TY 2015 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Carey Wagner...................................................................... Chair	1.0 ................. 1.0	X	X	0	0
(2) Joseph Piasek...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(3) Fred Marguiles...................................................................... Secretary	1.0 ................. 1.0	X	X	0	0
(4) Sandra Horan...................................................................... Chief Nursing Officer	4.69 ................. 32.81	X	X	197,242	12,030
(5) Arthur Martello...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(6) Jenny Morrill-Liddle...................................................................... 1st Vice Chair	1.0 ................. 1.0	X	X	0	0
(7) Thomas O'Brien...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(8) Philip Mehl...................................................................... Administrator MRCC	1.0 ................. 39.0	X		104,187	14,452
(9) David Riordan...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(10) Nancy Slauson...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(11) David Scarpino...................................................................... CEO	1.2 ................. 36.3	X	X	480,007	21,578
(12) Kent Garrett...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(13) Thomas Collins...................................................................... Trustee 3/12/2015-12/31/2015	1.0 ................. 1.0	X		0	0
(14) Susan McLean...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(15) James Howie...................................................................... Trustee	1.0 ................. 1.0	X		0	0
(16) Paul Llobet MD...................................................................... Chief Medical Director	33.5 ................. 4.0	X	X	50,741	0
(17) Rita Herbst...................................................................... Trustee	1.0 ................. 1.0	X		0	0

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) Kevin Ryan........................................................................ Trustee - 1/1/15 - 3/11/2015	1.0 .......................1.0	X					0	0	0
(19) Frank Ehrlich MD........................................................................ Chief Medical Officer	1.0 .......................36.5		X				0	298,617	11,028
(20) Steven Haas........................................................................ CFO 1/1/15-11/12/15	0.5 .......................37.0		X				0	254,361	19,761
(21) Patricia Gavis........................................................................ CFO 11/23/15-12/31/15	0.5 .......................37.0		X				0	24,683	0
(22) John Finch........................................................................ Chief Inf. & Comm. Officer	1.0 .......................36.5			X			0	216,207	30,604
(23) Joshua Ratner........................................................................ Chief Strategy Officer	4.58 .......................32.92			X			0	217,727	23,857
(24) Joseph Marsicovete........................................................................ Chief Operating Officer	3.0 .......................34.5			X			0	290,719	13,867
(25) Amy Smith........................................................................ RN	40.0 .......................0.0				X		105,762	0	17,932
(26) Randall Moore........................................................................ Director of Pharmacy	40.0 .......................0.0				X		122,099	0	18,559
(27) Eileen King........................................................................ Physicians Assistant	40.0 .......................0.0				X		202,945	0	17,810
(28) Nanette Treadwell........................................................................ Physician Assistant	40.0 .......................0.0				X		132,670	0	3,915
(29) Robert Seidman........................................................................ CAO 1/1/14 - 8/1/14	0.0 .......................0.0					X	0	166,663	10,778
(30) Kathleen Lunney........................................................................ CNO 1/1/14 - 8/1/14	0.0 .......................0.0					X	0	113,199	0
(31) David Lundquist........................................................................ CEO thru 7/25/2013	0.0 .......................0.0					X	0	347,638	7,984

(A) Name and business address	(B) Description of services	(C) Compensation
SECO PHYSICAL OCCUPATIONAL THERAP, PO BOX 1046 NORWICH,NY13815	CONSULTING	205,780
Laboratory Corp of America, PO Box 12140 BURLINGTON,NC27216	Laboratory Services	614,698
Llobet Medical, PO Box 1020 MARGARETVILLE,NY12455	Medical	166,674


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 3

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

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 (Form 990 or 990-EZ))

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 in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ..............

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

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.)..
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 section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2015. 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—2014. 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—2015. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. 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 VI 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) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 VI.) ..
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 section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. 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—2014. 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) 2015

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

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

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2015 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2015	(iii) Distributable Amount for 2015
1 Distributable amount for 2015 from Section C, line 6
2 Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2015:
a
b
c
d From 2013.......
e From 2014.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2015 distributable amount
i Carryover from 2010 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2015 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2015 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2016. Add lines 3j and 4c.
8 Breakdown of line 7:
a
b
c Excess from 2013.......
d From 2014.......
e From 2015.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

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

OMB No. 1545-0047

2015

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

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, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) 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), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions 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 an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled 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 totaling $5,000 or more during the year ......... Arrow Bullet

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

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2

Name of organization Margaretville 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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 3

Name of organization Margaretville Memorial Hospital		Employer identification number 15-0552726

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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 4


Name of organization Margaretville Memorial Hospital			Employer identification number 15-0552726
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ 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) (2015)

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

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

OMB No. 1545-0047

2015

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

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

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

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-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(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) 2015

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 on 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

1,157

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

1,157

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

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
PART II-B, LINE 1I - OTHER ACTIVITIES DESCRIPTION	MARGARETVILLE MEMORIAL HOSPITAL PAYS DUES TO THE IROQUOIS HEALTHCARE ALLIANCE OF NEW YORK STATE (IHA). IN ACCORDANCE WITH SECTION 6033(E) OF THE INTERNAL REVENUE CODE, AND AS REPORTED BY IHA, A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. THE LOBBYING ACTIVITIES APPLICABLE TO 2015 IHA ANNUAL DUES WERE $1,157.

Schedule C (Form 990 or 990EZ) 2015

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

Part I

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

			(a) Donor advised funds	(b) Funds and other accounts

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of 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" on 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, 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" on 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)

Revenue included on 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:

Revenue included on 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) 2015

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" on 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


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?

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" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land ...	23,128		23,128
b	Buildings	4,495,067	3,760,606	734,461
c	Leasehold improvements	456,812	326,441	130,371
d	Equipment ...	16,334,714	14,112,263	2,222,451
e	Other ...	95,874		95,874
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				3,206,285

Schedule D (Form 990) 2015

Page 3

Part VII

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

(a) Description of security or category (including name of security)	(b)Book value	(c)Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

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

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

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

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

(a) Description				(b) Book value
(1) ASSETS LIMITED AS TO USE				2,461,201
(2) INTEREST IN NA - MH FOUNDATION				309,036
(3) OTHER RECEIVABLE				180,552
(4) INSURANCE RECEIVABLE				948,922
(5) DUE FROM 3RD PARTY PAYORS				146,313
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				4,046,024

Part X

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

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
DUE TO RELATED PARTIES	1,945,505
DUE TO THIRD PARTY PAYORS	669,203
OTHER NON-CURRENT LIABILITIES	772,365
MALPRACTICE LIABILITY	948,922
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	4,335,995
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2015

Page 4

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

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d....................		2e
3	Subtract line 2e from line 1...................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.....................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

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

Return Reference	Explanation

Schedule D (Form 990) 2015

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" on Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. right arrow

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

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization
Margaretville Memorial Hospital

Employer identification number

15-0552726

Part I

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

Form 990-EZ filers are not required to complete this part.

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?

YesNo

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 contributions or has been notified it is exempt from registration or licensing.

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

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2015

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" on 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 Harvest Moon (event type)	(b) Event #2 Flea Market (event type)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . . . .	27,645	10,546	38,191
2	Less: Contributions . . . .
3	Gross income (line 1 minus line 2) . . . . . .	27,645	10,546	38,191

4	Cash prizes . . . . .
5	Noncash prizes . . . .
6	Rent/facility costs . . . .
7	Food and beverages . . .	5,535	1,631	7,166
8	Entertainment . . . .	950		950
9	Other direct expenses . . .	2,812	2,433	5,245
10	Direct expense summary. Add lines 4 through 9 in column (d) . . . . . . . . . .			13,361
11	Net income summary. Subtract line 10 from line 3, column (d). . . . . . . . . .			24,830

Part III

Gaming. Complete if the organization answered "Yes" on 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))
1	Gross revenue . . . . .

2	Cash prizes . . . . .
3	Noncash prizes . . . .
4	Rent/facility costs . . . .
5	Other direct expenses . . .	2,812	2,433	5,245

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. Subtract line 7 from line 1, column (d). . . . . . . . . right arrow

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

Is the organization licensed to conduct 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) 2015

Page 3

Does the organization conduct 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 conducted 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. 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).

Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2015

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" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

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 criteria used 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) . . .	140,339	26,760	113,579	0.850 %
b	Medicaid (from Worksheet 3, column a) . . . . .	1,824,969	495,208	1,329,761	9.910 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	1,965,308	521,968	1,443,340	10.760 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	2,887		2,887	0.030 %
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .	3,927,761	2,312,256	1,615,505	12.050 %
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .	3,930,648	2,312,256	1,618,392	12.080 %
k	Total. Add lines 7d and 7j .	5,895,956	2,834,224	3,061,732	22.840 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015

Schedule H (Form 990) 2015

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

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. ......

409,264

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

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

Section B. Medicare

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

3,963,810

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

3,219,953

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

743,857

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) 2015

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	Margaretville Memorial Hospital 42084 State Route 28 Margaretville,NY12455	X	X	X	X

Schedule H (Form 990) 2015

Page 4

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)

	Margaretville Memorial Hospital
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

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 12......................

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 significant 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 Section C)

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

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

Yes

6 a

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

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

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

Yes

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

Hospital facility’s website (list url): HTTPS//WWW.HAHV.ORG/COMMUNITY-HEALTH

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 13

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): www.hahv.org/wp-content/uploads/2014/01/commu

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, 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) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Margaretville Memorial Hospital
Name of hospital facility or letter of facility reporting group

Yes

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 100% and FPG family income limit for eligibility for discounted care of 300.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

www.hahv.org

The FAP application form was widely available on a website (list url):

www.hahv.org

A plain language summary of the FAP was widely available on a website (list url):
www.hahv.org

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

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 all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	Margaretville Memorial Hospital
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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 Section C)

Other (describe in Section C)

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 Section C)

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

If "Yes," explain in Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Part V, Sec. B, Line 6a	HealthAlliance Hospital Broadway Campus and HealthAlliance Hospital Mary's Avenue Campus
Part V, Sec B, Line 5	2014-2016 CHNA Implementation Plan In 2013, HealthAlliance of the Hudson Valleys ("HAHV") member hospitals were involved in collaborative planning groups to assess and define community health needs in Ulster and Delaware Counties. Analysis developed from this process was the basis for the development of an implementation plan to address community health needs for the next three years. HAHVs continuing progress and monitoring of goals identified in this assessment is managed by an internal Community Benefit Committee (CBC). The CBC engages internal and external resources to develop and implement evidence-based strategies across the service area to directly address the identified health needs HAHV will pursue. Current and new outreach strategies will be modified, if needed, and developed during the current term of the CSP (2014-2016). In accordance with the NYS Prevention Agenda mandate, HAHV Hospitals will align with County Departments of Health to focus on two priority areas, Prevent Chronic Disease and Promote Mental Health & Prevent Substance Abuse. These priority areas consist of focus areas that impact 12 of the 16 health needs identified in the Ulster County CHNA and all of the health needs identified in the Delaware County CHNA. NYS Prevention Agenda goals and objectives identified below are to be met as a collective statewide effort. HAHV will apply internal resources to help Ulster and Delaware Counties meet these expectations.
Part V, Sec B, Line 11	See response to Part VI, Line 2

Schedule H (Form 990) 2015

Page 8

Part VFacility Information (continued)

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

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

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

Form and Line Reference	Explanation
PART I, LINE 7 - EXPLANATION OF COSTING METHODOLOGY	Margaretville Memorial Hospital's ("MMH") costing methodology was based upon the 2015 New York State Institutional Cost Report and the 2015 Medicare (Form 2552) Cost Report. These cost reports are filed with the New York State Department of Health and the applicable CMS intermediary, respectably. The cost-to-charge ratio derived from the New York State Institutional Cost Report was used for the various sub-line items of line #7.
PART I, LINE 7G - COSTS ASSOCIATED WITH PHYSICANS CLINICS	THE COSTS ON LINE 7G INCLUDE $0 OF COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS.
PART III, LINE 2 - METHODOLOGY USED TO ESTIMATE AMOUNT OF BAD DEBT EXPENSE	The amount reported on line 2 is equal to the provision for bad debt expense per the audited financial statements ("AFS"). The explanation of the methodology used to estimate this amount can be found in Footnote #1 on pages 10-12 of the attached AFS.
PART III, LINE 4 - DESCRIPTION OF BAD DEBT EXPENSE	The text of the footnote that describes bad debt expense can be found on Pages 10-12 of the attached AFS.
PART III, LINE 8 - EXPLANATION OF SHORTFALL AS COMMUNITY BENEFIT	Since MMH is a critical access hospital, the hospital receives 101% of its cost for most of its services; therefore MMH should always have a profit from Medicare. The amount reported on Line 6 was derived by using the Medicare allowable costs as reported on the Medicare cost report and the applicable adjustments from Worksheet A.
PART III LINE 9B: PROVISIONS ON COLLECTION PRACTICES FOR QUALIFIED PATIENT	The credit and collection policy for self-pay balances provides that, in some cases, non-insured patients that do not qualify for Medicaid qualify for Charity Care. In those instances, the credit and collection department will follow the guidelines as set forth in the Charity Care policy (Attachment A). The Charity Care policy provides that the financial counselor evaluates the information provided in patients' charity care applications in conjunction with Federal income poverty guidelines to determine the write-off percentage. If the patient/guarantor qualifies for charity care based on the sliding scale, the patient will be required to pay the outstanding amount. A payment plan is established not to exceed 10% of the guarantor's gross monthly income.
PART I, LINE 6a - COMMUNITY NEEDS REPORTING	HAHV is required to file a Community Needs Health Assessment (CHNA) report every 3 years. The first filing requirement was fulfilled in 2013 and work is being done to file an updated report in FY2016. Since HAHV is the parent company of a 3-hospital health system, the CHNA report was prepared as part of an integrated filing organization with some specifics related to MMH since it resides in a different county.
PART VI, LINE 2: NEEDS ASSESSMENT	During the past year, we have worked hard to ensure that all of our service area continues to receive primary, specialty and emergency medical care as needed. We continue to analyze patient demographic data and health care migration patterns to ensure that we are current in our understanding of the communities' needs. Utilizing monthly patient survey/opinion scorecards, we monitor our performance based HCAP Scores as well place follow-up phone calls post discharge for Acute/Swing, ED and ASU Patients. MMH continues to receive recognition for quality medical care as evidenced by IPRO indicators, JCAHO/Department of Health and outpatient medical record compliance audit. Through community forums, speaking engagements by senior management and medical staff and Board of Trustees community outreach, we are confident that our performance is meeting the community health needs. Mountainside Residential Care Center in Margaretville is on track to receiving its seventh consecutive five-star quality rating from Medicare - the best rating possible - after being scored among the best in New York from the state Department of Health. Performance in Improving Access to Health Services for the Underserved: We continue to meet the identified needs and challenges of providing rural health services. Our initiatives have been specific to identified areas of need and complement our previous efforts. . Expand social services with increased utilization of the swing bed program. . Access to an Ipad which provides access to web sites to obtain information regarding medical concerns. . Continue operation of the hospital's ambulance service. . Continue to develop and expand the community Wellness program to provide educational opportunities in medical specialty areas. . Continue to provide 2 Health Fairs annually to the community. . Mobile van visits to community events. 2015 Community Service Plan Update of Public Participation/Assessment of Public Health Priorities For information on HAHV Background, Mission, Service Area, Three Year Plan of Action, Financial Aid Program, and Changes Impacting Community Health/Provision of Charity Care/Access to Services, please refer to the 2014-2016 Community Service Plan, also available on our website, www.hahv.org. MMH, Delaware County Professional and public focus groups were conducted in 2013 throughout Delaware County to gain insight from consumers and other stakeholders to identify the most pressing healthcare issues. The two other Critical Access Hospitals in Delaware County were consulted regarding their identified priority healthcare needs, with additional input received from the local Public Health Department, area community healthcare stakeholders, and our Acute and Emergency Department physicians and providers. The public health priorities selected were: 1) Prevent Chronic Disease 2) Promote Mental Health and Prevent Substance Abuse Prevention Agenda Priority: Prevent Chronic Disease Prevention Agenda Focus Area: Reduce Obesity in Children and Adults Community Health Needs Addressed: Obesity 1. Goal: Create Community environments that promote and support healthy beverage choices and physical activity a. Objective: increase the percentage of adults ages 18 and older who participate in leisure time physical activity. MMH Response: . Collaborate with the MMH Auxiliary Wellness Committee and area Chambers of Commerce, local government and other community organizations to develop a plan for mapping and advertising the available walking, biking, jogging and hiking routes within the hospital service area. . Educate and engage the local physicians, mid-level health care providers, and Emergency Departments to implement the walking trail prescription program. . Collaborate with the MMH Auxiliary Wellness Committee to investigate the organization of other physical activity initiatives, such as Peddlers and Paddlers, organized community activity events, and securing an indoor walking environment for the winter months to ensure leisure time activity availability year round. . Provide leisure time physical activity event information at the hospital health fairs and at our mobile van events. . Investigate the ability to provide diabetes educational support at MMH. 2015 Update > We continued to engage our community outreach programs to assist us to implement education in our community this quarter. Advertisement weekly in the Catskill Mountain News was continued. Flyers introducing our diabetes education program were given to CVS and Millers Pharmacy to distribute to any individual just starting on a diabetes medication or renewing their diabetes medications. Arrangements were made at Freshtown Supermarket to set up a table there to offer supermarket tours and hand out literature on healthy eating. A table was set up at the Catskills Forest Festival and the Cauliflower Festival with Diabetes information. > We have had one in-house referral and one individual session this quarter. There is another individual session planned this week for a new onset gestational diabetic. We did get two referrals to the program but both individuals were not interested in attending classes. Plans for increasing community education continue. Mountainside Residential Center was contacted regarding the possibility of presenting an educational program at their facility. They were excited about the idea of a presentation and we will be following up with them to schedule a date. Prevention Agenda Focus Area: Increase access to high quality chronic disease preventive care and management in both clinical and community settings Community Health Needs Addressed: Diabetes 1. Goal: Increase screening rates for cardiovascular disease, diabetes and breast/cervical/colorectal cancers, especially among disparate populations. a. Objective: Increase the percentage of adults 18 years and older who had a test for high blood sugar or diabetes within the past three years by 5% from 58.8% (2011) to 61.7%. MMH Response: . By December 31, 2014, complete an evaluation for the ability to establish a diabetes education program led by a certified diabetes educator at MMH. . Collaborate with the HAHV Diabetes Education Center in Kingston to assess the feasibility of establishing a program 2015 Update > We continued to engage our community outreach programs to assist us to implement education in our community this quarter. Advertisement weekly in the Catskill Mountain News was continued. Flyers introducing our diabetes education program were given to CVS and Millers Pharmacy to distribute to any individual just starting on a diabetes medication or renewing their diabetes medications. Arrangements were made at Freshtown Supermarket to set up a table there to offer supermarket tours and hand out literature on healthy eating. A table was set up at the Catskills Forest Festival and the Cauliflower Festival with Diabetes information. > We have had one in-house referral and one individual session this quarter. There is another individual session planned this week for a new onset gestational diabetic. We did get two referrals to the program but both individuals were not interested in attending classes. Plans for increasing community education continue. Mountainside Residential Center was contacted regarding the possibility of presenting an educational program at their facility. They were excited about the idea of a presentation and we will be following up with them to schedule a date. Prevention Agenda Priority: Promote Mental Health/Prevent Substance Abuse Prevention Agenda Focus Area: Prevent Substance Abuse and other MEB disorders Prevention Agenda Focus Area: Strengthen Infrastructure across Systems Community Health Needs Addressed: Mental Health, Suicide Goal: Prevent suicides among youth and adults a. Objective: reduce the age adjusted suicide mortality by 10% to 5.9% per 100,000. 2. Goal: Strengthen infrastructure for mental, emotional, and behavioral (MEB) health promotion and MEB disorder prevention a. Objective: Strengthen training and technical assistance of primary care physicians, MEB health workforce and community leaders in evidence-based training, cultural sensitivity training, approaches to MEB disorder prevention and mental health promotion. MMH Response: . Collaborate with Delaware County to provide Emergency Department staff with Applied Suicide Intervention Skills Training (ASIST) and suicide first aid training for first responders. . Collaborate with HAHV to provide education for our staff in recognition and therapeutic approaches for behavioral health issues such as the "Practical Tips for Promoting and Maintaining Behavorial Wellness in Youth" program. . Continue to serve as a location for weekly mental health and drug addiction counseling services through the Delaware County Mental Health Department. . Provide information, resources and referrals related to depression/suicide prevention at our hospital health fairs and during public event attendance by ou
PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	MMH is committed to: > Providing access to quality healthcare services with compassion, dignity and respect for those we serve, particularly the poor and the underserved in our communities. > Caring for all persons, regardless of their ability to pay for services. > Assisting patients who cannot pay for part or all of the care they receive. > Balancing needed financial assistance for some patients with broader fiscal responsibilities in order to sustain viability and provide the quality and quantity of services for all who may need care in a community. In accordance with AHA recommendations, MMH has adopted the following guiding principles when handling the billing, collection and financial support functions for our patients: > Provide effective communications with patients regarding hospital bills > Make affirmative efforts to help patients apply for public and private financial support programs > Offer financial support to patients with limited means > Implement policies for assisting low-income patients in a consistent manner > Implement fair and consistent billing and collection practices for all patients with patient payment obligations MMH effectively communicates with patients regarding patient payment obligations. Financial counseling is provided to patients about their payment obligation and hospital bills. Information on hospital-based financial support policies and external programs that provide coverage for services are made available to patients during the pre-registration and registration processes and in response to patients seeking financial assistance. Information regarding the financial assistance is also provided by the onsite financial counseling staff in both inpatient and outpatient areas. Patient accounting also supports the financial counseling program by providing patients with information and applications while handling customer service calls. Our financial counselors and county Medicaid workers also provide guidance regarding the financial assistance program when necessary. Financial assistance information is available on the back of every hospital bill. Financial counselors, both internal staff and a paid external vendors, make affirmative efforts to help patients apply for public and private programs for which they may qualify and that may help them obtain and pay for healthcare services. The hospital has onsite representatives from Fidelis Insurance Company to help patients who are in need of insurance coverage navigate through the application process. The patient does not need to have an account with the hospital; they just have to be in a situation where they are in need of insurance coverage. Fidelis screens the patient to see which plan will fit them and they are certified to enroll the patients in many different insurance policies based on their insurance needs. Every effort is made to determine a patients eligibility prior to or at the time of admission or service. However, determination for financial support can be made during any stage of the patients stay after stabilization or collection cycle. MMH offers financial support to patients with limited means. This support is available to uninsured and underinsured patients who do not qualify for public programs or other assistance. Notification about financial assistance, including contact information, is available through the hospital website, hospital posters and flyers, financials assistance applications and hospital statements. MMH has established a written policy (Attachment A) for the billing, collection and support for patients with payment obligations. MMH makes every effort to adhere to the policy and is committed to implementing and applying the policy for assisting patients with limited means in a professional, consistent manner. MMH has educated staff members who work closely with patients (including those working in Patient Registration and Admitting, Financial Assistance, Customer Service, Billing and Collections) about these policies which have an emphasis on treating all patients with dignity and respect regardless of their insurance status or their ability to pay for services. All patient registration staff receive in-service training regarding the Financial Assistance Program. Patient Accounting also receives information about the program and how to handle patients seeking financial assistance. Financial counselors receive in depth training to handle financial assistance requests, process applications, and manage outcomes. HAHV provides several options for patients who either do not have insurance coverage or who have inadequate insurance coverage. Our many programs have been very successful and many have taken advantage of our offerings. Often utilized, financial counseling offers a patient the opportunity to speak to a financial counselor to determine what assistance can be accessible based on family income. As a result, more than $1,704,000 of charity care has been provided in 2015. Patients often shop around for the most economical healthcare and we offer price quotes. This allows the patient to know their financial obligation up front and understand the competitive pricing being offered. Despite millions of dollars of charity care distributed to needy patients every year, a consistent challenge is patients not utilizing the programs we offer. Often they dont want to provide the necessary financial information to initiate the financial aid process. Continual outreach and education is occurring to minimize confusion and improve utilization. HealthAlliance is committed to providing the best possible healthcare and is very sensitive to low-income patients ability to pay. Our call center offers the convenience of calling one telephone number for all billing inquiries regardless of which hospital the patient is calling about. We are staffed Monday through Friday, 8AM to 4PM. Performance in Providing Charity Care: As reviewed by our Finance Committee and our Board of Trustees annually, our charity care policy stipulates that no patient shall be denied care or treatment as a result of his/her inability to pay for such care. In those cases where non-insured patients who do not qualify for Medicaid or other federal programs, but do quality for charity care, these individuals shall have access to and do receive the appropriate level of care consistent with the Mission of the hospital and our adopted Charity Care policies. Attachment A HEALTH ALLIANCE OF THE HUDSON VALLEY POLICY AND /OR PROCEDURE STATEMENT PATIENT ACCOUNTING TITLE: Charity Care - Policy and Procedure EFFECTIVE DATE: October 1, 2009, January 2011, January 2012, March 2013, December 2013, February 2014, February 2015, July 2015, February 2016 DATES REVISED: Full replacement of Policies in existence prior to October 2009 for HealthAlliance Marys Ave Campus, HealthAlliance Hospital Broadway Campus and Margaretville Memorial Hospital DISTRIBUTED BY: Patient Accounting Department RESPONSIBLE DEPARTMENTS: Patient Accounting Department, Financial Counseling POLICY: HAHV recognizes the responsibility to provide access to quality health care services meeting the community's needs. Patients who present themselves for emergency or urgent care will not be turned away because of their inability to pay. Charity care (Financial Assistance) will not be made available for non-medically necessary services such as, but not limited to - cosmetic surgery, patient convenience items or elective procedures. The population that this policy will apply to is defined as patients residing in New York State. HAHVs Charity Care Program will be used in conjunction with the Uninsured Discount which is automatically applied to all patient accounts where a patient does not have hospital medical coverage through a third party or government payer. (Please see Uninsured Discount Policy for further clarification) Both charity care discounts and self-pay discounts are reported by HealthAlliance of the Hudson Valley as charity care. Charity care is defined as health care services provided at no charge or at a reduced charge to patients who do not have nor cannot obtain adequate financial resources or other means to pay for their care. This is in contrast to bad debt which is defined as a patient and/or guarantor who, having the financial resources to pay for health care services, has demonstrated by their actions an unwillingness to resolve a bill. Partial or full charity care will be based solely on ability to pay and will not be abridged on the basis of age, sex, race, creed, disability or national origin. PURPOSE: To establish guidelines for processing and approving Charity Care. SCOPE: The Financial Assistance Policy for HealthAlliance covers bills from the following areas: Any Hospital Bill from or associated with any of the following providers: HealthAlliance Marys Avenue Campus: 105 Marys Avenue, Kingston New York 845-338-2500 HealthAlliance Hospital Broadway Campus: 396 Broadway, Kingston, New York 8
PART VI, LINE 4 - COMMUNITY INFORMATION	Community Description HAHV is a multi-campus health care system consisting of HealthAlliance Hospitals Marys Ave and Broadway Campuses in Kingston and Healthalliance Senior Living Corp, a continuing-care retirement community, in New Paltz, both of Ulster County, as well as, MMH and Mountainside Residential Care Center, a skilled nursing facility, co-located on a single campus in Margaretville, in adjacent Delaware County. In an area which once had strong shipping and manufacturing industries that have since departed, healthcare is now one of the primary sectors and a significant employer that now forms the basis of our regional economy. HAHV defines its primary service area by a federal definition that consists of the top 75% of hospital discharges from the lowest number of contiguous zip-codes. Due to the geographical location of acute care hospitals affiliated with HAHV, there are two distinct primary service areas within Ulster and Delaware counties, though not encompassing all of each county. For operational and community need development, HAHV regards these two service areas as a single primary service area with predominant population in Ulster County. The PSA population in 2010 was 147,700 while the broader population for Ulster County in 2014 was 180,445 and 46,581 for Delaware County with populations concentrated in the cities of Kingston, New Paltz and Saugerties for Ulster County and the Village of Margaretville for Delaware County. Patients from adjacent counties also visit either the hospitals or one of our many outpatient locations for services that may not be available in their respective communities. Overall population for the primary service area will grow by .1% over the next 5 years, compared to the U.S. growth of 4.9%. However, the population of the region is aging rapidly, with a 12% growth rate for Pre Medicare and Medicare populations of seniors (Truven Health, Market Expert). These demographic changes, consistent with national trends, are one of the defining aspects of HealthAlliances future community health planning.
PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTH	2014-2016 Community Service Plan Development Public Participation & Assessment of Public Health Priorities HealthAlliance Hospitals, Ulster County As the largest employer in the region and the only multi-campus healthcare system in Ulster County, HAHV takes a leadership role in collaborating with county public health and community-based organizations to assess health risks through a Community Health Needs Assessment (CHNA) and implement health improvement strategies in the community. Beginning in January of 2013, Ulster County Departments of Health and Mental Health commenced the CHNA planning initiative with HealthAlliance to review state and federal requirements. Additional health care leaders were invited to participate in the CHNA planning process including: Ellenville Regional Hospital, The Institute for Family Health, Mid-Hudson Medical Group, Hudson River Health Care, Ulster Prevention Council and SUNY New Paltzs Center for Research Regional Education and Outreach (CRREO), contracted through Ulster County to develop the CHNA. Ensuing focus groups involved other organizations that represent a broad cross-section of the population that serve the chronically ill, low-income and minority populations in our service area; these include: Department of Social Services, United Way, Cornell Cooperative Extension, Planned Parenthood, health insurance payers, fitness centers, and others. On May 22, 2013, CRREO mediated a community wide focus group to determine the publics perception of health risk and the awareness level of available interventions. Demographic data and trends, state inpatient and outpatient hospitalization data, NYS DOH county risk assessment indicator data and community focus group findings were utilized to develop the CHNA. On September 10, 2013, another focus group session occurred to determine the prioritization of community health needs utilizing the Hanlon Method, also known as the Basic Priority Rating System. The Hanlon Method for Prioritizing Health Problems is advantageous when the desired outcome is an objective list of health priorities based on baseline data and specific criteria. After reviewing various sources of quantitative and qualitative data, health needs were identified as those that pose risks to our communitys wellbeing. Prioritized health needs are: 1. Tobacco Use Among Children; 2. Childhood Obesity; 3. Asthma Hospitalizations (Child); 4. Unplanned Pregnancy; 5. Tobacco Use Among Adults; 6. Suicide Deaths; 7. Cardiovascular Disease; 8. Adult Obesity; 9. Poor Mental Health (Adults); 10. Exclusive Breastfeeding; 11. Coronary Heart Disease Deaths; 12. Breast Cancer Deaths; 13. Motor Vehicle Crash Deaths; 14. Fall Hospitalizations 65+; 15. Lung Cancer Deaths; 16. Colorectal Cancer Although there are sixteen identified health needs, most can be categorized in broader terms within two NYS Prevention Agenda priorities. As a result, the collective choices were Prevent Chronic Disease, a priority that directly links with heart disease, obesity, tobacco use and cancer; and Promote Mental Health and Prevent Substance Abuse, a priority that directly links with poor mental health and suicide deaths in the community. Margaretville Memorial Hospital, Delaware County In March 2013, the CHNA and Implementation Strategy initiative began through preliminary discussions and data review with key county stakeholders under the leadership of the Delaware County Public Health Nursing Service and included representatives from MMH, OConnor Hospital, Tri-Town Hospital and Delaware Valley Hospital. Three additional meetings have been held with community representatives including: Delaware County Departments of Social Services, Office of the Aging, OConnor Hospital, Delaware Valley Hospital (both Critical Access Hospitals), SUNY Binghamton, representatives from The Women Infant & Childrens (WIC) Program, public school officials, emergency services, law enforcement and mental health professionals, as well as groups who service the elderly, low income, chronically ill, minority and underserved populations. A community focus group convened on May 22nd, 2013 was facilitated by Pamela Stewart Fahs, RN, DNS, Professor, Decker School of Nursing at State University of New York (SUNY), Binghamton University, Binghamton, New York, and consisted of different age and socioeconomic groups. Contacts were also made with community service centers, such as the WIC program and senior meals sites, to secure additional community input regarding the health care needs of Delaware County residents served by these organizations. Data and information that were reviewed included the 2013 Delaware Community Health Needs Assessment Plan, NYS Statewide Planning and Research Cooperative System (SPARCS) data, community focus group findings, Delaware County Indicators for Tracking Health Priorities, and New York State Office of Mental Health Quality Indicator Overview 5/1/2013. After reviewing various sources of quantitative and qualitative data, health needs were identified as those that pose risks to our communitys wellbeing or prevent from achieving it: Access to Health Care; Cancer; Coronary Artery Disease; Diabetes Heart Disease; Mental Health; Obesity; Suicide The priority health needs identified as a result of our collaboration were Prevent Chronic Disease and Promote Mental Health and Prevent Substance Abuse. Heart disease, coronary artery disease, cancer and diabetes were specified as the major chronic disease concerns in Delaware County with Obesity an underlying issue related to chronic disease. Mental, Emotional and Behavioral (MEB) health concerns focused on children, parenting, disease diagnosis and treatment, and the high addiction rates among a range of age groups and persons. Delaware County is 100% rural, thus access to healthcare services and providers are limited especially to low income and elderly persons, creating a disparity of access for this population. Some primary causes of difficult access include: distance to a provider, lack of public transportation and geographic location (mountainous and difficult driving terrain). Related to lack of health care professionals, the CHNA identified a need for professionals in mental health, family practice, womens health, dentists, home care services and social workers. identified a need for professionals in mental health, family practice, womens health, dentists, home care services and social workers.
PART VI, LINE 6 - AFFILIATED HEALTH CARE SYSTEM	Background HAHV is the parent company to affiliate members HealthAlliance Hospital: Marys Avenue campus, formerly Benedictine Hospital; Broadway Campus, formerly The Kingston Hospital; MMH, a rural critical access hospital; Mountainside Residential Care Center, a skilled nursing facility; and HealthAlliance Senior Living Corp., a continuing care retirement community. This integrated healthcare system is committed to providing quality and compassionate medical care for our patients, their families and our community. The consolidation of two acute care hospital campuses was a focus of HAHV when incorporating in 2008, responding directly to New York States Berger Commission mandate to form a corporate alliance between the formerly known Benedictine Hospital and HAHV Broadway Campus to bring down the costs of hospital-based care. In addition to service consolidation between the two Kingston Hospitals, HAHV also committed to streamlining operations and improving care at the other affiliate locations. Despite significant operational improvement and at the suggestion of NYS Department of Health, HealthAlliance joined in 2014 with the Westchester Medical Health Performing Provider System in the Delivery System Reform Incentive Payment (DSRIP) again seeking to transform healthcare delivery to a more effective and efficient model that will benefit Ulster County on many levels. In 2015, HAHV was engaged in active affiliate discussions with Westchester Medical Center.

Schedule H (Form 990) 2015

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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

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 on 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
directors, trustees, officers, including 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 on 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? ................

Yes

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

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

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

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on 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," on line 5a or 5b, describe in Part III.

For persons listed on 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," on line 6a or 6b, describe in Part III.

For persons listed on 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 on 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" on 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) 2015

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 on 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 in column(B) reported as deferred on 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)
1Sandra HoranChief Nursing Officer	(i) (ii)	0 ------------- 188,966	0 ------------- 0	0 ------------- 8,276	0 ------------- 4,787	0 ------------- 7,243	0 ------------- 209,272	0 ------------- 0
2David ScarpinoCEO	(i) (ii)	0 ------------- 470,443	0 ------------- 0	0 ------------- 9,564	0 ------------- 6,625	0 ------------- 14,953	0 ------------- 501,585	0 ------------- 0
3Robert SeidmanCAO 1/1/14 - 8/1/14	(i) (ii)	0 ------------- 0	0 ------------- 0	0 ------------- 166,663	0 ------------- 0	0 ------------- 10,778	0 ------------- 177,441	0 ------------- 0
4Frank Ehrlich MDChief Medical Officer	(i) (ii)	0 ------------- 255,977	0 ------------- 0	0 ------------- 42,640	0 ------------- 3,289	0 ------------- 7,739	0 ------------- 309,645	0 ------------- 0
5John FinchChief Inf. & Comm. Officer	(i) (ii)	0 ------------- 207,594	0 ------------- 0	0 ------------- 8,613	0 ------------- 11,754	0 ------------- 18,850	0 ------------- 246,811	0 ------------- 0
6Joshua RatnerChief Strategy Officer	(i) (ii)	0 ------------- 212,919	0 ------------- 0	0 ------------- 4,808	0 ------------- 5,581	0 ------------- 18,276	0 ------------- 241,584	0 ------------- 0
7Steven HaasCFO 1/1/15-11/12/15	(i) (ii)	0 ------------- 219,721	0 ------------- 0	0 ------------- 34,640	0 ------------- 5,568	0 ------------- 14,193	0 ------------- 274,122	0 ------------- 0
8Kathleen LunneyCNO 1/1/14 - 8/1/14	(i) (ii)	0 ------------- 0	0 ------------- 0	0 ------------- 113,199	0 ------------- 0	0 ------------- 0	0 ------------- 113,199	0 ------------- 0
9Eileen KingPhysicians Assistant	(i) (ii)	201,904 ------------- 0	0 ------------- 0	1,041 ------------- 0	240 ------------- 0	17,570 ------------- 0	220,755 ------------- 0	0 ------------- 0
10David LundquistCEO thru 7/25/2013	(i) (ii)	0 ------------- 0	0 ------------- 0	0 ------------- 347,638	0 ------------- 0	0 ------------- 7,984	0 ------------- 355,622	0 ------------- 0
11Joseph MarsicoveteChief Operating Officer	(i) (ii)	0 ------------- 283,229	0 ------------- 0	0 ------------- 7,490	0 ------------- 6,625	0 ------------- 7,242	0 ------------- 304,586	0 ------------- 0

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

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

Return Reference	Explanation
Schedule J, Part I, line 3	THE ORGANIZATION'S TOP MANAGEMENT OFFICIALS RECEIVED THEIR COMPENSATION FROM A RELATED ORGANIZATION, WHICH USED ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE TOP MANAGEMENT OFFICIALS' COMPENSATION.
Schedule J, Part I, Line 4a	DAVID LUNDQUIST RECEIVED SEVERANCE PAYMENTS OF $355,622 IN 2015 FROM A RELATED ORGANIZATION. KATHLEEN LUNNEY RECEIVED SEVERANCE PAYMENTS OF $113,199 FROM A RELATED ORGANIZATION. ROBERT SEIDMAN RECEIVED SEVERANCE PAYMENTS OF $177,441 IN 2015 FROM A RELATED ORGANIZATION.

Schedule J (Form 990) 2015

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

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) 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 Benefiting 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) 2015

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) Paul Llobet MD	Current Trustee	166,674	On-Call Physician Contract		No

Part V

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

Return Reference	Explanation
Part V	PAUL LLOBET, MD IS A CURRENT TRUSTEE ON THE MARGARETVILLE MEMORIAL HOSPITAL BOARD OF DIRECTORS AND CHIEF MEDICAL OFFICER FOR HEALTHALLIANCE. DR. LLOBET OWNS A MEDICAL PRACTICE, LLOBET MEDICAL, THAT HAS A CONTRACT WITH THE HOSPITAL TO PROVIDE PHYSICIAN ON-CALL COVERAGE TO HOSPITAL PATIENTS. LLOBET MEDICAL WAS PAID $166,674 BY THE HOSPITAL FOR THESE SERVICES IN 2015.

Schedule L (Form 990 or 990-EZ) 2015

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

Return Reference	Explanation
FORM 990, PART VI, LINE 6	HEALTH ALLIANCE, INC., WHICH IS A TAX-EXEMPT ORGANIZATION, IS THE SOLE CORPORATE MEMBER OF MARGARETVILLE MEMORIAL HOSPITAL.
FORM 990, PART VI, LINE 7A	HEALTH ALLIANCE, INC., THE SOLE CORPORATE MEMBER OF MARGARETVILLE MEMORIAL HOSPITAL, HAS THE POWER TO ELECT ONE OR MORE MEMBERS OF THE LOCAL GOVERNING BODY OF THE HOSPITAL.
FORM 990, PART VI, LINE 7B	ALL DECISIONS MADE AT THE LOCAL BOARD LEVEL OF MARGARETVILLE MEMORIAL HOSPITAL, OTHER THAN THOSE RELATED TO QUALITY ASSURANCE AND BUILDING & GROUNDS, ARE SUBJECT TO APPROVAL BY MEMBERS OF HEALTH ALLIANCE, INC. BOARD OF TRUSTEES. THESE DECISIONS INCLUDE ELECTION AND REMOVAL OF MEMBERS OF THE LOCAL GOVERNING BODY, APPOINTMENT / REMOVAL OF CORPORATE OFFICERS, APPROVAL OF BYLAW AMENDMENTS, REVIEW OF ANNUAL CAPITAL AND OPERATING BUDGETS, REVIEW AND / OR MODIFICATION OF ANY CON APPLICATIONS, REVIEW INCURRENCE OF DEBT AND DEVELOP AND IMPLEMENT JOINT MEDICAL STAFF APPOINTMENTS.
FORM 990, PART VI, LINE 11B	THE FINANCE DIRECTOR AND CFO UNDERTAKE A DETAILED REVIEW OF THE 990. IN ADDITION, SELECT BOARD MEMBERS UNDERTAKE A REVIEW OF THE ORGANIZATION'S FORM 990 AND THEN REVIEW WITH THE CFO ANY COMMENTARY, OBSERVATIONS, AND RECOMMENDATIONS, AS APPROPRIATE.
FORM 990, PART VI, LINE 12C	ANNUAL COMPLIANCE QUESTIONNAIRES ARE REQUIRED TO BE SIGNED BY ALL OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES. ALL QUESTIONNAIRES ARE RETURNED TO THE CORPORATE COMPLIANCE OFFICER FOR REVIEW AND FILING. IF A CONFLICT IS NOTED, THE OFFICER REPORTS SAID CONFLICT TO THE CEO AND BOARD OF DIRECTORS FOR DISCUSSION AND RESOLUTION. ONCE A RESOLUTION IS MET, THE OFFICER INSTRUCTS THE INDIVIDUAL WHO COMPLETED THE QUESTIONNAIRE OF A FINAL OUTCOME AND ACTION PLAN IF APPLICABLE.
FORM 990, PART VI, LINE 19	UPON REQUEST, THE ORGANIZATION WILL MAKE AVAILABLE ONLY THOSE DOCUMENTS REQUIRED TO BE DISCLOSED UNDER THE PUBLIC INSPECTION LAWS.
FORM 990, PART XI, LINE 9	CHANGE IN INTEREST IN NA OF MARGARETVILLE HEALTH FDN . . . . $ 6,208 TRANSFER TO AFFILIATE. . . . . . . . . . . . . . . . . . . . .$ 656

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)MARGARETVILLE HEALTH FOUNDATION 42084 STATE HIGHWAY 28 MARGARETVILLE,NY12455 26-1998454	SUPPORT FDN	NY	501(c)(3)	11A	MMH	Yes
(2)MARGARETVILLE NURSING HOME INC 42158 STATE HIGHWAY 28 MARGARETVILLE,NY12455 22-3143565	NURSING FACIL	NY	501(c)(3)	9	MMH	Yes
(3)HEALTHALLIANCE HOSPITAL BROADWAY CAMPUS 396 BROADWAY KINGSTON,NY12401 14-1349558	EXEMPT HOSP	NY	501(c)(3)	3	HEALTH ALLIA		No
(4)HEALTH ALLIANCE INC 741 GRANT AVENUE LAKE KATRINE,NY12449 26-1850453	SUPPORT	NY	501(c)(3)	11A	NA		No
(5)FASC FOUNDATION 741 GRANT AVENUE LAKE KATRINE,NY12449 26-4201295	SUPPORT FDN	NY	501(c)(3)	7	BROADWAY CAM		No
(6)HEALTHALLIANCE HOSPITAL MARY'S AVE CAMPU 105 MARYS AVENUE KINGSTON,NY12401 14-1338470	EXEMPT HOSP	NY	501(c)(3)	3	HEALTH ALLIA		No
(7)HEALTHALLIANCE SENIOR LIVING CORP 396 BROADWAY KINGSTON,NY12401 30-0164277	CCRC	NY	501(c)(3)	9	HEALTH ALLIA		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2015

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) ULSTER RADIATION & ONCOLOGY CENTER 117 MARYS AVE KINGSTON NY KINGSTON,NY12401	RADIATION ONC	NY	NA	0	0		No	0		No
(2) COMPREHENSIVE SUPPORT SERVICES LLC 45 PINE GROVE AVE KINGSTONNY KINGSTON,NY12401 14-1805027	DIAGNOSTIC IM	NY	NA	0	0		No	0		No
(3) MULTI PROVIDER SUPPORT SERVICES LLC 105 MARYS AVE KINGSTON NY KINGSTON,NY12401 14-1811898	OFFICE SUPPOR	NY	NA	0	0		No	0		No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) KINGSTON REGIONAL HEALTH CARE ENTERPRISE 396 BROADWAY KINGSTON,NY12401 16-1514994	RE Investment	NY	BROADWAY CAMPUS	C CORP	0	0		No
(2) MID HUDSON PHYSICIANS PC 396 BROADWAY KINGSTON,NY12401 20-3564769	MEDICAL SVCS	NY	BROADWAY CAMPUS	C CORP	0	0		No

Schedule R (Form 990) 2015

Page 3

Part V

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

Yes

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

Yes

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

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

Yes

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

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) MARGARETVILLE NURSING HOME INC	O	224,062	COST
(2) MARGARETVILLE NURSING HOME INC	P	50,000	COST
(3) MARGARETVILLE NURSING HOME INC	Q	82,431	COST

Schedule R (Form 990) 2015

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2015

Page 5

Part VII

Supplemental Information

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

Return Reference	Explanation

Schedule R (Form 990) 2015

Additional Data

Software ID:
Software Version:

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,175,688	1,752,614
9	Program service revenue (Part VIII, line 2g) .........	10,317,412	9,248,871
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	63,943	75,458
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	509,948	535,616
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	12,066,991	11,612,559
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	6,351,766	6,712,242
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	6,345,600	6,689,303
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	12,697,366	13,401,545
19	Revenue less expenses. Subtract line 18 from line 12.......	-630,375	-1,788,986
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	11,720,057	9,166,004
21	Total liabilities (Part X, line 26).............	8,861,176	8,212,354
22	Net assets or fund balances. Subtract line 21 from line 20.....	2,858,881	953,650

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 10,677,719 including grants of $ ) (Revenue $ 9,248,871 )
	Margaretville Hospital is a voluntary, not for profit corporation providing acute health care services to residents and visitors to the Catskill region. Margaretville Memorial Hospital recorded 1,578 patient days, 4,187 Emergency Room visits, 220 outpatient surgeries, 212 discharges and 159 infusion therapies.

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 expenses10,677,719

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	563,476	2,761,991	224,155

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e	1,383,518

f	All other contributions, gifts, grants, and similar amounts not included above		1f	369,096

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		1,752,614

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE IMMEDIATE ACCESS TO HIGH QUALITY MEDICAL CARE AND DIAGNOSTIC TESTING SERVICES TO MEDICALLY UNDERSERVED AREAS IN THE CATSKILL MOUNTAINS.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	16
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	13
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	157
6	Total number of volunteers (estimate if necessary) .............	6	13
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

			Business Code
2a	NET PATIENT SERV. REV	621300	9,658,136	9,658,136
b	BAD DEBT EXPENSE	621300	-409,265	-409,265
c
d
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			9,248,871

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			75,458			75,458
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		62,302
b	Less: rental expenses		13,628
c	Rental income or (loss)	0	48,674
d	Net rental income or (loss)......			48,674			48,674
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss).....			0
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a		38,890
b	Less: direct expenses ...b		13,506
c	Net income or (loss) from fundraising events..			25,384			25,384
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
	a		29,041
b	Less: cost of goods sold ..b		22,427
c	Net income or (loss) from sales of inventory..			6,614
Business Code			Miscellaneous Revenue
11a	MISCELLANEOUS INCOME		900099	380,019			380,019
b	AMBULANCE INCOME		621910	74,925			74,925
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			454,944
12	Total revenue. See Instructions......			11,612,559	9,248,871		604,460

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0			0
7	Other salaries and wages	5,321,975	4,199,214	1,122,761
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	18,661	14,854	3,807
9	Other employee benefits .......	967,491	770,753	196,738
10	Payroll taxes ...........	404,115	321,653	82,462
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	4,212		4,212
c	Accounting ...........	59,554		59,554
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	0
12	Advertising and promotion ....	0
13	Office expenses .......	359,175	186,158	173,017
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	294,957	283,894	11,063
17	Travel ............	26,353	17,252	9,101
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	22,404	20,901	1,503
20	Interest ...........	139,152		139,152
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	2,302,864	2,302,864
23	Insurance ...	84,758		84,758
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	PURCHASED SERVICES	2,424,559	1,677,343	747,216
b	SHARED SERVICES	65,586		65,586
c	MEDICAL SUPPLIES	890,849	882,160	8,689
d	DUES & SUBSCRIPTIONS	14,880	673	14,207
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	13,401,545	10,677,719	2,723,826	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			405,101	1	429,384
2	Savings and temporary cash investments .........			183,747	2	0
3	Pledges and grants receivable, net ......			224,362	3	182,396
4	Accounts receivable, net .............			898,488	4	946,561
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net ....			0	7	0
8	Inventories for sale or use ........			209,942	8	210,747
9	Prepaid expenses and deferred charges ......			227,971	9	144,607
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,405,595
b	Less: accumulated depreciation	10b	18,199,310	4,755,772	10c	3,206,285
11	Investments—publicly traded securities .			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			4,814,674	15	4,046,024
16	Total assets. Add lines 1 through 15 (must equal line 34)...			11,720,057	16	9,166,004

17	Accounts payable and accrued expenses .....	2,048,498	17	2,149,936
18	Grants payable ...	0	18	0
19	Deferred revenue .........	2,165,211	19	1,545,120
20	Tax-exempt bond liabilities .........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	324,514	23	181,303
24	Unsecured notes and loans payable to unrelated third parties ..	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	4,322,953	25	4,335,995
26	Total liabilities. Add lines 17 through 25..	8,861,176	26	8,212,354

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	2,930,477	27	1,031,454
28	Temporarily restricted net assets ...........	150,904	28	144,696
29	Permanently restricted net assets	-222,500	29	-222,500
	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 ...........	2,858,881	33	953,650
34	Total liabilities and net assets/fund balances ........	11,720,057	34	9,166,004