TY 2012 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
CRYSTAL LAKE EMERGE6227 FRANKFORT HWYBENZONIAMI496169654	EMERGENCY SERVI	1,006,241
SPENCE BROTHERS417 MCCORSKRY STSAGINAWMI48605	CONSTRUCTION	660,225
MICHIGAN NEUROLOGY ASSOCIATES1500 WEST PARK DR STE 390WESTBOROUGHMA01581	MRI SERVICES	213,775
SODEXO INC AND AFFILIATES4880 PAYSHERE CIRCLECHICAGOIL60674	FOOD SERVICE	168,808

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 4

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	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	4,903,803	4,634,956	268,847
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	452,508	427,711	24,797
9	Other employee benefits .......	905,410	855,794	49,616
10	Payroll taxes ...........	365,020	345,017	20,003
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	700		700
c	Accounting ...........	30,000		30,000
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	4,456,552	3,753,053	585,493	118,006
12	Advertising and promotion ....	26,326	10,476	15,850
13	Office expenses .......	370,965	325,487	45,478
14	Information technology ......	146,971	137,308	9,663
15	Royalties ..
16	Occupancy ...........	679,623	679,623
17	Travel ............	71,903	32,907	38,996
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....	3,296	3,296
20	Interest ...........
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	1,019,028	921,507	97,521
23	Insurance ..............	-59,192	67,539	-126,731
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	1,350,427	1,350,427
b	BAD DEBT	685,401	685,401
c	LICENSES AND TAXES	333,947	13,992	319,955
d	MISCELLANEOUS	107,532	94,623	12,909
e	All other expenses	27,931	19,969	7,962
25	Total functional expenses. Add lines 1 through 24e	15,878,151	14,359,086	1,401,059	118,006
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	1,050	1	1,050
2	Savings and temporary cash investments .........	4,711,939	2	4,599,948
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	2,643,673	4	2,108,588
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
			6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............		8
9	Prepaid expenses and deferred charges ..........	117,397	9	108,570
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,102,402
b	Less: accumulated depreciation .....	10b	14,498,655	6,221,757	10c	6,603,747
11	Investments—publicly traded securities ..........	3,285,702	11	3,618,518
12	Investments—other securities. See Part IV, line 11 .....	3,862,347	12	3,376,501
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........	321,219	15	176,865
16	Total assets. Add lines 1 through 15 (must equal line 34)......	21,165,084	16	20,593,787
	17	Accounts payable and accrued expenses .........	1,011,201	17	1,006,144
18	Grants payable .................		18
19	Deferred revenue ................		19	5,000
20	Tax-exempt bond liabilities .............		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	2,268,087	25	419,643
26	Total liabilities. Add lines 17 through 25.........	3,279,288	26	1,430,787
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	14,023,449	27	15,786,499
28	Temporarily restricted net assets ...........	3,862,347	28	3,376,501
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	17,885,796	33	19,163,000
34	Total liabilities and net assets/fund balances ........	21,165,084	34	20,593,787

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

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

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

Page 2

Name of organization PAUL OLIVER MEMORIAL HOSPITAL

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

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

Page 3

Name of organization PAUL OLIVER MEMORIAL HOSPITAL

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

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

Page 4

Name of organization
PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part III

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

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below. SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

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

A Check SchCMd Bullet

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

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

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

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

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

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

5,036

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

5,036

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Identifier	Return Reference	Explanation
	SCHEDULE C, PART II-B, LINE 1	OTHER GRASSROOTS LOBBYING INCLUDES THE PORTION OF DUES ALLOCATED TO LOBBYING.

Schedule C (Form 990 or 990EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	7,148,049	5,253,482	4,052,095	3,736,794	4,099,630
b	Contributions ........	420,511	1,819,941	757,959	260,254	332,714
c	Net investment earnings, gains, and losses	348,070	91,515	458,819	288,192	-535,126
d	Grants or scholarships .....	906,358
e	Other expenditures for facilities and programs ........				224,769	149,924
f	Administrative expenses ....	15,253	16,889	15,390	8,376	10,500
g	End of year balance ......	6,995,019	7,148,049	5,253,483	4,052,095	3,736,794

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

Board designated or quasi-endowment SchDMd Bullet

51.730 %

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

48.270 %

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

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

Yes

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

3a(i)

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

3a(ii)

Yes

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

Yes

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	193,750		193,750
b	Buildings ................	12,889,626	8,889,048	4,000,578
c	Leasehold improvements ............	120,618	28,647	91,971
d	Equipment ................	7,785,707	5,477,200	2,308,507
e	Other .................	112,701	103,760	8,941
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				6,603,747

Schedule D (Form 990) 2012

Page 3

Part VII

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

(a) Description of security or category (including name of security)	(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
(3)Other (A) INVEST IN PAUL OLIVER MEM FOUNDATION	3,376,501	F








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	3,376,501

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value









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

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes
ESTIMATED THIRD PARTY PAYMENTS		275,181
CAREPAYMENT LIABILITY		144,462







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		419,643
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

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

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

Part XIII

Supplemental Information

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

Identifier	Return Reference	Explanation
INTENDED USES FOR ENDOWMENT FUNDS	SCHEDULE D, PAGE 2, PART V, LINE 4	THE FUNDS ARE INTENDED FOR THE OPERATIONS AND CAPITAL NEEDS OF THE PAUL OLIVER MEMORIAL HOSPITAL. A SIGNIFICANT PORTION OF THE TEMPORARILY RESTRICTED FUNDS ARE FOR THE CAPITAL NEEDS OF THE HOSPITAL.

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. 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
PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










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

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

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

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2012

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 GOLF OUTING (event type)	(b) Event #2 FALL EVENING TO (event type)	(c) Other events 1 (total number)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . .	23,353	21,120	12,465	56,938
2	Less: Contributions . .	8,125	11,324		19,449
3	Gross income (line 1 minus line 2) . . .	15,228	9,796	12,465	37,489
4	Cash prizes . . .
5	Noncash prizes . .
6	Rent/facility costs . .
7	Food and beverages .
8	Entertainment . . .
9	Other direct expenses .	7,552	7,907	565	16,024
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........				16,024
11	Net income summary. Combine line 3, column (d), and line 10. ..........				21,465

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add col.(a) through col.(c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2012

Page 3

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ..........................

YesNo

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

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

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

Yes

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

Yes

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

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	231,338		231,338	1.520 %
b	Medicaid (from Worksheet 3, column a) ....	3,855,921	3,192,667	663,254	4.370 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .	46,001	9,608	36,393	0.240 %
d	Total Financial Assistance and Means-Tested Government Programs .	4,133,260	3,202,275	930,985	6.130 %
Other Benefits		119,640	63	119,577	0.790 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	119,640	63	119,577	0.790 %
f	Health professions education (from Worksheet 5) ..	7,170		7,170	0.050 %
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	24,277		24,277	0.160 %
j	Total. Other Benefits ..	151,087	63	151,024	1.000 %
k	Total. Add lines 7d and 7j .	4,284,347	3,202,338	1,082,009	7.130 %

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

Schedule H (Form 990) 2012

Page

Part II

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

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	1,229	1,229	0.010 %
3	Community support	56,016	56,016	0.350 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	1,641	1,641	0.010 %
7	Community health improvement advocacy
8	Workforce development	492	492
9	Other
10	Total	59,378	59,378	0.370 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

332,660

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

27,965

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

Section B. Medicare

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

5,023,884

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

5,023,884

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

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	PAUL OLIVER MEMORIAL HOSPITAL 224 PARK AVE FRANKFORT,MI49635	X	X	X	X

Schedule H (Form 990) 2012

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Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	PAUL OLIVER MEMORIAL HOSPITAL
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

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

Yes

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

Yes

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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

Yes

If “No,” indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

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

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

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

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

Other (describe in Part VI)

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

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?5
Name and address		Type of Facility (describe)
1	PAUL OLIVER MEMORIAL HOSPITAL SNF 224 PARK AVE FRANKFORT,MI49635	LONG TERM CARE
2	PHYSICAL THERAPY 9975 W OTTAWA AVE EMPIRE,MI49630	PT, LAB, RADIOLOGY
3	FITNESS CENTER 102 AIRPORT RD FRANKFORT,MI49635	PHYSICAL THERAPY, CARDIAC REHAB AND EDU
4	PHYSICAL THERAPY 6227 FRANKFORT HIGHWAY BENZONIA,MI49616	PT, LAB, RADIOLOGY
5	PHYSICAL THERAPY 1975 STIRLING DR INTERLOCHEN,MI49643	PT, LAB, RADIOLOGY
6
7
8
9
10

Schedule H (Form 990) 2012

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Part VI

Supplemental Information

Complete this part to provide the following information.

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

Identifier	ReturnReference	Explanation
OTHER TESTING METHODS FOR FREE OR DISCOUNTED CARE	PART I LINE 3C	INCOME UP TO 200 OF THE FPG 100 DISCOUNT ON CHARGES INCOME BETWEEN 201 AND 300 FPG 75 DISCOUNT ON CHARGES INCOME BETWEEN 301 AND 400 FPG 50 DISCOUNT ON CHARGES FAMILY INCOME MAY INCLUDE ALL INCOME ATTRIBUTABLE TO ALL MEMBERS OF THE FAMILY IN THE RESIDENCE OTHER THAN MINIMAL AMOUNTS EARNED BY MINORS FAMILY INCOME INCLUDES THE FOLLOWING WHEN COMPUTING FPG INCLUDES EARNINGS UNEMPLOYMENT COMPENSATION WORKERS COMPENSATION SOCIAL SECURITY SUPPLEMENTAL SECURITY INCOME PUBLIC ASSISTANCE VETERANS PAYMENTS SURVIVOR BENEFITS PENSION OR RETIREMENT INCOME INTEREST DIVIDENDS RENTS ROYALTIES INCOME FROM ESTATES EDUCATIONAL ASSISTANCE ALIMONY CHILD SUPPORT ASSISTANCE FROM OUTSIDE THE HOUSEHOLD AND OTHER MISCELLANEOUS SOURCES CASH CHECKING AND SAVINGS BALANCES MONEY MARKET ACCOUNTS CERTIFICATES OF DEPOSIT IRAS TRUSTS INHERITANCES ANNUITIES SAVINGS BONDS STOCKS MUTUAL FUNDS ANDOR CASH VALUE OF LIFE INSURANCE
RELATED ORGANIZATION INFORMATION	PART I LINE 6A	MUNSON MEDICAL CENTER BROTHER CORPORATION
SUBSIDIZED HEALTH SERVICES EXPLANATION	PART I LINE 7G	THERE ARE NO PHYSICIAN CLINICS IN SUBSIDIZED HEALTH SERVICES
EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE	PART I LINE 7 COLUMN F	TOTAL EXPENSES FROM FORM 990 PART IX LINE 25 ARE 15878151 THE BAD DEBT EXPENSE INCLUDED IN THIS AMOUNT WAS 685401 THE NET EXPENSE OF 15192750 WAS USED FOR PURPOSES OF CALCULATING LINE 7 COLUMN F
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	COST VALUES FOR LINE 7 ARE BASED ON THE COST TO CHARGE RATIO COMPUTATION
COMMUNITY BUILDING ACTIVITIES	PART II	POMH PROVIDED 59379 TO COMMUNITYBUILDING ACTIVITIES DURING THE 2013 FISCAL YEAR WHILE WE BELIEVE THESE ACTIVITIES PROMOTE COMMUNITY HEALTH BY SUPPORTING THE UNDERLYING CAUSES OF COMMUNITY HEALTH THESE ACTIVITIES ARE NOT INCLUDED ELSEWHERE ON THE SCHEDULE H THESE ACTIVITIES INCLUDE ADMINISTRATIVE AND CASH SUPPORT FOR COALITION BUILDING ACTIVITIES IN BENZIE COUNTY MEETING THE BASIC NEEDS OF PEOPLE IN POVERTY ON A LOCAL LEVEL BY MULTIPLE COLLABORATIVE ACTIVITIES PARTICIPATION IN THE BENZIE COUNTY CHAMBER OF COMMERCE TO PROMOTE WORKFORCE DEVELOPMENT AND SEVERAL ENVIRONMENTAL IMPROVEMENTS RELATED TO COMMUNITY GARDENING AND HEALTHY SCHOOL LUNCHES ALSO BECAUSE BENZIE COUNTY IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA POMH INVESTS DOLLARS INTO THE RECRUITMENT OF CRITICALLY NEEDED PHYSICIANS TO THE AREA TO PROMOTE PATIENT ACCESS TO CARE
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	PAUL OLIVER HOSPITAL UTILIZES A HINDSIGHT ANALYSIS IN THEIR DATA EVALUATION THE ESTIMATE OF THE AMOUNT OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATIONS FINANCIAL ASSISTANCE POLICY WAS MADE USING AN ANALYSIS OF PATIENTS WITH SPECIFIED FINANCIAL CLASSES THAT WERE TURNED OVER TO BAD DEBT STATUS THE ACCOUNTS RECEIVABLE FOOTNOTE TO THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS OF MUNSON HEALTHCARE AND SUBSIDIARIES STATES THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENTS ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND GENERAL ECONOMIC CONDITIONS IN ITS SERVICE AREA TRENDS IN HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS THROUGHOUT THE YEAR MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON ACCOUNTS RECEIVABLE PAYOR COMPOSITION AND HISTORICAL WRITEOFF EXPERIENCE BY PAYOR CATEGORY AND OTHER FACTORS THE RESULTS OF THESE REVIEWS ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AFTER AMOUNTS DUE FROM THIRDPARTY PAYORS ARE SATISFIED AND REASONABLE EFFORTS TO COLLECT FROM THE PATIENT HAVE BEEN EXHAUSTED THE ORGANIZATION FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PASTDUE PATIENT BALANCES WITH COLLECTION AGENCIES
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	MUNSON HEALTHCARES INTERNAL AND EXTERNAL COLLECTION PRACTICES INCLUDING ACTIONS THE HOSPITAL MAY TAKE IN THE EVENT OF NONPAYMENT INCLUDING COLLECTIONS ACTIONS AND REPORTING TO COLLECTION AGENCIES SHALL TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY A PATIENTS GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM MUNSON HEALTHCARE AND A PATIENTS GOOD FAITH EFFORT TO COMPLY WITH HISHER PAYMENT AGREEMENTS WITH MUNSON HEALTHCARE FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DISCOUNTED HOSPITAL BILLS MUNSON HEALTHCARE MAY OFFER EXTENDED PAYMENT PLANS WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES AND WILL CEASE ALL COLLECTION EFFORTS ON ANY UNPAID BALANCES ON ACCOUNTS THAT WERE OPENED WITHIN ONE YEAR OF THE DATE THAT THE PATIENT QUALIFIED FOR CHARITY UNDER THIS POLICY
NEEDS ASSESSMENT	PART VI	THE MUNSON HEALTHCARE BOARD OF DIRECTORS MAINTAINS A STANDING COMMUNITY HEALTH COMMITTEE CHC TO SERVE THE MUNSON HEALTHCARE SYSTEM THE CHC CONSISTS OF MUNSON HEALTHCARE BOARD MEMBERS FROM MUNSON HEALTHCARE HOSPITALS AND OTHER INTERESTED AREA PHYSICIANS AND COMMUNITY MEMBERS APPOINTED BY THE MUNSON HEALTHCARE BOARD CHAIRPERSON THE CHC MEETS AT LEAST QUARTERLY TO REVIEW EXISTING PROGRAMS AND SERVICES RELATED TO CURRENT COMMUNITY HEALTH NEEDS CONSIDER THE MHC RESPONSE TO ANY EMERGING HEALTH TRENDS AS IDENTIFIED BY COMMUNITY HEALTH NEEDS ASSESSMENT AND REVIEW ANY NEW COMMUNITY HEALTH BASED COLLABORATION OR PROGRAM THE CHC IS RESPONSIBLE FOR COMMUNICATING INTERNALLY AND EXTERNALLY THE SIGNIFICANCE OF MHC COMMUNITY BENEFIT PROGRAMS AND SERVICES THIS COMMITTEE IS SUPPORTED BY A COMMUNITY HEALTH DEPARTMENT OF MUNSON MEDICAL CENTER A BROTHER CORPORATION PAUL OLIVER MEMORIAL HOSPITAL POMH A MEMBER OF THE MUNSON HEALTHCARE SYSTEM IS A CONTRIBUTOR TO REGIONAL EFFORTS THAT ASSESS THE HEALTH STATUS OF THE TOTAL POPULATION WITHIN MUNSON HEALTHCARES EXTENSIVE GEOGRAPHICAL AREA COMMUNITY HEALTH ASSESSMENT IS AN IMPORTANT COMPONENT OF A COMMUNITY HEALTH IMPROVEMENT STRATEGY AS IT PROVIDES GUIDANCE AS TO WHERE EFFORTS SHOULD BE CONCENTRATED AS WELL AS WHERE PROGRESS HAS BEEN MADE THE DATA DOCUMENTED THROUGH AN ASSESSMENT SERVES AS A USEFUL REFERENCE FOR PROGRAM AND RESOURCE DEVELOPMENT EFFORTS COMMUNITYWIDE MUNSON MEDICAL CENTER MMC IS A SIGNIFICANT CONTRIBUTOR TO REGIONAL EFFORTS THAT ASSESS THE HEALTH STATUS OF THE TOTAL POPULATION WITHIN THE MUNSON SYSTEMS EXTENSIVE GEOGRAPHICAL AREA MUNSON MEDICAL CENTER IN CONJUNCTION WITH PAUL OLIVER MEMORIAL HOSPITAL PREPARED A COMMUNITY NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY TO MEET THE REQUIREMENTS OF IRC SEC 501R DURING FISCAL 2013 IN ACCORDANCE WITH THE PLANS OF THE COMMUNITY HEALTH COMMITTEE OF THE BOARD POMH REGULARLY SEEKS INFORMATION FROM AND PARTICIPATES IN THE BENZIE COUNTY COLLABORATIVE THE LOCAL UNITED WAY AND OTHER REGIONAL ASSOCIATIONS TO MAINTAIN CURRENT UNDERSTANDING OF COMMUNITY HEALTH NEEDS POMH IN CONJUNCTION WITH MUNSON HEALTHCARE SEEKS TO COLLABORATE WITH REGIONAL PARTNERS ASSESSING FOR EXISTING PROGRAMS AND STRATEGIES THAT ARE ALREADY WORKING WELL AND THEN PARTNERING NOT REINVENTING IF A NEW PROGRAMMING NEED IS IDENTIFIED POMH SEEKS TO POOL ASSETS WITH 4 MULTICOUNTY HEALTH DEPARTMENTS OTHER NONPROFITS AND LOCAL GOVERNMENTAL SERVICES FOR THE MOST EFFECTIVE USAGE OF RESOURCES ADDITIONALLY MUNSON HEALTHCARE WORKS IN CONJUNCTION WITH EFFORTS BY THE FIVECOUNTY COLLABORATIVES OF ANTRIM BENZIE GRAND TRAVERSE LEELANAU AND KALKASKA COUNTIES THE TRAVERSE CITY CHAMBER OF COMMERCE THE LOCAL UNITED WAY AND OTHER REGIONAL ASSOCIATIONS TO MAINTAIN CURRENT UNDERSTANDING OF COMMUNITY NEED
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	IT IS THE GOAL OF MUNSON HEALTHCARE TO COMMUNICATE AND EDUCATE PATIENTS AND THE PUBLIC REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE THIS IS ACHIEVED THROUGH ONE OR MORE OF THE FOLLOWING METHODS STATEMENT ON BILLS STATEMENTS INCLUDE VERBIAGE THAT INSTRUCTS THE PATIENT TO CALL PATIENT FINANCIAL ASSISTANCE IF THEY NEED HELP WITH THEIR BILL SIGNS IN THE ER REGISTRATION AREA ADVISES THE PATIENTS THAT THEIR CARE IS NOT WITHHELD IF THEY HAVE NO INSURANCE OR MEANS TO PAY REFERRAL BY REGISTRATION STAFF AT THE TIME OF REGISTRATION SELFPAY PATIENTS OR ANY PATIENT THAT MAY HAVE CONCERNS REGARDING THEIR UPCOMING ADMISSION IS REFERRED TO THE FINANCIAL COUNSELING STAFF PAUL OLIVER MEMORIAL HOSPITAL FINANCIAL COUNSELORS ARE AVAILABLE TO TALK WITH PATIENTS ABOUT THEIR FINANCIAL CONCERNS IF THE PATIENT WOULD LIKE HELP THE COUNSELORS GATHER INCOME INFORMATION AND SCREEN THE PATIENT FOR MEDICAID ONCE THE COUNSELOR DETERMINES WHAT THE PATIENT MAY QUALIFY FOR THE COUNSELOR EDUCATES THE PATIENT ON THE AVAILABLE PROGRAMS AND ASSISTS THEM WITH COMPLETING THE APPROPRIATE APPLICATIONS AVAILABLE PROGRAMS INCLUDE BUT ARE NOT LIMITED TO MEDICAID AND ALL OF ITS SUBSETS SOCIAL SECURITY DISABILITY TRAVERSE HEALTH CLINIC CHARITY CARE CATASTROPHIC CARE COVERAGE AND CAREPAYMENT
COMMUNITY INFORMATION	PART VI	PAUL OLIVER MEMORIAL HOSPITAL POMH IS LOCATED IN FRANKFORT MICHIGAN ONE OF SEVEN HOSPITALS IN THE MUNSON HEALTHCARE SYSTEM POMH OFFERS QUALITY PERSONALIZED CARE FOR PRIMARY AND URGENT MEDICAL NEEDS DUE TO ITS RURAL GEOGRAPHIC LOCATION POMH IS DESIGNATED AS A MICHIGAN CRITICAL ACCESS HOSPITAL LABORATORY RADIOLOGY AND REHABILITATION SERVICES AT POMH ARE NETWORKED WITH MUNSON MEDICAL CENTER MMC BROTHER ORGANIZATION ENSURING PROMPT AND CONVENIENT DIAGNOSIS AND TREATMENT POMH HAS 8 ACUTE CARE BEDS AS WELL AS A 39BED EXTENDED CARE UNIT WHERE RESIDENTS ENJOY A SAFE WARM AND COMFORTABLE HOMELIKE SETTING FOUNDED ON PRINCIPLES OF QUALITY AND PERSONAL CARE BECAUSE THE CARE CENTER IS HOSPITALBASED PHYSICIANS AND EMERGENCY MEDICAL CARE ARE AVAILABLE 24 HOURS A DAY HOSPITAL SERVICES POMH PROVIDES 24HOUR EMERGENCY CARE ACUTE CARE LONGTERM CARE OUTPATIENT SURGICAL SERVICES AND RESPITE CARE MMC SPECIALISTS REGULARLY HOLD CLINICS AT POMH MAKING IT EASY TO RECEIVE SPECIALIZED CARE POPULATION SERVED BY PAUL OLIVER MEMORIAL HOSPITAL IN THE POMH MAIN SERVICE AREA OF BENZIE COUNTY 22 OF THE POPULATION IS 65 YEARS OR OLDER UNEMPLOYMENT IS 12 OR HIGHER 16 OF ADULTS AGED 1864 YEARS OF AGE LACK HEALTH INSURANCE 13 LIVE BELOW THE FEDERAL POVERTY LEVEL QUALITY PAUL OLIVER MEMORIAL HOSPITAL HAS RECEIVED THE FOLLOWING AWARDS 2009 2010 2011 AND 2012 SUMMIT AWARD FOR EMERGENCY CARE FROM PRESS GANEY ASSOCIATES INC POMH ALSO WON A SUMMIT AWARD IN 2011 FOR ITS OUTPATIENT CARE THE SUMMIT AWARD NOW CALLED THE GUARDIAN OF EXCELLENCE AWARD IS PRESENTED FOR RANKING IN THE TOP 5 PERCENT IN THE NATION FOR PATIENT SATISFACTION FOR 12 CONSECUTIVE QUARTERS 2013 GUARDIAN OF EXCELLENCE AWARDS FOR OUTPATIENT CARE AND EMERGENCY CARE THE 2009 2010 AND 2011 MICHIGAN RURAL HEALTH QUALITY IMPROVEMENT AWARD OF EXCELLENCE FOR ITS COMMITMENT TO QUALITY CARE AND EVIDENCEBASED MEDICINE IN THE AREA OF EMERGENCY ROOM TRANSFERS 2010 AND 2011 MICHIGAN RURAL HEALTH QUALITY IMPROVEMENT EXCELLENCE FOR ITS COMMITMENT TO OUTPATIENT CARE THE GOVERNORS AWARD OF EXCELLENCE FOR IMPROVING PATIENT SAFETY AND QUALITY OF CARE IN THE CRITICAL ACCESS SETTING THE AWARD HONORS MICHIGAN HOSPITALS THAT PERFORM QUALITY INITIATIVES AIMED AT IMPROVING PATIENT CARE THE HOSPITAL HAS REPEATEDLY RECEIVED THIS AWARD MOST RECENTLY IN 2012
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	THE POMH BOARD OF DIRECTORS IS MADE UP OF MEDICAL AND BUSINESS PROFESSIONALS THE MAJORITY OF WHOM RESIDE IN THE HOSPITALS PRIMARY SERVICE AREA THESE VOLUNTEERS GIVE NUMEROUS HOURS OF SERVICE TO THE HOSPITAL IN THEIR OVERSIGHT ROLE THEY ARE INVOLVED IN THE COMMUNITY NEEDS ASSESSMENT PROCESS IN FUNDRAISING AND IN GENERAL STEWARDSHIP ALL BOARD MEMBERS SUPPORT THE HOSPITAL FINANCIALLY MEDICAL STAFF PRIVILEGES ARE OFFERED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY SUBJECT TO CREDENTIALING REVIEW AND REQUIREMENTS OF THE MEDICAL STAFF AND THE BOARD OF DIRECTORS POMH UTILIZES SURPLUS FUNDS TO MAINTAIN ACCESS TO PATIENT SERVICES AND IMPROVE CARE TO PATIENTS THROUGHOUT ITS SERVICE AREA A DESCRIPTION OF SEVERAL SIGNIFICANT PROGRAMS INITIATED BY THE HOSPITAL FOLLOWS HEALTHY FUTURES A PARTNERSHIP OF AREA HEALTH CARE PROVIDERS HEALTH DEPARTMENTS AND MUNSON HEALTHCARE MUNSON HEALTHCARE SYSTEM PARENT AND SOLE MEMBER CREATED TO IMPROVE THE HEALTH OF PREGNANT WOMEN AND CHILDREN UNDER AGE TWO THE HEALTHY FUTURES MODEL OF RN CARE COORDINATION CONSISTS OF AN OUTCOMESBASED APPROACH TO INTERVENTION IN THE AREAS OF BREASTFEEDING LONGEVITY ACCESS TO HEALTH CARE AND IMMUNIZATIONS BECAUSE OF THE RURAL NATURE OF THE COMMUNITY TRAVEL TIME TO THE NEAREST MATERNAL CHILD HEALTHCARE SPECIALIST MAY BE GREATER THAN 30 MINUTES COST AND AVAILABILITY OF TRANSPORTATION CAN BE A DIFFICULT BARRIER TO ACCESS HEALTHCARE FOR YOUNG FAMILIES POMH PARTNERS WITH MUNSON MEDICAL CENTER TO BRING MATERNAL CHILD HEALTHCARE SPECIALISTS TO PAUL OLIVER MAKING IT EASY AND CONVINENT TO RECEIVE THE SPECIALIZED CARE NEEDED TRANSPORTATION AS PART OF MUNSON HEALTHCARE POMH SUBSIDIZES FUNDING FOR COUNTY TRANSPORTATION AUTHORITIES WHICH PROVIDES ACCESS TO HEALTHCARE SERVICES FOR DISADVANTAGED PERSONS SUCH AS THE ELDERLY PERSONS WITH DISABILITIES AND PERSONS OF LOW INCOME WHO HAVE DIFFICULTY PROVIDING THEIR OWN TRANSPORTATION BETSIE HOSICK HEALTH AND FITNESS CENTER THE BETSIE HOSICK HEALTH AND FITNESS CENTER IS OPEN TO PEOPLE OF ALL AGES ABILITIES AND FITNESS LEVELS TO ACHIEVE BETTER HEALTH THE FITNESS CENTER OFFERS A FULL RANGE OF FITNESS EQUIPMENT AND CLASSES MEDICALLY CREDENTIALED FITNESS PROFESSIONALS ARE ON STAFF TO ASSIST MEMBERS THROUGH THE BETSIE HOSICK HEALTH AND FITNESS CENTER SENIOR MOVEMENT AND BALANCE CLASSES ARE HELD AT SENIOR SITES AROUND THE COUNTY FREE OF CHARGE TO PROMOTE WELLNESS PAUL OLIVER HOLDS NUTRITIONAL EDUCATION CLASSES FOR COMMUNITY MEMBERS AT THE HOSPITAL CAREGIVER LIBRARY A LIBRARY INCLUDING COMPUTERS TO ASSIST THE PUBLIC TO OBTAIN HEALTHCARE INFORMATION SUPPORT GROUPS AND ASSISTANT ACTIVITIES FOR CHRONIC DISEASES SUCH AS ALZHEIMERS DISEASE PARKINSONS AND CANCER SCREENING SERVICES SUCH AS BLOOD PRESSURE CHECKS MAMMOGRAMS AND LABORATORY TESTS TO THOSE IN NEED NORTHERN MICHIGAN DIABETES INITIATIVE NMDI NORTHERN MICHIGAN DIABETES INITIATIVE NMDI A GROUP OF STAKEHOLDERS AND STEERING COMMITTEE MEMBERS THAT REPRESENT THE 11 COUNTY SERVICE AREA WITH A VISION TO IMPROVE THE CHRONIC CARE MANAGEMENT OF DIABETES NMDI IS COMMITTED TO PROVIDING LOCAL REGIONAL AND NATIONAL RESOURCES FOR THE PREVENTION AND MANAGEMENT OF DIABETES WHILE MOST DIABETES COLLABORATIVES FOCUS ON PROVIDING OPTIMAL EVIDENCE BASED CARE MANAGEMENT TO THE PERSON ALREADY DIAGNOSED WITH DIABETES NMDI FOCUSES ON CONCURRENT UPSTREAM TARGETED EDUCATION OF THREE SPECIFIC POPULATIONS THE GENERAL COMMUNITY THE SOCIOECONOMICALLY CHALLENGED HIGH RISK POPULATION AND RURAL PRIMARY CARE PROVIDERS PCP CARING FOR DIABETIC PATIENTS COLLABORATION WITH THE TRAVERSE HEALTH CLINIC THE TRAVERSE HEALTH CLINIC THC PROVIDES ACCESS TO AFFORDABLE HEALTH SERVICES THROUGH COMMUNITY COLLABORATION TO PEOPLE IN NEED IN BENZIE LEELANAU AND GRAND TRAVERSE COUNTIES THC SERVES AS A PRIMARY CARE PROVIDER FOR THOSE ADULTS WITH MEDICAID AND RUNS THE COALITION HEALTH ACCESS PROGRAM CHAP FOR THOSE ADULTS WITH NO INSURANCE WHO QUALIFY INCOME 200 OF FPG POMH DONATES LABS XRAYS AND OTHER SERVICES TO THC PATIENTS LIVING IN THEIR RURAL SERVICE AREA
AFFILIATED HEALTH CARE INFORMATION	PART VI	PAUL OLIVER MEMORIAL HOSPITAL IS A MEMBER OF THE MUNSON HEALTHCARE SYSTEM A COMMUNITYOWNED HEALTH SYSTEM THAT INCLUDES SEVEN ACUTE CARE HOSPITALS AS WELL AS NUMEROUS OUTPATIENT SERVICES AND CLINICS ALL THE HOSPITALS IN THE SYSTEM ARE AFFILIATED WITH EACH OTHER AND SERVE AS THE ONLY HOSPITALS IN THEIR RESPECTIVE COMMUNITIES EACH OF THE AFFILIATED HOSPITALS HAS INDIVIDUAL INITIATIVES ANDOR PROMOTION ACTIVITIES AS WELL AS SHARED INITIATIVES PAUL OLIVERS SOLE CORPORATE MEMBER IS MUNSON HEALTHCARE A 501C3 CORPORATION AFFILIATES OTHER THAN THE HOSPITALS INCLUDE TWO FOUNDATIONS HOME HEALTH ORGANIZATIONS MOBILE IMAGING COMPANIES AND AN EMERGENCY TRANSPORTATION ORGANIZATION ALL 501C ENTITIES IN ADDITION TO DIRECTING COMMUNITY BENEFIT ACTIVITIES OF THE SYSTEM MUNSON HEALTHCARE COORDINATES COMMUNITY BENEFITS PROGRAMS FOR THE SYSTEM THROUGH PLANNING DEVELOPING IMPLEMENTING AND FUNDING PROGRAMS THAT ADDRESS COMMUNITY NEEDS POMH WORKS IN COOPERATION WITH OTHER ENTITIES IN THE MUNSON HEALTHCARE SYSTEM TO PROVIDE A FULL RANGE OF HEALTH SERVICES TO THE COMMUNITIES IN ITS SERVICE AREA THE HOME HEALTH DIVISION OF MUNSON HEALTHCARE PROVIDES HOME NURSE AND AIDE SERVICES IN ADDITION TO DURABLE MEDICAL EQUIPMENT A PALLIATIVE CARE PROGRAM AND A HOSPICE PROGRAM ON THE MUNSON MEDICAL CENTER CAMPUS CLOSE TO 210000 DOLLARS IN COMMUNITY BENEFIT IN THE FORM OF CHARITY CARE AND UNREIMBURSED MEDICAID ARE PROVIDED THROUGH THIS DIVISION EACH YEAR NORTH FLIGHT INC IS THE CHARITABLE TRANSPORTATION ENTITY IN THE SYSTEM WITH ITS FIXED WING AND HELICOPTER AIR SERVICES IN COMBINATION WITH GROUND TRANSPORT PATIENTS IN THE SYSTEM ARE ABLE TO ACCESS APPROPRIATE CARE NORTH FLIGHT INC PROVIDED 12 MILLION IN CHARITY CARE AND UNREIMBURSED MEDICAID IN THE PAST FISCAL YEAR MUNSON MEDICAL GROUP THE EMPLOYED PHYSICIAN ORGANIZATION IN THE SYSTEM PROVIDED OVER A HALF MILLION DOLLARS IN CHARITY CARE AND COMMUNITY BENEFIT IN TAX YEAR 2012 PAUL OLIVER MEMORIAL HOSPITAL PARTICIPATES IN MUNSON HEALTHCARE SYSTEM NEEDS ASSESSMENT PROCESS UTILIZING THIS NEEDS ASSESSMENT MUNSON HEALTHCARE COORDINATES COMMUNITY BENEFIT PROGRAMS THROUGH PLANNING DEVELOPING IMPLEMENTING EVALUATING AND FUNDING PROGRAMS THAT ADDRESS COMMUNITY NEEDS IN TOTAL THE MUNSON HEALTHCARE SYSTEM PROVIDED 419 MILLION IN CHARITY CARE AND COMMUNITY BENEFITS INCLUDING NUMEROUS UNCOMPENSATED COMMUNITY HEALTH IMPROVEMENT SERVICES AND PROGRAMS OUTREACH PROGRAMS BAD DEBT AND UNREIMBURSED MEDICARE AND MEDICAID SERVICES TO NORTHERN MICHIGAN
PAUL OLIVER MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 3	PART V LINE 3	A COLLABORATIVE 12MEMBER STEERING COMMITTEE GUIDED THE CHNA PROCESS THIS STEERING COMMITTEE WAS COMPRISED OF HOSPITAL LEADERS AND PUBLIC HEALTH OFFICIALS AS THE CHNA PROCESS PROGRESSED 129 INDIVIDUALS FROM MULTIPLE AREA ORGANIZATIONS WERE INVOLVED TO ENSURE INPUT FROM THOSE WHO HAVE A BROAD KNOWLEDGE OF THE COMMUNITY FURTHER A GROUP OF KEY PHYSICIAN LEADERS FROM THE REGION ALSO WAS CONSULTED FOR INPUT INDIVIDUALS POSSESSING BROAD KNOWLEDGE OF ALL SEGMENTS OF THE FIVECOUNTY AREA PARTICIPATED IN 10 FOCUS GROUPS TO HELP ASSESS HEALTH CARE NEEDS SESSIONS WERE CONDUCTED WITH FIVE AREA COUNTY COLLABORATIVES AS WELL AS PEOPLE LIVING IN POVERTY YOUTH THOSE WHO PROVIDE SERVICES TO SENIORS AND BEHAVIORAL HEALTH PROVIDERS THESE GROUPS WERE SELECTED BECAUSE OF THEIR KNOWLEDGE OF PEOPLE AND AREAS MOST IMPACTED BY HEALTH DISPARITIES BEHAVIORAL HEALTH PROVIDERS WERE AN IMPORTANT INITIAL FOCUS GROUP BECAUSE THERE IS ALMOST NO SECONDARY MENTAL HEALTH DATA AVAILABLE FOCUS GROUPS SERVING A SPECIFIC POPULATION IE SENIORS BEHAVIORAL HEALTH WERE ASKED ABOUT HEALTH NEEDS SPECIFIC TO THE GROUPS AREA OF EXPERTISE EACH FOCUS GROUP DETERMINED A COMPREHENSIVE LIST OF HEALTH NEEDS THEN PRIORITIZED ITS TOP FOUR TO SIX HEALTH NEEDS IN ADDITION SIXTEEN KEY INFORMANT INTERVIEWS WERE CONDUCTED BETWEEN JANUARY 2012 TO JULY 2012 WITH INDIVIDUALS FROM THE COURTS AREA FOUNDATIONS FREE AND FEDERALLY QUALIFIED HEALTH CENTER CLINICS THE MIGRANT CLINIC THE TRIBAL CLINIC ORGANIZATIONS WHO SERVE SENIORS AND ADOLESCENT HEALTH CLINIC PROVIDERS TO ASSESS THE GREATEST HEALTH NEEDS THEY OBSERVE KEY INFORMANTS WERE ASKED THE SAME FOUR QUESTIONS AS THE FOCUS GROUPS FOCUSING ON THEIR SPECIFIC POPULATION AREA OF EXPERTISE KEY INFORMANTS WERE CHOSEN BECAUSE OF THEIR KNOWLEDGE OF PEOPLE AND AREAS MOST IMPACTED BY HEALTH DISPARITIES
PAUL OLIVER MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 4	PART V LINE 4	MUNSON MEDICAL CENTER
PAUL OLIVER MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 7	PART V LINE 7	LARGE HEALTH NEEDS NOT ADDRESSED BY POMH AT THIS TIME ARE MENTAL HEALTH AND SUBSTANCE ABUSE POMH DOES NOT HAVE THE RESOURCES FOR MENTAL HEALTH OUTREACH OR AN INPATIENT PSYCHIATRIC UNIT OUR REFERRALS FOR MENTAL HEALTH AND SUBSTANCE ABUSE CARE THAT CANNOT BE TREATED IN THE PRIMARY CARE SETTING ARE SENT TO MUNSON MEDICAL CENTER IN TRAVERSE CITY OR PINE REST IN GRAND RAPIDS OUR GOAL IS TO WORK WITH PRIMARY CARE GROUPS TO IDENTIFY OPPORTUNITIES FOR ESTABLISHMENT OF GREAT ACCESS TO OUTPATIENT MENTAL HEALTH SERVICES IN THE REGION AND A PAIN CLINIC FOR IMPROVED MANAGEMENT IN ADDITION POMH DOES NOT HAVE THE ABILITY TO ADDRESS DENTAL NEEDS AT THIS TIME ACCESS TO DENTAL HEALTH PROVIDERS IS AN ISSUE IN MANY RURAL REGIONS ALTHOUGH OUR OPTIONS ARE LIMITED IN THIS AREA WE WILL CONTINUE TO EXPLORE WAYS TO DEVELOP COLLABORATIVE OPPORTUNITIES WITH DENTAL CLINICS NORTH TO EXPAND FROM GRAND TRAVERSE COUNTY INTO BENZIE COUNTY OUR COORDINATION WITH MUNSON HEALTHCARE ON HOW TO EXPAND PERINATAL SERVICES FOR GREATER ACCESS IN THE REGION IS ONGOING WE DO NOT VIEW THIS AS DIRECTLY ADDRESSING THE NEEDS OF PERINATAL AND OBSTETRICAL SERVICES
PAUL OLIVER MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 12H	PART V LINE 12H	PATIENTS WHOSE FAMILY INCOME EXCEEDS 400 OF THE FPG MAY BE ELIGIBLE TO RECEIVE DISCOUNTED RATES ON A CASEBYCASE BASIS BASED ON THEIR SPECIFIC CIRCUMSTANCES IE HIGH DEBTTOINCOME RATIO AT THE SOLE DISCRETION OF MUNSON HEALTHCARE
PAUL OLIVER MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 14G	PART V LINE 14G	IT IS THE GOAL OF MUNSON HEALTHCARE TO COMMUNICATE TO THE PATIENTS AND TO THE PUBLIC THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THOSE WHO QUALIFY THIS WILL BE ACHIEVED THROUGH ONE OR MORE OF THE FOLLOWING METHODS INFORMATION BROCHURES AVAILABLE AT THE REGISTRATION DESKS INFORMATION POSTED ON THE WEBSITE STATEMENT ON BILLS ANDOR SIGNS IN THE REGISTRATION AREAS
PAUL OLIVER MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 20D	PART V LINE 20D	SELFPAYNO INSURANCE PATIENTS ARE GIVEN A DISCOUNT EQUAL TO 15 OFF THEIR TOTAL BILL FOR ALL MEDICALLY NECESSARY AND EMERGENCY SERVICES THIS RATE WAS DETERMINED BY TAKING THE AVERAGE OF COMMERCIAL RATES NOT INCLUDING BLUE CROSS

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)PAUL M SHIRILLADIRECTOR	(i) (ii)	264,793	33,615	3,887	32,025	14,946	349,266
(2)JAMES D AUSTINPRESIDENT	(i) (ii)	180,540	39,235	34,013	23,077	17,478	294,343	3,698
(3)MARK A HEPLERCFO	(i) (ii)	241,424	31,844	17,075	39,379	20,592	350,314	4,348

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
RELATED ORG METHODS USED FOR COMPENSATION EXPLANATION	SCHEDULE J, PAGE 1, PART I, LINE 3	THE PROCESS FOR DETERMINING APPROPRIATE LEVELS OF PAY FOR EXECUTIVE POSITIONS WITHIN MUNSON HEALTHCARE SYSTEM IS CAREFULLY AND THOUGHTFULLY DIRECTED BY THE MUNSON HEALTHCARE BOARD OF DIRECTORS, THROUGH THE COMPENSATION AND EXECUTIVE LEADERSHIP DEVELOPMENT COMMITTEE. THE COMMITTEE UTILIZES "BEST PRACTICES" METHODS OF DETERMINING COMPENSATION AND, AS SUCH, IS COMPOSED OF SEVEN MEMBERS WHOSE VOTING MEMBERS ARE INDEPENDENT. THE COMMITTEE IS CHARGED WITH ENSURING THAT EXECUTIVE COMPENSATION IS DESIGNED TO ATTRACT AND RETAIN HIGH QUALITY, PROFESSIONAL LEADERSHIP WHILE MAINTAINING STRONG STEWARDSHIP FOR THE ORGANIZATION. ANNUALLY, THE COMMITTEE RETAINS A NATIONAL INDEPENDENT CONSULTANT TO ENSURE THAT MUNSON HEALTHCARE'S COMPENSATION PRACTICES AND LEVELS ARE INDEPENDENTLY REVIEWED WHILE BEING COMPETITIVE AND REASONABLE. COMPENSATION LEVELS REFLECT THE SCOPE OF EACH EXECUTIVE'S RESPONSIBILITIES, EDUCATIONAL BACKGROUND, EXPERIENCE, AND INDUSTRY STANDING AS WELL AS INDIVIDUAL AND ORGANIZATIONAL PERFORMANCE. ANNUAL COMPENSATION FOR MUNSON HEALTHCARE SYSTEM EXECUTIVES IS DETERMINED, IN PART, BY MEASURABLE PROGRESS TOWARD TO THE ORGANIZATION'S GOALS INCLUDING CONTINUED IMPROVEMENT IN CLINICAL QUALIFY, COMMUNITY HEALTH, AND OPERATIONAL THE COMPENSATION AND EXECUTIVE LEADERSHIP DEVELOPMENT COMMITTEE USES THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE MUNSON FOUNDATION'S PRESIDENT: COMPENSATION COMMITTEE INDEPENDENT COMPENSATION CONSULTANT COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS	SCHEDULE J, PAGE 1, PART I, LINE 4	PAUL M. SHIRILLA 0 16,138 0 JAMES D. AUSTIN 0 12,244 0 MARK A. HEPLER 0 24,893 0
OTHER ADDITIONAL INFORMATION	SCHEDULE J, PART III	EXECUTIVE SUPPLEMENTAL EXECUTIVE RETIREMENT PLANS: SUBJECT TO REVIEW AND APPROVAL BY THE BOARD COMPENSATION AND EXECUTIVE LEADERSHIP COMMITTEE, IN ORDER TO RECRUIT AND MAINTAIN QUALIFIED EXECUTIVES, INCLUDING THE PRESIDENT AND VICE-PRESIDENTS, A COMPETITIVE BENEFIT PACKAGE IS OFFERED WHICH INCLUDES PARTICIPATION IN A NON-QUALIFIED SUPPLEMENTAL RETIREMENT PLAN. ANNUAL CONTRIBUTIONS, AT MUNSON'S DISCRETION, ARE MADE TO THE PLAN IN ORDER TO ACHIEVE THE TARGETED RETIREMENT BENEFIT LEVEL. THESE FUNDS ARE AVAILABLE TO VESTED PARTICIPANTS UPON SEPARATION OF EMPLOYMENT FROM MUNSON.

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

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

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

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No






Total ...... $

Part III

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

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

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) CRYSTAL LAKE CLINIC	OWNER DIRECTOR	58,214	MEDICAL SERVICES		No
(2) CRYSTAL LAKE EMERGENCY SERVICES PC	OWNER DIRECTOR	942,770	GROUP PHYSICIAN PRAC		No
(3) NRTW LLC	OWNER DIRECTOR	62,247	LEASE		No
(4) INTERLOCHEN MEDICAL PROPERTIES LLC	OWNER DIRECTOR	81,547	LEASE		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:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Identifier	Return Reference	Explanation
ORGANIZATION'S MISSION	FORM 990 - ORGANIZATION'S MISSION	PAUL OLIVER MEMORIAL HOSPITAL DELIVERS QUALITY HEALTHCARE FOR THE PEOPLE OF THE BENZIE REGION TO IMPROVE THE HEALTH OF THE COMMUNITY IN PARTNERSHIP WITH MUNSON HEALTHCARE. PAUL OLIVER MEMORIAL HOSPITAL'S EXEMPT PURPOSE IS TO OPERATE A HOSPITAL, LONG-TERM CARE FACILITY AND OTHER ANCILLARY FACILITIES TO PROMOTE AND IMPROVE THE HEALTH OF THE RESIDENTS OF THE BENZIE, MICHIGAN AREA. PAUL OLIVER MEMORIAL HOSPITAL IS PART OF THE MUNSON HEALTHCARE SYSTEM. THROUGH ITS HOSPITALS AND OTHER AFFILIATES, THE SYSTEM DELIVERS A BROAD ARRAY OF HEALTH CARE SERVICES TO 24 COUNTIES IN MICHIGAN'S NORTHERN LOWER PENINSULA AND THE EASTERN PORTION OF THE UPPER PENINSULA. CONSISTENT WITH ITS MISSION, THE MUNSON HEALTHCARE SYSTEM PROVIDED 39.9 MILLION IN CHARITY CARE AND OTHER COMMUNITY BENEFITS, INCLUDING BAD DEBT AND THE SYSTEM MEDICARE FUNDS SHORTFALL FOR RESIDENTS OF NORTHERN MICHIGAN IN THE 2011 TAX YEAR.
CLASSES OF MEMBERS OR STOCKHOLDERS	FORM 990, PAGE 6, PART VI, LINE 6	PAUL OLIVER MEMORIAL HOSPITAL IS ORGANIZED ON A NONSTOCK MEMBERSHIP BASIS. THE SOLE MEMBER IS MUNSON HEALTHCARE, AN IRS SECTION 501(C)(3) TAX-EXEMPT ORGANIZATION.
ELECTION OF MEMBERS AND THEIR RIGHTS	FORM 990, PAGE 6, PART VI, LINE 7A	DIRECTORS ARE ELECTED FROM AMONG THOSE PERSONS RECOMMENDED BY THE MUNSON HEALTHCARE GOVERNANCE COMMITTEE AT THE MUNSON HEALTHCARE ANNUAL MEETING.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS	FORM 990, PAGE 6, PART VI, LINE 7B	CERTAIN DECISIONS OF THE PAUL OLIVER MEMORIAL HOSPITAL DIRECTORS ARE SUBJECT TO APPROVAL BY THE MUNSON HEALTHCARE BOARD OF DIRECTORS INCLUDING THE AMENDMENT OF THE ARTICLES OF INCORPORATION; AMENDMENT OF THE MISSION STATEMENT; ADOPTION OF A PLAN OF DISSOLUTION, MERGER, CONSOLIDATION OR REORGANIZATION; SALE, LEASE, EXCHANGE OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL TO THE PROPERTY AND ASSETS; ACQUISITION OF OR THE ESTABLISHMENT OF ANY SUBSIDIARY OR AFFILIATE OF PAUL OLIVER MEMORIAL HOSPITAL; ACCEPTANCE OF THE ANNUAL BUDGET AND ANNUAL FINANCIAL STATEMENTS; INCURRENCE OF EXPENDITURES EXCEEDING BUDGETED AGGREGATES BY MORE THAN FIVE PERCENT; INCURRENCE OF CERTAIN DEBT; CHANGE IN SCOPE OF SERVICES OR PROGRAMS PROVIDED BY PAUL OLIVER MEMORIAL HOSPITAL; AND APPOINTMENT OF THE PRESIDENT.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	THE PAUL OLIVER MEMORIAL HOSPITAL BOARD IS COMMITTED TO THE ACCURACY AND THOROUGHNESS OF THE FORM 990 REPORTING. PAUL OLIVER MEMORIAL HOSPITAL BELONGS TO THE MUNSON HEALTHCARE SYSTEM. MUNSON HEALTHCARE IS THE PARENT COMPANY IN THE MUNSON HEALTHCARE SYSTEM, WHICH UNDERGOES AN AUDIT BY AN EXTERNAL AUDIT FIRM. AT THE CORPORATE LEVEL, THE RESPONSIBLE INDIVIDUALS FROM THE FINANCE, ADMINISTRATION, PATIENT FINANCIAL SERVICES, LEGAL, HUMAN RESOURCES, PUBLIC RELATIONS, AND FUND DEVELOPMENT DEPARTMENTS PREPARE AND REVIEW PORTIONS OF THE FORM 990. THE COMPENSATION AND LEADERSHIP DEVELOPMENT COMMITTEE REVIEWS THE COMPENSATION INFORMATION CONTAINED IN THE CORE FORM AS WELL AS THE SCHEDULE J INFORMATION. THE CONFLICT, VALUATION AND COMPLIANCE COMMITTEE OVERSEES THE CONFLICT OF INTEREST DISCLOSURE PROCESS FOR BOARD MEMBERS AND KEY EMPLOYEES TO ENSURE COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE AUDIT COMMITTEE OVERSEES THE FORM 990 PREPARATION PROCESS BY ENSURING PROPER CONTROLS, POLICIES, PEOPLE AND RESOURCES ARE IN PLACE TO PRODUCE AN ACCURATE RETURN.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	THE MUNSON HEALTHCARE BOARD OF DIRECTORS (THE SYSTEM PARENT ORGANIZATION) HAS A STANDING CONFLICT, VALUATION AND COMPLIANCE ("CVC") COMMITTEE. THE CVC COMMITTEE IS COMPOSED OF INDEPENDENT BOARD AND COMMUNITY MEMBERS. THE CVC COMMITTEE IS DELEGATED AUTHORITY BY THE BOARD TO REVIEW AND APPROVE THE REASONABLENESS/FAIR MARKET VALUE OF FINANCIAL TRANSACTIONS/ARRANGEMENTS WITH DISQUALIFIED PERSONS. ANNUALLY, EACH BOARD MEMBER OF MUNSON HEALTHCARE AND ALL OF ITS SUBSIDIARY/CONTROLLED ENTITIES AND ALL MUNSON EXECUTIVES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE/QUESTIONNAIRE. THE RESPONSES TO THE DISCLOSURE/QUESTIONNAIRE ARE REVIEWED BY THE MUNSON LEGAL DEPARTMENT. ANY FINANCIAL ARRANGEMENTS/POTENTIAL CONFLICTS IDENTIFIED THROUGH THE DISCLOSURE/QUESTIONNAIRES ARE PRESENTED TO THE CVC COMMITTEE FOR ITS REVIEW AND DETERMINATION AS TO THE REASONABLENESS/FAIR MARKET VALUE.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	THE PROCESS FOR DETERMINING APPROPRIATE LEVELS OF PAY FOR EXECUTIVE POSITIONS WITHIN MUNSON HEALTHCARE SYSTEM IS CAREFULLY AND THOUGHTFULLY DIRECTED BY THE MUNSON HEALTHCARE BOARD OF DIRECTORS, THROUGH THE COMPENSATION AND EXECUTIVE LEADERSHIP DEVELOPMENT COMMITTEE. THE COMMITTEE UTILIZES "BEST PRACTICES" METHODS OF DETERMINING COMPENSATION AND, AS SUCH, IS COMPOSED OF SEVEN MEMBERS WHOSE VOTING MEMBERS ARE INDEPENDENT. THE COMMITTEE IS CHARGED WITH ENSURING THAT EXECUTIVE COMPENSATION IS DESIGNED TO ATTRACT AND RETAIN HIGH QUALITY, PROFESSIONAL LEADERSHIP WHILE MAINTAINING STRONG STEWARDSHIP FOR THE ORGANIZATION. ANNUALLY, THE COMMITTEE RETAINS A NATIONAL INDEPENDENT CONSULTANT TO ENSURE THAT MUNSON HEALTHCARE'S COMPENSATION PRACTICES AND LEVELS ARE INDEPENDENTLY REVIEWED WHILE BEING COMPETITIVE AND REASONABLE. COMPENSATION LEVELS REFLECT THE SCOPE OF EACH EXECUTIVE'S RESPONSIBILITIES, EDUCATIONAL BACKGROUND, EXPERIENCE, AND INDUSTRY STANDING AS WELL AS INDIVIDUAL AND ORGANIZATIONAL PERFORMANCE. ANNUAL COMPENSATION FOR MUNSON HEALTHCARE SYSTEM EXECUTIVES IS DETERMINED, IN PART, BY MEASURABLE PROGRESS TOWARD THE ORGANIZATION'S GOALS INCLUDING CONTINUED IMPROVEMENT IN CLINICAL QUALITY, COMMUNITY HEALTH, AND OPERATIONAL EFFICIENCIES. MUNSON HEALTHCARE'S INTENT FOR EXECUTIVE BASE COMPENSATION IS TO BE AT THE MEDIAN WHEN COMPARED TO LIKE-SIZE NON-PROFIT HOSPITALS AND HEALTHCARE SYSTEMS.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	COMPENSATION OF OTHER OFFICERS IS CONSISTENT WITH THAT OF THE TOP EXECUTIVES PAUL OLIVER MEMORIAL HOSPITAL AND MUNSON HEALTHCARE.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	THE PAUL OLIVER MEMORIAL HOSPITAL ARTICLES OF INCORPORATION ARE AVAILABLE TO THE PUBLIC ON THE MICHIGAN DEPARTMENT OF TREASURY WEBSITE. PAUL OLIVER MEMORIAL HOSPITAL DOES NOT MAKE THE BYLAWS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC.
GROUP RETURN METHOD	FORM 990, PAGE 7, PART VII	PARENT ORGANIZATION HAS FILED A SEPARATE RETURN
OTHER FEES FOR SERVICES	FORM 990, PART IX, LINE 11G	PURCHASED SERVICES 2,787,530 575,100 118,006 PROFESSIONAL FEES 965,523 10,393 0
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 9	INVESTMENT IN SUB - PAUL OLIVER HOSPITAL FND 420,511 UNREALIZED INVESTEMENT GAIN 74,438 TRANSFER TO PARENT CORP -1,000,000 TEMP REST ASSET TRANSFER -906,358 -

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

PAUL OLIVER MEMORIAL HOSPITAL

Employer identification number

38-1415623

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) MUNSON DIALYSIS CENTER 1105 SIXTH ST TRAVERSE CITY,MI49684 38-3097861	DIALYSIS	MI	C3	3	MUNSON HC MUNSON HEALTHCARE		No
(2) MUNSON HEALTHCARE 1105 SIXTH ST TRAVERSE CITY,MI49684 38-2640544	PARENT	MI	C3	11B	NA		No
(3) MUNSON HEALTHCARE REGIONAL FOUNDATI 1105 SIXTH ST TRAVERSE CITY,MI49684 38-2642724	RAISE FUND	MI	C3	7	MUNSON HC MUNSON HEALTHCARE		No
(4) MUNSON HOME CARE 1105 SIXTH ST TRAVERSE CITY,MI49684 38-2191390	HOME HEALT	MI	C3	9	MUN HOME H MUNSON HOME HEALTH		No
(5) MUNSON HOME HEALTH 1105 SIXTH ST TRAVERSE CITY,MI49684 38-3335362	HOME HEALT	MI	C3	11B	MUNSON HC HEALTHCARE		No
(6) MUNSON HOME SERVICES 1105 SIXTH ST TRAVERSE CITY,MI49684 38-2543463	HOME HEALT	MI	C3	9	MUN HOME H MUNSON HOME HEALTH		No
(7) MUNSON MEDICAL CENTER 1105 SIXTH ST TRAVERSE CITY,MI49684 38-1362830	HOSPITAL	MI	C3	3	MUNSON HC MUNSON HEALTHCARE		No
(8) NORTH FLIGHT INC 1105 SIXTH ST TRAVERSE CITY,MI49684 38-2657917	MED TRANSP	MI	C3	11B	MUNSON HC MUNSON HEALTHCARE		No
(9) PAUL OLIVER MEMORIAL HOSPITAL FOUND 1105 SIXTH ST TRAVERSE CITY,MI49684 23-7201619	RAISE FUND	MI	C3	3	PAUL OLIVE PAUL OLIVER MEMORIAL HOSPITAL	Yes
(10) MUNSON MEDICAL GROUP 1105 SIXTH ST TRAVERSE CITY,MI49684 27-3600575	HEALTHCARE	MI	C3	9	MUNSON MED MUNSON MEDICAL CENTER		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) MUNSON MEDICAL BUILDING PARTNERS PO BOX 1188 TRAVERSE CITY,MI496851188 38-2830005	REAL ESTAT	MI	N/A				No			No
(2) NORTHERN MICHIGAN SUPPLY ALLIANCE 2651 AERO PARK DR TRAVERSE CITY,MI49686 38-3453378	PURCHASING	MI	N/A				No			No
(3) MUNSON MEDICAL BUILDING PARTNERS PO BOX 1188 TRAVERSE CITY,MI496851188 38-2830005	REAL ESTAT	MI	N/A				No			No
(4) NORTHERN MICHIGAN SUPPLY ALLIANCE 2651 AERO PARK DR TRAVERSE CITY,MI49686 38-3453378	PURCHASING	MI	N/A				No			No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) MEDICAL OFFICE BUILDING CONDOMINIUM MEDICAL OFFICE BUILDING CONDOMINIUM PO BOX 1188 TRAVERSE CITY,MI496851188 38-3567278	REAL ESTAT	MI	N/A					No
(2) MUNSON SERVICES INC PO BOX 1188 TRAVERSE CITY,MI496851188 38-3144382	PHARMACY	MI	N/A					No
(3) MUNSON SUPPORT SERVICES PO BOX 1188 TRAVERSE CITY,MI496851188 38-2872821	LAUNDRY	MI	N/A					No
(4) SIXTH STREET DRUGS INC PO BOX 1188 TRAVERSE CITY,MI496851188 38-2298290	PHARMACY	MI	N/A					No
(5) MEDICAL OFFICE CONDOMINIUM MEDICAL OFFICE CONDOMINIUM PO BOX 1188 TRAVERSE CITY,MI496851188 20-1902620	REAL ESTAT	MI	N/A					No
(6) MUNSON MOBILE IMAGING PO BOX 1188 TRAVERSE CITY,MI496851188 38-2704069	IMAGING	MI	N/A					No
(7) MEDICAL OFFICE BUILDING CONDOMINIUM MEDICAL OFFICE BUILDING CONDOMINIUM PO BOX 1188 TRAVERSE CITY,MI496851188 38-3567278	REAL ESTAT	MI	N/A					No
(8) MUNSON SERVICES INC PO BOX 1188 TRAVERSE CITY,MI496851188 38-3144382	PHARMACY	MI	N/A					No
(9) MUNSON SUPPORT SERVICES PO BOX 1188 TRAVERSE CITY,MI496851188 38-2872821	LAUNDRY	MI	N/A					No
(10) SIXTH STREET DRUGS INC PO BOX 1188 TRAVERSE CITY,MI496851188 38-2298290	PHARMACY	MI	N/A					No
(11) MEDICAL OFFICE CONDOMINIUM MEDICAL OFFICE CONDOMINIUM PO BOX 1188 TRAVERSE CITY,MI496851188 20-1902620	REAL ESTAT	MI	N/A					No
(12) MUNSON MOBILE IMAGING PO BOX 1188 TRAVERSE CITY,MI496851188 38-2704069	IMAGING	MI	N/A					No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

Yes

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

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

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

Yes

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

Yes

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

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

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

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

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

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

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

Yes

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

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

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

Yes

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

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

Yes

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

Yes

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

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

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

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

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) MUNSON DIALYSIS CENTER	J	65,985	FMV
(2) MUNSON HEALTHCARE	B	1,000,000	FMV
(3) MUNSON HEALTHCARE	M	165,372	FMV
(4) MUNSON HEALTHCARE	O	135,156	FMV
(5) MUNSON HEALTHCARE	P	115,267	FMV
(6) MUNSON HEALTHCARE REGIONAL FOUNDATI FOUNDATION	C	173,287	FMV
(7) MUNSON MEDICAL CENTER	P	6,135,851	FMV
(8) MUNSON MEDICAL CENTER	O	1,044,383	FMV
(9) MUNSON MEDICAL CENTER	M	811,113	FMV
(10) MUNSON SERVICES INC	M	56,456	FMV
(11) MUNSON SUPPORT SERVICES	M	84,319	FMV
(12) NORTHERN MICHIGAN SUPPLY ALLIANCE	P	225,210	FMV
(13) PAUL OLIVER MEM HOS FOUNDATION	M	117,970	FMV
(14) PAUL OLIVER MEM HOS FOUNDATION	C	906,358	FMV
(15) MUNSON DIALYSIS CENTER	J	65,985	FMV
(16) MUNSON HEALTHCARE	B	1,000,000	FMV
(17) MUNSON HEALTHCARE	M	165,372	FMV
(18) MUNSON HEALTHCARE	O	135,156	FMV
(19) MUNSON HEALTHCARE	P	115,267	FMV
(20) MUNSON HEALTHCARE REGIONAL FOUNDATI FOUNDATION	C	173,287	FMV
(21) MUNSON MEDICAL CENTER	P	6,135,851	FMV
(22) MUNSON MEDICAL CENTER	O	1,044,383	FMV
(23) MUNSON MEDICAL CENTER	M	811,113	FMV
(24) MUNSON SERVICES INC	M	56,456	FMV
(25) MUNSON SUPPORT SERVICES	M	84,319	FMV
(26) NORTHERN MICHIGAN SUPPLY ALLIANCE	P	225,210	FMV
(27) PAUL OLIVER MEM HOS FOUNDATION	M	117,970	FMV
(28) PAUL OLIVER MEM HOS FOUNDATION	C	906,358	FMV
(29) MUNSON DIALYSIS CENTER	J	65,985	FMV
(30) MUNSON HEALTHCARE	B	1,000,000	FMV
(31) MUNSON HEALTHCARE	M	165,372	FMV
(32) MUNSON HEALTHCARE	O	135,156	FMV
(33) MUNSON HEALTHCARE	P	115,267	FMV
(34) MUNSON HEALTHCARE REGIONAL FOUNDATI FOUNDATION	C	173,287	FMV
(35) MUNSON MEDICAL CENTER	P	6,135,851	FMV
(36) MUNSON MEDICAL CENTER	O	1,044,383	FMV
(37) MUNSON MEDICAL CENTER	M	811,113	FMV
(38) MUNSON SERVICES INC	M	56,456	FMV
(39) MUNSON SUPPORT SERVICES	M	84,319	FMV
(40) NORTHERN MICHIGAN SUPPLY ALLIANCE	P	225,210	FMV
(41) PAUL OLIVER MEM HOS FOUNDATION	M	117,970	FMV
(42) PAUL OLIVER MEM HOS FOUNDATION	C	906,358	FMV

Schedule R (Form 990) 2012

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation
ADDITIONAL INFORMATION	SCHEDULE R	PAUL OLIVER MEMORIAL HOSPITAL USED THE ACCRUAL METHOD OF ACCOUNTING TO VALUE THE TRANSACTIONS WITH RELATED ENTITIES ALL INTERCOMPANY TRANSACTIONS WITH RELATED ENTITIES WERE REVIEWED SUMMARIZED AND RECONCILED TO DETERMINE THE DISCLOSURE AMOUNTS

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: PAUL OLIVER MEMORIAL HOSPITAL DELIVERS QUALITY HEALTHCARE FOR THE PEOPLE OF THE BENZIE REGION TO IMPROVE THE HEALTH OF THE COMMUNITY IN PARTNERSHIP WITH MUNSON HEALTHCARE. PAUL OLIVER MEMORIAL HOSPITAL'S EXEMPT PURPOSE IS TO OPERATE A HOSPITAL, LONG-TERM CARE FACILITY AND OTHER ANCILLARY FACILITIES TO PROMOTE AND IMPROVE THE HEALTH OF THE RESIDENTS OF THE BENZIE, MICHIGAN AREA. PAUL OLIVER MEMORIAL HOSPITAL IS PART OF THE MUNSON HEALTHCARE SYSTEM. THROUGH ITS HOSPITALS AND OTHER AFFILIATES, THE SYSTEM DELIVERS A BROAD ARRAY OF HEALTH CARE SERVICES TO 24 COUNTIES IN MICHIGAN'S NORTHERN LOWER PENINSULA AND THE EASTERN PORTION OF THE UPPER PENINSULA. CONSISTENT WITH ITS MISSION, THE MUNSON HEALTHCARE SYSTEM PROVIDED 39.9 MILLION IN CHARITY CARE AND OTHER COMMUNITY BENEFITS, INCLUDING BAD DEBT AND THE SYSTEM MEDICARE FUNDS SHORTFALL FOR RESIDENTS OF NORTHERN MICHIGAN IN THE 2011 TAX YEAR.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	12
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	8
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	190
6	Total number of volunteers (estimate if necessary) .............	6	35
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	64,605	1,109,812
9	Program service revenue (Part VIII, line 2g) .........	17,486,866	17,039,128
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	137,683	265,348
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	76,678	152,476
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	17,765,832	18,566,764
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	6,561,317	6,626,741
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 118,006
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	9,439,776	9,251,410
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	16,001,093	15,878,151
19	Revenue less expenses. Subtract line 18 from line 12.......	1,764,739	2,688,613
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	21,165,084	20,593,787
21	Total liabilities (Part X, line 26).............	3,279,288	1,430,787
22	Net assets or fund balances. Subtract line 21 from line 20.....	17,885,796	19,163,000

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 14,359,086 including grants of $ ) (Revenue $ 16,871,459 )
	PROVIDING HOSPITAL AND LONG-TERM CARE SERVICES TO THE RESIDENTS OF THE BENZIE, MICHIGAN REGION.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses14,359,086

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)			(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(1) PAUL M SHIRILLA........................................................................ DIRECTOR	.......................40.00	X			0	302,295	46,971
(2) JAMES D AUSTIN........................................................................ PRESIDENT	16.00 .......................24.00	X	X		0	253,788	40,555
(3) GERARD MAHONEY DO........................................................................ DIRECTOR	2.00 .......................	X			9,500	0	0
(4) BRENDA SUE WEBBER........................................................................ VIC CHAIR	2.00 .......................	X	X		0	0	0
(5) CHARLES TULL........................................................................ DIRECTOR	2.00 .......................	X			0	0	0
(6) DAVID MICINSKI........................................................................ DIRECTOR	2.00 .......................	X			0	0	0
(7) HON PAUL J CLULO........................................................................ CHAIR	2.00 .......................	X	X		0	0	0
(8) IRENE A NUGENT........................................................................ DIRECTOR	2.00 .......................	X	X		0	0	0
(9) JOETTA RILEY PARRIS........................................................................ SEC/TREASURE	2.00 .......................	X	X		0	0	0
(10) PAUL PATTERSON........................................................................ DIRECTOR	2.00 .......................	X			0	0	0
(11) BETSY EVANS........................................................................ DIRECTOR	2.00 .......................	X			0	0	0
(12) GEORGE RYCKMAN DO........................................................................ DIRECTOR	2.00 .......................	X			0	0	0
(13) MARK A HEPLER........................................................................ CFO	.......................40.00		X		0	290,343	59,971
(14) PETER MARINOFF........................................................................ ASST ADMINIS	40.00 .......................			X	107,880	0	20,516

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	117,380	846,426	168,013

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c		19,449
d	Related organizations...1d		1,079,645
e	Government grants (contributions)1e		10,718

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.......			1,109,812
			Business Code
2a	MEDICARE AND MEDICAID PMTS		621990	9,960,147	9,960,147
b	PATIENT SERVICE REVENUE		621990	6,702,229	6,702,229
c	COMMUNITY FITNESS CENTER		713940	189,458	189,458
d	IN HOUSE CHILD CARE		624410	187,294			187,294
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			17,039,128
3	Investment income (including dividends, interest, and other similar amounts).......			77,741			77,741
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents	68,097
b	Less: rental expenses
c	Rental income or (loss)	68,097
d	Net rental income or (loss).......			68,097			68,097
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	183,053	4,687
b	Less: cost or other basis and sales expenses		133
c	Gain or (loss)	183,053	4,554
d	Net gain or (loss)..........			187,607			187,607
8a	Gross income from fundraising events (not including $ 19,449 of contributions reported on line 1c). See Part IV, line 18 ..
	a		42,089
b	Less: direct expenses ...b		16,024
c	Net income or (loss) from fundraising events..			26,065
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	CAFETERIA SALES		722210	30,689			30,689
b	MISCELLANEOUS		621990	19,625	19,625
c	AUXILIARY GIFT SHOP		446199	8,000			8,000
d	All other revenue ....
e	Total. Add lines 11a–11d ......			58,314
12	Total revenue. See Instructions......			18,566,764	16,871,459		559,428


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			1,050	1	1,050
2	Savings and temporary cash investments .........			4,711,939	2	4,599,948
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			2,643,673	4	2,108,588
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............				8
9	Prepaid expenses and deferred charges ..........			117,397	9	108,570
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,102,402
b	Less: accumulated depreciation .....	10b	14,498,655	6,221,757	10c	6,603,747
11	Investments—publicly traded securities ..........			3,285,702	11	3,618,518
12	Investments—other securities. See Part IV, line 11 .....			3,862,347	12	3,376,501
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			321,219	15	176,865
16	Total assets. Add lines 1 through 15 (must equal line 34)......			21,165,084	16	20,593,787
17	Accounts payable and accrued expenses .........			1,011,201	17	1,006,144
18	Grants payable .................				18
19	Deferred revenue ................				19	5,000
20	Tax-exempt bond liabilities .............				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			2,268,087	25	419,643
26	Total liabilities. Add lines 17 through 25.........			3,279,288	26	1,430,787
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			14,023,449	27	15,786,499
28	Temporarily restricted net assets ...........			3,862,347	28	3,376,501
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			17,885,796	33	19,163,000
34	Total liabilities and net assets/fund balances ........			21,165,084	34	20,593,787