROVIDING HIGH QUALITY, PATIENT FOCUSED EMERGENCY AND CLINICAL SUPPORT SERVICES IN PARTNERSHIP WITH BASSETT MEDICAL CENTER. IN ADDITION TO EMERGENCY CARE, THEY OFFER RADIOLOGY AND CLINICAL LAB SERVICES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	6
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	4
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	4
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

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	210,976	376,983
9	Program service revenue (Part VIII, line 2g) .........	7,342,052	8,154,363
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	4,095	1,504
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)		0
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	7,557,123	8,532,850
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		985
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)		0
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	7,408,583	8,085,712
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	7,408,583	8,086,697
19	Revenue less expenses. Subtract line 18 from line 12.......	148,540	446,153
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	3,392,608	3,509,657
21	Total liabilities (Part X, line 26).............	2,212,349	1,883,245
22	Net assets or fund balances. Subtract line 21 from line 20.....	1,180,259	1,626,412

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 6,106,645 including grants of $ 985 ) (Revenue $ 8,154,363 )
	EMERGENCY, CLINICAL LABORATORY, AND RADIOLOGY SERVICES PROVIDED TO OUR PATIENTS RESULTED IN: 17 OBSERVATIONS, 17 PATIENT DAYS EMERGENCY ROOM VISITS : 9,638 LABORATORY VISITS : 10,035 RADIOLOGY VISITS : 3,882

4b	(Code: ) (Expenses $ 89,184 including grants of $ ) (Revenue $ )
	COMMUNITY INVOLVEMENT IS LINKED TO TRI TOWN REGIONAL HOSPITAL'S MISSION, VISION, AND VALUES. WE ARE WORKING WITH OUR COMMUNITY TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE OF OUR REGION. OUR COMMUNITY SERVICES PROGRAMS PROVIDE FREE SERVICES TO PERSONS WHO CAN NOT AFFORD TO PAY, WHO DO NOT QUALIFY FOR MEDICAID, AND WHO FALL WITHIN THE ESTABLISHED INCOME GUIDELINES. IN 2012, WE PROVIDED 89,184 IN CHARITY CARE. OUR DOORS ARE OPEN 24 HOURS A DAY, 7 DAYS A WEEK, 365 DAYS A YEAR. WE ARE PROUD TO PROVIDE THIS CARE TO OUR COMMUNITIES. NOT ONLY DID WE PROVIDE 89,184 IN CHARITY CARE, PATIENT ACCOUNTS IN THE AMOUNT OF 1,050,058 WERE RECORDED AS BAD DEBT IN 2012.

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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses6,195,829

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(1) NICHOLAS J NICOLETTA........................................................................ TREASURER	2.00 .......................51.50	X	X	0	483,575	26,532
(2) JEFFREY J WOEPPEL........................................................................ VICE CHAIRPE	2.00 .......................48.00	X	X	0	197,600	22,077
(3) SCOTT MCLEAN........................................................................ CHAIRPERSON	2.00 ........................50	X	X	0	0	0
(4) JAMES MENO........................................................................ SECRETARY	.......................	X	X	0	0	0
(5) GAIL HOFFMAN........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(6) JOHN MIRABITO........................................................................ DIRECTOR	1.00 ........................30	X		0	0	0
(7) DANIEL AYRES........................................................................ CEO	16.00 .......................24.00		X	0	191,234	17,985
(8) SUE E ANDREWS........................................................................ ASSISTANT TR	6.00 .......................54.00		X	0	183,547	18,776
(9) JOAN WICKS........................................................................ ASSISTANT SE	6.00 .......................		X	0	31,674	3,776

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,087,630	89,146

(A) Name and business address	(B) Description of services	(C) Compensation
NEW YORK EMERGENCY SERVICES7032 COLLECTION CENTER DRIVECHICAGOIL60693	MD SERVICES	577,150




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 1

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		196,339
e	Government grants (contributions)1e		180,644

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.......			376,983
			Business Code
2a	DIRECT PATIENT SERVICES			7,022,550	7,022,550
b	OTHER PATIENT SERVICES			1,131,813	1,131,813
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			8,154,363
3	Investment income (including dividends, interest, and other similar amounts).......			1,504			1,504
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss)..........
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......
12	Total revenue. See Instructions......			8,532,850	8,154,363		1,504


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			228,770	1	395,077
2	Savings and temporary cash investments .........			751,932	2	653,296
3	Pledges and grants receivable, net ...........			138,595	3	142,822
4	Accounts receivable, net .............			697,449	4	700,063
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			65,019	8	42,987
9	Prepaid expenses and deferred charges ..........			28,688	9	24,073
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	2,758,546
b	Less: accumulated depreciation .....	10b	1,268,447	1,466,853	10c	1,490,099
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			15,302	15	61,240
16	Total assets. Add lines 1 through 15 (must equal line 34)......			3,392,608	16	3,509,657
17	Accounts payable and accrued expenses .........			523,521	17	645,082
18	Grants payable .................				18
19	Deferred revenue ................			58,266	19	43,699
20	Tax-exempt bond liabilities .............				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....			1,563,215	24	1,178,251
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....................			67,347	25	16,213
26	Total liabilities. Add lines 17 through 25.........			2,212,349	26	1,883,245
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			1,156,020	27	1,414,818
28	Temporarily restricted net assets ...........			24,239	28	211,594
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			1,180,259	33	1,626,412
34	Total liabilities and net assets/fund balances ........			3,392,608	34	3,509,657