TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) DENNIS VONDERFECHT........................................................................ CEO	57.00 .......................3.00	X	X		3,163,747	42,698
(2) JEFF FARROW MD........................................................................ DIRECTOR	5.00 .......................	X			41,413	0
(3) CLEM WILKES JR........................................................................ CHAIR	11.00 .......................3.00	X			0	0
(4) GARY PEACOCK........................................................................ DIRECTOR	7.00 .......................1.00	X			0	0
(5) SANDRA BROOKS MD........................................................................ DIRECTOR	6.00 .......................2.00	X			0	0
(6) RICK STOREY........................................................................ DIRECTOR	6.00 .......................	X			0	0
(7) THOMAS FOWLKES........................................................................ DIRECTOR	5.00 .......................1.00	X			0	0
(8) LINDA GARCEAU........................................................................ DIRECTOR	6.00 .......................	X			0	0
(9) DONALD JEANES........................................................................ PAST CHAIR	1.00 .......................	X			0	0
(10) JOANNE GILMER........................................................................ VICE CHAIR	9.00 .......................1.00	X			0	0
(11) DAVID MAY MD........................................................................ DIRECTOR	8.00 .......................	X			0	0
(12) ROBERT FEATHERS........................................................................ PAST CHAIR	6.00 .......................3.00	X			0	0
(13) MICHAEL CHRISTIAN........................................................................ TREASURER	10.00 .......................	X			0	0
(14) BARBARA ALLEN........................................................................ SECRETARY	8.00 .......................	X			0	0
(15) MARVIN EICHORN........................................................................ SENIOR VP/CF	58.00 .......................2.00		X		620,102	39,538
(16) CANDACE JENNINGS........................................................................ SR. VP TN OP	60.00 .......................			X	504,935	77,850
(17) ANN FLEMING........................................................................ SR. VP	53.50 .......................6.50			X	426,280	66,282

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(F) Estimated amount of other compensation from the organization and related organizations
(18) DAVID NICELY........................................................................ VP/CEO WASHI	55.00 .......................	X			355,009	54,424
(19) MONTY MCLAURIN........................................................................ VP/IPMC CEO	55.00 .......................	X			326,159	58,687
(20) LYNN KRUTAK........................................................................ VP/CORP. CFO	55.00 .......................	X			252,982	34,227
(21) SHANE HILTON........................................................................ VP/TN CFO	55.00 .......................	X			239,117	36,111
(22) MORRIS SELIGMAN MD........................................................................ SR. VP/CMO	60.00 .......................		X		547,923	93,706
(23) DOUGLAS EDEMA........................................................................ VP PRES./CEO	55.00 .......................		X		408,337	56,282
(24) JAMES PASKERT MD........................................................................ VP/CMO WASHI	55.00 .......................		X		403,873	55,967
(25) JOHN SCHARIO........................................................................ SVP	57.00 .......................3.00		X		401,522	31,188
(26) KATHERINE BALL........................................................................ FORMER VP/CM	50.00 .......................		X		398,795	21,625
(27) DALE CLAYTORE........................................................................ VP	55.00 .......................			X	231,575	13,855
(28) PAT NIDAY........................................................................ FORMER CNO W	55.00 .......................			X	196,642	33,699
(29) BRAD NURKIN........................................................................ FORMER CEO J	55.00 .......................			X	141,265	8,180
(30) CYNTHIA SALYER........................................................................ VP/CARDIO-PU	.......................			X	237,676	22,474

(A) Name and business address	(B) Description of services	(C) Compensation
SKANSKA USA BUILDING INC, 1633 LITTLETON ROADPARSIPPANYNJ07054	CONSTRUCTION	14,766,320
ETSU COLLEGE OF MEDICINE, BOX 70732JOHNSON CITYTN37614	PRIMARILY PHYS.	9,545,066
MORRISON MANAGEMENT SPECIALISTS, PO BOX 102289ATLANTAGA30368	DIETARY SERVICE	5,877,388
ANESTHESIA PAIN CONSULTANTS, STE 4 1113 SUNSET DRIVEJOHNSON CITYTN37605	PHYSICIAN SVC.	4,768,017
HOSPITAL HOUSEKEEPING SYSTEMS LTD, P O BOX 826SAN ANTONIOTX78293	HOUSEKEEPING	3,769,628
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 138

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	405,051	405,051
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	6,462,311		6,462,311
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	233,351,875	224,273,412	8,239,250	839,213
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	11,164,364	10,670,589	453,847	39,928
9	Other employee benefits .......	35,505,904	31,443,556	4,027,745	34,603
10	Payroll taxes ...........	18,572,983	16,436,281	2,087,586	49,116
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	1,391,092		1,391,092
c	Accounting ...........	291,270		291,270
d	Lobbying ...........	139,937	139,937
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	1,157,590		1,157,590
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	92,184,405	84,136,191	7,818,901	229,313
12	Advertising and promotion ....	2,824,684	2,192,837	618,937	12,910
13	Office expenses .......	8,187,946	8,071,791	27,997	88,158
14	Information technology ......	16,859,971	11,389,567	5,470,404
15	Royalties ..
16	Occupancy ...........	14,034,081	11,033,941	2,938,607	61,533
17	Travel ............	2,102,709	1,509,361	560,910	32,438
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....	198,260	131,485	62,957	3,818
20	Interest ...........	41,651,661		41,651,661
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	51,656,821	27,443,317	24,208,361	5,143
23	Insurance ..............	791,103	2,777	788,326
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 & DRUGS	120,184,686	119,991,972	190,589	2,125
b	REPAIRS & MAINTENANCE	15,057,143	14,296,334	716,244	44,565
c	DUES & SUBSCRIPTIONS	4,256,550	1,254,923	2,998,415	3,212
d	ALL OTHER EXPENSES	1,954,364	1,942,493	-8,466	20,337
e	All other expenses	1,916,977	1,279,297	625,167	12,513
25	Total functional expenses. Add lines 1 through 24e	682,303,738	568,045,112	112,779,701	1,478,925
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............		1
2	Savings and temporary cash investments .........	39,216,743	2	53,114,956
3	Pledges and grants receivable, net ...........	248,258	3	96,609
4	Accounts receivable, net .............	103,299,284	4	117,265,071
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		6,806,393	5	8,492,454
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 .............	15,373,693	7	17,189,476
8	Inventories for sale or use ..............	15,480,550	8	15,873,411
9	Prepaid expenses and deferred charges ..........	3,139,089	9	4,850,577
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	998,845,770
b	Less: accumulated depreciation .....	10b	480,937,560	494,025,566	10c	517,908,210
11	Investments—publicly traded securities ..........	271,118,030	11	285,653,065
12	Investments—other securities. See Part IV, line 11 .....		12
13	Investments—program-related. See Part IV, line 11 .....	307,033,212	13	313,693,918
14	Intangible assets ...............	143,276,118	14	144,707,541
15	Other assets. See Part IV, line 11 ...........	118,937,105	15	120,631,703
16	Total assets. Add lines 1 through 15 (must equal line 34)......	1,517,954,041	16	1,599,476,991
	17	Accounts payable and accrued expenses .........	85,554,685	17	69,022,047
18	Grants payable .................		18
19	Deferred revenue ................	2,928,666	19	2,130,026
20	Tax-exempt bond liabilities .............	813,947,753	20	882,984,693
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 ..	177,320,621	23	145,411,405
24	Unsecured notes and loans payable to unrelated third parties ....	4,437,945	24	2,319,713
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....................	85,155,390	25	100,026,944
26	Total liabilities. Add lines 17 through 25.........	1,169,345,060	26	1,201,894,828
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	348,411,488	27	397,408,151
28	Temporarily restricted net assets ...........	197,493	28	174,012
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 ...........	348,608,981	33	397,582,163
34	Total liabilities and net assets/fund balances ........	1,517,954,041	34	1,599,476,991

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

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

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

Page 2

Name of organization MOUNTAIN STATES HEALTH ALLIANCE

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

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

Page 3

Name of organization MOUNTAIN STATES HEALTH ALLIANCE

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

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

Page 4

Name of organization
MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Part III

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

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below. SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

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

A Check SchCMd Bullet

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

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

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

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

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

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

Yes

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

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

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

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

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

Yes

250,140

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

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

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

250,140

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Identifier	Return Reference	Explanation
	SCHEDULE C, PART II-B, LINE 1	THE COMMUNITY & GOVERNMENT RELATIONS VICE PRESIDENT AND/OR THE DEPARTMENT'S MANAGER OR DIRECTOR ATTENDED THE FOLLOWING LEGISLATIVE CONFERENCES: - PREMIER FEDERAL AFFAIRS NETWORK MEETING - AMERICAN HOSPITAL ASSOCIATION ANNUAL MEETING - TENNESSEE HOSPITAL ASSOCIATION LEGISLATIVE ADVOCACY DAY - TENNESSEE HOSPITAL ASSOCIATION ANNUAL MEETING - HOSPITAL ALLIANCE OF TENNESSEE ANNUAL MEETING - NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS AND RELATED INSTITUTIONS VIP ADVOCACY DAY - TENNESSEE PUBLIC & TEACHING HOSPITALS ASSOCIATION ANNUAL MEETING - VIRGINIA HOSPITAL & HEALTHCARE ASSOCIATION LEGISLATIVE ISSUES CONFERENCE - ASSOCIATION OF AMERICAN MEDICAL COLLEGES GOVERNMENT RELATIONS MEETING THE COMMUNITY & GOVERNMENT RELATIONS VICE PRESIDENT AND/OR DEPARTMENTAL STAFF ALSO CONTACTED CONGRESSIONAL OFFICES CONCERNING THE FOLLOWING ISSUES: - SUPPORT FOR PROVISIONS TO EXPAND INSURANCE COVERAGE (HEALTH INSURANCE EXCHANGES AND MEDICAID EXPANSION) - SUPPORT FOR INITIATIVES TO IMPROVE PAYMENT DELIVERY REDESIGN; SUCH AS ACCOUNTABLE CARE ORGANIZATION DEVELOPMENT - SUPPORT FOR CONTINUATION OF TENNESSEE MEDICAID DISPROPORTIONATE SHARE HOSPITAL PAYMENTS - OPPOSITION TO ADDITIONAL CUTS IN MEDICARE/MEDICAID - SUPPORT FOR REAUTHORIZATION AND FUNDING OF CHILDREN'S HOSPITAL GRADUATE MEDICAL EDUCATION - SUPPORT FEDERAL FUNDING FOR TRAUMA CARE - SUPPORT CONTINUATION OF GRADUATE MEDICAL EDUCATIONAL FUNDING - SUPPORT OF STATE MEDICAID PROVIDER TAX PROVISIONS - SUPPORT OF MEDICARE DEPENDENT HOSPITAL AND LOW-VOLUME DESIGNATIONS THE COMMUNITY & GOVERNMENT RELATIONS VICE PRESIDENT AND/OR THE DEPARTMENTAL DIRECTOR OR MANAGER RESPONDED VIA LETTER, PHONE, OR IN PERSON TO THE FOLLOWING TENNESSEE AND VIRGINIA LEGISLATIVE ISSUES: - SUPPORT OF MEDICAID EXPANSION - TENNESSEE AND VIRGINIA - SUPPORT OF STRONG CERTIFICATE OF NEED PROGRAMS IN TENNESSEE AND VIRGINIA - SUPPORT FOR CONTINUATION OF HOSPITAL ASSESSMENT FEE IN TENNESSEE - SUPPORT OF FUNDING FOR PERINATAL CENTERS IN TENNESSEE - SUPPORT OF SAFETY NET FUNDING FOR PROJECT ACCESS - SUPPORT OF STABLE MEDICAID RATES IN VIRGINIA - SUPPORT "SAFE HARBOR" LEGISLATION FOR DRUG ADDICTED PREGNANT WOMEN - SUPPORT HELMET REQUIREMENT FOR MOTORCYCLISTS

Schedule C (Form 990 or 990EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	43,542,989		43,542,989
b	Buildings ................	514,167,381	158,971,778	355,195,603
c	Leasehold improvements ............	952,503	482,065	470,438
d	Equipment ................	440,182,897	321,483,717	118,699,180
e	Other .................
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				517,908,210

Schedule D (Form 990) 2012

Page 3

Part VII

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

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








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

Part VIII

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

(a) Description of investment type	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) INVESTMENT IN JMH	132,000,000	C
(2) INVESTMENT IN BRMMC	100,273,634	C
(3) INVESTMENT IN SCCH	67,400,494	C
(4) INVESTMENT IN ISHN	14,387,897	C
(5) INVESTMENT IN OTHER	-368,107	F




Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)	313,693,918

Part IX

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

(a) Description				(b) Book value
(1) AWUL-UNDER BOND INDENTURE AGREEMENT				70,092,718
(2) AWUL - CURRENT				20,386,338
(3) DEFERRED CHARGES AND OTHER				17,755,375
(4) LONG TERM COMPENSATION INVESTMENT				12,397,272





Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				120,631,703

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes
ACCRUED SALARIES, ABSENCES & W/H		40,208,513
DUE TO THIRD-PARTY PAYERS		25,496,463
ACCRUED INTEREST		19,498,959
EST. FAIR VALUE OF INT. RATE SWAP		8,219,935
OTHER LONG-TERM LIABILITIES		6,603,074




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		100,026,944
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

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

Part XIII

Supplemental Information

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

Identifier	Return Reference	Explanation
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	"THE ALLIANCE IS CLASSIFIED AS AN ORGANIZATION EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS SUCH, NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS FOR THE ALLIANCE AND ITS TAX-EXEMPT SUBSIDIARIES. TAXABLE ENTITIES ACCOUNT FOR INCOME TAXES IN ACCORDANCE WITH FASB ASC740, "INCOME TAXES" (NOTE L). THE ALLIANCE HAS NO UNCERTAIN TAX POSITIONS AT JUNE 30, 2013 AND 2012. TAX RETURNS FOR FISCAL YEARS 2009 THROUGH 2013 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE".

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

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? ......

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	17,191,567		17,191,567	2.520 %
b	Medicaid (from Worksheet 3, column a) ....	21,036,012	15,635,590	5,400,422	0.790 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .	76,753,019	52,973,261	23,779,758	3.490 %
d	Total Financial Assistance and Means-Tested Government Programs .	114,980,598	68,608,851	46,371,747	6.800 %
Other Benefits		4,884,433	447,464	4,436,969	0.650 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	4,884,433	447,464	4,436,969	0.650 %
f	Health professions education (from Worksheet 5) ..	14,369,294	3,753,039	10,616,255	1.560 %
g	Subsidized health services (from Worksheet 6) ..	17,414,583	7,191,389	10,223,194	1.500 %
h	Research (from Worksheet 7)	347,164	212,960	134,204	0.020 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	186,718		186,718	0.030 %
j	Total. Other Benefits ..	37,202,192	11,604,852	25,597,340	3.750 %
k	Total. Add lines 7d and 7j .	152,182,790	80,213,703	71,969,087	10.550 %

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

Schedule H (Form 990) 2012

Page

Part II

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

		(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
9	Other	229,332	229,332	0.030 %
10	Total	229,332	229,332	0.030 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

72,662,827

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. ......

55,223,749

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).....

178,094,047

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

183,810,040

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

-5,715,993

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 %	(e) Physicians' profit % or stock ownership %
1MED'L SPEC OF JC LLC	MEDICAL SERVICES	51.000 %	49.000 %
2EMMAUS COMM HLTHCR	MEDICAL SERVICES	75.000 %	25.000 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?6 Name, address, and primary website address									Other (Describe)
1	JOHNSON CITY MEDICAL CENTER 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604	X	X	X	X		X	X	REHABILITATION & MENTAL HEALTH
2	INDIAN PATH MEDICAL CENTER 2000 BROOKSIDE DRIVE KINGSPORT,TN37660	X	X		X			X
3	FRANKLIN WOODS COMMUNITY HOSPITAL 300 MED TECH PARKWAY JOHNSON CITY,TN37604	X	X					X
4	SYCAMORE SHOALS HOSPITAL 1501 W ELK AVENUE ELIZABETHTON,TN37643	X	X					X
5	RUSSELL COUNTY MEDICAL CENTER 58 CARROLL STREET LEBANON,VA24266	X	X					X
6	JOHNSON COUNTY COMMUNITY HOSPITAL 16901 S SHADY STREET MOUNTAIN CITY,TN37683	X				X		X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	JOHNSON CITY MEDICAL CENTER
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

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

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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

Yes

If “No,” indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

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

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

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

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

Other (describe in Part VI)

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

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section 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)

	INDIAN PATH MEDICAL CENTER
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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)

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section 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)

	FRANKLIN WOODS COMMUNITY HOSPITAL
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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)

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section 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)

	SYCAMORE SHOALS HOSPITAL
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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)

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section 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)

	RUSSELL COUNTY MEDICAL CENTER
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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)

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section 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)

	JOHNSON COUNTY COMMUNITY HOSPITAL
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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)

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?10
Name and address		Type of Facility (describe)
1	JCMC AMBULATORY SURGERY CENTER 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604	LICENSED AMBULATORY SURGERY CENTER
2	MOUNTAIN STATES IMAGING CENTER 301 MED TECH PARKWAY SUITE 100 JOHNSON CITY,TN37604	LICENSED OUTPATIENT DIAGNOSTIC CENTER
3	PRINCETON TRANSITIONAL CARE 401 PRINCETON ROAD JOHNSON CITY,TN37601	LICENSED SKILLED NURSING FACILITY
4	INDIAN PATH TRANSITIONAL CARE 2000 BROOKSIDE DRIVE KINGSPORT,TN37660	LICENSED SKILLED NURSING FACILITY
5	MEDICAL CNTR HOME CARE-JOHNSON CITY 101 MED TECH PARKWAY SUITE 100 JOHNSON CITY,TN37604	LICENSED HOME HEALTH AGENCY
6	MEDICAL CNTR HOME CARE-KINGSPORT 2020 BROOKSIDE DRIVE 28 KINGSPORT,TN37660	LICENSED HOME HEALTH AGENCY
7	RUSSELL CO MEDICAL CNTR HOME HLTH 116 FLANNAGAN AVENUE LEBANON,VA24266	LICENSED HOME HEALTH AGENCY
8	MEDICAL CENTER HOSPICE 101 MED TECH PARKWAY SUITE 100 JOHNSON CITY,TN37604	LICENSED HOSPICE AGENCY
9	JOHNSON COUNTY HOME HEALTH 1987 SOUTH SHADY STREET MOUNTAIN CITY,TN37683	LICENSED HOME HEALTH AGENCY
10	RUSSELL COUNTY MEDICAL CNTR HOSPICE 116 FLANNAGAN AVENUE LABANON,VA24266	LICENSED HOSPICE AGENCY

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

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

Identifier	ReturnReference	Explanation
RELATED ORGANIZATION INFORMATION	PART I LINE 6A	MOUNTAIN STATES HEALTH ALLIANCE HAS PREPARED AND MADE PUBLIC A COMMUNITY BENEFIT REPORT TO INCLUDE INFORMATION FOR ALL OF THE HOSPITALS WITHIN THE HEALTH SYSTEM
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	A COST TO CHARGE RATIO WAS USED TO CALCULATE LINES 7A AND B UTILIZING THE SCHEDULE H APPLICABLE WORKSHEETS INCLUDING WORKSHEET 2 A RATIO OF PATIENT CARE COST TO CHARGES LINES 7E F G AND H USED DIRECT COSTS OF SPECIFIC PROGRAMS LINE 7I REFLECTS CHARITABLE CONTRIBUTIONS AT COST WE SUBTRACTED LINES 7EI COLUMN C EXPENSE FROM WORKSHEET 2 LINE 4 SO THAT THE EXPENSE WOULD NOT BE DUBLICATED PART I LINE 7G JOHNSON COUNTY COMMUNITY HOSPITAL A FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL OPERATES A PHYSICIAN SPECIALTY CLINIC WHICH INCURRED AN OPERATING LOSS OF 55015 FOR THE TWELVE MONTHS ENDING JUNE 30 2013 THE SPECIALTY CLINIC INCLUDES CARDIOLOGY GENERAL SURGERY PODIATRY AND OTHER SPECIALTY SERVICES THIS CONTINUES TO BE A VALUABLE RESOURCE TO THE RESIDENTS OF THE AREA BY AIDING WITH TRANSPORTATION ISSUES OTHER PHYSICIAN OFFICES ARE MORE THAN AN HOUR AWAY RESOLVING ACCESS LIMITATIONS FOR SPECIALTY SERVICES AND PROVIDING RELIEF TO THE SPECIAL HEALTH PROBLEMS OF A LARGELY ELDERLY POPULATION RUSSELL COUNTY MEDICAL CENTER OPERATES A RURAL HEALTH CLINIC LOCATED IN ST PAUL VA ON THE BORDER OF WISE AND RUSSELL COUNTIES RIVERSIDE CLINIC FIRST OPENED IN 1991 TO PROVIDE PRIMARY CARE SERVICES TO THIS ELDERLY UNDERSERVED POPULATION THE CLINICS LARGEST PAYOR IS MEDICARE WHICH ACCOUNTS FOR 51 OF PATIENT SERVICES DURING FY13 THE CLINIC INCURRED UNREIMBURSED EXPENSES OF 221246 SOME OTHER SUBSIDIZED SERVICES WITHIN MSHA INCLUDE SKILLED NURSING FACILITIES WITHIN TWO HOSPITALS OUR AIR TRANSPORT SERVICE WINGS BABYCHILD GROUND TRANSPORT AND MENTAL HEALTH
COMMUNITY BUILDING ACTIVITIES	PART II	MSHA LEADERS SUPPORT AND ENCOURAGE ALL TEAM MEMBERS TO VOLUNTEER TIME MONEY AND SKILLS TO COMMUNITY SERVICE PROJECTS AND CHARITABLE ORGANIZATIONS SENIOR LEADERS AND BOARD MEMBERS SET A POSITIVE EXAMPLE FOR MSHA TEAM MEMBERS SERVING VOLUNTARILY ON COMMITTEES AND MANAGING BOARDS OF LOCAL SERVICE AND NONPROFIT ORGANIZATIONS MANY ALSO SERVE AS MEMBERS AND CONSULTANTS ON PROFESSIONAL COMMITTEES AND TASK FORCES THAT AFFECT REGIONAL DEVELOPMENT IN HEALTHCARE AND EDUCATION SOME OF THESE TEAM MEMBERS DEVOTE TWO WEEKS OF NORMAL WORK TIME TO OUTSIDE CHARITABLE ACTIVITIES MSHA IN COLLABORATION WITH AREA HEALTH AGENCIES AND PROVIDERS MAY OFFER ASSISTANCE WITH COORDINATION ADVOCACY AND PUBLICITY PROVIDE SPACE OR CONTRIBUTE SUPPLIES TO SUPPORT GROUPS FOR THEIR PROGRAM ACTIVITIES MSHA INCURRED EXPENSES OF ALMOST 2 MILLION ON PHYSICIAN RECRUITMENT TO REPLACE PHYSICIANS RETIRING OR LEAVING OUR SERVICE AREAS INCLUDING RECRUITMENT TO ONE OF OUR FEDERALLY DESIGNATED UNDERSERVED COMMUNITIES WITHOUT MSHAS DEDICATION TO RURAL HEALTH THERE WOULD NOT BE AN ADEQUATE NUMBER OF PHYSICIANS TO SERVE THIS PATIENT POPULATION MSHA SUPPORTS THE ECONOMIC DEVELOPMENT OF THE REGION BY PROVIDING FINANCIAL SUPPORT TO ECONOMIC DEVELOPMENT PROGRAMS EVIDENCE SHOWS THAT A HEALTHY ECONOMY RELATES TO A HEALTHIER POPULATION
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	OUR VICE PRESIDENT OF PATIENT FINANCIAL SERVICES ESTIMATES THAT 76 OF BAD DEBT EXPENSE WAS ASSUMED ATTRIBUTABLE TO PATIENTS LIKELY ELIGIBLE FOR FINANCIAL ASSISTANCE WE HAVE MANY INSTANCES DURING THE YEAR OF PATIENTS WITH LARGE ACCOUNT BALANCES AND NO HEALTH INSURANCE COVERAGE THAT WE ARE SURE WOULD QUALIFY FOR CHARITY CARE ALTHOUGH HOSPITAL TEAM MEMBERS ENCOURAGE THESE INDIVIDUALS TO COMPLETE OUR FINANCIAL ASSISTANCE APPLICATION MANY WILL NOT DO SO EVEN WHEN THESE INDIVIDUALS ARE TOLD WE FEEL SURE THEY DO QUALIFY FOR FULL OR PARTIAL ASSISTANCE THEY STILL REFUSE TO COMPLETE OUR FINANCIAL ASSISTANCE APPLICATION REGARDING LINE 3 IT IS IMPLAUSIBLE TO DETERMINE THE AMOUNT OF MSHAS BAD DEBT ASSOCIATED WITH THOSE PATIENTS WHO MAY HAVE MET THE CRITERIA SET FORTH IN OUR FINANCIAL ASSISTANCE POLICY WITHOUT HAVING A COMPLETED FINANCIAL ASSESSMENT WE ARE UNABLE TO DETERMINE OUR PATIENTS FINANCIAL CIRCUMSTANCES UNLESS A COMPLETED FINANCIAL ASSESSMENT FORM IS VOLUNTARILY PROVIDED TO US WE CAN ASSERT THAT MORE THAN 97 OF OUR PATIENTS WHO HAVE PROVIDED COMPLETED FINANCIAL ASSESSMENT FORMS HAVE BEEN APPROVED FOR AT LEAST PARTIAL FINANCIAL ASSISTANCE THE FOLLOWING TEXT IS INCLUDED IN MSHAS FY13 AUDITED FINANCIAL STATEMENTS FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRDPARTY COVERAGE THE ALLIANCE ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS IF NECESSARY FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLE ACCOUNTS FOR WHICH THE THIRDPARTY PAYER HAS NOT PAID OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY FOR RECEIVABLES ASSOCIATED WITH PATIENTS WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLES AND COPAYMENT BALANCES DUE FOR WHICH THIRDPARTY COVERAGE EXISTS FOR PART OF THE BILL THE ALLIANCE RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE THE FOOTNOTES TO THE AUDITED FINANCIAL STATEMENTS REPORT THE AMOUNT OF ESTIMATED UNCOLLECTIBLE SELFPAY AND EXPLAIN THAT UNCOLLECTIBLE PATIENT ACCOUNTS RECEIVABLE ESTIMATED RESERVES ARE BASED UPON PRIOR COLLECTION HISTORY FOR GROUPS OF RECEIVABLES KNOWN COLLECTION RISKS AND OTHER ENVIRONMENTAL FACTORS INCLUDING THE AGE OF THE RECEIVABLES
MEDICARE EXPLANATION	PART III LINE 8	MEDICARE ALLOWABLE COSTS WERE REPORTED USING MSHAS FILED MEDICARE COST REPORT CR THE CR USES A COST TO CHARGE RATIO BASED ON A STEPDOWN ALLOCATION METHODOLOGY IN CARING FOR THE PATIENT THERE ARE SEVERAL SERVICES THAT ARE CONSIDERED NONALLOWABLE SUCH AS TRANSPORTATION OF A PATIENT COMFORT ITEMS TO INCLUDE A TELEVISION MAGAZINES OR A TELEPHONE ADDITIONAL NONALLOWABLE COSTS INCLUDE THE RECRUITMENT OF PHYSICIANS PHYSICIAN GUARANTEES AND A PORTION OF THE BAD DEBT 12 ASSOCIATED WITH THE CARE OF THE PATIENT MEDICARE LOSSES INCLUDING SOME NONALLOWABLE COSTS SHOULD BE COUNTED AS A COMMUNITY BENEFIT AS THIS IS THE COST OF CARE FOR SERVING THE AGING POPULATION AS A NOTFORPROFIT ORGANIZATION WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF THE COMMUNITY AND THE INDIVIDUAL WHILE MAINTAINING A HIGH LEVEL OF HEALTH CARE SERVICES WITHOUT LOSSES SINCE LOSSES DO OCCUR THROUGH THE CMS SYSTEM OF REIMBURSEMENT THESE LOSSES ARE A COST OF DOING BUSINESS FOR OUR COMMUNITY AND SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS A PARTICIPATING PROVIDER IN THE MEDICARE PROGRAM MSHA IS REQUIRED TO PROVIDE THE FULL REGIMEN OF CARE FOR OUR MEDICARE POPULATION THERE ARE A NUMBER OF CARE REGIMENS THAT ARE COMPENSATED BY THE MEDICARE PROGRAM AT LEVELS BELOW OUR COST THEREFORE IT IS ONLY LOGICAL TO ALLOW MSHA TO REPORT THESE UNCOMPENSATED SERVICES AS A COMMUNITY BENEFIT ON THIS DOCUMENT BY MAKING THIS CHANGE NONPROFIT PROVIDERS WILL BE ENCOURAGED TO SUSTAIN IMPORTANT CARE DELIVERY MODELS FOR OUR AGING POPULATION IN SPITE OF THE FACT IT IS SOMETIMES ECONOMICALLY INJURIOUS
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	MSHA FOLLOWS A STRONG COLLECTION PROGRAM THAT COMMUNICATES FINANCIAL RESPONSIBILITY TO THE PATIENT COLLECTION PRACTICES APPLY TO ALL PATIENTS CHARITY AND NONCHARITY CARE IN ROUTINE CIRCUMSTANCES WHEN IT IS DETERMINED THAT A PATIENT HAS NOT RESPONDED TO REQUESTS FOR PAYMENT AND HAS NOT PROVIDED INFORMATION TO ASCERTAIN ABILITY TO PAY AN ACCOUNT CAN BE REFERRED TO AN OUTSIDE COLLECTION AGENCY FOR COLLECTION ASSISTANCE MSHA ENSURES THAT OUTSIDE COLLECTION AGENCIES FOLLOW HOSPITAL BILLING AND COLLECTION GUIDELINES ONCE A DELINQUENT PATIENT ACCOUNT HAS BEEN SUBMITTED TO AN OUTSIDE AGENCY IT CAN BE ADJUSTED TO CHARITY IF THE DETERMINATION IS LATER MADE THAT THE PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE ALL REQUESTS FOR FINANCIAL ASSISTANCE MUST BE ACCOMPANIED BY A COMPLETED FINANCIAL ASSESSMENT FORM AND SUPPORTING DOCUMENTATION
NEEDS ASSESSMENT	PART VI	PART VI LINE 2 MSHA INCLUDED AMERICAS HEALTH RANKINGS AHR IN ITS ASSESSMENT IN ORDER TO BETTER DEFINE THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES TENNESSEE RANKS 42ND AND VIRGINIA RANKS 26TH HOWEVER IT SHOULD BE NOTED THAT SOUTHWEST VIRGINIA WHERE SOME OF MSHA FACILITIES ARE LOCATED CLOSELY RESEMBLES THE HEALTH RANKINGS FOR TENNESSEE AMERICAS HEALTH RANKINGS ARE BASED ON A SERIES OF MEASURES INCLUDING SEVERAL HEALTH OUTCOMES AND HEALTH FACTORS A SURVEY WAS GIVEN TO 67 INDIVIDUALS REPRESENTING THE NINE COUNTIES IN WHICH MSHA OWNS A FACILITY THESE INDIVIDUALS INCLUDED PHYSICIANS PUBLIC HEALTH LEADERS NONPROFIT DIRECTORS SCHOOL NURSES AND OFFICIALS AND BUSINESS LEADERS A SURVEY WAS GIVEN TO EACH INDIVIDUAL SEEKING FEEDBACK REGARDING AVAILABLE RESOURCES IN EACH AREA THE HEALTH STATUS HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT THE MAJORITY OF RESPONSES SUGGESTED FOCUSING ON EDUCATION IN ORDER TO PROMOTE HEALTHY HABITS OTHER RESPONSES INCLUDED MAKE PHYSICAL EDUCATION A REQUIREMENT AS PART OF SCHOOL CURRICULUM IMPROVE NATURAL TRAILS AND WALKWAYS INCREASE COMMUNITY SUPPORT FOR SMOKEFREE AREAS PARTNER WITH LOCAL FARMERS MARKETS SHARE HEALTH INFORMATION BETWEEN PHARMACIES NETWORK WITH SMALL BUSINESSES AND NONPROFITS IN ORDER TO AVOID DUPLICATING RESOURCES AND PROVIDE EARLY SCREENINGS FOR THE UNINSURED OR UNDERINSURED OVERALL THE COMMUNITY MEMBERS GAVE MSHAS CORE SERVICE AREA A HEALTH STATUS RANKING OF 424 OUT OF 10 1 BEING THE LOWEST 10 BEING THE HIGHEST ALSO ALL 67 PARTICIPANTS AGREED THAT OBESITY CANCER HEART DISEASE AND DIABETES WERE THE TOP HEALTH PRIORITIES IN EACH COUNTY AHR REPORTS THAT TENNESSEE AND VIRGINIA BOTH SAW AN INCREASE IN DIABETES AND OBESITY WITHIN THE PAST TEN YEARS TENNESSEE ALSO RANKS 44TH FOR CARDIOVASCULAR DISEASE AND 45TH FOR CANCER DEATHS AND 46TH FOR DIABETES VIRGINIA OVERALL HAS A BETTER RANKING IN THESE THREE CATEGORIES BUT AS STATED EARLIER SOUTHWEST VIRGINIA CLOSELY RESEMBLES TENNESSEE SINCE COMPLETION OF THE CHNA AND ITS IMPLEMENTATION PLAN MSHA HAS PARTNERED WITH SCHOOLS NONPROFIT AGENCIES AND OTHERS ON VARIOUS INITIATIVES TO ADDRESS HEALTH ISSUES CHILDHOOD OBESITY IN PARTICULAR
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	PART VI LINE 3 MSHA PROVIDES COMMUNICATION OF FINANCIAL ASSISTANCE ON ITS WEBSITE AND ON POSTERS LOCATED IN PROMINENT AREAS OF THE HOSPITALS SUCH AS ADMITTING AND THE EMERGENCY DEPARTMENTS PRINTED EDUCATIONAL MATERIALS INCLUDING FINANCIAL ASSISTANCE CONTACT INFORMATION ARE ALSO PROVIDED IN EACH PATIENTS PAPERWORK POSTERS AND REFERENCE MATERIALS ARE WRITTEN IN BOTH ENGLISH AND SPANISH ADMITTING STAFF ARE TRAINED TO EDUCATE PATIENTS ON MSHAS FINANCIAL ASSISTANCE POLICY MSHA ALSO HAS FINANCIAL COUNSELORS TO PROVIDE FURTHER INFORMATION AND ASSISTANCE TO MSHA PATIENTS REGARDING MSHAS FINANCIAL ASSISTANCE POLICY THESE COUNSELORS ALSO HELP UNINSURED PATIENTS DETERMINE SOURCES OF PAYMENT FOR MEDICAL BILLS AND HELP PATIENTS DETERMINE ELIGIBILITY FOR PROGRAMS SUCH AS TNCAREMEDICAID IN ADDITION MSHA CONTRACTS WITH THE COMPANY FIRSTSOURCE SOLUTIONS USA TO WORK WITH SELFPAYING PATIENTS WHO HAVE LIMITED FINANCIAL RESOURCES FIRSTSOURCE SOLUTIONS DETERMINES A PATIENTS ELIGIBILITY IN MEDICAL COVERAGE OPTIONS AND ASSISTS WITH THEIR ENROLLMENT MSHA BEARS THE COST FOR THE FIRSTSOURCE SOLUTIONS PROGRAM
COMMUNITY INFORMATION	PART VI	PART VI LINE 4 MSHA SERVES THE HEALTHCARE NEEDS OF 29 APPALACHIAN COUNTIES IN TENNESSEE SOUTHWEST VIRGINIA KENTUCKY AND NORTH CAROLINA SOME OF THE COUNTIES MSHA SERVES ARE FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS MSHA OPERATES 2 CRITICAL ACCESS HOSPITALS DICKENSON COMMUNITY HOSPITAL IN VIRGINIA AND JOHNSON COUNTY COMMUNITY HOSPITAL IN TENNESSEE THESE TWO FACILITIES OPERATE IN FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS THE HEALTH STATUS OF THE POPULATION IN MSHAS SERVICE AREA IS GENERALLY POOR THE SERVICE AREA EXTENDS TO SOME OF THE POOREST RURAL COUNTIES IN THE REGION WITH A POVERTY RATE OF ALMOST 30 SOME OF THE MOST WELL OFF COUNTIES IN MSHAS SERVICE AREA STILL HAVE A MEDIAN HOUSEHOLD INCOME LOWER THAN STATE AND NATIONAL AVERAGES RURAL SERVICE AREA COUNTIES SHARE COMMON CHALLENGES OF 1 HIGH RATES OF UNINSURED 2 HIGH PREVALENCE OF OBESITY 3 HIGH PREVALENCE OF DIABETES
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	PART VI LINE 5 MSHA IS DEDICATED TO OPERATING EFFICIENTLY SO THAT WASTE IS MINIMIZED MSHAS LEADERSHIP REMAINS MINDFUL OF MANAGING THE ALLIANCES LIMITED RESOURCES SO THAT ADEQUATE FACILITIES AND EQUIPMENT ARE AVAILABLE FOR THE CARE OF OUR PATIENTS VARIOUS CHECKS AND BALANCES ARE ESTABLISHED TO ENSURE THAT EXPENDITURES FOR OPERATING EXPENSES AND CAPITAL COSTS ARE REASONABLE AND NECESSARY SURPLUS FUNDS ARE INVESTED IN IMPROVING HEALTHCARE WITHIN OUR COMMUNITIES THE MAJORITY OF MSHAS GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATIONS PRIMARY SERVICE AREA PHYSICIANS THAT REQUEST PRIVILEGES WHO ARE QUALIFIED AND CREDENTIALED ARE EXTENDED PRIVILEGES BY MSHA
AFFILIATED HEALTH CARE INFORMATION	PART VI	PART VI LINE 6 MSHA PROVIDES CARE TO PEOPLE IN 29 COUNTIES IN TENNESSEE VIRGINIA KENTUCKY AND NORTH CAROLINA EACH HOSPITAL IS FULLY ACCREDITED MOST BY THE JOINT COMMISSION MSHA IS INTEGRATED BOTH VERTICALLY AND HORIZONTALLY AND IS THE LARGEST REGIONAL HEALTHCARE SYSTEM WITH 13 HOSPITALS NINE FACILITIES ARE WHOLLYOWNED FACILITIES 8 FACILITIES IN TENNESSEE AND 1 IN VIRGINIA EACH FACILITY IN THIS FORM 990 IS ACCREDITED BY THE JOINT COMMISSION WITH THE EXCEPTION OF JCCH JCCH RECEIVES CERTIFICATION THROUGH THE STATE OF TENNESSEE SINCE IT IS A CRITICAL ACCESS HOSPITAL IN ADDITION TO THE WHOLLYOWNED HOSPITALS WITHIN THIS FORM 990 MSHA ALSO HAS MAJORITY OWNERSHIP IN 4 HOSPITALS IN SOUTHWEST VIRGINIA IN ADDITION TO OUR ACUTE CARE HOSPITALS OUR SYSTEM ALSO INCLUDES SUCH SERVICES AS PRIMARYSPECIALTY PHYSICIAN PRACTICES URGENT CARE CENTERS EMERGENCY DEPARTMENTS OCCUPATIONAL MEDICINE REHABILITATION OUTREACH LABORATORY MENTAL HEALTH NEONATAL INTENSIVE CARE A NACHRIAFFILIATED CHILDRENS HOSPITAL RENAL DIALYSIS ST JUDES ONCOLOGY INPATIENTOUTPATIENT SURGERY SKILLED NURSING HOME HEALTH AIR AMBULANCE TRANSPORT AND MORE WITH THESE ADDITIONAL FACILITIES AND SERVICES MSHA EXTENDS A HIGHLY EFFECTIVE HEALTH CARE DELIVERY SYSTEM SINCE OUR SYSTEM IS BOTH HORIZONTALLY AND VERTICALLY INTEGRATED PATIENTS CAN BE EFFICIENTLY MOVED ALONG AN INTEGRATED COMPREHENSIVE CONTINUUM OF CARE AS THEIR HEALTH STATUS DICTATES OUR FLAGSHIP FACILITY JOHNSON CITY MEDICAL CENTER IS AT THE CORE OF OUR SYSTEM OFFERING FULL SERVICE TERTIARY CARE IN ADDITION TO OUR HOSPITALS MSHA IS THE SOLE MEMBER OF BLUE RIDGE MEDICAL MANAGEMENT CORPORATION BRMMC MSHA EXTENDS AN INTEGRATED HEALTHCARE DELIVERY SYSTEM THROUGH BRMMC TO INCLUDE MULTIPLE PRIMARY AND SPECIALTY CARE PATIENT ACCESS CENTERS AND NUMEROUS OUTPATIENT CARE SITES INCLUDING URGENT CARE CENTERS OCCUPATIONAL MEDICINE SERVICES A SAME DAY SURGERY CENTER AND OUTPATIENT REHABILITATION MSHA COUNTYSPECIFIC OPERATIONS ARE GOVERNED BY A COMMUNITY BOARD OF DIRECTORS COUNTY BOARDS REPORT TO A SYSTEM LEVEL BOARD OF DIRECTORS ALL BOARDS ARE PRIMARILY COMPOSED OF LOCAL COMMUNITY RESIDENTS PART VI LINE 8 MSHA SUBMITS COMMUNITY BENEFIT DATA TO THE VIRGINIA HEALTH AND HOSPITAL ASSOCIATION VHHA AND THE HOSPITAL ALLIANCE OF TENNESSEE HAT VHHA COMBINES DATA FROM ALL SOURCES TO DEMONSTRATE THE COMMUNITY BENEFITS PROVIDED BY BOTH FORPROFIT AND NOTFORPROFIT HOSPITALS AND HEALTH SYSTEMS TO THE STATE OF VIRGINIA HAT PROVIDES ITS MEMBERS AND TENNESSEE LEGISLATORS WITH COMMUNITY BENEFIT DATA IN AN EFFORT TO PROVIDE A CLEAR PICTURE OF NOTFORPROFIT HEALTH SYSTEMS INVESTMENT IN THE COMMUNITIES THEY SERVE
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED	PART VI	TENNESSEE VIRGINIA
JOHNSON CITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 3	PART V LINE 3	MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING ALL OF THE HOSPITALS INCLUDED IN THIS 990 LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
JOHNSON CITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 4	PART V LINE 4	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES JCMCS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE FRANKLIN WOODS COMMUNITY HOSPITAL INDIAN PATH MEDICAL CENTER SYCAMORE SHOALS HOSPITAL JOHNSON COUNTY COMMUNITY HOSPITAL RUSSELL COUNTY MEDICAL CENTER JOHNSTON MEMORIAL HOSPITAL SMYTH COUNTY COMMUNITY HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
JOHNSON CITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 7	PART V LINE 7	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
JOHNSON CITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 14G	PART V LINE 14G	THE MOUNTAIN STATES FINANCIAL ASSISTANCE POLICY HAS BEEN APPROVED BY THE BOARD OF DIRECTORS AND APPLIES TO ALL MSHA HOSPITALS DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISES THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
JOHNSON CITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 20D	PART V LINE 20D	UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT
INDIAN PATH MEDICAL CENTER LINE NUMBER 2 PART V LINE 3	PART V LINE 3	MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING ALL OF THE HOSPITALS INCLUDED IN THIS 990 LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
INDIAN PATH MEDICAL CENTER LINE NUMBER 2 PART V LINE 4	PART V LINE 4	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES IPMCS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE FRANKLIN WOODS COMMUNITY HOSPITAL JCMC SYCAMORE SHOALS HOSPITAL JOHNSON COUNTY COMMUNITY HOSPITAL RUSSELL COUNTY MEDICAL CENTER JOHNSTON MEMORIAL HOSPITAL SMYTH COUNTY COMMUNITY HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
INDIAN PATH MEDICAL CENTER LINE NUMBER 2 PART V LINE 7	PART V LINE 7	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
INDIAN PATH MEDICAL CENTER LINE NUMBER 2 PART V LINE 14G	PART V LINE 14G	DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISES THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
INDIAN PATH MEDICAL CENTER LINE NUMBER 2 PART V LINE 20D	PART V LINE 20D	UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT
FRANKLIN WOODS COMMUNITY HOSPITAL LINE NUMBER 3 PART V LINE 3	PART V LINE 3	MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING ALL OF THE HOSPITALS INCLUDED IN THIS 990 LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
FRANKLIN WOODS COMMUNITY HOSPITAL LINE NUMBER 3 PART V LINE 4	PART V LINE 4	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES FWCHS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE JCMC INDIAN PATH MEDICAL CENTER SYCAMORE SHOALS HOSPITAL JOHNSON COUNTY COMMUNITY HOSPITAL RUSSELL COUNTY MEDICAL CENTER JOHNSTON MEMORIAL HOSPITAL SMYTH COUNTY COMMUNITY HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
FRANKLIN WOODS COMMUNITY HOSPITAL LINE NUMBER 3 PART V LINE 7	PART V LINE 7	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
FRANKLIN WOODS COMMUNITY HOSPITAL LINE NUMBER 3 PART V LINE 14G	PART V LINE 14G	DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISES THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
FRANKLIN WOODS COMMUNITY HOSPITAL LINE NUMBER 3 PART V LINE 20D	PART V LINE 20D	UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT
SYCAMORE SHOALS HOSPITAL LINE NUMBER 4 PART V LINE 3	PART V LINE 3	MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING ALL OF THE HOSPITALS INCLUDED IN THIS 990 LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
SYCAMORE SHOALS HOSPITAL LINE NUMBER 4 PART V LINE 4	PART V LINE 4	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES SSHS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE FRANKLIN WOODS COMMUNITY HOSPITAL INDIAN PATH MEDICAL CENTER JCMC JOHNSON COUNTY COMMUNITY HOSPITAL RUSSELL COUNTY MEDICAL CENTER JOHNSTON MEMORIAL HOSPITAL SMYTH COUNTY COMMUNITY HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
SYCAMORE SHOALS HOSPITAL LINE NUMBER 4 PART V LINE 7	PART V LINE 7	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
SYCAMORE SHOALS HOSPITAL LINE NUMBER 4 PART V LINE 14G	PART V LINE 14G	DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISES THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
SYCAMORE SHOALS HOSPITAL LINE NUMBER 4 PART V LINE 20D	PART V LINE 20D	UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT
RUSSELL COUNTY MEDICAL CENTER LINE NUMBER 5 PART V LINE 3	PART V LINE 3	MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING ALL OF THE HOSPITALS INCLUDED IN THIS 990 LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
RUSSELL COUNTY MEDICAL CENTER LINE NUMBER 5 PART V LINE 4	PART V LINE 4	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES RCMCS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE FRANKLIN WOODS COMMUNITY HOSPITAL INDIAN PATH MEDICAL CENTER SYCAMORE SHOALS HOSPITAL JOHNSON COUNTY COMMUNITY HOSPITAL JCMC JOHNSTON MEMORIAL HOSPITAL SMYTH COUNTY COMMUNITY HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
RUSSELL COUNTY MEDICAL CENTER LINE NUMBER 5 PART V LINE 7	PART V LINE 7	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
RUSSELL COUNTY MEDICAL CENTER LINE NUMBER 5 PART V LINE 14G	PART V LINE 14G	THE MOUNTAIN STATES FINANCIAL ASSISTANCE POLICY HAS BEEN APPROVED BY THE BOARD OF DIRECTORS AND APPLIES TO ALL MSHA HOSPITALS DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISES THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
RUSSELL COUNTY MEDICAL CENTER LINE NUMBER 5 PART V LINE 20D	PART V LINE 20D	UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT
JOHNSON COUNTY COMMUNITY HOSPITAL LINE NUMBER 6 PART V LINE 3	PART V LINE 3	MSHA MET WITH TEN FOCUS GROUPS EACH REPRESENTING ONE OF THE TEN HOSPITAL FACILITIES INCLUDING ALL OF THE HOSPITALS INCLUDED IN THIS 990 LOCATED WITHIN THE CORE COUNTIES OF MSHA FACILITIES 16 COUNTIES EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS NURSES NONPROFIT DIRECTORS COMMUNITY DEVELOPERS FAITH BASED LEADERS PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES EACH GROUP RANGED IN ATTENDANCE FROM 6 TO 21 INDIVIDUALS PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTYS HEALTH STATUS RATING AVAILABLE RESOURCES TOP HEALTH PRIORITIES AND SUGGESTIONS FOR IMPROVEMENT OPEN DISCUSSION FOLLOWED THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS THE SPECIFIC NEEDS FOR EACH COUNTY WERE INCLUDED IN THE APPROPRIATE FACILITY IMPLEMENTATION PLAN
JOHNSON COUNTY COMMUNITY HOSPITAL LINE NUMBER 6 PART V LINE 4	PART V LINE 4	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA FOR THOSE HOSPITALS THAT ARE LOCATED IN THE SAME COUNTY ONLY ONE COMMUNITY GROUP WAS SURVEYED FOR INSTANCE JOHNSON CITY MEDICAL CENTER AND FRANKLIN WOODS COMMUNITY HOSPITAL ARE BOTH LOCATED IN WASHINGTON COUNTY TENNESSEE WE SURVEYED 21 INDIVIDUALS FROM WASHINGTON COUNTY IN ORDER TO DETERMINE HEALTH PRIORITIES JCCHS CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE FRANKLIN WOODS COMMUNITY HOSPITAL INDIAN PATH MEDICAL CENTER SYCAMORE SHOALS HOSPITAL JCMC RUSSELL COUNTY MEDICAL CENTER JOHNSTON MEMORIAL HOSPITAL SMYTH COUNTY COMMUNITY HOSPITAL NORTON COMMUNITY HOSPITAL AND DICKENSON COMMUNITY HOSPITAL
JOHNSON COUNTY COMMUNITY HOSPITAL LINE NUMBER 6 PART V LINE 7	PART V LINE 7	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29 OF FY12 THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2011 AND 2012 AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL AND EACH HOSPITALS BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF MAY AND JUNE 2012 MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL DUE TO LACK OF RESOURCES SOME OF MSHA FACILITIES WERE UNABLE TO ADDRESS ISSUES THAT WERE IDENTIFIED
JOHNSON COUNTY COMMUNITY HOSPITAL LINE NUMBER 6 PART V LINE 14G	PART V LINE 14G	THE MOUNTAIN STATES FINANCIAL ASSISTANCE POLICY HAS BEEN APPROVED BY THE BOARD OF DIRECTORS AND APPLIES TO ALL MSHA HOSPITALS DURING THE ADMISSION PROCESS PATIENTS ARE TOLD THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY AND ADMISSION PAPERS GIVEN TO EACH PATIENT ADVISES THEM OF THE POLICY BILLING CORRESPONDENCE ALSO ADVISES THAT FINANCIAL ASSISTANCE MAY BE AVAILABLE A COMMUNITY RESOURCE GUIDE REPORTS THAT THE HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY
JOHNSON COUNTY COMMUNITY HOSPITAL LINE NUMBER 6 PART V LINE 20D	PART V LINE 20D	UNINSURED PATIENTS RECEIVE A 62 DISCOUNT AND BASED ON OTHER FACTORS SUCH AS INCOME OR MEDICAL INDIGENCY MAY QUALIFY FOR AN ADDITIONAL DISCOUNT

Schedule H (Form 990) 2012

Additional Data

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- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number
62-0476282

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(g) Description of non-cash assistance	(h) Purpose of grant or assistance
(1) AMERICAN CANCER SOCIETY 508 PRINCETON RD SUITE 102 JOHNSON CITY,TN37601	64-0329009	501C3	20,100			PROGRAM SUPPORT
(2) AMERICAN HEART ASSOCIATION 208 SUNSET DRIVE JOHNSON CITY,TN37604	13-5613797	501C3	66,250	702	PRINTING	PROGRAM SUPPORT
(3) BARTER THEATRE PO BOX 867 ABINGDON,VA24212	54-6000120	501C3	19,000		PRINTING	CONTRIBUTION
(4) BRISTOL FAMILY YMCA 400 ML KING JR BLVD BRISTOL,TN37620	62-0521204	501C3	7,000			PROGRAM SUPPORT
(5) COALITION FOR KIDS INC PO BOX 3156 JOHNSON CITY,TN37602	62-1765487	501C3	2,000	5,601	PRINTING	FIGHT CHILD OBESITY
(6) EAST TENNESSEE STATE UNIVERSITY PO BOX 70732 JOHNSON CITY,TN37614	62-6021046	501C3	11,500			SUPPORT FIT KIDS
(7) ETSU FOUNDATION P O BOX 70721 JOHNSON CITY,TN37614	23-7092731	501C3	10,000			ECONOMIC DEVELOPMENT
(8) GOOD SAMARITAN MINISTRY 100 NORTH ROAN STREET JOHNSON CITY,TN37601	62-1233320	501C3		5,657	PRINTING	PROGRAM SUPPORT
(9) JOHNSON CITY PARKS & RECREATION PO BOX 1535 JOHNSON CITY,TN37605	62-6000320	501C3	5,000	405	PRINTING	SPONSORSHIP
(10) JOHNSON CITY SYMPHONY ORCHESTRA PO BOX 533 JOHNSON CITY,TN37605	62-0910261	501C3		5,897	PRINTING	PROGRAM SUPPORT
(11) MARCH OF DIMES 2313 BROWNS MILL ROAD JOHNSON CITY,TN37604	13-1846366	501C3	15,000			PROGRAM SUPPORT
(12) MOUNTAIN STATES FOUNDATION 2335 KNOB CREEK ROAD SUITE 101 JOHNSON CITY,TN37604	58-1418862	501C3	59,500			PROGRAM SUPPORT
(13) NORTHEAST STATE COMMUNITY COLLEGE 2425 HIGHWAY 75 BLOUNTVILLE,TN37617	62-1265326	501C3		11,000	LAB EQUIPMENT
(14) PREMIER PURCHASING 13034 BALLANTYNE CORPORATE PLACE CHARLOTTE,NC28277	33-0387407	501C3	61,052			SUPPORT
(15) SUSAN KOMEN BREAST CANCER FOUND PO BOX 5835 KINGSPORT,TN37663	84-1689067	501C3	5,000	590	PRINTING	SPONSORSHIP
(16) TOWN OF JONESBOROUGH 123 BOONE STREET JONESBOROUGH,TN37659	62-6000322	501C3		10,069	PRINTING	CONTRIBUTION

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2012

Page 2

Part III

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

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

Part IV

Supplemental Information.

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

Identifier	Return Reference	Explanation
PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS INSIDE THE UNITED STATES	SCHEDULE I, PAGE 1, PART I, LINE 2	MSHA ADHERED TO THE FOLLOWING CRITERIA FOR OUR CONTRIBUTIONS TO ORGANIZATIONS IN THE REGION: HEALTHCARE: THE ORGANIZATION ENHANCED OR IMPROVED ACCESS FOR THE UNINSURED OR UNDERINSURED POPULATION OR SUPPORTED A PROGRAM TO IMPROVE THE HEALTH OF OUR CHILDREN (I.E., CHILDHOOD OBESITY PREVENTION). EDUCATION: THE ORGANIZATION PROVIDED A PROGRAM TO IMPROVE EDUCATION OF THE RESIDENTS IN OUR REGION ALL THE WAY TO COLLEGE AGE STUDENTS (SUCH AS RN NURSING AND LAB TECHNOLOGY PROGRAMS). QUALITY OF LIFE: THE ORGANIZATION SUPPORTED PROGRAMS TO ENHANCE THE QUALITY OF LIFE, WHICH IS IMPORTANT IN THE RECRUITMENT EFFORTS OF BUSINESSES IN THE REGION AS WE WORK TO ATTRACT AND RETAIN THE BEST TALENT. FOR THE SUPPORTED PROGRAMS, METRICS WERE ESTABLISHED TO DETERMINE THE SUCCESS (OR FAILURE) OF EACH PROGRAM TO WHICH MSHA CONTRIBUTES. AS DOWNWARD REIMBURSEMENT CONTINUED DURING FY13, THE CRITERIA USED IN THE DECISION MAKING PROCESS FOR LARGER DONATIONS WAS REVISED TO SUPPORT THOSE PROGRAMS WHICH FOCUSED ON HEALTH AND WELLNESS INITIATIVES, PARTICULARLY THOSE FIGHTING CHILDHOOD OBESITY.

Schedule I (Form 990) 2012

Additional Data

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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, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

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 officers,
directors, trustees, and 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? .........

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)DENNIS VONDERFECHTCEO	(i) (ii)	777,545	1,900,431	485,771	20,000	22,698	3,206,445	125,000
(2)MARVIN EICHORNSENIOR VPCFO	(i) (ii)	447,614	94,466	78,022	15,000	24,538	659,640
(3)CANDACE JENNINGSSR VP TN OPERATIONS	(i) (ii)	402,118	82,014	20,803	53,557	24,293	582,785
(4)ANN FLEMINGSR VP	(i) (ii)	351,697	51,836	22,747	48,425	17,857	492,562
(5)DAVID NICELYVPCEO WASHINGTON CO	(i) (ii)	291,022	52,219	11,768	28,073	26,351	409,433
(6)MONTY MCLAURINVPIPMC CEO	(i) (ii)	260,109	51,174	14,876	28,444	30,243	384,846
(7)LYNN KRUTAKVPCORP CFO	(i) (ii)	213,083	37,903	1,996	15,089	19,138	287,209
(8)SHANE HILTONVPTN CFO	(i) (ii)	198,625	36,612	3,880	12,794	23,317	275,228
(9)MORRIS SELIGMAN MDSR VPCMO	(i) (ii)	421,443	82,938	43,542	55,862	37,844	641,629
(10)DOUGLAS EDEMAVP PRESCEO MSPG	(i) (ii)	327,718	62,141	18,478	29,188	27,094	464,619
(11)JAMES PASKERT MDVPCMO WASHINGTON CO	(i) (ii)	342,153	49,161	12,559	29,961	26,006	459,840
(12)JOHN SCHARIOSVP	(i) (ii)	326,339	68,681	6,502	6,630	24,558	432,710
(13)KATHERINE BALLFORMER VPCMIO	(i) (ii)	124,094	41,113	233,588	4,897	16,728	420,420
(14)DALE CLAYTOREVP	(i) (ii)	175,520	34,278	21,777	10,531	3,324	245,430
(15)PAT NIDAYFORMER CNO WASH CO	(i) (ii)	152,049	26,352	18,241	7,985	25,714	230,341
(16)BRAD NURKINFORMER CEO JCMC	(i) (ii)			141,265		8,180	149,445
(17)CYNTHIA SALYERVPCARDIO-PULMONARY	(i) (ii)	63,790	19,891	153,995	4,206	18,268	260,150

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
FRINGE OR EXPENSE EXPLANATION	SCHEDULE J, PAGE 1, PART I, LINE 1A	BOARD MEMBERS AND TEAM MEMBERS OF MSHA ARE NOT PERMITTED TO TRAVEL FIRST-CLASS WITH THE EXCEPTION OF MSHA'S CEO. AS SANCTIONED BY MSHA'S BOARD OF DIRECTORS, MSHA'S CEO IS PERMITTED TO TRAVEL FIRST-CLASS WHEN THE FLIGHT'S DURATION IS GREATER THAN TWO HOURS. DUE TO THE LENGTH OF SUCH FLIGHTS, THE BOARD BELIEVES IT IS IN THE BEST INTEREST OF MSHA FOR THE CEO TO TRAVEL FIRST-CLASS. CHARTER TRAVEL IS LIMITED TO MSHA BUSINESS TRIPS THAT INCLUDE NUMEROUS TRAVELERS AND WHICH CAN BE JUSTIFIED BASED UPON FINANCIAL AND/OR ESSENTIAL TIME SAVINGS. CHARTER FLIGHTS MUST BE APPROVED BY THE CEO PRIOR TO BOOKING THE FLIGHT.
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS	SCHEDULE J, PAGE 1, PART I, LINE 4	CANDACE JENNINGS 0 41,057 0 ANN FLEMING 0 35,925 0 DAVID NICELY 0 14,885 0 MONTY MCLAURIN 0 13,518 0 MORRIS SELIGMAN, M.D. 0 43,110 0 DOUGLAS EDEMA 0 16,778 0 JAMES PASKERT, M.D. 0 17,385 0
OTHER ADDITIONAL INFORMATION	SCHEDULE J, PART III	PART I, LINE 4B: DENNIS VONDERFECHT RECEIVED PAYMENT OF 1,683,614 DURING THE REPORTING PERIOD FROM A 457(F) DEFERRED COMPENSATION PLAN THAT SPANNED A NUMBER OF YEARS. MR. VONDERFECHT MET THE CONDITIONS FOR PAYOUT FROM THE AT-RISK PLAN AND MSHA WITHHELD FEDERAL, STATE AND LOCAL TAXES AS REQUIRED BY LAW. MR. VONDERFECHT SERVED AS MSHA'S CEO FOR 24 YEARS AND RETIRED AT THE END OF 2013. THE FOLLOWING EXECUTIVES LISTED IN SCHEDULE J, PART II PARTICIPATED IN A 457(F) RETIREMENT PLAN PROVIDED BY MOUNTAIN STATES HEALTH ALLIANCE (MSHA): DENNIS VONDERFECHT, ANN FLEMING, CANDACE JENNINGS, MONTY MCLAURIN, CINDY SALYER, MORRIS SELIGMAN, FRANK LAURO, DAVID NICELY, JAMES PASKERT, DOUGLAS EDEMA, AND CARL KILGORE. THE 457(F)PLAN IS A NONQUALIFIED TAX-DEFERRED COMPENSATION PLAN AVAILABLE TO A SELECT GROUP OF KEY EXECUTIVES FOR THE INTENT OF SUPPORTING RETENTION AND TO OFFER A COMPETITIVE TOTAL RETIREMENT PROGRAM. ACCOUNT BALANCES HAVE A "SUBSTANTIAL RISK OF FORFEITURE". IN ADDITION TO CREDITOR RISK, SUBSTANTIAL RISK OF FORFEITURE IS CREATED THROUGH DEFAULT RISK IF THE PARTICIPANT'S EMPLOYMENT WITH MSHA IS TERMINATED PRIOR TO AGE 65. HOWEVER, THE 457(F) PLAN CONTAINS A NON-COMPETE PROVISION THAT PROVIDES THE ACCOUNT BALANCE TO BE PAID IN A LUMP SUM AFTER THE EXECUTIVE SATISFIES THE TWO-YEAR NON-COMPETE PERIOD. THIS PROVISION APPLIES TO EMPLOYER CONTRIBUTIONS IF THE EXECUTIVE HAS PROVIDED ELIGIBLE SERVICE FOR SIX OR MORE YEARS. (ELIGIBLE SERVICE IS OFFICER SERVICE THAT PERMITTED THE EXECUTIVE TO PARTICIPATE IN THE PLAN.) THE EXECUTIVE WILL RECEIVE THE ENTIRE ACCOUNT BALANCE IF HE/SHE BECOMES DISABLED, DIES OR IF THE EXECUTIVE TERMINATES FOR "GOOD REASON" OR IS INVOLUNTARILY TERMINATED WITHOUT "GOOD CAUSE" WITHIN A 24 MONTH PERIOD AFTER A CHANGE-OF-CONTROL OCCURS. DISTRIBUTIONS FROM THIS PLAN ARE SUBJECT TO FEDERAL, STATE, AND LOCAL TAXES ON THE ENTIRE ACCOUNT BALANCE UPON DISTRIBUTION.

Schedule J (Form 990) 2012

Additional Data

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Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number
62-0476282

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	HLTH & EDU FACIL BD 2011A&B&C&D OF THE CITY OF JOHNSON CITY TN	62-1464028	478271JS9	10-19-2011	195,840,000	CONSTRUCTION & EQUIP.		X		X		X
B	HLTH & EDU FACILITIES BD 2010A&B	62-1464028	478271JH3	04-29-2010	205,877,528	PARTIAL REFUNDING		X		X		X
C	HLTH & EDU FACILIT BD 2009AB&C	62-1464028	478271HT9	03-31-2009	124,301,533	CONSTRUCTION & EQUIP.		X		X		X
D	HLTH & EDU FACILITIES BD 2008A&B	62-1464028	478271HL6	02-20-2008	127,000,000	ACQUIRE, CONSTRUCT		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .	4,975,000		17,070,000		2,435,000		61,790,000
2 Amount of bonds legally defeased . . . . . . . . . . .
3 Total proceeds of issue . . . . . . . . . . . . . .	195,840,000		206,132,699		125,642,956		129,700,306
4 Gross proceeds in reserve funds . . . . . . . . . . . .
5 Capitalized interest from proceeds . . . . . . . . . . .	2,719,365						2,719,365
6 Proceeds in refunding escrows . . . . . . . . . . . .
7 Issuance costs from proceeds . . . . . . . . . . . .	2,353,905		3,474,644		2,481,706		1,953,563
8 Credit enhancement from proceeds . . . . . . . . . . .	324,975						324,975
9 Working capital expenditures from proceeds . . . . . . . . .
10 Capital expenditures from proceeds . . . . . . . . . . .	157,897,590				99,702,968		77,394,022
11 Other spent proceeds . . . . . . . . . . . . . .	34,166,505		197,461,005		15,096,666		47,308,380
12 Other unspent proceeds . . . . . . . . . . . . . .	1,422,000		8,297,792		8,361,616
13 Year of substantial completion . . . . . . . . . . . .	2012						2012
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .	X		X			X		X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X		X		X		X
16 Has the final allocation of proceeds been made? . . . . . . . .		X		X		X	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X		X		X		X

Part III

Private Business Use

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

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

Cat. No. 50193E

Schedule K (Form 990) 2012

Page 2

Part III

Private Business Use (Continued)

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

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T? . . . . .		X		X		X		X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .	X		X		X			X
b Exception to rebate? . . . . . . . .		X		X		X		X
c No rebate due? . . . . . . . . . .		X		X		X	X
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . .	X			X		X	X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X		X	X
b Name of provider . . . . . . . . .	MERRILL LYNCH CAPITAL SERVICES INC						CAPITAL SERVICES INC CAPITAL SERVICES INC
c Term of hedge . . . . . . . . . .	30.4						30.4
d Was the hedge superintegrated? . . . . . .		X						X
e Was a hedge terminated? . . . . . . .		X						X

Schedule K (Form 990) 2012

Page 3

Part IV

Arbitrage (Continued)

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

Part V

Procedures To Undertake Corrective Action

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

Part VI

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

Identifier	Return Reference	Explanation
PURPOSE OF ISSUE DESCRIPTION	SCHEDULE K	HLTH EDU FACIL BD 2011ABCD LINE A CONSTRUCT AND EQUIP HOSPITAL FACILITIESINCLUDING REFINANCING TAXABLE DEBT RELATING THERETO REFUND BONDS ISSUED 12012001 REFINANCING LOANS AND EQUIPMENT LEASES HLTH EDU FACILITIES BD 2010AB LINE B PARTIAL REFUNDING OF BONDS ISSUED 12142007 2007A AND 2007C AND 2202008 2008A HLTH EDU FACILIT BD 2009ABC LINE C CONSTRUCT AND EQUIP HOSPITAL FACILITIESINCLUDING REFINANCING OF TAXABLE INDEBTEDNESS RELATING THERETO HLTH EDU FACILITIES BD 2008AB LINE D ACQUIRE CONSTRUCT AND EQUIP HOSPITAL FACILITIES INCLUDING REFINANCING OF TAXABLE INDEBTEDNESS RELATING THERETO AND WORKING CAPITAL EXPENDITURES RELATING TO CAPITAL EXPENDITURES HLTH EDU FACILITIES BD 2006A LINE E CONSTRUCT AND EQUIP HOSPITAL FACILITIESINCLUDING REFINANCING TAXABLE DEBT RELATING THERETO AND COST OF INTEREST RATE HEDGE REFUND BONDS ISSUED 32801 70103 70804 112304 9705 AND 112305 HLTH EDU FACILIL BD 2012ABC LINE F CONSTRUCT AND EQUIP SURGERY CENTER AT JCMC CONSTRUCT AND EQUIP HOSPITAL FACILITIES INCLUDING REFINANCING OF INDEBTEDNESS RELATING THERETO
DATE REBATE COMPUTATION PERFORMED	SCHEDULE K	HLTH EDU FACILITIES BD 2008AB 022013 HLTH EDU FACILITIES BD 2006A 021710
ADDITIONAL INFORMATION	SCHEDULE K	HLTH EDU FACILITIES BD 2006A SCHEDULE K PART VI 1COMMENT ON SCHEDULE K PART I LINES A B C D AND F MOUNTAIN STATES HEALTH ALLIANCE OWNS ANDOR OPERATES HOSPITALS IN A NUMBER OF DIFFERENT LOCATIONS BOTH IN TENNESSEE AND IN VIRGINIA AS A RESULT MOUNTAIN STATES HEALTH ALLIANCE MUST UTILIZE CONDUIT GOVERNMENTAL BOND ISSUERS IN A NUMBER OF JURISDICTIONS IN ORDER TO FINANCE IMPROVEMENTS TO ITS HOSPITAL FACILITIES IN 2008 2009 2010 2011 AND 2012 MOUNTAIN STATES HEALTH ALLIANCE WAS THE CONDUIT BORROWER OF TAXEXEMPT BONDS ISSUED BY MULTIPLE ISSUERS IN TENNESSEE AND VIRGINIA FOR FEDERAL TAX PURPOSES EVEN THOUGH DIFFERENT GOVERNMENT ISSUERS WERE INVOLVED THESE MULTIPLE ISSUES IN EACH YEAR WERE REQUIRED TO BE TREATED AND WERE TREATED AS A SINGLE ISSUE BECAUSE THEY MET THE SINGLE ISSUE TEST UNDER THE APPLICABLE FEDERAL TAX REGULATIONS THEREFORE MULTIPLE ISSUERS ARE LISTED UNDER LINES A B C D AND F BECAUSE THE BONDS THAT WERE ISSUED WERE PART OF A SINGLE ISSUE FOR FEDERAL TAX PURPOSES 2COMMENT ON SCHEDULE K PART II LINE 3 FOR THE BOND ISSUES LISTED IN LINES B C D E AND F DOES NOT MATCH THE APPLICABLE ISSUE PRICE FOR EACH SUCH BOND ISSUE BECAUSE OF INTEREST EARNINGS EARNED ON THE SALE PROCEEDS OF EACH SERIES OF BONDS 3COMMENT ON SCHEDULE K PART II LINES 9 THROUGH 11 THE INSTRUCTIONS ARE UNCLEAR AS TO WHETHER AMOUNTS USED TO REFINANCE SHORTTERM TAXABLE LOANS INCURRED TO TEMPORARILY FINANCE ELIGIBLE COSTS SHOULD BE SHOWN AS CAPITAL EXPENDITURES AND WORKING CAPITAL LINES 9 AND 10 OR AS OTHER SPENT PROCEEDS LINE 11 BASED UPON A REVIEW OF OTHER 990 FILINGS IT APPEARS THAT MOST REPORTING ENTITIES HAVE LISTED THE APPLICATION OF PROCEEDS FOR SUCH PURPOSE UNDER OTHER SPENT PROCEEDS LINE 11 THIS FILING TAKES THAT APPROACH 4COMMENT ON SCHEDULE K PART II LINE 12 IT IS UNCLEAR UNDER THE INSTRUCTIONS WHETHER TRANSFERRED PROCEEDS SHOULD BE TREATED AS OTHER UNSPENT PROCEEDS FOR REPORTING PURPOSES ON LINE 12 AS AN ABUNDANCE OF CAUTION TRANSFERRED PROCEEDS HAVE BEEN INCLUDED ON LINE 12 FOR EACH ISSUE TO THE EXTENT APPLICABLE DURING THE FISCAL YEAR AS TO WHICH THIS SCHEDULE RELATES MOUNTAIN STATES HEALTH ALLIANCE WAS ABLE TO REMOVE THE REQUIREMENT THAT CERTAIN DEBT SERVICE RESERVE FUNDS BE MAINTAINED AS A RESULT MOUNTAIN STATES HEALTH ALLIANCE WAS ABLE TO TRANSFER PROCEEDS FROM DEBT SERVICE RESERVE FUNDS FOR CERTAIN ISSUES TO BOND SINKING FUNDS FOR THOSE ISSUES TO PAY PRINCIPAL ON THE ISSUE AND TO REDUCE THE AMOUNT OF TAXEXEMPT BONDS OUTSTANDING IN THE MARKET AS A RESULT UNSPENT PROCEEDS HAVE INCREASED FOR CERTAIN ISSUES WHILE SUCH FUNDS ARE HELD IN THE BOND SINKING FUNDS AND THE AMOUNTS PREVIOUSLY HELD IN DEBT SERVICE RESERVE FUNDS FOR SUCH ISSUES HAVE BEEN REDUCED MOUNTAIN STATES HEALTH ALLIANCE IS USING SUCH PROCEEDS TO PAY PRINCIPAL AS QUICKLY ON THOSE ISSUES AS THE BOND DOCUMENTS PERMIT 5COMMENT ON SCHEDULE K PART IV LINE 1 PRIOR TO JUNE 30 2013 THE REPORTING DATE OF THE 990 THE ONLY ARBITRAGE REBATE CALCULATIONS THAT WERE REQUIRED RELATED TO THE BONDS DESCRIBED IN LINES D AND E OF PART I THE SERIES 2006 AND 2008 BONDS MOUNTAIN STATES HEALTH ALLIANCE RETAINED A REBATE CALCULATION AGENT TO CALCULATE WHETHER ANY ARBITRAGE REBATE WAS DUE WITH RESPECT TO THOSE BONDS AND THERE WAS NEGATIVE ARBITRAGE REBATE LIABILITY IN A SIGNIFICANT AMOUNT THEREFORE NO FORM 8038T WAS REQUIRED TO BE FILED WITH RESPECT TO THOSE BOND ISSUES 6COMMENT ON SCHEDULE K PART IV LINE 4D PART IV LINE 4D RELATIVE TO THE BOND ISSUE DESCRIBED ON LINE E SHOWS THAT THE REGULATORY SAFE HARBOR FOR ESTABLISHING FAIR MARKET VALUE OF THE GIC DESCRIBED IN LINE 4A WAS NOT SATISFIED DUE TO MARKET CONDITIONS AT THE TIME MOUNTAIN STATES HEALTH ALLIANCE DID NOT RECEIVE THREE BIDS FOR THIS GIC HOWEVER THE YIELD ON THE GIC WAS SO SUBSTANTIALLY BELOW THE YIELD ON THE RELEVANT BONDS THAT THERE WAS NO DOUBT THAT THE YIELD ON THE GIC DID NOT EXCEED THE APPROPRIATE YIELD ON THE RELEVANT BONDS 7COMMENT ON SCHEDULE K PART IV LINE 5 THE BOND ISSUES DESCRIBED IN LINES B C AND D OF PART I FINANCED SIGNIFICANT CAPITAL IMPROVEMENTS TO HOSPITAL FACILITIES THERE HAVE BEEN UNEXPECTED DELAYS IN THE CONSTRUCTION AND EQUIPPING OF CERTAIN OF THESE HOSPITAL FACILITIES AND THEREFORE NOT ALL OF THE BOND PROCEEDS WERE SPENT WITHIN THE THREEYEAR TEMPORARY PERIOD RELATIVE TO CONSTRUCTION PROJECTS HOWEVER MOUNTAIN STATES HEALTH ALLIANCE HAS YIELD RESTRICTED THESE PROCEEDS AFTER THE END OF THE APPLICABLE TEMPORARY PERIOD ANDOR WILL BE MAKING A YIELD REDUCTION PAYMENT WITH RESPECT TO THOSE PROCEEDS IF REQUIRED

Schedule K (Form 990) 2012

Additional Data

Software ID:
Software Version:

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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.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

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) DENNIS VONDERFECHT		SPLIT LIFE INSUR.LOAN,INCL.PR.YRS		X	6,444,805	7,367,035		No	Yes		Yes
(2) MARVIN EICHORN		SPLIT DOLLAR LIFE INSURANCE LOAN		X	350,000	360,710		No	Yes		Yes
(3) MARVIN EICHORN		SPLIT DOLLAR LIFE INSURANCE LOAN		X	304,332	304,332		No	Yes		Yes
(4) MARVIN EICHORN		SPLIT DOLLAR LIFE INSURANCE LOAN		X	272,483	272,483		No	Yes		Yes
(5) MARVIN EICHORN		SPLIT DOLLAR LIFE INSURANCE LOAN		X	91,682	93,947		No	Yes		Yes
(6) MARVIN EICHORN		SPLIT DOLLAR LIFE INSURANCE LOAN		X	91,682	93,947		No	Yes		Yes
Total ...... $						8,492,454

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

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) WATAUGA PATHOLOGY ASSOC PC	M.D. SERVICES	340,304	SEE PART V		No
(2) MATTHEW MARTIN	FAMILY MEMBER	18,268	SEE PART V		No
(3) MITCH HATHAWAY	FAMILY MEMBER	98,315	SEE PART V		No
(4) SYCAMORE SHOALS ANESTHESIA ASSOC	M.D. SERVICES	819,996	SEE PART V		No
(5) PAULA CLAYTORE	FAMILY MEMBER	272,107	SEE PART V		No
(6) CLEM WILKES III	FAMILY MEMBER	65,040	SEE PART V		No
(7) JAMES TEIXEIRA	FAMILY MEMBER	76,017	SEE PART V		No
(8) WORKSPACE INTERIORS INC	VENDOR	645,484	SEE PART V		No

Part V

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

Identifier	Return Reference	Explanation
ADDITIONAL INFORMATION	SCHEDULE L PART V	1 SANDRA BROOKS MD MSHA BOARD MEMBER IS A PARTNER WITH OWNERSHIP INTEREST IN WATAUGA PATHOLOGY ASSOCIATES PC WATAUGA PATHOLOGY ASSOCIATES PC PROVIDES MEDICAL SERVICES TO MSHA 2 JOANNE GILMER VICECHAIR MSHA BOARD OF DIRECTORS IS A FAMILY MEMBER OF MATTHEW MARTIN AN EMPLOYEE OF MSHA 3 JOANNE GILMER VICECHAIR MSHA BOARD OF DIRECTORS IS A FAMILY MEMBER OF MITCH HATHAWAY AN EMPLOYEE OF MSHA 4 DAVID MAY MD MSHA BOARD MEMBER SERVES AS BOARD CHAIR FOR SYCAMORE SHOALS ANESTHESIA ASSOCIATES PC AND HAS AN OWNERSHIP SHARE IN THE PROFESSIONAL CORPORATION SYCAMORE SHOALS ANESTHESIA ASSOCIATES PC PROVIDES MEDICAL SERVICES TO MSHA 5 DALE CLAYTORE FORMER KEY EMPLOYEE OF MSHA IS A FAMILY MEMBER OF PAULA CLAYTORE AN EMPLOYEE OF MSHA 6 CLEM WILKES JR TREASURER OF THE MSHA BOARD OF DIRECTORS IS A FAMILY MEMBER OF CLEM WILKES III AN EMPLOYEE OF MSHA 7 PAT NIDAY FORMER KEY EMPLOYEE OF MSHA IS A FAMILY MEMBER OF JAMES TEIXEIRA AN EMPLOYEE OF MSHA 8 ROBERT FEATHERS MSHA BOARD MEMBER IS OWNER OF WORKSPACE INTERIORS INC WHICH PROVIDES COMMERCIAL FURNISHINGS AND DESIGN SERVICES TO MSHA TRANSACTIONS ARE CONDUCTED AT ARMSLENGTH

Schedule L (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Identifier	Return Reference	Explanation
DOING BUSINESS AS	FORM 990, PAGE 1, ITEM C	NISWONGER CHILDREN'S HOSPITAL; QUILLEN REHABILITATION HOSPITAL; FRANKLIN WOODS COMMUNITY HOSPITAL; INDIAN PATH MEDICAL CENTER; SYCAMORE SHOALS HOSPITAL; WOODRIDGE HOSPITAL FOR BEHAVIORAL HEALTH SERVICES; JOHNSON COUNTY COMMUNITY HOSPITAL; RUSSELL COUNTY MEDICAL CENTER
ORGANIZATION'S MISSION	FORM 990 - ORGANIZATION'S MISSION	PART I, LINE 1: MOUNTAIN STATES HEALTH ALLIANCE (MSHA) IS COMMITTED TO OUR MISSION OF BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTHCARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN THE 29-COUNTY AREA WE SERVE, HELPING THEM ATTAIN THEIR HIGHEST LEVEL OF HEALTH. MSHA DELIVERS THIS CARE THROUGH THE PHILOSOPHY OF PATIENT-CENTERED CARE, AND THE DEVELOPMENT OF COMPREHENSIVE STRATEGIC PLANNING AND IMPLEMENTATION. SEE ATTACHED NARRATIVE-PROGRAM SERVICE ACCOMPLISHMENTS.
SIGNIFICANT CHANGES TO ORGANIZATIONAL DOCUMENTS	FORM 990, PAGE 6, PART VI, LINE 4	BY OPERATION OF THE CHARTER OF THE ORGANIZATION, THE VOTING MEMBERSHIP OF THE ORGANIZATION CEASED TO EXIST DURING THIS FISCAL YEAR. AS A RESULT OF THIS OCCURRENCE, THE ORGANIZATION BECAME A NON-MEMBERSHIP CORPORATION UNDER TENNESSEE LAW, AND THE BOARD OF DIRECTORS BECAME A SELF PERPETUATING BOARD. AS A RESULT, THE CHARTER AND BYLAWS OF THE ORGANIZATION WERE MODIFIED TO REFLECT THE CURRENT STRUCTURE OF THE ORGANIZATION.
CLASSES OF MEMBERS OR STOCKHOLDERS	FORM 990, PAGE 6, PART VI, LINE 6	DURING A PORTION OF THIS FISCAL YEAR, THE ORGANIZATION DID HAVE MEMBERS, BUT THE MEMBERSHIP CEASED TO EXIST DURING THE YEAR, AND THE ORGANIZATION BECAME A NON-MEMBERSHIP CORPORATION.
ELECTION OF MEMBERS AND THEIR RIGHTS	FORM 990, PAGE 6, PART VI, LINE 7A	DURING A PORTION OF THE YEAR, THE ORGANIZATION HAD MEMBERS. AS A RESULT, THE ANSWER TO THIS QUESTION IS YES, BUT FOR ONLY A PORTION OF THE YEAR. DURING THE PERIOD WHEN MSHA HAD MEMBERS, THE CLASS A MEMBERS ANNUALLY ELECTED MEMBERS TO THE BOARD OF DIRECTORS.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS	FORM 990, PAGE 6, PART VI, LINE 7B	DURING A PORTION OF THE YEAR, THE ORGANIZATION HAD MEMBERS. CERTAIN DECISIONS OF THE BOARD ARE, PURSUANT TO TENNESSEE STATUTE, SUBJECT TO APPROVAL BY THE CLASS A MEMBERS. THESE DECISIONS INCLUDE: DISSOLUTION OF THE CORPORATION; MERGER OF THE CORPORATION; NON-ORDINARY COURSE OF BUSINESS SALE OF ASSETS, ETC. NO ORDINARY DAY-TO-DAY DECISIONS ARE SUBJECT TO MEMBER APPROVAL.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	THE CFO AND SENIOR VP REVIEWED THE FORM 990 WITH THE BOARD OF DIRECTORS PRIOR TO FILING AND THE RETURN WAS MADE AVAILABLE TO EACH BOARD MEMBER IN AN ELECTRONIC FORMAT PRIOR TO THE REVIEW.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	ANNUALLY, THE CORPORATE AUDIT AND COMPLIANCE DEPARTMENT OF MSHA FORWARDS THE CONFLICT OF INTEREST POLICY AND DISCLOSURE FORM TO ALL MSHA MANAGEMENT TEAM MEMBERS AND BOARD MEMBERS. EMPLOYEES AND BOARD MEMBERS MUST NOTE ANY CONFLICTS OR ATTEST THEY HAVE "NONE", AND RETURN THE FORM TO THE AUDIT AND COMPLIANCE DEPARTMENT. ANY NOTED DISCLOSURES ARE FORWARDED TO THE APPROPRIATE MANAGEMENT OR BOARD PERSONNEL TO EVALUATE AND UTILIZE WHEN A TRANSACTION INVOLVING A CONFLICTED PERSON ARISES. ADDITIONALLY, PERSONNEL WHO HAVE A CONFLICT ARISE BETWEEN THE ANNUAL DISTRIBUTION OF THE POLICY AND FORMS ARE REQUIRED TO DISCLOSE THE CONFLICT AND WOULD BE DISCIPLINED IN ANY INSTANCE WHERE THEY HAVE NOT DISCLOSED AND ENGAGED IN A CONFLICTED TRANSACTION.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	THE CEO'S COMPENSATION AND BENEFITS ARE SUBJECT TO THE EXECUTIVE COMPENSATION POLICY OF MOUNTAIN STATES HEALTH ALLIANCE (MSHA). THE POLICY WAS ESTABLISHED BY MSHA'S BOARD OF DIRECTORS AND IS ALLIGNED WITH THE MSHA MISSION, VISION, AND VALUES, SUPPORTING THE ACHIEVEMENT OF THE HEALTH SYSTEM'S STRATEGIC PLANS AND ANNUAL GOALS AND OBJECTIVES. THE POLICY ENSURES THAT MSHA'S EXECUTIVE COMPENSATION IS COMPLIANT WITH THE LEGAL, REGULATORY, AND STATUTORY ENVIRONMENT AFFECTING COMPENSATION. MSHA'S PRESIDENT AND CEO MAKES RECOMMENDATIONS TO THE EXECUTIVE COMMITTEE OF THE MSHA BOARD FOR ALL ELEMENTS OF COMPENSATION FOR THE SENIOR MANAGEMENT TEAM. THE BOARD OF DIRECTORS MONITORS THE PERFORMANCE OF THE SENIOR MANAGEMENT TEAM ON AN ONGOING BASIS, BUT AT LEAST ANNUALLY.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	SIMILAR TO THE CEO'S COMPENSATION, THE CFO RECEIVES COMPENSATION AND BENEFITS THAT COMPLY WITH MSHA'S SALARY POLICY. HIS PAY IS SET AT A MARKET PERCENTILE SPECIFIC TO HIS POSITION.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE UPON REQUEST TO APPROPRIATE PARTIES REQUESTING THEM. FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST TO APPROPRIATE PARTIES REQUESTING THEM, AND THEY ARE MADE AVAILABLE TO THOSE PARTIES WHO OWN INDEBTEDNESS OF THE COMPANY ON A QUARTERLY BASIS.
GROUP RETURN EXPLANATION	FORM 990, PAGE 7, PART VII	OFFICER, KEY EMPLOYEE & HIGHEST PAID COMPENSATION: LYNN KRUTAK, CFO AND MSHA KEY EMPLOYEE, IS PAID BY MSHA. BLUE RIDGE MEDICAL MANAGEMENT CORPORATION (BRMMC) REIMBURSES MSHA FOR 50% OF KRUTAK'S SALARY AND BENEFITS. MSHA IS THE SOLE MEMBER OF BRMMC. KRUTAK DEVOTES AN EQUAL AMOUNT OF TIME BETWEEN MSHA AND BRMMC. DR. DOUGLAS EDEMA, REPORTABLE AS A HIGHEST COMPENSATED EMPLOYEE, IS PAID BY MSHA AND HIS SALARY AND BENEFITS ARE FULLY REIMBURSED TO MSHA BY BRMMC. CERTAIN EXECUTIVES OF THE ORGANIZATION, SUCH AS THE CEO AND SR VP/CFO, PROVIDE SERVICES TO SOME OR ALL OF THE ORGANIZATIONS RELATED TO MSHA.
OTHER FEES FOR SERVICES	FORM 990, PART IX, LINE 11G	84,136,191 7,818,901 229,313
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 9	PARTNERSHIP CHARITABLE CONTRIBUTION NOT ON BOOKS 61,080 PORTFOLIO EXPENSES NOT ON BOOKS 5 PARTNERSHIP GAIN NOT ON BOOKS -119 CHANGE IN FAIR VALUE OF DERIVATIVES -29,805 P/S ORDINARY INCOME/LOSS-NOT ON BOOKS -2,104,308 P/S INTEREST INCOME-NOT ON BOOKS -19,823 TEMPORARILY RESTRICTED GRANTS 23,482 TOTAL TO FORM 990, PART XI, LINE 9 -2,116,452

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

MOUNTAIN STATES HEALTH ALLIANCE

Employer identification number

62-0476282

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) DICKENSON COMMUNITY HOSPITAL ONE HOSPITAL DRIVE CLINTWOOD,VA24228 77-0599553	HOSPITAL	VA	501C3	3	NCH		No
(2) MOUNTAIN STATES FOUNDATION 2335 KNOB CREEK ROAD STE 101 JOHNSON CITY,TN37604 58-1418862	FUNDRAISER	TN	501C3	11A	NA		No
(3) MSHA AUXILIARY 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604 58-1418345	SUPPORT	TN	501C3	11A	NA		No
(4) SMYTH COUNTY COMMUNITY HOSPITAL 245 MEDICAL PARK DRIVE MARION,VA24354 54-0794913	HOSPITAL	VA	501C3	3	MSHA		No
(5) NORTON COMMUNITY HOSPITAL 100 15TH STREET NW NORTON,VA24273 54-0566029	HOSPITAL	VA	501C3	3	NA		No
(6) JOHNSTON MEMORIAL HOSPITAL 16000 JOHNSTON MEMORIAL DRIVE ABINGDON,VA24211 54-0544705	HOSPITAL	VA	501C3	3	NA		No
(7) ABINGDON PHYSICIAN PARTNERS 16000 JOHNSTON MEMORIAL DRIVE ABINGDON,VA24211 20-5485346	MED. SERV.	VA	501C3	11A	JMH		No
(8) APPALACHIAN EMERGENCY PHYSICIANS 1021 W OAKLAND AVENUE STE 207 JOHNSON CITY,TN37604 80-0592504	MED. SERV	VA	501C3	11A	NA		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(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 VUBI 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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) INTEGRATED SOLUTIONS HEALTH NETWORK 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604 62-1711997	INVESTMENT	TN	NA	EXCLUDED	-17,985	5,942,091		No			No	99.170 %
(2) EMMAUS COMMUNITY HEALTHCARE LLC 6070 HWY 11E PINEY FLATS,TN37686 20-0577483	MED. SERV.	TN	NA					No			No
(3) MEDICAL SPECIALISTS OF JC LLC 2528 WESLEY STREET SUITE 2 JOHNSON CITY,TN37601 27-2199037	MED. SERV.	TN	NA	EXCLUDED	-234,419	81,508		No			No	51.000 %
(4) INTEGRATED SOLUTIONS HEALTH NETWORK 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604 62-1711997	INVESTMENT	TN	NA	EXCLUDED	-17,985	5,942,091		No			No	99.170 %
(5) EMMAUS COMMUNITY HEALTHCARE LLC 6070 HWY 11E PINEY FLATS,TN37686 20-0577483	MED. SERV.	TN	NA					No			No
(6) MEDICAL SPECIALISTS OF JC LLC 2528 WESLEY STREET SUITE 2 JOHNSON CITY,TN37601 27-2199037	MED. SERV.	TN	NA	EXCLUDED	-234,419	81,508		No			No	51.000 %

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(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) BLUE RIDGE MEDICAL MANAGEMENT CORP 1021 W OAKLAND AVENUE STE 207 JOHNSON CITY,TN37604 62-1490616	MED. SERV.	TN	NA	C CORP	105,058,961	203,141,889	100.000 %		No
(2) MEDISERVE MEDICAL EQUIPMENT 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1212286	DME	TN	BRMMC	C CORP	5,065,565	4,279,186	100.000 %		No
(3) MOUNTAIN STATES PROPERTIES 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1845895	PROP. MGMT	TN	BRMMC	C CORP	14,786,575	149,156,249	100.000 %		No
(4) MOUNTAIN STATES PHYSICIAN GROUP 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1700412	MED. SERV.	TN	BRMMC	C CORP	59,446,917	6,131,411	100.000 %		No
(5) COMMUNITY HOME CARE INC 1460 PARK AVENUE NORTON,VA24273 54-1453810	DME	VA	NCH	C CORP	375,002	382,370	50.100 %		No
(6) SOUTHWEST COMMUNITY HEALTH SERV PO BOX 880 MARION,VA24354 54-1460695	MED. SERV.	VA	SCCH	C CORP	190,852	1,098,214	80.000 %		No
(7) WILSON PHARMACY INC PO BOX 5289 JOHNSON CITY,TN37604 62-0329587	PHARMACY	TN	BRMMC	C CORP	4,782,181	2,903,651	100.000 %		No
(8) CRESTPOINT HEALTH INSURANCE COMPANY 208 SUNSET DRIVE SUITE 101 JOHNSON CITY,TN37604 62-0381170	INSURANCE	TN	ISHN	C CORP			99.170 %		No
(9) BLUE RIDGE MEDICAL MANAGEMENT CORP 1021 W OAKLAND AVENUE STE 207 JOHNSON CITY,TN37604 62-1490616	MED. SERV.	TN	NA	C CORP	105,058,961	203,141,889	100.000 %		No
(10) MEDISERVE MEDICAL EQUIPMENT 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1212286	DME	TN	BRMMC	C CORP	5,065,565	4,279,186	100.000 %		No
(11) MOUNTAIN STATES PROPERTIES 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1845895	PROP. MGMT	TN	BRMMC	C CORP	14,786,575	149,156,249	100.000 %		No
(12) MOUNTAIN STATES PHYSICIAN GROUP 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1700412	MED. SERV.	TN	BRMMC	C CORP	59,446,917	6,131,411	100.000 %		No
(13) COMMUNITY HOME CARE INC 1460 PARK AVENUE NORTON,VA24273 54-1453810	DME	VA	NCH	C CORP	375,002	382,370	50.100 %		No
(14) SOUTHWEST COMMUNITY HEALTH SERV PO BOX 880 MARION,VA24354 54-1460695	MED. SERV.	VA	SCCH	C CORP	190,852	1,098,214	80.000 %		No
(15) WILSON PHARMACY INC PO BOX 5289 JOHNSON CITY,TN37604 62-0329587	PHARMACY	TN	BRMMC	C CORP	4,782,181	2,903,651	100.000 %		No
(16) CRESTPOINT HEALTH INSURANCE COMPANY 208 SUNSET DRIVE SUITE 101 JOHNSON CITY,TN37604 62-0381170	INSURANCE	TN	ISHN	C CORP			99.170 %		No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

Yes

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

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

Yes

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

Yes

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

Yes

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

Yes

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

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

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

Yes

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

Yes

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

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

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved
(1) MSHA AUXILIARY	P	71,464
(2) MSHA AUXILIARY	Q	279,988
(3) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(4) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(5) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(6) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(7) HEALTH PLUS	J	57,281
(8) HEALTHPLUS	L	408,335
(9) HEALTHPLUS	M	332,150
(10) HEALTHPLUS	O	103,659
(11) HEALTHPLUS	P	68,399
(12) HEALTHPLUS	Q	12,333,583
(13) HEALTHPLUS	R	621,612
(14) MEDISERVE	K	179,587
(15) MEDISERVE	L	169,719
(16) MEDISERVE	O	53,550
(17) MEDISERVE	P	193,553
(18) MEDISERVE	Q	2,441,200
(19) MOUNTAIN STATES PROPERTIES	G	941,514
(20) MOUNTAIN STATES PROPERTIES	K	2,070,952
(21) MOUNTAIN STATES PROPERTIES	L	249,140
(22) MOUNTAIN STATES PROPERTIES	O	73,430
(23) MOUNTAIN STATES PROPERTIES	Q	745,635
(24) MOUNTAIN STATES PROPERTIES	R	736,347
(25) MOUNTAIN STATES FOUNDATION	B	58,000
(26) MOUNTAIN STATES FOUNDATION	C	1,513,427
(27) NORTON COMMUNITY HOSPITAL	D	21,238,380
(28) NORTON COMMUNITY HOSPITAL	L	5,850,147
(29) NORTON COMMUNITY HOSPTIAL	N	482,656
(30) NORTON COMMUNITY HOSPITAL	P	6,856,647
(31) NORTON COMMUNITY HOSPITAL	Q	691,339
(32) DICKENSON COMMUNITY HOSPITAL	P	982,689
(33) ISHN	A	50,000
(34) ISHN	B	6,882,150
(35) ISHN	L	232,591
(36) ISHN	M	2,158,748
(37) ISHN	P	133,333
(38) ISHN	Q	1,351,630
(39) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(40) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(41) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(42) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(43) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(44) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(45) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(46) APP	M	1,078,900
(47) APP	L	1,927,539
(48) MSHA AUXILIARY	P	71,464
(49) MSHA AUXILIARY	Q	279,988
(50) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(51) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(52) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(53) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(54) HEALTH PLUS	J	57,281
(55) HEALTHPLUS	L	408,335
(56) HEALTHPLUS	M	332,150
(57) HEALTHPLUS	O	103,659
(58) HEALTHPLUS	P	68,399
(59) HEALTHPLUS	Q	12,333,583
(60) HEALTHPLUS	R	621,612
(61) MEDISERVE	K	179,587
(62) MEDISERVE	L	169,719
(63) MEDISERVE	O	53,550
(64) MEDISERVE	P	193,553
(65) MEDISERVE	Q	2,441,200
(66) MOUNTAIN STATES PROPERTIES	G	941,514
(67) MOUNTAIN STATES PROPERTIES	K	2,070,952
(68) MOUNTAIN STATES PROPERTIES	L	249,140
(69) MOUNTAIN STATES PROPERTIES	O	73,430
(70) MOUNTAIN STATES PROPERTIES	Q	745,635
(71) MOUNTAIN STATES PROPERTIES	R	736,347
(72) MOUNTAIN STATES FOUNDATION	B	58,000
(73) MOUNTAIN STATES FOUNDATION	C	1,513,427
(74) NORTON COMMUNITY HOSPITAL	D	21,238,380
(75) NORTON COMMUNITY HOSPITAL	L	5,850,147
(76) NORTON COMMUNITY HOSPTIAL	N	482,656
(77) NORTON COMMUNITY HOSPITAL	P	6,856,647
(78) NORTON COMMUNITY HOSPITAL	Q	691,339
(79) DICKENSON COMMUNITY HOSPITAL	P	982,689
(80) ISHN	A	50,000
(81) ISHN	B	6,882,150
(82) ISHN	L	232,591
(83) ISHN	M	2,158,748
(84) ISHN	P	133,333
(85) ISHN	Q	1,351,630
(86) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(87) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(88) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(89) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(90) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(91) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(92) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(93) APP	M	1,078,900
(94) APP	L	1,927,539
(95) MSHA AUXILIARY	P	71,464
(96) MSHA AUXILIARY	Q	279,988
(97) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(98) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(99) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(100) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(101) HEALTH PLUS	J	57,281
(102) HEALTHPLUS	L	408,335
(103) HEALTHPLUS	M	332,150
(104) HEALTHPLUS	O	103,659
(105) HEALTHPLUS	P	68,399
(106) HEALTHPLUS	Q	12,333,583
(107) HEALTHPLUS	R	621,612
(108) MEDISERVE	K	179,587
(109) MEDISERVE	L	169,719
(110) MEDISERVE	O	53,550
(111) MEDISERVE	P	193,553
(112) MEDISERVE	Q	2,441,200
(113) MOUNTAIN STATES PROPERTIES	G	941,514
(114) MOUNTAIN STATES PROPERTIES	K	2,070,952
(115) MOUNTAIN STATES PROPERTIES	L	249,140
(116) MOUNTAIN STATES PROPERTIES	O	73,430
(117) MOUNTAIN STATES PROPERTIES	Q	745,635
(118) MOUNTAIN STATES PROPERTIES	R	736,347
(119) MOUNTAIN STATES FOUNDATION	B	58,000
(120) MOUNTAIN STATES FOUNDATION	C	1,513,427
(121) NORTON COMMUNITY HOSPITAL	D	21,238,380
(122) NORTON COMMUNITY HOSPITAL	L	5,850,147
(123) NORTON COMMUNITY HOSPTIAL	N	482,656
(124) NORTON COMMUNITY HOSPITAL	P	6,856,647
(125) NORTON COMMUNITY HOSPITAL	Q	691,339
(126) DICKENSON COMMUNITY HOSPITAL	P	982,689
(127) ISHN	A	50,000
(128) ISHN	B	6,882,150
(129) ISHN	L	232,591
(130) ISHN	M	2,158,748
(131) ISHN	P	133,333
(132) ISHN	Q	1,351,630
(133) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(134) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(135) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(136) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(137) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(138) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(139) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(140) APP	M	1,078,900
(141) APP	L	1,927,539
(142) MSHA AUXILIARY	P	71,464
(143) MSHA AUXILIARY	Q	279,988
(144) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(145) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(146) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(147) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(148) HEALTH PLUS	J	57,281
(149) HEALTHPLUS	L	408,335
(150) HEALTHPLUS	M	332,150
(151) HEALTHPLUS	O	103,659
(152) HEALTHPLUS	P	68,399
(153) HEALTHPLUS	Q	12,333,583
(154) HEALTHPLUS	R	621,612
(155) MEDISERVE	K	179,587
(156) MEDISERVE	L	169,719
(157) MEDISERVE	O	53,550
(158) MEDISERVE	P	193,553
(159) MEDISERVE	Q	2,441,200
(160) MOUNTAIN STATES PROPERTIES	G	941,514
(161) MOUNTAIN STATES PROPERTIES	K	2,070,952
(162) MOUNTAIN STATES PROPERTIES	L	249,140
(163) MOUNTAIN STATES PROPERTIES	O	73,430
(164) MOUNTAIN STATES PROPERTIES	Q	745,635
(165) MOUNTAIN STATES PROPERTIES	R	736,347
(166) MOUNTAIN STATES FOUNDATION	B	58,000
(167) MOUNTAIN STATES FOUNDATION	C	1,513,427
(168) NORTON COMMUNITY HOSPITAL	D	21,238,380
(169) NORTON COMMUNITY HOSPITAL	L	5,850,147
(170) NORTON COMMUNITY HOSPTIAL	N	482,656
(171) NORTON COMMUNITY HOSPITAL	P	6,856,647
(172) NORTON COMMUNITY HOSPITAL	Q	691,339
(173) DICKENSON COMMUNITY HOSPITAL	P	982,689
(174) ISHN	A	50,000
(175) ISHN	B	6,882,150
(176) ISHN	L	232,591
(177) ISHN	M	2,158,748
(178) ISHN	P	133,333
(179) ISHN	Q	1,351,630
(180) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(181) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(182) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(183) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(184) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(185) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(186) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(187) APP	M	1,078,900
(188) APP	L	1,927,539
(189) MSHA AUXILIARY	P	71,464
(190) MSHA AUXILIARY	Q	279,988
(191) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(192) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(193) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(194) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(195) HEALTH PLUS	J	57,281
(196) HEALTHPLUS	L	408,335
(197) HEALTHPLUS	M	332,150
(198) HEALTHPLUS	O	103,659
(199) HEALTHPLUS	P	68,399
(200) HEALTHPLUS	Q	12,333,583
(201) HEALTHPLUS	R	621,612
(202) MEDISERVE	K	179,587
(203) MEDISERVE	L	169,719
(204) MEDISERVE	O	53,550
(205) MEDISERVE	P	193,553
(206) MEDISERVE	Q	2,441,200
(207) MOUNTAIN STATES PROPERTIES	G	941,514
(208) MOUNTAIN STATES PROPERTIES	K	2,070,952
(209) MOUNTAIN STATES PROPERTIES	L	249,140
(210) MOUNTAIN STATES PROPERTIES	O	73,430
(211) MOUNTAIN STATES PROPERTIES	Q	745,635
(212) MOUNTAIN STATES PROPERTIES	R	736,347
(213) MOUNTAIN STATES FOUNDATION	B	58,000
(214) MOUNTAIN STATES FOUNDATION	C	1,513,427
(215) NORTON COMMUNITY HOSPITAL	D	21,238,380
(216) NORTON COMMUNITY HOSPITAL	L	5,850,147
(217) NORTON COMMUNITY HOSPTIAL	N	482,656
(218) NORTON COMMUNITY HOSPITAL	P	6,856,647
(219) NORTON COMMUNITY HOSPITAL	Q	691,339
(220) DICKENSON COMMUNITY HOSPITAL	P	982,689
(221) ISHN	A	50,000
(222) ISHN	B	6,882,150
(223) ISHN	L	232,591
(224) ISHN	M	2,158,748
(225) ISHN	P	133,333
(226) ISHN	Q	1,351,630
(227) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(228) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(229) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(230) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(231) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(232) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(233) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(234) APP	M	1,078,900
(235) APP	L	1,927,539
(236) MSHA AUXILIARY	P	71,464
(237) MSHA AUXILIARY	Q	279,988
(238) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(239) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(240) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(241) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(242) HEALTH PLUS	J	57,281
(243) HEALTHPLUS	L	408,335
(244) HEALTHPLUS	M	332,150
(245) HEALTHPLUS	O	103,659
(246) HEALTHPLUS	P	68,399
(247) HEALTHPLUS	Q	12,333,583
(248) HEALTHPLUS	R	621,612
(249) MEDISERVE	K	179,587
(250) MEDISERVE	L	169,719
(251) MEDISERVE	O	53,550
(252) MEDISERVE	P	193,553
(253) MEDISERVE	Q	2,441,200
(254) MOUNTAIN STATES PROPERTIES	G	941,514
(255) MOUNTAIN STATES PROPERTIES	K	2,070,952
(256) MOUNTAIN STATES PROPERTIES	L	249,140
(257) MOUNTAIN STATES PROPERTIES	O	73,430
(258) MOUNTAIN STATES PROPERTIES	Q	745,635
(259) MOUNTAIN STATES PROPERTIES	R	736,347
(260) MOUNTAIN STATES FOUNDATION	B	58,000
(261) MOUNTAIN STATES FOUNDATION	C	1,513,427
(262) NORTON COMMUNITY HOSPITAL	D	21,238,380
(263) NORTON COMMUNITY HOSPITAL	L	5,850,147
(264) NORTON COMMUNITY HOSPTIAL	N	482,656
(265) NORTON COMMUNITY HOSPITAL	P	6,856,647
(266) NORTON COMMUNITY HOSPITAL	Q	691,339
(267) DICKENSON COMMUNITY HOSPITAL	P	982,689
(268) ISHN	A	50,000
(269) ISHN	B	6,882,150
(270) ISHN	L	232,591
(271) ISHN	M	2,158,748
(272) ISHN	P	133,333
(273) ISHN	Q	1,351,630
(274) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(275) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(276) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(277) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(278) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(279) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(280) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(281) APP	M	1,078,900
(282) APP	L	1,927,539
(283) MSHA AUXILIARY	P	71,464
(284) MSHA AUXILIARY	Q	279,988
(285) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(286) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(287) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(288) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(289) HEALTH PLUS	J	57,281
(290) HEALTHPLUS	L	408,335
(291) HEALTHPLUS	M	332,150
(292) HEALTHPLUS	O	103,659
(293) HEALTHPLUS	P	68,399
(294) HEALTHPLUS	Q	12,333,583
(295) HEALTHPLUS	R	621,612
(296) MEDISERVE	K	179,587
(297) MEDISERVE	L	169,719
(298) MEDISERVE	O	53,550
(299) MEDISERVE	P	193,553
(300) MEDISERVE	Q	2,441,200
(301) MOUNTAIN STATES PROPERTIES	G	941,514
(302) MOUNTAIN STATES PROPERTIES	K	2,070,952
(303) MOUNTAIN STATES PROPERTIES	L	249,140
(304) MOUNTAIN STATES PROPERTIES	O	73,430
(305) MOUNTAIN STATES PROPERTIES	Q	745,635
(306) MOUNTAIN STATES PROPERTIES	R	736,347
(307) MOUNTAIN STATES FOUNDATION	B	58,000
(308) MOUNTAIN STATES FOUNDATION	C	1,513,427
(309) NORTON COMMUNITY HOSPITAL	D	21,238,380
(310) NORTON COMMUNITY HOSPITAL	L	5,850,147
(311) NORTON COMMUNITY HOSPTIAL	N	482,656
(312) NORTON COMMUNITY HOSPITAL	P	6,856,647
(313) NORTON COMMUNITY HOSPITAL	Q	691,339
(314) DICKENSON COMMUNITY HOSPITAL	P	982,689
(315) ISHN	A	50,000
(316) ISHN	B	6,882,150
(317) ISHN	L	232,591
(318) ISHN	M	2,158,748
(319) ISHN	P	133,333
(320) ISHN	Q	1,351,630
(321) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(322) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(323) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(324) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(325) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(326) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(327) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(328) APP	M	1,078,900
(329) APP	L	1,927,539
(330) MSHA AUXILIARY	P	71,464
(331) MSHA AUXILIARY	Q	279,988
(332) BLUE RIDGE MEDICAL MANAGMENT CORP	L	10,728,044
(333) BLUE RIDGE MEDICAL MANAGEMENT CORP	M	37,124,494
(334) BLUE RIDGE MEDICAL MANAGEMENT CORP	O	1,980,659
(335) BLUE RIDGE MEDICAL MANAGEMENT CORP	Q	8,844,230
(336) HEALTH PLUS	J	57,281
(337) HEALTHPLUS	L	408,335
(338) HEALTHPLUS	M	332,150
(339) HEALTHPLUS	O	103,659
(340) HEALTHPLUS	P	68,399
(341) HEALTHPLUS	Q	12,333,583
(342) HEALTHPLUS	R	621,612
(343) MEDISERVE	K	179,587
(344) MEDISERVE	L	169,719
(345) MEDISERVE	O	53,550
(346) MEDISERVE	P	193,553
(347) MEDISERVE	Q	2,441,200
(348) MOUNTAIN STATES PROPERTIES	G	941,514
(349) MOUNTAIN STATES PROPERTIES	K	2,070,952
(350) MOUNTAIN STATES PROPERTIES	L	249,140
(351) MOUNTAIN STATES PROPERTIES	O	73,430
(352) MOUNTAIN STATES PROPERTIES	Q	745,635
(353) MOUNTAIN STATES PROPERTIES	R	736,347
(354) MOUNTAIN STATES FOUNDATION	B	58,000
(355) MOUNTAIN STATES FOUNDATION	C	1,513,427
(356) NORTON COMMUNITY HOSPITAL	D	21,238,380
(357) NORTON COMMUNITY HOSPITAL	L	5,850,147
(358) NORTON COMMUNITY HOSPTIAL	N	482,656
(359) NORTON COMMUNITY HOSPITAL	P	6,856,647
(360) NORTON COMMUNITY HOSPITAL	Q	691,339
(361) DICKENSON COMMUNITY HOSPITAL	P	982,689
(362) ISHN	A	50,000
(363) ISHN	B	6,882,150
(364) ISHN	L	232,591
(365) ISHN	M	2,158,748
(366) ISHN	P	133,333
(367) ISHN	Q	1,351,630
(368) SMYTH COUNTY COMMUNITY HOSPITAL	D	16,208,216
(369) SMYTH COUNTY COMMUNITY HOSPITAL	L	4,757,932
(370) SMYTH COUNTY COMMUNITY HOSPITAL	Q	67,367
(371) JOHNSTON MEMORIAL HOSPITAL	L	10,436,254
(372) JOHNSTON MEMORIAL HOSPTIAL	O	887,811
(373) JOHNSTON MEMORIAL HOSPITAL	P	72,637
(374) JOHNSTON MEMORIAL HOSPITAL	R	216,014
(375) APP	M	1,078,900
(376) APP	L	1,927,539

Schedule R (Form 990) 2012

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: PART I, LINE 1: MOUNTAIN STATES HEALTH ALLIANCE (MSHA) IS COMMITTED TO OUR MISSION OF BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTHCARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN THE 29-COUNTY AREA WE SERVE, HELPING THEM ATTAIN THEIR HIGHEST LEVEL OF HEALTH. MSHA DELIVERS THIS CARE THROUGH THE PHILOSOPHY OF PATIENT-CENTERED CARE, AND THE DEVELOPMENT OF COMPREHENSIVE STRATEGIC PLANNING AND IMPLEMENTATION. SEE ATTACHED NARRATIVE-PROGRAM SERVICE ACCOMPLISHMENTS.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	14
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	7
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	9,102
6	Total number of volunteers (estimate if necessary) .............	6	2,897
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	1,245,620
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	160,672

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,745,426	2,474,339
9	Program service revenue (Part VIII, line 2g) .........	697,705,296	674,372,724
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	24,259,649	31,675,503
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	10,171,526	9,360,388
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	734,881,897	717,882,954
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	990,095	405,051
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	309,796,341	305,057,437
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 1,478,925
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	372,114,544	376,841,250
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	682,900,980	682,303,738
19	Revenue less expenses. Subtract line 18 from line 12.......	51,980,917	35,579,216
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	1,517,954,041	1,599,476,991
21	Total liabilities (Part X, line 26).............	1,169,345,060	1,201,894,828
22	Net assets or fund balances. Subtract line 21 from line 20.....	348,608,981	397,582,163

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 568,045,112 including grants of $ 405,051 ) (Revenue $ 674,348,316 )
	SEE ATTACHED DOCUMENT: MSHA - PROGRAM SERVICE ACCOMPLISHMENTS FOR GUIDESTAR READERS, OUR PROGRAM SERVICE ACCOMPLISHMENTS MAY BE FOUND AT THE END.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses568,045,112

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	8,897,352	746,793

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		1,599,266
e	Government grants (contributions)1e		760,280

f	All other contributions, gifts, grants, and similar amounts not included above1f		114,793

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			2,474,339
			Business Code
2a	PATIENT REVENUE-OTHER		622110	651,506,371	651,506,371
b	WELLNESS PROGRAMS		622110	20,670,478	20,670,478
c	P/S PROG. SERV. INCOME		622110	1,820,608	1,820,608
d	LAB UBI REVENUE		622110	313,011		313,011
e	PREMIER PYMT D'S BOARD SERVCE		541610	62,256		62,256
f	All other program service revenue .
g	Total. Add lines 2a–2f........			674,372,724
3	Investment income (including dividends, interest, and other similar amounts).......			15,341,173			15,341,173
4	Income from investment of tax-exempt bond proceeds..			173,144			173,144
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents	192,727
b	Less: rental expenses	107,960
c	Rental income or (loss)	84,767
d	Net rental income or (loss).......			84,767		40,519	44,248
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	16,185,475	126,692
b	Less: cost or other basis and sales expenses		150,981
c	Gain or (loss)	16,185,475	-24,289
d	Net gain or (loss)..........			16,161,186	-24,408		16,185,594
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	CAFE' SALES		722210	4,331,346			4,331,346
b	DIETARY,SECURITY,ENGIN., ETC.		541900	3,104,282			3,104,282
c	DAY CARE		624410	1,010,159			1,010,159
d	All other revenue ....			829,834		829,834
e	Total. Add lines 11a–11d ......			9,275,621
12	Total revenue. See Instructions......			717,882,954	673,973,049	1,245,620	40,189,946


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............				1
2	Savings and temporary cash investments .........			39,216,743	2	53,114,956
3	Pledges and grants receivable, net ...........			248,258	3	96,609
4	Accounts receivable, net .............			103,299,284	4	117,265,071
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				6,806,393	5	8,492,454
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 .............			15,373,693	7	17,189,476
8	Inventories for sale or use ..............			15,480,550	8	15,873,411
9	Prepaid expenses and deferred charges ..........			3,139,089	9	4,850,577
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	998,845,770
b	Less: accumulated depreciation .....	10b	480,937,560	494,025,566	10c	517,908,210
11	Investments—publicly traded securities ..........			271,118,030	11	285,653,065
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 .....			307,033,212	13	313,693,918
14	Intangible assets ...............			143,276,118	14	144,707,541
15	Other assets. See Part IV, line 11 ...........			118,937,105	15	120,631,703
16	Total assets. Add lines 1 through 15 (must equal line 34)......			1,517,954,041	16	1,599,476,991
17	Accounts payable and accrued expenses .........			85,554,685	17	69,022,047
18	Grants payable .................				18
19	Deferred revenue ................			2,928,666	19	2,130,026
20	Tax-exempt bond liabilities .............			813,947,753	20	882,984,693
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 ..			177,320,621	23	145,411,405
24	Unsecured notes and loans payable to unrelated third parties ....			4,437,945	24	2,319,713
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....................			85,155,390	25	100,026,944
26	Total liabilities. Add lines 17 through 25.........			1,169,345,060	26	1,201,894,828
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			348,411,488	27	397,408,151
28	Temporarily restricted net assets ...........			197,493	28	174,012
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 ...........			348,608,981	33	397,582,163
34	Total liabilities and net assets/fund balances ........			1,517,954,041	34	1,599,476,991