Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private
foundations)
MediumBullet Do not enter social security numbers on this form as it may be made public.
MediumBullet Information about Form 990 and its instructions is at www.IRS.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
A For the 2014 calendar year, or tax year beginning 07-01-2014 , and ending 06-30-2015
BCheck if applicable:
CName of organization
Mary Hitchcock Memorial Hospital
 
Doing business as
 
 
Number and street (or P.O. box if mail is not delivered to street address)
One Medical Center Drive
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Lebanon, NH03756
D Employer identification number

02-0222140
E Telephone number

G Gross receipts $ 1,103,321,593
F Name and address of principal officer:
James Weinstein DO MS
One Medical Center Drive
Lebanon,NH03756
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.dartmouth-hitchcock.org
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1889
M State of legal domicile: NH
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: Advancing Health Through Research, Education, Clinical Practice, Community Partnerships, providing each person the best care in the right place, at the right time, every time
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 20
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 15
5 Total number of individuals employed in calendar year 2014 (Part V, line 2a) ...... 5 5,780
6 Total number of volunteers (estimate if necessary) ............. 6 480
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 4,012,573
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 502,506
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 20,984,972 5,075,715
9 Program service revenue (Part VIII, line 2g) ......... 892,093,711 908,783,191
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 17,100,684 17,620,625
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 57,253,892 47,796,806
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 987,433,259 979,276,337
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 5,272,967 1,947,820
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) 576,706,269 602,661,971
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet2,159,116    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 354,233,094 377,996,999
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 936,212,330 982,606,790
19 Revenue less expenses. Subtract line 18 from line 12....... 51,220,929 -3,330,453
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 1,331,158,473 1,294,964,551
21 Total liabilities (Part X, line 26)............. 689,440,250 696,007,861
22 Net assets or fund balances. Subtract line 21 from line 20..... 641,718,223 598,956,690
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet
Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2014)
Form 990 (2014)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III ..............
1
Briefly describe the organization’s mission: WE ADVANCE HEALTH THROUGH RESEARCH, EDUCATION, CLINICAL PRACTICE, AND COMMUNITY PARTNERSHIPS, PROVIDING EACH PERSON THE BEST CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, EVERY TIME.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 795,956,490 including grants of $ 1,947,820 ) (Revenue $ 925,032,743 )
Mary Hitchcock Memorial Hospital (the Hospital), is an acute and tertiary care teaching hospital located in Lebanon, New Hampshire. The Hospital is a not-for-profit organization, as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from Federal income taxes on related income pursuant to Section 501(a) of the Code. The Hospital provides a broad range of patient services and health related community services, consistent with its role as a community hospital, a major teaching hospital and a tertiary care referral hospital. These include a full range of services in both acute and critical medicine, surgery, psychiatry and rehabilitation for infants, children and adults. During FY 2015 the Hospital provided 127,558 acute patient days of inpatient service and had 26,317 total acute care discharges, while the Hospital's emergency room was open to the public 24 hours per day, 7 days per week and had 31,477 discharges. The Hospital operates as an integral component of Dartmouth-Hitchcock Medical Center (DHMC), a New Hampshire nonprofit corporation organized for the exploration and coordination of matters of mutual interest among its members: the Hospital, Dartmouth-Hitchcock Clinic (the Clinic), Geisel School of Medicine (GSM), a component of Dartmouth College, and the Veterans Affairs Medical Center in White River Junction, Vermont. The Clinic provides the physician staff to the Hospital and the sophistication essential for the development of the Hospital as the largest and only teaching hospital in New Hampshire and the designation by the federal government as a Rural Referral Center for northern New England. The shared mission of the Hospital and Clinic is to advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time. Its strategic operating plan lays out a path to creating a "sustainable health system to improve the lives of the people and communities we serve, for generations to come." The focus of this work, across the Dartmouth-Hitchcock organization, i.e. all Hospital and Clinic sites, is in three main areas: Improving Population Health; Delivering Value Based Care; and Developing and Implementing New Payment Models. Consistent with this mission and in partnership with the Clinic, the Hospital provides high quality, cost effective, comprehensive, and integrated health care to individuals, families, and the communities it serves regardless of a patient's ability to pay. The Hospital actively supports community-based health care and promotes the coordination of services among health care providers and social services organizations. The Hospital also seeks to work collaboratively with other area health care providers to improve the health status of the region. Effective with fiscal year 2000, the Hospital and the Clinic began filing an annual Community Benefit Report with the State of New Hampshire which outlines the community and charitable benefits they provide. The most recent Community Benefit Reports are available upon request or can be found on Dartmouth-Hitchcock's web site (www.dartmouth-hitchcock.org). Financial assistance, formerly called charity care, represents services provided to patients who cannot afford health care services due to inadequate financial resources which result from being uninsured or underinsured. For the year ended June 30, 2015 the Hospital provided financial assistance to 10,988 patients in the amount of $27,052,265, as measured by gross charges. The estimated cost of providing this care for the year ended June 30, 2015 was $10,531,447. The Hospital also routinely provides services to Medicaid patients at reimbursement levels that are below the cost of the care provided. The Community health activities includes the cost or value of several different types of programs including the cost of community based education, health fairs, health screenings, support groups, and programs and materials that promote wellness and prevent illness. Examples of these types of efforts include partnering with the Healthy Eating Active Living NH initiative, the Women's Health Resource Center, and smoking prevention and cessation. This category also includes financial contributions and the contribution of time and services to community programs, hospitals and agencies. The Hospital also provides a significant amount of uncompensated care to its patients reported as provision for bad debts, which is not included in the amounts reported above. During the years ended June 30, 2015, the Hospital reported a provision for bad debts of approximately $9,436,007.
4b (Code:   ) (Expenses $ 43,249,817 including grants of $   ) (Revenue $ 24,839,995 )
As a component of New Hampshire's only integrated academic medical center, the Hospital provides significant support for academic and research programs through its support of The Geisel School of Medicine at Dartmouth (GSM), the Hospital provides support for Physicians' unpaid teaching time as part of its Community Benefit Initiatives, consisting of the time physicians spend providing clinical supervision and education for residents and medical students. In addition, the Hospital provides in-kind support for research and other grants representing costs in excess of awards for numerous grant-funded health research and service initiatives awarded to the Clinic and GSM. Other community benefit initiatives include subsidizing the costs of providing medical and clinical education to professionals across New Hampshire, Vermont and beyond as well as uncompensated costs of academic and medical research activities.
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet839,206,307
Form 990 (2014)
Form 990 (2014)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If "Yes," complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIClick to see attachment.......
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment.........................
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If "Yes," complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
Yes
 
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IVClick to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV... Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions) ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H.... Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see list of attachments
20b
Yes
 
Form 990 (2014)
Form 990 (2014)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
Yes
 
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a................ Click to see list of attachments
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I.... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If "Yes," complete Schedule L, Part II................ Click to see attachment
26
Yes
 
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV .......................... Click to see attachment
28a
Yes
 
b
A family member of a current or former officer, director, trustee, or key employee? If "Yes,"
complete Schedule L, Part IV..................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV... Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..Click to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M............. Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2014)
Form 990 (2014)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V ..............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
1,046
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
3
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
5,780
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
Yes
 
b
If "Yes," enter the name of the foreign country: MediumBulletBD
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If "Yes," did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds.
Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year?.........................
8
 
 
9a
Did the sponsoring organization make any taxable distributions under section 4966?...
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
Form 990 (2014)
Form 990 (2014)
Page 6
Part VI
Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI ..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
20
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
15
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
Yes
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
NH
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletROBIN KILFEATHER-MACKEY
ONE MEDICAL CENTER DRIVE
Lebanon,NH03756 (603) 650-5634
Form 990 (2014)
Form 990 (2014)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII ..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) Jennie L Norman........................................................................
Trustee/Board Sec End 12/31/14
 1.5
.......................2.5 		X   X       0 0 0
(2) Hugh C Smith MD........................................................................
Trustee End 12/31/14
 0.75
.......................1.25 		X           0 0 0
(3) Vincent S Conti MHA........................................................................
Trustee
 0.75
.......................1.25 		X           0 0 0
(4) Anne-Lee Verville........................................................................
Trustee
 0.75
.......................1.25 		X           0 0 0
(5) Barbara Couch MS........................................................................
Trustee/Board Sec Eff 1/1/15
 0.75
.......................1.25 		X   X       0 0 0
(6) Wiley Souba MD ScD........................................................................
Trustee/Ex-Officio End 6/30/14
 0.75
.......................1.26 		X           0 0 0
(7) William J Conaty........................................................................
Trustee
 0.75
.......................1.25 		X           0 0 0
(8) William W Helman IV........................................................................
Trustee End 9/30/14
 0.75
.......................1.26 		X           0 0 0
(9) Robert A Oden Jr PhD........................................................................
Trustee/Board Chair
 1.5
.......................2.5 		X   X       0 0 0
(10) James N Weinstein DO MS........................................................................
Trustee Ex-Officio/CEO
 38.0
.......................23.01 		X   X       0 1,229,653 225,752
(11) Michael J Goran MD........................................................................
Trustee End 12/31/14
 0.75
.......................1.25 		X           0 0 0
(12) Denis A Cortese MD........................................................................
Trustee
 0.75
.......................1.25 		X           0 0 0
(13) Matthew B Dunne........................................................................
Trustee
 0.75
.......................1.25 		X           0 0 0
(14) Senator Judd A Gregg........................................................................
Trustee
 0.75
.......................0.75 		X           0 0 0
(15) Laura K Landy MBA........................................................................
Trustee
 0.75
.......................1.25 		X           0 0 0
(16) Paul P Danos PhD........................................................................
Trustee/Brd Treasurer
 1.5
.......................2.5 		X   X       0 0 0
(17) Barbara C Jobst MD........................................................................
Trustee
 0.75
.......................0.75 		X           0 0 0
Form 990 (2014)
Form 990 (2014)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) Troyen Brennan MD MPH........................................................................
Trustee Eff 4/1/15
 0.75
.......................1.25 		X           0 0 0
(19) R William Burgess Jr MBA........................................................................
Trustee Eff 1/1/15
 0.75
.......................1.25 		X           0 0 0
(20) Duane A Compton PhD........................................................................
Trustee/Ex-Officio Eff 7/15/14
 0.75
.......................1.56 		X           0 0 0
(21) M Brooke Herndon MD MS........................................................................
Trustee Eff 3/20/15
 0.75
.......................0.75 		X           0 0 0
(22) Charles G Plimpton MBA........................................................................
Trustee Eff 4/1/15
 0.75
.......................1.25 		X           0 0 0
(23) Richard J Powell MD........................................................................
Trustee Eff 7/1/15
 28.0
.......................12.8 		X           0 449,269 145,523
(24) Richard Rothstein MD........................................................................
Trustee Eff 7/1/15
 28.0
.......................12.0 		X           0 536,148 159,867
(25) Steven A Paris MD........................................................................
Trustee Eff 7/1/15
 28.0
.......................12.51 		X           0 357,571 117,329
(26) Robin Kilfeather-Mackey CPA........................................................................
Chief Financial Officer
 37.0
.......................24.01 		    X       0 520,432 214,698
(27) Daniel Jantzen CPA........................................................................
Chief Operating Officer
 41.0
.......................20.0 		    X       604,478 0 210,934
(28) Stephen Leblanc........................................................................
Exec VP Strtgy & Ntwrk Rltns
 15.0
.......................45.01 		    X       0 602,197 269,589
(29) Vincent Fusca III........................................................................
Chief of Staff
 28.0
.......................12.0 		    X       308,695 0 22,752
(30) Edward Merrens MD........................................................................
Chief Medical Officer
 28.0
.......................12.0 		    X       0 386,917 94,435
(31) George Blike MD........................................................................
Chief Quality & Value Officer
 28.0
.......................12.0 		    X       0 447,955 263,509
(32) Darlene A Saler........................................................................
Actg Chf Nrsg Ofr End 9/27/14
 41.0
.......................19.0 		    X       170,680 0 117,273
(33) John S Malanowski MILR........................................................................
Chief HR Officer
 41.0
.......................19.0 		    X       446,455 0 54,754
(34) Clifford J Belden MD........................................................................
CHF CLNCL OFCR END 6/22/15
 28.0
.......................12.0 		    X       0 710,709 55,414
(35) Terrence P Carroll PHD........................................................................
Chief Innovation Officer
 28.0
.......................12.0 		    X       641,630 0 53,393
(36) John Birkmeyer MD........................................................................
Chf Clncl Offr/EVP Entprs Sup
 37.0
.......................23.0 		    X       0 261,699 34,858
(37) Gay Landstrom PhD RN NEA-BC........................................................................
Chf Nursing Offr Eff 9/28/14
 41.0
.......................19.0 		    X       281,442 0 27,901
(38) Kimberly Troland JD........................................................................
General Counsel End 4/19/15
 37.0
.......................23.0 		    X       248,343 0 34,246
(39) Robert Greene MD MHCDS FACP........................................................................
Chf Popul Mgmt Ofr Eff 7/28/14
 41.0
.......................19.0 		    X       0 374,106 27,231
(40) John Kacavas JD........................................................................
General Counsel Eff 4/20/15
 41.0
.......................19.0 		    X       0 0 0
(41) Christine Schon........................................................................
V.P Comm. Grp. Pract. Ops
 28.0
.......................12.01 		      X     0 227,406 58,292
(42) Gail Dahlstrom........................................................................
V.P. Facilities Mgmt
 41.0
.......................19.0 		      X     230,720 0 102,141
(43) Tina Naimie CPA........................................................................
VP Corporate Finance
 28.0
.......................13.5 		      X     222,873 0 25,900
(44) Wendy Fielding........................................................................
VP Financial Planning
 28.0
.......................12.0 		      X     220,559 0 57,824
(45) Wendy Wells MD........................................................................
Dept. Chair Pathology
 28.0
.......................12.0 		      X     0 430,798 168,546
(46) Jocelyn Chertoff MD MS........................................................................
Dept Chair Diagnost Radiology
 28.0
.......................12.0 		      X     0 513,849 204,718
(47) Douglas Merrill........................................................................
Center Director Periop Svs
 28.0
.......................12.0 		      X     0 558,557 55,489
(48) Stephen Boyce........................................................................
VP Ambulatory Care
 28.0
.......................12.0 		      X     0 196,780 60,119
(49) Bruce King........................................................................
Pres & CEO New London Hosp
 0.0
.......................50.0 		        X   351,565 0 183,662
(50) Roderic Young........................................................................
VP Communications & Marketing
 28.0
.......................12.0 		        X   301,316 0 45,714
(51) Martin Purcell........................................................................
VP IS Operations
 28.0
.......................12.0 		        X   309,514 0 130,615
(52) Susan Reeves........................................................................
VP Colby Sawyer Nursing
 28.0
.......................8.0 		        X   317,485 0 129,187
(53) Elwood Leonard........................................................................
VP Development
 28.0
.......................12.0 		        X   303,342 0 57,286
(54) Carl Dematteo MD........................................................................
Fmr Chf Ql Compl Ofr/Physician
 28.0
.......................12.0 		          X 0 114,301 2,381
(55) Linda Von Reyn........................................................................
Fmr Chf Nursng Officer
 41.0
.......................19.0 		          X 230,017 0 104,641
(56) John Butterly MD........................................................................
Fmr Offr/Exec VP Med Affairs
 8.0
.......................32.0 		          X 0 552,569 72,826
(57) Lawrence Dacey MD........................................................................
Former CMO/ Phys
 26.7
.......................13.3 		          X 0 132,136 242,566
(58) Alan Weston........................................................................
Fmr Chief HR Officer
 41.0
.......................19.0 		          X 295,536 0 0
(59) Jeanine Arden-Ornt........................................................................
Fmr General Counsel
 37.0
.......................24.0 		          X 361,457 0 42,717
(60) Thomas Colacchio MD........................................................................
Former Officer/Phys
 28.0
.......................13.0 		          X 0 1,067,539 130,947
(61) Mary Oseid........................................................................
Fmr Key Emp/VP Enterprise Svcs
 28.0
.......................12.0 		          X 0 374,245 240,234
(62) Barbara Walters DO MBA........................................................................
Fmr Key Emp/Med Dir Acct Care
 22.0
.......................10.0 		          X 0 329,833 21,631
(63) Mary Kay Boudewyns........................................................................
Fmr Key Emp/Adm Dir Rev Mgmt
 28.0
.......................12.0 		          X 213,992 0 129,667
(64) Thomas Dodds MD........................................................................
Former Key Emp/Dept Chr Anesth
 28.0
.......................12.0 		          X 0 535,557 231,969
(65) Edward Catherwood MD MS........................................................................
Former Key Emp/Ctr Dir Hrt/Vsc
 28.0
.......................12.0 		          X 0 443,720 148,473
(66) Jeffrey OBrien........................................................................
Fmr Key Emp/VP Oncology
 28.0
.......................12.0 		          X 276,051 0 41,966
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 6,336,150 11,353,946 4,818,969
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet324
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
TRUSTEES OF DARTMOUTH COLLEGE,
37 DEWEY FIELD
HANOVER,NH03755 		ADMIN & DIR SUPPORT 31,647,452
Cross Country Staffing,
PO Box 404674
ATLANTA,GA303844674 		Staffing Services 10,053,381
Accretive Health,
401 N Michigan Ave Ste 2700
CHICAGO,IL60611 		REVENUE MGMT 8,304,381
Towers Watson Delaware Inc,
800 Boylston St
BOSTON,MA02199 		Employee Benefits 3,713,533
Turner Construction,
Two Seaport Lane
BOSTON,MA02210 		Construction Svcs 45,504,496
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet95
Form 990 (2014)
Form 990 (2014)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII .............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512-514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e 3,932,320
f All other contributions, gifts, grants, and
similar amounts not included above1f 		1,143,395
g Noncash contributions included in lines
1a-1f:$ 		682,435
h Total. Add lines 1a-1f.......MediumBullet 5,075,715
Program Service RevenueAmt Business Code
2a NET PATIENT SERVICE REVENUE 621110 902,108,753 901,494,418 614,335  
b RESEARCH RELATED ACTIVITIES 621110 6,674,438 6,674,438    
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 908,783,191
OtherAmt RevenueAmt 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 4,805,488   214,519 4,590,969
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents 1,145,093  
b Less: rental expenses 608,907  
c Rental income or (loss) 536,186 0
d Net rental income or (loss).......MediumBullet 536,186     536,186
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 135,708,724 542,762
b Less: cost or other basis and sales expenses 123,272,564 163,785
c Gain or (loss) 12,436,160 378,977
d Net gain or (loss)..........MediumBullet 12,815,137     12,815,137
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a PHARMACY INCOME 621110 21,795,010 21,636,817 158,193  
b CAFETERIA INCOME 621110 2,987,354     2,987,354
c OTHER ALLOCATED INCOME 611710 22,478,256 19,452,730 3,025,526  
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 47,260,620
12 Total revenue. See Instructions......MediumBullet 979,276,337 949,258,403 4,012,573 20,929,646
Form 990 (2014)
Form 990 (2014)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 1,162,906 1,162,906
2 Grants and other assistance to domestic individuals. See Part IV, line 22 .... 784,914 784,914
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 .... 10,367,083 2,574,405 7,610,905 181,773
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 4,948,969 4,948,969    
7 Other salaries and wages .... 453,106,031 375,993,776 77,107,156 5,099
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 39,428,081 32,824,049 6,604,022 10
9 Other employee benefits ....... 63,172,879 52,515,141 10,657,721 17
10 Payroll taxes ........... 31,638,928 26,339,545 5,299,375 8
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 2,080,956 62,447 2,018,509  
c Accounting ........... 490,727   490,727  
d Lobbying ........... 41,400 41,400    
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) .... 57,550,137 47,011,686 10,538,451  
12 Advertising and promotion .... 2,961,146 20,381 2,940,765  
13 Office expenses ....... 7,172,318 4,824,887 2,347,362 69
14 Information technology ...... 7,938,656 7,065,404 873,252  
15 Royalties .. 0      
16 Occupancy ........... 13,623,761 12,078,931 1,544,830  
17 Travel ............ 3,535,387 1,650,551 1,884,836  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 70,881 69,123 1,758  
20 Interest ........... 13,212,880 11,759,463 1,453,417  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 39,956,680 35,558,959 4,397,721  
23 Insurance .............. 3,518,309 3,518,309    
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES 139,005,955 138,922,282 83,673  
b MEDICAID ENHANCEMENT TAX 45,839,294 45,839,294    
c EQUIPMENT RENTAL & MAINT 11,928,207 10,616,104 1,312,103  
d ACDM, GME, TEACHING,& SUP 5,876,806 5,876,806    
e All other expenses 23,193,499 17,146,575 4,074,784 1,972,140
25 Total functional expenses. Add lines 1 through 24e 982,606,790 839,206,307 141,241,367 2,159,116
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2014)
Form 990 (2014)
Page 11
Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ............. 193,761 1 115,693
2 Savings and temporary cash investments ......... 44,744,859 2 10,175,102
3 Pledges and grants receivable, net ........... 5,000,000 3 0
4 Accounts receivable, net ............. 145,452,357 4 125,676,961
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
438,160 5 313,922
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 ............. 1,092,351 7 806,671
8 Inventories for sale or use .............. 14,174,352 8 15,427,916
9 Prepaid expenses and deferred charges .......... 8,055,419 9 7,906,477
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 963,834,764
b Less: accumulated depreciation ..... 10b 536,521,721 407,066,625 10c 427,313,043
11 Investments—publicly traded securities .......... 280,390,609 11 325,346,264
12 Investments—other securities. See Part IV, line 11 ..... 331,518,264 12 254,702,840
13 Investments—program-related. See Part IV, line 11 ..... 4,385,931 13 8,808,343
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 88,645,785 15 118,371,319
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 1,331,158,473 16 1,294,964,551
Liabilities 17 Accounts payable and accrued expenses ......... 123,803,858 17 125,289,886
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 412,543 19 465,950
20 Tax-exempt bond liabilities ............. 343,068,534 20 335,292,116
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 .. 148,038,569 23 147,351,381
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.................... 74,116,746 25 87,608,528
26 Total liabilities. Add lines 17 through 25......... 689,440,250 26 696,007,861
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 555,516,650 27 519,605,834
28 Temporarily restricted net assets ........... 57,291,018 28 50,053,367
29 Permanently restricted net assets ........... 28,910,555 29 29,297,489
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 641,718,223 33 598,956,690
34 Total liabilities and net assets/fund balances ........ 1,331,158,473 34 1,294,964,551
Form 990 (2014)
Form 990 (2014)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI ..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
979,276,337
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
982,606,790
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
-3,330,453
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
641,718,223
5
Net unrealized gains (losses) on investments ...............
5
-17,816,000
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-21,615,080
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
598,956,690
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII .............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? .................
3a
Yes
 
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
Yes
 
Form 990 (2014)
Form 990 (2014)
Page 13
Form 990, Special Condition Description:
Special Condition Description
Form 990 (2014)
Form 990 (2014)
Page 14
Additional Data


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

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ.
right arrow 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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
a
b
c
d
e
f
Enter the number of supported organizations .............................  
g
Provide the following information about the supported organization(s).
(i)Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
Yes No
Total    

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2014
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) right arrow (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) right arrow (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.  
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2014
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) right arrow (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) right arrow (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.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2014
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
No
1
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.
1
 
 
2
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).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.
3a
 
 
b
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.
3b
 
 
c
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.
3c
 
 
4a
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.
4a
 
 
b
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....
4b
 
 
c
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.
4c
 
 
5a
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).
5a
 
 
b
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?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
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.
6
 
 
7
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) .
7
 
 
8
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).
8
 
 
9a
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.
9a
 
 
b
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.
9b
 
 
c
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.
9c
 
 
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
 
 
b
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
 
 
11
Has the organization accepted a gift or contribution from any of the following persons?
a
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
 
 
b
A family member of a person described in (a) above?
11b
 
 
c
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
Schedule A (Form 990 or 990-EZ) 2014
Page 5
Part IV
Supporting Organizations (continued)

Section B. Type I Supporting Organizations
Yes
No
1
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.
1
 
 
2
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.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
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).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
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?
1
 
 
2
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).
2
 
 
3
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.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer (a) and (b) below.
Yes
No
a
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.
2a
 
 
b
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.
2b
 
 
3
Parent of Supported Organizations. Answer (a) and (b) below.
a
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.
3a
 
 
b
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.
3b
 
 
Schedule A (Form 990 or 990-EZ) 2014
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
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:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......... Arrow Bullet $  
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)
Page 2
Name of organization
Mary Hitchcock Memorial Hospital
  		Employer identification number

02-0222140
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
 
 

   
 
 
  ,    

$RESTRICTED


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)
Page 3
Name of organization
Mary Hitchcock Memorial Hospital
  		Employer identification number

02-0222140
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)
Page 4
Name of organization
Mary Hitchcock Memorial Hospital
  		Employer identification number

02-0222140
Part III
Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10)
that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd Bullet 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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

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

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

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

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2014

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 Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
Not over $500,00020% of the amount on line 1e.
Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
Over $17,000,000$1,000,000.
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the 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


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)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
Yes
 
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
165,290
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
73,062
j
Total. Add lines 1c through 1i ...............................
238,352
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
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 ACTIVITY EXPLANATION FORM 990, SCHEDULE C, PART II B, LINES 1B & 1G MARY HITCHCOCK MEMORIAL HOSPITAL EMPLOYS TWO FULL TIME STAFF WHOSE DUTIES INCLUDE LOBBYING. TYPICAL EXPENSES ASSOCIATED WITH THE LOBBYING ACTIVITIES INCLUDE STAFF SALARY, TRAVEL, MEMBERSHIP FEES AND DUES. FROM TIME TO TIME, MARY HITCHCOCK MEMORIAL HOSPITAL, THROUGH ITS EMPLOYEES AND THE USE OF CONSULTANTS, CONTACTS GOVERNMENT OFFICIALS AND LEGISLATORS. THIS CONTACT IS FOR THE PURPOSE OF PROPOSING LEGISLATION OR EXPRESSING AN OPINION ON CHANGES IN LEGISLATION THAT AFFECT THE HOSPITAL AND ITS ABILITY TO CARRY OUT ITS MISSION. THE ACTIVITIES INCLUDE SENDING LETTERS TO, CALLING, AND MEETING WITH GOVERNMENT OFFICIALS AND LEGISLATORS. FOR THE FISCAL YEAR ENDED JUNE 30, 2015, MARY HITCHCOCK MEMORIAL HOSPITAL INCURRED $165,290 IN CONJUCTION WITH THESE ACTIVITIES.
Form 990 Schedule C, Part II B, Line 1I MHMH pays dues to various organizations related to its exempt mission. The amount reported under other activities on line 1I refers to the amount of lobbying activities identified in dues payments to outside organizations.
Schedule C (Form 990 or 990EZ) 2014

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet Attach to Form 990.
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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
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 ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenue included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenue included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2014

Schedule D (Form 990) 2014
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII .......
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance .... 74,609,411 54,935,134 57,050,185 54,023,225 54,110,647
b Contributions ........ 208,107 17,029,356 188,155 30,717 398,541
c Net investment earnings, gains, and losses -516,882 3,029,123 -357,053 3,834,255 842,732
d Grants or scholarships .....   16,800 5,322 15,000  
e Other expenditures for facilities
and programs ........ 		1,580,301 1,648,675 1,940,831 823,012 1,328,695
f Administrative expenses ....          
g End of year balance ...... 72,720,335 73,328,138 54,935,134 57,050,185 54,023,225
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet29.622 %
b
Permanent endowment SchDMd Bullet52.720 %
c
Temporarily restricted endowment SchDMd Bullet17.658 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   40,738,341 40,738,341
b Buildings ................   484,087,239 270,348,317 213,738,922
c Leasehold improvements ............   4,130,597 3,615,129 515,468
d Equipment ................   390,849,622 262,558,275 128,291,347
e Other .................   44,028,965   44,028,965
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 427,313,043
Schedule D (Form 990) 2014

Schedule D (Form 990) 2014
Page 3
Part VII
Investments—Other 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    
(3)Other
(A) FIXED INCOME 		92,652,896 F

(B) PRIVATE EQUITIES 		30,475,622 F

(C) HEDGE FUNDS 		49,689,467 F

(D) OTHER INVESTMENTS 		81,884,855 F





Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet 254,702,840
Part VIII
Investments—Program 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.)Small Bullet  
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) INVESTMENT IN CAPTIVE 2,878,669
(2) DUE FROM AFFILIATES 77,503,062
(3) BOND ISSUANCE COSTS 2,992,348
(4) OTHER MISC ASSETS 20,002,257
(5) CAPITAL LEASE RECEIVABLE 14,994,983




Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 118,371,319
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
THIRD PARTY SETTLEMENTS 26,960,967
ACCRUED POST RETMNT PENS & MED 52,436,110
INTEREST RATE SWAP 8,211,451






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 87,608,528
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

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
Intended use of Endowment Funds Form 990 Schedule D Part V Line 4 The intended use of the endowment funds is to promote and advance the following mission-related programs: healthcare services, research, charity care, and health education. ASC 740 (Fin 48) Footnote Form 990 Schedule D Part X No ASC 740 (Fin 48) footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption.
Schedule D (Form 990) 2014

Additional Data


Software ID:  
Software Version:  




SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16.Right pointing arrow large image Attach to Form 990.Right pointing arrow large image Information about Schedule F (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
General Information on Activities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of its grants
and other assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria
used to award the grants or assistance? ...........................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other assistance outside the United States.
3
Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in region (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total expenditures
for and investments
in region
East Asia and the Pacific     Program Services Educational Travel Exp 241
Europe (Including Iceland and Greenland)     Program Services Dues 310
Europe (Including Iceland and Greenland)     Program Services Honorarium Payments 1,370
Europe (Including Iceland and Greenland)     Program Services Software 8,207
Europe (Including Iceland and Greenland)     Program Services Insurance 103,500
Europe (Including Iceland and Greenland)     Program Services Travel 26,428
Europe (Including Iceland and Greenland)     Program Services Publications 2,908
North America     Program Services Honorarium Payments 815
North America     Program Services License 1,570
North America     Program Services Software 5,765
North America     Program Services Office Equipment 113,320
North America     Program Services Travel 32,283
North America     Program Services Services 23,294
North America     Program Services Publications 752
North America     Program Services Waste 70
North America     Program Services Studies Book 3,450
North America     Program Services Outdoor Lighting 405
North America     Program Services Activities Supplies 185
Middle East and North Africa     Program Services Software 9,522
South America     Program Services Travel 646
Central America and the Caribbean     Program Services Travel 5,383
South America   6 Program Services Medical Services 16,406
South Asia   1 Program Services Medical Services 1,105
East Asia and the Pacific   2 Program Services Medical Services 9,083
Central America and the Caribbean   3 Program Services Medical Services 3,425
Sub-Saharan Africa   7 Program Services Medical Services 494,063
Central America and the Caribbean     Investments Inv in Ins Captive 2,878,669
3a Sub-total .....     324,688
b Total from continuation sheets to Part I ...   19 3,418,487
c Totals (add lines 3a and 3b)   19 3,743,175
For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2014
Schedule F (Form 990) 2014
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (a)(c) Region (b)(d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter ....MediumBullet
 
3
Enter total number of other organizations or entities .......................MediumBullet
 
Schedule F (Form 990) 2014
Schedule F (Form 990) 2014Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2014
Schedule F (Form 990) 2014
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes,"the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................
2 Did the organization have an interest in a foreign trust during the tax year? If "Yes," the organization may be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A; do not file with Form 990)............................
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If “Yes,” the organization may be required to file Form 8621, Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)...............................................
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713; do not file with Form 990).....................................
Schedule F (Form 990) 2014
Schedule F (Form 990) 2014
Page 5
Part V
Supplemental Information
Provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
ReturnReference Explanation
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule F (Form 990) 2014
Additional Data


Software ID:  
Software Version:  



SCHEDULE H (Form 990)
Department of the TreasuryInternal Revenue Service
Hospitals
MediumBullet 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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
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.
3
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.
a
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:
3a
Yes
 
b
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: .........
3b
Yes
 
%
c
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.
4
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"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
 
No
c
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? ..............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (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) .. 		    10,504,394   10,504,394 1.070 %
b Medicaid (from Worksheet 3,
column a) .... 		    163,787,802 61,489,942 102,297,860 10.410 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    174,292,196 61,489,942 112,802,254 11.480 %
Other Benefits
     3,616,956 1,828,448 1,788,508 0.180 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		    41,697,435 12,258,261 29,439,174 3.000 %
g Subsidized health services
(from Worksheet 6) .. 		    1,790,076 273,855 1,516,221 0.180 %
h Research (from Worksheet 7)     3,607,916 21,594 3,586,322 0.360 %
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		    3,650,468   3,650,468 0.370 %
j Total. Other Benefits ..     54,362,851 14,382,158 39,980,693 4.090 %
k Total. Add lines 7d and 7j .     228,655,047 75,872,100 152,782,947 15.570 %
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.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing     10,350   10,350  
2 Economic development     638,873 477,970 160,903  
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy     49,788   49,788  
8 Workforce development     14,594   14,594  
9 Other            
10 Total     713,605 477,970 235,635  
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
9,436,077
3
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. ......
3
 
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
269,468,394
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
295,037,671
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-25,569,277
8
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:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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.......................

9b

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
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) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 Mary Hitchcock Memorial Hospital
One Medical Center Drive
Lebanon,NH03756
www.dartmouth-hitchcock.org 		X X X X   X X   Psych Unit and Transplant Unit Cancer Center  
Schedule H (Form 990) 2014
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)
Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 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?....................... 1   No
2 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.......... 2   No
3 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.................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
5 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 ................. 5 Yes  
6a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C................................ 6a Yes  
b 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. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public? .............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 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. ............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 12
10 Is the hospital facility's most recently adopted implementation strategy posted on a website? ........ 10 Yes  
a If "Yes" (list url): Please see Section C, Supplemental Info
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b   No
11 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   No
b If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 12b    
c 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
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Financial Assistance Policy (FAP)
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 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):
a
b
c
d
e
16 Included measures to publicize the policy within the community served by the hospital facility?....... 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
h
i
Billing and Collections
17 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?.................................. 17 Yes  
18 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:
a
b
c
d
e
Schedule H (Form 990) 2014
Schedule H (Form 990) 2014
Page
Part VFacility Information (continued)

Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
19 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?......... 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
20 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):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 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?................ 21 Yes  
If "No," indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
22 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.
a
b
c
d
23 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? ................................ 23   No
If "Yes," explain in Section C.
24 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? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2014
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
Form 990, Sch H, Part V, Section B Line 3 Input From Representatives of Community Served by the Hospital Facility D-H is actively engaged in the development of an active Upper Valley Regional Public Health Advisory Council (35+ community representatives) and broader ReThink Health Initiatives (100+ community representatives). Members of these two community health advisory groups have had the opportunity to review and comment on drafts of Dartmouth-Hitchock's Community Health Improvement Plan. The plan document has also been circulated to public health officials in Vermont for their comment. In addition, Dartmouth-Hitchcock representatives serve on numerous boards, task forces, municipal health leadership and planning teams, and other community health leadership entities in order to ensure that we both participate in and better understand the needs of our community. Form 990, Schedule H, Part V, Section B Line 6A CHNA Conducted With One Or More Other Hospital Facilities During 2012, MHMH partnered with Alice Peck Day Memorial Hospital and Mount Ascutney Hospital and Health Care. Form 990, Schedule H, Part V, Section B Line 6B CHNA Conducted With One Or More Organizations Other Than Hospital Facilities In 2012, in addition to other hospitals, the assessment was completed in partnership with Granite State United Way. Form 990, Schedule H, Part V, Section B Line 7a Community Health Needs Assessment The Community Health Needs Assessment can be found online at http://www.dartmouth-hitchcock.org/about_dh/community_benefits_program.htm l Form 990, Schedule H, Part V, Section B Line 7c & 7d Community Health Needs Assessment The Needs Assessment was distributed to non-profit organizations throughout the region including the United Way. It is also available from the Organization upon request. Form 990, Schedule H, Part V, Section B Line 10a Community Health Needs Assessment Implementation Strategy The Community Health Needs Assessment Implementation Strategy can be found online at http://www.dartmouth-hitchcock.org/about_dh/community_benefits_program.htm l Form 990, Schedule H, Part V, Section B Line 11 Community Health Needs Identified Based upon the most recent community benefits report, MHMH is increasing community benefits spending to address identified community needs, particularly, oral health, needs of older adults, substance misuse prevention, and obesity/nutrition/physical activity. In FY 2015, Mary Hitchcock Memorial Hospital's (MHMH) Community Health Improvement strategies were consistent with the intentions identified in our Community Health Improvement Plan to address identified community health needs by: a) increase investment; b) maintain similar levels of investments for services and initiatives already provided by MHMH; or c) limit investment in areas where other community organizations already provide leadership and services to address the need, or where the identified need is significantly outside the mission/services/scope of MHMH. Mary Hitchcock Memorial Hospital's Community Health Improvement Plan is a 3-year document identifying anticipated investments and activities that it will take to address needs identified in the most recent Upper Valley Community Health Needs Assessment (CHNA). In four cases, items identified in the CHNA were not adddressed by MHMH: 1) the need for more affordable housing; 2) the need for more livable wage jobs; 3) the need to reduce rural isolation; and 4) the need for improved quality of education. These needs are outside the traditional mission/services/scope of the hospital; the region looks to other entities, such as Granite United Way, Twin Pines Housing Trust, Lebanon Housing Authority; Vital Communities; and others, for leadership to address these needs. In these cases, MHMH's response may include: a) minimal investment of time, leadership, and expertise, such as serving on community committees; b) making cash investments in the lead organization or addressing smaller aspects of the identified need as part of a collaboration with community organizations, such as cash support for the Upper Valley Housing Coalition and investing in an on-site employment training program for young adults with developmental disabilities; or c) investing in the issue, but in a way that may not meet criteria for inclusion as a Community Benefit, such as investing significantly in regional jobs training activities that help individuals move to higher paying, stable jobs at Dartmouth-Hitchcock or developing pediatric clinic-community approaches to improving care for children with asthma. While these efforts address an identified community need, the cost of these efforts cannot be separated from MHMH's business model or standard of clinical care, thus do not qualify as Community Benefits. Additionally, leadership to address two community needs: cancer prevention; and prevention of unintentional injuries, is led primarily by teams who are employed by the Geisel School of Medicine at Dartmouth College. In many cases, while leadership for these efforts are provided by staff who have dual appointments to both the Geisel School of Medicine and MHMH, the cost accounting for these efforts occurs through the Geisel School, so MHMH does not claim leadership in these areas of community health improvement. In both cases, however, MHMH does provide cash support to the Geisel School of Medicine teams who do this work in our Hospital Service Area and throughout New Hampshire and Vermont. Form 990, Schedule H, Part V, Section B Line 13B Discounted Care by income level other than FPG Patients whose family income exceeds 300% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of D-H. Form 990, Schedule H, Part V, Section B Line 13G Residency In order to receive financial assistance, an individual must be a resident of NH or VT, or a non-resident who experiences a medical emergency. Form 990, Schedule H, Part V, Section B Line 13H Uninsured Discount Policy D-H has a separate Uninsured Discount Policy that outlines how the discount is calculated annually and is applied prior to billing any uninsured patient. This assures a patient is not billed at an amount greater than the amount generally billed to patients with insurance. This is referenced as a link in the Financial Assistance Policy.
Form 990, Schedule H, Part V, Section B Line 16 A-C The financial assistance policy can be found at: http://www.dartmouth-hitchcock.org/documents/dh_financial_assistance_polic y.pdf The financial assistance application can be found at: http://www.dartmouth-hitchcock.org/documents/DH-NHHAN_Application_SR_WEB.p df The plain language financial assistance summary can be found at: http://www.dartmouth-hitchcock.org/documents/financial_services_brochure-1 2152015.pdf Form 990, Schedule H, Part V, Section B Line 16i Financial Assistance Policy availability within the Community MHMH financial assistance policy is posted on MHMH's website, including the verbatim policy and a shorter, more patient-friendly version. MHMH provides the patient friendly brochure version of the policy to all uninsured patients who enter the health system. MHMH continues to notify patients on the back of the billing statement about financial assistance being available to them. Additionally, MHMH posts information about the policy in public areas throughout the facilities including admission offices. MHMH has also made additional changes internally to increase awareness of the policy, including adding information to the back of the patient's statement about financial assistance available to them, posting information about the policy in public areas throughout the facilities, and ensuring financial assistance policy brochures are available in patient areas. MHMH Screens 100% of uninsured inpatient and same-day patients prior to admission. As part of this process, MHMH checks all state and federal programs to see if individuals are eligible for assistance. Patients are also screened to determine qualification for financial assistance and the application is provided and/or completed at this time. Form 990, Schedule H, Part V, Section B Line 22B Maximum charges to financial assistance policy-eligible individuals for emergency or medically-necessary care MHMH uses the average of the three highest commerical payer discounts and applies this as a discount for all uninsured patients. The discount rate is 43%. Form 990, Schedule H, Part V, Section D Facility information The Hospital has a Cancer Treatment Center located in Saint Johnsbury, Vermont. This location is registered under the same license as the Organization's main Campus located in Lebanon, New Hampshire.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2014
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
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
Form 990, Schedule H, Part I, Line 3c Other factors used in determining eligibility other than FPG Guidelines D-H uses the FPG guidelines in determining the initial level of financial assistance provided. In addition, D-H allows for catastrophic assistance consideration based on a calculation of 10% of two years income plus 10% of amount over sheltered assets. If the projected or current selfpay balance is greater than this calculation, the Selfpay balance is reduced to the sum of 10% of two years income plus 10% of assets. Each household is allowed certain sheltered assets which are not used when calculating household income or assets. Savings is sheltered up to 100% of FPL based on family size, equity in primary residence up to $200,000 up to 55 and $250,000 for aged 55 and older, and a retirement shelter of up to $ 100,000 in retirement assets as long as it is employer based contributions if working or IRA if self-employed. If a patient is retired, prior retirement accounts would be included as a sheltered asset. Form 990, Schedule H, Part I, Line 6a Community Benefits Report Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic (Collectively referred to as Dartmouth-Hitchcock (D-H)) share common board members and operate under an affiliation agreement. D-H performs a joint Community Health Needs Assessment (CHNA) and files a consolidated Community Benefits report with the state of New Hampshire. For purposes of IRS Form Schedule H, only Hospital numbers were used. All amounts relating to DHC were excluded. The New Hampshire Community Benefits Report filed for fiscal year 2015, DHC and MHMH combined, totaled $184,854,551.
Form 990, Schedule H, Part I, Line 7 Costing Methodology The costing methodology used to calculate the amounts reported was a cost-to-charge ratio derived from worksheet 2, Ratio of Patient Care Cost-to-Charges.
Form 990, Schedule H, Part I, Line 7G Subsidized health services related to physician clinics The Organization did not include any subsidized health service costs attributable to a physician clinic on Part I, line 7G.
Form 990, Schedule H, Part II Community Building Activities Community Building activities include expenses related to coalitions that address rural emergency/trauma services, prevention of pediatric obesity, prevention of substance abuse, falls reduction for older adults, public health networks, prescription drug misuse, and low-income housing. These also include cash support and/or contributed in-kind support for the development and maintenance of housing for low-income families, regional economic development, and support for regional workforce development services.
Form 990, Schedule H, Part III, Section A Lines 2 and 3 Bad Debt Expense The amounts reported on Part III, Section A, line 2 were derived from MHMH's audited financial statements (provision for bad debt). MHMH's Policy is to exert everything in the Organization's power to obtain sufficient and adequate information to determine eligibility for financial assistance. MHMH's discount for uninsured patients is currently 43% (before financial assistance is applied). As part of MHMH's Financial Assistance Policy, MHMH makes information available to patients for eligibility and how to apply for free or discounted care. If the patient does not respond to the hospital's attempts to complete the financial assistance package, these patients may be written off to bad debt. Prior to moving any balance to bad debt it is assessed for charity through the organization's presumptive charity process. If the patient balance meets the presumptive charity qualification, it is adjusted to financial assistance and therefore never charged to bad debt.
Form 990, Schedule H, Part III, Section A Line 4 Audited financial Statement Disclosure for Charity Care and Provision for Bad Debt (Please note that MHMH files a combined audited financial statement with Dartmouth-Hitchcock Clinic and other Subsidiaries). MHMH provides care to patients who meet certain criteria under their financial assistance policies without charge or at amounts less than their established rates. Because MHMH does not anticipate collection of amounts determined to qualify as charity care, they are not reported as revenue. MHMH grants credit without collateral to patients. Most are local residents and are insured under third-party arrangements. Additions to the allowance for uncollectible accounts are made by means of the provision for bad debts. Accounts written off as uncollectible are deducted from the allowance and subsequent recoveries are added. The amount of the provision for bad debts is based upon managements assessment of historical and expected net collections, business and economic conditions, trends in federal and state governmental healthcare coverage, and other collection indicators.
Form 990, Schedule H, Part III, Section B Line 8 Medicare Shortfalls The costing methodology used to calculate the amounts reported as Medicare Shortfalls was derived from the Internal Revenue Service's Worksheet B as provided for Part III calculations. MHMH had revenues of $22,391,314 and costs of $31,023,274 for services not included on the Medicare Cost Report (Ambulance Services, Laboratory and other fees screens, and Medicare Part C & D services). MHMH incurred a net loss of $8,631,960 on the provision of these services. Because of the central role of the organization in serving the healthcare needs of its community and the demographic characteristics of the community served, it is likely that a portion of the Medicare shortfall should be considered community benefit expenditure. MHMH has not identified a specific amount of Medicare Shortfall that should be reported as such.
Form 990, Schedule H, Part III, Line 9b Credit and Collection Policy MHMH has a Credit and Collection Policy that addresses the procedures for patients who choose not to make payment or work with MHMH to make payment arrangements for their bill. The Organization has a separate Financial Assistance Policy that addresses those patients who are unable to make payment. MHMH is a charitable health care organization who treats patients that come for medically necessary care, regardless of their financial status. MHMH offers financial assistance in the form of free or discounted care to those patients who have an inability to pay their bills. The Financial Assistance Policy outlines eligibility criteria for financial assistance; the method by which patients may apply for financial assistance; the basis for calculating amounts charged to patients eligible for financial assistance under this policy; D-H's measures to widely publicize the policy within the community served; and the limitation of charges for emergency or other medically necessary care. Patients can qualify for 25%, 50%, 75%, or 100% reduction based on Federal Poverty Levels as well as a catastrophic guideline of 10% of 2 year's income for those that may not qualify based on assets and income, but who have a bill beyond their means to pay. If a financial assistance policy eligible patient has a balance for which they are responsible after a financial assistance discount is applied, the standard collection practices are followed as outlined in the D-H Credit and Collections policy. Under the Credit and Collections Policy, Dartmouth-Hitchcock routinely attempts to collect the most current insurance information for a patient. For any unpaid balances, D-H will issue the billing statement and request payment in full within 30 days. Partial payments are accepted as long as minimum payment expectations are met as outlined in the budget plan procedure. Regulatory requirements mandate no account be transferred to a collection agency less than 120 days from the initial date of service. Balances move to collections when they are determined to be uncollectible and at that time they are moved to a collection agency and are considered in default. Collection agencies are allowed to report balances due D-H to credit reporting agencies 60 days after placement if there is no resolution of the balance reached during this period. D-H reserves the right to file a lien in liability cases for the interest of the hospital.
Form 990, Schedule H, Part VI, Line 2 Needs Assessment Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic (Collectively referred to as Dartmouth-Hitchcock (D-H)) share common board members and operate under an affiliation agreement. D-H performs a joint Community Needs Assessment and files a consolidated Community Benefits report. Dartmouth-Hitchcock participates with other health care charitable trusts and community partners in each of our service areas to complete community health needs assessments. During 2012, MHMH partnered with Alice Peck Day Memorial Hospital, Mount Ascutney Hospital and Health Care, and Granite State United Way to conduct a Community Needs Assessment. The needs assessment included reviewing health data available throughout NH and VT Health Departments; Behavioral Risk Factor Surveillance Survey and youth Risk Behavior Surveys; focus groups with community members from lower-income neighborhoods; and electronic surveys of professional health and social service providers as well as community residents. This information was reviewed by a Steering Committee comprised of community leaders from the health care system, education, public health, and other social service organizations to develop a community needs assessment. The Steering Committee's work was reviewed at larger community gatherings in fall 2012 for further comments and feedback. In addition, MHMH reviewed related health data generated through www.CHNA.org as a comparative tool. MHMH monitors emerging health data on an ongoing basis as it is released by each state, schools, and other community entities. As part of the needs assessment, the Steering Committee reviewed: 1. Health, economic, and education data from sources including Youth Risk Behavior Surveys, the Behavioral Risk Factor Surveillance System, public health and hospital discharge data available in NH Health WRQS, census data, and reports from the New England Common Assessment Program. Additionally, it reviewed the 2011 NH State Health Profile and Upper Valley Regional Health Profile, quantitative and qualitative data from local sources (newspapers, regional planning offices, community forums) to identify concerns that emerged, intensified, or were the source of local attention since the last secondary data was collected. Emergent issues that are not well-reflected in secondary data but were reflected elsewhere include oral health needs (data from UV Smiles school-based oral health clinics), prescription drug misuse (data from the NH Governor's Commission on Alcohol and other Drug Abuse Prevention, Intervention, and Treatment), housing assessments (data from Upper Valley Lake Sunapee Regional Planning Commission), and reductions in availability of appropriate mental health services (news outlets and professional stakeholder interviews). 2. Opinion data from professional stakeholders using an online opinion poll of regional leaders in health, public health, education, municipal governments, public safety, and social service providers. 67 informed stakeholders responded to this survey. 3. Focus group data collected from 6 focus groups largely consisting of lower-income consumers of health/welfare services. 4. Opinion data from residents collected through community list-servs, individual interviews at human service organizations, and focus groups. These surveys were targeted primarily to economically stable households. 196 residents responded to surveys. Dartmouth-Hitchcock regularly monitors newly released health, economic, and education data from our service region to identify emerging regional needs and concerns, including FY 2013 Youth risk Behavior Surveys, the 2013 NH State Health Improvement Plan, NH's emerging state plans to address substance misuse, prescription drug misuse, obesity, and children's behavioral health.
Form 990, Schedule H, Part VI, Line 3 Patient Education of Eligibility for Assistance All uninsured inpatients, same day surgery, observation, and Emergency Department patients are pro-actively screened using an automated tool to identify potential qualification for other federal, state, and local programs. In addition, specific outpatient activities deemed to have a higher rate of need are screened as part of regular protocol. If a patient appears to be eligible, on-site Financial Counselors assist the patient in completing the appropriate paperwork/applications and provide instruction regarding how to complete the qualification process. In some cases a Financial Counselor will act on behalf of the patient, at their signed consent, in order to complete the application process (for example, in New Hampshire a patient must be physically present at the District Office). If a patient doesn't qualify for specific programs, they are also considered for financial assistance as part of their screening. For outpatient services that are not routinely screened, staff interacting with patients are instructed to provide either a financial assistance application or contact information for a Financial Counselor when a patient expresses their inability to make payment. Every application is screened for completed income and asset documentation. Applications are also screened to assure there are no other potential options of federal, state, or local programs. The website, patient statements, and financial brochures all include information about financial assistance and how to apply. Form 990, Schedule H, Part VI, Line 4 Community Information The Organization defines its service region as New Hampshire and eastern Vermont, with the largest presence in the Lebanon, New Hampshire region, site of Dartmouth-Hitchcock Medical Center which includes Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinics main Northern clinic. MHMH serves the general population with a wide range of services. In addition to general hospital populations, the Organization provides services to patients with highly-specialized needs that are not available elsewhere in New Hampshire. MHMH is the states only tertiary referral center, provides the states only comprehensive cancer center (Norris Cotton Cancer Center - NCCC), operates the only Level I Trauma Center in New Hampshire, operates the only comprehensive childrens hospital and accredited pediatric trauma center in New Hampshire (Childrens Hospital at Dartmouth CHaD), hosts the only Level IV neonatal intensive care nursery and one of two pediatric intensive care units in New Hampshire, and operates the only helicopter transport service in the state. As such, the service population is both the general public seeking primary health care services as well as residents with unique and highly-specialized health care needs.
Form 990, Schedule H, Part VI, Line 5 Promotion of Community Health MHMH supports organizations and initiatives that further health by strengthening and developing key community capacities to address identified community health needs. This includes hosting or leading community partnerships to address substance misuse, reduce obestiy through community-level strategies; provide funding for children's oral health initiatives, and participation of our staff in other partnerships including the Outpatient Falls Prevention Task Force; the Transportation Management Association, and the Upper Valley Housing Authority. In addition, MHMH operates health education and support services such as a Women's Health Resource Center, the Aging Resource Center; and a Health Education Center. MHMH uses cash contributions, contracted services, and in-kind contribution of staff time and expertise, to support these strategies which improve community health. At MHMH's Lebanon, NH campus, the Hospital extends Professional Staff Privileges to qualified and appropriate physicians who are employees of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and Dartmouth College, who also hold a faculty appointment at Geisel School of Medicine. Mary-Hitchcockss Trustees annually set strategic priorities for the institution and approve operating and capital budgets which allocate surplus funds to improvements in patient care, medical education, research, as well as maintenance of a prudent reserve. Examples of these investments include the development of Mary Hitchcockss Patient Safety and Training Center, ongoing Quality and Patient Safety initiatives; purchases of new and emerging medical technologies, awards made to support translational research, and support for undergraduate medical education at Geisel School of Medicine. Of the 20 voting members of Mary Hitchcock Board of Trustees, 17 are neither contractors nor employees of MHMH.
Form 990, Schedule H, Part VI, Line 6 Affiliated Health Care System Community Benefits are provided by the Dartmouth-Hitchcock health care system, which includes Mary Hitchcock Memorial Hospital, Dartmouth-Hitchcock Clinic, and other related organizations whose primary mission is health care. Mary Hitchcock Memorial Hospital (MHMH) in Lebanon is New Hampshires largest hospital. In Fiscal Year 2015 MHMH had 396 licensed inpatient beds. The Dartmouth-Hitchcock Clinic (DHC) is a multi-specialty physician practice with a network of providers across New Hampshire and Vermont. While DHCs main offices are located in Lebanon, the Clinic also has multi-specialty practices in Manchester, Nashua, Concord, and Keene, NH areas as well as Bennington, VT. In addition, the Clinic provides primary care in rural communities in Vermont and northern New Hampshire. MHMH, DHC, and the Geisel School of Medicine faculty and students make up the Dartmouth-Hitchcock (D-H) health care system. The Hospital and Clinic operate jointly through interlocking directorates, strategic planning and management and share identical missions. The Medical School, which works closely with the Hospital and Clinic, is focused on medical education and research.
Form 990, Schedule H, Part VI, Line 7 State filing of Community Benefit Report MHMH files a Community Benefit Report with the State of New Hampshire jointly with Dartmouth-Hitchcock Clinic.
Schedule H (Form 990) 2014
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990.
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
Mary Hitchcock Memorial Hospital
 
Employer identification number
02-0222140
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to 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 (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) Granite State United Way
46 South Main St
Concord,NH03301 		02-6006033 501(c)(3) 18,630   FMV   Program Support
(2) David's House
461 Mount Support Rd
Lebanon,NH03766 		22-2593431 501(C)(3) 22,770   FMV   Program Support
(3) Mascoma Valley Health Initiative
PO Box 2013
Canaan,NH03741 		75-2991608 501(C)(3) 11,385   FMV   Hlth Adv Cnsl Sppt S
(4) The Trustees of Dartmouth College
1 Rope Ferry Road
Hanover,NH03755 		02-0222111 501(C)(3) 690,000   FMV   Educ and Prog Suppt
(5) Advance Transit
PO Box 1027
Wilder,VT05088 		22-2558708 501(C)(3) 75,060   FMV   Transportn Subsidy
(6) Upper Valley Transportation MGMT Assoc
195 No Main St
White River Jct,VT05001 		03-0355283 501(C)(3) 10,350   FMV   Transportn Subsidy
(7) March of Dimes- NH Chapter
25 Lowell St Ste 304
Manchester,NH03101 		13-1846366 501(c)(3) 9,574   FMV   Program Support
(8) Southwestern VT Health Care
100 Hospital Dr BOX 41
Bennington,VT05201 		03-0179435 501(c)(3) 12,938   FMV   Program Support
(9) City Year NH Pledge
287 Columbus Avenue
Boston,MA02116 		22-2882549 501(c)(3) 17,250   FMV   Program Support
(10) Indian Stream Health Center
2 Corliss Ln Rr2 Box 14
Colebrook,NH03576 		20-0999212 501(c)(3) 34,500   FMV   Program Sponsor
(11) American Cancer Society
250 Williams Street NW
Atlanta,GA30303 		13-1788491 501(c)(3) 11,644   FMV   Program Support
(12) American Heart Association
7272 Greenville Avenue
Dallas,TX75231 		13-5613797 501(c)(3) 7,763   FMV   Program Support
(13) Daniel Webster Council
571 Holt Ave
Manchester,NH03109 		02-0222115 501(c)(3) 5,693   FMV   Program Support
(14) University of NH School of Law
2 White St
Concord,NH03301 		02-0332032 501(c)(3) 10,350   FMV   Program Support
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
14
3
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

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
(1) E. Hintze Nursing Awards 2 1,894   FMV  
(2) Levine Nursing Awards 10 35,531   FMV  
(3) Patterson Awards 19 10,284   FMV  
(4) The Trustees of Dartmouth College 13 136,239   FMV  
(5) Knox Awards 13 22,120   FMV  
(6) Prouty Awards 39 24,277   FMV  
(7) Daniels Awards 9 6,167   FMV  
(8) Waterman Awards 4 13,315   FMV  
(9) D-H Tuition Reimbursement Program 604 507,494   FMV  
(10) Varnum Nursing Awards 43 27,593   FMV  
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
Description of Organization's Procedures for Monitoring the Use of Grants Form 990, Schedule I, Part I, Line 1 Each award established by Mary Hitchcock Memorial Hospital (Levine Nursing Awards, Knox Nursing Award, Patterson, Varnum, Hintze, and Prouty) has written established guidelines and procedures. Award payments are processed in accordance with the specific terms of each of the awards noted above. The Dartmouth Institute Scholarships (TDI) are paid directly to the College on the behalf of the individuals receiving the award. The coordinators of the program(s) are responsible for assuring that all terms are met, including proper documentation of expenses with receipts.
Schedule I (Form 990) 2014


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, 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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..
2
Yes
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2014

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
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
1Carl Dematteo MDFmr Chf Ql Compl Ofr/Physician (i)
(ii)		 0
...............................
112,103 		0
...............................
0 		0
...............................
2,198 		0
...............................
1,080 		0
...............................
1,301 		0
...............................
116,682 		0
...............................
0
2Robin Kilfeather-Mackey CPAChief Financial Officer (i)
(ii)		 0
...............................
500,806 		0
...............................
0 		0
...............................
19,626 		0
...............................
194,123 		0
...............................
20,575 		0
...............................
735,130 		0
...............................
0
3Linda Von ReynFmr Chf Nursng Officer (i)
(ii)		 133,716
...............................
0 		0
...............................
0 		96,301
...............................
0 		99,057
...............................
0 		5,584
...............................
0 		334,658
...............................
0 		0
...............................
0
4Daniel Jantzen CPAChief Operating Officer (i)
(ii)		 515,042
...............................
0 		0
...............................
0 		89,436
...............................
0 		190,359
...............................
0 		20,575
...............................
0 		815,412
...............................
0 		0
...............................
0
5Stephen LeblancExec VP Strtgy & Ntwrk Rltns (i)
(ii)		 0
...............................
478,894 		0
...............................
0 		0
...............................
123,303 		0
...............................
249,014 		0
...............................
20,575 		0
...............................
871,786 		0
...............................
0
6John Butterly MDFmr Offr/Exec VP Med Affairs (i)
(ii)		 0
...............................
498,440 		0
...............................
0 		0
...............................
54,129 		0
...............................
72,826 		0
...............................
0 		0
...............................
625,395 		0
...............................
0
7Lawrence Dacey MDFormer CMO/ Phys (i)
(ii)		 0
...............................
82,044 		0
...............................
9,000 		0
...............................
41,092 		0
...............................
230,712 		0
...............................
11,854 		0
...............................
374,702 		0
...............................
0
8Alan WestonFmr Chief HR Officer (i)
(ii)		 0
...............................
0 		0
...............................
0 		295,536
...............................
0 		0
...............................
0 		0
...............................
0 		295,536
...............................
0 		0
...............................
0
9Bruce KingPres & CEO New London Hosp (i)
(ii)		 313,800
...............................
0 		0
...............................
0 		37,765
...............................
0 		163,148
...............................
0 		20,514
...............................
0 		535,227
...............................
0 		0
...............................
0
10Mary OseidFmr Key Emp/VP Enterprise Svcs (i)
(ii)		 0
...............................
365,364 		0
...............................
0 		0
...............................
8,881 		0
...............................
228,572 		0
...............................
11,662 		0
...............................
614,479 		0
...............................
0
11Christine SchonV.P Comm. Grp. Pract. Ops (i)
(ii)		 0
...............................
223,696 		0
...............................
0 		0
...............................
3,710 		0
...............................
42,762 		0
...............................
15,530 		0
...............................
285,698 		0
...............................
0
12Gail DahlstromV.P. Facilities Mgmt (i)
(ii)		 226,090
...............................
0 		0
...............................
0 		4,630
...............................
0 		86,615
...............................
0 		15,526
...............................
0 		332,861
...............................
0 		0
...............................
0
13James N Weinstein DO MSTrustee Ex-Officio/CEO (i)
(ii)		 0
...............................
1,145,559 		0
...............................
0 		0
...............................
84,094 		0
...............................
209,341 		0
...............................
16,411 		0
...............................
1,455,405 		0
...............................
0
14Tina Naimie CPAVP Corporate Finance (i)
(ii)		 222,765
...............................
0 		0
...............................
0 		108
...............................
0 		24,097
...............................
0 		1,803
...............................
0 		248,773
...............................
0 		0
...............................
0
15Wendy FieldingVP Financial Planning (i)
(ii)		 220,289
...............................
0 		0
...............................
0 		270
...............................
0 		37,462
...............................
0 		20,362
...............................
0 		278,383
...............................
0 		0
...............................
0
16Barbara Walters DO MBAFmr Key Emp/Med Dir Acct Care (i)
(ii)		 0
...............................
286,993 		0
...............................
0 		0
...............................
42,840 		0
...............................
21,631 		0
...............................
0 		0
...............................
351,464 		0
...............................
0
17Jeanine Arden-OrntFmr General Counsel (i)
(ii)		 340,566
...............................
0 		0
...............................
0 		20,891
...............................
0 		38,457
...............................
0 		4,260
...............................
0 		404,174
...............................
0 		0
...............................
0
18Vincent Fusca IIIChief of Staff (i)
(ii)		 306,308
...............................
0 		0
...............................
0 		2,387
...............................
0 		21,284
...............................
0 		1,468
...............................
0 		331,447
...............................
0 		0
...............................
0
19Mary Kay BoudewynsFmr Key Emp/Adm Dir Rev Mgmt (i)
(ii)		 206,293
...............................
0 		0
...............................
0 		7,699
...............................
0 		121,696
...............................
0 		7,971
...............................
0 		343,659
...............................
0 		0
...............................
0
20Edward Merrens MDChief Medical Officer (i)
(ii)		 0
...............................
368,912 		0
...............................
0 		0
...............................
18,005 		0
...............................
73,184 		0
...............................
21,251 		0
...............................
481,352 		0
...............................
0
21George Blike MDChief Quality & Value Officer (i)
(ii)		 0
...............................
402,600 		0
...............................
0 		0
...............................
45,355 		0
...............................
242,258 		0
...............................
21,251 		0
...............................
711,464 		0
...............................
0
22Thomas Colacchio MDFormer Officer/Phys (i)
(ii)		 0
...............................
648,749 		0
...............................
0 		0
...............................
418,790 		0
...............................
116,627 		0
...............................
14,320 		0
...............................
1,198,486 		0
...............................
0
23Darlene A SalerActg Chf Nrsg Ofr End 9/27/14 (i)
(ii)		 169,385
...............................
0 		0
...............................
0 		1,295
...............................
0 		101,528
...............................
0 		15,745
...............................
0 		287,953
...............................
0 		0
...............................
0
24John S Malanowski MILRChief HR Officer (i)
(ii)		 432,266
...............................
0 		0
...............................
0 		14,189
...............................
0 		37,650
...............................
0 		17,104
...............................
0 		501,209
...............................
0 		0
...............................
0
25Clifford J Belden MDCHF CLNCL OFCR END 6/22/15 (i)
(ii)		 0
...............................
668,497 		0
...............................
0 		0
...............................
42,212 		0
...............................
41,093 		0
...............................
14,321 		0
...............................
766,123 		0
...............................
0
26Terrence P Carroll PHDChief Innovation Officer (i)
(ii)		 540,130
...............................
0 		100,000
...............................
0 		1,500
...............................
0 		37,650
...............................
0 		15,743
...............................
0 		695,023
...............................
0 		0
...............................
0
27Roderic YoungVP Communications & Marketing (i)
(ii)		 296,109
...............................
0 		100
...............................
0 		5,107
...............................
0 		27,634
...............................
0 		18,080
...............................
0 		347,030
...............................
0 		0
...............................
0
28Martin PurcellVP IS Operations (i)
(ii)		 267,978
...............................
0 		25,000
...............................
0 		16,536
...............................
0 		110,169
...............................
0 		20,446
...............................
0 		440,129
...............................
0 		0
...............................
0
29Thomas Dodds MDFormer Key Emp/Dept Chr Anesth (i)
(ii)		 0
...............................
499,435 		0
...............................
0 		0
...............................
36,122 		0
...............................
210,719 		0
...............................
21,250 		0
...............................
767,526 		0
...............................
0
30Wendy Wells MDDept. Chair Pathology (i)
(ii)		 0
...............................
406,536 		0
...............................
0 		 
...............................
24,262 		0
...............................
147,305 		0
...............................
21,241 		0
...............................
599,344 		0
...............................
0
31Jocelyn Chertoff MD MSDept Chair Diagnost Radiology (i)
(ii)		 0
...............................
454,304 		0
...............................
28,500 		0
...............................
31,045 		0
...............................
183,467 		0
...............................
21,251 		0
...............................
718,567 		0
...............................
0
32Edward Catherwood MD MSFormer Key Emp/Ctr Dir Hrt/Vsc (i)
(ii)		 0
...............................
440,464 		0
...............................
0 		0
...............................
3,256 		0
...............................
132,062 		0
...............................
16,411 		0
...............................
592,193 		0
...............................
0
33Douglas MerrillCenter Director Periop Svs (i)
(ii)		 0
...............................
297,465 		0
...............................
0 		0
...............................
261,092 		0
...............................
42,850 		0
...............................
12,639 		0
...............................
614,046 		0
...............................
0
34Stephen BoyceVP Ambulatory Care (i)
(ii)		 0
...............................
190,631 		0
...............................
0 		0
...............................
6,149 		0
...............................
39,913 		0
...............................
20,206 		0
...............................
256,899 		0
...............................
0
35Jeffrey OBrienFmr Key Emp/VP Oncology (i)
(ii)		 273,570
...............................
0 		0
...............................
0 		2,481
...............................
0 		21,530
...............................
0 		20,436
...............................
0 		318,017
...............................
0 		0
...............................
0
36Susan ReevesVP Colby Sawyer Nursing (i)
(ii)		 288,501
...............................
0 		0
...............................
0 		28,984
...............................
0 		111,170
...............................
0 		18,017
...............................
0 		446,672
...............................
0 		0
...............................
0
37Elwood LeonardVP Development (i)
(ii)		 296,367
...............................
0 		0
...............................
0 		6,975
...............................
0 		39,208
...............................
0 		18,078
...............................
0 		360,628
...............................
0 		0
...............................
0
38Richard J Powell MDTrustee Eff 7/1/15 (i)
(ii)		 0
...............................
368,104 		0
...............................
55,633 		0
...............................
25,532 		0
...............................
124,282 		0
...............................
21,241 		0
...............................
594,792 		0
...............................
0
39Richard Rothstein MDTrustee Eff 7/1/15 (i)
(ii)		 0
...............................
529,679 		0
...............................
0 		0
...............................
6,469 		0
...............................
143,455 		0
...............................
16,412 		0
...............................
696,015 		0
...............................
0
40Steven A Paris MDTrustee Eff 7/1/15 (i)
(ii)		 0
...............................
329,589 		0
...............................
0 		0
...............................
27,982 		0
...............................
100,968 		0
...............................
16,361 		0
...............................
474,900 		0
...............................
0
41John Birkmeyer MDChf Clncl Offr/EVP Entprs Sup (i)
(ii)		 0
...............................
211,596 		0
...............................
0 		0
...............................
50,103 		0
...............................
30,458 		0
...............................
4,400 		0
...............................
296,557 		0
...............................
0
42Gay Landstrom PhD RN NEA-BCChf Nursing Offr Eff 9/28/14 (i)
(ii)		 219,611
...............................
0 		50,000
...............................
0 		11,831
...............................
0 		21,842
...............................
0 		6,059
...............................
0 		309,343
...............................
0 		0
...............................
0
43Kimberly Troland JDGeneral Counsel End 4/19/15 (i)
(ii)		 248,150
...............................
0 		0
...............................
0 		193
...............................
0 		16,308
...............................
0 		17,938
...............................
0 		282,589
...............................
0 		0
...............................
0
44Robert Greene MD MHCDS FACPChf Popul Mgmt Ofr Eff 7/28/14 (i)
(ii)		 0
...............................
219,696 		0
...............................
150,000 		0
...............................
4,410 		0
...............................
20,150 		0
...............................
7,081 		0
...............................
401,337 		0
...............................
0
Schedule J (Form 990) 2014

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
Supplemental Compensation Information Form 990, Schedule J, Part I - Line 1a FROM TIME TO TIME, THE ORGANIZATION PROVIDES CHARTERED TRAVEL SERVICES TO THE CEO. THE COST OF PROVIDING THE CHARTERED SERVICE HAS BEEN DEEMED A COST-EFFICIENT MANNER TO ALLOW THE OFFICER TO WORK WHILE TRAVELLING VERSUS THE TIME LOST DRIVING, ETC. THIS EXPENSE HAS BEEN DEEMEND AN ORDINARY AND NECESSARY BUSINESS EXPENSE AND NON-TAXABLE TO THE RECIPIENT. ALL REQUESTS ARE APPROVED BEFORE PAYMENT TO ENSURE COMPLIANCE WITH INTERNAL POLICIES. The Organization has in place a Management Self Development Plan (MSDP) designed to promote professional and personal development. The MSDP is capped at 2% of gross pay and may be utilized for expenses such as professional dues, meetings and seminars, tuition reimbursement, and other miscellaneous items that promote professional knowledge. The monies may also be used for up to a 50% reimbursement of the cost of a fitness/wellness program designed to maintain the health of management personnel. All expenses are submitted for approval before reimbursement.
Severance Payments Form 990, Schedule J, Part I Line 4a The following listed individuals received Severance and/or change in control payments during calendar year 2014: During 2012, Thomas Colacchio transitioned from an officer role to a staff physician role. As part of this transition, Thomas Colacchio received a multi-year $320,000 change of control payment from Dartmouth-Hitchcock in 2014. The payment is included on Schedule J, Part II, Column (B)iii. During calendar year 2014, Former Chief Human Resource Officer Alan Weston received a one-time $295,536 severance payment from Dartmouth-Hitchcock. The payment is included on Schedule J, Part II, Column (B)iii. Supplemental Nonqualified Retirement Plan: SCHEDULE J, PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (WHICH ARE REFLECTED IN SCHEDULE J, PART II, COLUMN B (III)): James Weinstein $82,952 Robin Kilfeather-Mackey $19,090 Linda Von Reyn $95,981 Daniel Jantzen $73,637 Stephen Leblanc $121,249 John Butterly $47,038 Jeanine Arden Ornt $19,862 Edward Merrens $17,745 George Blike $44,957 Mary Oseid $8,881 Barbara Walters $41,835 Bruce King $10,185 Susan Reeves $5,717 Lawrence Dacey $40,914 Thomas Colacchio $98,790 Clifford Belden $42,160 Richard Rothstein $4,911 Thomas Dodds $35,378 Wendy Wells $22,757 Jocelyn Chertoff $30,301 Edward Catherwood $3,256 Douglass Merrill $38,160 Jeffrey OBrien $2,000 Martin Purcell $15,468 Roderic Young $5,107 Dartmouth-Hitchcock Supplemental Retirement Plan: Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the Plans for the plan year, but are limited by IRC Section 401(a)(17) and/or 415. For eligible employees, the Employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. MHMH sponsors a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen in 1998 and therefore no further costs of the individual employee insurance premiums have been funded by the organization. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization.
Schedule J (Form 990) 2014

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990.
SchKMediumBulletInformation about Schedule K (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number
02-0222140
Part I
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer 		(i) Pool
financing
Yes No Yes No Yes No
A New Hampshire Health and Education Facilities Auth
  		02-0279866 644614Y07 08-19-2009 134,661,088 CURRENT REFUND 2008 (A), (B), (C)   X   X   X
B New Hampshire Health and Education Facilities Auth
  		02-0279866 644614G29 06-16-2010 73,647,839 CONSTR. OF FACILITY AND EQUIP.   X   X   X
C New Hampshire Health and Education Facilities Auth
  		02-0279866 000000000 08-31-2011 38,119,624 CURRENT REFUND 2001 (A)   X   X   X
D New Hampshire Health and Education Facilities Auth
  		02-0279866 000000000 11-28-2012 116,170,000 CURRENT REFUND 2002   X   X   X
NH Health and Ed Facilities Auth
  		02-0279866 000000000 08-13-2014 41,242,990 Refund Portion of 2009 Issued Date   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . . 65,950,000 0 4,002,041 1,990,000
2 Amount of bonds legally defeased . . . . . . . . . . . 0 0 0 0
3 Total proceeds of issue . . . . . . . . . . . . . . 134,841,419 73,666,926 38,119,624 116,170,000
4 Gross proceeds in reserve funds . . . . . . . . . . . . 0 0 0 0
5 Capitalized interest from proceeds . . . . . . . . . . . 0 3,766,049 0 0
6 Proceeds in refunding escrows . . . . . . . . . . . . 0 0 0 0
7 Issuance costs from proceeds . . . . . . . . . . . . 2,273,111 1,168,560 97,500 520,000
8 Credit enhancement from proceeds . . . . . . . . . . . 0 0 0 0
9 Working capital expenditures from proceeds . . . . . . . . . 0 0 0 0
10 Capital expenditures from proceeds . . . . . . . . . . . 0 68,732,317 0 0
11 Other spent proceeds . . . . . . . . . . . . . . 132,387,977 0 38,022,124 115,650,000
12 Other unspent proceeds . . . . . . . . . . . . . . 0 0 0 0
13 Year of substantial completion . . . . . . . . . . . . 2010 2012 2011 2013
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . . X     X X   X  
15 Were the bonds issued as part of an advance refunding issue? . . . . .   X   X   X   X
16 Has the final allocation of proceeds been made? . . . . . . . . X   X   X   X  
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . . X   X   X   X  
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X   X        
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .   X   X        
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2014
Schedule K (Form 990) 2014
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .   X   X        
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .   X   X        
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0 % 0 % 0 % 0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet        
6 Total of lines 4 and 5 . . . . . . . . . . . . .        
7 Does the bond issue meet the private security or payment test? . . . . .   X   X        
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .   X   X        
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of.        
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .   X   X        
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2? . . . . . . . 		X   X          
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? . .   X   X   X   X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .   X   X X   X  
b Exception to rebate? . . . . . . . . X     X   X   X
c No rebate due? . . . . . . . .   X X     X   X
If "Yes" to line 2c, provide in Part VI the date the rebate
computation was performed . . . . . .
3 Is the bond issue a variable rate issue? . . . .   X   X X     X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X   X X     X
b Name of provider . . . . . . . . . 0
  		0
  		Morgan Stanley
  		 
 
c Term of hedge . . . . . . . . . . 29.8   29.8  
d Was the hedge superintegrated? . . . . X       X      
e Was the hedge terminated? . . . . . .   X       X    
Schedule K (Form 990) 2014
Schedule K (Form 990) 2014
Page 3
Part IV
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .   X   X   X   X
b Name of provider . . . . . . . . . 0
  		0
  		0
  		0
 
c Term of GIC . . . . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .                
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .   X   X   X   X
7 Has the organization established written procedures to monitor the requirements of section 148? . . . X   X   X   X  
Part V
Procedures To Undertake Corrective Action
A B C D
Yes No Yes No Yes No Yes No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? X   X   X   X  
Part VI
Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions).
Return Reference Explanation
Part 1, Column F, Additional Information: Line A: Current Refund 2008 (A), Issued 9/4/2008, Which Advance Refunded 1985 Current Refund 2008 (B), Issued 10/31/2008, Which Advance Refunded 1993 Current Refund 2008 (C), Issued 12/19/2008 Line C: Current Refund 2001(A), Issued 10/17/2001, Which Advance Refunded 1997 & 1994 Part II Line 11, Column A, C, & D The other spent proceeds are the refunding proceeds of the issue that are no longer in escrow Part IV, Line 2C, Column B The rebate calculation was performed on 6/17/2015
Schedule K (Form 990) 2014

Additional Data


Software ID:  
Software Version:  

Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990.
SchKMediumBulletInformation about Schedule K (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number
02-0222140
Part I
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer 		(i) Pool
financing
Yes No Yes No Yes No
A New Hampshire Health and Education Facilities Auth
  		02-0279866 644614Y07 08-19-2009 134,661,088 CURRENT REFUND 2008 (A), (B), (C)   X   X   X
B New Hampshire Health and Education Facilities Auth
  		02-0279866 644614G29 06-16-2010 73,647,839 CONSTR. OF FACILITY AND EQUIP.   X   X   X
C New Hampshire Health and Education Facilities Auth
  		02-0279866 000000000 08-31-2011 38,119,624 CURRENT REFUND 2001 (A)   X   X   X
D New Hampshire Health and Education Facilities Auth
  		02-0279866 000000000 11-28-2012 116,170,000 CURRENT REFUND 2002   X   X   X
NH Health and Ed Facilities Auth
  		02-0279866 000000000 08-13-2014 41,242,990 Refund Portion of 2009 Issued Date   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . . 65,950,000 0 4,002,041 1,990,000
2 Amount of bonds legally defeased . . . . . . . . . . . 0 0 0 0
3 Total proceeds of issue . . . . . . . . . . . . . . 134,841,419 73,666,926 38,119,624 116,170,000
4 Gross proceeds in reserve funds . . . . . . . . . . . . 0 0 0 0
5 Capitalized interest from proceeds . . . . . . . . . . . 0 3,766,049 0 0
6 Proceeds in refunding escrows . . . . . . . . . . . . 0 0 0 0
7 Issuance costs from proceeds . . . . . . . . . . . . 2,273,111 1,168,560 97,500 520,000
8 Credit enhancement from proceeds . . . . . . . . . . . 0 0 0 0
9 Working capital expenditures from proceeds . . . . . . . . . 0 0 0 0
10 Capital expenditures from proceeds . . . . . . . . . . . 0 68,732,317 0 0
11 Other spent proceeds . . . . . . . . . . . . . . 132,387,977 0 38,022,124 115,650,000
12 Other unspent proceeds . . . . . . . . . . . . . . 0 0 0 0
13 Year of substantial completion . . . . . . . . . . . . 2010 2012 2011 2013
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . . X     X X   X  
15 Were the bonds issued as part of an advance refunding issue? . . . . .   X   X   X   X
16 Has the final allocation of proceeds been made? . . . . . . . . X   X   X   X  
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . . X   X   X   X  
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X   X        
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .   X   X        
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2014
Schedule K (Form 990) 2014
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .   X   X        
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .   X   X        
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0 % 0 % 0 % 0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet        
6 Total of lines 4 and 5 . . . . . . . . . . . . .        
7 Does the bond issue meet the private security or payment test? . . . . .   X   X        
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .   X   X        
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of.        
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .   X   X        
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2? . . . . . . . 		X   X          
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? . .   X   X   X   X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .   X   X X   X  
b Exception to rebate? . . . . . . . . X     X   X   X
c No rebate due? . . . . . . . .   X X     X   X
If "Yes" to line 2c, provide in Part VI the date the rebate
computation was performed . . . . . .
3 Is the bond issue a variable rate issue? . . . .   X   X X     X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X   X X     X
b Name of provider . . . . . . . . . 0
  		0
  		Morgan Stanley
  		 
 
c Term of hedge . . . . . . . . . . 29.8   29.8  
d Was the hedge superintegrated? . . . . X       X      
e Was the hedge terminated? . . . . . .   X       X    
Schedule K (Form 990) 2014
Schedule K (Form 990) 2014
Page 3
Part IV
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .   X   X   X   X
b Name of provider . . . . . . . . . 0
  		0
  		0
  		0
 
c Term of GIC . . . . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .                
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .   X   X   X   X
7 Has the organization established written procedures to monitor the requirements of section 148? . . . X   X   X   X  
Part V
Procedures To Undertake Corrective Action
A B C D
Yes No Yes No Yes No Yes No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? X   X   X   X  
Part VI
Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions).
Return Reference Explanation
Part 1, Column F, Additional Information: Line A: Current Refund 2008 (A), Issued 9/4/2008, Which Advance Refunded 1985 Current Refund 2008 (B), Issued 10/31/2008, Which Advance Refunded 1993 Current Refund 2008 (C), Issued 12/19/2008 Line C: Current Refund 2001(A), Issued 10/17/2001, Which Advance Refunded 1997 & 1994 Part II Line 11, Column A, C, & D The other spent proceeds are the refunding proceeds of the issue that are no longer in escrow Part IV, Line 2C, Column B The rebate calculation was performed on 6/17/2015
Schedule K (Form 990) 2014

Additional Data


Software ID:  
Software Version:  

Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ.
MediumBulletInformation about Schedule L (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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





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

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
(1) DANIEL JANTZEN Officer SPLIT DOLLAR LIFE   X 108,765 108,765   No Yes   Yes  
(2) Deborah Jantzen Family Member Split Dollar Life   X 53,425 53,425   No Yes   Yes  
Total ......Small Bullet $ 162,190
Part III
Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2014
Schedule L (Form 990 or 990-EZ) 2014
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Hypertherm Trustee Barbara Couch 484,000 See Part V   No
(2) Vincent Fusca III Officer Fusca II 112,979 Family member employed by MHMH   No
(3) Garth Dunkel Officer Fusca II 17,662 Family member employed by MHMH   No
(4) Christopher Weston Officer Alan Weston 30,044 Family member employed by DHC   No
(5) Linda Billings Former KE Mary Oseid 103,824 Family member employed by MHMH   No
(6) Richard Alfred Powell Trustee Powell 59,234 Family member employed by MHMH   No
Part V
Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).
Return Reference Explanation
Form 990, Schedule L Part IV Name of Interested Person: Barbara Couch Relationship: Trustee Description of Transaction: Barbara Couch is a greater than 35% owner of Hypertherm, an entity that conducts business with MHMH.
Schedule L (Form 990 or 990-EZ) 2014

Additional Data


Software ID:  
Software Version:  




SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
Noncash Contributions
Right pointing arrow large imageComplete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
Right pointing arrow large imageInformation about Schedule M (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 24 682,435 Fair Market Value
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that
it must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ..........................
32a
Yes
 
b
If "Yes," describe in Part II.
33
If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) (2014)
Schedule M (Form 990) (2014)
Page 2
Part II
Supplemental Information. Provide the information required by Part I, lines 30b,
32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Return Reference Explanation
Schedule M, Part I, Column B The organization reported the number of contributions received in column (b). Use of related organizations to solicit noncash donations Line 32B The organization uses Dartmouth-Hitchcock Medical Center, a supporting Organization, for solicitation of contributions and annual fund activities. From time to time, the Hospital may receive non-cash contributions directly from its donors.
Schedule M (Form 990) (2014)
Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

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

Complete to provide information for responses to specific questions on
Form 990 or 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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Return Reference Explanation
Business relationships Form 990, Part VI, Section A, Line 2 Mary Hitchcock Memorial Hospital owns for-profit subsidiaries that provide services and support the mission of the organization. As a result, some officers of the Hospital also are officers of for-profit entities within the healthcare system. Description of classes of members, persons, and the nature of their rights Form 990, Part VI, Section A, Line 6 & 7a Dartmouth-Hitchcock Health (D-HH) is the sole corporate Member of Mary Hitchcock Memorial Hospital (MHMH). D-HH has specific authority and reserved powers, including the power to confirm the election of members of the MHMH's Board of Trustees and the power to approve significant governance, financial and operational decisions of MHMH's Trustees. Governance decisions reserved to or subject to approval by persons other than the governing body Form 990, Part VI, Section A, Line 7B In addition to reserved powers, Dartmouth-Hitchcock Health (D-HH) shall have the authority to take actions to establish, manage, and govern the System as an integrated health care delivery system in furtherance of the mission of the Hospital and other Organizations. These powers include but are not limited to items such as the ability to approve, disapprove or modify all material governance, programmatic and financial decisions of MHMH's Board of Trustees, to appoint or remove a member of the Hospital's Board of Trustees, assess the Hospital a monetary amount for the payment of the expenses of D-HH, approve the Hospital's budget, approve the borrowings or dispositions of assets by the Hospital, approve key strategic relationships, approve the elimination or addition of any material health care service or program, and other authority to take action on behalf of the Hospital.
Process used by management and/or Governing Body to Review 990 Form 990, Part VI, Line 11b THE FORMS 990 AND 990-T ARE REVIEWED BY THE DIRECTOR OF CORPORATE FINANCE, VICE PRESIDENT OF CORPORATE FINANCE, AND THE CHIEF FINANCIAL OFFICER BEFORE THE FILING OF THE RETURN. ONCE THE RETURN HAS BEEN FULLY PREPARED A FINAL 990 AND 990-T COMPLETE ELECTRONIC VERSION IS SENT OUT TO EACH BOARD MEMBER AND TIME IS ALLOCATED FOR COMMENTS/RESPONSES PRIOR TO OFFICIAL FILING.
Conflict of Interest Policy Form 990, Part VI Section B Line 12C The Mary Hitchcock Memorial Hospital BOARD OF TRUSTEES APPROVED A POLICY CONCERNING A VOLUNTARY SELF-DISCLOSURE OF ANY POTENTIAL CONFLICT OF INTEREST. THE DARTMOUTH-HITCHCOCK, OFFICE OF POLICY SUPPORT, COMPLIANCE AND AUDIT SERVICES CONDUCTS AN ANNUAL SURVEY OF ALL OFFICERS AND TRUSTEES AND PERFORMS OTHER PROCEDURES AS CONSIDERED NECESSARY TO REPORT ON COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT THEN REPORTS TO EACH BOARD ANY POTENTIAL CONFLICTS FOR THEIR REVIEW. PER THE POLICY, ANY CONFLICTS OR OTHERWISE PERCEIVED CONFLICTS ARE REQUIRED TO BE ADDRESSED BY THE BOARD OF TRUSTEEES ON AN ONGOING BASIS. IN THE EVENT A CONFLICT ARISES, THE INDIVIDUAL MAY BE REMOVED FROM PARTICIPATING IN ANY DECISION MAKING REGARDING THE IDENTIFIED CONFLICT AND/OR ITS CORRESPONDING TRANSACTIONS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION.
OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR UNDERTAKEN Form 990, Part VI, Line 15a Although paid by a related organization, Dartmouth-Hitchcock Clinic, the Compensation for the President is evaluated by an independent third party firm for reasonableness and national data benchmarking. The Compensation Committee along with Independent Trustees approve the final compensation in consideration with the independent third party firm's recommendations and suggestions. This process was contemporaneously documented and last undertaken in 2014.
Offices & Positions for Which Process was Used & Year Undertaken Form 990, Part VI, Line 15b Compensation for officers and key employees are evaluated by internal HR staff using national benchmarking data, along with ongoing evaluations by an independent third party firm for reasonableness, with the last formal process in 2012. External benchmarking from an independent third party has been used for any Officer who was hired or received a compensation adjustment since the last process 2012. Compensation rates are determined by following the guidelines of the compensation committee charter and philosophy documents and/or a formal review by compensation committee members.
Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Line 19 MHMH's governing documents are available through the New Hampshire Secretary of State. Certain financial information is disclosed through the Community Benefits Annual Report. The audited financial statements, governing documents, and conflict of interest policy are available upon request either in electronic or hardcopy form. Average Hours Per Week Form 990 Part VII Section A, Line 1A, Column B As part of MHMH's and Dartmouth-Hitchcock Clinic's affiliation agreement, the two organizations share officers. As such, the average hours per week are allocated between the two organizations' 990's even though compensation reported in part VII is based on the entity issuing the W-2. In addition, certain officers spend time on Dartmouth-Hitchcock Health, the sole corporate member of both MHMH and DHC, along with three supporting organizations: Dartmouth-Hitchcock Medical Center, Hamden Risk Retention Group, and Everwell, Inc., and related hospitals: Mount Ascutney Hospital and Health Center, Cheshire Medical Center, and New London Hospital. Statement of Functional Expenses Form 990 Part IX Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic operate under an affiliation agreement as directed by Dartmouth-Hitchcock Health, the sole Corporate Member of both entities. Due to the integrated operating structure, related mission, and close relationship of the two tax-exempt organizations, expenses are shared between the two entities. All expenses reported within this 990 are the organization's share of expenses as designated by the affiliation agreement.
Financial Statements and Reporting Form 990 Part XI, Line 9 Other Changes in Net Assets Include: Pension-related changes: ($20,938,391) Unrealized Gain/Loss on Hedge and other ($676,689) Total changes in net assets: ($21,615,080) Audited Financial Statements Form 990 Part XII, Line 2d The organization's financial information is included in the audited financial statements of Dartmouth-Hitchcock Health and Subsidiaries, which consists of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, Mount Ascutney Hospital and Health Center, Cheshire Medical Center, New London Hospital, and subsidiaries.
A-133 Audit Form 990 Part XII, Line 3A DURING FISCAL YEAR 2015, MARY HITCHCOCK MEMORIAL HOSPITAL EXPENDED FUNDS FROM FEDERAL AWARDS IN EXCESS OF THE MINIMUM THRESHOLD SET FORTH IN THE SINGLE AUDIT ACT AND OMB CIRCULAR A-133, THEREFORE REQUIRING AN AUDIT. DUE TO THE ISSUANCE OF THE COMBINED FINANCIAL STATEMENTS, THE SINGLE AUDIT WAS PERFORMED ON THE COMBINED FINANCIAL INFORMATION OF ALL ORGANIZATIONS, INCLUDING MARY HITCHCOCK MEMORIAL HOSPITAL.
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:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach 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
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
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
(1) NEW ENGLAND ALLIANCE FOR HEALTH LLC
ONE MEDICAL CENTER DRIVE
LEBANON,NH03756
26-4232401 		HLTH IMPROVMT NH 4,726 1,729,900 MHMH
 
(2) D-H Specialty Services LLC
One Medical Center Drive
Lebanon,NH03756
46-0876427 		Shd Svgs Prgm NH 0 0 MHMH
 








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?
Yes No
(1) DARTMOUTH-HITCHCOCK CLINIC
ONE MEDICAL CENTER DRIVE

LEBANON,NH03756
22-2519596 		PHYSICIAN SVC NH 501(c)(3) 9 D-HH
 
Yes
 
(2) DARTMOUTH-HITCHCOCK MEDICAL CENTER
ONE MEDICAL CENTER DRIVE

LEBANON,NH03756
22-2715483 		SUPPORTNG ORG NH 501(c)(3) 11 TYPE I NA
 
Yes
 
(3) DARTMOUTH - HITCHCOCK HEALTH
One Medical Center Drive

Lebanon,NH03756
26-4812335 		SUPPORTNG ORG NH 501(C)(3) 7 NA
 
 
No
(4) HAMDEN RISK RETENTION GROUP INC
30 MAIN STREET STE 330

BURLINGTON,VT05401
20-8530788 		Self Ins VT 501(c)(3) 11 TYPE I DHC
 
Yes
 
(5) The Hitchcock Foundation
One Medical Center Drive

Lebanon,NH03756
02-0222139 		HLTHCRE RSRCH NH 501(c)(3) 7 DHC
 
Yes
 
(6) EverWell Inc
One Medical Center Drive

Lebanon,NH03756
35-2506275 		Supportng Org NH 501(c)(3) 11 Type I NA
 
Yes
 
(7) The New London Hospital Association Inc
273 County Rd

New London,NH03257
02-0222171 		Hospital NH 501(c)(3) 3 D-HH
 
Yes
 
(8) Windsor Hospital Association
289 Country Road

Windsor,VT05089
03-0183721 		Hospital VT 501(C)(3) 3 D-HH
 
Yes
 
(9) Cheshire Medical Center
580 Court Street

Keene,NH03431
02-0354549 		Hospital NH 501(C)(3) 3 D-HH
 
Yes
 
(10) Cheshire Health Foundation
580 Court Street

Keene,NH03431
02-0202220 		SUPPORTNG ORG NH 501(C)(3) 11, TYPE II CMC
 
Yes
 
(11) Mt Ascutney Hosp Cmmty Hlth Found
289 Country Road

Windsor,VT05089
03-0300481 		Foundation VT 501(c)(3) 3 WHA
 
Yes
 
(12) Historic Homes of Runnemede
289 County Road

Windsor,VT05089
23-7396147 		Healthcare VT 501(c)(3) 9 WHA
 
Yes
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2014
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?



 		(k)
Percentage
ownership
Yes No Yes No
(1) D-H Mster Invst Prg

1 Med Ctr Dr
LEBANON,NH03756
02-0205863 		POOLED INVEST NH MHMH
  		Excluded 22,766,096 524,681,801   No 214,519 Yes   93.234 %
(2) KEENE HLTH ALLIANCE

580 Court St
Keene,NH03431
30-0179297 		Healthcare NH NA
  		                 
(3) Obnet Services LLC

1 Med Ctr Dr
Lebanon,NH03756
04-3746287 		Database Serv NH NA
  		                 
(4) One Care VT ACOLLC

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






Part IV
Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" 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
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Charit Remndr Unitrusts (5)

One Medical Center Drive
Lebanon,NH03756
 Chart. Trust NH MHMH
  		TRUST       Yes  
(2) Pompanoosuc Investment Corp

1 Medical Ctr Dr
Lebanon,NH03756
02-0352330 		Real Est Hldg NH DHC
  		C Corporation       Yes  
(3) Hamden Assurance Co Ltd

44 Church St
Hamilton   HM 12
BD
98-0121409 		Liab. Insuanc BD DHC
  		Foreign Corp 0 2,878,669 25.800 % Yes  
(4) Hitchcock Health Connect

1 Medical Ctr Dr
Lebanon,NH03756
80-0908979 		Telehealth DE D-HH
  		C Corp       Yes  
(5) Kearsarge Community Services Inc

273 County Road
New London,NH03257
02-0460136 		Real Est Hldg NH NLH
  		C Corp       Yes  
(6) New London Physician Group Inc

 
 
02-0494420 		Physician Gro NH NLH
  		C Corp       Yes  
(7) New London Medical Center East

273 County Road
New London,NH03257
02-0480857 		Real Est Hldg NH NLH
  		C Corp       Yes  
(8) Keene Health Services

580 Court Street
Keene,NH03431
02-0374997 		Real Est Hldg NH CMC
  		C Corp       Yes  
(9) Keene Health Realty

580 Court Street
Keene,NH03431
02-0374998 		Real Est Hldg NH CMC
  		C Corp       Yes  
(10) Keene Health Enterprises

580 Court Street
Keene,NH03431
02-0374999 		Real Est Hldg NH CMC
  		C Corp       Yes  
(11) Cheshire Health Services

580 Court St
Keene,NH03431
47-3379283 		HEALTHCARE NH CMC
  		C COPR       Yes  
Schedule R (Form 990) 2014
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
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
 
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) Dartmouth-Hitchcock Clinic

 JKLMN 29,325,261 FMV
(2) Dartmouth-Hitchcock Medical Center

 M 2,135,230 FMV
(3) Hamden Risk Retention Group

 O 5,373,734 FMV
(4) The Hitchcock Foundation

 Q 15,573 FMV
(5) The Hitchcock Foundation

 P 37,145 FMV
(6) The New London Hospital Association

 Q 1,935,251 FMV
(7) Windsor Hospital Association

 Q 1,410,072 FMV
(8) Cheshire Medical Center

 Q 2,808,969 FMV
(9) The Hitchcock Foundation

 C 99,071 FMV
Schedule R (Form 990) 2014
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) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

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




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






























Schedule R (Form 990) 2014
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


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