TY 2014 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) Louis Jenkins Jr........................................................................ Chairman	1.0 .......................0.0	X	X	0	0
(2) Shelly Culhane........................................................................ Vice Chair	1.0 .......................0.0	X	X	0	0
(3) Richard Winkler........................................................................ Secretary/Treasurer	1.0 .......................0.0	X	X	0	0
(4) Dianna Abney MD........................................................................ Director	1.0 .......................0.0	X		0	0
(5) Khadar Baig MD........................................................................ Director	1.0 .......................0.0	X		0	0
(6) Wayne Barnes........................................................................ Director	1.0 .......................0.0	X		0	0
(7) Michael Cady........................................................................ Director	1.0 .......................0.0	X		0	0
(8) Anthony Covington........................................................................ Director	1.0 .......................0.0	X		0	0
(9) B Larry Jenkins Jr MD........................................................................ Director	1.0 .......................0.0	X		0	0
(10) Sara A Middleton........................................................................ Director	1.0 .......................0.0	X		0	0
(11) Ashvin J Patel MD........................................................................ Director	1.0 .......................0.0	X		0	0
(12) Joseph Slater........................................................................ Director	1.0 .......................0.0	X		0	0
(13) Richard Ferraro MD........................................................................ Chief of Staff	1.0 .......................0.0	X		0	0
(14) Joel Sewchand MD........................................................................ Chief of Staff (THRU 12/31/14)	1.0 .......................0.0	X		0	0
(15) Candice Quinn Kelly........................................................................ Ex-Officio/Director	1.0 .......................0.0	X		0	0
(16) Jon P Burns........................................................................ Ex-Officio/Director	1.0 .......................49.0	X		591,209	20,269
(17) John W Ashworth III........................................................................ Ex-Officio/Dir. (thru 1/31/15)	1.0 .......................49.0	X		597,210	21,095

(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) Robert Chrencik........................................................................ Ex-Officio/Director	1.0 .......................49.0	X				0	6,881,071	21,095
(19) Noel Cervino........................................................................ Ex-Officio/President & CEO	40.0 .......................10.0	X	X			881,764	0	16,975
(20) Erik Boas........................................................................ Chief Financial Officer	40.0 .......................10.0		X			405,276	0	8,169
(21) Mark R Dumais........................................................................ Chief Medical Officer	40.0 .......................0.0			X		406,517	0	55,136
(22) Dana Levy........................................................................ Chief Nursing Officer	40.0 .......................0.0			X		221,998	0	30,464
(23) Paul Blackwood........................................................................ VP Planning	40.0 .......................0.0			X		214,558	0	34,226
(24) William Grimes........................................................................ VP Ancilliary Services	40.0 .......................0.0			X		196,399	0	20,767
(25) Stacey Cook........................................................................ VP Human Resources	40.0 .......................0.0				X	207,763	0	38,799
(26) Marilyn Gregory........................................................................ RN	40.0 .......................0.0				X	190,924	0	7,545
(27) Katherine Middleton........................................................................ RN	40.0 .......................0.0				X	185,666	0	13,465
(28) Eugene Suwandhi MD........................................................................ pediatric hospitalist phys.	40.0 .......................0.0				X	173,967	0	7,553
(29) Gabriel Abiola........................................................................ Pharmacist Manager	40.0 .......................0.0				X	159,900	0	21,968

(A) Name and business address	(B) Description of services	(C) Compensation
Maryland Inpatient Care Specialists, 6934 Aviation Blvd Ste B GLEN BURNIE,MD21061	Physicians	1,300,000
Southern MD Pulmonary Critical Ca, 4475 Regency Place Ste 303 WHITE PLAINS,MD20695	Respiratory	1,091,196
Healogics Wound Care, 3087 Momentum Place CHICAGO,IL60689	Wound Care	750,503
NDG Communications Inc, 105 Centennial Str Ste K LA PLATA,MD20646	Marketing	625,406
ROI Eligibility Services Corp, 1920 Greenspring Dr Ste 200 TIMONIUM,MD21094	PT Acctg Purc Svc	606,799
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 26

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	52,129	52,129
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ....	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. 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 ....	3,244,732	628,515	2,616,217
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages ....	39,706,094	35,879,687	3,826,407
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,743,629	1,482,085	261,544
9	Other employee benefits .......	6,202,687	5,272,284	930,403
10	Payroll taxes ...........	3,150,861	2,678,232	472,629
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	459,255		459,255
c	Accounting ...........	18,631		18,631
d	Lobbying ...........	4,869		4,869
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) ....	7,375,295	6,269,001	1,106,294
12	Advertising and promotion ....	344,943	293,202	51,741
13	Office expenses .......	3,538,121		3,538,121
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	3,300,029	2,805,025	495,004
17	Travel ............	52,433	44,568	7,865
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	188,438	160,172	28,266
20	Interest ...........	2,791,954	2,373,161	418,793
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	4,197,028	3,567,474	629,554
23	Insurance ..............	45,758	38,894	6,864
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	SUPPLIES AND DRUGS	16,586,737	16,586,737
b	PURCHASED SERVICES	13,800,506	11,730,430	2,070,076
c	BAD DEBT	8,221,156	8,221,156
d	EQUIPMENT SERVICE CONTRACTS	1,674,918	1,423,680	251,238
e	All other expenses	2,033,249	1,728,261	304,988
25	Total functional expenses. Add lines 1 through 24e	118,733,452	101,234,693	17,498,759	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
	1	Cash–non-interest-bearing .............	0	1	0
2	Savings and temporary cash investments .........	21,245,679	2	20,680,284
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	7,988,094	4	7,944,863
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	1,586,764	8	1,675,458
9	Prepaid expenses and deferred charges ..........	205,947	9	319,972
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	110,981,019
b	Less: accumulated depreciation .....	10b	40,656,610	70,840,719	10c	70,324,409
11	Investments—publicly traded securities ..........	20,457,797	11	20,278,998
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 ...........	35,851,511	15	28,724,314
16	Total assets. Add lines 1 through 15 (must equal line 34)......	158,176,511	16	149,948,298
	17	Accounts payable and accrued expenses .........	13,949,677	17	13,697,614
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
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 ..	19,523,669	23	18,484,229
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....................	74,057,476	25	71,382,025
26	Total liabilities. Add lines 17 through 25.........	107,530,822	26	103,563,868
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	50,553,092	27	46,291,833
28	Temporarily restricted net assets ...........	92,597	28	92,597
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	50,645,689	33	46,384,430
34	Total liabilities and net assets/fund balances ........	158,176,511	34	149,948,298

- 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.
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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

2014

Open to Public
Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box 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 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2014

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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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 2014 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2013 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2014. 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—2013. 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—2014. 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—2013. 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) 2014

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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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 2014 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2013 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2014 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2013 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2014. 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—2013. 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) 2014

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 (a) its supported organizations; (b) individuals that are part of the charitable class benefited by one or more of its supported organizations; or (c) 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 IRC 4958(c)(3)(C)), a family member of a substantial contributor, or a 35-percent controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .

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

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 9(a)) 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 9(a)) 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 IRC 4943 because of IRC 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer b 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

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

Schedule A (Form 990 or 990-EZ) 2014

Page 5

Part IV

Supporting Organizations (continued)

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, (1) a written notice describing the type and amount of support provided during the prior tax year, (2) a copy of the Form 990 that was most recently filed as of the date of notification, and (3) 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) 2014

Page 6

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

1. 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
7	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) 2014

Page 7

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 2014 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-2014	(iii) Distributable Amount for 2014
1 Distributable amount for 2014 from Section C, line 6
2 Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2014:
a From 2009.......X
b From 2010.......X
c From 2011.......X
d From 2012.......X
e From 2013.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2014 distributable amount
i Carryover from 2009 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2014 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2014 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2015. Add lines 3j and 4c.
8 Breakdown of line 7:
a From 2010.......X
b From 2011.......X
c From 2012.......X
d From 2013.......
e From 2014.......

Schedule A (Form 990 or 990-EZ) (2014)

Schedule A (Form 990 or 990-EZ) 2014

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) 2014

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

2014

Open to Public
Inspection

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

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

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

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

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

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" to Form 990, Part IV, Line 5 (Proxy Tax) (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

Civista Medical Center Inc

Employer identification number

52-0445374

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2014

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) 2011	(b) 2012	(c) 2013	(d) 2014	(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) 2014

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

4,869

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

4,869

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
Lobbying Activities	Schedule C, Part II-B, Line 1i The organization does not engage in any direct lobbying activities. The organization pays membership dues to the Maryland Hospital Association (MHA) and the American Hospital Association (AHA). MHA and AHA engage in many support activities including lobbying and advocating for their member hospitals. The MHA and AHA reported that 4.80% and 22.80% of member dues were used for lobbying purposes and as such, the organization has reported this amount on Schedule C Part II-B as lobbying activities.

Return Reference

Explanation

Lobbying Activities

Schedule C, Part II-B, Line 1i The organization does not engage in any direct lobbying activities. The organization pays membership dues to the Maryland Hospital Association (MHA) and the American Hospital Association (AHA). MHA and AHA engage in many support activities including lobbying and advocating for their member hospitals. The MHA and AHA reported that 4.80% and 22.80% of member dues were used for lobbying purposes and as such, the organization has reported this amount on Schedule C Part II-B as lobbying activities.

Schedule C (Form 990 or 990EZ) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

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

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

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

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate 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" to Form 990, Part IV, line 7.

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2014

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

Did the organization include an amount on Form 990, Part X, line 21, 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" to Form 990, Part IV, line 10.

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................	75,134,563	17,208,521	57,926,042
c	Leasehold improvements ............	498,563	292,665	205,898
d	Equipment ................	35,113,499	23,155,424	11,958,075
e	Other .................	234,394		234,394
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				70,324,409

Schedule D (Form 990) 2014

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' to 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
Other








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

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' to 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









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

Part IX

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

(a) Description				(b) Book value
(1) SECURITY DEPOSITS				11,473
(2) OTHER CURRENT RECEIVABLES				665,753
(3) INV. CHES POTOMAC HEALTHCARE				3,353,172
(4) OTHER ASSETS				19,619,520
(5) PHYSICIAN LOANS				134,136
(6) INVESTMENT MARYLAND ECARE				10,000
(7) ECONOMIC INTEREST- NET ASSETS				4,930,260


Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				28,724,314

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes		0
ADVANCES FROM THIRD PARTIES		4,161,675
ACCRUED PENSION COSTS		6,702,525
DUE TO AFFILIATES		52,689,467
LEASE LIABILITIES		457,331
MALPRACTICE IBNR		739,274
OTHER LIABILITIES		6,631,753



Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		71,382,025
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) 2014

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to 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' to 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
Liability for Uncertain Tax Position (ASC 740)	Schedule D, Part X, Line 2 THE ORGANIZATION IS A SUBSIDIARY OF THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM CORPORATION (THE CORPORATION). THE CORPORATION ADOPTED THE PROVISIONS OF ASC 740, ACCOUNTING FOR UNCERTAINTY IN THE INCOME TAXES (FIN 48) ON JULY 1, 2007. THE FOOTNOTE RELATED TO ASC 740 IN THE CORPORATION'S AUDITED FINANCIAL STATEMENTS IS AS FOLLOWS: THE CORPORATION FOLLOWS A THRESHOLD OF MORE-LIKELY-THAN-NOT FOR RECOGNITION AND DERECOGNITION OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. MANAGEMENT DOES NOT BELIEVE THAT THERE ARE ANY UNRECOGNIZED TAX BENEFITS THAT SHOULD BE RECOGNIZED.

Return Reference

Explanation

Liability for Uncertain Tax Position (ASC 740)

Schedule D, Part X, Line 2 THE ORGANIZATION IS A SUBSIDIARY OF THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM CORPORATION (THE CORPORATION). THE CORPORATION ADOPTED THE PROVISIONS OF ASC 740, ACCOUNTING FOR UNCERTAINTY IN THE INCOME TAXES (FIN 48) ON JULY 1, 2007. THE FOOTNOTE RELATED TO ASC 740 IN THE CORPORATION'S AUDITED FINANCIAL STATEMENTS IS AS FOLLOWS: THE CORPORATION FOLLOWS A THRESHOLD OF MORE-LIKELY-THAN-NOT FOR RECOGNITION AND DERECOGNITION OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. MANAGEMENT DOES NOT BELIEVE THAT THERE ARE ANY UNRECOGNIZED TAX BENEFITS THAT SHOULD BE RECOGNIZED.

Schedule D (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the TreasuryInternal Revenue Service

Hospitals

Complete if the organization answered "Yes" to 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

2014

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

If the organization used factors other than FPG in determining eligibility, describe in Part VI the 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? ......

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	1,400,571		1,400,571	1.270 %
b	Medicaid (from Worksheet 3, column a) ....
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	1,400,571		1,400,571	1.270 %
Other Benefits		742,003		742,003	0.670 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	742,003		742,003	0.670 %
f	Health professions education (from Worksheet 5) ..	502,991		502,991	0.460 %
g	Subsidized health services (from Worksheet 6) ..	9,089,619	4,951,905	4,137,714	3.740 %
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	58,611		58,611	0.050 %
j	Total. Other Benefits ..	10,393,224	4,951,905	5,441,319	4.920 %
k	Total. Add lines 7d and 7j .	11,793,795	4,951,905	6,841,890	6.190 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2014

Schedule H (Form 990) 2014

Page

Part II

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

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	105	105
3	Community support	104,630	104,630	0.090 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	11,773	11,773	0.010 %
7	Community health improvement advocacy	735	735
8	Workforce development	36,794	36,794	0.030 %
9	Other
10	Total	154,037	154,037	0.130 %

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. ......

5,959,787

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).....

49,198,261

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

48,003,359

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

1,194,902

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) 2014

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	Civista Medical Center Inc 5 Garrett Avenue La Plata,MD20646 www.charlesregional.org 08-001	X	X	X

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	Civista Medical Center Inc
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 15

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

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

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): http://www.charlesregional.org/siteasset

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 15

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

Yes

If "Yes" (list url): http://www.charlesregional.org/siteasset

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

12b

If "Yes" to 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) 2014

Page

Part VFacility Information (continued)

	Civista Medical Center Inc
Name of hospital facility or letter of facility reporting group

Yes

Financial Assistance Policy (FAP)

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 200.%
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): http://www.charlesregional.org

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

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

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) 2014

Page

Part VFacility Information (continued)

	Civista Medical Center Inc
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized third 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 18. (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) 2014

Page

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
FINANCIAL ASSISTANCE POLICY	Schedule H, Part V, Section B In compliance with the new IRC Section 501(r) regulations Civista Medical Center is currently in the process of updating their Financial ASsistance Policy to ensure its compliance with IRS regulations. Input from Individuals Representing the Community Schedule H, Part V, Section B, Line 5 Civista Medical Center DBA University of Maryland Charles Regional Medical Center (CRMC) completed the Community Health Needs Assessment CHNA) in FY 2015. This process involved the following people: PHCC Executive Committee: Noel A. Cervino CEO Civista Health (CRMC) Dr. Devadason Health Officer CC Health Department (CCDOH) Dr. Brad Gottfried President College of Southern Maryland (CSM) Jim Richmond Superintendent Charles County Public Schools PHCC Steering Committee: Joyce Riggs Dir., Community Dev./ Planning Civista (CRMC) Fay Reed, RN Deputy Health Officer CCDOH William Leebel Public Information Officer CCDOH Linda Smith Project Coordinator CSM Tanisha Saunders Coordinator of Integrated Student Services CCPS Amber Starn, MPH Epidemiologist (Contract) Civista (CRMC) Partnerships for a Healthier Charles County: Civista Medical Center Civista Health, Board Of Directors Charles County Department of Health University of Maryland Clinical Trials Program Bel Alton Alumni Community Development Association Charles County Department of Community Services, Transportation Tri County Council for Southern Maryland Ministers Alliance of Charles County Charles County Department of Social Services Maryland Foundation for Quality Healthcare Health Partners Clinic Greater Baden FQHC Shiloh Community United Methodist Church Charles County Nursing and Rehabilitation Center Alzheimers Association Center for Children Chesapeake Potomac Home Health Agency College of Southern Maryland Charles County Department of Aging Priority Partners Big Brothers/Big Sisters Community Hispanic Advocates Black Leadership Council for Excellence Young Researchers Community Project Pinnacle Center (Mental Health) Hospice of Charles County Breast Cancer Support Advocates Charles County Public Schools School Nurses Charles County Commissioners Charles County Emergency Services Charles County Sheriffs Office So. MD Delegation Charles County Community Foundation Community Physicians Charles County Fire and Rescue Board Lifestyles, Inc. (Homeless) The plan was presented and approved by the Board of Directors on 01/28/2015.
Needs Not Addressed By the Most Recently Conducted CHNA	Schedule H, Part V, Section B, Line 11 All the primary needs outlined in the Community Health Needs Assessment are being addressed and funded by Civista Regional Medical Center either directly (i.e., OB Clinic, Physician Recruitment) or through partnerships with other organizations (i.e., Childhood Obesity Program, Fetal Infant Mortality). Policy to ensure its compliance with IRS regulations.
Individuals Eligible for Financial Assistance	Schedule H, Part V, Section B, Line 22D All patients are charged state regulated rates regardless of their ability to pay.
Individuals Eligible for Financial Assistance	Schedule H, Part V, Section B, Line 24 The State of Maryland is a unique State in regard to the provision of health care services and their related charges by hospitals. All hospital charges processed to all Payors, including Governmental Payors, are set through Marylands Health Services Cost Commission. Accordingly, all Hospital charges are NOT gross charges as defined by the IRS under Internal Revenue Code section 501(r)(5)(B).

Schedule H (Form 990) 2014

Page

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) 2014

Page

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
Related Organization Report	Schedule H, Part I, Line 6a AN ANNUAL COMMUNITY BENEFIT REPORT IS PREPARED FOR EACH FISCAL YEAR ENDING JUNE 30. THIS REPORT IS SUBMITTED TO THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC), A STATE REGULATORY AGENCY, BY DECEMBER 31 OF EACH YEAR. IN ADDITION, THE ANNUAL COMMUNITY BENEFIT REPORT IS AVAILABLE UPON REQUEST AT THE ENTITY'S CORPORATE OFFICES.
Cost Attributable to a Physical Clinic	Schedule H, Part I, Line 7 Marylands regulatory system creates a unique process for hospital payment that differs from the rest of the Nation. The Health Services Cost Review Commission (HSCRC) determines payment through a rate setting process and All Payors, including Governmental Payors, pay the same amount for the same services delivered at the same hospital. Marylands unique All Payor system includes a method for referencing uncompensated care in each Payors rates, which does not enable Maryland hospitals to breakout any offsetting revenue related to uncompensated care. Schedule H, Part I, Line 7B, Columns (C) through (F) MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE. COMMUNITY BENEFIT EXPENSES ARE EQUAL TO MEDICAID REVENUES IN MARYLAND, AS SUCH, THE NET EFFECT IS ZERO. ADDITIONALLY, NET REVENUES FOR MEDICAID SHOULD REFLECT THE FULL IMPACT ON THE HOSPITAL OF ITS SHARE OF THE MEDICAID ASSESSMENT. SCHEDULE H, PART I, LINE 7F COLUMN (C) & (D) MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR REFERENCING UNCOMPENSATED CARE IN EACH PAYORS' RATES, WHICH DOES NOT ENABLE MARYLAND HOSPITALS TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE.
Community Building Activities	Schedule H, Part II As the only hospital serving Charles County, Maryland, University of Maryland Charles Regional Medical Center (UM CRMC) supports programs and activities where the hospital's expertise and resources can influence the fundamental issues that affect the health of the community. UM CRMC supports economic development of the community through leadership participation in organizations such as the Chamber of Commerce, Economic Development Commission, Leadership Southern Maryland, and the Tri-County Council of Southern Maryland. UM CRMC participates in many County, State and Region-wide Emergency Preparedness planning activities and drills with our community partners such as Emergency Services, Fire and Rescue, Department of Health, County Government, FEMA and MEMA. This serves to ensure that in the event of a disaster, the hospital is ready to support and care for our community. Hospital Administration participates in healthcare workforce development by serving on committees such as the Charles County Commissioner's healthcare taskforce and support of College of Southern Maryland Nursing and Allied Health programs. In addition, UM CRMC participates and supports the Black Leadership Council on Excellence's Young Researchers Community Project which offers disadvantaged youth in high school an opportunity to shadow medical professionals. According to the 2007 Maryland Physician workforce study, the Southern Maryland region has a physician shortage for primary care physicians. Southern Maryland had the regional low requirement for primary care physicians per 100,000 residents of 56.5. The Maryland state average rate was 58.2 per 100,000 residents. Under medical specialties, the Southern Maryland region has a shortage for cardiology, dermatology, endocrinology, gastroenterology, hematology, oncology, infectious disease, nephrology, psychiatry, pulmonary medicine, and rheumatology. The only medical specialties with adequate physician supplies were allergy and neurology. Charles County has one Neurologist which is deemed adequate for the population; however, the physician plans to retire which will leave the county in a critical shortage in this specialty. As a result of the prevailing physician shortage, and to mitigate the effects of the lack of access of the community to medical care, UM CRMC has developed a robust and ongoing physician recruitment and retainment program.
Bad Debt Expense	Schedule H, Part III, Line 2 & 4 CIVISTA REPORTS BAD DEBT EXPENSE IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP) HFMA 15. THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENTS ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY, AS WELL AS, THE ACCUMULATION OF RECEIVABLE BALANCES BY PERIOD OUTSTANDING. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY NECESSARY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS AND THE ESTABLISHED ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER COLLECTION OF AMOUNTS DUE FROM INSURERS, THE CORPORATION FOLLOWS INTERNAL GUIDELINES FOR PLACING CERTAIN PAST DUE BALANCES WITH COLLECTION AGENCIES. Medicare Cost Report Schedule H, Part III, Line 8 IN MARYLAND, THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC)STARTED SETTING HOSPITAL RATES IN 1974. AT THAT TIME, THE HSCRC APPROVED RATES APPLIED ONLY TO COMMERCIAL INSURERS. IN 1977, THE HSCRC NEGOTIATED A WAIVER FROM MEDICARE HOSPITAL PAYMENT RULES FOR MARYLAND HOSPITALS TO BRING THE FEDERAL MEDICARE PAYMENTS UNDER HSCRC CONTROL. MEDICARE REIMBURSES MARYLAND HOSPITALS ACCORDING TO RATES ESTABLISHED BY THE HSCRC AS LONG AS THE STATE CONTINUES TO MEET A TWO-PART TEST. THIS TWO-PART WAIVER TEST ALLOWS MEDICARE TO PARTICIPATE IN THE MARYLAND SYSTEM AS LONG AS TWO CONDITIONS ARE MET: ALL OTHER PAYERS PARTICIPATING IN THE SYSTEM PAY HSCRC SET RATES. THE RATE OF GROWTH IN MEDICARE PAYMENTS TO MARYLAND HOSPITALS FROM 1981 TO THE PRESENT IS NOT GREATER THAN THE RATE OF GROWTH IN MEDICARE PAYMENTS TO HOSPITALS NATIONALLY OVER THE SAME TIME FRAME.
Collection Practices	Schedule H, Part III, Line 9b THE ORGANIZATION EXPECTS PAYMENT AT THE TIME THE SERVICE IS PROVIDED. OUR POLICY IS TO COMPLY WITH ALL STATE AND FEDERAL LAW AND THIRD PARTY REGULATIONS AND TO PERFORM ALL CREDIT AND COLLECTION FUNCTIONS IN A DIGNIFIED AND RESPECTFUL MANNER. Currently, Civista Medical Center is in the process of updating its billing and collections process to ensure it is in compliance with the new IRC Section 501(R) regulations. EMERGENCY SERVICES WILL BE PROVIDED TO ALL PATIENTS REGARDLESS OF ABILITY TO PAY. FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS BASED ON FINANCIAL NEED AS DEFINED IN THE FINANCIAL ASSISTANCE POLICY. THE ORGANIZATION DOES NOT DISCRIMINATE ON THE BASIS OF AGE, RACE, CREED, SEX OR ABILITY TO PAY. PATIENTS WHO ARE UNABLE TO PAY MAY REQUEST A FINANCIAL ASSISTANCE APPLICATION AT ANY TIME PRIOR TO SERVICE OR DURING THE BILLING AND COLLECTION PROCESS. THE ORGANIZATION MAY REQUEST THE PATIENT TO APPLY FOR MEDICAL ASSISTANCE PRIOR TO APPLYING FOR FINANCIAL ASSISTANCE. THE ACCOUNT WILL NOT BE FORWARDED FOR COLLECTION DURING THE MEDICAL ASSISTANCE APPLICATION PROCESS OR THE FINANCIAL ASSISTANCE APPLICATION PROCESS.
Community Health Care Needs Assessment	Schedule H, Part VI, Line 2 Civista Medical Center completed a comprehensive community health needs assessment (CHNA) for fiscal year 2015 completed on 6/30/16. Fiscal year 2016 completes the first year of the implementation plan, which will be reported in the fiscal year 2016 community benefit report. The following summarizes the results of the community benefit report issued in fiscal year 2015, based on the fiscal year 2012 CHNA. These results represent the third and final year of the 2012 CHNA implementation plan. This process involved the following people: PHCC Executive Committee: Noel A. Cervino CEO Civista Health (CRMC) Dr. Devadason Health Officer CC Health Department (CCDOH) Dr. Brad Gottfried President College of Southern Maryland (CSM) Jim Richmond Superintendent Charles County Public Schools PHCC Steering Committee: Joyce Riggs Dir., Community Dev./ Planning Civista CRMC Fay Reed, RN Deputy Health Officer CCDOH William Leebel Public Information Officer CCDOH Linda Smith Project Coordinator CSM Tanisha Saunders Coordinator of Integrated Student Services CCPS Amber Starn, MPH Epidemiologist (Contract) Civista CRMC Partnerships for a Healthier Charles County: Civista Medical Center Civista Health, Board Of Directors Charles County Department of Health University of Maryland Clinical Trials Program Bel Alton Alumni Community Development Association Charles County Department of Community Services, Transportation Tri County Council for Southern Maryland Minister's Alliance of Charles County Charles County Department of Social Services Maryland Foundation for Quality Healthcare Health Partner's Clinic Greater Baden FQHC Shiloh Community United Methodist Church Charles County Nursing and Rehabilitation Center Alzheimer's Association Center for Children Chesapeake Potomac Home Health Agency College of Southern Maryland Charles County Department of Aging Priority Partners Big Brothers/Big Sisters Community Hispanic Advocates Black Leadership Council for Excellence Young Researchers Community Project Pinnacle Center (Mental Health) Hospice of Charles County Breast Cancer Support Advocates Charles County Public Schools School Nurses Charles County Commissioners Charles County Emergency Services Charles County Sheriff's Office So. MD Delegation Charles County Community Foundation Community Physicians Charles County Fire and Rescue Board Lifestyles, Inc. (Homeless) The plan was presented and approved by the Board of Directors on 11/28/2011. Hospital identified the following as needs of the community: - Reproductive Health - Healthy Babies (Infant Mortality Disparity) - STD Reduction/Prevention - Chronic Disease - Heart Disease - Diabetes - Obesity - Access to Care - Dental health - Transportation - Physician Shortage - Cancer Team - Lung Cancer - Prostate Cancer - Colorectal Cancer - Injury and Violence free Community - Roadway incidents - Injuries and Fall Prevention - Behavioral Health - Substance Abuse - Mental Health Hospital publicized the CHNA via website (www.charlesregional.org) and is available printed upon request. Did Civista Medical Center (CRMC) take into account input from representatives of the community it serves while conducting its CHNA? If yes, please describe how and by whom input was taken. Civista Health (CRMC) and the Charles County Department of Health (CCDOH) collaborated to complete a comprehensive assessment of the health needs (CHNA) of Charles County, Maryland. An epidemiologist with a Master's Degree in Public Health Epidemiology was contracted to analyze the qualitative and quantitative data. Civista lead the effort and covered 80% of the cost of the CHNA. To provide a comprehensive assessment of the health needs of the county, a four method plan was developed which included 4 different sources of data: a long online survey of Charles County residents perceptions of health and health behaviors, a short paper survey on health perceptions throughout the county, 7 focus groups with community leaders, citizens, and stakeholders, and a quantitative data analysis. The use of the multiple data collection methods strengthened the validity of the assessment's findings, as well as ensured that Charles County residents had an opportunity to participate in the assessment process and to feel invested in its outcome. Three hundred and two (302) Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health (CRMC) website. The first section of the survey asked participants about their perception of health and health services within the county. The second section asked them about their health behaviors, in order to determine their risk for the development of certain health conditions. A short three question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista (CRMC) waiting rooms, CCDOH waiting rooms, libraries, senior centers, community centers. Thirty five were completed in Spanish (17.5%). Seven focus groups were held throughout the county. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC) (community leaders and stakeholders). Approximately 165 people participated in the county focus groups. Survey for Community Members: 302 Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the Civista Health (CRMC) website. A short 3 question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including Civista waiting rooms, Charles County Department of Health waiting rooms, libraries, senior centers, community centers. 35 were completed in Spanish (17.5%). Description of Individuals and Organizations Consulted for CHNA Input: Seven focus groups were held throughout the county with representation from the following organizations. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC) (community leaders and stakeholders). Approximately 165 people participated in the county focus groups from the following Organizations. Organization Representative Name Title Amber Starn Epidemiologist CC Dept of Health Faye Grillo Deputy Health Officer Bel Alton Community Development Center Judy Rudolf Dept. of Community Services Brenda Walcott Van Go Jeff Barnett Donna Harris Tri County Council for So MD Elaine Lancaster First Gospel Church of Bryans Road Rev. James Briscoe Pastor Department of Social Services Juan Thompson Ombudsman Danielle Green Terry Sullivan Lifestyles, Inc. (Homeless) Sandy Washington Ex. Director Marie Robinson Renee Curry Health Partners Clinic Dr. Howard Haft Medical Director Chrissie Mulcahey Ex. Director Hispanic Community Representative Maria Michletec Community member CC Nursing and Rehab. Bud Zimmerman Ex. Director Bill Holman Denise McCann Alzheimer's Association Linda Gottfried Director Center for Children Colleen Wilburn UM CRMC Maureen Jenkins Mgr, Labor and Delivery Chesapeake Potomac Home Health Kelly Winters College of Southern MD Linda Smith CC Dept. Of Aging Bonnie Hampton CC Dept. of Health Linda Blake Director Priority Partners Angela Deale Outreach worker Big Brothers Big Sisters Cynthia Graham Black leadership Council for Excellence Bonita Adeeb Rose Haft Young Researchers CP Anthony Quick Community member Pinnacle Counseling Center Jackie Burson Lic. Counselor Hospice Colleen Wilson CC Dept. of Health Mary Beth Klick Tobacco Counselor UM CRMC Betsy Wolford CDE CCDOH Dawn Cox Breast and Cervical Cancer UM CRMC Dr. Rich Ferraro Med. Dir. ED. Sisters at Heart Roberta Kieliger Chair Cambridge Pediatrics Diana Abney, MD Pediatrician UM CRMC Angie Booker Respiratory Therapist UM CRMC Teresa Brannigan Director of Nursing School Nurses - Sheila Brockman - Cheryl Smith - Peggy Bird - Tammy Dilling - Carolyn Engleson - Tammy Crozier - Jennifer Ledford - Lisa Bazzare - Kathleen DeBolt - Patricia Horner - Karl J.Muehlfeld - Lucy Wathen - Charlene Falken - Joanne Collins - Marge Charron - Elizabeth Gallacher - Erica Hadley - Jan Siewertsen - Lenure Petty - Natasha Williams - Kofo Williams - Nadja De Los Santos - Phyliss Renard - Karen Grace - Deborah Heim - Constance Larsen - Diane Gardiner - Shelley Presnell - Laurie Mulert - Betsy Keesler - Edith Patten - Barbara Balazek - Carole Noyes - Katie Popp - Dorothy Reeves - Kim Jameson - Stephanie Kiesel - Carol A. Dawn Charles Coun
Eligibility Education	Schedule H, Part VI, Line 3 Civista Medical Center DBA University of Maryland Charles Regional Medical Center (UM CRMC). UM CRMC posts its charity care policy, or a summary thereof, as well as financial assistance contact information, in admissions areas, emergency rooms, business offices and other areas of the facility where eligible patients are likely to present. In addition, the policy is available on the UM CRMC website and is posted in the local paper twice each year. The FAP is written in a culturally sensitive and at an appropriate reading level. It is available in English and Spanish. All Patient Access Customer Service Staff have training in the financial assistance process. During the intake or discharge process or when there is contact regarding a billing matter, if a patient discloses financial difficulty or concern with payment of the bill, the patient is provided with FAP information. A packet with the application, criteria and a documentation checklist is provided. Assistance completing the application is available. Additionally, assistance is provided for patients or their families in qualification and application of government benefits, Medicaid and other state programs. Once an application is processed and if it is deemed incomplete, a letter is sent to the patient requesting the missing or incomplete items. Patients may call the Call Center or come into the Patient Access Office for assistance. In compliance with the new IRC Section 501(R) regulations Civista Medical Center is currently in the process of updating their Financial Assistance Policy to ensure its compliance with IRS regulations.
Description of Community Served	Schedule H, Part VI, Line 4 The Community Benefit Service Area for Civista Medical Center (UM CRMC) is all 28 zip codes located within the borders of Charles County. This includes the six zip codes identified as the Primary Service Area. Civista Medical Center (UM CRMC) is Charles County's only hospital and, as such, serves the residents of the entire county. Geography Charles County is located 23 miles south of Washington, D.C. It is one of five Maryland counties, which are part of the Washington, DC MD VA metropolitan area. At 458 square miles, Charles County is the eighth largest of Maryland's twenty four counties and accounts for about 5 percent of Maryland's total landmass. The northern part of the county is the "development district" where commercial, residential, and business growth is focused. The major communities of Charles County are La Plata (the county seat), Port Tobacco, Indian Head, and St Charles, and the main commercial cluster of Hughesville Waldorf White Plains. Approximately 60 percent of the county's residents live in the greater Waldorf La Plata area. By contrast, the southern (Cobb Neck area) and western (Nanjemoy, Indian Head, Marbury) areas of the region still remain very rural with smaller populations. Population Charles County has experienced rapid growth since 1970, expanding its population from 47,678 in 1970 to 120,546 in the 2000 census and 146,551 in the 2010 census. The current Census Bureau 2012 estimates the population at 150,592 for a 2.8% increase in two years. The magnitude of growth can be seen in the changes in population density. The 1990 census showed that there were 219.4 individuals per square mile, which increased to 261.5 individuals per square mile by 2000, an increase of 19.2%, and to 320.2 individuals per square mile by 2010, an increase of 22.5%. Transportation The percent change in the population growth for Charles County has been slightly greater than the change seen in the Maryland population growth. This growth has created transportation issues for the County in particular for the "development district" in the northern part of the county where many residents commute to Washington D.C. to work. The average work commute time for a Charles County resident is 42.3 minutes which is higher than the Maryland average by slightly more than 10 minutes. Public transportation consists of commuter bus for out of county travel and the county run Van Go bus service for in county transportation. Diversity As the population of the county changes, the diversity of the county also increases. The African American population has experienced the greatest increase. In 2000, African Americans made up 26% of the total Charles County population; by 2012, they comprise 42.4% of the total county population. As of 2012, minorities make up roughly 54% of the Charles County population. The Hispanic community has also seen increases over the past few years. They now comprise 4.7% of the total county population. This is the one of the highest percentages among the 24 Maryland jurisdictions. Economy Employment and economic indicators for the county are fairly strong. The 2010 US Census estimates found that 73.8% of the Charles County population is currently in the labor work force. The 2011 update estimates that approximately 5.6% of Charles County individuals are living below the poverty level, up 0.4% from 2010, however this is lower than the Maryland rate of 9% in 2011. The Charles County median household income was $92,135, an increase of $3,310 over the 2010 estimates and still well above the Maryland median household income of $72,419. The diversity of the county is also represented in the business community with 29.3% of all Charles County businesses being Black owned firms. This is higher than the State of Maryland at 19.3%. Education Charles County has a larger percentage of high school graduates than Maryland (90.6% vs. 88.2%); however, Charles County has a smaller percentage than Maryland of individuals with a bachelor's degree or higher (26.3% vs. 36.1%). Housing There is a high level of home ownership in Charles County (80.1%), however, this is slightly down from the 2010 level of 81.8%. The median value of a housing unit in Charles County is higher than the Maryland average ($341,200 vs. $319,800). Home values across Maryland have decreased and Charles County showed a slightly larger decrease than the Maryland average (4% vs. 3%). The average household size in Charles County is 2.86 persons. Life Expectancy The life expectancy for a Charles County resident, as calculated for 2009 2011, was 78.4 years. This is similar to the state average life expectancy of 79.2 years. Births There were 1,923 births in Charles County in 2012. Charles County represents 54% of the births in Southern Maryland (up 11% from 2009) and 2.6% of the total births in Maryland for 2012. Minorities made up just over half of the babies born in Charles County in 2012 (51.5%) which is in line with the composition of the county. Source: 2012 Maryland Vital Statistics Report
Promoting the Health of the Community	Schedule H, Part VI, Line 5 Implementation Strategy: The Charles County Health Improvement Plan (CCHIP): Upon completion of the CHNA, the Steering Committee of Partnerships for a Healthier Charles County (PHCC) reviewed the results and the identified top 11 health needs. The Steering Committee set county objectives through 2015 based on Maryland SHIP objectives and Healthy People 2020 Goals. The results and goals were presented to the PHCC membership at the quarterly General Membership Meeting. Six teams were formed based on expertise and interest to formulate 3 year action plans to address the following health needs using one or more of the "Seven Strategies for Community Change" found on the last page of the Charles County Health Improvement Plan. 1. Reproductive Health A. Healthy Babies (Infant Mortality Disparity) B. STD Reduction/Prevention 2. Chronic Disease A. Heart Disease B. Diabetes C. Obesity 3. Access to Care A. Dental health B. Transportation C. Physician Shortage 4. Cancer Team A. Lung Cancer B. Prostate Cancer C. Colorectal Cancer 5. Injury and Violence free Community A. Roadway incidents B. Injuries and Fall Prevention 6. Behavioral Health A. Substance Abuse B. Mental Health The Charles County Health Needs Assessment and Health Improvement Plan were presented to the Civista Health Board (UM CRMC) of Directors and approved. Annual updates to the Plan are reviewed and approved. The CCHIP objectives are the Charles County Health Improvement Plan and available at: http://www.charlesregional.org/index.cfm? fuseaction=HealthResources.showHealthActionPlans The Health Improvement Team Action Plans (Implementation Plans) are available at: http://www.charlesregional.org/index.cfm?fuseaction=HealthResources. showHealthActionPlans All the primary needs outlined in the Needs Assessment are being addressed by Civista Health (UM CRMC) either directly (i.e., OB Clinic, Physician Recruitment) or through partnerships with other organizations (i.e., Childhood Obesity Program, Fetal Infant Mortality, Prostate Cancer) or through the PHCC which is led and primarily financed by Civista Health (UM CRMC). Where a need is appropriately addressed by another entity, Civista provides leadership through the Charles County Health Improvement Plan and the local health coalition (PHCC) to communicate initiatives, provide financial support and/or assistance when needed and review results (i.e., Substance Abuse, Mental Health). All the primary needs outlined in the Needs Assessment are being addressed and funded by Civista (UM CRMC) either directly (i.e., OB Clinic, Physician Recruitment) or through partnerships with other organizations (i.e., Childhood Obesity Program, Fetal Infant Mortality). Where a need is appropriately addressed by another entity, Civista provides leadership through the Charles County Health Improvement Plan and the coalition of Partnerships for a Healthier Charles County to communicate initiatives, provide assistance when needed and review results (i.e., Substance Abuse, Mental Health). The majority of the governing body, the Board of Directors, of Civista Medical Center (UM CRMC) is comprised of persons who reside in the community served by the hospital and who are neither employees nor contractors of the organization. Civista Medical Center (UM CRMC) extends medical privileges to all qualified medical staff in the community. Continuing Medical Education seminars and Grand Rounds are open to all community physicians.
Affiliated Health Care System Roles	Schedule H, Part VI, Line 6 Civista Medical Center (UM CRMC) is a member of the University of Maryland Medical System (UMMS). System hospitals meet monthly to coordinate and plan Community Benefit Operations such as Health Needs Assessments and Maryland State Health Improvement Plan objectives. UMMS provides leadership and guidance to local system jurisdictions regarding alignment with System and State wide goals. Southern Maryland had the highest percentage of physician shortages of all of the regions in Maryland (89.9%). To address the shortage, Civista Medical Center (UM CRMC) and UMMS have developed a recruitment and retention plan to successfully attract and retain private physicians to the community.
Community Benefit Report State Filings	Schedule H, Part VI, Line 7 Community Benefit Report was filed in the state of Maryland.

Schedule H (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990.
lBullet

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

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization
Civista Medical Center Inc

Employer identification number
52-0445374

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(b) EIN	(c) IRC section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) Charles County Chamber of Commerce 101 Centennial St Ste A laplata La Plata,MD20646	52-0699475		11,150	2015 Sponsorship
(2) Charles Regional Medical Center Foundation 5 Garrett Avenue La Plata,MD20646	52-1414564	501(c)(3)	8,000	Paint the Town Pink

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2014

Page 2

Part III

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

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

Part IV

Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Return Reference	Explanation
Procedure for Monitoring Use of Grant Funds Inside U.S.	Part I, Line 2 CIVISTY MEDICAL CENTER MAKES FINANCIAL AND IN-KIND CONTRIBUTIONS TO VARIOUS ORGANIZATIONS IN THE COMMUNITY. EACH OF THE CONTRIBUTION RECIPIENTS ARE EITHER GOVERNMENTAL UNITS OR SECTION 501(c)(3) CHARITABLE ORGANIZATIONS WHICH WORK TO FULFILL THE ORGANIZATION'S MISSION OF PROMOTING HEALTH WITHIN THE COMMUNITY.

Schedule I (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990, Part IV, 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

2014

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Yes

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? ..

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2014

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column(B) reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Jon P BurnsEx-Officio/Director	(i) (ii)	0 ............................... 381,339	0 ............................... 154,634	0 ............................... 55,236	0 ............................... 10,400	0 ............................... 9,869	0 ............................... 611,478	0 ............................... 0
2John W Ashworth IIIEx-Officio/Dir. (thru 1/31/15)	(i) (ii)	0 ............................... 373,547	0 ............................... 155,458	0 ............................... 68,205	0 ............................... 10,400	0 ............................... 10,695	0 ............................... 618,305	0 ............................... 0
3Robert ChrencikEx-Officio/Director	(i) (ii)	0 ............................... 1,183,796	0 ............................... 1,004,469	0 ............................... 4,692,806	0 ............................... 10,400	0 ............................... 10,695	0 ............................... 6,902,166	0 ............................... 4,526,360
4Noel CervinoEx-Officio/President & CEO	(i) (ii)	356,893 ............................... 0	182,000 ............................... 0	342,871 ............................... 0	10,400 ............................... 0	6,575 ............................... 0	898,739 ............................... 0	0 ............................... 253,407
5Erik BoasChief Financial Officer	(i) (ii)	202,281 ............................... 0	75,000 ............................... 0	127,995 ............................... 0	8,169 ............................... 0	0 ............................... 0	413,445 ............................... 0	88,982 ............................... 0
6Mark R DumaisChief Medical Officer	(i) (ii)	283,580 ............................... 0	122,005 ............................... 0	932 ............................... 0	44,441 ............................... 0	10,695 ............................... 0	461,653 ............................... 0	0 ............................... 0
7Dana LevyChief Nursing Officer	(i) (ii)	179,270 ............................... 0	40,014 ............................... 0	2,714 ............................... 0	23,558 ............................... 0	6,906 ............................... 0	252,462 ............................... 0	0 ............................... 0
8Paul BlackwoodVP Planning	(i) (ii)	173,501 ............................... 0	40,015 ............................... 0	1,042 ............................... 0	23,598 ............................... 0	10,628 ............................... 0	248,784 ............................... 0	0 ............................... 0
9William GrimesVP Ancilliary Services	(i) (ii)	154,255 ............................... 0	37,500 ............................... 0	4,644 ............................... 0	20,357 ............................... 0	410 ............................... 0	217,166 ............................... 0	0 ............................... 0
10Stacey CookVP Human Resources	(i) (ii)	160,449 ............................... 0	45,010 ............................... 0	2,304 ............................... 0	22,435 ............................... 0	16,364 ............................... 0	246,562 ............................... 0	0 ............................... 0
11Marilyn GregoryRN	(i) (ii)	190,595 ............................... 0	0 ............................... 0	329 ............................... 0	2,700 ............................... 0	4,845 ............................... 0	198,469 ............................... 0	0 ............................... 0
12Katherine MiddletonRN	(i) (ii)	185,590 ............................... 0	0 ............................... 0	76 ............................... 0	13,300 ............................... 0	165 ............................... 0	199,131 ............................... 0	0 ............................... 0
13Eugene Suwandhi MDpediatric hospitalist phys.	(i) (ii)	173,867 ............................... 0	0 ............................... 0	100 ............................... 0	3,085 ............................... 0	4,468 ............................... 0	181,520 ............................... 0	0 ............................... 0
14Gabriel AbiolaPharmacist Manager	(i) (ii)	159,120 ............................... 0	0 ............................... 0	780 ............................... 0	17,500 ............................... 0	4,468 ............................... 0	181,868 ............................... 0	0 ............................... 0

Schedule J (Form 990) 2014

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
Health or Social Club Dues	Schedule J, Part I, Line 1a UMMS Executives receive a benefit package which may be used towards health club dues or other health maintenance programs. Such benefits are capped at $7,000, $5,000, or $3,000 depending on job title as described in the program documents.
SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN	SCHEDULE J, PART I, LINE 4B DURING THE FISCAL YEAR ENDED JUNE 30, 2015, CERTAIN OFFICERS AND KEY EMPLOYEES PARTICIPATED IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THE INDIVIDUALS LISTED BELOW HAVE NOT VESTED IN THE PLAN. THEREFORE, THE ACCRUED CONTRIBUTION TO THE PLAN FOR THE FISCAL YEAR IS REPORTED ON SCHEDULE J, PART II, COLUMN C, RETIREMENT AND OTHER DEFERRED COMPENSATION: MARK R DUMAIS DANA LEVY PAUL BLACKWOOD WILLIAM GRIMES DURING THE FISCAL YEAR ENDED JUNE 30, 2015, CERTAIN OFFICERS AND KEY EMPLOYEES PARTICIPATED IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THE INDIVIDUALS LISTED BELOW HAVE VESTED IN THE PLAN IN A PRIOR YEAR. THEREFORE, THE CONTRIBUTIONS TO THE PLAN FOR THE FISCAL YEAR ARE REPORTED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II, LINE B(III), OTHER REPORTABLE COMPENSATION: JOHN W. ASHWORTH, III JON BURNS DURING THE FISCAL YEAR ENDED JUNE 30, 2015, CERTAIN OFFICERS AND KEY EMPLOYEES PARTICIPATED IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THE INDIVIDUALS LISTED BELOW HAVE VESTED IN THE PLAN IN THE REPORTING TAX YAR. THEREFORE, THE FULL VALUE OF THE PLAN, INCLUDING ANY CONTRIBUTIONS TO THE PLAN FOR THE CURRENT FISCAL YEAR, IS REPORTED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II, LINE B(III), OTHER REPORTABLE COMPENSATION. PRIOR YEAR CONTRIBUTIONS TO THE PLAN WERE PREVIOUSLY REPORTED ON FORM 990 AND ARE INDICATED ON SCHEDULE J, PART II, COLUMN (F). ROBERT CHRENCIK NOEL CERVINO ERIK BOAS
Non-fixed payments	Schedule J, Part I, Line 7 Bonuses paid are based on a number of variables including but not limited to individual goal achievements as well as organization operation achievements. The final determination of the bonus amount is determined and approved by the board as part of the overall compensation review of the officers and key employees.

Schedule J (Form 990) 2014

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

2014

Open to Public
Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Return Reference	Explanation
Tax Exempt Bond Issues	Form 990, Part IV, Question 24 Pursuant to a Master Loan Agreement dated June 20, 1991 (The "Master Loan Agreement"), as Amended, The University Of Maryland Medical System Corporation (The "Corporation") and several of its subsidiaries have issued debt through the Maryland Health and Higher Educational Facilities Authority (the "Authority"). As Security for the performance of the bond obligation under the Master Loan Agreement, The Authority maintains a security interest in the revenue of the obligors. The Master Loan Agreement contains certain restrictive covenants. These covenants require that rates and charges be set at certain levels, limit incurrence of additional debt, require compliance with certain operating ratios and restrict the disposition of assets. The obligated group under the Master Loan Agreement includes the Corporation, The James Lawrence Kernan Hospital, Inc., Maryland General Hospital, Inc., Baltimore Washington Medical Center, Inc., Shore Health System, Inc., Chester River Hospital Center, Inc., Civista Medical Center, Inc., University of Maryland St. Joseph Medical Center, LLC, Upper Chesapeake Medical Center, Inc., Harford Memorial Hospital, Inc. and the University of Maryland Medical System Foundation, Inc. Each member of the obligated Group is jointly and severally liable for the repayment of the obligations under the Master Loan Agreement of the Corporation's $1,417,355,000 of outstanding Authority Bonds on June 30, 2015. All of the bonds were issued in the name of the University of Maryland Medical System Corporation and are reported on Schedule K of its Form 990.
Members or Stockholders	Form 990, Part VI, Line 6, 7A AND 7B University of Maryland Charles Regional Health, Inc. and University of Maryland Medical System Corporation may elect members and approve decisions of the Civista Medical Center board.
Form 990 Review Process	Form 990, Part VI, Line 11b THE IRS FORM 990 IS PREPARED AND REVIEWED BY THE ACCOUNTING FIRM OF GRANT THORNTON. ACCOUNTING PERSONNEL IN FINANCE SHARED SERVICES AT THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM GATHER THE INFORMATION NEEDED TO COMPLETE THE RETURN AND INPUT THE DATA INTO THE GRANT THORNTON TAX ORGANIZER, WHICH IS AN EXCEL-BASED SYSTEM. WHEN ALL DATA HAS BEEN ENTERED, THE INFORMATION IS SUBMITTED TO GRANT THORNTON FOR IMPORTATION INTO THEIR TAX SOFTWARE. AT THIS POINT, GRANT THORNTON STAFF MEMBERS REVIEW THE DATA, ASK FOR ADDITIONAL INFORMATION IF NEEDED AND PREPARE THE TAX RETURN. EACH RETURN IS REVIEWED AT SEVERAL LEVELS AT GRANT THORNTON INCLUDING THE TAX PARTNER. AFTER THEIR REVIEW PROCESS, A DRAFT RETURN IS SENT TO THE ACCOUNTING STAFF AT UMMS FOR AN IN-HOUSE REVIEW. UPON COMPLETION OF THE IN-HOUSE REVIEW, GRANT THORNTON IS INSTRUCTED TO MAKE ANY NECESSARY CHANGES AND TO PREPARE THE FINAL TAX RETURN. THE FINAL RETURN UNDERGOES ANOTHER REVIEW BY THE ACCOUNTING STAFF AT FINANCE SHARED SERVICES AND IS ALSO REVIEWED BY THE ACCOUNTING MANAGER, THE DIRECTOR OF FINANCIAL REPORTING, THE VICE PRESIDENT OF FINANCE AND THE CFO, WHO SIGNS THE RETURN. PRIOR TO FILING THE IRS FORM 990, THE ORGANIZATION'S BOARD CHAIRMAN, TREASURER, AUDIT COMMITTEE CHAIRMAN, EXECUTIVE COMMITTEE CHAIRMAN OR OTHER MEMBER OF THE BOARD WITH SIMILAR AUTHORITY WILL REVIEW THE IRS FORM 990. AT THE DISCRETION OF THE REVIEWING BOARD MEMBER, SUCH MEMBER WILL BRING ANY ISSUES OR QUESTIONS RELATED TO THE COMPLETED IRS FORM 990 TO THE ATTENTION OF THE BOARD. NOTWITHSTANDING THE ABOVE, A BOARD RESOLUTION IS NOT REQUIRED FOR THE FILING OF THE ORGANIZATION'S IRS FORM 990. EACH BOARD MEMBER IS PROVIDED WITH A COPY OF THE FINAL IRS FORM 990 BEFORE FILING.
Conflict of Interest Policy Monitoring & Enforcement	Form 990, Part VI, Line 12c THE ORGANIZATION'S OFFICERS, DIRECTORS, EMPLOYEES AND MEDICAL STAFF MEMBERS, AS APPLICABLE, SHALL DISCLOSE CONFLICTS OF INTEREST OR POTENTIAL CONFLICTS OF INTEREST BETWEEN THEIR PERSONAL INTERESTS AND THE INTERESTS OF THE ORGANIZATION, OR ANY ENTITY CONTROLLED BY OR OWNED IN SUBSTANTIAL PART BY THE ORGANIZATION. A QUESTIONNAIRE WHICH DISCLOSES POTENTIAL CONFLICTS OF INTEREST IS DISTRIBUTED ANNUALLY TO ALL OFFICERS, DIRECTORS AND KEY EMPLOYEES. THE GENERAL COUNSEL OF THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM CORPORATION (UMMSC) REVIEWS THE RESPONSES FOR UMMSC AND JAMES LAWRENCE KERNAN HOSPITAL. THE CEO OR CFO OF EACH OF THE OTHER ENTITIES IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM REVIEWS THE RESPONSES FOR THOSE ENTITIES. THE GENERAL COUNSEL, IN CONSULTATION WITH THE AUDIT COMMITTEE, IF NECESSARY, WOULD DETERMINE IF A CONFLICT OF INTEREST EXISTED FOR UMMSC, AND JAMES LAWRENCE KERNAN HOSPITAL. WITH RESPECT TO THE OTHER ENTITIES IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM, THE GENERAL COUNSEL MAY BE CALLED FOR CONSULT. IF SO, THE GENERAL COUNSEL MAY CONSULT THE AUDIT COMMITTEE, IF NECESSARY. WHENEVER A CONFLICT OR POTENTIAL CONFLICT OF INTEREST EXISTS, THE NATURE OF THE CONFLICT OR POTENTIAL CONFLICT OF INTEREST MUST BE DISCLOSED IN WRITING TO THE ORGANIZATION'S BOARD, BOARD COMMITTEE, AN OFFICER OF THE ORGANIZATION OR OTHER APPROPRIATE EXECUTIVE. SUCH INDIVIDUAL HAVING A POTENTIAL CONFLICT OF INTEREST SHALL PLAY NO ROLE ON BEHALF OF THE ORGANIZATION, OR ANY ORGANIZATION CONTROLLED OR SUBSTANTIALLY OWNED, IN ANY TRANSACTION IN WHICH A CONFLICT EXISTS. ALL INVITATIONS FOR BIDS, PROPOSALS OR SOLICITATIONS FOR OFFERS INCLUDE THE FOLLOWING PROVISION: ANY VENDOR, SUPPLIER OR CONTRACTOR MUST DISCLOSE ANY ACTUAL OR POTENTIAL TRANSACTION WITH ANY ORGANIZATION OFFICER, DIRECTOR, EMPLOYEE OR MEMBER OF THE MEDICAL STAFF, INCLUDING FAMILY MEMBERS WITHIN FIVE DAYS OF THE TRANSACTION. FAILURE TO COMPLY WITH THIS PROVISION IS A MATERIAL BREACH OF AGREEMENT. IN ADDITION, A BOARD DISCLOSURE REPORT IS FILED WITH THE MARYLAND HEALTH SERVICES COST REVIEW COMMISSION ON AN ANNUAL BASIS SHOWING ANY BUSINESS TRANSACTIONS BETWEEN THE BOARD MEMBERS AND THE ORGANIZATION.
Process for Determining Compensation	Form 990, Part VI, Line 15a & 15b THE ORGANIZATION DETERMINES THE EXECUTIVE COMPENSATION PAID TO ITS EXECUTIVES IN THE FOLLOWING MANNER PRESCRIBED IN THE IRS REGULATIONS: EXECUTIVE COMPENSATION PACKAGES ARE DETERMINED BY A COMMITTEE OF THE BOARD THAT IS COMPOSED ENTIRELY OF BOARD MEMBERS WHO HAVE NO CONFLICT OF INTEREST. THE COMMITTEE ACQUIRES CREDIBLE COMPARABILITY MARKET DATA CONCERNING THE COMPENSATION PACKAGES OF SIMILARLY SITUATED EXECUTIVES. THE COMMITTEE CAREFULLY REVIEWS THAT DATA, THE EXECUTIVE'S PERFORMANCE AND THE PROPOSED COMPENSATION PACKAGES DURING THE DECISION MAKING PROCESS. THE COMMITTEE MEMORIALIZES ITS DELIBERATIONS IN DETAILED MINUTES REVIEWED AND ADOPTED AT THE NEXT-FOLLOWING MEETING. THE COMMITTEE SEEKS AN OPINION OF COUNSEL THAT IT HAS MET THE REQUIREMENTS OF THE IRS INTERMEDIATE SANCTIONS REGULATIONS. THIS PROCESS IS USED TO DETERMINE THE COMPENSATION PACKAGES FOR ALL MANAGEMENT EMPLOYEES FROM THE VICE PRESIDENT LEVEL AND UP.
How Documents are Made Available to the Public	Form 990, Part VI, Line 19 IN GENERAL, FINANCIAL AND TAX INFORMATION RELATING TO THE ORGANIZATION IS DEEMED PROPRIETARY AND NOT SUBJECT TO DISCLOSURE UPON REQUEST. HOWEVER, SPECIFIC PROVISIONS OF FEDERAL AND STATE LAW REQUIRE THE ORGANIZATION TO DISCLOSE CERTAIN LIMITED FINANCIAL AND TAX DATA UPON A SPECIFIC REQUEST FOR THAT INFORMATION. REQUESTS FOR FORM 990 AND FORM 1023: A REQUESTOR SEEKING TO REVIEW AND/OR OBTAIN A COPY OF THE ORGANIZATION'S IRS FORM 990 OR FORM 1023 AS FILED WITH THE INTERNAL REVENUE SERVICE, INCLUDING ALL SCHEDULES AND ATTACHMENTS, MAY APPEAR IN PERSON OR SUBMIT A WRITTEN REQUEST. THE MOST RECENT THREE YEARS OF IRS FORM 990 MAY BE REQUESTED. IF THE REQUESTER APPEARS IN PERSON, THE INDIVIDUAL IS DIRECTED TO THE OFFICE OF THE CHIEF FINANCIAL OFFICER FOR THE ORGANIZATION AND THE FORM 990 AND/OR FORM 1023 ARE MADE AVAILABLE FOR INSPECTION. THE INDIVIDUAL IS PERMITTED TO REVIEW THE RETURN, TAKE NOTES AND REQUEST A COPY. IF REQUESTED, A COPY IS PROVIDED ON THE SAME DAY. A NOMINAL FEE IS CHARGED FOR MAKING THE COPIES. THE ORGANIZATION MAY HAVE AN EMPLOYEE PRESENT DURING THE PUBLIC INSPECTION OF THE DOCUMENT. WRITTEN REQUESTS FOR AN ENTITY'S FORM 990 OR FORM 1023 ARE DIRECTED IMMEDIATELY TO THE OFFICE OF THE CHIEF FINANCIAL OFFICER FOR THE ORGANIZATION. THE REQUESTED COPIES ARE MAILED WITHIN 30 DAYS OF THE REQUEST. REPRODUCTION FEES AND MAILING COSTS ARE CHARGED TO THE REQUESTOR. CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS: IF THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY OF OUR ORGANIZATION ARE SUBJECT TO THE FEDERAL PUBLIC DISCLOSURE RULES (OR STATE PUBLIC DISCLOSURE RULES), THESE DOCUMENTS WILL BE MADE PUBLICLY AVAILABLE AS APPLICABLE LAW MAY REQUIRE. OTHERWISE, THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY WILL BE PROVIDED TO THE PUBLIC AT THE DISCRETION OF MANAGEMENT.
Hours on Related Entities	FORM 990, PART VII, SECTION A, COLUMN B THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) IS A MULTI-ENTITY HEALTH CARE SYSTEM THAT INCLUDES 11 ACUTE CARE HOSPITALS, 1 ACUTE CARE HOSPITAL OWNED IN A JOINT VENTURE ARRANGEMENT AND VARIOUS SUPPORTING ENTITIES. A NUMBER OF INDIVIDUALS PROVIDE SERVICES TO VARIOUS ENTITIES WITHIN THE SYSTEM. IN GENERAL, THE OFFICERS AND KEY EMPLOYEES OF UMMS AVERAGE IN EXCESS OF 40 HOURS PER WEEK SERVING THE DIFFERENT ENTITIES THAT COMPRISE UMMS.
Other Changes in Net Assets or Fund Balances	Form 990, Part XI, Line 9 Change in Equity of Affiliates, ccs -3,489,794 Change in Equity of Affiliates, chi -10,000,000 Change in Equity of Affiliates, ccp -4,061,250 Change in Equity of Affiliates, Foundation -11,752 Change in FMV of Alternative Investments -47,986 Pension liability adjustment -991,664 ------------ -18,602,446

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2014

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

2014

Open to Public Inspection

Name of the organization

Civista Medical Center Inc

Employer identification number

52-0445374

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" 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) Baltimore Washington Emergency Phys Inc 301 Hospital Drive Glen Burnie,MD21061 52-1756326	Healthcare	MD	501(c)(3)	11a	UMBWMS		No
(2) Baltimore Washington Healthcare Services 301 Hospital Drive Glen Burnie,MD21061 52-1830243	Healthcare	MD	501(c)(3)	11a	UMBWMS		No
(3) Baltimore Washington Medical Center Inc 301 Hospital Drive Glen Burnie,MD21061 52-0689917	Healthcare	MD	501(c)(3)	3	UMBWMS		No
(4) UMD Baltimore Washington Medical Center 301 Hospital Drive Glen Burnie,MD21061 52-1830242	Healthcare	MD	501(c)(3)	11a	UMMSC		No
(5) BW Medical Center Foundation Inc 301 Hospital Drive Glen Burnie,MD21061 52-1813656	Fundraising	MD	501(c)(3)	11c	UMBWMS		No
(6) North Arundel Development Corporation 301 Hospital Drive Glen Burnie,MD21061 52-1318404	Real Estate	MD	501(c)(2)		ncc		No
(7) North County Corporation 301 Hospital Drive Glen Burnie,MD21061 52-1591355	Real Estate	MD	501(c)(2)		UMBWMS		No
(8) Shipleys Choice Medical Park Inc 22 South Greene Street Baltimore,MD21201 04-3643849	Real Estate	MD	501(c)(2)		ncc		No
(9) Chester River Health Foundation Inc 100 Brown Street Chestertown,MD21620 52-1338861	Fundraising	MD	501(c)(3)	8	umsrh		No
(10) Univ of MD Shore Regional HealthInc 100 Brown Street Chestertown,MD21620 52-2046500	Healthcare	MD	501(c)(3)	11a	UMMSC		No
(11) Chester River Hospital Center 100 Brown Street Chestertown,MD21620 52-0679694	Healthcare	MD	501(c)(3)	3	umsrh		No
(12) Chester River Manor Inc 200 Morgnec Road Chestertown,MD21620 52-6070333	Healthcare	MD	501(c)(3)	9	umsrh		No
(13) Maryland General Clinical Practice Group 827 Linden Avenue Baltimore,MD21201 52-1566211	Healthcare	MD	501(c)(3)	11b	ummth		No
(14) Maryland General Comm Health Foundation 827 Linden Avenue Baltimore,MD21201 52-2147532	Fundraising	MD	501(c)(3)	11c	ummth		No
(15) University of Maryland Midtown Health 827 Linden Avenue Baltimore,MD21201 52-1175337	Healthcare	MD	501(c)(3)	11b	UMMSC		No
(16) Maryland General Hospital Inc 827 Linden Avenue Baltimore,MD21201 52-0591667	Healthcare	MD	501(c)(3)	3	ummth		No
(17) Care Health Services Inc 219 South Washington Street Easton,MD21601 52-1510269	Healthcare	MD	501(c)(3)	9	umsrh		No
(18) Dorchester General Hospital Foundation 219 South Washington Street Easton,MD21601 52-1703242	Fundraising	MD	501(c)(3)	11d	umsrh		No
(19) Memorial Hospital Foundation Inc 219 South Washington Street Easton,MD21601 52-1282080	Fundraising	MD	501(c)(3)	11a	umsrh		No
(20) UM Community Medical Group Inc 920 Elkridge Landing Road Linthicum,MD21090 52-1874111	Healthcare	MD	501(c)(3)	3	UMMSC		No
(21) Shore Health System Inc 219 South Washington Street Easton,MD21601 52-0610538	Healthcare	MD	501(c)(3)	3	UMMSC		No
(22) James Lawrence Kernan Hosp Endow Fd 2200 Kernan Drive Baltimore,MD21207 23-7360743	Fundraising	MD	501(c)(3)	11b	UMMSC		No
(23) James Lawrence Kernan Hospital Inc 2200 Kernan Drive Baltimore,MD21207 52-0591639	Healthcare	MD	501(c)(3)	3	UMMSC		No
(24) UMMS Foundation Inc 22 South Greene Street Baltimore,MD21201 52-2238893	Fundraising	MD	501(c)(3)	11a	UMMSC		No
(25) University of MD Medical System Corp 22 South Greene Street Baltimore,MD21201 52-1362793	Healthcare	MD	501(c)(3)	3	NA		No
(26) University of Maryland Charles Regional PO Box 1070 La Plata,MD20646 52-2155576	Healthcare	MD	501(c)(3)	11c	UMMSC		No
(27) Charles Regional Medical Center Foundati PO Box 1070 La Plata,MD20646 52-1414564	Fundraising	MD	501(c)(3)	11a	umcrh		No
(28) Charles Regional Medical Center Auxiliar PO Box 1070 La Plata,MD21204 52-1131193	Fundraising	MD	501(c)(3)	11a	umcrh		No
(29) Univ of MD St Joseph Foundation Inc 7601 Osler Drive Towson,MD21014 52-1681044	Fundraising	MD	501(c)(3)	11a	UMMSC		No
(30) Harford Memorial Hospital Inc 520 Upper Chesapeake Dr Bel Air,MD21014 52-0591484	Healthcare	MD	501(c)(3)	3	UMUCHS		No
(31) UCH Legacy Funding Corporation 520 Upper Chesapeake Dr Bel Air,MD21014 52-0882914	Fundraising	MD	501(c)(3)	11a	UMUCHS		No
(32) Univ of MD Upper Chesapeake Health Sys 520 Upper Chesapeake Dr Bel Air,MD21014 52-1398513	Healthcare	MD	501(c)(3)	11c; III-FI	UMUCHS		No
(33) Upper Chesapeake Health Foundation Inc 520 Upper Chesapeake Dr Bel Air,MD21014 52-1398507	Fundraising	MD	501(c)(3)	11a	UMUCHS		No
(34) Upper Chesapeake Medical Center Inc 520 Upper Chesapeake Dr Bel Air,MD21014 52-1253920	Healthcare	MD	501(c)(3)	3	UMUCHS		No
(35) Upper Chesapeake Medical Services Inc 520 Upper Chesapeake Dr Bel Air,MD21014 52-1501734	Healthcare	MD	501(c)(3)	9	UMUCHS		No
(36) Upper Chesapeake Properties Inc 520 Upper Chesapeake Dr Bel Air,MD21014 52-1907237	Real Estate	MD	501(c)(2)		UMUCHS		No
(37) Upper Ches Residential Hospice House 520 Upper Chesapeake Dr Bel Air,MD21014 26-0737028	Hospice	MD	501(c)(3)	7	UMUCHS		No
(38) Upper ChesapeakeSt Joe's Home Careinc 520 Upper Chesapeake Dr Bel Air,MD21204 52-1229742	Hospice	MD	501(c)(3)	9	UMUCHS		No
(39) UMSJ Health System LLC 7601 Osler Drive Towson,MD21204 46-0797956	Healthcare	MD	501(c)(3)	3	UMMSC		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2014

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	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(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) Arundel Physicians Associates LLC 301 Hospital Drive Glen Burnie,MD20161 52-2000762	Healthcare	MD	NA	N/A
(2) Baltimore Washington Imaging LLC 301 Hospital Drive Glen Burnie,MD20161 20-0806027	Healthcare	MD	NA	N/A
(3) NAHSunrise of Severna Park LLC 301 Hospital Drive Glen Burnie,MD20161 54-1810729	Healthcare	MD	NA	N/A
(4) North Arundel Senior Living LLC 301 Hospital Drive Glen Burnie,MD20161 54-1810728	Healthcare	MD	NA	N/A
(5) Innovative Health LLC 29165 Canvasback Drive Suite 100 Easton,MD21601 52-1997287	Billing	MD	NA	N/A
(6) Central Maryland Radiology Oncology LLC 10710 Charter Drive Columbia,MD21044 27-0879418	Healthcare	MD	NA	N/A
(7) Universitycare LLC 22 South Greene Street Baltimore,MD21201 52-1914892	Healthcare	MD	NA	N/A
(8) O'Dea Medical Arts Limited Partnership 7601 Osler Drive Towson,MD21204 52-1682964	Rental	MD	NA	N/A
(9) Advanced Imaging at St Joseph Medical C 7601 Osler Drive Towson,MD21204 52-1958002	Healthcare	MD	NA	N/A
(10) UCHSUMMS Real Estate Trust 520 Upper Chesapeake Dr Bel Air,MD21014 27-6803540	Real Estate	MD	NA	N/A

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) Arundel Physicians Associates Inc 301 Hospital Drive Glen Burnie,MD21061 52-1992649	Healthcare	MD	NA	C Corp
(2) Baltimore Washington Health Enterprises 301 Hospital Drive Glen Burnie,MD21061 52-1936656	Healthcare	MD	NA	C Corp
(3) BW Professional Services Inc 301 Hospital Drive Glen Burnie,MD21061 52-1655640	Healthcare	MD	NA	C Corp
(4) Univ of Maryland Charles Regional Care P PO Box 1070 La Plata,MD20646 52-2176314	Healthcare	MD	NA	C Corp
(5) University Midtown Prof Center A Condo 827 Linden Avenue Baltimore,MD21201 52-1891126	Real Estate	MD	NA	C Corp
(6) NA Executive Building Condo Assn Inc 301 Hospital Drive Glen Burnie,MD21061	Real Estate	MD	NA	C Corp
(7) Terrapin Insurance Company 98-0129232	Insurance		NA	C Corp
(8) UMMS Self Insurance Trust 22 South Greene Street Baltimore,MD21201 52-6315433	Insurance	MD	NA	Trust
(9) Upper Chesapeake Insurance Company PO Box 1109 Grand Cayman,Cayman Islands CJ 98-0468438	Captive Insurance	CJ	NA	ltd
(10) Upper Chesapeake Health Ventures Inc 520 Upper Chesapeake Dr Bel Air,MD21014 52-2031264	Healthcare	MD	NA	C Corp
(11) Upper Chesapeake Medical Center Land Con 520 Upper Chesapeake Dr Bel Air,MD21014 77-0674478	Real Estate	MD	NA	C Corp
(12) Upper Chesapeake Medical Office Building 520 Upper Chesapeake Dr Bel Air,MD21014 52-1946829	Real Estate	MD	NA	C Corp

Schedule R (Form 990) 2014

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

Yes

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

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

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

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

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

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

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

Schedule R (Form 990) 2014

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) 2014

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) 2014

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: Civista Medical Center, Inc. is a component of a reginal integrated health system serving the health needs of Charles County and the citizens of southern Maryland.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	17
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	14
5	Total number of individuals employed in calendar year 2014 (Part V, line 2a) ......	5	1,105
6	Total number of volunteers (estimate if necessary) .............	6	120
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	134,498
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-10,898

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	373,966	0
9	Program service revenue (Part VIII, line 2g) .........	128,305,767	132,649,970
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	-79,506	551,842
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	510,252	557,258
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	129,110,479	133,759,070
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	87,252	52,129
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)	52,674,539	54,048,003
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)....	65,768,408	64,633,320
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	118,530,199	118,733,452
19	Revenue less expenses. Subtract line 18 from line 12.......	10,580,280	15,025,618
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	158,176,511	149,948,298
21	Total liabilities (Part X, line 26).............	107,530,822	103,563,868
22	Net assets or fund balances. Subtract line 21 from line 20.....	50,645,689	46,384,430

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 101,234,693 including grants of $ 52,129 ) (Revenue $ 133,072,730 )
	University of Maryland Charles Regional Medical Center (UM CRMC) is the parent company of a regional integrated health system serving the health needs of Charles County and the citizens of Southern Maryland. UM CRMC's Community Benefits Program utilizes a planned, managed, organized, and measured approach to meeting the identified community needs of the area we serve. The mission is to improve overall community health by improving access to health care, enhancing the health of the community, advancing healthcare knowledge and working with health - providing agency partners. UM CRMC collaborated with the Charles County Department of Health (CCDOH) to complete a comprehensive assessment of the health needs (CHNA) of Charles County, Maryland. An epidemiologist with a Master's Degree in Public Health Epidemiology was contracted to analyze the qualitative and quantitative data. UM CRMC lead the effort and covered 80% of the cost of the CHNA. To provide a comprehensive assessment of the health needs of the county, a four method plan was developed which included four different sources of data: a long online survey of Charles County residents perceptions of health and health behaviors, a short paper survey on health perceptions throughout the county, seven focus groups with community leaders, citizens, and stakeholders, and a quantitative data analysis. The use of the multiple data collection methods strengthened the validity of the assessment's findings, as well as ensured that Charles County residents had an opportunity to participate in the assessment process and to feel invested in its outcome. Three hundred and two Charles County residents completed the 74 question online survey that was created using Survey Monkey. The link to the survey was available on the UM CRMC website. The first section of the survey asked participants about their perception of health and health services within the county. The second section asked them about their health behaviors, in order to determine their risk for the development of certain health conditions. A short three question survey was distributed throughout the county regarding perceptions of health within the county. A total of 200 short surveys were completed. Surveys were located throughout the county including UM CRMC waiting rooms, CCDOH waiting rooms, libraries, senior centers, community centers. Thirty five were completed in Spanish (17.5%). Seven focus groups were held throughout the county. The focus group topics included: age related health issues, chronic disease specific health, special populations, county leadership, substance abuse, youth through the school nurses, and the Partnerships for a Healthier Charles County (PHCC). Approximately 165 people participated in the county focus groups from a wide variety of organizations and community groups. Quantitative data was analyzed for several health topics including: mortality, population and demographic data, natality, infant mortality, heart disease, stroke, hypertension, access to health care/health uninsurance, cancer, asthma, injuries, diabetes, obesity, osteoporosis, arthritis, dementia/Alzheimer's disease, communicable disease, sexually transmitted diseases, HIV/AIDS, mental health, dental health, substance abuse, disabilities, and tobacco use. Cumulative analysis of all quantitative and qualitative data identified the top 11 health needs of Charles County which was presented to the Partnerships for a Healthier Charles County, a coalition of Charles County agencies and organizations. The direction of Partnerships for a Healthier Charles County is guided by the Steering Committee which consists of leadership from UM CRMC, Charles County Department of Health, Charles County Public Schools, the College of Southern Maryland as well as a Public Health Epidemiologist. Focus Groups Included representatives from the following organizations: Partnerships for a Healthier Charles County University of Maryland Charles Regional Medical Center UM CRMC, Board Of Directors Charles County Department of Health University of Maryland Clinical Trials Program Bel Alton Alumni Association Charles County Department of Community Services, Transportation Tri County Council for Southern Maryland Minister's Alliance of Charles County CC Department of Social services Maryland Foundation for Quality healthcare Health Partner's Clinic Shiloh Community United Methodist Church CC Nursing and Rehabilitation Center Alzheimer's Association Center for Children Chesapeake Potomac Home Health Agency College of Southern Maryland Charles County Department of Aging Priority partners Big Brothers/Big sisters Community Hispanic Advocates Black Leadership Council for Excellence Young Researchers Community Project Pinnacle Center (Mental Health) Hospice Breast Cancer Support Advocates Charles County Public Schools - School Nurses Charles County Commissioners Charles County Emergency Services Charles County Sheriff's Office So MD Delegates Charles County Community Foundation Community Physicians Charles County Fire and Rescue Board Accomplishments: UM CRMC provided $10.5 million in charity care, health professions education, community benefit operations, community health improvement services, subsidized health services, cash and in-kind donations and community building activities in FY 2015. This year, we provided and supported programs, activities and screenings such as blood pressure, glucose, cholesterol, breast and cervical cancer, prostate cancer and stroke risk reduction education. We provided health education programs on hearty healthy eating, diabetes education, cancer education, breast and cervical cancer, tobacco cessation program. In addition, we sponsored American Cancer Society's Look Good Feel Better, advanced directives, arthritis, car safety seat inspections, community disaster drills, school career days, the Young Researches Community Project, and support groups such as stroke support, cardiac support, and the Better Breathers Club. We offer clinics and clinic services such as prenatal, OB clinic, renal dialysis services and American Red Cross blood drives. We participated in community coalitions and boards such as the United Way, Partnerships for a Healthier Charles County, Charles County Tobacco Coalition, Leadership Southern Maryland, Hospice of Charles County, Healthy Families, Fetal Infant Mortality Board, Center for Abused Persons, Juvenile Drug Court, Mission of Mercy; Chamber of Commerce and Charles County Child Advocacy Partnership. We participated in community events such as Christmas Connection, American Cancer Society's Relay for Life, Alzheimer's Walk, March of Dimes and Safe Nights.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses101,234,693

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	3,244,732	8,069,490	317,526

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

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

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			0
			Business Code
2a	NET PATIENT REVENUE		900099	132,649,970	132,649,970
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			132,649,970
3	Investment income (including dividends, interest, and other similar amounts).......			213,406			213,406
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	338,436
b	Less: cost or other basis and sales expenses
c	Gain or (loss)	338,436
d	Net gain or (loss)..........			338,436			338,436
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	ANSWERING SERVICE		561000	134,498		134,498
b	CAFETERIA & COFFEE BAR SALES		900099	355,975	355,975
c	CHANGE IN EQUITY OF AFFILIATES CPHA		900099	74,010	74,010
d	All other revenue ....			-7,225	-7,225
e	Total. Add lines 11a–11d ......			557,258
12	Total revenue. See Instructions......			133,759,070	133,072,730	134,498	551,842


				(A) Beginning of year		(B) End of year
1	Cash–non-interest-bearing .............			0	1	0
2	Savings and temporary cash investments .........			21,245,679	2	20,680,284
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			7,988,094	4	7,944,863
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			1,586,764	8	1,675,458
9	Prepaid expenses and deferred charges ..........			205,947	9	319,972
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	110,981,019
b	Less: accumulated depreciation .....	10b	40,656,610	70,840,719	10c	70,324,409
11	Investments—publicly traded securities ..........			20,457,797	11	20,278,998
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 ...........			35,851,511	15	28,724,314
16	Total assets. Add lines 1 through 15 (must equal line 34)......			158,176,511	16	149,948,298
17	Accounts payable and accrued expenses .........			13,949,677	17	13,697,614
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
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 ..			19,523,669	23	18,484,229
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....................			74,057,476	25	71,382,025
26	Total liabilities. Add lines 17 through 25.........			107,530,822	26	103,563,868
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			50,553,092	27	46,291,833
28	Temporarily restricted net assets ...........			92,597	28	92,597
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			50,645,689	33	46,384,430
34	Total liabilities and net assets/fund balances ........			158,176,511	34	149,948,298