TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Shelly Culhane........................................................................ Vice Chair	2.0 .......................	X	X	0	0
(2) B Larry Jenkins Jr........................................................................ Director	1.0 .......................	X		0	0
(3) R Wayne Barnes........................................................................ Director	1.0 .......................	X		0	0
(4) Sara A Middleton........................................................................ Director	1.0 .......................	X		0	0
(5) Candice Quinn Kelly........................................................................ Ex-Officio/Director	1.0 .......................	X		0	0
(6) Faye Reed........................................................................ Ex-Officio/Dir/Retired 12/1/12	1.0 .......................	X		0	0
(7) Khadar Baig........................................................................ Director	1.0 .......................	X		0	0
(8) Van Mitchell........................................................................ Director	1.0 .......................	X		0	0
(9) Louis Jenkins Jr........................................................................ Chairman	2.0 .......................	X	X	0	0
(10) Seetaramayya Nagula........................................................................ Director	1.0 .......................	X		0	0
(11) Richard Winkler........................................................................ Secretary/Treasurer	2.0 .......................	X	X	0	0
(12) Michael Cady........................................................................ Director	1.0 .......................	X		0	0
(13) Ashvin J Patel MD........................................................................ Ex-O/ChiefStaff/End12/31/12	2.0 .......................	X	X	0	0
(14) James Burke........................................................................ Director	1.0 .......................	X		0	0
(15) John Ashworth........................................................................ Ex-Officio/Director	1.0 .......................49.0	X		588,536	20,541
(16) Robert Chrencik........................................................................ Ex-Officio/Director	1.0 .......................49.0	X		2,174,569	234,466
(17) Noel Cervino........................................................................ Ex-Officio/President & CEO	40.0 .......................10.0	X	X	525,741	66,648

(A) Name and business address	(B) Description of services	(C) Compensation
Maryland Inpatient Care Specialists, 6934 Aviation Blvd Ste BGLEN BURNIEMD21061	Physicians	1,300,000
Southern MD Pulmonary Critical Ca, 3575 Old Washington Rd Ste CWALDORFMD20602	Respiratory	897,780
Newbridge Anesthesia LLC, 9901 Bentcross DrivePOTOMACMD20854	Anesthesia	560,002
ROI Eligibility Services Corp, 1920 Greenspring Drive Ste 200TIMONIUMMD21094	Pt Acctg Purch Serv	546,125
NDG Communications INC, 105 Centennial Str Ste KLAPLATAMD20646	Advertising	507,775
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 19

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	58,392	58,392
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	1,343,495	1,047,926	295,569
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	42,613,830	33,238,787	9,375,043
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,272,144	992,272	279,872
9	Other employee benefits .......	4,823,686	3,762,475	1,061,211
10	Payroll taxes ...........	3,037,522	2,369,267	668,255
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	449,663		449,663
c	Accounting ...........	17,910		17,910
d	Lobbying ...........	13,018		13,018
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	8,293,712	6,469,095	1,824,617
12	Advertising and promotion ....	316,244	246,670	69,574
13	Office expenses .......	4,252,676	3,317,087	935,589
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	2,671,064	2,083,430	587,634
17	Travel ............	55,069	42,954	12,115
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	2,974,635	2,320,215	654,420
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	3,932,621	3,067,444	865,177
23	Insurance ..............	2,380,636	1,856,896	523,740
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	SUPPLIES AND DRUGS	18,686,003	14,575,082	4,110,921
b	PURCHASED SERVICES	6,648,597	5,149,260	1,499,337
c	BAD DEBT	4,922,763	4,922,763
d	DUES & SUBSCRIPTIONS	609,137	475,127	134,010
e	All other expenses	395,751	308,688	87,063
25	Total functional expenses. Add lines 1 through 24e	109,768,568	86,303,830	23,464,738	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	0	1	0
2	Savings and temporary cash investments .........	37,974,354	2	28,125,065
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	11,344,222	4	11,705,089
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	1,490,645	8	1,459,352
9	Prepaid expenses and deferred charges ..........	930,555	9	459,932
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	107,621,747
b	Less: accumulated depreciation .....	10b	38,611,562	66,994,942	10c	69,010,185
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 .....	0	12	0
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	28,510,375	15	32,647,221
16	Total assets. Add lines 1 through 15 (must equal line 34)......	147,245,093	16	143,406,844
	17	Accounts payable and accrued expenses .........	13,117,763	17	12,114,172
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	54,348,613	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	21,568,471	23	20,599,450
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	27,422,921	25	71,301,195
26	Total liabilities. Add lines 17 through 25.........	116,457,768	26	104,014,817
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	30,770,543	27	39,182,155
28	Temporarily restricted net assets ...........	16,782	28	209,872
29	Permanently restricted net assets ...........	0	29	0
	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 ...........	30,787,325	33	39,392,027
34	Total liabilities and net assets/fund balances ........	147,245,093	34	143,406,844

- 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

Civista Medical Center Inc

Employer identification number

52-0445374

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

Civista Medical Center Inc

Employer identification number

52-0445374

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 Civista Medical Center Inc

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 Civista Medical Center Inc

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
Civista Medical Center Inc

Employer identification number

52-0445374

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

Civista Medical Center Inc

Employer identification number

52-0445374

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

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

A Check SchCMd Bullet

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

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

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

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

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

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

13,018

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

13,018

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
Lobbying Activities	Schedule C, Part II-B, Line 1i	THE ORGANIZATION DOES NOT ENGAGE IN ANY DIRECT LOBBYING ACTIVITIES. THE ORGANIZATION PAYS MEMBERSHIP DUES TO THE MARYLAND HOSPITAL ASSOCIATION (MHA) AND THE AMERICAN HOSPITAL ASSOCIATION (AHA). MHA AND AHA ENGAGE IN MANY SUPPORT ACTIVITIES INCLUDING LOBBYING AND ADVOCATING FOR THEIR MEMBER HOSPITALS. THE MHA AND AHA REPORTED THAT 7.71% AND 23.98% OF MEMBER DUES WERE USED FOR LOBBYING PURPOSES AND AS SUCH, THE ORGANIZATION HAS REPORTED THIS AMOUNT ON SCHEDULE C PART IV AS LOBBYING ACTIVITIES.

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

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................	78,614,777	20,792,336	57,822,441
c	Leasehold improvements ............	498,563	226,341	272,222
d	Equipment ................	27,017,211	17,592,885	9,424,326
e	Other .................	1,491,196		1,491,196
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				69,010,185

Schedule D (Form 990) 2012

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value
(1) SECURITY DEPOSITS				2,675
(2) OTHER CURRENT RECEIVABLES				1,193,245
(3) INV CHES POTOMAC HEALTHCARE				3,317,448
(4) OTHER ASSETS				7,513,265
(5) PHYSICIAN LOANS				192,844
(6) INVESTMENT IN JV FREESTATE				15,000
(7) INVESTMENT MARYLAND ECARE				10,000
(8) DUE FROM AFFILIATES				15,829,221
(9) ECONOMIC INTEREST - NET ASSETS				4,573,523
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				32,647,221

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes		0
ADVANCES FROM THIRD PARTIES		3,235,242
ACCRUED PENSION COSTS		5,139,192
DUE TO AFFILIATES		54,715,931
LEASE LIABILITIES		450,311
MALPRACTICE IBNR		2,764,484
OTHER LIABILITIES		4,996,035



Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		71,301,195
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 for Uncertain Tax Position (ASC 740)	Schedule D, Part X, Line 2	The organization is a subsidiary of the University of Maryland Medical System Corporation (The Corporation). The Corporation adopted the provisions of ASC 740, Accounting for Uncertainty in the Income Taxes (FIN 48) on July 1, 2007. The footnote related to ASC 740 in the Corporation's audited financial statements is as follows: The Corporation follows a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. Management does not believe that there are any unrecognized tax benefits that should be recognized.

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE F(Form 990)

Department of the Treasury
Internal Revenue Service

Statement of Activities Outside the United States

Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16. Right pointing arrow large image

Attach to Form 990. Right pointing arrow large image

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization
Civista Medical Center Inc

Employer identification number

52-0445374

Part I

General Information on Activities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 14b.

For grantmakers. 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

For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside
the United States.

Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)

(a) Region		(d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region)	(e) If activity listed in (d) is a program service, describe specific type of service(s) in region	(f) Total expenditures for and investments in region
	Central America and the Caribbean	Program Services	Insurance	984,413
















3a	Sub-total .....			984,413
b	Total from continuation sheets to Part I ...
c	Totals (add lines 3a and 3b)			984,413

For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2012

Schedule F (Form 990) 2012

Page 2

Part II

Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.

1 (a) Name of organization		(b) IRS code section and EIN (if applicable)	(c) Region	(d) Purpose of grant	(e) Amount of cash grant	(f) Manner of cash disbursement	(g) Amount of of non-cash assistance	(h) Description of non-cash assistance	(i) Method of valuation (book, FMV, appraisal, other)

Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .... MediumBullet

Enter total number of other organizations or entities ....................... MediumBullet

Schedule F (Form 990) 2012

Schedule F (Form 990) 2012Page 3

Part III

Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.

Part III can be duplicated if additional space is needed.

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

Schedule F (Form 990) 2012

Page 4

Part IV

Foreign Forms

Schedule F (Form 990) 2012

Page 5

Part V

Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	ReturnReference	Explanation
Activities per Region	Schedule F, Part I, Line 3	Civista Medical Center, Inc. joined the University of Maryland Medical System Corporation's Malpractice program as of March 1, 2013.

Schedule F (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

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) ..	3,546,328		3,546,506	3.230 %
b	Medicaid (from Worksheet 3, column a) ....
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	3,546,328		3,546,506	3.230 %
Other Benefits		694,485		694,485	0.630 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	694,485		694,485	0.630 %
f	Health professions education (from Worksheet 5) ..	348,551		348,551	0.320 %
g	Subsidized health services (from Worksheet 6) ..	5,869,444	3,316,475	2,552,969	2.330 %
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	74,237		74,237	0.070 %
j	Total. Other Benefits ..	6,986,717	3,316,475	3,670,242	3.350 %
k	Total. Add lines 7d and 7j .	10,533,045	3,316,475	7,216,748	6.580 %

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

Schedule H (Form 990) 2012

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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	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	298		298
3	Community support	35,421		35,421	0.030 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	10,333		10,333	0.010 %
7	Community health improvement advocacy	795		795
8	Workforce development	139,564	6,032	133,532	0.120 %
9	Other
10	Total	186,411	6,032	180,379	0.160 %

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. ......

3,357,621

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. ......

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).....

47,171,538

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

43,581,711

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

3,589,827

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2012

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Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	Civista Medical Center Inc 5 Garrett Ave La Plata,MD20646	X	X	X

Schedule H (Form 990) 2012

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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)

	Civista Medical Center Inc
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 12

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

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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.% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	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

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Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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

Yes

If “No,” indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

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

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

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

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

Other (describe in Part VI)

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

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Schedule H (Form 990) 2012

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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 Report	Schedule H, Part I, Line 6a	AN ANNUAL COMMUNITY BENEFIT REPORT IS PREPARED FOR EACH FISCAL YEAR ENDING JUNE 30. THIS REPORT IS SUBMITTED TO THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC), A STATE REGULATORY AGENCY, BY DECEMBER 31 OF EACH YEAR. IN ADDITION, THE ANNUAL COMMUNITY BENEFIT REPORT IS AVAILABLE UPON REQUEST AT THE ENTITY'S CORPORATE OFFICES.
Cost Attributable to a Physical Clinic	Schedule H, Part I, Line 7	Marylands regulatory system creates a unique process for hospital payment that differs from the rest of the Nation. The Health Services Cost Review Commission (HSCRC) determines payment through a rate setting process and All Payors, including Governmental Payors, pay the same amount for the same services delivered at the same hospital. Marylands unique All Payor system includes a method for referencing uncompensated care in each Payors rates, which does not enable Maryland hospitals to breakout any offsetting revenue related to uncompensated care. Schedule H, Part I, Line 7B, Columns (C) through (F) MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE. COMMUNITY BENEFIT EXPENSES ARE EQUAL TO MEDICAID REVENUES IN MARYLAND, AS SUCH, THE NET EFFECT IS ZERO. ADDITIONALLY, NET REVENUES FOR MEDICAID SHOULD REFLECT THE FULL IMPACT ON THE HOSPITAL OF ITS SHARE OF THE MEDICAID ASSESSMENT. SCHEDULE H, PART I, LINE 7F COLUMN (C) MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE. SCHEDULE H, PART I, LINE 7F COLUMN (D) MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE.
Community Building Activities	Schedule H, Part II	As the only hospital serving Charles County, Maryland, Civista Medical Center supports programs and activities where the hospital's expertise and resources can influence the fundamental issues that affect the health of the community. Civista supports economic development of the community through leadership participation in organizations such as the Economic Development Commission and the Tri-County Council of Southern Maryland. Hospital Administration participates in healthcare workforce development through by serving on committees such as the Charles County Commissioner's healthcare taskforce and support of College of Southern Maryland Nursing and Allied Health programs. In addition, Civista Medical Center participates and supports the Black Leadership Council on Excellence's Young Researchers Community Project which offers disadvantage youth in high school an opportunity to shadow medical professionals. According to the 2007 Maryland Physician workforce study, the Southern Maryland region has a physician shortage for primary care physicians. Southern Maryland had the regional low requirement for primary care physicians per 100,000 residents of 56.5. The Maryland state average rate was 58.2 per 100,000 residents. Under medical specialties, the Southern Maryland region had a shortage for cardiology, dermatology, endocrinology, gastroenterology, hematology, oncology, infectious disease, nephrology, psychiatry, pulmonary medicine, and rheumatology. The only medical specialties with adequate physician supplies were allergy and neurology. Charles County has one Neurologist which is deemed adequate for the population however, the physician plans to retire which will leave the county in a critical shortage in this specialty. As a result of the prevailing physician shortage, and to mitigate the effects of the lack of access of the community to medical care, Civista Medical Center, along with the University of Maryland has developed a robust and ongoing physician recruitment and retainment program.
Bad Debt Expense	Schedule H, Part III, Line 2 & 4	CIVISTA REPORTS BAD DEBT EXPENSE IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP) HFMA 15. THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENTS ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY, AS WELL AS, THE ACCUMULATION OF RECEIVABLE BALANCES BY PERIOD OUTSTANDING. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY NECESSARY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS AND THE ESTABLISHED ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER COLLECTION OF AMOUNTS DUE FROM INSURERS, THE CORPORATION FOLLOWS INTERNAL GUIDELINES FOR PLACING CERTAIN PAST DUE BALANCES WITH COLLECTION AGENCIES.
Medicare Cost Report	Schedule H, Part III, Line 8	IN MARYLAND, THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC)STARTED SETTING HOSPITAL RATES IN 1974. AT THAT TIME, THE HSCRC APPROVED RATES APPLIED ONLY TO COMMERCIAL INSURERS. IN 1977, THE HSCRC NEGOTIATED A WAIVER FROM MEDICARE HOSPITAL PAYMENT RULES FOR MARYLAND HOSPITALS TO BRING THE FEDERAL MEDICARE PAYMENTS UNDER HSCRC CONTROL. MEDICARE REIMBURSES MARYLAND HOSPITALS ACCORDING TO RATES ESTABLISHED BY THE HSCRC AS LONG AS THE STATE CONTINUES TO MEET A TWO-PART TEST. THIS TWO-PART WAIVER TEST ALLOWS MEDICARE TO PARTICIPATE IN THE MARYLAND SYSTEM AS LONG AS TWO CONDITIONS ARE MET: ALL OTHER PAYERS PARTICIPATING IN THE SYSTEM PAY HSCRC SET RATES. THE RATE OF GROWTH IN MEDICARE PAYMENTS TO MARYLAND HOSPITALS FROM 1981 TO THE PRESENT IS NOT GREATER THAN THE RATE OF GROWTH IN MEDICARE PAYMENTS TO HOSPITALS NATIONALLY OVER THE SAME TIME FRAME.
Collection Practices	Schedule H, Part III, Line 9b	THE ORGANIZATION EXPECTS PAYMENT AT THE TIME THE SERVICE IS PROVIDED. OUR POLICY IS TO COMPLY WITH ALL STATE AND FEDERAL LAW AND THIRD PARTY REGULATIONS AND TO PERFORM ALL CREDIT AND COLLECTION FUNCTIONS IN A DIGNIFIED AND RESPECTFUL MANNER. EMERGENCY SERVICES WILL BE PROVIDED TO ALL PATIENTS REGARDLESS OF ABILITY TO PAY. FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS BASED ON FINANCIAL NEED AS DEFINED IN THE FINANCIAL ASSISTANCE POLICY. THE ORGANIZATION DOES NOT DISCRIMINATE ON THE BASIS OF AGE, RACE, CREED, SEX OR ABILITY TO PAY. PATIENTS WHO ARE UNABLE TO PAY MAY REQUEST A FINANCIAL ASSISTANCE APPLICATION AT ANY TIME PRIOR TO SERVICE OR DURING THE BILLING AND COLLECTION PROCESS. THE ORGANIZATION MAY REQUEST THE PATIENT TO APPLY FOR MEDICAL ASSISTANCE PRIOR TO APPLYING FOR FINANCIAL ASSISTANCE. THE ACCOUNT WILL NOT BE FORWARDED FOR COLLECTION DURING THE MEDICAL ASSISTANCE APPLICATION PROCESS OR THE FINANCIAL ASSISTANCE APPLICATION PROCESS.
Individuals Eligible for Financial Assistance	Schedule H, Part V, Section B, Line 20D	All patients are charged state regulated rates regardless of their ability to pay.
Individuals Eligible for Financial Assistance	Schedule H, Part V, Section B, Line 22	As previously discussed in an earlier Schedule H narrative, the State of Maryland is a unique State in regard to the provision of health care services and their related charges by hospitals. All hospital charges processed to all Payors, including Governmental Payors, are set through Marylands Health Services Cost Commission. Accordingly, all Hospital charges are NOT gross charges as defined by the IRS under Internal Revenue Code section 501(r )(5)(B).
Community Health Care Needs Assessment	Schedule H, Part VI, Line 2	Community Health Needs Assessment (CHNA) and Implementation Plan (CCHIP) Description of CHNA Process: Civista Health and the Charles County Department of Health (CCDOH) collaborated to complete a comprehensive assessment of the health needs (CHNA) of Charles County, Maryland. An epidemiologist with a Master's Degree in Public Health Epidemiology was contracted to analyze the qualitative and quantitative data. Civista lead the effort and covered 80% of the cost of the CHNA. To provide a comprehensive assessment of the health needs of the county, a four method plan was developed which included 4 different sources of data: a long online survey of Charles County residents perceptions of health and health behaviors, a short paper survey on health perceptions throughout the county, 7 focus groups with community leaders, citizens, and stakeholders, and a quantitative data analysis. The use of the multiple data collection methods strengthened the validity of the assessment's findings, as well as ensured that Charles County residents had an opportunity to participate in the assessment process and to feel invested in its outcome. Three hundred and two (302) Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health website. The first section of the survey asked participants about their perception of health and health services within the county. The second section asked them about their health behaviors, in order to determine their risk for the development of certain health conditions. A short three question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista waiting rooms, CCDOH waiting rooms, libraries, senior centers, community centers. Thirty five were completed in Spanish (17.5%). Seven focus groups were held throughout the county. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC) (community leaders and stakeholders). Approximately 165 people participated in the county focus groups. Survey for Community Members: 302 Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health website. A short 3 question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista waiting rooms, Charles County Department of Health waiting rooms, libraries, senior centers, community centers. 35 were completed in Spanish (17.5%). The CHNA was completed during the fiscal year ended June 30, 2012 and is currently being implemented. This CHNA report and implementation plan was approved by UMMC Board of Directors on June 28, 2012. The CHNA report is available on the following website: WWW.CHARLESREGIONAL.ORG/.../CHARLESCOUNTYCOMMUNITYHEALTHNEEDSASSESSMENT201 1.PDF Description of Individuals and Organizations Consulted for CHNA Input: Seven focus groups were held throughout the county with representation from the following organizations. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC) (community leaders and stakeholders). Approximately 165 people participated in the county focus groups from the following organizations: Partnerships for a Healthier Charles County Civista Medical Center Civista Health, Board Of Directors Charles County Department of Health University of Maryland Clinical Trials Program Bel Alton Alumni Community Development Association Charles County Department of Community Services, Transportation Tri County Council for Southern Maryland Minister's Alliance of Charles County Charles County Department of Social Services Maryland Foundation for Quality Healthcare Health Partner's Clinic Greater Baden FQHC Shiloh Community United Methodist Church Charles County Nursing and Rehabilitation Center Alzheimer's Association Center for Children Chesapeake Potomac Home Health Agency College of Southern Maryland Charles County Department of Aging Priority Partners Big Brothers/Big Sisters Community Hispanic Advocates Black Leadership Council for Excellence Young Researchers Community Project Pinnacle Center (Mental Health) Hospice of Charles County Breast Cancer Support Advocates Charles County Public Schools School Nurses Charles County Commissioners Charles County Emergency Services Charles County Sheriff's Office So. MD Delegation Charles County Community Foundation Community Physicians Charles County Fire and Rescue Board Lifestyles, Inc. (Homeless) Prioritization of Community Health Needs Quantitative data was analyzed for several health topics including: mortality, population and demographic data, natality, infant mortality, heart disease, stroke, hypertension, access to health care/health uninsurance, cancer, asthma, injuries, diabetes, obesity, osteoporosis, arthritis, dementia/Alzheimer's disease, communicable disease, sexually transmitted diseases, HIV/AIDS, mental health, dental health, substance abuse, disabilities, and tobacco use. Cumulative analysis of all quantitative and qualitative data identified the top 11 health needs of Charles County which was presented to the PHCC, a coalition of Charles County agencies and organizations. The direction of PHCC is guided by the Steering Committee which consists of leadership from Civista Health, CCDOH, CCPS and the CSM, as well as a Public Health Epidemiologist. PHCC Executive Committee: Noel A. Cervino CEO Civista Health Dr. Devadason Health Officer CC Health Department (CCDOH) Dr. Brad Gottfried President College of Southern Maryland Jim Richmond Superintendent Charles County Public Schools PHCC Steering Committee: Joyce Riggs Dir., Community Development & Planning CHI Fay Reed, RN Deputy Health Officer CCDOH William Leebel Public Information Officer CCDOH Linda Smith Project Coordinator CSM Tanisha Saunders Coordinator of Integrated Student Serv. CCPS Amber Starn, MPH Epidemiologist CHI
Eligibility Education	Schedule H, Part VI, Line 3	Civista Medical Center posts its Financial Assistance Policy (FAP), or a summary thereof, as well as financial assistance contact information, in admissions areas, emergency rooms, business offices and other areas of the facility where eligible patients are likely to present. In addition, the policy is available on the Civista website and is posted in the local paper twice each year. The FAP is written in a culturally sensitive and at an appropriate reading level. It is available in English and Spanish. During the intake or discharge process or when there is contact regarding a billing matter, if a patient discloses financial difficulty or concern with payment of the bill, the patient is provided with FAP information. Additionally, assistance is provided for patients or their families in qualification and application of government benefits, Medicaid and other state programs.
Description of Community Served	Schedule H, Part VI, Line 4	The Community Benefit Service Area for Civista Medical Center is all 28 zip codes located within the borders of Charles County. This includes the six zip codes identified as the Primary Service Area. Civista Medical Center is Charles County's only hospital and, as such, serves the residents of the entire county. Geography Charles County is located 23 miles south of Washington, D.C. It is one of five Maryland counties, which are part of the Washington, DC MD VA metropolitan area. At 458 square miles, Charles County is the eighth largest of Maryland's twenty four counties and accounts for about 5 percent of Maryland's total landmass. The northern part of the county is the "development district" where commercial, residential, and business growth is focused. The major communities of Charles County are La Plata (the county seat), Port Tobacco, Indian Head, and St Charles, and the main commercial cluster of Hughesville Waldorf White Plains. Approximately 60 percent of the county's residents live in the greater Waldorf La Plata area. By contrast, the southern (Cobb Neck area) and western (Nanjemoy, Indian Head, Marbury) areas of the region still remain very rural with smaller populations. Population Charles County has experienced rapid growth since 1970, expanding its population from 47,678 in 1970 to 120,546 in the 2000 census and 146,551 in the 2010 census. The current Census Bureau 2012 estimates the population at 150,592 for a 2.8% increase in two years. The magnitude of growth can be seen in the changes in population density. The 1990 census showed that there were 219.4 individuals per square mile, which increased to 261.5 individuals per square mile by 2000, an increase of 19.2%, and to 320.2 individuals per square mile by 2010, an increase of 22.5%. Transportation The percent change in the population growth for Charles County has been slightly greater than the change seen in the Maryland population growth. This growth has created transportation issues for the County in particular for the "development district" in the northern part of the county where many residents commute to Washington D.C. to work. The average work commute time for a Charles County resident is 42.3 minutes which is higher than the Maryland average by slightly more than 10 minutes. Public transportation consists of commuter bus for out of county travel and the county run Van Go bus service for in county transportation. Diversity As the population of the county changes, the diversity of the county also increases. The African American population has experienced the greatest increase. In 2000, African Americans made up 26% of the total Charles County population; by 2012, they comprise 42.4% of the total county population. As of 2012, minorities make up roughly 54% of the Charles County population. The Hispanic community has also seen increases over the past few years. They now comprise 4.7% of the total county population. This is the one of the highest percentages among the 24 Maryland jurisdictions. Economy Employment and economic indicators for the county are fairly strong. The 2010 US Census estimates found that 73.8% of the Charles County population is currently in the labor work force. The 2011 update estimates that approximately 5.6% of Charles County individuals are living below the poverty level, up 0.4% from 2010, however this is lower than the Maryland rate of 9% in 2011. The Charles County median household income was $92,135, an increase of $3,310 over the 2010 estimates and still well above the Maryland median household income of $72,419. The diversity of the county is also represented in the business community with 29.3% of all Charles County businesses being Black owned firms. This is higher than the State of Maryland at 19.3%. Education Charles County has a larger percentage of high school graduates than Maryland (90.6% vs. 88.2%); however, Charles County has a smaller percentage than Maryland of individuals with a bachelor's degree or higher (26.3% vs. 36.1%). Housing There is a high level of home ownership in Charles County (80.1%), however, this is slightly down from the 2010 level of 81.8%. The median value of a housing unit in Charles County is higher than the Maryland average ($341,200 vs. $319,800). Home values across Maryland have decreased and Charles County showed a slightly larger decrease than the Maryland average (4% vs. 3%). The average household size in Charles County is 2.86 persons. Life Expectancy The life expectancy for a Charles County resident, as calculated for 2009 2011, was 78.4 years. This is similar to the state average life expectancy of 79.2 years. Births There were 1,923 births in Charles County in 2012. Charles County represents 54% of the births in Southern Maryland (up 11% from 2009) and 2.6% of the total births in Maryland for 2012. Minorities made up just over half of the babies born in Charles County in 2012 (51.5%) which is in line with the composition of the county. Source: 2012 Maryland Vital Statistics Report
Promoting the health of the community	Schedule H, Part VI, Line 5	Implementation Strategy: The Charles County Health Improvement Plan (CCHIP): Upon completion of the CHNA, the Steering Committee of Partnerships for a Healthier Charles County (PHCC) reviewed the results and the identified top 11 health needs. The Steering Committee set county objectives through 2014 based on Maryland SHIP objectives and Healthy People 2020 Goals. The results and goals were presented to the PHCC membership at the quarterly General Membership Meeting. Six teams were formed based on expertise and interest to formulate 3 year action plans to address the following health needs using one or more of the "Seven Strategies for Community Change" found on the last page of the Charles County Health Improvement Plan . 1. Reproductive Health a. Healthy Babies (Infant Mortality Disparity) b. STD Reduction/Prevention 2. Chronic Disease a. Heart Disease b. Diabetes c. Obesity 3. Access to Care a. Dental health b. Transportation c. Physician Shortage 4. Cancer Team a. Lung Cancer b. Prostate Cancer c. Colorectal Cancer 5. Injury and Violence free Community a. Roadway incidents b. Injuries and Fall Prevention 6. Behavioral Health a. Substance Abuse b. Mental Health The Charles County Health Needs Assessment and Health Improvement Plan were presented to the Civista Health Board of Directors and approved. Annual updates to the Plan are reviewed and approved. The CCHIP objectives are the Charles County Health Improvement Plan and available at: http://www.charlesregional.org/index.cfm?fuseaction=HealthResources.showHe althActionPlans The Health Improvement Team Action Plans (Implementation Plans) are available at: http://www.charlesregional.org/index.cfm?fuseaction=HealthResources.showHe althActionPlans All the primary needs outlined in the Needs Assessment are being addressed by Civista Health either directly (i.e., OB Clinic, Physician Recruitment) or through partnerships with other organizations (i.e., Childhood Obesity Program, Fetal Infant Mortality, Prostate Cancer) or through the PHCC which is led and primarily financed by Civista Health. Where a need is appropriately addressed by another entity, Civista provides leadership through the Charles County Health Improvement Plan and the local health coalition (PHCC) to communicate initiatives, provide financial support and/or assistance when needed and review results (i.e., Substance Abuse, Mental Health). All the primary needs outlined in the Needs Assessment are being addressed and funded by Civista either directly (i.e., OB Clinic, Physician Recruitment) or through partnerships with other organizations (i.e., Childhood Obesity Program, Fetal Infant Mortality). Where a need is appropriately addressed by another entity, Civista provides leadership through the Charles County Health Improvement Plan and the coalition of Partnerships for a Healthier Charles County to communicate initiatives, provide assistance when needed and review results (i.e., Substance Abuse, Mental Health). The majority of the governing body, the Board of Directors, of Civista Medical Center is comprised of persons who reside in the community served by the hospital and who are neither employees nor contractors of the organization. Civista Medical Center extends medical privileges to all qualified medical staff in the community. Continuing Medical Education seminars and Grand Rounds are open to all community physicians.
Affiliated Health Care System Roles	Schedule H, Part VI, Line 6	Civista Medical Center is a member of the University of Maryland Medical System (UMMS). System hospitals meet monthly to coordinate and plan Community Benefit Operations such as Health Needs Assessments and Maryland State Health Improvement Plan objectives. UMMS provides leadership and guidance to local system jurisdictions regarding alignment with System and State wide goals. Southern Maryland had the highest percentage of physician shortages of all of the regions in Maryland (89.9%). To address the shortage, Civista Medical Center and UMMS have developed a recruitment and retention plan to successfully attract and retain private physicians to the community.
Community Benefit Report State Filings	Schedule H, Part VI, Line 7	Community Benefit Report was filed in the state of Maryland.

Schedule H (Form 990) 2012

Additional Data

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Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
Civista Medical Center Inc

Employer identification number
52-0445374

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) March of Dimes 2120 Washington Blvd Ste 425 Arlington,VA22204	13-1846366	501(c)(3)	11,000	March for Babies sponsorship
(2) Charles County Chamber of Commerce 101 Centennial Street Ste A LaPlata,MD20646	52-0699475	501(c)(3)	6,450	2013 Expo Sponsorship
(3) Civista Health Foundation 6 Garrett Avenue La Plata,MD20646	52-1414564	501(c)(3)	13,000	Southern MD Caregivers Sponsor

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
Procedure for Monitoring Use of Grant Funds Inside U.S.	Part I, Line 2	CIVISTA MEDICAL CENTER MAKES FINANCIAL AND IN-KIND CONTRIBUTIONS TO VARIOUS ORGANIZATIONS IN THE COMMUNITY.

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

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

Yes

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)John AshworthEx-Officio/Director	(i) (ii)	0 368,549	0 157,673	0 62,314	0 10,000	0 10,541	0 609,077	0 0
(2)Robert ChrencikEx-Officio/Director	(i) (ii)	0 1,166,972	0 994,524	0 13,073	0 223,385	0 11,081	0 2,409,035	0 0
(3)Noel CervinoEx-Officio/President & CEO	(i) (ii)	0 337,544	0 167,621	0 20,576	0 61,499	0 5,149	0 592,389	0 0
(4)Erik BoasChief Financial Officer	(i) (ii)	0 192,019	0 58,118	0 15,605	0 23,363	0 0	0 289,105	0 0
(5)Mark DumaisChief Medical Officer	(i) (ii)	0 271,296	0 100,341	0 2,446	0 36,148	0 7,316	0 417,547	0 0
(6)Gary HerbekChief Operating Officer	(i) (ii)	199,180 0	0 0	2,030 0	9,271 0	13,531 0	224,012 0	0 0
(7)Melanie SageVP Patient Care/Nurse Exec.	(i) (ii)	147,832 0	19,630 0	262 0	7,670 0	6,250 0	181,644 0	0 0
(8)Paul BlackwoodVP Planning	(i) (ii)	161,783 0	17,215 0	2,056 0	5,494 0	15,793 0	202,341 0	0 0
(9)Katherine MiddletonRN	(i) (ii)	157,904 0	0 0	70 0	6,481 0	9,337 0	173,792 0	0 0
(10)Marilyn GregoryClinical Nurse IV	(i) (ii)	171,637 0	0 0	201 0	6,456 0	1,964 0	180,258 0	0 0
(11)Gabriel AbiolaPharmacy Clinical Manager	(i) (ii)	154,269 0	6,062 0	781 0	6,995 0	13,531 0	181,638 0	0 0
(12)Stacey CookVP Human Resources	(i) (ii)	149,013 0	20,859 0	485 0	7,526 0	24,365 0	202,248 0	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
Supplemental Nonqualified Retirement Plan	Schedule J, Part I, Line 4B	DURING THE FISCAL YEAR-ENDED JUNE 30, 2013, CERTAIN OFFICERS AND KEY EMPLOYEES PARTICIPATED IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THE INDIVIDUALS LISTED BELOW HAVE VESTED IN THE PLAN IN A PRIOR YEAR, THEREFORE THE CONTRIBUTIONS TO THE PLAN FOR THE FISCAL YEAR ARE REPORTED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II, LINE B(III), OTHER REPORTABLE COMPENSATION: JOHN W. ASHWORTH THE INDIVIDUAL LISTED BELOW HAS NOT VESTED IN THE PLAN THEREFORE THE ACCRUED CONTRIBUTION TO THE PLAN FOR THE FISCAL YEAR IS REPORTED ON SCHEDULE J, PART II, COLUMN C, RETIREMENT AND OTHER DEFERRED COMPENSATION: ROBERT A. CHRENCIK
Non-fixed payments	Schedule J, Part I, Line 7	Bonuses paid are based on a number of variables including but not limited to individual goal achievements as well as organization operation achievements. The final determination of the bonus amount is determined and approved by the Board as part of the overall compensation review of the officers and key employees.

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Identifier	Return Reference	Explanation
Tax Exempt Bond Issues	Form 990, Part IV, Question 24	Pursuant to a Master Loan Agreement dated June 20, 1991 (The "Master Loan Agreement"), as Amended, The University Of Maryland Medical System Corporation (The "Corporation") and several of its subsidiaries have issued debt through the Maryland Health and Higher Education Facility Authority (the "Authority"). As Security for the performance of the bond obligation under the Master Loan Agreement, The Authority maintains a security interest in the revenue of the obligors. The Master Loan Agreement contains certain restrictive covenants. These covenants require that rates and charges be set at certain levels, limit incurrence of additional debt, require compliance with certain operating ratios and restrict the disposition of assets. The obligated group under the Master Loan Agreement includes the Corporation, The James Lawrence Kernan Hospital, Inc., Maryland General Hospital, Inc., Baltimore Washington Medical Center, Inc., Shore Health System, Inc., Chester River Hospital Center, Inc., Civista Medical Center, Inc., University of Maryland St. Joseph Medical Center, LLC and the University of Maryland Medical System Foundation, Inc. Each member of the obligated Group is jointly and severally liable for the repayment of the obligations under the Master Loan Agreement of the Corporation's $1,267,185,000 of outstanding Authority Bonds on June 30, 2013. All of the bonds were issued in the name of the University of Maryland Medical System Corporation. As of June 30, 2013, Civista Medical Center refinanced its Maryland Health and Higher Education Facility Authority bonds. The issuance of debt was made by the University of Maryland Medical System Corporation for the obligated group, of which Civista Medical Center is a member.
Members or Stockholders	Form 990, Part VI, Line 6, 7a, and 7b	Civista medical Center, Inc. and University of Maryland Medical System Corporation may elect members and approve decisions of the Civista Medical Center board.
Form 990 Review Process	Form 990, Part VI, Line 11b	The I.R.S. form 990 is prepared and reviewed by the accounting firm of Grant Thornton. Accounting personnel in finance shared services at the university of Maryland medical system gather the information needed to complete the return and input the data into the Grant Thornton tax organizer. When all data has been entered, the information is submitted to Grant Thornton for importation into their tax software. At this point, Grant Thornton staff members review the data, ask for additional information if needed and prepare the tax return. Each return is reviewed at several levels at Grant Thornton including the tax partner. After their review process, a draft return is sent to the accounting staff at UMMS for an in-house review. Upon completion of the in-house review, Grant Thornton is instructed to make any necessary changes and to prepare the final tax return. The final return undergoes another review by the accounting staff at finance shared services and is also reviewed by the accounting manager, the director of financial reporting, the vice president of finance and the CFO, who signs the return. Prior to filing the I.R.S. Form 990, the organization's board chairman, treasurer, audit committee chairman, executive committee chairman or other member of the board with similar authority will review the I.R.S. Form 990. At the discretion of the reviewing board member, such member will bring any issues or questions related to the completed I.R.S. Form 990 to the attention of the board. Notwithstanding the above, a board resolution is not required for the filing of the organization's I.R.S. form 990. Each board member is provided with a copy of the final I.R.S. Form 990 before filing.
Conflict of Interest Policy Monitoring & Enforcement	Form 990, Part VI, Line 12c	THE ORGANIZATION'S OFFICERS, DIRECTORS, EMPLOYEES AND MEDICAL STAFF MEMBERS, AS APPLICABLE, SHALL DISCLOSE CONFLICTS OF INTEREST OR POTENTIAL CONFLICTS OF INTEREST BETWEEN THEIR PERSONAL INTERESTS AND THE INTERESTS OF THE ORGANIZATION, OR ANY ENTITY CONTROLLED BY OR OWNED IN SUBSTANTIAL PART BY THE ORGANIZATION. A QUESTIONNAIRE WHICH DISCLOSES POTENTIAL CONFLICTS OF INTEREST IS DISTRIBUTED ANNUALLY TO ALL OFFICERS, DIRECTORS AND KEY EMPLOYEES. THE GENERAL COUNSEL OF THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM CORPORATION (UMMSC) REVIEWS THE RESPONSES FOR UMMSC, UNIVERSITY SPECIALTY HOSPITAL AND JAMES LAWRENCE KERNAN HOSPITAL. THE CEO OR CFO OF EACH OF THE OTHER ENTITIES IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM REVIEWS THE RESPONSES FOR THOSE ENTITIES. THE GENERAL COUNSEL, IN CONSULTATION WITH THE AUDIT COMMITTEE, IF NECESSARY, WOULD DETERMINE IF A CONFLICT OF INTEREST EXISTED FOR UMMSC, UNIVERSITY SPECIALTY HOSPITAL AND JAMES LAWRENCE KERNAN HOSPITAL. WITH RESPECT TO THE OTHER ENTITIES IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM, THE GENERAL COUNSEL MAY BE CALLED FOR CONSULT. IF SO, THE GENERAL COUNSEL MAY CONSULT THE AUDIT COMMITTEE, IF NECESSARY. WHENEVER A CONFLICT OR POTENTIAL CONFLICT OF INTEREST EXISTS, THE NATURE OF THE CONFLICT OR POTENTIAL CONFLICT OF INTEREST MUST BE DISCLOSED IN WRITING TO THE ORGANIZATION'S BOARD, BOARD COMMITTEE, AN OFFICER OF THE ORGANIZATION OR OTHER APPROPRIATE EXECUTIVE. SUCH INDIVIDUAL HAVING A POTENTIAL CONFLICT OF INTEREST SHALL PLAY NO ROLE ON BEHALF OF THE ORGANIZATION, OR ANY ORGANIZATION CONTROLLED OR SUBSTANTIALLY OWNED, IN ANY TRANSACTION IN WHICH A CONFLICT EXISTS. ALL INVITATIONS FOR BIDS, PROPOSALS OR SOLICITATIONS FOR OFFERS INCLUDE THE FOLLOWING PROVISION: ANY VENDOR, SUPPLIER OR CONTRACTOR MUST DISCLOSE ANY ACTUAL OR POTENTIAL TRANSACTION WITH ANY ORGANIZATION OFFICER, DIRECTOR, EMPLOYEE OR MEMBER OF THE MEDICAL STAFF, INCLUDING FAMILY MEMBERS WITHIN FIVE DAYS OF THE TRANSACTION. FAILURE TO COMPLY WITH THIS PROVISION IS A MATERIAL BREACH OF AGREEMENT. IN ADDITION, A BOARD DISCLOSURE REPORT IS FILED WITH THE MARYLAND HEALTH SERVICES COST REVIEW COMMISSION ON AN ANNUAL BASIS SHOWING ANY BUSINESS TRANSACTIONS BETWEEN THE BOARD MEMBERS AND THE ORGANIZATION.
Process for Determining Compensation	Form 990, Part VI, Line 15a & 15b	The organization determines the executive compensation paid to its executives in the following manner prescribed in the I.R.S. regulations: executive compensation packages are determined by a committee of the board that is composed entirely of board members who have no conflict of interest. The committee acquires credible comparability market data concerning the compensation packages of similarly situated executives. The committee carefully reviews that data, the executive's performance and the proposed compensation packages during the decision making process. The committee memorializes its deliberations in detailed minutes reviewed and adopted at the next-following meeting. The committee seeks an opinion of counsel that it has met the requirements of the I.R.S. intermediate sanctions regulations. This process is used to determine the compensation packages for all management employees from the vice president level and up.
How Documents are Made Available to the Public	Form 990, Part VI, Line 19	IN GENERAL, FINANCIAL AND TAX INFORMATION RELATING TO THE ORGANIZATION IS DEEMED PROPRIETARY AND NOT SUBJECT TO DISCLOSURE UPON REQUEST. HOWEVER, SPECIFIC PROVISIONS OF FEDERAL AND STATE LAW REQUIRE THE ORGANIZATION TO DISCLOSE CERTAIN LIMITED FINANCIAL AND TAX DATA UPON A SPECIFIC REQUEST FOR THAT INFORMATION. REQUESTS FOR FORM 990 AND FORM 1023: A REQUESTOR SEEKING TO REVIEW AND/OR OBTAIN A COPY OF THE ORGANIZATION'S IRS FORM 990 OR FORM 1023 AS FILED WITH THE INTERNAL REVENUE SERVICE, INCLUDING ALL SCHEDULES AND ATTACHMENTS, MAY APPEAR IN PERSON OR SUBMIT A WRITTEN REQUEST. THE MOST RECENT THREE YEARS OF IRS FORM 990 MAY BE REQUESTED. IF THE REQUESTER APPEARS IN PERSON, THE INDIVIDUAL IS DIRECTED TO THE OFFICE OF THE CHIEF FINANCIAL OFFICER FOR THE ORGANIZATION AND THE FORM 990 AND/OR FORM 1023 ARE MADE AVAILABLE FOR INSPECTION. THE INDIVIDUAL IS PERMITTED TO REVIEW THE RETURN, TAKE NOTES AND REQUEST A COPY. IF REQUESTED, A COPY IS PROVIDED ON THE SAME DAY. A NOMINAL FEE IS CHARGED FOR MAKING THE COPIES. THE ORGANIZATION MAY HAVE AN EMPLOYEE PRESENT DURING THE PUBLIC INSPECTION OF THE DOCUMENT. WRITTEN REQUESTS FOR AN ENTITY'S FORM 990 OR FORM 1023 ARE DIRECTED IMMEDIATELY TO THE OFFICE OF THE CHIEF FINANCIAL OFFICER FOR THE ORGANIZATION. THE REQUESTED COPIES ARE MAILED WITHIN 30 DAYS OF THE REQUEST. REPRODUCTION FEES AND MAILING COSTS ARE CHARGED TO THE REQUESTOR. CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS: IF THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY OF OUR ORGANIZATION ARE SUBJECT TO THE FEDERAL PUBLIC DISCLOSURE RULES (OR STATE PUBLIC DISCLOSURE RULES), THESE DOCUMENTS WILL BE MADE PUBLICLY AVAILABLE AS APPLICABLE LAW MAY REQUIRE. OTHERWISE, THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY WILL BE PROVIDED TO THE PUBLIC AT THE DISCRETION OF MANAGEMENT.
Hours on Related Entities	Form 990, Part VII, Section A, Column B	THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) IS A MULTI-ENTITY HEALTH CARE SYSTEM THAT INCLUDES 10 ACUTE CARE HOSPITALS, 3 ACUTE CARE HOSPITALS OWNED IN JOINT VENTURE ARRANGEMENTS AND VARIOUS SUPPORTING ENTITIES. A NUMBER OF INDIVIDUALS PROVIDE SERVICES TO VARIOUS ENTITIES WITHIN THE SYSTEM. IN GENERAL, THE OFFICERS AND KEY EMPLOYEES OF UMMS AVERAGE IN EXCESS OF 40 HOURS PER WEEK SERVING THE DIFFERENT ENTITIES THAT COMPRISE UMMS.
Other Changes in net assets or fund balances	Form 990, Part XI, Line 5	Swap Costs Bond Refinancing -76,924 Change in Pension Liability 3,625,800 Net assets released from restrictions -117,482 Change in temp. restricted net assets -247,450 Change in Equity of Affiliates, Foundation 500,878 Change in Equity of affiliates, CPHA 411,250 Unrealized Bonds FMV Adjustment -2,916,360 Miscellaneous -5,976 ------------------------------------ ------------ Total change in net assets 1,173,736

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

Civista Medical Center Inc

Employer identification number

52-0445374

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) Baltimore Washington Emergency Phys Inc 301 Hospital Drive Glen Burnie,MD21061 52-1756326	Healthcare	MD	501(c)(3)	11A	BWMS		No
(2) Baltimore Washington Healthcare Services 301 Hospital Drive Glen Burnie,MD21061 52-1830243	Healthcare	MD	501(c)(3)	11A	BWMS		No
(3) Baltimore Washington Medical Center Inc 301 Hospital Drive Glen Burnie,MD21061 52-0689917	Healthcare	MD	501(c)(3)	3	BWMS		No
(4) Baltimore Washington Medical System Inc 301 Hospital Drive Glen Burnie,MD21061 52-1830242	Healthcare	MD	501(c)(3)	11A	UMMSC		No
(5) BW Medical Center Foundation Inc 301 Hospital Drive Glen Burnie,MD21061 52-1813656	Fundraising	MD	501(c)(3)	11C	BWMS		No
(6) North Arundel Development Corporation 301 Hospital Drive Glen Burnie,MD21061 52-1318404	Real Estate	MD	501(c)(2)		NCC		No
(7) North County Corporation 301 Hospital Drive Glen Burnie,MD21061 52-1591355	Real Estate	MD	501(c)(2)		BWMS		No
(8) Chester River Health Foundation Inc 100 Brown Street Chestertown,MD21620 52-1338861	Fundraising	MD	501(c)(3)	7	CRHS		No
(9) Univ of MD Shore Regional Health Inc 100 Brown Street Chestertown,MD21620 52-2046500	Healthcare	MD	501(c)(3)	11A	UMMSC		No
(10) Chester River Hospital Center Inc 100 Brown Street Chestertown,MD21620 52-0679694	Healthcare	MD	501(c)(3)	3	CRHS		No
(11) Chester River Manor Inc 200 Morgnec Road Chestertown,MD21620 52-6070333	Healthcare	MD	501(c)(3)	9	CRHS		No
(12) Maryland General Clinical Practice Group 827 Linden Avenue Baltimore,MD21201 52-1566211	Healthcare	MD	501(c)(3)	11B	MGHS		No
(13) Maryland General Comm Health Foundation 827 Linden Avenue Baltimore,MD21201 52-2147532	Fundraising	MD	501(c)(3)	11C	MGHS		No
(14) University of Maryland Midtown Health 827 Linden Avenue Baltimore,MD21201 52-1175337	Healthcare	MD	501(c)(3)	11B	UMMSC		No
(15) Maryland General Hospital Inc 827 Linden Avenue Baltimore,MD21201 52-0591667	Healthcare	MD	501(c)(3)	3	MGHS		No
(16) Care Health Services Inc 219 South Washington Street Easton,MD21601 52-1510269	Healthcare	MD	501(c)(3)	9	SHS		No
(17) Dorchester General Hospital Foundation 219 South Washington Street Easton,MD21601 52-1703242	Fundraising	MD	501(c)(3)	11D	SHS		No
(18) Memorial Hospital Foundation Inc 219 South Washington Street Easton,MD21601 52-1282080	Fundraising	MD	501(c)(3)	11A	SHS		No
(19) Shore Clinical Foundation Inc 219 South Washington Street Easton,MD21601 52-1874111	Healthcare	MD	501(c)(3)	3	SHS		No
(20) Shore Health System Inc 219 South Washington Street Easton,MD21601 52-0610538	Healthcare	MD	501(c)(3)	3	UMMSC		No
(21) James Lawrence Kernan Hosp Endow Fd 2200 Kernan Drive Baltimore,MD21207 23-7360743	Fundraising	MD	501(c)(3)	11B	UMMSC		No
(22) James Lawrence Kernan Hospital Inc 2200 Kernan Drive Baltimore,MD21207 52-0591639	Healthcare	MD	501(c)(3)	3	UMMSC		No
(23) Shipleys Choice Medical Park Inc 22 South Greene Street Baltimore,MD21201 04-3643849	Real Estate	MD	501(c)(2)		UMMSC		No
(24) UMMS Foundation Inc 22 South Greene Street Baltimore,MD21201 52-2238893	Fundraising	MD	501(c)(3)	11A	UMMSC		No
(25) University of MD Medical System Corp 22 South Greene Street Baltimore,MD21201 52-1362793	Healthcare	MD	501(c)(3)	3	NA		No
(26) University Specialty Hospital 611 South Charles Street Baltimore,MD21230 52-0882914	Healthcare	MD	501(c)(3)	3	UMMSC		No
(27) Civista Health Inc PO Box 1070 La Plata,MD20646 52-2155576	Healthcare	MD	501(c)(3)	11C	UMMSC		No
(28) Civista Health Foundation Inc PO Box 1070 La Plata,MD20646 52-1414564	Fundraising	MD	501(c)(3)	3	CIVHS		No
(29) Civista Health Auxiliary Inc PO Box 1070 La Plata,MD20646 52-1131193	Fundraising	MD	501(c)(3)	11A	CIVHS		No
(30) Univ of MD St Joseph Foundation Inc 7601 Osler Drive Towson,MD21204 52-1681044	Fundraising	MD	501(c)(3)	11A	UMMSC		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?
(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) Arundel Physicians Associates LLC 301 Hospital Drive Glen Burnie,MD20161 52-2000762	Healthcare	MD	NA	N/A
(2) Baltimore Washington Imaging LLC 301 Hospital Drive Glen Burnie,MD20161 20-0806027	Healthcare	MD	NA	N/A
(3) Central Maryland Radiology Oncology LLC 10710 Charter Drive Columbia,MD21044 27-0879418	Healthcare	MD	NA	N/A
(4) Innovative Health LLC 29165 Canvasback Drive Suite 100 Easton,MD21601 52-1997287	Billing	MD	NA	N/A
(5) NAHSunrise of Severna Park LLC 301 Hospital Drive Glen Burnie,MD20161 54-1810729	Healthcare	MD	NA	N/A
(6) North Arundel Senior Living LLC 301 Hospital Drive Glen Burnie,MD20161 54-1810728	Healthcare	MD	NA	N/A
(7) Shipley's Imaging Center LLC 22 South Greene Street Baltimore,MD21201 52-2040338	Healthcare	MD	NA	N/A
(8) Universitycare LLC 22 South Greene Street Baltimore,MD21201 52-1914892	Healthcare	MD	NA	N/A
(9) O'Dea Medical Arts Limited Partnership 7601 Osler Drive Towson,MD21204 52-1682964	Rental	MD	NA	N/A

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(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) Arundel Physicians Associates Inc 301 Hospital Drive Glen Burnie,MD21061 52-1992649	Healthcare	MD	NA	C Corp
(2) Baltimore Washington Health Enterprises 301 Hospital Drive Glen Burnie,MD21061 52-1936656	Healthcare	MD	NA	C Corp
(3) BW Professional Services Inc 301 Hospital Drive Glen Burnie,MD21061 52-1655640	Healthcare	MD	NA	C Corp
(4) Civista Care Partners Inc PO Box 1070 La Plata,MD20646 52-2176314	Healthcare	MD	NA	C Corp
(5) Univ Midtown Prof Center A Condominium 827 Linden Avenue Baltimore,MD21201 52-1891126	Real Estate	MD	NA	C Corp
(6) Shore Health Enterprises Inc 219 South Washington Street Easton,MD21601 52-1363201	Real Estate	MD	NA	C Corp
(7) NA Executive Building Condo Assn Inc 301 Hospital Drive Glen Burnie,MD21061	Real Estate	MD	NA	C Corp
(8) Terrapin Insurance Company PO Box 1109 Grand Cayman KY1-1102 CJ 98-0129232	Insurance	CJ	NA	C Corp
(9) UMMS Self Insurance Trust 22 South Greene Street Baltimore,MD21201 52-6315433	Insurance	MD	NA	Trust

Schedule R (Form 990) 2012

Page 3

Part V

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

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

Yes

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

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

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

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

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

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: Civista Medical Center, Inc. is a component of a regional integrated health system serving the health needs of Charles County and the citizens of southern Maryland.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	16
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	13
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	1,020
6	Total number of volunteers (estimate if necessary) .............	6	118
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	144,140
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	32,420

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	165,000	528,633
9	Program service revenue (Part VIII, line 2g) .........	111,209,188	118,309,645
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	88,269	796,545
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	542,401	-2,428,080
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	112,004,858	117,206,743
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	34,654	58,392
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	48,691,670	53,090,677
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	55,007,273	56,619,499
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	103,733,597	109,768,568
19	Revenue less expenses. Subtract line 18 from line 12.......	8,271,261	7,438,175
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	147,245,093	143,406,844
21	Total liabilities (Part X, line 26).............	116,457,768	104,014,817
22	Net assets or fund balances. Subtract line 21 from line 20.....	30,787,325	39,392,027

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 86,303,830 including grants of $ 58,392 ) (Revenue $ 118,693,209 )
	Civista Health is the parent company of a regional integrated health system serving the health needs of Charles County and the citizens of Southern Maryland. Civista Medical Center's Community Benefits Program utilizes a planned, managed, organized, and measured approach to meeting the identified community needs of the area we serve. The mission is to improve overall community health by improving access to health care, enhancing the health of the community, advancing healthcare knowledge and working with health - providing agency partners. Civista Health collaborated with the Charles County Department of Health (CCDOH) to complete a comprehensive assessment of the health needs (CHNA) of Charles County, Maryland. An epidemiologist with a Master's Degree in Public Health Epidemiology was contracted to analyze the qualitative and quantitative data. Civista lead the effort and covered 80% of the cost of the CHNA. To provide a comprehensive assessment of the health needs of the county, a four method plan was developed which included four different sources of data: a long online survey of Charles County residents perceptions of health and health behaviors, a short paper survey on health perceptions throughout the county, seven focus groups with community leaders, citizens, and stakeholders, and a quantitative data analysis. The use of the multiple data collection methods strengthened the validity of the assessment's findings, as well as ensured that Charles County residents had an opportunity to participate in the assessment process and to feel invested in its outcome. Three hundred and two Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey is available on the Civista Health website. The first section of the survey asked participants about their perception of health and health services within the county. The second section asked them about their health behaviors, in order to determine their risk for the development of certain health conditions. A short three question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista waiting rooms, CCDOH waiting rooms, libraries, senior centers, community centers. Thirty five were completed in Spanish (17.5%). Seven focus groups were held throughout the county. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC). Approximately 165 people participated in the county focus groups from a wide variety of organizations and community groups. Quantitative data was analyzed for several health topics including: mortality, population and demographic data, natality, infant mortality, heart disease, stroke, hypertension, access to health care/health uninsurance, cancer, asthma, injuries, diabetes, obesity, osteoporosis, arthritis, Childhood Obesity Program, Faith-Based Health Expo. Support groups such as Stroke Support, Parkinson's support group, Pink Ladies and Sister's at Heart and Ostomy Support Group. Clinics and clinic services such as pre natal and OB clinic, flu vaccine clinic, renal dialysis services, American Red Cross blood drives Community committees, boards, and organizations (employee participation) such as United Way, Partnerships for a Healthier Charles County, Charles County Tobacco Coalition, Leadership Maryland, Hospice of Charles County, Healthy Families, Health Partners Free Clinic Board, Fetal Infant Mortality Board, Center for Abused Persons, Juvenile Drug Court; Chamber of Commerce, Charles County Commission for Women, Charles County child advocacy partnership, healthcare roundtable community events such as Christmas Connection, Relay for Life, Alzheimer's Walk, March of Dimes, and safe nights.

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 expenses86,303,830

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)				(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) Joel Sewchand MD........................................................................ Ex-O/ChiefStaff/Begin 1/1/13	2.0 .......................	X	X			0	0	0
(19) Erik Boas........................................................................ Chief Financial Officer	40.0 .......................10.0		X			0	265,742	23,363
(20) Mark Dumais........................................................................ Chief Medical Officer	40.0 .......................			X		0	374,083	43,464
(21) Gary Herbek........................................................................ Chief Operating Officer	40.0 .......................			X		201,210	0	22,802
(22) Melanie Sage........................................................................ VP Patient Care/Nurse Exec.	40.0 .......................			X		167,724	0	13,920
(23) Paul Blackwood........................................................................ VP Planning	40.0 .......................				X	181,054	0	21,287
(24) Katherine Middleton........................................................................ RN	40.0 .......................				X	157,974	0	15,818
(25) Marilyn Gregory........................................................................ Clinical Nurse IV	40.0 .......................				X	171,838	0	8,420
(26) Gabriel Abiola........................................................................ Pharmacy Clinical Manager	40.0 .......................				X	161,112	0	20,526
(27) Stacey Cook........................................................................ VP Human Resources	40.0 .......................				X	170,357	0	31,891

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,211,269	3,928,671	523,146

				(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		500,878
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f		27,755

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			528,633
			Business Code
2a	NET PATIENT REVENUE		900099	118,309,645	118,309,645
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			118,309,645
3	Investment income (including dividends, interest, and other similar amounts).......			18,876			18,876
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	777,669
b	Less: cost or other basis and sales expenses
c	Gain or (loss)	777,669
d	Net gain or (loss)..........			777,669			777,669
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..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	ANSWERING SERVICE		561000	144,140		144,140
b	CAFETERIA & COFFEE BAR SALES		900099	339,080	339,080
c	MEDICAL RECORD COPIES & APPLICATION FEES		900099	33,110	33,110
d	All other revenue ....			-2,944,410	11,374		-2,955,784
e	Total. Add lines 11a–11d ......			-2,428,080
12	Total revenue. See Instructions......			117,206,743	118,693,209	144,140	-2,159,239


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			0	1	0
2	Savings and temporary cash investments .........			37,974,354	2	28,125,065
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			11,344,222	4	11,705,089
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			1,490,645	8	1,459,352
9	Prepaid expenses and deferred charges ..........			930,555	9	459,932
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	107,621,747
b	Less: accumulated depreciation .....	10b	38,611,562	66,994,942	10c	69,010,185
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			28,510,375	15	32,647,221
16	Total assets. Add lines 1 through 15 (must equal line 34)......			147,245,093	16	143,406,844
17	Accounts payable and accrued expenses .........			13,117,763	17	12,114,172
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			54,348,613	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			21,568,471	23	20,599,450
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			27,422,921	25	71,301,195
26	Total liabilities. Add lines 17 through 25.........			116,457,768	26	104,014,817
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			30,770,543	27	39,182,155
28	Temporarily restricted net assets ...........			16,782	28	209,872
29	Permanently restricted net assets ...........			0	29	0
	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 ...........			30,787,325	33	39,392,027
34	Total liabilities and net assets/fund balances ........			147,245,093	34	143,406,844

1	Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If “Yes,”the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................	Yes	No
2	Did the organization have an interest in a foreign trust during the tax year? If “Yes,” the organizationmay be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A).......................................	Yes	No
3	Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................	Yes	No
4	Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)	Yes	No
5	Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................	Yes	No
6	Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713)................................................	Yes	No