TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Daniel M Asquino........................................................................ Trustee	0 .......................0	X		0	0	0
(2) Michael Azzoni........................................................................ Trustee	0 .......................0	X		0	0	0
(3) James Garrison........................................................................ Trustee	0 .......................0	X		0	0	0
(4) John Kerney........................................................................ Trustee	0 .......................0	X		0	0	0
(5) Roy Lake........................................................................ Trustee	0 .......................0	X		0	0	0
(6) Michele Parker........................................................................ Trustee	0 .......................0	X		0	0	0
(7) JoAnne Parks........................................................................ Trustee	0 .......................0	X		0	0	0
(8) Kenneth J Pierce........................................................................ Chairman-Trustee	0 .......................0	X		0	0	0
(9) Glenn A Hunt........................................................................ Vice Chairman -Trustee	0 .......................0	X		0	0	0
(10) Rebecca Bialecki........................................................................ 2nd Vice Chairman - Trustee	0 .......................0	X		0	0	0
(11) Cheney Castine........................................................................ Treasurer - Trustee	0 .......................0	X		0	0	0
(12) Tina Sbrega........................................................................ Trustee	0 .......................0	X		0	0	0
(13) Winfield Brown........................................................................ President /CEO	40 .......................0	X	X	526,138	0	50,699
(14) Robert Chauvin........................................................................ Trustee	0 .......................0	X		0	0	0
(15) Joyce Fletcher........................................................................ Trustee	0 .......................0	X		0	0	0
(16) John Flick........................................................................ Trustee	0 .......................0	X		0	0	0
(17) James Meehan........................................................................ Trustee	0 .......................40	X		0	33,400	3,247

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(18) Donald Mruk........................................................................ Trustee	0 .......................0	X				0	0
(19) Moshen Noreldin........................................................................ Trustee	0 .......................0	X				0	0
(20) John Skrzypczak........................................................................ Trustee	0 .......................0	X				0	0
(21) Douglas Starrett........................................................................ Trustee	0 .......................0	X				0	0
(22) Robert Crosby........................................................................ Sr VP of Finance / CFO	40 .......................0		X			268,605	48,958
(23) Michael Grimmer........................................................................ VP of Support Services	40 .......................0		X			228,187	43,961
(24) Tina Santos........................................................................ VP of Patient Care Srvcs/CNO	40 .......................0		X			221,225	29,541
(25) Thomas Cady........................................................................ VP of Human Resources	40 .......................0		X			175,347	45,927
(26) Rose Kavalchuck........................................................................ VP of Quality Services	40 .......................0		X			201,940	42,668
(27) Carol Roosa........................................................................ VP of Information Services/CIO	40 .......................0		X			7,558	1,800
(28) Dawn Casavant........................................................................ VP of Philanthropy	40 .......................0		X			15,603	2,457
(29) David Gill........................................................................ Staff Phychologist	40 .......................0			X		255,824	28,343
(30) Faith Pinkerton........................................................................ Emergency Physician	40 .......................0			X		192,560	18,332
(31) Sheila Ebert........................................................................ Oncology Physician	24 .......................0			X		196,069	14,653
(32) Ellen Ray........................................................................ Emergency Physician	40 .......................0			X		182,261	18,130
(33) Alice Vaine........................................................................ OR Nurse Practitioner	40 .......................0			X		174,778	13,937
(34) James Mullen........................................................................ Sr VP of Patient Care / CNO (termed 5/27/11)	40 .......................0				X	101,328	7,819

(A) Name and business address	(B) Description of services	(C) Compensation
Quartulli and Associates IncPO Box 423GardnerMA01440	Physical Therapy	3,099,625
Bay State Emergency Medical Inc44 Crosby RoadAshburnhamMA01430	Emergency Room Physicians	1,455,524
Alliance Healthcare Services100 Bay View CircleNewport BeachCA92660	MRI	1,308,445
UMass Memorial Medical Group, 3654 Plantation StWorcesterMA01605	Physician Services	1,104,301
Quest Diagnostics Inc5763 Collection Center DriveChicagoIL60693	Lab Contracted Services	796,422
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 27

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	120,000	120,000
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0	0
4	Benefits paid to or for members	0	0
5	Compensation of current officers, directors, trustees, and key employees ....	1,964,485	443,411	1,399,898	121,176
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0	0	0	0
7	Other salaries and wages	44,372,423	43,741,246	604,852	26,325
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	822,765	713,429	95,684	13,652
9	Other employee benefits .......	5,163,413	4,845,622	291,590	26,201
10	Payroll taxes ...........	3,506,077	3,329,057	166,695	10,325
11	Fees for services (non-employees):
a	Management ......	0	0	0	0
b	Legal .........	698,750	11,301	687,449	0
c	Accounting ...........	106,640	0	106,640	0
d	Lobbying ...........	0	0	0	0
e	Professional fundraising services. See Part IV, line 17	6,744			6,744
f	Investment management fees ......	0	0	0	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	10,576,756	10,545,400	31,356	0
12	Advertising and promotion ....	99,582	89,919	9,663	0
13	Office expenses .......	14,983,097	14,739,854	239,450	3,793
14	Information technology ......	1,360,901	1,298,747	62,154	0
15	Royalties ..	0	0	0	0
16	Occupancy ...........	1,701,811	1,678,956	22,855	0
17	Travel ............	95,509	78,890	16,619	0
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0	0	0	0
19	Conferences, conventions, and meetings ....	84,335	63,505	19,681	1,149
20	Interest ...........	708,193	708,193	0	0
21	Payments to affiliates .......	0	0	0	0
22	Depreciation, depletion, and amortization .....	4,587,648	4,572,888	14,760	0
23	Insurance ..............	578,508	509,673	68,835	0
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	5,502,302	5,502,302	0	0
b	Free Care	2,847,338	2,847,338	0	0
c	Professional Fees	5,056,562	3,681,459	1,365,486	9,617
d	Subscriptions & Dues	714,935	225,100	487,861	1,974
e	All other expenses	1,585,479	1,487,496	97,983	0
25	Total functional expenses. Add lines 1 through 24e	107,244,253	101,233,786	5,789,511	220,956
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 .............	2,438,924	1	4,168,080
2	Savings and temporary cash investments .........	0	2	0
3	Pledges and grants receivable, net ...........	2,398,884	3	2,264,477
4	Accounts receivable, net .............	10,258,616	4	12,802,618
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	72,338	7	171,515
8	Inventories for sale or use ..............	1,371,294	8	1,413,035
9	Prepaid expenses and deferred charges ..........	1,080,396	9	1,057,751
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	104,097,688
b	Less: accumulated depreciation .....	10b	51,408,268	54,706,913	10c	52,689,420
11	Investments—publicly traded securities ..........	17,190,937	11	18,185,573
12	Investments—other securities. See Part IV, line 11 .....	489,451	12	437,650
13	Investments—program-related. See Part IV, line 11 .....	129,347	13	134,526
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	1,640,000	15	2,143,340
16	Total assets. Add lines 1 through 15 (must equal line 34)......	91,777,100	16	95,467,985
	17	Accounts payable and accrued expenses .........	13,297,762	17	14,314,680
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	258,468
20	Tax-exempt bond liabilities .............	26,312,766	20	24,679,160
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	729,023	23	294,782
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	5,819,350	25	6,066,285
26	Total liabilities. Add lines 17 through 25.........	46,158,901	26	45,613,375
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	40,274,861	27	44,503,392
28	Temporarily restricted net assets ...........	4,337,245	28	4,345,057
29	Permanently restricted net assets ...........	1,006,093	29	1,006,161
	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 ...........	45,618,199	33	49,854,610
34	Total liabilities and net assets/fund balances ........	91,777,100	34	95,467,985

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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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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:	12000197
Software Version:	v1.00

- 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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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 HENRY HEYWOOD MEMORIAL 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 HENRY HEYWOOD MEMORIAL 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
HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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:	12000197
Software Version:	v1.00

- 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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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 ....	17,128,384	11,897,431	17,367,013	16,786,738	18,164,728
b	Contributions ........	2,200	5,683	5,000	4,875	5,250
c	Net investment earnings, gains, and losses	2,044,839	1,966,503	-128,702	958,017	-686,973
d	Grants or scholarships .....	0	0	0	0	0
e	Other expenditures for facilities and programs ........	1,096,659	-3,258,767	5,345,880	382,617	696,267
f	Administrative expenses ....	0	0	0	0	0
g	End of year balance ......	18,078,764	17,128,384	11,897,431	17,367,013	16,786,738

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

Board designated or quasi-endowment SchDMd Bullet

85 %

Permanent endowment SchDMd Bullet

6 %

Temporarily restricted endowment SchDMd Bullet

9 %

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		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	0	125,271		125,271
b	Buildings ................	0	65,922,189	22,700,335	43,221,854
c	Leasehold improvements ............	0	0	0	0
d	Equipment ................	0	37,252,134	28,707,933	8,544,201
e	Other .................	0	798,094	0	798,094
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......					52,689,420

Schedule D (Form 990) 2012

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value









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

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes		0
Est Settlement with 3rd Party		4,205,784
Est Insurance Claims		1,860,501







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		6,066,285
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
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
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part 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

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

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
SchD_P05_S00_L04	Schedule D, Part V, Line 4	Perm Endow funds are established by donor restricted gifts and maintained to provide a permanent source of income. The principal of which is kept in perpetuity. Board Designated Endow funds are established by the governing body to fund capital projects and/or improvements of the organization. Temp Restricted funds are established by donor restricted gifts that maintain a source of income for a specific period of time.
SchD_P10_S00_L02	Schedule D, Part X, Line 2	The Hospital and HMGI (as of April 2006) have been determined to be not-for-profit corporations as described in Section 501(c)(3), and the Realty Corp has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Internal Revenue Code (the "Code") and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The IRS has also previously determined that the Hospital is not a private foundation because it is an organization described under the IRC section 170(i)(A)(iii). Any income not substantially related to these Organizations' exempt purposes may be considered unrelated business income under IRC Section 511 and, as such, subject to tax at normal corporate rates. In accordance with generally accepted accounting principles, the Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years from 2008 through the current year remain open for examination by federal and state taxing authorities.

Schedule D (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrow

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
HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










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

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

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

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2012

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 Golf Classic (event type)	(c) Other events (total number)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . .	83,375		83,375
2	Less: Contributions . .	55,350		55,350
3	Gross income (line 1 minus line 2) . . .	28,025		28,025
4	Cash prizes . . .	0		0
5	Noncash prizes . .	5,277		5,277
6	Rent/facility costs . .	14,017		14,017
7	Food and beverages .	17,158	0	17,158
8	Entertainment . . .	400	0	400
9	Other direct expenses .	5,988		5,988
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........			42,840
11	Net income summary. Combine line 3, column (d), and line 10. ..........			-14,815

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add col.(a) through col.(c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2012

Page 3

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ..........................

YesNo

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- 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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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 %

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

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

Yes

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

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		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..			1,882,213	506,134	1,376,079	1.35 %
b	Medicaid (from Worksheet 3, column a) ....			17,041,326	14,859,011	2,182,315	2.14 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .			0	0	0	0 %
d	Total Financial Assistance and Means-Tested Government Programs .	0	0	18,923,539	15,365,145	3,558,394	3.49 %
Other Benefits				982,953	113,321	869,632	0.85 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..			982,953	113,321	869,632	0.85 %
f	Health professions education (from Worksheet 5) ..			239,160	616	238,544	0.23 %
g	Subsidized health services (from Worksheet 6) ..			0	0	0	0 %
h	Research (from Worksheet 7)			0	0	0	0 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8)			44,743	0	44,743	0.04 %
j	Total. Other Benefits ..	0	0	1,266,856	113,937	1,152,919	1.12 %
k	Total. Add lines 7d and 7j .	0	0	20,190,395	15,479,082	4,711,313	4.61 %

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	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing			0	0	0 %
2	Economic development			0	0	0 %
3	Community support			0	0	0 %
4	Environmental improvements			240	240	0 %
5	Leadership development and training for community members			0	0	0 %
6	Coalition building			126,353	126,353	0.12 %
7	Community health improvement advocacy			0	0	0 %
8	Workforce development			110,701	110,701	0.11 %
9	Other			0	0	0 %
10	Total	0	0	237,294	237,294	0.23 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

2,255,163

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. ......

92,236

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).....

32,944,291

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

28,809,621

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

4,134,670

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
1	Henry Heywood Memorial Hospital 242 Green Street Gardner,MA01440	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	Henry Heywood Memorial Hospital
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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 11

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

Yes

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

Yes

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

Yes

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 ........

Yes

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: 100% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17	Yes
	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
SchH_P01_S00_L06a	Schedule H, Part I, Line 6a	The Organization makes it's annual Community Benefit Report available to the public by transmitting the report electronically to the Attorney General's Community Benefit office which then makes it public on their website.
SchH_P01_S00_L07	Schedule H, Part I, Line 7	The costing methodology used to calculate the amounts reported in the table in Part I, for lines 7a through 7c was based on the cost to charge ratio derived from the supplied Worksheet 2, in the IRS schedule H instructions. The costs for lines 7e through 7i were actual costs incurred.
SchH_P02_S00_L00	Schedule H, Part II	The Heywood Hospital's community Benefits Mission Statement is "Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health needs of the under-served and collaborating with others to enhance quality and contain the growth of community healthcare costs".
SchH_P02_S00_L04	Schedule H, Part II, Line 4	This year's expenses were related to Heywood Hospital's Green Team and their sponsorship of Earth Day events which included a recycling day and plant sales.
SchH_P02_S00_L06	Schedule H, Part II, Line 6	Heywood's approach to Community Benefits has been to collaborate with others through the Joint Coalition on Health and other coalitions to develop our plan, goals and strategies. Partners include the Joint Coalition on Health, Gardner Interagency Team, the CHNA, The Minority Coalition, Montachusetts Opportunity Council, Mount Wachusett Community College, the Community Health Connections Health Centers, North Central Human Services, Luc, Inc., Community Health Link, Gardner VNA, the Gardner Public Schools, the Winchendon Public Schools, the Health Foundation of Central MA, Kresge Foundation, the Dpt of Public Health, AHEC and others. At his time, we continue to focus our efforts on mental health and substance abuse, insuring those without jobs and/or insurance, addressing the needs of under-served populations, focusing on the needs of youth and children, and targeting adults and children with overweight and obesity issues which lead to chronic diseases and diabetes.
SchH_P02_S00_L08	Schedule H, Part II, Line 8	Heywood Hospital serves a medically underserved population area, because of this, the Hospital is constantly working to recruit and search for physicians to serve our community.
SchH_P03_S0A_L02	Schedule H, Part III, Section A, Line 2	The costing methodology used for line 2 was based on the cost charge ratio derived from the supplied worksheet 2 in the IRS sch H instructions.
SchH_P03_S0A_L03	Schedule H, Part III, Section A, Line 3	The methodology used for line 3 was to take the percentage of financial assistance applications that were due to inadequate documentation divided by the total applications received for FY 2013. This amounted to approximately 4.09% which was applied against the number on line2.. It is our belief that the $92,236 amount of bad debt should be included as a community benefit. As a ax exempt hospital, we must provide necessary services regardless of the patient's ability to pay for the service provided. As a not for profit, patient care is provided to all, regardless of ability to pay for that care, making quality patient care available to all in our community, regardless of their economic means, qualifies bad devts as a community benefit.
SchH_P03_S0A_L04	Schedule H, Part III, Section A, Line 4	The footnote can be found on Page 8 of the financial statements - footnote #2 under "Allowance of Doubtful Accounts".
SchH_P03_S0B_L06	Schedule H, Part III, Section B, Line 6	The allowable costs on line 6 were obtained from our FY 2013 Medicare Cost Report, Worksheet D schedules.
SchH_P03_S0B_L08	Schedule H, Part III, Section B, Line 8	There is no shortfall.
SchH_P03_S0C_L09b	Schedule H, Part III, Section C, Line 9b	Heywood Hospital provides patients with information about financial assistance programs that are available through the Commonwealth of MA or through Heywood Hospital's own financial assistance program, which may cover all or some of their unpaid hospital bills. For those patients that request such assistance, Heywood Hospital assists patients by screening them for eligibility in an available public program and assisting them in applying for the program. These programs, include but are not limited to MassHealth, Commoneealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net and others. It is the patient's obligation to provide Heywood Hospital with accurate and timely information to determine if the patient is eligible to apply for certain health insurance programs. If the patient or guarantor is unable to provide the necessary information Heywood Hospital may make reasonable efforts to obtain any additional information from other sources. Information that Heywood obtains will be maintained in accordance with applicable federal and state privacy and security laws. The screening and application process for a public health insurance program is done through Virtual Gateway, which is an internet portal designed by the MA Executive Office of Health and Human Services. The Virtual Gateway manages the application process from the programs listed above, which is available for children, adults, seniors, veterans, homeless and disabled individuals. Heywood specifically assists the patient in completing the application and secure the necessary documentation required by the applicable financial assistance program. Heywod Hospital will then submit this document to the Commonwealth Office of Medicaid and assist the patient in any additional documentation if such is required by the Commonwealth after completing the application. All Virtual Gateway applications are reviewed and processed by the Commonweatlh of MA, Office of Medicaid. Special circumstance applications are reviewed and approved by the MA Division of Health Care Finance and Policy. Hospitals have no role in the determination of program eligibility made by the Commonwealth, but at the patient's request may take a direct role in appealing or decisions made by the Commonwealth to ensure accurate and timely adjudication of all hospital bills. If the patient does not comply with the request for documentation, then our standard collection procedures apply.
SchH_P05_S0B_L03	Schedule H, Part V, Section B, Line 3	The 2011 Community Health Needs Assessment of North Cental Massachusetts was a joint effort between MA Dept of Public Health's Community Health Network Area of North Central Massachusetts (CHNA 9) and the Joint Coalition on Health. The assessment is designed to provide information and analyses relative to the health status, issues, concerns and assets of the North Central Region of Massachusetts. The assessment includes 27 cities and towns covered by CHNA 9 of which Gardner, Ashburnham, Westminster, Winchendon, Templeton and Hubbardston are primary service areals of Heywood Hospital, and are included within the reporting region of Gardner. Comparisons are made to Massachusetts as a whole and to Healthy People 2010 goals. All data was gathered systematically utilizing standards which guided the methodologies. The quantitative data collected came from the Massachusetts Community Health Information Profile, the Massachusetts Dept of Public Health, the US Census Bureau, the MA Dept of Workforce Development, the MA Dept of Elementary and Secondary Education and the Massachusetts Behavorial Health Partnership. Qualitative data was gathered using focus groups and interviews that were conducted in cooperation with the Minority Coalition of North Central Beautiful Gate Church, Twin Cities CDC, Gardner CDC, Memorial Congregational Church, New Hope Community Church, Montachusestt Opportunity Council, in addition to other area agencies.
SchH_P05_S0B_L04	Schedule H, Part V, Section B, Line 4	Hospitals included in the development of the 2012 Community Health Needs Assessment are Heywood Hospital, Gardner, MA; HealthAlliance Hospital, Leominster MA; and Clinton Hospital, Clinton, MA.
SchH_P05_S0B_L12	Schedule H, Part V, Section B, Line 12	12h:Medical Hardship, wherein the patient's medical expenses exceed the patient's income
SchH_P05_S0B_L18	Schedule H, Part V, Section B, Line 18	18e: The Hospital posts general notices throughout the hospital about the financial assistance policy.
SchH_P06_S00_L02	Schedule H, Part VI, Line 2	Heywood Hospital assesses the health needs of the communities it serves in a variety of ways in addition to the CHNA. The Patient and Family Advisory Council which meets every other month includes 14 patients and two hospital representatives. This council, comprised of former patients and their families, provides general input on community needs, as well as input on hospital-specific services and opportunities for improvement. In addition, the hospital works closely throughout the year with area social service agencies obtaining input on community health needs including, Gardner Board of Health, the Joint Coalition on Healthcare, the Minority Coalition of North Central MA, Gardner CDC, the Massachusetts Department of Public Health, more than 100 agencies belonging to the Suicide Prevention Taskforce, Gardner Public Schools, Ashburnham Public Schools, Winchendon Public Schools, Gardner Area Interagency Team, Mount Wachusett Community College, Alzheimer Association, Montachusett Veterans Outreach, Gardner Area Seniors, Gardner VNA and the Greater Gardner Religious Council. The hospital solicits feedback from social service and nursing staff, as well as physicians regarding patient feedback. The hospital also provides space for/and facilitates support groups which provide feedback on community interests and needs.
SchH_P06_S00_L03	Schedule H, Part VI, Line 3	General Principles: For those patients who are uninsured or under-insured, Heywood Hospital will work with them to assist with applying for available financial assistance programs that may cover some or all of their unpaid hospital bills. In order to help uninsured and under-insured patients find available and appropriate financial assistance programs, Heywood Hospital will provide all patients with a general notice of the availability of programs in both the bills that are sent to patients as well as in general notices that are posted throughout the hospital. The goal of these notices is to assist patients in applying for coverage within a financial assistance program, such as MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start and Health Safety Net. When applicable, Heywood Hospital may also assist patients in applying for coverage of services as a Medical Hardship based on the patients who are low income through Heywood Hospital's own internal financial assistance program. Heywood Hospital will also notify the patient about available payment plans that may available to them based on their family size and income. Role of Hospital Patient Financial Counselors and other Finance staff: Heywood Hospital will try to identify available coverage options for patients who may be uninsured or under-insured with their current insurance program when the patient is scheduling their services, while the patient is in Heywood Hospital, upon discharge, and for a reasonable time following discharge from the hospital. The hospital registration and admission staff will direct all patients seeking available coverage options or financial assistance to the hospital's patient financial counseling office to determine if they are eligible and then o screen for eligibility in an appropriate coverage option. Heywood Hospital will then assist the patient in applying for the appropriate coverage options that are available or notify them of the availability of financial assistance through the hospital's own internal financial assistance program. Heywood Hospital will also provide information on how to contact the appropriate staff within the hospital's finance office to verify the accuracy of the hospital bill or to dispute certain charges. Notification Practices: Heywood Hospital will post a notice of availability of financial assistance in the following locations; 1) Service Delivery Areas such as Inpatient, Clinic and Emergency Department admissions and registration areas. 2) Patient Financial Counselor areas. 3) Central Admission and Registration areas. and 4) Business office areas that are open to patients. Posted signs will be clearly visible and legible to patients visiting these areas. Heywood Hospital will also include a notice about the availability of financial assistance in all initial bills. When the patient contacts Heywood Hospital, the hospital finance staff will attempt to identify if a patient qualifies for a public financial assistance program or a payment plan... A patient who is enrolled in a public financial assistance program may qualify for certain plans. Patients may also qualify for additional assistance based on Heywood Hospital's own internal criteria for financial assistance, or qualify for coverage of services as a Medical Hardship based on the patient's documented income and allowable medical expenses. For cases where Heywood Hospital is using the Virtual Gateway application, the hospital will assist the patient in completing the application for MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net or other forms of financial assistance programs, as they become part of the Virtual Gateway program.
SchH_P06_S00_L04	Schedule H, Part VI, Line 4	The Greater Gardner area, comprised of the City of Gardner and five surrounding towns, has a population of 60,000 people , a median income below the state average and an unemployment rate above the state average. The community has been affected by the loss of the furniture industry over the past few decades, and by the current economic downturn. Mental Health and Substance Abuse are significant challenges for many residents of the area. The Hospital is the largest employer in the area, with around 1,000 employees. The community is largely white, non hispanic, but has a growing hispanic population. Gardner is one of three cities in the region the others are Fitchburg and Leominster which frequently collaborates for the betterment of the region. Heywood Hospital collaborates with the competing hospital in the Fitchburg Leominster area, HealthAlliance, on the community health improvement activities.
SchH_P06_S00_L05	Schedule H, Part VI, Line 5	The Greater Gardner area, comprised of the City of Gardner and five surrounding towns, has a population of 60,000 people , a median income below the state average and an unemployment rate above the state average. The community has been affected by the loss of the furniture industry over the past few decades, and by the current economic downturn. Mental Health and Substance abuse are significant challenges for many residents of the area. The Hospital is the largest employer in the area, with around 1,000 employees. The community is largely white, non Hispanic, but has a growing Hispanic population. Gardner is one of three cities in the region the others are Fitchburg and Leominster which frequently collaborates for the betterment of the region. Heywood Hospital collaborates with the competing hospital in the Fitchburg Leominster area, HealthAlliance, on the community health improvement activities.
SchH_P06_S00_L06	Schedule H, Part VI, Line 6	Heywood Hospital works closely with the community to promote health in areas identified by the 2011 Community Health Needs Assessment (CHNA) through a variety of means. The hospital works with area school systems to address childhood obesity and onset of adult diabetes through nutrition/fitness programs targeting young students K-2, in order to help develop healthy habits which may result in a reduction of chronic illness and obesity as indicated in the 2011 CHNA. Financial counselors help uninsured populations, ncluding those recently unemployed and those experiencing financial hardship to enroll in appropriate programs to ensure healthcare coverage, an identified barrier to obtaining health care, as indicated in the 2011 CHNA. Community programs targeting nutrition and fitness are offered free and at reduced rates focusing on nutrition, healthy cooking and consistent exercise, focusing on the reduction of chronic disease including diabetes and cardiovascular disease in adults as indicated in the 2011 CHNA. Operation of a school-based health center which enrolls an average of 79% of all students at the school, providing nearly 1000 behavioral health visits annually, addressing higher than normal suicide and substance abuse rate, as indicated in the 2011 CHNA, The Suicide Prevention Taskforce, which partners with approximately 100 area social service agencies, provides educational tools and raises community and legislative awareness of significant area mental health and substance abuse issues, resulting in a Gardner suicide rate approximately twice the state average. Continue to work with the Minority Coalition, Joint Coalition of Health and other community agencies to raise awareness and skills among health providers to reduce disparities and strive for health equity.

Schedule H (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number
04-2103581

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance
(1) Montachusett Home Care Corp 680 Mechanic St Leominster,MA01453	04-2551175	501(c)(3)	76,800	0	N/A	N/A	The funds will be used by the Community Health Network of North Central MA as support and collaborative community health assessment work.
(2) Montachusett Opportunity Council 133 Pritchard St Fitchburg,MA01420	04-2401111	501(c)(3)	43,200	0	N/A	N/A	The funds will be used by Joint Coalition on Health as support of operations, to provide Community Health grants in conjunction with identified priorities of the JCOH service area, and to support the Gardner Area InterAgency Team.

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

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

Cat. No. 50055P

Schedule I (Form 990) 2012

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance

Part IV

Supplemental Information.

Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Identifier	Return Reference	Explanation
SchI_P01_S00_L02	Schedule I, Part I, Line 2	Montachusett Home Care Corp and the Community Health Network of MA file an annual report with the Office of Healthy Communities that contains a summary of how the funds are allocated.

Schedule I (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- 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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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? ................

Yes

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? ...........................

Yes

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)Winfield BrownPresident /CEO	(i) (ii)	383,569 0	133,569 0	9,000 0	19,261 0	31,438 0	576,837 0	0 0
(2)Robert CrosbySr VP of Finance / CFO	(i) (ii)	225,978 0	41,469 0	1,158 0	21,255 0	27,703 0	317,563 0	0 0
(3)Michael GrimmerVP of Support Services	(i) (ii)	190,066 0	25,621 0	12,500 0	17,000 0	26,961 0	272,148 0	0 0
(4)Tina SantosVP of Patient Care Srvcs/CNO	(i) (ii)	195,816 0	25,233 0	176 0	17,780 0	11,761 0	250,766 0	0 0
(5)Thomas CadyVP of Human Resources	(i) (ii)	153,094 0	21,352 0	901 0	20,283 0	25,643 0	221,273 0	0 0
(6)Rose KavalchuckVP of Quality Services	(i) (ii)	177,031 0	23,938 0	971 0	20,675 0	21,993 0	244,608 0	0 0
(7)David GillStaff Phychologist	(i) (ii)	253,233 0	0 0	2,591 0	5,326 0	23,017 0	284,167 0	0 0
(8)Faith PinkertonEmergency Physician	(i) (ii)	182,352 0	10,000 0	208 0	0 0	18,332 0	210,892 0	0 0
(9)Sheila EbertOncology Physician	(i) (ii)	195,570 0	0 0	499 0	3,901 0	10,752 0	210,722 0	0 0
(10)Ellen RayEmergency Physician	(i) (ii)	171,937 0	10,000 0	324 0	0 0	18,130 0	200,391 0	0 0
(11)Alice VaineOR Nurse Practitioner	(i) (ii)	174,279 0	0 0	499 0	3,601 0	10,335 0	188,714 0	0 0
(12)James MullenSr VP of Patient Care / CNO (termed 5/27/11)	(i) (ii)	0 0	0 0	101,328 0	0 0	7,819 0	109,147 0	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
SchJ_P01_S00_L01a	Schedule J, Part I, Line 1a	Housing allowance provided to Michael Grimmer, VP of Support Services, per contract. Paid through his weekly salary.
SchJ_P01_S00_L01b	Schedule J, Part I, Line 1b	Housing allowance was part of his employment contract.
SchJ_P01_S00_L04	Schedule J, Part I, Line 4	James Mullen, former CNO received severance payments in CY 2012. Total severance paid in 2012 was $101,328.
SchJ_P01_S00_L06	Schedule J, Part I, Line 6	Heywood Hospital accrues 15% of the executive team's salary for a bonus payment that is based on the financial condition of the hospital and other quality based criteria.

Schedule J (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number
04-2103581

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	MA Health and Educational Facilitiy Authority	04-2456011	57586EGT2	03-31-2009	17,785,000	Funds used for new Watkins Bldg project		X		X		X
B	MA Health and Educational Facility Authority	04-2456011	57586C7E9	06-19-2008	6,715,000	Refunding and new Watkins Bldg project		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .	0		0
2 Amount of bonds legally defeased . . . . . . . . . . .	0		0
3 Total proceeds of issue . . . . . . . . . . . . . .	66,235		19,154
4 Gross proceeds in reserve funds . . . . . . . . . . . .	0		0
5 Capitalized interest from proceeds . . . . . . . . . . .	0		0
6 Proceeds in refunding escrows . . . . . . . . . . . .	0		0
7 Issuance costs from proceeds . . . . . . . . . . . .	281,690		329,467
8 Credit enhancement from proceeds . . . . . . . . . . .	0		0
9 Working capital expenditures from proceeds . . . . . . . . .	0		3,597,891
10 Capital expenditures from proceeds . . . . . . . . . . .	17,569,545		2,806,796
11 Other spent proceeds . . . . . . . . . . . . . .	0		0
12 Other unspent proceeds . . . . . . . . . . . . . .	0		0
13 Year of substantial completion . . . . . . . . . . . .	2010		2008
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .		X	X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X		X
16 Has the final allocation of proceeds been made? . . . . . . . .	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .		X		X

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

Cat. No. 50193E

Schedule K (Form 990) 2012

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .		X		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .		X		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . .	0%		0%		%		%
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . .	0%		0%		%		%
6 Total of lines 4 and 5 . . . . . . . . . . . . . . .	0%		0%		%		%
7 Does the bond issue meet the private security or payment test? . . . . .	X		X
8a Has there been a sale or disposition of any of the bond financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .		X		X
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of.	%		%		%		%
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2?	X		X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T? . . . . .		X		X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .		X		X
b Exception to rebate? . . . . . . . .		X		X
c No rebate due? . . . . . . . . . .	X		X
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . .	X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?	X		X
b Name of provider . . . . . . . . .	TD Bank		Piper Jaffrey
c Term of hedge . . . . . . . . . .	18.7		18.7
d Was the hedge superintegrated? . . . . . .		X		X
e Was a hedge terminated? . . . . . . .		X		X

Schedule K (Form 990) 2012

Page 3

Part IV

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .		X		X
b Name of provider . . . . . . . . .
c Term of GIC . . . . . . . . . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .	X		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X		X

Part VI

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

Identifier	Return Reference	Explanation
SchK_P04_S00_L02c	Schedule K, Part IV, Line 2c	Rebate computation was performed October 8, 2013.

Schedule K (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- 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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

Identifier	Return Reference	Explanation
F990_P03_S00_L03	Form 990, Part III, Line 3	In August 2013, Heywood Hospital closed its Transitional Care Unit and reduced the number of beds in its Pediatric unit.
F990_P06_S0B_L11b	Form 990, Part VI, Section B, Line 11b	The Senior Accountant at Heywood Hospital prepares the form 900 and provides to the controller for review. The form is then sent to the CFO for final review. Once review, 990 is placed on Hospital Cyber Board for Board of Trustee review. The 990 is then approved by the board and submitted by the accounting department.
F990_P06_S0B_L12c	Form 990, Part VI, Section B, Line 12c	Annually, a Conflict of Interest form is sent out to the managers, trustees and employees with broad discretionary authority. These forms are required to be signed and are monitored by the Corporate Compliance office for completion.
F990_P06_S0B_L15	Form 990, Part VI, Section B, Line 15	The CEO and Officer's salary is determined by the market data provided to the search committee by a search firm, an independent third party. This data supplemented the first hand knowledge of other comparable facilities in New England and that search firm had based on prior searches. Sources such as the Massachusetts Hospital Salary Survey and intimate knowledge of the going salaries for senior executives in healthcare also played a major role in determining salaries
F990_P06_S0C_L19	Form 990, Part VI, Section C, Line 19	The organization makes the governing documents, conflict of interest policy and financial statements available to the public by providing completed copies to the Administrative Assistant, who provides copies upon request.
F990_P11_S00_L09	Form 990, Part XI, Line 9	The amount that makes up the other changes in net assets or fund balance is from discounts on pledge receivables and inter-corporate and inter-corporate transfers to related organizations, to support their operations.

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:	12000197
Software Version:	v1.00

- 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

HENRY HEYWOOD MEMORIAL HOSPITAL

Employer identification number

04-2103581

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) Heywood Affiliated Medical Group 242 Green Street Gardner,MA01440 04-3163589	employ physicians	MA	501(c)(3)	9	Heywood Healthcare		No
(2) Heywood Hospital Realty Corporation 242 Green Street Gardner,MA01440 04-3327447	property holding company	MA	501(c)(2)		Heywood Healthcare		No
(3) Athol Memorial Hospital 2033 Main Street Athol,MA01331 04-2126583	Hospital	MA	501(c)(3)	3	Heywood Healthcare		No
(4) Heywood Healthcare Inc 242 Green Street Gardner,MA01440 22-2720658	Parent Corp	MA	501(c)(3)	7	N/A		No
(5) Heywood Healthcare Charitable Foundation 242 Green Street Gardner,MA01440 22-2720562	Charitable Foundation	MA	501(c)(3)	7	Heywood Healthcare		No
(6) HHMH Aid Association 242 Green Street Gardner,MA01440 04-2198019	raise funds for the Hospital	MA	501(c)(3)	9	N/A		No
(7) Winchendon Health Foundation 87 Central Street Winchendon,MA01475 04-2113276	supporting organization	MA	501(c)(3)	PF	N/A		No
(8) Heywood Physician Hospital Organization 242 Green Street Gardner,MA01440 04-3153119	Managed care contracted physicians	MA	501(c)(3)	9	N/A		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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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

Yes

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

Yes

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

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

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

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

Yes

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

Yes

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

Yes

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) Heywood Hospital Realty Corporation	q	229,571	Actual Cost.

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:	12000197
Software Version:	v1.00

- TIN:

TY 2012 ReasonableCauseExplanation

Name:

HENRY HEYWOOD MEMORIAL HOSPITAL

EIN: 04-2103581

Software ID:12000197

Software Version:v1.00

Explanation:

Extension was granted.

1	Briefly describe the organization’s mission or most significant activities: To be our communities' trusted choice for exceptional patient-centered care.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	21
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	19
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	1,037
6	Total number of volunteers (estimate if necessary) .............	6	281
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	3,474,560	908,638
9	Program service revenue (Part VIII, line 2g) .........	100,862,323	107,379,169
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,034,227	495,533
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	967,815	1,341,743
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	106,338,925	110,125,083
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	118,567	120,000
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	52,430,754	55,829,163
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	12,925	6,744
b	Total fundraising expenses (Part IX, column (D), line 25) 220,956
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	49,513,662	51,288,346
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	102,075,908	107,244,253
19	Revenue less expenses. Subtract line 18 from line 12.......	4,263,017	2,880,830
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	91,777,100	95,467,985
21	Total liabilities (Part X, line 26).............	46,158,901	45,613,375
22	Net assets or fund balances. Subtract line 21 from line 20.....	45,618,199	49,854,610

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 101,233,786 including grants of $ 120,000 ) (Revenue $ 107,379,169 )
	Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health care needs of the under-served and collaborating with others to enhance quality and contain the growth of community health care costs. Details to this are published in "The Community Benefit Report of Heywood Hospital - Fiscal Year 2012" filed with the MA Attorney Generals Office.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ 0 including grants of $ 0 ) (Revenue $ 0 )
4e	Total program service expenses101,233,786

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	2,747,423	33,400	370,472

				(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		0
b	Membership dues....1b		0
c	Fundraising events....1c		55,350
d	Related organizations...1d		0
e	Government grants (contributions)1e		566,103

f	All other contributions, gifts, grants, and similar amounts not included above1f		287,185

g	Noncash contributions included in lines 1a-1f:$		0
h	Total. Add lines 1a-1f.......			908,638
			Business Code
2a	Ancillary O/P Service		621110	60,367,903	60,367,903	0	0
b	Ancillary I/P & Routine		621110	45,117,072	45,117,072	0	0
c	Contracted Services		900099	1,357,235	1,357,235	0	0
d	HMG Patient Revenue (Net)		621111	400,582	400,582	0	0
e	Lifeline		624120	54,033	54,033	0	0
f	All other program service revenue .			82,344	82,344	0	0
g	Total. Add lines 2a–2f........			107,379,169
3	Investment income (including dividends, interest, and other similar amounts).......			301,252	0	0	301,252
4	Income from investment of tax-exempt bond proceeds..			0	0	0	0
5	Royalties...........			0	0	0	0
		(i) Real	(ii) Personal
6a	Gross rents	178,929	0
b	Less: rental expenses	0	0
c	Rental income or (loss)	178,929	0
d	Net rental income or (loss).......			178,929	0	0	178,929
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	10,236,398	1,966
b	Less: cost or other basis and sales expenses	10,042,117	1,966
c	Gain or (loss)	194,281	0
d	Net gain or (loss)..........			194,281	0	0	194,281
8a	Gross income from fundraising events (not including $ 55,350 of contributions reported on line 1c). See Part IV, line 18 ..
	a		28,025
b	Less: direct expenses ...b		42,840
c	Net income or (loss) from fundraising events..			-14,815		0	-14,815
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	Meal Revenue		722310	685,913	0	0	685,913
b	Purchase Discounts		900099	175,857	0	0	175,857
c	Pharmacy Misc Revenue		900099	197,516	0	0	197,516
d	All other revenue ....			118,343	0	0	118,343
e	Total. Add lines 11a–11d ......			1,177,629
12	Total revenue. See Instructions......			110,125,083	107,379,169	0	1,837,276


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			2,438,924	1	4,168,080
2	Savings and temporary cash investments .........			0	2	0
3	Pledges and grants receivable, net ...........			2,398,884	3	2,264,477
4	Accounts receivable, net .............			10,258,616	4	12,802,618
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			72,338	7	171,515
8	Inventories for sale or use ..............			1,371,294	8	1,413,035
9	Prepaid expenses and deferred charges ..........			1,080,396	9	1,057,751
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	104,097,688
b	Less: accumulated depreciation .....	10b	51,408,268	54,706,913	10c	52,689,420
11	Investments—publicly traded securities ..........			17,190,937	11	18,185,573
12	Investments—other securities. See Part IV, line 11 .....			489,451	12	437,650
13	Investments—program-related. See Part IV, line 11 .....			129,347	13	134,526
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			1,640,000	15	2,143,340
16	Total assets. Add lines 1 through 15 (must equal line 34)......			91,777,100	16	95,467,985
17	Accounts payable and accrued expenses .........			13,297,762	17	14,314,680
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	258,468
20	Tax-exempt bond liabilities .............			26,312,766	20	24,679,160
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			729,023	23	294,782
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			5,819,350	25	6,066,285
26	Total liabilities. Add lines 17 through 25.........			46,158,901	26	45,613,375
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			40,274,861	27	44,503,392
28	Temporarily restricted net assets ...........			4,337,245	28	4,345,057
29	Permanently restricted net assets ...........			1,006,093	29	1,006,161
	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 ...........			45,618,199	33	49,854,610
34	Total liabilities and net assets/fund balances ........			91,777,100	34	95,467,985