TY 2013 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) DAVID TRIEBES........................................................................ BOARD SECRETARY & TREASURER/CEO AGH	32.00 .......................8.00	X	X		0	319,329	49,216
(2) MARIA DELAPOER........................................................................ BOARD MEMBER	1.00 .......................1.00	X			0	0	0
(3) BRUCE MADSEN MD........................................................................ BOARD MEMBER	1.00 .......................2.00	X			0	10,750	0
(4) PAUL DASKALOS DO........................................................................ BOARD VICE-CHAIR/PHYSICIAN	39.00 .......................1.00	X	X		423,626	0	47,690
(5) JIM DENHAM........................................................................ BOARD MEMBER	1.00 .......................3.00	X			0	0	0
(6) PATRICK HAGERTY DMD........................................................................ BOARD CHAIR	1.00 .......................2.00	X	X		0	0	0
(7) GREGG MILLER MD........................................................................ BOARD MEMBER/PHYSICIAN	39.00 .......................1.00	X			247,698	0	47,060
(8) SENATOR FRANK MORSE........................................................................ BOARD MEMBER	1.00 .......................2.00	X			0	0	0
(9) PAUL GREAVES MD........................................................................ BOARD MEMBER	1.00 .......................1.00	X			0	0	0
(10) STEPHEN NEWMAN MD........................................................................ BOARD MEMBER/PHYSICIAN	39.00 .......................1.00	X			524,509	0	31,001
(11) BRIAN CARROL........................................................................ BOARD MEMBER	1.00 .......................1.00	X			0	0	0
(12) DANIEL B SMITH........................................................................ VP FINANCE/CFO	2.00 .......................38.00		X		0	307,300	50,407
(13) JEFFREY PALMGREN MD........................................................................ PHYSICIAN	40.00 .......................			X	516,067	0	33,124
(14) RICK D STANLEY MD........................................................................ PHYSICIAN	40.00 .......................			X	402,286	0	31,698
(15) SHANE GJESDAL MD........................................................................ PHYSICIAN	40.00 .......................			X	362,128	0	42,143
(16) JONATHAN LARSEN MD........................................................................ PHYSICIAN	40.00 .......................			X	417,372	0	47,722
(17) STEVEN BALLINGER MD........................................................................ PHYSICIAN	40.00 .......................			X	480,752	0	30,996

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	31,750	31,750
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	104,168	104,168
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	1,321,584	1,321,584
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	62,220,270	59,874,729	2,157,021	188,520
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	3,447,859	3,320,587	117,043	10,229
9	Other employee benefits .......	11,282,009	10,865,553	382,984	33,472
10	Payroll taxes ...........	4,793,994	4,617,032	162,739	14,223
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	52,452	16,026	36,426
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	1,256,331	1,148,017	93,501	14,813
12	Advertising and promotion ....	11,516	1,744	5,409	4,363
13	Office expenses .......	4,800,361	4,577,675	171,734	50,952
14	Information technology ......	6,160,723	5,925,411	235,312
15	Royalties ..
16	Occupancy ...........	4,083,246	4,017,086	63,819	2,341
17	Travel ............	220,849	212,818	6,782	1,249
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....	244,976	238,581	6,277	118
20	Interest ...........	629,207	605,174	24,033
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	3,804,220	3,656,470	145,207	2,543
23	Insurance ..............	1,685,904	1,526,573	159,331
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	MEDICAL SUPPLIES	26,124,447	26,124,447
b	PURCHASED SERVICES	18,344,318	5,663,291	12,664,841	16,186
c	DUES, TAXES, & LICENSES	6,012,253	5,945,456	66,472	325
d
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	156,632,437	139,794,172	16,498,931	339,334
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
	1	Cash–non-interest-bearing .............	9,909	1	10,109
2	Savings and temporary cash investments .........	13,335	2	13,373
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	15,572,496	4	20,485,951
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5	60,637
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
			6
7	Notes and loans receivable, net .............	243,954	7	52,870
8	Inventories for sale or use ..............	1,848,007	8	2,045,675
9	Prepaid expenses and deferred charges ..........	743,612	9	969,705
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	73,364,225
b	Less: accumulated depreciation .....	10b	38,597,803	35,343,781	10c	34,766,422
11	Investments—publicly traded securities ..........	5,691,087	11	6,480,832
12	Investments—other securities. See Part IV, line 11 .....	609,998	12	593,849
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............	11,175	14
15	Other assets. See Part IV, line 11 ...........	11,166,335	15	1,766,893
16	Total assets. Add lines 1 through 15 (must equal line 34)......	71,253,689	16	67,246,316
	17	Accounts payable and accrued expenses .........	11,985,153	17	8,680,985
18	Grants payable .................		18
19	Deferred revenue ................		19
20	Tax-exempt bond liabilities .............		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	1,017,689	23	1,608,538
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	2,322,328	25	3,555,987
26	Total liabilities. Add lines 17 through 25.........	15,325,170	26	13,845,510
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	55,928,519	27	53,400,806
28	Temporarily restricted net assets ...........		28
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	55,928,519	33	53,400,806
34	Total liabilities and net assets/fund balances ........	71,253,689	34	67,246,316

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.
right arrow

Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2013

Page 2

Part II

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

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

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

Section C. Computation of Public Support Percentage

Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2012 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2013. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2012. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2013. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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

Schedule A (Form 990 or 990-EZ) 2013

Page 3

Part III

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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

Section C. Computation of Public Support Percentage

Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2012 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2012 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2013. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2012. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

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

Schedule A (Form 990 or 990-EZ) 2013

Page 4

Part IV

Supplemental Information. 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) 2013

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 2

Name of organization ALBANY GENERAL HOSPITAL

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTEDRESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 3

Name of organization ALBANY GENERAL HOSPITAL

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 4

Name of organization
ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Part III

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

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions. SchDMd Bullet

Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2013

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	1,246,029	1,478,711	1,635,632	1,445,397	1,168,991
b	Contributions ........	228,168	46,732	7,727	49,713	78,184
c	Net investment earnings, gains, and losses	127,262	178,839	-49,372	141,559	198,963
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........	4,045	458,253	115,276	1,037	741
f	Administrative expenses ....
g	End of year balance ......	1,597,414	1,246,029	1,478,711	1,635,632	1,445,397

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

Board designated or quasi-endowment SchDMd Bullet

30.400 %

Permanent endowment SchDMd Bullet

69.600 %

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

Yes

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

Yes

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

Part VI

Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	1,720,447		1,720,447
b	Buildings ................	45,833,898	21,448,810	24,385,088
c	Leasehold improvements ............	1,328,878	410,978	917,900
d	Equipment ................	22,487,254	16,005,871	6,481,383
e	Other .................	1,993,748	732,144	1,261,604
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				34,766,422

Schedule D (Form 990) 2013

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

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








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

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

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









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

Part IX

Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value









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

Part X

Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes
PROFESSIONAL LIABILITY RESERVE		917,922
CONTRACTUAL REIMBURSEMENT OBLIGATIONS		853,938
ACCRUED INTEREST		142,534
OTHER LIABILITIES		598,449
ACCOUNTS PAYABLE - AFFILIATES		1,043,144




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		3,555,987
2. Liability for uncertain tax positions 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) 2013

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
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. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
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

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.

Return Reference	Explanation
PART V, LINE 4:	THE ALBANY GENERAL HOSPITAL FOUNDATION (AGHF) HOLDS ENDOWMENT FUNDS THAT WILL ULTIMATELY BENEFIT THE HOSPITAL. AGHF'S BOARD-DESIGNATED QUASI ENDOWMENT FUND IS USED FOR GENERAL HOSPITAL SUPPORT. AGHF'S SNELL ENDOWMENT FUND IS USED TO FUND EQUIPMENT PURCHASES AND PERMANENT IMPROVEMENTS TO THE HOSPITAL'S FACILITIES. THE HOSPICE HOUSE ENDOWMENT FUND WILL BE USED TO SUPPORT PATIENTS WITHOUT FINANCIAL RESOURCES TO STAY AT THE HOUSE AND FOR FUTURE BUILDING MAINTENANCE.
PART X, LINE 2:	FOOTNOTE DISCLOSURE FROM THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS: U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE THE SHS' MANAGEMENT TO EVALUATE TAX POSITIONS AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF SHS HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE NETWORK AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. SHS IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. SHS' MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO 2010.

Return Reference

Explanation

PART V, LINE 4:

THE ALBANY GENERAL HOSPITAL FOUNDATION (AGHF) HOLDS ENDOWMENT FUNDS THAT WILL ULTIMATELY BENEFIT THE HOSPITAL. AGHF'S BOARD-DESIGNATED QUASI ENDOWMENT FUND IS USED FOR GENERAL HOSPITAL SUPPORT. AGHF'S SNELL ENDOWMENT FUND IS USED TO FUND EQUIPMENT PURCHASES AND PERMANENT IMPROVEMENTS TO THE HOSPITAL'S FACILITIES. THE HOSPICE HOUSE ENDOWMENT FUND WILL BE USED TO SUPPORT PATIENTS WITHOUT FINANCIAL RESOURCES TO STAY AT THE HOUSE AND FOR FUTURE BUILDING MAINTENANCE.

PART X, LINE 2:

FOOTNOTE DISCLOSURE FROM THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS: U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE THE SHS' MANAGEMENT TO EVALUATE TAX POSITIONS AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF SHS HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE NETWORK AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. SHS IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. SHS' MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO 2010.

Schedule D (Form 990) 2013

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	15	14,082	4,725,692		4,725,692	3.020 %
b	Medicaid (from Worksheet 3, column a) ....	10	63,983	27,661,986	20,285,181	7,376,805	4.710 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	25	78,065	32,387,678	20,285,181	12,102,497	7.730 %
Other Benefits		12	8,064	574,054	92,500	481,554	0.310 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	12	8,064	574,054	92,500	481,554	0.310 %
f	Health professions education (from Worksheet 5) ..	3	221	588,430		588,430	0.380 %
g	Subsidized health services (from Worksheet 6) ..	17	117,552	26,425,708	20,557,009	5,868,699	3.750 %
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	12	9,160	668,713	11,671	657,042	0.420 %
j	Total. Other Benefits ..	44	134,997	28,256,905	20,661,180	7,595,725	4.860 %
k	Total. Add lines 7d and 7j .	69	213,062	60,644,583	40,946,361	19,698,222	12.590 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2013

Schedule H (Form 990) 2013

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
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	1	93	7,140	7,140	0 %
9	Other
10	Total	1	93	7,140	7,140

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

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

3,276,230

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. ......

567,083

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

Section B. Medicare

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

16,824,960

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

19,873,394

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

-3,048,434

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2013

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number
1	ALBANY GENERAL HOSPITAL 1046 SIXTH AVE SW ALBANY,OR97321 WWW.SAMHEALTH.ORG STATE LICEN	X	X	X

Schedule H (Form 990) 2013

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)

	ALBANY GENERAL HOSPITAL
Name of hospital facility or facility reporting group

If reporting on Part V, Section B for a single hospital facility only: line number of
hospital facility (from Schedule H, Part V, Section A)

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 13

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

Yes

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

Yes

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

Yes

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

Hospital facility’s website (list url): HTTP://WWW.SAMHEALTH.ORG/COMMUNITYSUPPORT

Other website (list url):

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply as of the end of the tax year):

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

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

Schedule H (Form 990) 2013

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: 150.000000000000% 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: 200.000000000000% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If "Yes," indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Residency
i	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Section C)
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 individual’s eligibility under the facility’s FAP?..........	17		No
	If "Yes," check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Section C)

Schedule H (Form 990) 2013

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Section C)

Policy Relating to Emergency Medical Care

Yes

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

Yes

If "No," indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

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

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

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

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

Other (describe in Part VI)

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

If "Yes," explain in Part VI.

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

If "Yes," explain in Part VI.

Schedule H (Form 990) 2013

Page

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B.Provide descriptions required for Part V, Section B, lines 1j, 3, 4, 5d, 6i, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, provide separate descriptions for each facility in a facility reporting group, designated by "Facility A," "Facility B," etc.
Form and Line Reference	Explanation
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 3: THE STAFF FROM THE COMMUNITY HEALTH PROMOTION DEPARTMENT AND OTHER EMPLOYEES OF ALBANY GENERAL HOSPITAL (AGH) PARTICIPATED IN THE COMMUNITY-WIDE LINN COUNTY COMMUNITY HEALTH ASSESSMENT PROCESS DURING 2013. THE OVERALL AGH COMMUNITY HEALTH NEEDS ASSESSMENT IS ADOPTED FROM THE LINN COUNTY COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN; HOWEVER IN CONSULTATION WITH THE EPIDEMIOLOGIST FROM BENTON COUNTY HEALTH DEPARTMENT, ADDITIONAL INFORMATION WAS GATHERED THAT IS SPECIFIC TO THE AGH SERVICE AREA IS INCLUDED IN THE CHNA. PERSONS CONSULTED FOR THE HOSPITALS CHNA WERE LINN COUNTY HEALTH DEPARTMENT, COMMUNITY OUTREACH INC., BENTON EAST LINN HEALTH CENTER, OREGON STATE UNIVERSITY, SAMARITAN HEALTH PLANS, WESTERN UNIVERSITY-COMP NORTHWEST, LINN-BENTON COMMUNITY COLLEGE, GREATER ALBANY PUBLIC SCHOOL DISTRICT, LINN-BENTON COUNTY HEALTH EQUITY ALLIANCE, OREGON CASCADES WEST COUNCIL OF GOVERNMENTS, SAMARITAN INTERCOMMUNITY HEALTH NETWORK, DEPARTMENT OF HUMAN SERVICES, OREGON HEALTH AUTHORITY, COMMUNITY SERVICES CONSORTIUM, INREACH CLINIC, BOYS AND GIRLS CLUB OF ALBANY, THE MENNONITE VILLAGE, UNITED WAY OF LINN COUNTY, BOYS & GIRLS CLUB OF THE GREATER SANTIAM, THE RIVER CENTER, SWEET HOME EMERGENCY MINISTRIES, LEBANON SCHOOL DISTRICT, SWEET HOME SCHOOL DISTRICT, CENTRAL LINN SCHOOL DISTRICT, LINN-BENTON HISPANIC ADVISORY COUNCIL, LINN COUNTY ORAL HEALTH COALITION AND COMMUNITY MEMBERS.
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 4: SAMARITAN LEBANON COMMUNITY HOSPITAL
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 5D: COPIES OF THE CHNA WERE EMAILED TO KEY COMMUNITY PARTNERS AND DISTRIBUTED DURING LOCAL COALITION MEETINGS.
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 7: AGH HAS NOT DIRECTLY ADDRESSED EVERY NEED IDENTIFIED BY THE COMMUNITY BECAUSE THEY DO NOT FALL WITHIN THE SCOPE OF THE ORGANIZATION'S ROLE. THESE NEEDS INCLUDE GROUND WATER MANAGEMENT, ENVIRONMENTAL HAZARDS, AIR QUALITY AND WASTE MANAGEMENT. THESE NEEDS ARE BEING ADDRESSED BY THE APPROPRIATE LOCAL AND STATE AGENCIES.
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 14G: REGISTRATION REFERS UNINSURED AND OR LOW INCOME PATIENTS TO THE ONSITE PATIENT FINANCIAL ADVOCATE AND A THIRD PARTY VENDOR WHO CONTACTS THE PATIENTS TO ASSESS THEIR FINANCIAL STATUS AND NEEDS.
PART V, SECTION B, LINE 14A:	THE ORGANIZATION'S WEBSITE PROVIDES INFORMATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE, INCLUDING FREE AND DISCOUNTED CARE, ALONG WITH CONTACT INFORMATION FOR PATIENTS TO BE ABLE TO APPLY FOR FINANCIAL ASSISTANCE.
PART V, SECTION B, LINE 20D:	THE MAXIMUM AMOUNT CHARGED BY THE HOSPITAL FACILITY TO FAP-ELIGIBLE INDIVIDUALS IS SET TO BE LESS THAN THE AVERAGE OF ALL NEGOTIATED COMMERCIAL INSURANCE RATES.

Schedule H (Form 990) 2013

Page

Part VFacility Information (continued)

Section D. 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?24
Name and address		Type of Facility (describe)
1	OUTPATIENT SURGERY 1048 SIXTH AVE SW ALBANY,OR97321	OUTPATIENT SURGERY
2	SAMARITAN ALBANY SURGICAL ASSOCIATIES 705 ELM ST SW STE 300 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
3	SAMARITAN MID-VALLEY ORTHOPEDICS 832 ELM STREET STE 101 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
4	SAMARITAN VALLEY IMAGING SERVICES 400 NW HICKORY AVE ALBANY,OR97321	IMAGING/WOMEN'S SERVICES
5	HEARTSPRING WELLNESS CENTER - ALBANY 1700 GEARY STREET SE ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
6	SAMARITAN UROLOGY ALBANY 631 ELM ST SW STE 201 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
7	CARDIAC REHAB 620 ELM ST SW ALBANY,OR97321	CARDIAC REHAB CLINIC
8	ALBANY INTERNAL MEDICINE GROUP 1086 7TH AVE SW ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
9	ALBANY LASER SERVICES 705 ELM ST SW STE 200 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
10	ALBANY OBSTETRICS & GYNECOLOGY 705 ELM ST SW STE 200 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
11	CALAPOOIA FAMILY MEDICINE 1100 7TH AVE SW ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
12	MID-VALLEY CHILDREN'S CLINIC 734 ELM ST SW ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
13	ALBANY PULMONOLOGY 400 NW HICKORY AVE STE 200 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
14	SAMARITAN BREAST & SURGICAL SPEC 400 NW HICKORY AVE STE 300 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
15	SAMARITAN FAMILY MEDICINE GEARY ST 1700 GEARY STREET SE ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
16	SAMARITAN FAMILY MEDICINE N ALBANY 400 NW HICKORY AVE STE 302 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
17	SAM HAND & UPPER EXTREMITY THERAPY 400 NW HICKORY AVE STE 302 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
18	SAMARITAN INT MED & PEDIATRIC SPEC 400 NW HICKORY AVE STE 300 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
19	SAMARTIAN OB & GYN N ALBANY 400 NW HICKORY AVE STE 302 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
20	SAMARITAN REBOUND PHY THERAPY 400 NW HICKORY AVE STE 201 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
21	SAMARITAN URGENT CARE GEARY ST 1700 GEARY STREET SE ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
22	SAMARITAN URGENT CARE N ALBANY 400 NW HICKORY AVE STE 303 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
23	WREN OBSTETRICS & GYNECOLOGY 631 ELM ST SW STE 204 ALBANY,OR97321	MEDICAL CLINIC - OUTPATIENT
24	HEARTSPRING WELLNESS CTR - CORVALLIS 990 NW CIRCLE BLVD STE 101 CORVALLIS,OR97330	MEDICAL CLINIC - OUTPATIENT

Schedule H (Form 990) 2013

Page

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 3: THE STAFF FROM THE COMMUNITY HEALTH PROMOTION DEPARTMENT AND OTHER EMPLOYEES OF ALBANY GENERAL HOSPITAL (AGH) PARTICIPATED IN THE COMMUNITY-WIDE LINN COUNTY COMMUNITY HEALTH ASSESSMENT PROCESS DURING 2013. THE OVERALL AGH COMMUNITY HEALTH NEEDS ASSESSMENT IS ADOPTED FROM THE LINN COUNTY COMMUNITY HEALTH ASSESSMENT AND COMMUNITY HEALTH IMPROVEMENT PLAN; HOWEVER IN CONSULTATION WITH THE EPIDEMIOLOGIST FROM BENTON COUNTY HEALTH DEPARTMENT, ADDITIONAL INFORMATION WAS GATHERED THAT IS SPECIFIC TO THE AGH SERVICE AREA IS INCLUDED IN THE CHNA. PERSONS CONSULTED FOR THE HOSPITALS CHNA WERE LINN COUNTY HEALTH DEPARTMENT, COMMUNITY OUTREACH INC., BENTON EAST LINN HEALTH CENTER, OREGON STATE UNIVERSITY, SAMARITAN HEALTH PLANS, WESTERN UNIVERSITY-COMP NORTHWEST, LINN-BENTON COMMUNITY COLLEGE, GREATER ALBANY PUBLIC SCHOOL DISTRICT, LINN-BENTON COUNTY HEALTH EQUITY ALLIANCE, OREGON CASCADES WEST COUNCIL OF GOVERNMENTS, SAMARITAN INTERCOMMUNITY HEALTH NETWORK, DEPARTMENT OF HUMAN SERVICES, OREGON HEALTH AUTHORITY, COMMUNITY SERVICES CONSORTIUM, INREACH CLINIC, BOYS AND GIRLS CLUB OF ALBANY, THE MENNONITE VILLAGE, UNITED WAY OF LINN COUNTY, BOYS & GIRLS CLUB OF THE GREATER SANTIAM, THE RIVER CENTER, SWEET HOME EMERGENCY MINISTRIES, LEBANON SCHOOL DISTRICT, SWEET HOME SCHOOL DISTRICT, CENTRAL LINN SCHOOL DISTRICT, LINN-BENTON HISPANIC ADVISORY COUNCIL, LINN COUNTY ORAL HEALTH COALITION AND COMMUNITY MEMBERS.
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 4: SAMARITAN LEBANON COMMUNITY HOSPITAL
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 5D: COPIES OF THE CHNA WERE EMAILED TO KEY COMMUNITY PARTNERS AND DISTRIBUTED DURING LOCAL COALITION MEETINGS.
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 7: AGH HAS NOT DIRECTLY ADDRESSED EVERY NEED IDENTIFIED BY THE COMMUNITY BECAUSE THEY DO NOT FALL WITHIN THE SCOPE OF THE ORGANIZATION'S ROLE. THESE NEEDS INCLUDE GROUND WATER MANAGEMENT, ENVIRONMENTAL HAZARDS, AIR QUALITY AND WASTE MANAGEMENT. THESE NEEDS ARE BEING ADDRESSED BY THE APPROPRIATE LOCAL AND STATE AGENCIES.
ALBANY GENERAL HOSPITAL	PART V, SECTION B, LINE 14G: REGISTRATION REFERS UNINSURED AND OR LOW INCOME PATIENTS TO THE ONSITE PATIENT FINANCIAL ADVOCATE AND A THIRD PARTY VENDOR WHO CONTACTS THE PATIENTS TO ASSESS THEIR FINANCIAL STATUS AND NEEDS.
PART V, SECTION B, LINE 14A:	THE ORGANIZATION'S WEBSITE PROVIDES INFORMATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE, INCLUDING FREE AND DISCOUNTED CARE, ALONG WITH CONTACT INFORMATION FOR PATIENTS TO BE ABLE TO APPLY FOR FINANCIAL ASSISTANCE.
PART V, SECTION B, LINE 20D:	THE MAXIMUM AMOUNT CHARGED BY THE HOSPITAL FACILITY TO FAP-ELIGIBLE INDIVIDUALS IS SET TO BE LESS THAN THE AVERAGE OF ALL NEGOTIATED COMMERCIAL INSURANCE RATES.

Schedule H (Form 990) 2013

Additional Data

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Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990
lBullet

Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization
ALBANY GENERAL HOSPITAL

Employer identification number
93-0110095

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) FISH OF ALBANY 1800 SE HILL STREET ALBANY,OR97322	51-0175818	501(C)(3)	7,000	SUPPORT FOR TEMPORARY HOUSING SERVICES FOR INDIGENT COMMUNITY MEMBERS
(2) ABC HOUSE PO BOX 68 ALBANY,OR97321	93-1163555	501(C)(3)	7,000	FUNDS FOR THE HEALTHY LIVING COUNSELING PROGRAM
(3) FAMILY TREE RELIEF NURSERY PO BOX 844 ALBANY,OR97321	14-1872327	501(C)(3)	7,000	FUNDS FOR THE EARLY CHILDHOOD THERAPEUTIC PRESCHOOL PROGRAM
(4) BOYS AND GIRLS CLUB OF ALBANY 1215 HILL SE ALBANY,OR97322	93-0549842	501(C)(3)	7,750	FUNDS FOR THE HEALTHY KIDS INITIATIVE

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2013

Page 2

Part III

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

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant
(1) SCHOLARSHIPS	15	27,000
(2) TRANSPORTATION ASSISTANCE	687	76,791
(3) PATIENT SUPPORT	1	109
(4) MEDICAL ASSISTANCE	5	268

Part IV

Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Return Reference

Explanation

PART I, LINE 2:

AGENCIES IN THE COMMUNITY ARE INVITED TO SUBMIT GRANT PROPOSALS THROUGH AN APPLICATION PROCESS. A COMMITTEE REVIEWS THE APPLICATIONS TO DETERMINE IF THE FUNDS REQUESTED WILL BE USED TO ADDRESS THE ORGANIZATION'S ESTABLISHED COMMUNITY HEALTH PRIORITIES, IDENTIFIED NEEDS, AND SUPPORTS THE ORGANIZATION'S MISSION. ONCE APPROVED AND FUNDED, AGENCIES MUST SUBMIT A COMPLETE ANNUAL REPORT DESCRIBING HOW THE FUNDS WERE USED, THE NUMBER OF CLIENTS SERVED, AND HOW OUTCOMES WERE ACHIEVED. THE ALBANY GENERAL HOSPITAL AUXILIARY SCHOLARSHIPS ARE GIVEN ANNUALLY TO STUDENTS AND ADULT EMPLOYEES OF SAMARITAN HEALTH SERVICES AND OTHER LOCAL HEALTH CARE ORGANIZATIONS PURSUING EDUCATION AT THE EDUCATIONAL INSTITUTIONS OF THEIR CHOICE IN THE HUMAN MEDICAL FIELD. THE SCHOLARSHIPS ARE FOR TUITION, BOOKS AND SUPPLIES REQUIRED BY THE STUDENTS' PROGRAM. SCHOLARSHIPS NOT USED FOR INTENDED PURPOSES ARE RETURNED TO THE ORGANIZATION.

Schedule I (Form 990) 2013

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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, line 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Yes

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

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2013

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)DAVID TRIEBESBOARD SECRETARY & TREASURER/CEO AGH	(i) (ii)	0 295,860	0 0	0 23,469	0 20,952	0 28,264	0 368,545	0 0
(2)PAUL DASKALOS DOBOARD VICE-CHAIR/PHYSICIAN	(i) (ii)	408,425 0	14,637 0	564 0	20,952 0	26,738 0	471,316 0	0 0
(3)GREGG MILLER MDBOARD MEMBER/PHYSICIAN	(i) (ii)	246,641 0	500 0	557 0	20,552 0	26,508 0	294,758 0	0 0
(4)STEPHEN NEWMAN MDBOARD MEMBER/PHYSICIAN	(i) (ii)	522,069 0	0 0	2,440 0	20,952 0	10,049 0	555,510 0	0 0
(5)DANIEL B SMITHVP FINANCE/CFO	(i) (ii)	0 299,635	0 0	0 7,665	0 20,952	0 29,455	0 357,707	0 0
(6)JEFFREY PALMGREN MDPHYSICIAN	(i) (ii)	479,260 0	0 0	36,807 0	6,736 0	26,388 0	549,191 0	0 0
(7)RICK D STANLEY MDPHYSICIAN	(i) (ii)	395,758 0	0 0	6,528 0	20,952 0	10,746 0	433,984 0	0 0
(8)SHANE GJESDAL MDPHYSICIAN	(i) (ii)	352,396 0	9,732 0	0 0	15,852 0	26,291 0	404,271 0	0 0
(9)JONATHAN LARSEN MDPHYSICIAN	(i) (ii)	408,488 0	8,245 0	639 0	20,952 0	26,770 0	465,094 0	0 0
(10)STEVEN BALLINGER MDPHYSICIAN	(i) (ii)	479,576 0	0 0	1,176 0	20,952 0	10,044 0	511,748 0	0 0

Schedule J (Form 990) 2013

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation
PART I, LINE 1A	IN CONNECTION WITH ITS EMPLOYEE WELLNESS PROGRAM, THE ORGANIZATION HAS A GYM/FITNESS FACILITY BENEFIT THAT IS AVAILABLE TO ALL EMPLOYEES WHO WORK AT LEAST 32 HOURS PER MONTH. UNDER THIS PROGRAM, EMPLOYEES MUST MEET MINIMUM USAGE REQUIREMENTS IN ORDER TO QUALIFY FOR ONGOING BENEFITS. IF AN EMPLOYEE PARTICIPATES AT A NON-SAMARITAN GYM, REIMBURSEMENT IS MADE FOR UP-FRONT FEES, AND THEN PERIODICALLY UPON COMPLETION OF AT LEAST 60 VISITS. REIMBURSEMENT DOES NOT EXCEED $300 PER YEAR AND IS INCLUDED IN THE EMPLOYEE'S TAXABLE WAGES AND IS SUBJECT TO FEDERAL/STATE WITHHOLDING TAX. NO PERSONS LISTED IN PART VII THAT ARE EMPLOYED BY THE FILING ORGANIZATION UTILIZED THIS TAXABLE TAXABLE GYM BENEFIT DURING 2013. IF AN EMPLOYEE PARTICIPATES AT A SAMARITAN FITNESS CENTER (SAMFIT), MEMBERSHIP IS FREE OF CHARGE (PROVIDED AS A NONTAXABLE FRINGE BENEFIT), BUT THE EMPLOYEE IS REQUIRED TO ATTEND THE GYM 50 TIMES DURING EACH PERIOD OF 6 CONSECUTIVE MONTHS TO MAINTAIN THIS BENEFIT. ONE BOARD MEMBER AND ONE HIGHEST PAID EMPLOYEE UTILIZED THE SAMFIT BENEFIT DURING 2013.
PART I, LINE 3	THE CHIEF EXECUTIVE OFFICER IS EMPLOYED AND PAID BY A RELATED ORGANIZATION. THE RELATED ORGANIZATION CONDUCTS A COMPENSATION ANALYSIS EACH YEAR TO COMPARE COMPENSATION OF ALL PAID POSITIONS TO MARKET SURVEYS OF COMPENSATION FOR SIMILAR POSITIONS IN OTHER ORGANIZATIONS. PERIODICALLY, THE RELATED ORGANIZATION WILL ALSO USE WRITTEN EMPLOYMENT CONTRACTS, FORM 990 OF OTHER ORGANIZATIONS, AND INDEPENDENT COMPENSATION CONSULTANTS TO DETERMINE THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER.
PART I, LINE 5	VARIOUS PHYSICIAN COMPENSATION METHODOLOGIES ARE UTILIZED AND, DEPENDING ON SPECIALTY, RELATIVE VALUE UNITS (RVU'S) MAY BE USED IN DETERMINING A PORTION OF OR ALL OF THEIR COMPENSATION.

Schedule J (Form 990) 2013

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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.
MediumBullet

Information about Schedule L (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

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	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

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?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No
(1) J PALMGREN MD	EMPLOYEE	RECRUIT		X	100,000	60,637		No	Yes		Yes





Total ...... $						60,637

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) 2013

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?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) STEPHANIE HAGERTY	FAM MBR, P HAGERTY	94,667	EMP BY ORG		No
(2) ELM ST MEDICAL PROP LLC	>5% PT. P DASKALOS	238,728	PROP RENTAL		No
(3) ELM ST MEDICAL PROP LLC	>5% PT. G MILLER	238,728	PROP RENTAL		No
(4) ALBANY ANESTHESIA PC	>5% SH PC P GREAVES	121,829	PROF SVCS		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2013

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 2	PAUL DASKALOS, DO AND GREGG MILLER, MD HAVE A BUSINESS RELATIONSHIP.
FORM 990, PART VI, SECTION A, LINE 6	ALBANY GENERAL HOSPITAL HAS A SOLE CORPORATE MEMBER, SAMARITAN HEALTH SERVICES, INC., WHICH IS A SECTION 501(C)(3) TAX-EXEMPT ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A	ALBANY GENERAL HOSPITAL ELECTS MEMBERS OF ITS BOARD OF DIRECTORS. THOSE ELECTED MEMBERS ARE THEN SUBMITTED TO THE SOLE CORPORATE MEMBER FOR APPROVAL.
FORM 990, PART VI, SECTION A, LINE 7B	THE SOLE CORPORATE MEMBER HAS SEVERAL RESERVED POWERS OVER THE ORGANIZATION. THESE RESERVED POWERS INCLUDE, BUT ARE NOT LIMITED TO, APPROVAL AT CERTAIN THRESHOLD LEVELS: THE BORROWING OF FUNDS, MERGERS AND ACQUISITIONS, AND SALES OR TRANSFERS OF ASSETS. IN ADDITION, THE SOLE CORPORATE MEMBER MUST APPROVE ANY CHANGE IN THE MISSION OF THE ORGANIZATION, THE ANNUAL BUDGET, AND ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS.
FORM 990, PART VI, SECTION B, LINE 11	A COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES), AS ULTIMATELY FILED WITH THE IRS, WAS PROVIDED TO EACH VOTING MEMBER OF THE SAMARITAN HEALTH SERVICES (SHS) AUDIT AND COMPLIANCE COMMITTEE PRIOR TO ITS FILING WITH THE IRS. SHS IS A 501(C)(3) CORPORATION AND IS THE SOLE MEMBER OF THE FILING ORGANIZATION. SHS'S CHIEF FINANCIAL OFFICER CONDUCTED THE FORM 990 REVIEW WITH THE COMMITTEE AND PROVIDED TIME FOR QUESTIONS FROM THE GROUP. A FORMAL REPORT OF THIS COMMITTEE HAS BEEN MADE TO THE FULL BOARD OF DIRECTORS OF SHS.
FORM 990, PART VI, SECTION B, LINE 12C	BOARD MEMBER CONFLICTS OF INTEREST: THE MEMBERS OF THE BOARD MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE, WHICH REQUIRES DISCLOSURE OF ANY CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THE COMPLETED QUESTIONNAIRES ARE REVIEWED BY THE CHIEF FINANCIAL OFFICER AND CORPORATE COMPLIANCE OFFICER. IF A CONFLICT IS DISCLOSED THAT COULD PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THIS IS EVALUATED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES (SHS) BOARD OF DIRECTORS TO DETERMINE WHETHER THE MEMBER SHOULD CONTINUE TO SERVE ON THE BOARD. IF A CONFLICT IS DISCLOSED THAT DOES NOT PROHIBIT A MEMBER FROM SERVING ON THE BOARD, THE CONFLICT IS MANAGED THROUGH A PROCESS SET FORTH IN THE ORGANIZATION'S BYLAWS. THE BYLAWS PROHIBIT ANY BOARD MEMBER FROM VOTING ON AN ACTION WHERE AN INDIVIDUAL MEMBER HAS A CONFLICT OF INTEREST. EMPLOYEE CONFLICTS OF INTEREST: THE SHS CODE OF ETHICS AND CONDUCT POLICY REQUIRES THAT ALL SHS EMPLOYEES COMPLETE AN ANNUAL DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST. THROUGH THE HUMAN RESOURCES SOFTWARE, PERFORMANCE MANAGER, THE DISCLOSURE REQUIREMENT NOTICE IS ASSIGNED TO ALL EMPLOYEES AND BY YEAR END ALL TASKS ARE TO BE COMPLETED. IF THERE IS A PERCEIVED CONFLICT OF INTEREST IT IS REVIEWED BY THE CORPORATE COMPLIANCE OFFICER, LEGAL COUNSEL AND/OR SENIOR MANAGEMENT. ACTUAL CONFLICTS OF INTEREST ARE REVIEWED AND DISCUSSED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE SAMARITAN HEALTH SERVICES BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 15	THE CEO OF THE PARENT COMPANY, SAMARITAN HEALTH SERVICES (SHS) USES PUBLICLY AVAILABLE INFORMATION TO DETERMINE THE COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL OF THE FILING ORGANIZATION. HE CONSULTS WITH THE INDEPENDENT CONSULTANT AS TO THE REASONABLENESS OF THIS DATA TO ENSURE THAT THE TOP MANAGEMENT OFFICIAL'S COMPENSATION IS REASONABLE AS COMPARED TO SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. PHYSICIAN EMPLOYEE COMPENSATION, INCLUDING PHYSICIANS WHO ARE BOARD MEMBERS, IS REVIEWED AT LEAST ANNUALLY BY SENIOR MANAGEMENT. THIS REVIEW INCLUDES COMPARISON WITH PUBLISHED PHYSICIAN COMPENSATION STUDIES. FOR ALL OTHER EMPLOYEES, THE ORGANIZATION PERFORMS AN ANALYSIS EACH YEAR TO COMPARE COMPENSATION OF ALL PAID POSITIONS TO MARKET SURVEYS OF COMPENSATION FOR SIMILAR POSITIONS IN OTHER ORGANIZATIONS.
FORM 990, PART VI, SECTION C, LINE 19	FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. SYSTEM-WIDE SUMMARIZED DATA IS ALSO PROVIDED IN THE ANNUAL REPORT TO THE COMMUNITY. THIS REPORT IS MADE AVAILABLE IN ALL KIOSKS AND HIGH-TRAFFIC AREAS OF ALL HOSPITALS AND PHYSICIAN CLINICS, AS WELL AS COMMUNITY PLACES SUCH AS THE PUBLIC LIBRARY. IT IS ALSO DISTRIBUTED TO THE BOARDS OF DIRECTORS AND DIRECTLY MAILED TO DONORS AND NEW RESIDENTS IN THE COMMUNITY. ADDITIONALLY, THE REPORT IS MADE AVAILABLE AT ALL EVENTS, COMMUNITY OUTREACH PROJECTS, AND SCREENINGS ATTENDED THROUGHOUT THE YEAR. GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 9:	INTERCOMPANY TRANSFERS -287,948.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2013

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

ALBANY GENERAL HOSPITAL

Employer identification number

93-0110095

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on 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" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) GOOD SAMARITAN HOSPITAL CORVALLIS PO BOX 3000 CORVALLIS,OR973393000 93-0391573	HOSPITAL SERVICES FOR THE COMMUNITY	OR	501(C)(3)	3	SAMARITAN HEALTH SERVICES		No
(2) ALBANY GENERAL HOSPITAL FOUNDATION 1046 SIXTH AVENUE SW ALBANY,OR97321 93-0712890	TO SUPPORT ALBANY GENERAL HOSPITAL	OR	501(C)(3)	7	ALBANY GENERAL HOSPITAL	Yes
(3) FIRSTCARE HEALTH FOUNDATION PO BOX 3000 CORVALLIS,OR973393000 93-0900124	TO SUPPORT AFFILIATED EXEMPT ENTITIES	OR	501(C)(3)	11B, II	SAMARITAN HEALTH SERVICES		No
(4) FIRSTCARE MEDICAL FOUNDATION PO BOX 3000 CORVALLIS,OR973393000 93-0932697	FUTURE CHARITABLE HEALTHCARE INITIATIVES (NO CURRENT YEAR ACTIVITY)	OR	501(C)(3)	9	SAMARITAN HEALTH SERVICES		No
(5) GOOD SAMARITAN HOSPITAL FOUNDATION PO BOX 1068 CORVALLIS,OR97339 23-7252406	TO SUPPORT GOOD SAMARITAN HOSPITAL	OR	501(C)(3)	7	GOOD SAMARITAN HOSPITAL		No
(6) INTERCOMMUNITY HEALTH PLANS INC PO BOX 3000 CORVALLIS,OR973393000 93-1124326	SERVE OREGON HEALTH PLAN FOR MEDICAID	OR	501(C)(4)	N/A	SAMARITAN HEALTH SERVICES		No
(7) LEBANON COMMUNITY HOSPITAL FOUNDATION PO BOX 739 LEBANON,OR97355 93-1260080	TO SUPPORT LEBANON COMMUNITY HOSPITAL	OR	501(C)(3)	7	MID-VALLEY HEALTHCARE INC		No
(8) MID-VALLEY HEALTHCARE INC PO BOX 3000 CORVALLIS,OR973393000 93-0396847	HOSPITAL SERVICES FOR THE COMMUNITY	OR	501(C)(3)	3	SAMARITAN HEALTH SERVICES		No
(9) PARADIGM INDEMNITY CORPORATION PO BOX 3000 CORVALLIS,OR973393000 73-1668317	PURE NON-PROFIT CAPTIVE INSURANCE COMPANY	HI	501(C)(3)	11A, I	SAMARITAN HEALTH SERVICES		No
(10) SAMARITAN HEALTH SERVICES INC PO BOX 3000 CORVALLIS,OR973393000 93-0951989	PROVIDE HEALTHCARE SUPPORT SERVICES	OR	501(C)(3)	11C, III-FI	N/A		No
(11) SAMARITAN NORTH LINCOLN HOSPITAL 3043 NE 28TH STREET LINCOLN CITY,OR97367 93-1305493	HOSPITAL SERVICES FOR THE COMMUNITY	OR	501(C)(3)	3	SAMARITAN HEALTH SERVICES		No
(12) SAMARITAN PACIFIC HEALTH SERVICES 930 SW ABBEY STREET NEWPORT,OR97365 93-1329784	HOSPITAL SERVICES FOR THE COMMUNITY	OR	501(C)(3)	3	SAMARITAN HEALTH SERVICES		No
(13) SAMARITAN SENIOR CARE INC PO BOX 3000 CORVALLIS,OR973393000 93-1245534	FUTURE CHARITABLE HEALTHCARE INITIATIVES (NO CURRENT YEAR ACTIVITY)	OR	501(C)(3)	9	SAMARITAN HEALTH SERVICES		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2013

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) SAMARITAN ENDOSCOPY CENTER LLC 3600 NW SAMARITAN DR CORVALLIS,OR97330 20-2860067	MEDICAL SERVICES	OR	N/A
(2) CORVALLIS MEDICAL BUILDINGS LLC 3600 NW SAMARITAN DRIVE CORVALLIS,OR97330 93-1257913	REAL ESTATE RENTAL	OR	N/A
(3) EAST LINN MRI LLC 3600 NW SAMARITAN DRIVE CORVALLIS,OR97330 32-0229399	IMAGING	OR	N/A
(4) HULL IMAGING LLC 3600 NW SAMARITAN DRIVE CORVALLIS,OR97330 20-3255479	IMAGING	OR	N/A
(5) CORVALLIS MRI A JOINT VENTURE 3615 NW SAMARITAN DRIVE CORVALLIS,OR97330 93-0949704	IMAGING	OR	N/A
(6) MID-VALLEY MEDICAL PROPERTIES ASSOC LLC 1046 SIXTH AVE SW ALBANY,OR97321 30-0508747	REAL ESTATE RENTAL	OR	ALBANY GENERAL HOSPITAL	EXCLUDED	45,303	593,852		No		Yes		36.760 %
(7) MID-VALLEY MEDICAL BUILDINGS LLC PO BOX 557 LEBANON,OR97355 93-1126353	REAL ESTATE RENTAL	OR	N/A
(8) NORTHWEST MEDICAL ISOTOPES LLC 815 NW 9TH ST STE 256 CORVALLIS,OR97330 27-3007752	RESEARCH	OR	N/A
(9) CASCADE VIEW MEDICAL OFFICE BUILDING LLC PO BOX 3000 CORVALLIS,OR973393000 30-0658805	REAL ESTATE RENTAL	OR	N/A
(10) 2750 HARRISON BLVD LLC 413 SW 13TH AVE STE 300 PORTLAND,OR97205 27-4665571	REAL ESTATE RENTAL	OR	N/A

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) SAMARITAN HEALTH PLANS INC 3600 NW SAMARITAN DRIVE CORVALLIS,OR97330 93-0860860	HEALTH INSURANCE CARRIER FOR THE COMMUNITY	OR	N/A	C				No

Schedule R (Form 990) 2013

Page 3

Part V

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

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

Yes

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

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

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

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

Yes

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

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

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

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

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) INTERCOMMUNITY HEALTH PLANS INC	L	10,681,065	COST
(2) ALBANY GENERAL HOSPITAL FOUNDATION	C	672,249	COST
(3) ALBANY GENERAL HOSPITAL FOUNDATION	O	311,259	COST
(4) ALBANY GENERAL HOSPITAL FOUNDATION	R	85,217	COST

Schedule R (Form 990) 2013

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2013

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2013

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO IMPROVE THE HEALTH AND WELL BEING OF THE COMMUNITY.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	11
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	4
5	Total number of individuals employed in calendar year 2013 (Part V, line 2a) ......	5	1,094
6	Total number of volunteers (estimate if necessary) .............	6	265
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,329,573	672,249
9	Program service revenue (Part VIII, line 2g) .........	127,733,604	151,728,662
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	893,794	504,370
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,061,510	1,073,818
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	132,018,481	153,979,099
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	85,891	135,918
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)	67,141,227	83,065,716
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 339,334
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	59,376,006	73,430,803
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	126,603,124	156,632,437
19	Revenue less expenses. Subtract line 18 from line 12.......	5,415,357	-2,653,338
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	71,253,689	67,246,316
21	Total liabilities (Part X, line 26).............	15,325,170	13,845,510
22	Net assets or fund balances. Subtract line 21 from line 20.....	55,928,519	53,400,806

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 139,658,254 including grants of $ ) (Revenue $ 151,940,476 )
	PROGRAM SERVICES:ALBANY GENERAL HOSPITAL (AGH) IS A 79-BED ACUTE CARE FACILITY AND HEALTH CENTER PROVIDING MEDICAL SERVICES TO THE GREATER ALBANY AREA. AGH HAS MORE THAN 900 EMPLOYEES AND 250 VOLUNTEERS SERVING THE MEDICAL NEEDS OF THE COMMUNITY. DURING 2013, AGH SERVED 2,879 INPATIENTS, HAD 24,059 EMERGENCY DEPARTMENT VISITS, PERFORMED 6,591 SURGERIES AND DELIVERED 578 BABIES. IN ADDITION, AGH PERFORMED 49,812 IMAGING PROCEDURES, HAD 33,869 HOSPICE VISITS, AND HAD 159,946 PHYSICIAN CLINIC VISITS.

4b	(Code: ) (Expenses $ 31,750 including grants of $ 31,750 ) (Revenue $ )
	GRANTS:GRANTS MADE BY ALBANY GENERAL HOSPITAL TO VARIOUS ORGANIZATIONS TO BENEFIT THE COMMUNITY. SEE PART IX, LINE 1 AND RELATED SCHEDULE I FOR MORE DETAILS.

4c	(Code: ) (Expenses $ 104,168 including grants of $ 104,168 ) (Revenue $ )
	SCHOLARSHIPS / INDIVIDUAL ASSISTANCE:COLLEGE SCHOLARSHIPS ARE AWARDED BY THE HOSPITAL AUXILIARY. THE HOSPITAL ALSO GIVES ASSISTANCE TO INDIGENT INDIVIDUALS IN NEED OF ACCESS TO CARE BY PROVIDING TRANSPORTATION ASSISTANCE, PATIENT SUPPORT, AND MEDICAL ASSISTANCE. SEE PART IX, LINE 2 AND SCHEDULE I FOR MORE DETAIL.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses139,794,172

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	3,374,438	637,379	411,057

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





2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 0

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512-514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		672,249
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.......			672,249
			Business Code
2a	NET PATIENT REVENUE		622110	143,689,603	143,689,603
b	RETAIL PHARMACY		446110	7,358,645	7,358,645
c	LIFELINE REVENUE		622110	605,841	605,841
d	OTHER PATIENT REVENUE		622110	74,573	74,573
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			151,728,662
3	Investment income (including dividends, interest, and other similar amounts).......			235,938			235,938
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents	81,052
b	Less: rental expenses	9,653
c	Rental income or (loss)	71,399
d	Net rental income or (loss).......			71,399			71,399
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	3,455,141	11,163
b	Less: cost or other basis and sales expenses	3,197,872	0
c	Gain or (loss)	257,269	11,163
d	Net gain or (loss)..........			268,432			268,432
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a		478,238
b	Less: cost of goods sold ..b		268,931
c	Net income or (loss) from sales of inventory..			209,307			209,307
Miscellaneous Revenue			Business Code
11a	CAFETERIA		722210	581,298			581,298
b	RELEASE OF INFORMATION		561000	131,414	131,414
c	MISCELLANEOUS REVENUE		900099	74,187	74,187
d	All other revenue ....			6,213	6,213
e	Total. Add lines 11a–11d ......			793,112
12	Total revenue. See Instructions......			153,979,099	151,940,476	0	1,366,374


				(A) Beginning of year		(B) End of year
1	Cash–non-interest-bearing .............			9,909	1	10,109
2	Savings and temporary cash investments .........			13,335	2	13,373
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			15,572,496	4	20,485,951
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5	60,637
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net .............			243,954	7	52,870
8	Inventories for sale or use ..............			1,848,007	8	2,045,675
9	Prepaid expenses and deferred charges ..........			743,612	9	969,705
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	73,364,225
b	Less: accumulated depreciation .....	10b	38,597,803	35,343,781	10c	34,766,422
11	Investments—publicly traded securities ..........			5,691,087	11	6,480,832
12	Investments—other securities. See Part IV, line 11 .....			609,998	12	593,849
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............			11,175	14
15	Other assets. See Part IV, line 11 ...........			11,166,335	15	1,766,893
16	Total assets. Add lines 1 through 15 (must equal line 34)......			71,253,689	16	67,246,316
17	Accounts payable and accrued expenses .........			11,985,153	17	8,680,985
18	Grants payable .................				18
19	Deferred revenue ................				19
20	Tax-exempt bond liabilities .............				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			1,017,689	23	1,608,538
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			2,322,328	25	3,555,987
26	Total liabilities. Add lines 17 through 25.........			15,325,170	26	13,845,510
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			55,928,519	27	53,400,806
28	Temporarily restricted net assets ...........				28
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			55,928,519	33	53,400,806
34	Total liabilities and net assets/fund balances ........			71,253,689	34	67,246,316