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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
KENNESTONE HOSPITAL INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
805 Sandy Plains Road
Suite
Room/suite
City or town, state or country, and ZIP + 4
Marietta, GA300666340
D Employer identification number

58-2032904
E Telephone number

G Gross receipts $ 791,485,576
F Name and address of principal officer:
REYNOLD J JENNINGS
805 SANDY PLAINS ROAD
MARIETTA,GA30066
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.wellstar.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1993
M State of legal domicile: GA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: To provide world-class charitable healthcare to the community.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 14
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 5,336
6 Total number of volunteers (estimate if necessary) ............. 6 410
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 586,179
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b  
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 0
9 Program service revenue (Part VIII, line 2g) ......... 725,011,981 772,656,090
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 32,955 -468,013
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 14,573,763 18,814,851
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 739,618,699 791,002,928
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 2,150 890
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) 272,571,926 289,902,566
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 350,085,746 377,828,313
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 622,659,822 667,731,769
19 Revenue less expenses. Subtract line 18 from line 12....... 116,958,877 123,271,159
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 529,669,305 571,422,413
21 Total liabilities (Part X, line 26)............. 292,181,675 279,660,854
22 Net assets or fund balances. Subtract line 21 from line 20..... 237,487,630 291,761,559
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: TO CREATE AND DELIVER HIGH QUALITY HOSPITAL, PHYSICIAN AND OTHER HEALTHCARE RELATED SERVICES THAT IMPROVE THE HEALTH AND WELL-BEING OF THE INDIVIDUALS AND COMMUNITIES WE SERVE.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 593,708,685 including grants of $ 890 ) (Revenue $ 772,656,090 )
As discussed herein, Kennestone Hospital, Inc (an affiliate of Wellstar Health System, Inc.) operates as a charitable organization consistent with the requirements of Internal Revenue Code Section 501(c)(3) and the "community benefit standard" of IRS Revenue Ruling 69-545. In this regard, the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualified physicians in the area, consistent with the size and nature of the facility; one of the hospitals operates a full-time emergency room open to all regardless of the ability to pay; the hospital provides care to needy members of its community consistent with its charity care policy regardless of their ability to pay for these services and admits as patients those able to pay for care, either themselves or through third-party payers such as private health insurance or government programs such as Medicare and Medicaid; and the hospital's excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement in patient care, community benefit activities, and charity care. Kennestone Hospital, Inc. consists of two hospitals, Wellstar Kennestone and Wellstar Windy Hill. These hospitals combined to invest approximately $101.4 million in capital expenditures for the fiscal period. Wellstar Kennestone Hospital is a general acute hospital which provides a full range of inpatient and outpatient services for the overall health of the community. The hospital is located in Marietta, Georgia. The original hospital was constructed in 1950. The present main building was constructed in 1975. Kennestone is licensed to operate 633 beds and is currently staffed to operate 588 beds. Wellstar Windy Hill Hospital is located in the unincorporated area of Cobb County in northwest metropolitan Atlanta. It is an acute care hospital concentrating at the present time on long term care inpatient and outpatient services. The original structure was built in 1973 and renovated in 1987. The beds at Windy Hill serve medically complex patients whose average stay is approximately 30 days. Kennestone Hospital, Inc. affiliated with Northwest Georgia Health System in 1993. In 1994 Northwest Georgia Health System helped form the Promina Health System and changed its name to Promina Northwest Health System. In 1998 Promina Northwest changed its name to Wellstar Health System. Wellstar became totally independent of Promina in 2000. Kennestone Hospital, Inc. was organized in 1993 and is subordinate to, and subject to the authority of, Wellstar Health System and its governing board. Kennestone offers most major inpatient clinical services, a variety of outpatient services, women's services and open heart surgery. It is one of the largest hospitals in the state of Georgia. Kennestone is also home to a variety of state-of-the-art procedures and equipment not offered elsewhere in the larger Atlanta metro service area. The hospital has also opened several satellite outpatient imaging centers to provide easier access to our patient population. One additional service offered on the campus of Kennestone is called Atherton Place. This residential facility provides independent housing as well as assisted living to residents needing these services--especially the elderly. Kennestone also now operates a residential hospice facility at Kennesaw Mountain near the Kennestone campus. Windy Hill has transitioned its focus to long-term inpatient and outpatient services. These services include a concentration in geriatrics, rehabilitation, orthopedics and senior care. An additional service offered at Windy Hill Hospital includes a women's imaging department. The following stats constitute the overall program services for the period ended June 30, 2013: Kennestone Hospital Total Adult Discharges-35,895 Med/Surg Short StayCases-1,073 Newborn Discharges-5,418 Emergency Room Visits-122,883 Total surgery cases-22,736 Non ED OP Radiology Procedures-151,685 Cath Lab Procedures-6,754 GI Lab Procedures-3,509 Radiology Oncology procedures-16,145 Total FTEs (Paid)-3,880 Windy Hill Hospital Total Adult Discharges-379 Total Surgery Cases-2,200 Non ED OP Radiology Procedures-10,205 GI Lab Procedures-312 Sleep Lab Procedures-1,928 Total FTEs (Paid)-248 Community Benefit Reporting Community Outreach and Health Improvements-$1,566,595 Unreimbursed Charity Care (at cost)-$44,751,019 (based on charges of $159.5 million) Health professions education-$221,678 Medicaid Shortfalls(at cost)-$5,664,727 Total community benefit expense for the two hospitals was $52,204,019. Community Benefits Detail Kennestone and Windy Hill, affiliates of Wellstar Health System, participate in many community and educational programs for the overall health and benefit of the area that it serves. The following are examples of programs or services that are provided by Kennestone Hospital, Inc. for the charitable benefit of the community: Community Health/Education Wellstar's Marketing and Public Relations department provides free brochures on a variety of health-related topics such as blood pressure, diabetes, cholesterol, osteoporosis, and nutrition. Kennestone Hospital specifically offers the community the space and instructors for many support groups and educational opportunities--some free of charge and others at a nominal fee (examples of the offerings are women's health, palliative care, birthing classes, etc.) Kennestone and Windy Hill also offer free and/or low cost screenings for health issues such as blood pressure, cholesterol, flu shots, and others. System-wide for the reporting period over 200,000 area residents were seen at either the screenings or health fairs. School Health Program--This program is operated in conjunction with area school systems and seeks to teach school-aged children about health and safety topics such as dental health, water safety, seat belt safety and others. Safe Kids-Cobb/Cherokee Wellstar and the Cobb Public Health Department sponsor safety education events on an annual basis to the community, specifically the Cobb County area. The safety initiatives are centered around car seat checks, bike helmets, water safety and other preventive initiatives. The mission is to reduce the number of accidental injuries for children ages 14 and under. The SafeKids Cobb program provided 1,700 car seat checks with a number of car seats distributed to families in need. The Partner-in-Education program provides health-related supplies and support to area elementary and middle schools. Through the "Partners in Ministry" program, the Pastoral Care Department leads a partnership between the health system and local area congregations to link between the spiritual and clinical community needs. Sponsorships and Community Activities As part of the October Breast Cancer Awareness Month WellStar and the WellStar Cancer Network has partnered with a local television station to sponsor "Buddy Check 11", an 11Alive program designed to encourage breast self exam. The participants choose a buddy and subsequently remind their buddy to perform a monthly self exam. The program is now in its third year. WellStar Health System was the only Atlanta health system honored with a "Celebrating Our Heritage" Award by Renovacion Conyugal, a nonprofit organization dedicated to strengthening, supporting and empowering Latino youth. WellStar has a 10-year partnership with the organization to provide financial and facility support. Team members from the Acworth Health Park participated in the building of a Habitat for Humanity home in Acworth, Georgia. The home was built on property donated to Northwest Atlanta Habitat by a retired Army Lt Col Ashley Ivey before his passing. He had stipulated that a home be built and presented to a disabled veteran. Accomplishments and Recognition Kennestone and Windy Hill Hospitals are accredited by the Joint Commission. Wellstar was granted accreditation by the Intersocietal Commission for the Accreditation of Echocardiography Labs after rigorous testing and quality outcomes for diagnosis of heart disease. All five Wellstar hospital labs earned "Accreditation with Distinction" from the College of American Pathologists (CAP), recognized as one of the most stringent in laboratory quality assurance. Wellstar's labs are part of the 6,000 CAP-accredited laboratories nationwide. Wellstar Sleep Disorders Center at Windy Hill Hospital offers world class care as one of the 10 largest sleep centers nationwide. The center consists of 12 rooms with more board-certified sleep specialists on staff than any sleep center in the southeast US. The program is accredited by the American Academy of Sleep Medicine. As affiliates of Wellstar Health System, Kennestone and Windy Hill are part of a system that is ranked in the Top 100 in the nation according to Verispan's annual listing of the Top 100 In
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet593,708,685
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? ...
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part II........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H.... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see list of attachments
20b
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II...
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........ Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV..................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV... Click to see attachment
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
5,336
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
No
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
No
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
No
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
No
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
18
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
14
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
GA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletJAMES M SWARTZ805 SANDY PLAINS ROADMariettaGA300666340 (770) 792-5023
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) AVRIL P BECKFORD MD........................................................................
TRUSTEE
 2.0
.......................48.0 		X           0 433,483 22,804
(2) RANDALL BENTLEY JR........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 19,122 0
(3) OTIS BRUMBY III........................................................................
TRUSTEE
 1.0
.......................7.0 		X           0 4,120 0
(4) SHAN COOPER........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 468 0
(5) ROBERT N CROSS MD........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 5,166 0
(6) TE RUSTY DURHAM........................................................................
TRUSTEE
 1.0
.......................14.0 		X           0 37,201 1,410
(7) THOMAS GEARHARD MD........................................................................
TRUSTEE
 2.0
.......................48.0 		X           0 533,324 70,106
(8) DAVID HAFNER MD........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 21,314 0
(9) T FITZ JOHNSON........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 10,551 0
(10) CHARLES J JONES........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 15,887 0
(11) JANIE MADDOX........................................................................
TRUSTEE-CHAIR
 1.0
.......................5.0 		X           0 16,829 0
(12) GARY A MILLER........................................................................
TRUSTEE- VICE CHAIR
 1.0
.......................5.0 		X           0 3,140 0
(13) STEVEN W OWEIDA MD........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 19,041 0
(14) TOM PHILLIPS........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 2,599 0
(15) WALTER G ROBINSON........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 9,684 0
(16) FRANK ROS........................................................................
TRUSTEE
 1.0
.......................5.0 		X           0 927 0
(17) W ALLEN SEPARK........................................................................
TRUSTEE
 1.0
.......................7.0 		X           0 9,168 0
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) JEFFERY THARP MD........................................................................
TRUSTEE
 2.0
.......................48.0 		X           0 609,909 65,330
(19) VALERY A AKOPOV MD........................................................................
VP & CHIEF HOSPITALISTS
 2.0
.......................48.0 		    X       0 369,292 30,115
(20) DAVID W ANDERSON........................................................................
EXEC VP HR/OL/CCO
 2.0
.......................48.0 		    X       0 1,009,113 77,916
(21) NICOLE V ASHE........................................................................
VP FINANCE & CFO WMG
 2.0
.......................48.0 		    X       0 229,204 34,796
(22) BARBARA G BALLARD........................................................................
VP HOMECARE & HOSPICE
 2.0
.......................48.0 		    X       0 269,237 41,328
(23) BETTY ANN BRAKOVICH........................................................................
VP/CNO PATIENT CARE SRVCS WH
 50.0
.......................0.0 		    X       187,026 0 21,552
(24) JOSEPH L BRYWCZYNSKI........................................................................
SR VP HEALTH PARKS DEVELOPMENT
 2.0
.......................48.0 		    X       0 321,402 48,393
(25) A JAMES BUDZINSKI........................................................................
EXEC VP and CFO
 2.0
.......................50.0 		    X       0 811,452 72,350
(26) DONALD CAMPBELL MD........................................................................
SR VP PHYS EDUC & STUDENT AFF
 2.0
.......................48.0 		    X       0 441,997 54,362
(27) LAURA CARAMANICA........................................................................
VP/CNO PATIENT CARE SRV KENN
 50.0
.......................0.0 		    X       300,131 0 43,634
(28) LEE RANDOLPH COOK........................................................................
VP MEDICINE & BEHAVIORAL HLTH
 2.0
.......................48.0 		    X       0 378,589 54,807
(29) BARBARA B COREY........................................................................
SR VP MANAGED CARE
 2.0
.......................48.0 		    X       0 437,376 49,536
(30) BRUCE A DEAN........................................................................
VP REAL ESTATE & DEP GEN COUN
 2.0
.......................48.0 		    X       0 289,509 48,725
(31) SARATH DEGALA........................................................................
VP REVENUE CYCLE MGMT
 2.0
.......................48.0 		    X       0 124,354 10,914
(32) MARCIA DELK-PAYNE MD........................................................................
SR VP MED AFFAIRS & CQO
 2.0
.......................48.0 		    X       0 537,139 47,333
(33) CAROL S EDWARDS........................................................................
VP CARDIAC SERVICES
 2.0
.......................48.0 		    X       0 172,501 27,149
(34) CLARENCE HARLEE EVINS JR........................................................................
VP REVENUE CYCLE
 2.0
.......................48.0 		    X       0 198,801 22,150
(35) MICHAEL L GRAUE........................................................................
EXEC VP & COO
 2.0
.......................48.0 		    X       0 704,412 82,434
(36) MARTIN L GUTKIN........................................................................
VP FINANCE & HOSPITAL CFO
 50.0
.......................0.0 		    X       239,282 0 17,552
(37) ELIZABETH A HOFFMANN........................................................................
VP BUDGET & ANALYSIS
 2.0
.......................48.0 		    X       0 242,637 16,592
(38) ROBERT D JANSEN MD........................................................................
EXEC VP & PRES WMG
 2.0
.......................48.0 		    X       0 651,191 66,994
(39) REYNOLD J JENNINGS........................................................................
PRESIDENT & CEO
 2.0
.......................50.0 		    X       0 1,571,726 64,901
(40) CHRISTOPHER M KANE........................................................................
SR VP STRATEGIC PLAN & BUS DEV
 2.0
.......................48.0 		    X       0 478,493 45,700
(41) BETH KOST........................................................................
VP COMPLIANCE & CHIEF PRIVACY
 2.0
.......................48.0 		    X       0 279,215 24,478
(42) KENNETH C KUNZE MD........................................................................
SR VP & CHIEF MEDICAL OFFICER
 2.0
.......................48.0 		    X       0 1,125,716 76,665
(43) ELLEN LANGFORD........................................................................
VP & COO WELLSTAR PHYS GRP
 2.0
.......................48.0 		    X       0 312,399 39,496
(44) LOUIS W LITTLE........................................................................
SR VP POST ACUTE & HOSP PRES
 40.0
.......................10.0 		    X       356,956 0 40,332
(45) ROBERT M LUBITZ MD........................................................................
VP MEDICAL AFFAIRS KH
 50.0
.......................0.0 		    X       76,731 0 3,673
(46) ROBERT MANDLER........................................................................
VP DIAGNOSTIC OUTREACH
 2.0
.......................48.0 		    X       0 273,344 47,743
(47) CAROL B MAXWELL........................................................................
VP TALENT ACQUISTION
 2.0
.......................48.0 		    X       0 239,468 20,708
(48) PATRICIA A MAYNE........................................................................
VP EMERGENCY SERVICES
 50.0
.......................0.0 		    X       202,664 0 36,387
(49) KIMBERLY W MENEFEE........................................................................
SR VP MARKETING & GOV AFFAIRS
 2.0
.......................48.0 		    X       0 396,281 53,325
(50) JONATHAN B MORRIS MD........................................................................
SR VP & CIO
 2.0
.......................48.0 		    X       0 427,588 43,417
(51) BRADFORD B NEWTON........................................................................
VP INFO TECHNOLOGY ADMIN
 2.0
.......................48.0 		    X       0 57,854 3,589
(52) LEO E REICHERT........................................................................
EXEC VP & GENERAL COUNSEL
 2.0
.......................48.0 		    X       0 611,562 48,028
(53) MICHELLE M ROBINSON........................................................................
VP MARKETING, PR INTERNAL COMM
 2.0
.......................48.0 		    X       0 201,213 28,691
(54) DEBORAH ROEGGE DE VITA........................................................................
VP WOMEN & NEWBORN
 2.0
.......................48.0 		    X       0 266,969 15,303
(55) CANDICE L SAUNDERS........................................................................
EXEC VP & HOSP PRESIDENT
 48.0
.......................2.0 		    X       554,816 0 60,784
(56) CHRISTOPHER B SCULLEN........................................................................
VP PULMONARY OPERATIONS
 2.0
.......................48.0 		    X       0 200,049 10,678
(57) JEFFERY D STANLEY........................................................................
VP PHARMACY & SYS COORDINATOR
 2.0
.......................48.0 		    X       0 60,671 5,109
(58) MICHAEL R STREETMAN........................................................................
VP INFO TECHNOLOGY OPERATIONS
 2.0
.......................48.0 		    X       0 76,243 6,493
(59) JAMES M SWARTZ........................................................................
VP ACCOUNTING
 2.0
.......................48.0 		    X       0 226,256 30,541
(60) MARY L TAVERNARO........................................................................
VP HUMAN RESOURCES OPERATIONs
 2.0
.......................48.0 		    X       0 243,135 24,803
(61) ADAM C THOMPSON........................................................................
VP SURGERY
 2.0
.......................48.0 		    X       0 191,828 22,669
(62) JERRY TILLERY........................................................................
VP OPERATIONS KENNESTONE
 50.0
.......................0.0 		    X       205,990 0 18,045
(63) AMANDA ELIZ T TRASK........................................................................
VP PROF & SUPPORT SRVCS KH
 50.0
.......................0.0 		    X       184,767 0 32,597
(64) ANOTHONY M TRUPIANO........................................................................
SR VP SUPPLY CHAIN
 2.0
.......................48.0 		    X       0 327,328 35,439
(65) MARY L WESLEY........................................................................
SR VP NURSING SERVICES CNE
 2.0
.......................48.0 		    X       0 383,494 37,702
(66) ROBIN WILSON MD........................................................................
SR VP CHIEF INNOVATION OFFICER
 2.0
.......................48.0 		    X       0 462,855 43,631
(67) DANIEL J WOODS........................................................................
SR VP & COO KENN HOSPITAL
 50.0
.......................0.0 		    X       299,410 0 26,380
(68) CHESTER A ZBOROWSKI........................................................................
VP HEALTH PARK OPERATIONS
 2.0
.......................48.0 		    X       0 137,711 15,717
(69) KRISTYN GREIFER MD........................................................................
VP POPULATION HLTH MGMT
 2.0
.......................48.0 		    X       0 0 0
(70) PETER JUNGBLUT MD........................................................................
SR VP & MEDICAL DIRECTOR
 2.0
.......................48.0 		    X       0 0 0
(71) RICK SEIGEL........................................................................
VP CARDIO SRVC & MED ADMIN
 2.0
.......................48.0 		    X       0 0 0
(72) JYOTSNA R VANAPALLI........................................................................
RADIATION ONCOLOGY PHYSICIST
 50.0
.......................0.0 		        X   170,876 0 21,070
(73) MARK G VAN EWYK........................................................................
PHARMACIST SPECIALTY
 50.0
.......................0.0 		        X   168,535 0 16,196
(74) ROBERT J DeCOUX........................................................................
AVP HUMAN RESOURCES
 50.0
.......................0.0 		        X   163,878 0 26,571
(75) HEATHER S ROCHFORD........................................................................
MANAGER PHARMACY
 50.0
.......................0.0 		        X   164,331 0 21,162
(76) DONNA H THOMAS........................................................................
AVP QUALITY SRV & PATIENT SAFE
 50.0
.......................0.0 		        X   167,622 0 7,423
(77) CHARLES 'PETE WOOD........................................................................
TRUSTEE
 0.0
.......................0.0 		          X 0 13,091 0
(78) RICHARD T LOPES MD........................................................................
FORMER SR VP & PRES WMG
 0.0
.......................0.0 		          X 0 480,426 19,938
(79) GREGORY L SIMONE........................................................................
FORMER PRES & CEO
 0.0
.......................0.0 		          X 0 226,763 23,597
(80) BONNIE L WILSON........................................................................
FORMER EXEC VP & GEN COUNSEL
 0.0
.......................0.0 		          X 0 227,237 13,210
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 3,443,015 18,439,054 2,140,473
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet165
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Brasfield Gorrie, 1990 Vaughn Rd NW Suite 100KENNESAWGA30144 General Contractor 39,917,793
CDH Partners, 675 Tower RoadMARIETTAGA30060 General Contractor 2,821,887
Cork-Howard Construction Inc, 2121 New Market Pkwy Suite 118MARIETTAGA30067 General Contractor 2,505,234
Inglett and Stubbs LLC, PO Box 932506ATLANTAGA311932506 General Contractor 2,343,913
Quest Diagnostics, PO Box 740736ATLANTAGA303740736 Lab Services 1,709,380
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet50
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 0
Program Service Revenue Business Code
2a PATIENT REVENUE 621990 766,791,529 766,791,529    
b MEDICAL RECORDS 621990 744 744    
c INDEPENDENT & ASSISTED LIVING REVENUE 623000 5,750,666 5,750,666    
d PATIENT EDUCATION 621990 113,151 113,151    
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 772,656,090
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 0      
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 1,406,644  
b Less: rental expenses    
c Rental income or (loss) 1,406,644 0
d Net rental income or (loss).......MediumBullet 1,406,644     1,406,644
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   14,635
b Less: cost or other basis and sales expenses   482,648
c Gain or (loss)   -468,013
d Net gain or (loss)..........MediumBullet -468,013     -468,013
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a PHARMACY/RETAIL PHARMACY 446199 9,144,667   586,179 8,558,488
b LAB OUTREACH   588,357     588,357
c CAFETERIA   4,612,314     4,612,314
d All other revenue .... 3,062,869     3,062,869
e Total. Add lines 11a–11d ...... MediumBullet 17,408,207
12 Total revenue. See Instructions......MediumBullet 791,002,928 772,656,090 586,179 17,760,659
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 890 890
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 2,908,711 2,618,955 289,756  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 230,261,062 208,002,543 22,258,519  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 18,219,674 16,452,635 1,767,039  
9 Other employee benefits ....... 21,606,326 19,513,937 2,092,389  
10 Payroll taxes ........... 16,906,793 15,273,300 1,633,493  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 24,744   24,744  
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 27,588,819 26,988,228 600,591  
12 Advertising and promotion .... 405,459 110,259 295,200  
13 Office expenses ....... 27,143,362 25,755,703 1,387,659  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 11,899,810 5,022,483 6,877,327  
17 Travel ............ 261,816 221,172 40,644  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 292,779 231,666 61,113  
20 Interest ........... 39,751   39,751  
21 Payments to affiliates ....... 124,548,708 112,556,127 11,992,581  
22 Depreciation, depletion, and amortization ..... 33,546,479 17,370,743 16,175,736  
23 Insurance .............. 5,743,140   5,743,140  
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 REPAIRS & MAINTENANCE 11,705,327 9,109,330 2,595,997  
b MEDICAL SUPPLIES 134,483,225 134,422,111 61,114  
c OTHER OPERATING EXPENSES 144,894 58,603 86,291  
d
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 667,731,769 593,708,685 74,023,084 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 20,200 1 21,975
2 Savings and temporary cash investments ......... 4,146,714 2 -17,973
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 121,621,833 4 147,987,765
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 ............. 0 7 0
8 Inventories for sale or use .............. 14,584,035 8 13,895,896
9 Prepaid expenses and deferred charges .......... 4,743,978 9 6,697,514
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 691,829,446
b Less: accumulated depreciation ..... 10b 297,515,503 376,326,779 10c 394,313,943
11 Investments—publicly traded securities .......... 0 11 0
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ............... 1,280,943 14 1,280,943
15 Other assets. See Part IV, line 11 ........... 6,944,823 15 7,242,350
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 529,669,305 16 571,422,413
Liabilities 17 Accounts payable and accrued expenses ......... 51,064,914 17 32,046,308
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 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 .. 67,814 23 18,178
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.................... 241,048,947 25 247,596,368
26 Total liabilities. Add lines 17 through 25......... 292,181,675 26 279,660,854
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 237,487,630 27 291,761,559
28 Temporarily restricted net assets ........... 0 28 0
29 Permanently restricted net assets ........... 0 29 0
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 237,487,630 33 291,761,559
34 Total liabilities and net assets/fund balances ........ 529,669,305 34 571,422,413
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
791,002,928
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
667,731,769
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
123,271,159
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
237,487,630
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-68,997,230
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
291,761,559
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
SCHEDULE A
(Form 990 or 990EZ)

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

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
 
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? (vii) Amount of monetary support
Yes No Yes No Yes No
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
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) right arrow (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) right arrow (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).            
12
12
 
13
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
14
14
 
15
15
 
16a
b
17a
b
18
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
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) right arrow (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) right arrow (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.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
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.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
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):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part 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 .................   44,606,550 44,606,550
b Buildings ................   352,824,098 127,503,366 225,320,732
c Leasehold improvements ............   15,567,618 4,483,152 11,084,466
d Equipment ................   266,003,266 165,528,985 100,474,281
e Other .................   12,827,914   12,827,914
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 394,313,943
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








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








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








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
ASSET RETIREMENT OBLIGATION LT 1,076,104
TAX EXEMPT BOND LIAB-DUE TO WH 246,520,264







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 247,596,368
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

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
SCHEDULE D Part X Line 2 FIN 48 FOOTNOTE   The following footnote is related to the organization's application of FIN 48 (ASC 740). "Wellstar (including Douglas Hospital) and all but one of its affiliates have been recognized as exempt from Federal income tax under Internal Revenue Code Section 501 (a) as organizations described in Section 501 (c)(3) and, therefore, related income is generally not subject to Federal or state income taxes. Community Assurance Corporation is a controlled foreign corporation not subject to Federal tax. Wellstar applies FASB ASC 740, Income Taxes, which addresses accounting for uncertainties in income tax positions. It also provides guidance on when tax positions are recognized in an entity's financial statements and how the values of these positions are determined. There is no impact on Wellstar's combined financial statements as a result of the application of ASC 740."
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) 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:
3a
Yes
 
b
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: .........
3b
Yes
 
%
c
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.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

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

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    44,751,019   44,751,019 6.330 %
b Medicaid (from Worksheet 3,
column a) .... 		    64,994,047 59,329,319 5,664,728 0.800 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    109,745,066 59,329,319 50,415,747 7.130 %
Other Benefits
     1,566,595   1,566,595 0.220 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		    221,678   221,678 0.030 %
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		           
j Total. Other Benefits ..     1,788,273   1,788,273 0.250 %
k Total. Add lines 7d and 7j .     111,533,339 59,329,319 52,204,020 7.380 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
26,975,579
3
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. ......
3
3,870,962
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
229,172,493
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
265,018,225
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-35,845,732
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(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
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?2
Name, address, and primary website address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 KENNESTONE HOSPITAL
677 CHURCH STREET
MARIETTA,GA30060
www.wellstar.org 		X X         X   HEALTH PARK INPATIENT HOSPICE  
2 WINDY HILL HOSPITAL
2540 WINDY HILL ROAD
MARIETTA,GA30067
www.wellstar.org 		X X             LONG TERM ACUTE CARE  
Schedule H (Form 990) 2012
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)
KENNESTONE 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) 1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 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.................... 1 Yes  
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
3 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 .................... 3 Yes  
4 Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................ 4   No
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5 Yes  
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):
a
b
c
d
e
f
g
h
i
7 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 ........ 7   No
8a 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)? ........................... 8a   No
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b    
c 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
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: 125.%
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: 300.%
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
b
c
d
e
f
g
h
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
b
c
d
e
f
g
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
b
c
d
e
17 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 17   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 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?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
21 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? ............................ 21   No
If “Yes,” explain in Part VI.
22 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? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
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)
WINDY HILL 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 No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 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.................... 1 Yes  
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
3 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 .................... 3 Yes  
4 Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................ 4   No
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5    
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):
a
b
c
d
e
f
g
h
i
7 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 ........ 7   No
8a 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)? ........................... 8a   No
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b    
c 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
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: 125.%
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: 300.%
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
b
c
d
e
f
g
h
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
b
c
d
e
f
g
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
b
c
d
e
17 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 17   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 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?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
21 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? ............................ 21   No
If “Yes,” explain in Part VI.
22 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? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
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
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
Publication of Community Benefit Report Schedule H Part I Line 6a Kennestone Hospital, Inc.(consisting of Kennestone Hospital and Windy Hill Hospital) is an affiliate of Wellstar Health System, Inc. which on an annual basis issues a community benefit report. This report is subsequently distributed in and around the five county service area of the health system. It is also annually filed with Cobb County and the state of Georgia Department of Community Health. Additionally the information on community benefit is included in aggregate for Wellstar Health System, Inc. and affiliated hospitals as part of the Georgia Hospital Association's annual report.
Cost to Charge Ratio Schedule H Part I Line 7 For purposes of the IRS Form 990 Schedule H, Wellstar Health System and Affiliates (including Kennestone and Windy Hill Hospitals) have estimated the current year cost to charge ratio for each hospital as it is reported in the annual community benefit report and as it will be reported in the state's Annual Hospital Financial Survey.
Footnote on Bad Debt and Rationale for Community Benefit Schedule H Part III Line 4 The following footnote is detailed in the Wellstar Health System, Inc. and Affiliates Combined Financial Statements related to bad debt or uncollectible accounts: "During 2011, Wellstar adopted the provisions of FASB Accounting Standards Update (2011-07), Healthcare Entities (Topic 954). ASU 2011-07 requires the reclassification of the provision for uncollectible accounts associated with patient service revenue from an operating expense to a deduction from patient service revenue (net of contractual allowances and discounts)." " Wellstar recognizes patient service revenue associated with services provided to patients with third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for community financial aid, Wellstar recognizes revenue on the basis of its discounted rates for services provided. On the basis of historical experience, a significant portion of Wellstar's uninsured patients are unable or unwilling to pay for the services provided. Thus, Wellstar records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided." Subsequent to the end of the reporting period a propensity to pay review of patient accounts often results in prior year bad debt accounts which are deemed eligible for the organization's financial assistance policy. Those bad debt accounts are reclassified as charity and thus our rationale for including in community benefit.
Medicare Shortfalls Schedule H Part III Line 8 Kennestone and Windy Hill Hospitals are providers of inpatient and outpatient services to Medicare program beneficiaries at determined rates. Without the participation in the Medicare program these patients may not have had convenient access to those services. The Medicare shortfall on Part III Section B line 7 represents the uncompensated difference between the expected reimbursement and the Medicare charges for those services stated at cost. We determine a cost to charge ratio for Medicare patients as part of the annual filing of the Medicare cost report.
Collection Practices Sch H Part III Sec C Line 9b The policy written for collection practices that applies to all Wellstar Health System entities incorporates guidelines for personnel in the admissions and patient access areas to be trained in identifying patients that might qualify for financial assistance. It is also the policy of all Wellstar facilities to have at least one employee or contractor available at all times, especially in the hospitals with emergency rooms, who can provide assistance with the paperwork necessary to help patients who would qualify for governmental and other assistance programs.
Facility Descriptions-Kennestone and Windy Hill Schedule H Part V Kennestone Hospital ia a general acute care hospital providing a full range of services, is licensed to operate 633 beds, and is presently staffed to operate 588 beds. It is located on an approximately 41-acre campus in Marietta, Georgia and is housed within a complex of connected buildings containing a total square footage in excess of 1,112,000 square feet. The original hospital was constructed in 1950, major structural additions were made during the 1960s, 1975, 1998, and 2006. A new patient tower was completed in 2005 and greatly expanded the cardiac services capabilities of the hospital. Additionally a fourth patient tower recently opened to transition the hospital to private rooms from the current semi-private bed methodology. Kennestone Hospital provides medical, surgical, obstetrical, and rehabilitative inpatient care and outpatient care, including one of the busiest emergency rooms in the state of Georgia--recently designated a level II Trauma center for the service area. The hospital experiences over 300,000 annual visits in its adult and pediatric emergency room facilities. With its full range of inpatient and outpatient services the hospital has expanded programs in open-heart surgery and services including a Congestive Heart Failure Clinic which opened in February of 2012; ambulatory surgery; oncology services and surgery including cyberknife technology; radiology services and surgery; and women's and children's services. In May of 2012, Kennestone began performing Transcatheter Aortic Valve Replacement surgery (TAVR). Windy Hill Hospital, located in the unincorporated area of Cobb County in northwest metropolitan Atlanta, is an acute care hospital concentrating on long-term acute inpatient and outpatient services. It is licensed to operate 115 beds, is presently staffed to operate 55 beds, is located on an approximately 15-acre campus, and contains total square footage of approximately 100,000 square feet. A twelve bed sleep disorder center is located at Windy Hill. Windy Hill was originally constructed in 1973 and renovated in 1987. The main areas of focus for Windy Hill Hospital include long-term acute care, rehabilitation, orthopedics, and diagnostics. Windy Hill also offers a service in the treatment of sleep disorders.
Needs Assessment Schedule H Part VI Line 2 Wellstar Health System (and affiliates) is a key stakeholder in MAPP, Mobilizing for Action through Planning and Partnerships. MAPP, developed by the National Association of County and City Health Officials (NACCHO) in collaboration with the CDC, provides a structured guidance on creating and implementing a community-wide strategic planning process focused on improving the health and safety of our population. Through MAPP, a broad collection of community partners and residents come together to identify and prioritize health and safety issues and to identify resources for addressing them. The process results in an actionable community health improvement plan (CHIP) for measurable improvements in the community's health and quality of life as well as a scorecard for implementation and evaluation. The resulting community plan does not focus on one agency or community health challenge; rather, MAPP provides a long-term strategy that addresses the multiple factors that affect health in the community. Community involvement throughout the creation and the implementation of a health improvement plan results in creative solutions to community health problems with an improved focus on priorities, reduced duplication of services, increased collaboration on projects and activities, and increased capacity to garner additional resources. Moreover, continous community involvement leads to community ownership of the process. Community ownership, in turn, increases the credibility and sustainability of the health improvement efforts.
Patient Education of Eligibility for Assistance Schedule H Part VI Line 3 Kennestone and Windy Hill Hospitals provide its patients with hospital personnel or contracted personnel who are trained in all aspects of governmental programs, payments plans, charity discounts, and other financial assistance offered to assist them in their hospital bills. If the patient is eligible for federal or state assistance programs, a staff member is knowledgeable in the steps necessary to qualify those individuals. If a patient is indigent or charity eligible they will be offered assistance through the hospital's charity and indigent care policy including the state's indigent care trust fund. If the patient has no other insurance and fails to qualify for indigent care assistance, the financial counselor can then offer the patient an opportunity to accept a payment plan with discounted payment options based on their ability to pay immediately or over time. All patient are afforded these opportunities.
Community Information Schedule H Part VI Line 4 Kennestone and Windy Hill Hospitals are two of five hospitals that are affiliated with Wellstar Health System. The primary service area of the system is located in the Northwest Georgia area and receives the majority of its patients from one of five counties (Cherokee, Cobb, Douglas, Bartow and Paulding). Generally about 85% to 90% of the patient volume comes from this service area although other health systems have a presence in the area as well. Demographically the region is one of the fastest growing in the state as well as the country and the expansion of the services for the patient population reflects a desire to offer healthcare "closer to home" since Wellstar is considered a part of a larger metropolitan Atlanta market. Economically the region is strong in per capita income but given recent trends a rise in the uninsured and indigent population has occured.
Promotion of Community Health Schedule H Part VI Line 5 As stated in the Wellstar Health System, Inc and Affiliates audited financial statments for the period ended June 30, 2013, Kennestone and Windy Hill Hospitals (affiliates of Wellstar Health System, Inc.) operate as charitable organizations consistent with the requirements of Internal Revenue Code Sect 501 (c) (3) and the "community benefit standard" of IRS Ruling 69-545. In this regard the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualifed physicians in the area consistent with the size and nature of the facility; Kennestone Hospital operates a full-time emergency room open to all regardless of ability to pay; and the hospitals (Kennestone and Windy Hill) provide care to the needy members of the community consistent with its charity care policy. The hospital's excess funds are genrally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement fo patient care, community benefit activities, and charity care. Kennestone Hospital committed approximately $91.6 million and Windy Hill Hospital committed approximately $9.8 million in capital expenditures for the year to meet those needs.
Publication of Financial Assistance Policy Sch H Part V Line 13g In addition to the other methods of posting the financial assistance policy, the hospital makes available for patients in admissions and outpatient registration areas a brochure including frequently asked questions.
Other Descriptions from the CHNA Part V Section B Line 1j The Community Health Needs Assessment for both Kennestone and Windy Hill also provide a list of WellStar Health System CHNA collaborators including individuals, organizations and governmental agencies consulted that contributed special knowledge of medically underserved and low income populations and/or expertise in public health
CHNA Input from Community Representative and Sources Part V Section B Line 3 WellStar Kennestone and Windy Hill Hospitals integrated multiple sources of data from national and state web-based data platforms with multiple primary data gathering methods (see list below). As a partner in the strategic planning process utilized by Cobb & Douglas Public Health (CDPH) called Mobilizing for Action through Planning and Partners (MAPP) from the National Association of County & City Health Officials, the hospital leveraged the findings from community health needs assessments conducted in tax year 2012. Through a grant by the Centers for Disease Control and Prevention, WellStar Kennestone and Windy Hill partnered with CDPH and formed a coalition, Cobb 2020, to conduct its needs assessment via multiple modalities: MAPP workgroups, focus groups, surveys, Key Informant interviews, and implementation teams to act upon identified strategic issues in the community. To collect robust data for counties WellStar serves outside of Cobb, WellStar enlisted expertise of county and regional public health officials, independent consultants, and other Key Informants. A listing of collaborators can be found in the Appendix of both of the hospital facility's CHNA reports publicly available at wellstar.org. Quantitative Data Sources Including: 1. Georgia Department of Public Health, OASIS 2. Centers for Disease Control and Prevention (CDC) Vital Statistics 3. Agency for Healthcare Research and Quality (AHRQ) 4. U. S. Census Bureau 5. U.S. Department of Health and Human Services 6. Kaiser Permanente Web-Based CHNA Platform 7. Catholic Health Association CHNA resources 8. County Health Rankings & Roadmaps, University of Wisconsin 9. Healthy People 2020 10.Behavorial Risk Factor Surveillance System (BRFSS) 11.WellStar Health System - WellStar Kennestone & Windy Hill Hospital's FY2012 utilization data to assess service area zip codes accounting for 90 percent of hospital admissions and visits and primary service areas. Qualitative Data Sources Including: 1. Cobb County Focus Group Report-58 people participated in six focus group representing 14 zip codes. Demographics varied among the groups indicative of the zip codes represented. Two groups were conducted in Spanish and reflected low-income, low education attainment and medically underserved populations. 2. MAPP Assessment Workgroups with representatives from Douglas and Cobb counties conducted four community assessments which helped develop the Cobb2020 Community Health Improvement Plan. This included the 2011 Field Test Local Public Health System Assessment by the National Public Health Performance Standards Program (NPHPSP) 3. Cobb Key Informant Interview Report-20 participants identified by Cobb 2020's Community Strengths and Themes Workgroup to represent different sectors of the Cobb community who possessed above average knowledge of the healthcare issues, healthcare system or the community. 4. Cobb MAPP Community Survey Report-44-question telephone surveys of 1,244 adults ages 18-94 performed by the A.L. Burruss Institute for Public Service and Research, Kennesaw State University. 5. Cobb County 2010 - How Healthy Are We? 6. Cobb County MAPP Forces of Change Assessment Summary Report 7. Bartow, Cherokee and Paulding County Key Informant interviews of community stakeholders led by Ron Chapman, Principal, Magnetic North, LLC, a third-party consultant LLC, a third-party consultant
Facility Community Needs Assessment Part V Section B Line 4 While both WellStar Kennestone and WellStar Windy Hill each conduct its own community health needs assessment there may be some overlap with the other hospitals in WellStar Health System simply because of the geographic constraints and structure of the organization. The community served therefore is defined by similar zip codes and areas of services.
Explanation of Unaddressed CHNA Needs Part V Section B Line 7 Selection criteria for WellStar Kennestone and Windy Hill Hospital's prioritized health needs were primarily based upon the bandwidth to build a sustainable community benefit model focused on preventable health behaviors and access to care. Sexually transmitted infections and teen pregnancy are not addressed leaving awareness education with schools, family and churches since the health needs are more cultural and societal. Improvement to health needs stemming from socioeconomic and physical environmental such as air quality and transportation, gain traction from public policy and education. A health system can complement efforts to impact policy, but has to rely on public health, state and local municipalities and federal governmental agencies to drive these types of health improvements. Key questions when addressing health needs are do we have existing facilities and resources dedicated to the health needs showing clear disparities and poor performance? And do we have effective and feasible interventions, a successful solution that has the potential to solve multiple problems, and the opportunity to intervene at the prevention level? WellStar Health System, Inc. and its affiliates will continue to address these and other questions.
Affiliated Health Care System Part VI Line 6 WellStar Health System, Inc., as the parent corporation, and Cobb Hospital, Douglas Hospital, Kennestone Hospital, Paulding Medical Center and Windy Hill Hospital provide a variety of health care and related services to the community. In addition a nursing home, two residential hospice facilities, an assisted living and retirement facility as well as a group of physicians provide a full continuum of care to the area we serve.
CHNA Implementation Strategy Schedule H Part VI Item 2 In order to access the proposed Community Health Needs Assessment Implementation Strategy for Kennestone Hospital Inc. (Kennestone and Windy Hill Hospitals), a link has been established at www.wellstar.org under the "about us" tab of the website.
Schedule H (Form 990) 2012
Additional Data


Software ID:  
Software Version:  
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
No
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......
2
Yes
 
3
Indicate which, if any, of the following the 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.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
Yes
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

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
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)AVRIL P BECKFORD MDTRUSTEE (i)
(ii)		 0
391,098 		0
34,682 		0
7,703 		0
22,804 		0
0 		0
456,287 		0
0
(2)THOMAS GEARHARD MDTRUSTEE (i)
(ii)		 0
374,127 		0
149,896 		0
9,301 		0
44,344 		0
25,762 		0
603,430 		0
0
(3)JEFFERY THARP MDTRUSTEE (i)
(ii)		 0
453,052 		0
144,219 		0
12,638 		0
47,325 		0
18,005 		0
675,239 		0
0
(4)CHARLES 'PETE WOODTRUSTEE (i)
(ii)		 0
0 		0
0 		0
13,091 		0
0 		0
0 		0
13,091 		0
0
(5)VALERY A AKOPOV MDVP & CHIEF HOSPITALISTS (i)
(ii)		 0
289,320 		0
49,819 		0
30,153 		0
20,530 		0
9,585 		0
399,407 		0
0
(6)DAVID W ANDERSONEXEC VP HR/OL/CCO (i)
(ii)		 0
396,057 		0
113,256 		0
499,800 		0
63,675 		0
14,241 		0
1,087,029 		0
0
(7)NICOLE V ASHEVP FINANCE & CFO WMG (i)
(ii)		 0
197,655 		0
24,868 		0
6,681 		0
14,552 		0
20,244 		0
264,000 		0
0
(8)BARBARA G BALLARDVP HOMECARE & HOSPICE (i)
(ii)		 0
221,400 		0
39,137 		0
8,700 		0
16,066 		0
25,262 		0
310,565 		0
0
(9)BETTY ANN BRAKOVICHVP/CNO PATIENT CARE SRVCS WH (i)
(ii)		 148,096
0 		28,355
0 		10,575
0 		10,908
0 		10,644
0 		208,578
0 		0
0
(10)JOSEPH L BRYWCZYNSKISR VP HEALTH PARKS DEVELOPMENT (i)
(ii)		 0
252,245 		0
58,357 		0
10,800 		0
32,749 		0
15,644 		0
369,795 		0
0
(11)A JAMES BUDZINSKIEXEC VP and CFO (i)
(ii)		 0
507,658 		0
147,371 		0
156,423 		0
54,844 		0
17,506 		0
883,802 		0
0
(12)DONALD CAMPBELL MDSR VP PHYS EDUC & STUDENT AFF (i)
(ii)		 0
313,078 		0
71,586 		0
57,333 		0
40,224 		0
14,138 		0
496,359 		0
0
(13)LAURA CARAMANICAVP/CNO PATIENT CARE SRV KENN (i)
(ii)		 257,082
0 		34,349
0 		8,700
0 		34,473
0 		9,161
0 		343,765
0 		0
0
(14)LEE RANDOLPH COOKVP MEDICINE & BEHAVIORAL HLTH (i)
(ii)		 0
253,643 		0
53,103 		0
71,843 		0
37,847 		0
16,960 		0
433,396 		0
0
(15)BARBARA B COREYSR VP MANAGED CARE (i)
(ii)		 0
280,236 		0
80,891 		0
76,249 		0
34,459 		0
15,077 		0
486,912 		0
0
(16)BRUCE A DEANVP REAL ESTATE & DEP GEN COUN (i)
(ii)		 0
210,603 		0
37,339 		0
41,567 		0
33,613 		0
15,112 		0
338,234 		0
0
(17)MARCIA DELK-PAYNE MDSR VP MED AFFAIRS & CQO (i)
(ii)		 0
352,282 		0
90,990 		0
93,867 		0
44,131 		0
3,202 		0
584,472 		0
0
(18)CAROL S EDWARDSVP CARDIAC SERVICES (i)
(ii)		 0
166,152 		0
0 		0
6,349 		0
22,617 		0
4,532 		0
199,650 		0
0
(19)CLARENCE HARLEE EVINS JRVP REVENUE CYCLE (i)
(ii)		 0
157,714 		0
33,371 		0
7,716 		0
11,150 		0
11,000 		0
220,951 		0
0
(20)MICHAEL L GRAUEEXEC VP & COO (i)
(ii)		 0
532,619 		0
157,139 		0
14,654 		0
51,672 		0
30,762 		0
786,846 		0
0
(21)MARTIN L GUTKINVP FINANCE & HOSPITAL CFO (i)
(ii)		 188,380
0 		24,120
0 		26,782
0 		9,616
0 		7,936
0 		256,834
0 		0
0
(22)ELIZABETH A HOFFMANNVP BUDGET & ANALYSIS (i)
(ii)		 0
199,287 		0
34,650 		0
8,700 		0
10,108 		0
6,484 		0
259,229 		0
0
(23)ROBERT D JANSEN MDEXEC VP & PRES WMG (i)
(ii)		 0
519,908 		0
118,865 		0
12,418 		0
46,463 		0
20,531 		0
718,185 		0
0
(24)REYNOLD J JENNINGSPRESIDENT & CEO (i)
(ii)		 0
981,858 		0
562,478 		0
27,390 		0
64,901 		0
0 		0
1,636,627 		0
0
(25)CHRISTOPHER M KANESR VP STRATEGIC PLAN & BUS DEV (i)
(ii)		 0
321,428 		0
74,695 		0
82,370 		0
24,938 		0
20,762 		0
524,193 		0
0
(26)BETH KOSTVP COMPLIANCE & CHIEF PRIVACY (i)
(ii)		 0
230,396 		0
40,119 		0
8,700 		0
16,456 		0
8,022 		0
303,693 		0
0
(27)KENNETH C KUNZE MDSR VP & CHIEF MEDICAL OFFICER (i)
(ii)		 0
581,156 		0
100,435 		0
444,125 		0
68,643 		0
8,022 		0
1,202,381 		0
0
(28)ELLEN LANGFORDVP & COO WELLSTAR PHYS GRP (i)
(ii)		 0
193,742 		0
33,394 		0
85,263 		0
34,854 		0
4,642 		0
351,895 		0
0
(29)LOUIS W LITTLESR VP POST ACUTE & HOSP PRES (i)
(ii)		 233,362
0 		58,935
0 		64,659
0 		24,451
0 		15,881
0 		397,288
0 		0
0
(30)RICHARD T LOPES MDFORMER SR VP & PRES WMG (i)
(ii)		 0
480,426 		0
0 		0
0 		0
19,938 		0
0 		0
500,364 		0
0
(31)ROBERT MANDLERVP DIAGNOSTIC OUTREACH (i)
(ii)		 0
208,264 		0
35,125 		0
29,955 		0
33,059 		0
14,684 		0
321,087 		0
0
(32)CAROL B MAXWELLVP TALENT ACQUISTION (i)
(ii)		 0
209,071 		0
28,397 		0
2,000 		0
14,177 		0
6,531 		0
260,176 		0
0
(33)PATRICIA A MAYNEVP EMERGENCY SERVICES (i)
(ii)		 159,475
0 		22,489
0 		20,700
0 		12,334
0 		24,053
0 		239,051
0 		0
0
(34)KIMBERLY W MENEFEESR VP MARKETING & GOV AFFAIRS (i)
(ii)		 0
264,110 		0
9,000 		0
123,171 		0
36,736 		0
16,589 		0
449,606 		0
0
(35)JONATHAN B MORRIS MDSR VP & CIO (i)
(ii)		 0
346,239 		0
72,286 		0
9,063 		0
22,886 		0
20,531 		0
471,005 		0
0
(36)LEO E REICHERTEXEC VP & GENERAL COUNSEL (i)
(ii)		 0
456,529 		0
133,697 		0
21,336 		0
25,403 		0
22,625 		0
659,590 		0
0
(37)MICHELLE M ROBINSONVP MARKETING, PR INTERNAL COMM (i)
(ii)		 0
172,139 		0
24,268 		0
4,806 		0
12,162 		0
16,529 		0
229,904 		0
0
(38)DEBORAH ROEGGE DE VITAVP WOMEN & NEWBORN (i)
(ii)		 0
185,959 		0
32,087 		0
48,923 		0
11,698 		0
3,605 		0
282,272 		0
0
(39)CANDICE L SAUNDERSEXEC VP & HOSP PRESIDENT (i)
(ii)		 365,299
0 		81,992
0 		107,525
0 		44,658
0 		16,126
0 		615,600
0 		0
0
(40)CHRISTOPHER B SCULLENVP PULMONARY OPERATIONS (i)
(ii)		 0
163,084 		0
28,265 		0
8,700 		0
10,296 		0
382 		0
210,727 		0
0
(41)GREGORY L SIMONEFORMER PRES & CEO (i)
(ii)		 0
226,763 		0
0 		0
0 		0
9,581 		0
14,016 		0
250,360 		0
0
(42)JAMES M SWARTZVP ACCOUNTING (i)
(ii)		 0
184,730 		0
32,826 		0
8,700 		0
13,409 		0
17,132 		0
256,797 		0
0
(43)MARY L TAVERNAROVP HUMAN RESOURCES OPERATIONs (i)
(ii)		 0
199,674 		0
34,761 		0
8,700 		0
14,330 		0
10,473 		0
267,938 		0
0
(44)ADAM C THOMPSONVP SURGERY (i)
(ii)		 0
155,225 		0
27,353 		0
9,250 		0
8,055 		0
14,614 		0
214,497 		0
0
(45)JERRY TILLERYVP OPERATIONS KENNESTONE (i)
(ii)		 168,921
0 		22,677
0 		14,392
0 		12,114
0 		5,931
0 		224,035
0 		0
0
(46)AMANDA ELIZ T TRASKVP PROF & SUPPORT SRVCS KH (i)
(ii)		 154,196
0 		21,871
0 		8,700
0 		11,783
0 		20,814
0 		217,364
0 		0
0
(47)ANOTHONY M TRUPIANOSR VP SUPPLY CHAIN (i)
(ii)		 0
253,706 		0
62,612 		0
11,010 		0
35,439 		0
0 		0
362,767 		0
0
(48)MARY L WESLEYSR VP NURSING SERVICES CNE (i)
(ii)		 0
302,455 		0
69,297 		0
11,742 		0
27,058 		0
10,644 		0
421,196 		0
0
(49)BONNIE L WILSONFORMER EXEC VP & GEN COUNSEL (i)
(ii)		 0
227,237 		0
0 		0
0 		0
9,581 		0
3,629 		0
240,447 		0
0
(50)ROBIN WILSON MDSR VP CHIEF INNOVATION OFFICER (i)
(ii)		 0
295,561 		0
155,781 		0
11,513 		0
19,506 		0
24,125 		0
506,486 		0
0
(51)DANIEL J WOODSSR VP & COO KENN HOSPITAL (i)
(ii)		 174,556
0 		118,000
0 		6,854
0 		15,240
0 		11,140
0 		325,790
0 		0
0
(52)CHESTER A ZBOROWSKIVP HEALTH PARK OPERATIONS (i)
(ii)		 0
113,075 		0
2,301 		0
22,335 		0
5,784 		0
9,933 		0
153,428 		0
0
(53)JYOTSNA R VANAPALLIRADIATION ONCOLOGY PHYSICIST (i)
(ii)		 170,669
0 		207
0 		0
0 		10,426
0 		10,644
0 		191,946
0 		0
0
(54)MARK G VAN EWYKPHARMACIST SPECIALTY (i)
(ii)		 168,328
0 		207
0 		0
0 		10,351
0 		5,845
0 		184,731
0 		0
0
(55)ROBERT J DeCOUXAVP HUMAN RESOURCES (i)
(ii)		 146,019
0 		16,659
0 		1,200
0 		9,982
0 		16,589
0 		190,449
0 		0
0
(56)HEATHER S ROCHFORDMANAGER PHARMACY (i)
(ii)		 161,229
0 		3,102
0 		0
0 		9,739
0 		11,423
0 		185,493
0 		0
0
(57)DONNA H THOMASAVP QUALITY SRV & PATIENT SAFE (i)
(ii)		 150,194
0 		16,228
0 		1,200
0 		6,888
0 		535
0 		175,045
0 		0
0
Schedule J (Form 990) 2012

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
Non-Fixed Payments to Officers Form 990 Schedule J Line 7 Wellstar has instituted an annual incentive plan for key leaders in the company. On an annual basis performance measures are proposed by management and approved and recommended by the Compensation Committee of the Board. The plan is designed to retain and reward leaders with incentives that keep them competitive with the market and comparable health systems. The criteria used to measure the performance consists of weighted factors in the areas of financial performance, customer service, employee engagement and quality indicators. Upon successful acheivement in the targeted levels for each factor, a performance payout is recommended and approved by the Board after the annual financial audit is completed. Last year the board and senior management extended the incentive program to include all team members or non-management personnel. The performance pay plan for this group of employees is based on successful attainment of various system and facility goals and the fixed dollar awarded for that achievement.
Severance Benefits Schedule J Pursuant to their respective employment agreements, the following groups of officers are entitled to severance payments based on their base salary and wages at that time in the event of certain identified circumstances. The officers with a severance payment period of 24 months as per their contractual agreement are: David Anderson Reynold Jennings The officers with a severance payment period of 18 months as per their respective agreements are: Joseph Brywczynski; A James Budzinski; Donald Campbell MD; Barbara Corey; Marcia Delk MD; Michael Graue; T Mark Haney; Robert Jansen MD; Peter Jungblut, MD; Christopher Kane; Kenneth Kunze MD; Lou Little; Richard Lopes MD; Kimberly Menefee; Jonathan Morris MD; Leo E Reichert; Candice Saunders; Ron Strachan; Anthony Trupiano; Mary L Wesley; Robin Wilson MD. The officers with a severance payment period of 12 months as per their agreement: Valery Akopov MD; Nicole Ashe; Barbara Ballard; Betty A Brakovich; Laura Caramanica; Bruce Dean; Carol Edwards; Lee Evins; Kristyn Greifer, MD; Martin Gutkin; Elizabeth Hoffmann; Beth Kost; Ellen Langford; Robert Mandler; Patricia Mayne; Carol Maxwell; Deborah Roegge DeVita; C Brett Scullen; Rick Siegel; James Swartz; Mary L Tavernaro; Adam Thompson; Jerry Tillery; Amanda Trask; and Chester Zborowski. During the calendar year, the following individuals received a payout in the amounts listed in accordance with their severance agreements as set forth above: Gregory L Simone $250,360; Bonnie Wilson $240,446; Richard T Lopes, MD $ 500,363 and Ronald Strachan $104,106.
Other Compensation Form 990, Schedule J, Part I, Line 1b & 2 While Wellstar Health System and its affiliates do not have a written policy regarding payment or reimbursement for the items listed in Part 1 Line 1a, the organization follows IRS guidelines in the payment of any of these items to individuals listed in Form 990 Part VII Section A. These items are added as taxable wages on the individual's Form W-2 as appropriate.
Compensation Exceptions   The following individuals became officers of Wellstar Health System and Affiliates during the accounting period covered by this return but were not compensated during the calendar year for which salary and benefits are reported in the return: Kristyn Greifer, MD; Peter Jungblut MD; and Rick Siegel.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
Total ......Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Pamela Etheridge Wife of Officer 60,897 Employee of Wellstar   No
(2) Greg Fortgang Son-in-Law of Trustee 99,034 Employee of Wellstar   No
(3) Greg Separk Son of Trustee 23,420 Employee of Wellstar   No
(4) George Fleming Brother of Officer 65,701 Employee of Wellstar   No
(5) Matthew Maddox Son of Trustee 67,037 Employee of Wellstar   No
(6) Bonnie Miller Wife of Trustee 35,100 Employee of Wellstar   No
(7) Jessica Haney Daughter of Officer 57,127 Employee of Wellstar   No
(8) Greg Kost Brother-in-law of officer 47,539 Employee of Wellstar   No
(9) Jennifer Haney Daughter-in-law of offcer 77,821 Employee of Wellstar   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Business Transactions with Interested Parties Form 990 Schedule L Part IV All transactions listed in Schedule L Part IV are for interested parties or in this case family members of either trustees or officers of Kennestone Hospital, Inc. or its related organizations. The transactions all represent payment of services as employees of Wellstar Health System.
Schedule L (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

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

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Identifier Return Reference Explanation
Compensation Form 990 Part V Line 2 All compensation amounts reported on Form 990 Part V, Part VII, and Part IX as well as Schedule J represent compensation provided to individuals that provide services to the organization. Likewise, the number of employees reported on Form 990 represent the number of individuals providing services to the organization. All Federal employment tax responsibilities for these individuals (including Federal Employment Tax reporting responsibilities) are handled by Wellstar Health System, Inc (EIN 58-1649541).
Conflict of Interest Policy Form 990 Part VI Section B Line 12A, B, & C Our conflict of interest policy requires all covered persons to annually review the policy and then complete, sign and return the Conflicts of Interest Survey and Attestation to the Compliance Office. The Policy requires an on-going disclosure obligation in the event a conflict arises during the year. The following is our process to regularly and consistently monitor and enforce the policy: Compliance identifies all covered persons who must complete the Survey and Attestation. Compliance verifies that the Survey and Attestation is distributed to these persons. Compliance verifies that these persons return a fully completed and signed Survey and Attestation. Compliance reviews each completed and signed Survey and Attestation to identify all conflicts listed in the document. All conflicts, potential conflicts and incidences of non-compliance are referred to the Chief Compliance Officer. The CCO takes appropriate action to completely resolve all identified conflicts and incidences of non-compliance.
Process of Determining Officer Comp Form 990 Part VI Line 15A & B Wellstar engages the Hay Group to work with the governing board to review and recommend executive compensation. The executive compensation process at Wellstar is overseen by a committee of independent trustees, which follows a board-approved executive compensation philosophy. The compensation committee consist of five trustees as well as the CEO in an advisory role and not a voting member. Further in committtee discussions about the compensation for the Chief Executive Officer, The CEO will recuse himself/herself from that process but is a non-voting committee member for discussions on all other officers. The executive compensation philosophy empowers the committee to oversee the executive compensation process and administer the executive compensation program on behalf of the full board of trustee of Wellstar; provided, however, the full Board of Trustees evaluates and approves the compensation of the Chief Executive Officer. The philosophy requires annual disclosure of the committee's actions and decisions to the full board, which it has done. The committee is guided by the board-approved philosophy. Overall, the philosophy is intended to reward for organizational and individual performance. When performance is at a predetermined targeted level, the compensation is intended to be at or around the median of compensation paid to similar positions at similar organizations (the "market"). Wellstar's executive compensation philosophy defines the market as being comprised of comparable not-for-profit health care delivery systems, i.e., not-for-profit organizations similar in complexity and scale to Wellstar. To assist the committee in fulfilling its duties, the committee engaged the Hay Group to provide market compensation data to compare to the Wellstar positions whose compensation the committee oversees. The committee uses this data to provide context when making decisions in administering the compensation program. Accurate minutes of the committee's discussion and decisions are recorded during each committee meeting, and reviewed and approved by the full Board of Trustees at its next scheduled meeting.
Audited Financial Statements Form 990 Part IV Line 12 & Part IX Kennestone Hospital, Inc. is audited on an annual basis by an outside auditing firm, KPMG, and as part of that audit a consolidated financial statement is issued for all of WellStar Health System, Inc and its Affiliates. "The independent auditors report includes the accounts of Wellstar and its controlled affiliates, Kennestone Hospital, Inc., Cobb Hospital, Inc., Douglas Hospital, Inc., Paulding Medical Center, Inc., Wellstar Foundation, Inc. CHS Foundation, Inc., Community Assurance Company, Ltd., various Wellstar owned physician practices, a hospice facility, a nursing facility, home health business, and entities for infusion therapy and durable medical equipment. All significant intercompany accounts and transactions have been eliminated in combination. The Board of Trustees of Wellstar has the authority to approve appointments of the members of the board of trustees of all affiliate corporations."
Tax Exempt Bond Allocation Form 990 Part IV Line 24a & Part X For purposes of the Form 990 reporting, Wellstar Health System, Inc EIN 58-1649541 will list all tax-exempt bonds issued since January 1, 2003 on Schedule K as it typically allocates the proceeds of the bonds to members of the Obligated Group (including the hospitals and physician group). Kennestone Hospital, Inc. will report this tax exempt bond liability on Part X, Line 25 Other Liabilities-Due to WHS, Inc.
Organization Structure Form 990 Part VI Section A Lines 6, 7a & 7b As per the Articles of Incorporation, the sole member of the organization is Wellstar Health System, Inc., a GA nonprofit corporation. As sole member, Wellstar Health System, Inc. holds certain powers of election and approval in connection with the governing body of the organization. These powers are presented in detail in the governing documents which the company makes available to the public upon request.
Officers Hours Worked Form 990 General Statement The officers devote their time to all of the organizations within Wellstar Health System that are listed in Schedule R, Part II. As such, the total hours worked by the officers across all organizations exceeds 40 hours a week.
990 Board Review Form 990 Part VI Line 11A Internal staff prepare the organization's Form 990. Before filing the return with the Internal Revenue Service an external accounting firm, PricewaterhouseCoopers, reviews and sign-offs on the completed return of each organization. The current year Form 990 is then reviewed by the Finance Committee along with a question and answer session. A motion is then made by the Finance committee to approve the returns and present to the full board copies of the forms in an electronic (pdf. format) version as well as a hard copy . The organization's CFO or designee subsequently signs the return for either manual or electronic filing by the appropriate due date.
Disclosure of Financial Documents FORM 990 PART VI SECTION C Line 19 The organization and its subsidiaries are subject to the Open Records Law in the State of Georgia. Therefore, by law, citizens are permitted to inspect and copy its governing documents, policies and financial statements as may be requested from time to time. Additionally, the organization's Form 990 is made readily available on the Guidestar website. Periodically, the organization publishes its financial performance in the local newspaper for citizens to review, and it also publishes a community benefit report once a year for distribution to the public.
Changes in Net Assets Form 990 Part XI Line 5 For the reporting period Kennestone Hospital, Inc. had a change in net assets of ($68,997,230) related to transfers to affiliates as part of the allocation of income statement and balance sheet transactions over the year.
Bylaws Amendments Part VI Line 4 During the reporting period the Board of Trustees voted to amend the bylaws for WellStar Health System, Inc. to add an Audit Committee and a Compensation Committee as additional named board committees with authority to act on hehalf of the governing body.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


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

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
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?
Yes No
(1) CHS Foundation Inc

805 Sandy Plains Road

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

805 Sandy Plains Road

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

805 Sandy Plains Road

Marietta,GA30066
58-2026750 		Healthcare GA 501 (C) 3 3 WHS Inc
 
Yes
 
(4) Paulding Medical Center Inc

805 Sandy Plains Road

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

805 Sandy Plains Road

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

805 Sandy Plains Road

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


For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
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



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



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

805 Sandy Plains Road
Marietta,GA300666340
75-2999669 		Parking GA NA
  		N/A                
(2) Kennestone East Parking Deck LLC

805 Sandy Plains Road
Marietta,GA300666340
20-0537100 		Parking GA NA
  		N/A                










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
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Community Assurance Co

3rd Fl Barclays House Shedden Rd
George Town,Grand Cayman, BWI  
CJ
58-1649541 		Insurance CJ N/A
         Yes  












Schedule R (Form 990) 2012
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
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
 
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2012
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) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

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




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






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


Software ID:  
Software Version: