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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
DARTMOUTH-HITCHCOCK CLINIC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
ONE MEDICAL CENTER DRIVE
Suite
Room/suite
City or town, state or country, and ZIP + 4
LEBANON, NH03756
D Employer identification number

22-2519596
E Telephone number

G Gross receipts $ 407,298,233
F Name and address of principal officer:
James Weinstein DO MS
One Medical Center Drive
Lebanon,NH03756
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.dartmouth-hitchcock.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1983
M State of legal domicile: NH
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: WE ADVANCE HEALTH THROUGH RESEARCH, EDUCATION, CLINICAL PRACTICE AND COMMUNITY PARTNERSHIPS, PROVIDING EACH PERSON THE BEST CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, EVERY TIME.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 22
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 15
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 4,484
6 Total number of volunteers (estimate if necessary) ............. 6 600
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 624,628
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 5,244
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 0
9 Program service revenue (Part VIII, line 2g) ......... 247,880,635 312,867,125
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... -66,567 86,264
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 53,429,403 93,249,217
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 301,243,471 406,202,606
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 173,027 2,646,503
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) 189,868,415 253,764,588
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet884,514    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 111,870,818 131,081,080
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 301,912,260 387,492,171
19 Revenue less expenses. Subtract line 18 from line 12....... -668,789 18,710,435
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 301,634,312 228,949,164
21 Total liabilities (Part X, line 26)............. 518,759,859 376,500,812
22 Net assets or fund balances. Subtract line 21 from line 20..... -217,125,547 -147,551,648
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: WE ADVANCE HEALTH THROUGH RESEARCH, EDUCATION, CLINICAL PRACTICE AND COMMUNITY PARTNERSHIPS, PROVIDING EACH PERSON THE BEST CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, EVERY TIME.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 320,097,884 including grants of $ 230,215 ) (Revenue $ 402,644,857 )
Dartmouth-Hitchcock Clinic (the Clinic) is a not-for-profit organization as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from Federal income taxes on related income pursuant to Section 501(a) of the Code. The Clinic and subsidiaries, a multispecialty physician practice group that operates clinics throughout New Hampshire and Vermont, provides medical services to patients and performs medical education and research. Health care services in 2013 resulted in approx. 665,693 office visits recorded by Clinic personnel. The promotion of health through the medical practice activities of the Clinic provides the basis for the organization's tax exempt activities. The Clinic is a member of Dartmouth-Hitchcock Medical Center (DHMC), a New Hampshire nonprofit corporation organized for the exploration and coordination of matters of mutual interest among its members: the Hospital, Dartmouth-Hitchcock Clinic (the Clinic), Geisel School of Medicine (GSM), a component of Dartmouth College; and the Veterans Affairs Medical Center in White River Junction, Vermont. The Clinic provides the physician staff to the Hospital and the sophistication essential for the development of the Hospital as the largest hospital and only academic medical center in New Hampshire, and for the designation by the federal government as a Rural Referral Center for northern New England. The shared mission of the Hospital and Clinic is to "advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time". Its strategic operating plan lays out a path to creating a "sustainable health system to improve the lives of the people and communities we serve, for generations to come." The focus of this work, across the Dartmouth-Hitchcock organization, i.e. all Hospital and Clinic sites, is in three main areas: Improving Population Health; Delivering Value Based Care; and Developing and Implementing New Payment Models. Consistent with this mission and in partnership with the Hospital, the Clinic provides high quality, cost effective, comprehensive, and integrated health care to individuals, families, and the communities it serves, regardless of a patient's ability to pay. The Clinic actively supports community-based health care and promotes the coordination of services among health care providers and social services organizations. The Clinic also seeks to work collaboratively with other area health care providers to improve the health status of the region. In 2012, Dartmouth-Hitchcock (D-H) was selected by the Centers for Medicare and Medicaid (CMS) as one of 32 organizations nationally to participate in the Pioneer Accountable Care demonstration project. At the end of one year, it was one of only 13 to meet all quality and safety metrics and show significant cost reductions, while providing coordinated, patient-centered care to the assigned Medicare population. Also in 2012, D-H joined with Fletcher Allen Health Care, Vermont's academic medical center, to form OneCare Vermont, an ACO that includes all 14 of the state's hospitals, hundreds of primary care physicians and specialists, two federally qualified health centers, and several rural health clinics, to coordinate the health care of approximately 42,000 of Vermont's 118,000 Medicare beneficiaries, (40 percent of the Hospital and Clinic patients are from Vermont). During the same period, Dartmouth-Hitchcock entered into a non-ownership affiliation with Mayo Clinic as part of the Mayo Clinic Care Network. This arrangement allows D-H physicians to partner with colleagues from Mayo for second opinions and consultations, thus bringing the expertise of both organizations to individual patient care. Much of the consultation is done via telemedicine, another expanding initiative of D-H in 2012. The program is intended to strengthen our ability to serve patients in our region with the highest-quality care, close to home. It also allows the Hospital and Clinic to get care to patients in emergency situations quickly and to partner with local health organizations in the delivery of care, something that is particularly important in our rural area. The Dartmouth-Hitchcock Center for Telehealth currently offers neurological and stroke care via telemedicine, as well as dermatology services. Additional care disciplines are being brought on line as of this writing. In late 2012, Dartmouth-Hitchcock formed the Partners in Community Wellness, a group of more than 300 volunteer members from throughout New Hampshire and Vermont. With the resources of D-H, the group is engaged in education and community health initiatives. An example is the Vial of Life campaign, through which the Partners have distributed, at no charge, more than 10,000 emergency information kits to physicians, emergency responders, fire departments and public safety organizations, and businesses and individuals. This ongoing effort will next focus on getting the kits to more than 1,000 schools in the region. Nationally, Dartmouth-Hitchcock is a founding member, with Mayo Clinic, Intermountain Health Care, Denver Health, and The Dartmouth Institute for Health Policy and Clinical Practice, of the High Value Healthcare Collaborative (HVHC). The Collaborative currently comprises 19 health systems and the TRICARE system of the Department of Defense. Together, they have a patient base of more than 100 million. The goal of the Collaborative is to improve the quality of health care while lowering costs. Through data sharing and defining of best practices for 8 high-cost, high-variation conditions, the members are improving outcomes and already seeing cost savings. A $26 million grant from CMS is making it possible to integrate shared decision making - the Clinic and Hospital were the first in the nation to create a Center for Shared Decision Making and integrate tools into clinical care - into the work of the Collaborative. Beyond that grant, however, the HVHC is self-funded by the member health systems. Effective with fiscal year 2000, the Clinic and the Hospital began filing an annual Community Benefit Report with the State of New Hampshire, which outlines the community and charitable benefits they provide. The most recent Community Benefit Reports are available upon request or can be found on Dartmouth-Hitchcock's web site (www.dartmouth-hitchcock.org). Financial assistance, formerly called charity care, represents services provided to patients who cannot afford health care services due to inadequate financial resources which result from being uninsured or underinsured. For the year ended June 30, 2013 the Hospital provided financial assistance to patients in the amount of $21,329,978, as measured by gross charges. The estimated cost of providing this care for the year ended June 30, 2013 was $6,861,854. The Clinic also routinely provides services to Medicaid patients at reimbursement levels that are well below the cost of the care provided. The community health activities section of the report includes the cost or value of several different types of hospital-sponsored programs, such as community based education, health fairs, health screenings, support groups, and programs and materials that promote wellness and prevent illness. Examples of these types of efforts include partnering with the Healthy Eating Active Living NH initiative, the Partners in Community Wellness, ReThink Health, the Women's Health Resource Center, and smoking prevention and cessation programs. This category also includes financial contributions and the contribution of time and services to community programs, hospitals and agencies. The Clinic also provides a significant amount of uncompensated care to its patients reported as provision for bad debts, which is not included in the amounts reported above. During the year ended June 30, 2013, the Clinic reported a bad debt expense of $17,325,863.
4b (Code:   ) (Expenses $ 19,572,548 including grants of $ 2,416,288 ) (Revenue $ 130,172 )
As a component of an integrated academic medical center, the Clinic provides significant support for academic and research programs. Through its affiliation with The Geisel School of Medicine at Dartmouth, the Clinic provides support for physicians' unpaid teaching time, consisting of the time physicians spend providing clinical supervision and education for residents and medical students. In addition, the Clinic provides in-kind support for research and other grants awarded to the Hospital and Medical School, to offset costs in excess of grant awards. Other community benefit initiatives include subsidizing the costs of providing medical and clinical education to professionals across New Hampshire, Vermont and beyond, as well as uncompensated costs of academic and medical research activities.
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet339,670,432
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? ...
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
Yes
 
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IVClick to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV... Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
Yes
 
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........ Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.......................... Click to see attachment
26
Yes
 
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
Yes
 
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV..................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV... Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
4,484
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
Yes
 
b
If "Yes," enter the name of the foreign country: MediumBulletBD
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
22
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
15
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
NH
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletROBIN KILFEATHER-MACKEYONE MEDICAL CENTER DRIVELebanonNH03756 (603) 650-5634
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Wayne G Granquist........................................................................
Trustee/Brd Chair end 12/31/12
 2.0
.......................5.5 		X   X       0 0 0
(2) Alan C Keiller........................................................................
Trustee/Board Treasurer
 2.0
.......................4.5 		X   X       0 0 0
(3) Jennie L Norman........................................................................
Trustee/Board Secretary
 2.0
.......................4.0 		X   X       0 0 0
(4) Hugh C Smith MD........................................................................
Trustee
 1.0
.......................2.0 		X           0 0 0
(5) James Weinstein DO MS........................................................................
Trustee Ex-Officio/CEO
 17.0
.......................44.5 		X   X       833,051 0 59,682
(6) Michael J Goran MD........................................................................
Trustee
 1.0
.......................2.0 		X           0 0 0
(7) Vincent S Conti........................................................................
Trustee
 1.0
.......................2.0 		X           0 0 0
(8) Barbara Couch........................................................................
Trustee
 1.0
.......................2.0 		X           0 0 0
(9) Anne-Lee Verville........................................................................
Trustee
 1.0
.......................2.0 		X           0 0 0
(10) William Abdu MD MS........................................................................
Trustee/Physician
 12.0
.......................29.0 		X           634,897 0 60,774
(11) Wiley Souba MD ScD........................................................................
Trustee/Ex-Officio, Dean DMS
 1.0
.......................2.5 		X           0 0 0
(12) Richard S Shreve........................................................................
Trustee/Ex Officio Pres Apptee
 1.0
.......................2.0 		X           0 0 0
(13) William J Conaty........................................................................
Trustee
 1.0
.......................2.0 		X           0 0 0
(14) Robert A Oden Jr PhD........................................................................
Trustee/Board Chair Eff 1/1/13
 2.0
.......................4.0 		X   X       0 0 0
(15) Stephen D Surgenor MD MS........................................................................
Trustee End 2/29/13 Physician
 12.0
.......................29.0 		X           406,696 0 63,062
(16) Nancy Formella MSN RN........................................................................
Trustee Advisor End 12/1/2012
 18.0
.......................42.5 		X   X       0 3,209,060 58,814
(17) William W Helman IV........................................................................
Trustee
 1.0
.......................2.5 		X           0 0 0
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Ruth Williams Brinkley........................................................................
Trustee Ended 11/2/12
 1.0
.......................2.0 		X           0 0 0
(19) Peter Delong MD........................................................................
Trustee/Physician
 12.0
.......................28.0 		X           270,762 0 48,410
(20) Richard I Rothstein MD........................................................................
Trustee/Dept Chair Med
 12.0
.......................28.0 		X           564,259 0 51,200
(21) Denis A Cortese MD........................................................................
Trustee Eff 1/1/13
 1.0
.......................2.0 		X           0 0 0
(22) Matthew B Dunne........................................................................
Trustee Eff 1/1/13
 1.0
.......................2.0 		X           0 0 0
(23) Senator Judd A Gregg........................................................................
Trustee Eff 1/1/13
 1.0
.......................2.0 		X           0 0 0
(24) Laura K Landy........................................................................
Trustee Eff 1/1/13
 1.0
.......................2.0 		X           0 0 0
(25) Steven A Paris MD........................................................................
Trustee Eff 2/1/13
 1.0
.......................   		X           351,548 0 56,119
(26) Richard J Powell MD........................................................................
Trustee Eff 2/1/13/Phys
 12.0
.......................28.3 		X           520,702 0 92,517
(27) Robin Kilfeather-Mackey CPA........................................................................
Chief Financial Officer
 17.0
.......................44.0 		    X       451,645 0 37,043
(28) Linda Von Reyn........................................................................
Chief Nursing Officer
 19.0
.......................41.0 		    X       0 458,727 37,027
(29) Daniel Jantzen CPA........................................................................
Chief Operating Officer
 19.0
.......................42.0 		    X       0 608,217 59,542
(30) Stephen LeBlanc........................................................................
ExecVP Strtgy&Ntwrk Eff 2/3/13
 6.0
.......................54.0 		    X       535,986 0 36,773
(31) John Butterly MD........................................................................
Exec VP of Med Affairs, D-HH
 8.0
.......................52.0 		    X       538,707 0 93,348
(32) Alan Weston........................................................................
Chief Human Resources Officer
 19.0
.......................41.0 		    X       0 311,437 65,426
(33) Gregg Meyer MD........................................................................
CCO/EVP Pop Hlth
 19.0
.......................41.0 		    X       531,180 0 97,818
(34) Neil Castaldo........................................................................
Sr Advisor to CEO Eff 7/1/12
 19.0
.......................41.0 		    X       0 622,913 70,272
(35) Jeanine Arden Ornt........................................................................
General Counsel
 17.0
.......................39.0 		    X       0 415,319 72,262
(36) Vincent Fusca........................................................................
Chief of Staff
 19.0
.......................41.0 		    X       0 230,806 20,753
(37) Edward Merrens MD........................................................................
CMO Eff 9/1/12
 12.0
.......................28.0 		    X       343,307 0 65,544
(38) George Blike MD........................................................................
Chf Qlty&Value Ofr Eff 7/1/12
 19.0
.......................41.0 		    X       389,078 0 48,677
(39) Mary Oseid........................................................................
V.P Ambulatory Care
 12.0
.......................28.0 		      X     258,638 0 45,523
(40) Christine Schon........................................................................
V.P Comm. Grp. Pract. Ops
 12.0
.......................28.0 		      X     209,756 0 58,175
(41) William Mroz........................................................................
V.P. Operations/Clinical Svcs
 19.0
.......................41.0 		      X     0 245,900 48,844
(42) Gail Dahlstrom........................................................................
V.P. Facilities Mgmt
 19.0
.......................41.0 		      X     0 225,829 32,934
(43) Michael Ward........................................................................
V.P. Cancer Svcs end 7/31/12
 12.0
.......................28.0 		      X     182,530 0 29,397
(44) Tina Naimie CPA........................................................................
VP Corporate Finance
 12.0
.......................29.5 		      X     0 213,338 39,214
(45) Wendy Fielding........................................................................
VP Financial Planning
 12.0
.......................28.0 		      X     0 213,833 70,331
(46) Barbara Walters DO MBA........................................................................
Med Dir/Dir Acct Care eff 11/1
 12.0
.......................28.0 		      X     353,318 0 57,527
(47) David Roberts MD........................................................................
Physician
 12.0
.......................28.0 		        X   856,984 0 81,196
(48) Nathan Simmons MD........................................................................
Physician
 12.0
.......................28.0 		        X   753,172 0 75,941
(49) Kadir Erkmen MD........................................................................
Physician
 12.0
.......................28.0 		        X   1,123,113 0 49,966
(50) Thomas Colacchio MD........................................................................
Former Officer/Phys
 12.0
.......................29.0 		        X   1,041,556 0 66,668
(51) Daniel Stewart MD........................................................................
Physician
 12.0
.......................28.0 		        X   824,442 0 67,649
(52) Carl DeMatteo MD........................................................................
Former Chf Qual Compl Ofr
 12.0
.......................28.0 		          X 496,126 0 7,530
(53) Lawrence Dacey MD........................................................................
Former CMO END 6/30/12/DH Phys
 12.0
.......................29.0 		          X 507,485 0 37,711
(54) Andrew Gettinger MD........................................................................
Former Chief Med Info Ofr
 12.0
.......................28.0 		          X 336,449 0 39,315
(55) Sandra Dickau........................................................................
Former VP Ops/Ptnt Care
 12.0
.......................28.0 		          X 0 127,765 0
(56) Mary Kay Boudewyns........................................................................
Former Key Employee
 12.0
.......................28.0 		          X 0 212,298 48,103
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 13,315,387 7,095,442 2,051,087
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet1,095
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
See Schedule O,      
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet0
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 0
Program Service Revenue Business Code
2a NET PATIENT SERVICE REVENUE 621110 312,867,125 312,867,125    
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 312,867,125
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 16,245     16,245
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 2,961,261 644,024
b Less: rental expenses 741,230 147,370
c Rental income or (loss) 2,220,031 496,654
d Net rental income or (loss).......MediumBullet 2,716,685     2,716,685
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory -19,842 296,888
b Less: cost or other basis and sales expenses   207,027
c Gain or (loss) -19,842 89,861
d Net gain or (loss)..........MediumBullet 70,019     70,019
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a CONTRACTED REVENUE 621110 83,453,774 82,829,694 624,080  
b RISK SHARING REVENUE & INCOME FROM AFFILIATES 211110 3,359,593 3,359,593    
c DHC ALLOCATED REVENUE 621110 3,247,560 3,247,012 548  
d All other revenue .... 471,605 471,605    
e Total. Add lines 11a–11d ...... MediumBullet 90,532,532
12 Total revenue. See Instructions......MediumBullet 406,202,606 402,775,029 624,628 2,802,949
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 2,180,200 2,180,200
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 466,303 466,303
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 .... 6,273,875 2,940,966 3,017,365 315,544
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 795,167 795,167    
7 Other salaries and wages 184,443,212 161,133,099 23,310,071 42
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 23,797,653 20,790,083 3,007,565 5
9 Other employee benefits ....... 25,435,333 22,220,791 3,214,536 6
10 Payroll taxes ........... 13,019,348 11,373,950 1,645,395 3
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 978,313 5,941 972,372  
c Accounting ........... 178,938   178,938  
d Lobbying ........... 30,167 30,167    
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) ........ 22,365,473 18,084,362 4,281,111  
12 Advertising and promotion .... 743,367 9,369 733,998  
13 Office expenses ....... 6,792,446 6,327,115 465,321 10
14 Information technology ...... 2,413,185 2,413,185    
15 Royalties .. 0      
16 Occupancy ........... 6,174,205 5,155,472 1,018,733  
17 Travel ............ 987,590 563,704 423,886  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 41,573 41,225 348  
20 Interest ........... 6,807,571 5,718,360 1,089,211  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 16,983,654 14,264,214 2,719,440  
23 Insurance .............. 1,501,356 1,088,301 413,055  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES 54,368,048 54,368,048    
b EQUIP REPAIR & MAINT 4,667,337 3,920,563 746,774  
c ACADEMIC,GME,TEACHING & SPT 1,038,771 1,038,771    
d BOND RELATED EXPENSES 1,106,068 929,097 176,971  
e All other expenses 3,903,018 3,811,979 -477,865 568,904
25 Total functional expenses. Add lines 1 through 24e 387,492,171 339,670,432 46,937,225 884,514
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 24,313 1 15,745
2 Savings and temporary cash investments ......... 149,198 2 -189,306
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 36,877,683 4 35,110,240
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
354,641 5 384,015
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 ............. 6,476,070 7 6,679,138
8 Inventories for sale or use .............. 339,320 8 330,456
9 Prepaid expenses and deferred charges .......... 0 9 0
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 140,069,768
b Less: accumulated depreciation ..... 10b 98,807,473 46,183,158 10c 41,262,295
11 Investments—publicly traded securities .......... 93,523 11 149,037
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 1,500 13 1,500
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 211,134,906 15 145,206,044
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 301,634,312 16 228,949,164
Liabilities 17 Accounts payable and accrued expenses ......... 56,965,205 17 65,608,899
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 58,555,011 20 56,747,863
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 .. 18,108,655 23 16,748,892
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.................... 385,130,988 25 237,395,158
26 Total liabilities. Add lines 17 through 25......... 518,759,859 26 376,500,812
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. -218,350,102 27 -148,777,030
28 Temporarily restricted net assets ........... 226,096 28 226,923
29 Permanently restricted net assets ........... 998,459 29 998,459
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... -217,125,547 33 -147,551,648
34 Total liabilities and net assets/fund balances ........ 301,634,312 34 228,949,164
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
406,202,606
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
387,492,171
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
18,710,435
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
-217,125,547
5
Net unrealized gains (losses) on investments ...............
5
55,513
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
50,807,951
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
-147,551,648
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
Yes
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


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

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

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

22-2519596
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
 
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? (vii) Amount of monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . 4,383 142,981 0 0 0 147,364
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...... 434,650,631 365,093,409 368,081,102 298,584,597 402,775,030 1,869,184,769
3 Gross receipts from activities that are not an unrelated trade or business under section 513..           0
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...           0
5 The value of services or facilities furnished by a governmental unit to the organization without charge..           0
6 Total. Add lines 1 through 5. 434,655,014 365,236,390 368,081,102 298,584,597 402,775,030 1,869,332,133
7a Amounts included on lines 1, 2, and 3 received from disqualified persons... 0 0 0 0   0
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.           0
c Add lines 7a and 7b.. 0 0 0 0   0
8 Public support (Subtract line 7c from line 6.)           1,869,332,133
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6... 434,655,014 365,236,390 368,081,102 298,584,597 402,775,030 1,869,332,133
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 4,052,931 3,383,606 3,085,762 -66,568 86,263 10,541,994
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.           0
c Add lines 10a and 10b. 4,052,931 3,383,606 3,085,762 -66,568 86,263 10,541,994
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.       905,573 5,244 910,817
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) .. 4,574,675 0 287,656     4,862,331
13 Total support. (Add lines 9, 10c, 11, and 12.).. 443,282,620 368,619,996 371,454,520 299,423,602 402,866,537 1,885,647,275
14
Section C. Computation of Public Support Percentage
15
15
99.135 %
16
16
98.834 %
Section D. Computation of Investment Income Percentage
17
17
0.559 %
18
18
0.773 %
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE 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
DARTMOUTH-HITCHCOCK CLINIC
 
Employer identification number

22-2519596
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
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

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 Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(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? ......................................

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


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)
No
Yes
(b)
Amount
1
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:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
Yes
 
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
58,687
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
28,670
j
Total. Add lines 1c through 1i ...............................
87,357
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
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
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
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."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
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? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
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 activity explanation FORM 990 SCHEDULE C, PART II B, LINES 1B & 1G Dartmouth-Hitchcock Clinic employs two full time staff whose duties include lobbying. Typical expenses associated with the lobbying activities include staff salary, travel, membership fees and dues. From time to time, Dartmouth-Hitchcock Clinic, through its employees and the use of consultants, contacts government officials and legislators. This contact is for the purpose of proposing legislation or expressing an opinion on changes in legislation that affect the Clinic and its ability to carry out its mission. Typical activities include emailing, calling, and meeting with government officials and legislators.For the fiscal year ended June 30, 2013, Dartmouth-Hitchcock Clinic incurred $58,687 in conjunction with these activities. FORM 990 SCHEDULE C, PART II B, LINE 1I DHC pays dues to various organizations related to its exempt mission. The amount reported under other activities on line 1I refers to the amount of lobbying activities identified in dues payments to outside organizations.
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID:  
Software Version:  

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

22-2519596
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance .... 999,533 998,459 998,459 855,478 137,536
b Contributions ........   0 0 142,981 717,942
c Net investment earnings, gains, and losses 950 1,074 0    
d Grants or scholarships .....   0 0    
e Other expenditures for facilities
and programs ........ 		  0 0    
f Administrative expenses ....   0 0    
g End of year balance ...... 1,000,483 999,533 998,459 998,459 855,478
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet99.910 %
c
Temporarily restricted endowment SchDMd Bullet0.090 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land ................. 3,816,840 7,215,859 11,032,699
b Buildings ................ 11,337,976 72,493,046 55,849,675 27,981,347
c Leasehold improvements ............   27,569,189 26,672,990 896,199
d Equipment ................   17,636,858 16,284,808 1,352,050
e Other .................        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 41,262,295
Schedule D (Form 990) 2012

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








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








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) INVESTMENT IN CAPTIVE - HAMDEN 109,432,393
(2) BOND ISSUANCE COSTS - NET 130,231
(3) DHC 457(B) PLAN ASSETS 34,264,377
(4) DUE FROM AFFILIATE 1,029,043
(5) NOTES RECEIVABLE 350,000




Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 145,206,044
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
INTEREST RATE SWAP 13,544,983
ACCRUED POST RETIRMNT PENSION 122,106,863
RESERVES FOR INSUR. RLTD LOSS 89,334,998
DUE TO AFFILIATES AND 3RD PARTY ESTIMATES 12,408,314





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 237,395,158
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
INTENDED USE OF ENDOWMENT FUNDS FORM 990 SCHEDULE D PART V LINE 4 THE ENDOWMENT FUND WAS ESTABLISHED TO PROVIDE RESEARCH AND CLINICAL SUPPORT FOR THE CARDIOTHORACIC SURGERY CHAIR AT DARTMOUTH-HITCHCOCK CLINIC. ASC 740 (Fin 48) Footnote Form 990 Schedule D Part X No ASC 740 (Fin 48) footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption.
Schedule D (Form 990) 2012

Additional Data


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Software Version:  




SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image 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
DARTMOUTH-HITCHCOCK CLINIC
 
Employer identification number

22-2519596
Part I
General Information on Activities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 14b.
1
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? ...................................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside
the United States.
3
Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in 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 Educational Travel Exp 4,159
East Asia and the Pacific     Program Services Educational Travel Exp 1,877
Europe (Including Iceland and Greenland)     Program Services Educational Travel Exp 16,375
Middle East and North Africa     Program Services Educational Travel Exp 1,325
North America     Program Services Educational Travel Exp 14,313
South America     Program Services Educational Travel Exp 1,151
Sub-Saharan Africa     Program Services Educational Travel Exp 319
North America     Program Services Medical Labs & Suppls 488,140
Europe (Including Iceland and Greenland)     Program Services Medical Labs & Suppls 184,646
Europe (Including Iceland and Greenland)     Program Services Insurance Services 108,190
Middle East and North Africa     Program Services Collection Services 9,724
North America     Program Services Dues, Lic, & Publicatn 3,809
North America     Program Services Marketing Services 7,141
North America     Program Services IT Services & Misc 13,541
Sub-Saharan Africa   1 Program Services Medical Svcs in Rwanda 34,664
Sub-Saharan Africa     Fundraising Fundraising Event 1,362
           
3a Sub-total .....   1 890,736
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b)   1 890,736
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)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2 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
 
3
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
Schedule F (Form 990) 2012
Page 4
Part IV
Foreign Forms
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)......................................
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).......................................
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)..............................
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)
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)....................................
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)................................................
Schedule F (Form 990) 2012
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
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2012
Additional Data


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Software Version:  



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
DARTMOUTH-HITCHCOCK CLINIC
 
Employer identification number
22-2519596
Part I
General Information on Grants and Assistance
1
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? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) Good Neighbor Health Clinic
70 No Main St
White River Jct,VT05001 		03-0346949 501(C)(3) 20,150   FMV   Program/Clinic Svcs
(2) Stagecoach
7 Bayberry Way
Mont Vernon,NH03057 		03-0276517 501(C)(3) 11,625   FMV   Transportn Subsidy
(3) Granite State United Way
46 South Main St
Concord,NH03301 		02-6006033 501(c)(3) 9,920   FMV   Program Support
(4) Grafton Country Senior Citizens Council
P O Box 433
Lebanon,NH03766 		23-7248316 501(C)(3) 11,160   FMV   Elder Services
(5) Indian Stream Health Center
141 Corliss Ln
Colebrook,NH03756 		20-0999212 501(C)(3) 15,500   FMV   Program/Clinic Svcs
(6) David's House
461 Mount Support Rd
Lebanon,NH03766 		22-2593431 501(C)(3) 10,385   FMV   Program Support
(7) The Trustees of Dartmouth College
1 Rope Ferry Road
Lebanon,NH03755 		02-0222111 501(C)(3) 1,949,985   FMV   Educ and Prog Svcs
(8) Lamprey Health
22 Prospect Street
Nashua,NH03060 		23-7305106 501(C)(3) 23,029   FMV   Program Services
(9) Albert Schweitzer Fellowship Inc
10 Sausville Road
Etna,NH03750 		13-1982786 501(C)(3) 6,200   FMV   Program Support
(10) Advance Transit
PO Box 1027
Wilder,VT05088 		22-2558708 501(C)(3) 29,748   FMV   Transportn Subsidy
(11) Connecticut River Transit
706 Rockingham Road
Rockingham,VT05101 		86-1069523 501(C)(3) 9,300   FMV   Transportn Subsidy
(12) City of Manchester NH
1 City Hall Plaza
Manchester,NH03101 		  7,750   FMV   Child Hlth Svcs
(13) Child Health Services
1245 Elm St
Manchester,NH03105 		02-0348711 501(C)(3) 18,427   FMV   Program Support
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
13
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

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
(1) The Dartmouth Institute Scholarships 45 264,171   FMV  
(2) D-H Tuition Reimbursement Program 294 189,731   FMV  
(3) Varnum Nursing Awards 34 12,400   FMV  








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
Form 990, Schedule I Description of Organization's Procedures for Monitoring the Use of Grants For each award established by Dartmouth Hitchcock Clinic there are written and established guidelines and procedures. Grant award payments are processed in accordance with the specific terms of each of the grants noted above. The Dartmouth Institute Scholarships (TDI) are paid directly to the College on the behalf of the individuals receiving the award. The coordinators of the program(s) are responsible for assuring that all terms are met, including proper documentation of expenses with receipts.
Schedule I (Form 990) 2012


Additional Data


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Software Version:  


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

22-2519596
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......
2
Yes
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)James Weinstein DO MSTrustee Ex-Officio/CEO (i)
(ii)		 777,576
0 		0
0 		55,475
0 		38,368
0 		21,314
0 		892,733
0 		0
0
(2)William Abdu MD MSTrustee/Physician (i)
(ii)		 541,170
0 		39,445
0 		54,282
0 		39,460
0 		21,314
0 		695,671
0 		0
0
(3)Stephen D Surgenor MD MSTrustee End 2/29/13 Physician (i)
(ii)		 330,926
0 		59,000
0 		16,770
0 		41,323
0 		21,739
0 		469,758
0 		0
0
(4)Carl DeMatteo MDFormer Chf Qual Compl Ofr (i)
(ii)		 56,240
0 		0
0 		439,886
0 		6,733
0 		797
0 		503,656
0 		0
0
(5)Robin Kilfeather-Mackey CPAChief Financial Officer (i)
(ii)		 420,635
0 		0
0 		31,010
0 		17,000
0 		20,043
0 		488,688
0 		0
0
(6)Linda Von ReynChief Nursing Officer (i)
(ii)		 0
310,148 		0
0 		0
148,579 		0
17,000 		0
20,027 		0
495,754 		0
0
(7)Daniel Jantzen CPAChief Operating Officer (i)
(ii)		 0
477,890 		0
0 		0
130,327 		0
39,500 		0
20,042 		0
667,759 		0
0
(8)Stephen LeBlancExecVP Strtgy&Ntwrk Eff 2/3/13 (i)
(ii)		 451,778
0 		0
0 		84,208
0 		17,000
0 		19,773
0 		572,759
0 		0
0
(9)John Butterly MDExec VP of Med Affairs, D-HH (i)
(ii)		 491,826
0 		0
0 		46,881
0 		72,035
0 		21,313
0 		632,055
0 		0
0
(10)Lawrence Dacey MDFormer CMO END 6/30/12/DH Phys (i)
(ii)		 464,816
0 		0
0 		42,669
0 		24,265
0 		13,446
0 		545,196
0 		0
0
(11)Alan WestonChief Human Resources Officer (i)
(ii)		 0
307,083 		0
0 		0
4,354 		0
45,316 		0
20,110 		0
376,863 		0
0
(12)David Roberts MDPhysician (i)
(ii)		 597,676
0 		192,665
0 		66,643
0 		63,995
0 		17,201
0 		938,180
0 		0
0
(13)Nathan Simmons MDPhysician (i)
(ii)		 513,705
0 		192,665
0 		46,802
0 		53,995
0 		21,946
0 		829,113
0 		0
0
(14)Kadir Erkmen MDPhysician (i)
(ii)		 597,982
0 		495,107
0 		30,024
0 		28,697
0 		21,269
0 		1,173,079
0 		0
0
(15)Mary OseidV.P Ambulatory Care (i)
(ii)		 251,102
0 		0
0 		7,536
0 		34,000
0 		11,523
0 		304,161
0 		0
0
(16)Christine SchonV.P Comm. Grp. Pract. Ops (i)
(ii)		 206,145
0 		0
0 		3,611
0 		42,749
0 		15,426
0 		267,931
0 		0
0
(17)William MrozV.P. Operations/Clinical Svcs (i)
(ii)		 0
242,039 		0
0 		0
3,861 		0
40,833 		0
8,011 		0
294,744 		0
0
(18)Sandra DickauFormer VP Ops/Ptnt Care (i)
(ii)		 0
0 		0
0 		0
127,765 		0
0 		0
0 		0
127,765 		0
0
(19)Gail DahlstromV.P. Facilities Mgmt (i)
(ii)		 0
219,112 		0
0 		0
6,717 		0
17,000 		0
15,934 		0
258,763 		0
0
(20)Michael WardV.P. Cancer Svcs end 7/31/12 (i)
(ii)		 177,843
0 		0
0 		4,687
0 		20,568
0 		8,829
0 		211,927
0 		0
0
(21)Nancy Formella MSN RNTrustee Advisor End 12/1/2012 (i)
(ii)		 0
699,182 		0
0 		0
2,509,878 		0
39,000 		0
19,814 		0
3,267,874 		0
0
(22)Gregg Meyer MDCCO/EVP Pop Hlth (i)
(ii)		 530,732
0 		0
0 		448
0 		83,828
0 		13,990
0 		628,998
0 		0
0
(23)Andrew Gettinger MDFormer Chief Med Info Ofr (i)
(ii)		 190,974
0 		0
0 		145,475
0 		31,490
0 		7,825
0 		375,764
0 		0
0
(24)Neil CastaldoSr Advisor to CEO Eff 7/1/12 (i)
(ii)		 0
490,202 		0
70,000 		0
62,711 		0
48,907 		0
21,365 		0
693,185 		0
0
(25)Peter Delong MDTrustee/Physician (i)
(ii)		 245,333
0 		25,159
0 		270
0 		39,245
0 		9,165
0 		319,172
0 		0
0
(26)Richard I Rothstein MDTrustee/Dept Chair Med (i)
(ii)		 499,410
0 		24,162
0 		40,687
0 		34,000
0 		17,200
0 		615,459
0 		0
0
(27)Thomas Colacchio MDFormer Officer/Phys (i)
(ii)		 987,376
0 		0
0 		54,180
0 		46,995
0 		19,673
0 		1,108,224
0 		0
0
(28)Tina Naimie CPAVP Corporate Finance (i)
(ii)		 0
213,166 		0
0 		0
172 		0
37,410 		0
1,804 		0
252,552 		0
0
(29)Wendy FieldingVP Financial Planning (i)
(ii)		 0
213,563 		0
0 		0
270 		0
50,447 		0
19,884 		0
284,164 		0
0
(30)Barbara Walters DO MBAMed Dir/Dir Acct Care eff 11/1 (i)
(ii)		 330,728
0 		0
0 		22,590
0 		39,421
0 		18,106
0 		410,845
0 		0
0
(31)Jeanine Arden OrntGeneral Counsel (i)
(ii)		 0
413,330 		0
0 		0
1,989 		0
58,995 		0
13,267 		0
487,581 		0
0
(32)Vincent FuscaChief of Staff (i)
(ii)		 0
228,833 		0
0 		0
1,973 		0
19,471 		0
1,282 		0
251,559 		0
0
(33)Mary Kay BoudewynsFormer Key Employee (i)
(ii)		 0
203,146 		0
0 		0
9,152 		0
39,000 		0
9,103 		0
260,401 		0
0
(34)Steven A Paris MDTrustee Eff 2/1/13 (i)
(ii)		 329,228
0 		0
0 		22,320
0 		40,093
0 		16,026
0 		407,667
0 		0
0
(35)Richard J Powell MDTrustee Eff 2/1/13/Phys (i)
(ii)		 353,783
0 		144,900
0 		22,019
0 		70,995
0 		21,522
0 		613,219
0 		0
0
(36)Edward Merrens MDCMO Eff 9/1/12 (i)
(ii)		 331,888
0 		0
0 		11,419
0 		51,519
0 		14,025
0 		408,851
0 		0
0
(37)George Blike MDChf Qlty&Value Ofr Eff 7/1/12 (i)
(ii)		 376,104
0 		0
0 		12,974
0 		27,682
0 		20,995
0 		437,755
0 		0
0
(38)Daniel Stewart MDPhysician (i)
(ii)		 739,910
0 		60,000
0 		24,532
0 		45,697
0 		21,952
0 		892,091
0 		0
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
CHARTERED TRAVEL SERVICES FORM 990 SCHEDULE J, PART I, LINE 1A FROM TIME TO TIME, THE ORGANIZATION PROVIDES CHARTERED TRAVEL SERVICES TO THE CEO. THE COST OF PROVIDING THE CHARTERED SERVICE HAS BEEN DEEMED A COST-EFFICIENT MANNER TO ALLOW THE OFFICER TO WORK WHILE TRAVELLING VERSUS THE TIME LOST DRIVING, ETC. ALL REQUESTS ARE APPROVED BEFORE PAYMENT TO ENSURE COMPLIANCE WITH INTERNAL POLICIES. Severance Payments Form 990, Schedule J, Part I line 4a The following listed individuals received Severance and/or change in control payments during calendar year 2012: During 2012 Nancy Formella received a $2,281,750 separation package which included severance pay, medical and dental benefits, life and disability benefits (including tax gross-up, and a SERP make-up benefit). The separation payment is in lieu of a multi-year contractual obligation.The payment is included on Schedule J, Line B, Part iii. During 2012, Thomas Colacchio transitioned from an officer role to a staff physician role. As part of this transition, Thomas Colacchio received a $320,000 change of control payment from Dartmouth-Hitchcock. The payment is included on Schedule J, Line B, Part i. During 2012 Carl Dematteo received a $436,667 separation payment in lieu of a multi-year contracutal obligation.The payment is included on Schedule J, Line B, Part iii. Supplemental Nonqualified Retirement Plan: FORM 990 SCHEDULE J, PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (WHICH ARE REFLECTED IN SCHEDULE J, PART II, COLUMN B (III)): William Mroz $2,955 Nancy Formella $223,316 Andrew Gettinger $145,475 Neil Castaldo $40,949 Richard Rothstein $40,121 Thomas Colacchio $54,180 Barbara Walters $21,402 James Weinstein $53,721 William Abdu $53,677 Stephen Surgenor $16,546 Carl DeMatteo $2,020 Robin Kilfeather-Mackey $13,832 Linda Von Reyn $117,277 Daniel Jantzen $98,663 Stephen LeBlanc $61,531 John Butterly $43,380 Lawrence Dacey $41,895 Alan Weston $3,580 David Roberts $61,449 Nathan Simmons $46,532 Kadir Erkman $29,969 Mary Oseid $7,536 Richard Powell $21,555 Edward Merrens $11,149 George Blike $12,560 Daniel Stewart $24,376 Thomas Dodds $32,130 Wendy Wells $2,823 Cliff Belden $21,264 Douglass Merrill $25,500 Dartmouth-Hitchcock Supplemental Retirement Plan: Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the Plans for the plan year, but are limited by IRC Section 401 (a)(17) and/or 415. For eligible employees, the Employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. DHC sponsors a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable DHC to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen in 1998 and therefore no further costs of the individual employee insurance premiums have been funded by the organization. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization. retire/leave the organization.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
DARTMOUTH-HITCHCOCK CLINIC
 
Employer identification number
22-2519596
Part I
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer 		(i) Pool
financing
Yes No Yes No Yes No
A New Hampshire Health and Education Facilities Auth
  		02-0279866   08-31-2011 61,582,591 Current Refund 2001(A)   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . . 0      
2 Amount of bonds legally defeased . . . . . . . . . . . 0      
3 Total proceeds of issue . . . . . . . . . . . . . . 61,582,591      
4 Gross proceeds in reserve funds . . . . . . . . . . . . 0      
5 Capitalized interest from proceeds . . . . . . . . . . . 0      
6 Proceeds in refunding escrows . . . . . . . . . . . . 0      
7 Issuance costs from proceeds . . . . . . . . . . . . 152,499      
8 Credit enhancement from proceeds . . . . . . . . . . . 0      
9 Working capital expenditures from proceeds . . . . . . . . . 0      
10 Capital expenditures from proceeds . . . . . . . . . . . 0      
11 Other spent proceeds . . . . . . . . . . . . . . 61,430,092      
12 Other unspent proceeds . . . . . . . . . . . . . . 0      
13 Year of substantial completion . . . . . . . . . . . . 2011
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . . X              
15 Were the bonds issued as part of an advance refunding issue? . . . . .   X            
16 Has the final allocation of proceeds been made? . . . . . . . . X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .                
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .                
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .                
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2012
Schedule K (Form 990) 2012
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .                
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .                
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0%   %   %   %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet   %   %   %   %
6 Total of lines 4 and 5 . . . . . . . . . . . . . . .   %   %   %   %
7 Does the bond issue meet the private security or payment test? . . . . .                
8a Has there been a sale or disposition of any of the bond financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .                
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of.   %   %   %   %
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .                
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
               
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T? . . . . .   X            
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . . X              
b Exception to rebate? . . . . . . . . X              
c No rebate due? . . . . . . . . . .
  X            
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . . X              
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue? X              
b Name of provider . . . . . . . . . Morgan Stanley
  		 
  		 
  		 
 
c Term of hedge . . . . . . . . . . 29.8      
d Was the hedge superintegrated? . . . . . . X              
e Was a hedge terminated? . . . . . . .   X            
Schedule K (Form 990) 2012
Schedule K (Form 990) 2012
Page 3
Part IV
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .   X            
b Name of provider . . . . . . . . . 0
  		 
  		 
  		 
 
c Term of GIC . . . . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .                
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .   X            
7 Has the organization established written procedures to monitor the requirements of section 148? . . . X              
Part V
Procedures To Undertake Corrective Action
A B C D
Yes No Yes No Yes No Yes No
1 Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? X              
Part VI
Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
Additional Information Part I(F) 0 Form 990 Schedule K, Tax-Exempt Bonds Current Refund 2001(A), Issued 10/17/2001, Which Advance Refunds 1997 & 1994
Schedule K (Form 990) 2012

Additional Data


Software ID:  
Software Version:  

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

22-2519596
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
(1) Thomas Colacchio Former Officer Split Dollar Life   X 52,828 52,828   No Yes   Yes  
(2) Stephen LeBlanc Officer Split Dollar Life   X 40,776 40,776   No Yes   Yes  
(3) Mary Oseid Key Employee Split Dollar Life   X 27,130 27,130   No Yes   Yes  
(4) David Roberts Highly-Compensated Split Dollar Life   X 72,474 72,474   No Yes   Yes  
(5) Michael Ward Key Employee Split Dollar Life   X 61,612 61,612   No Yes   Yes  
(6) Andrew Gettinger Former Officer Split Dollar Life   X 56,363 56,363   No Yes   Yes  
(7) Richard Rothstein Trustee Split Dollar Life   X 72,832 72,832   No Yes   Yes  
Total ......Small Bullet $ 384,015
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Janice Kilfeather-Mackey Officer Kilfeather-Mac. 76,465 Family member employed by DHC   No
(2) Linda Billings Key Emp. Mary Oseid 79,057 Family member employed by DHC   No
(3) Lynn Butterly Officer John Butterly 432,342 Family member employed by DHC   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

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

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

22-2519596
Identifier Return Reference Explanation
Changes to Organizational Documents Since Last 990 Filing FORM 990 Part VI Section A Line 4 Effective January 1, 2013, the Dartmouth-Hitchcock Clinic (DHC) Board of Trustees amended and restated the DHC Bylaws. The primary purpose of the amendments was to simplify the corporation's governance structure, which had become unwieldy. The amendments did not alter the mission of DHC, the role of its Board of Trustees, the Trustees' oversight of the chief executive officer selection, performance and compensation, the disposition of assets upon dissolution, or any other fundamental component of the DHC governance documents. The following is a brief statement of the significant changes to the DHC Bylaws: 1. The number of Trustees was reduced from 28 to a range from 17 to 24. Two new categories of Trustees also were established: a physician Trustee who is a Clinical Chair or Center Director, and a physician who practices in one of the Community Group Practices. 2. The Assembly of Overseers, primarily responsible for nominating Trustees and serving in an advisory role to the Board, was eliminated. The Bylaws now provide for different nominations by category of Trustee. For example, the Board of Governors will nominate physician positions, and the DHC Board will nominate candidates for the Public Trustee positions. Others serve ex officio. 3. The Board of Governors was reduced in size from 31 to 18 and will be chaired by the DHC President/CEO. Three new categories of Governors were established: a provider from a Community Group Practice, a nurse, and an associate provider. The Board of Governors' role was consolidated to the following three functions: -Serve as the executive committee of the professional staff in satisfaction of Joint Commission requirements; -Provide input and make recommendations to the CEO as to management issues and matters of concern to the professional staff; and -Provide input and make recommendations to the DHC Board of Trustees. 4. The selection process for a new President/CEO must be reviewed by the Board of Governors and include two criteria: (1) the candidate must be a licensed physician; and (2) a preference for an internal candidate. 5. The Committees of the DHC Board were reorganized into six standing committees: Governance, Value, Finance, Compensation, Research and Education, and Audit and Compliance. 6. The process for amending or repealing the DHC Bylaws, which maintain the requirements of a 2/3 majority vote of all Trustees, was modified to require the following in lieu of the requirements contained in the previous DHC Bylaws regarding the change in control process and involvement of the Divisional Boards of Governors of the Community Practices: - The proposed amendment(s) and the reason for it must be published and available to all Dartmouth-Hitchcock employees. - All Dartmouth-Hitchcock employees will be given the opportunity to provide input to the Trustees about the amendment. - All physicians credentialed at any Dartmouth-Hitchcock facility will have the opportunity to vote on an advisory recommendation regarding the amendment. - All associate providers credentialed at any Dartmouth-Hitchcock facility will have the opportunity to vote on an advisory recommendation regarding the amendment. - The Board of Trustees must request the written advice and recommendation of the Board of Governors on each proposed amendment.
Description of classes of Members, Persons, and their rights Form 990, Part VI, Question 6 & 7a Dartmouth-Hitchcock Health (D-HH) is the sole corporate Member of Dartmouth-Hitchcock Clinic (DHC). D-HH has specific authority and reserved powers, including the power to confirm the election of members of the DHC's Board of Trustees and the power to approve significant governance, financial and operational decisions of DHC's Trustees. In addition, The Dartmouth-Hitchcock Assembly of Overseers (Overseers) acts in an advisory capacity to the DHC Board of Trustees. It elects the Public Trustee members of the DHC Board, subject to the subsequent confirmation of such members by the D-HH Board of Trustees. The Overseers have no other voting rights with respect to the Board of Trustees. Form 990, Part VI, Question 7b In addition to reserved powers, Dartmouth-Hitchcock Health (D-HH) shall have the authority to take actions to establish, manage, and govern the System as an integrated health care delivery system in furtherance of the mission of the Clinic and other Organizations. These powers include but are not limited to items such as the ability to approve, disapprove or modify all material governance, programmatic and financial decisions of DHC's Board of Trustees, to appoint or remove a member of the Clinic's Board of Trustees, assess the Clinic a monetary amount for the payment of the expenses of D-HH, approve the Clinic's budget, approve the borrowings or dispositions of assets by the Clinic, approve key strategic relationships, approve the elimination or addition of any material health care service or program, and other authority to take action on behalf of the clinic.
Process used by management and/or Governing Body to Review 990 Form 990, Part VI, Line 11b The Audit Committee of the DHC Board of Trustees is presented with a substantially complete Form 990. THE FORMS 990 AND 990-T ARE REVIEWED BY THE DIRECTOR OF CORPORATE FINANCE, VICE PRESIDENT OF CORPORATE FINANCE, AND THE CHIEF FINANCIAL OFFICER BEFORE THE FILING OF THE RETURN. The Committee members are expected to review these forms before the meeting. AT THE MEETING A PRESENTATION IS MADE BY THE VICE PRESIDENT OF CORPORATE FINANCE, WITH TIME ALLOTTED FOR QUESTIONS FROM THE COMMITTEE. ONCE THE RETURN HAS BEEN FULLY PREPARED A FINAL 990 AND 990-T COMPLETE ELECTRONIC VERSION IS SENT OUT TO EACH BOARD MEMBER PRIOR TO THE OFFICIAL FILING.
Description of Process to Monitor Transactions For Conflicts of Interest Form 990, Part VI, Question 12c The Dartmouth-Hitchcock Clinic Board of Trustees approved a policy concerning a voluntary self-disclosure of any potential conflict of interest. The Compliance and Audit Services Department conducts an annual survey and performs other procedures as considered necessary to report on compliance with the conflict of interest policy. The Compliance and Audit Services Department then reports to the board any potential conflicts for their review. Per the policy any conflicts or otherwise perceived conflicts are required to be addressed by the Board of Trustees on an ongoing basis. If a conflict arises, the individual is asked to recuse themselves from voting on any related items. The policy applies to all trustees, employees, and their immediate family members. All DHC board members are included in the annual conflict of interest survey.
Offices & Positions for Which Process was Used & Year Undertaken Form 990, Part VI, Question 15a Compensation for the President is evaluated by an independent third party firm for reasonableness and national data benchmarking. The Compensation Committee along with Independent Trustees approve the final compensation in consideration with the independent third party firm's recommendations and suggestions. This process was last undertaken in 2013.
Form 990, Part VI, Question 15b   Compensation for Officers and Key Employees are evaluated by an independent third party firm for reasonableness and national data benchmarking. The Compensation Committee along with Independent Trustees approve the final compensation in consideration with the independent third party firm's recommendations and suggestions. This process was last undertaken in 2013 for each person identified as an Officer or Key Employee.
Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Question 19 DHC's governing documents are available through the New Hampshire Secretary of State. Certain financial information is disclosed through the Community Benefits Annual Report. The audited financial statements, governing documents, and conflict of interest policy are available upon request either in electronic or hardcopy form. Average Hours Per Week Form Part VII Section A, Line 1A, Column B As part of DHC's and Mary Hitchcock Memorial Hospital's affiliation agreement, the two organizations share officers. As such, the average hours per week are allocated between the two organizations' 990's even though compensation reported in part VII is based on the entity issuing the W-2. In addition, certain officers spend time on Dartmouth-Hitchcock Health, the sole corporate member of both MHMH and DHC, along with two supporting organizations Dartmouth-Hitchcock Medical Center and Hamden Risk Retention Group. Independent Contractors Form 990 Part VII Section B Dartmouth-Hitchcock Clinic is part of the Dartmouth-Hitchcock (D-H) Healthcare System which includes DHC, Mary Hitchcock Memorial Hospital (MHMH) and subsidiaries. MHMH received authority from the Internal Revenue Service to act as DHC's Pay Agent and implemented this process at the beginning of fiscal year 2010. All expenses are paid directly by MHMH and reimbursed by DHC. MHMH manages all required IRS reporting in regards to 1099's for independent contractors. Statement of Functional Expenses Form 990 Part IX Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic operate under an affiliation agreement as directed by Dartmouth-Hitchcock Health, the sole Corporate Member of both entities. Due to the integrated operating structure, related mission, and close relationship of the two tax-exempt organizations, expenses are shared between the two entities. All expenses reported within this 990 are the organization's share of expenses as designated by the affiliation agreement.
FINANCIAL STATEMENTS AND REPORTING Form 990 Part XI, Question 5 Other Changes in Net Assets Include: Pension-related charges and other ($50,807,951) Audited Financial Statements Form 990 Part XII, Question 2d The organization's financial information is included in the audited financial statements of Dartmouth-Hitchcock and Subsidiaries, which consists of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and subsidiaries. A-133 Audit Form 990 Part XII, Question 3a DURING FISCAL YEAR 2013, MARY HITCHCOCK MEMORIAL HOSPITAL EXPENDED FUNDS FROM FEDERAL AWARDS IN EXCESS OF THE MINIMUM THRESHHOLD SET FORTH IN THE SINGLE AUDIT ACT AND OMB CIRCULAR A-133, THEREFORE REQUIRING AN AUDIT. DUE TO THE ISSUANCE OF THE COMBINED FINANCIAL STATEMENTS, THE SINGLE AUDIT WAS PERFORMED ON THE COMBINED FINANCIAL INFORMATION OF ALL ORGANIZATIONS, INCLUDING DARTMOUTH-HITCHCOCK CLINIC.
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


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

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
DARTMOUTH-HITCHCOCK CLINIC
 
Employer identification number

22-2519596
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) Mary Hitchcock Memorial Hospital

One Medical Center Drive

Lebanon,NH03756
02-0222140 		Healthcare NH 501(c)(3) 3 D-HH
 
Yes
 
(2) Dartmouth-Hitchcock Medical Center

One Medical Center Drive

Lebanon,NH03756
22-2715483 		SUPPORTNG ORG NH 501(c)(3) 11 TYPE I NA
 
Yes
 
(3) The Hitchcock Foundation

One Medical Center Drive

Lebanon,NH03756
02-0222139 		HLTHCRE RSRCH NH 501(c)(3) 7 DHC
 
Yes
 
(4) Hamden Risk Retention Group Inc

30 Main Street Suite 330

Burlington,VT05401
20-8530788 		SELF INS. VT 501(c)(3) 11 TYPE I DHC
 
Yes
 
(5) Dartmouth-Hitchcock Health

One Medical Center Drive

Lebanon,NH03756
26-4812335 		SUPPORTNG ORG NH 501(c)(3) 11 Type II NA
 
 
No




For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No
(1) OBNET Services LLC

1 Med Ctr Dr
Lebanon,NH03756
04-3746287 		Database Serv NH DHC
  		Related 54,794 352,749   No 0 Yes   50.000 %
(2) D-H Mster Invst Prg

1 Med Ctr Dr
Lebanon,NH03756
02-0505863 		Pooled Invest NH NA
  		                 
(3) Keene Hlth Alliance

580 Court St
Keene,NH03431
30-0179297 		Healthcare NH NA
  		Related -683,000 0   No 0   No 50.000 %
(4) The Hitchcock Ptshp

1 Med Ctr Dr
Lebanon,NH03756
02-0514823 		Invst in Ptnr NH MHMH
  		Investment 6,123 76,534   No 0   No 38.580 %
(5) One Care VT ACO LLC

111 COLCHESTER AVE
Burlington,VT05401
45-5399218 		Shared Saving VT NA
  		                 




Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Pompanoosuc Investment Corporation

One Medical Center Drive
Lebanon,NH03756
02-0352330 		Rl Estate Hld NH DHC
  		C CORP -2,654 75,632 100.000 % Yes  
(2) Hamden Assurance Company Limited

Canons Court 22 Victoria St
Hamilton   HM EX
BD
98-0121409 		Liab Insur. BD DHC
  		C CORP 0 0 70.200 % Yes  
(3) Hitchcock Health Connect

1 Medical Ctr Dr
Lebanon,NH03756
80-0908979 		Telehealth DE NA
  		C Corp 0 0      








Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) Mary Hitchcock Memorial Hospital

 MNOPQ 103,062,318 FMV
(2) Dartmouth-Hitchcock Health

 Q 1,015,909 FMV
(3) Dartmouth-Hitchcock Health

 P 872,491 FMV
(4) Dartmouth-Hitchcock Medical Center

 M 691,264 FMV
(5) Dartmouth-Hitchcock Medical Center

 L 156,069 FMV
(6) The Hitchcock Foundation

 Q 526,632 FMV
(7) The Hitchcock Foundation

 P 340,833 FMV
(8) Hamden Risk Retention Group

 M 2,473,146 FMV
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

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




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






























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

Additional Data


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