TY 2015 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) SHANE HILTON...................................................................... MSHA VP/CFO	1.00 ................. 44.00	X				0	406,667	55,701
(2) MONTY MCLAURIN...................................................................... MSHA VP/CEO	0.20 ................. 44.80	X				0	357,781	52,277
(3) ROBERT LEONARD...................................................................... TREASURER	0.30 ................. 0.60	X	X			0	21,190	0
(4) JAMES MANICURE...................................................................... VICE-CHAIR	0.30 ................. 0.60	X	X			0	14,299	0
(5) BUFORD STURGILL...................................................................... DIRECTOR	0.20 ................. 0.60	X				0	13,825	0
(6) DONALD BAKER...................................................................... CHAIR	1.00 .................	X	X			0	0	0
(7) ROGER DEEL...................................................................... DIRECTOR	0.30 .................	X				0	0	0
(8) VONDA BUCHANAN...................................................................... SECRETARY	0.30 .................	X	X			0	0	0
(9) PAUL BUCHANAN...................................................................... DIRECTOR	0.10 .................	X				0	0	0
(10) MARK LEONARD...................................................................... DCH/NCH CEO	6.00 ................. 39.00		X			0	335,259	42,872
(11) KEVIN MORRISON...................................................................... DCH/NCH CFO	6.00 ................. 39.00		X			0	129,326	10,409
(12) ROY DEEL DO...................................................................... PHYSICIAN	40.00 .................			X		0	257,697	22,424
(13) LURTON LYLE MD...................................................................... PHYSICIAN	40.00 .................			X		0	129,081	9,011
(14) JOHN WRIGHT...................................................................... FORMER DIREC	0.00 ................. 0.00				X	0	13,816	0
(15) STEPHEN SAWYER AVPCFO NW MKT...................................................................... IPMC CFO/FMR	0.00 ................. 45.00				X	0	211,868	24,929

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I

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

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

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

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ))

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

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

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

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

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

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

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

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

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

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

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

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

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

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

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

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

Page 2

Part II

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any unusual grants.) ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10.

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

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

Section C. Computation of Public Support Percentage

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

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

16a

33 1/3% support test—2015. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2014. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2015. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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

Schedule A (Form 990 or 990-EZ) 2015

Page 3

Part III

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513...
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support. (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

331/3% support tests—2015. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2014. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

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

Schedule A (Form 990 or 990-EZ) 2015

Page 4

Part IV

Supporting Organizations

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

Section A. All Supporting Organizations

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

10a

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

10a

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

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

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

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

11a

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

11b

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

11c

Section B. Type I Supporting Organizations

Yes

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

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

Section C. Type II Supporting Organizations

Yes

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

Section D. All Type III Supporting Organizations

Yes

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

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

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

Section E. Type III Functionally-Integrated Supporting Organizations

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

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

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

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

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

Yes

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

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

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

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

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

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

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

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

OMB No. 1545-0047

2015

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

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

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

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

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

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

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

Name of organization DICKENSON COMMUNITY HOSPITAL

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

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

Page 3

Name of organization DICKENSON COMMUNITY HOSPITAL		Employer identification number 77-0599553

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

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

Page 4


Name of organization DICKENSON COMMUNITY HOSPITAL			Employer identification number 77-0599553
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below. SchCMd Bullet

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

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

OMB No. 1545-0047

2015

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

Page 2

Part II-A

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

A Check SchCMd Bullet

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

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

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

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

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(e) Total

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2015

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

Yes

329

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

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

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

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

329

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Return Reference	Explanation
SCHEDULE C, PART IV	DCH HAD LOBBYING EXPENSES OF 329 WHICH REPRESENTS THE PORTION OF VIRGINIA HOSPITAL & HEALTHCARE ASSOCIATION DUES ATTRIBUTABLE TO DIRECT LOBBYING.

Schedule C (Form 990 or 990EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I

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

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

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ....

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2015

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No


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

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

Yes No

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

Part V

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

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

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

1a	Land ...
b	Buildings	770,459	238,531	531,928
c	Leasehold improvements	557,292	470,064	87,228
d	Equipment ...	3,472,607	2,389,858	1,082,749
e	Other ...
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				1,701,905

Schedule D (Form 990) 2015

Page 3

Part VII

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

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

Part VIII

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

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

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

Part IX

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

(a) Description				(b) Book value
(1) DUE FROM CMS				1,078,000
(2) OTHER RECEIVABLES				515,804
(3) DUE FROM AFFILIATES				114,373
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,708,177

Part X

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

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
DUE TO THIRD PARTIES	361,856
PENSION BENEFIT LIABILITIES	211,700
PROF. LIABILITY RESERVE	43,129
OTHER	750
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	617,435
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2015

Page 4

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

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

Part XIII

Supplemental Information

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

Return Reference

Explanation

SCHEDULE D, PAGE 3, PART X

"THE ALLIANCE IS CLASSIFIED AS AN ORGANIZATION EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3)OF THE INTERNAL REVENUE CODE. AS SUCH, NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS FOR THE ALLIANCE AND ITS TAX-EXEMPT SUBSIDIARIES. THE ALLIANCE'S TAXABLE SUBSIDIARIES ARE DISCUSSED IN NOTE L. THE ALLIANCE HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS AT JUNE 30, 2016 AND 2015. AT JUNE 30, 2016, TAX RETURNS FOR 2013 THROUGH 2015 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE."

Schedule D (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

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

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

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	77,094		77,094	0.880 %
b	Medicaid (from Worksheet 3, column a) . . . . .	1,700,776	784,212	916,564	10.480 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	1,777,870	784,212	993,658	11.360 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	2,091		2,091	0.020 %
f	Health professions education (from Worksheet 5) . . .	71,113		71,113	0.810 %
g	Subsidized health services (from Worksheet 6) . . . .	2,039,236	632,682	1,406,554	16.080 %
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .	2,112,440	632,682	1,479,758	16.920 %
k	Total. Add lines 7d and 7j .	3,890,310	1,416,894	2,473,416	28.280 %

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

Schedule H (Form 990) 2015

Page

Part II

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

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

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

1,596,969

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. ......

1,079,858

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

Section B. Medicare

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

2,412,011

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

2,578,709

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

-166,698

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2015

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)						Other (Describe)
1	DICKENSON COMMUNITY HOSPITAL PO BOX 1440 1 HOSPITAL DRIVE CLINTWOOD,VA24228 WWW.MOUNTAINSTATESHEALTH.COM/DCH H 1918	X	X	X	X	MENTAL HEALTH

Schedule H (Form 990) 2015

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	DICKENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group	PO BOX 1440

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

Yes

Community Health Needs Assessment

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

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

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The significant health needs of the community

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

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

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

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

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 15

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

Yes

6 a

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

Yes

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

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

Yes

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

Hospital facility’s website (list url): WWW.MOUNTAINSTATESHEALTH.COM/DCH

Other website (list url):

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

Other (describe in Section C)

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

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 16

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

If "Yes" (list url):

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

10b

Yes

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

12a

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

12a

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

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	DICKENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group	PO BOX 1440

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

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

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.000000000000% and FPG family income limit for eligibility for discounted care of 400.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

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

Yes

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

Yes

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

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

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

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

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

Other (describe in Section C)

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

Yes

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

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

WWWMOUNTAINSTATESHEALTHCOM

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

WWWMOUNTAINSTATESHEALTHCOM

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

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

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

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

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

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

Other (describe in Section C)

Billing and Collections

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	DICKENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group	PO BOX 1440

Yes

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

Yes

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

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

Yes

If "No," indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Section C)

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

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

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

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

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

Other (describe in Section C)

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

If "Yes," explain in Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
FACILITY 1, DICKENSON COMMUNITY HOSPITAL - PART V, LINE 5	MSHA MET WITH TEN FOCUS GROUPS, EACH REPRESENTING ONE OF THE THIRTEEN HOSPITAL FACILITIES, INCLUDING DCH. EACH GROUP CONSISTED OF PUBLIC HEALTH LEADERS, NURSES, NON-PROFIT DIRECTORS, COMMUNITY DEVELOPERS, FAITH BASED LEADERS, PUBLIC OFFICIALS AND SCHOOL REPRESENTATIVES. SPECIFIC TO DCH, THE GROUP CONSISTED OF REPRESENTATIVES FROM PUBLIC SCHOOLS, DICKENSON COMMUNITY HOSPITAL, DICKENSON COUNTY SHERIFF'S OFFICE, AND DICKENSON COUNTY TREASURER'S OFFICE. EACH GROUP RANGED IN ATTENDANCE FROM 5 TO 18 INDIVIDUALS. PARTICIPANTS WERE GIVEN SURVEYS TO DETERMINE A COUNTY'S PERCEIVED HEALTH STATUS RATING, AVAILABLE RESOURCES, TOP HEALTH PRIORITIES (DISEASE CONDITIONS, HEALTH BEHAVIORS, AND SOCIOECONOMIC FACTORS), AND SUGGESTIONS FOR IMPROVEMENT. OPEN DISCUSSION FOLLOWED. THE COLLECTED INFORMATION WAS THEN PAIRED WITH STATISTICAL DATA IN ORDER TO PRIORITIZE HEALTH NEEDS. THE FACILITY COMMUNITY BOARDS (SUCH AS DCH'S BOARD) WERE PRESENTED THIS INFORMATION AND SHARED THEIR THOUGHTS AS WELL ON THE HEALTH NEEDS TO PRIORITIZE. THE SPECIFIC NEEDS FOR EACH COUNTY WERE THEN ADDRESSED IN THE RESPECTIVE FACILITY IMPLEMENTATION PLAN WHICH WAS ADOPTED SEVERAL MONTHS LATER.
FACILITY 1, DICKENSON COMMUNITY HOSPITAL - PART V, LINE 6A	EACH HOSPITAL WITHIN THE MSHA SYSTEM COMPLETED A CHNA. DCH'S CHNA WAS CONDUCTED WITH ALL MSHA HOSPITALS TO INCLUDE: JOHNSON CITY MEDICAL CENTER (INCLUDES NISWONGER CHILDREN'S HOSPITAL AND WOODRIDGE HOSPITAL), FRANKLIN WOODS COMMUNITY HOSPITAL, INDIAN PATH MEDICAL CENTER, SYCAMORE SHOALS HOSPITAL, JOHNSON COUNTY COMMUNITY HOSPITAL, UNICOI COUNTY MEMORIAL HOSPITAL, RUSSELL COUNTY MEDICAL CENTER, SMYTH COUNTY COMMUNITY HOSPITAL, JOHNSTON MEMORIAL HOSPITAL AND NORTON COMMUNITY HOSPITAL.
FACILITY 1, DICKENSON COMMUNITY HOSPITAL - PART V, LINE 11	MSHA PUBLISHED ITS COMMUNITY HEALTH NEEDS ASSESSMENT ON JUNE 29, 2015. THE DATA INCLUDED WAS COLLECTED OVER THE COURSE OF 2014 AND 2015. DUE TO LIMITED RESOURCES, EACH FACILITY PRIORITIZED FOUR TO FIVE HEALTH PRIORITIES ON WHICH TO FOCUS AND DEVELOP IMPLEMENTATION PLANS TO IMPACT. THERE WERE SEVEN COMMON HEALTH PRIORITIES SELECTED BY THE VARIOUS 11 FACILITIES, BUT NOT ALL FACILITIES SELECTED THE SAME AREAS. THE SEVEN ARE OBESITY, SUBSTANCE/PRESCRIPTION DRUG ABUSE, DIABETES, CANCER, HEART DISEASE, SMOKING AND MENTAL HEALTH. ALL OF THESE ARE SIGNIFICANT ISSUES FOR ALL 11 FACILITIES, BUT EACH CHOSE TO PRIORITIZE ON A DIFFERENT SET SO THEY COULD TARGET THEIR EFFORTS AND BE MORE EFFECTIVE WITH LIMITED RESOURCES. FOR EXAMPLE, WHILE NEARLY ALL THE FACILITIES IDENTIFIED OBESITY (11 OF 11) AND SUBSTANCE/ PRESCRIPTION DRUG ABUSE (10 OF 11), ONLY CERTAIN FACILITIES ELECTED TO FOCUS ON SOME NUMBER OF THE OTHER FIVE COMMON HEALTH PRIORITIES. WHILE MENTAL HEALTH IS CLEARLY A SIGNIFICANT ISSUE FOR ALL 11 FACILITIES, ONLY THREE ARE FOCUSED ON IT DUE TO LIMITED RESOURCES. THE SAME IS TRUE WITH SMOKING WHERE ONLY 5 OF THE 11 FACILITIES ARE FOCUSED ON IT, BUT IT IS AN ISSUE FOR ALL FACILITIES. SIX OF THE 11 FACILITIES SELECTED CANCER; 6 OF THE 11 SELECTED HEART DISEASE; AND 9 OF THE 11 CHOSE DIABETES. ANOTHER WAY TO STATE THIS IS BY FACILITY. FOR EXAMPLE, WHILE CANCER AND MENTAL HEALTH ARE PREVALENT CHALLENGES FOR JCMC'S PRIMARY SERVICE AREA, THE HOSPITAL ELECTED NOT TO FOCUS ON THOSE DUE TO LIMITED TIME, FUNDING, PERSONNEL AND OTHER RESOURCES NEEDED TO EFFECTUATE CHANGE. UCMH FELT IT WAS UNABLE TO ADDRESS HEART DISEASE, SMOKING, AND MENTAL HEALTH ISSUES IN ITS PRIMARY SERVICE AREA. SOME FACILITIES IDENTIFIED ISSUES SUCH AS TRANSPORTATION AND EDUCATION AS BARRIERS TO GOOD HEALTH, BUT WERE ALSO UNABLE TO SET ASIDE SUFFICIENT RESOURCES TO MEANINGFULLY IMPACT THOSE CHALLENGES. AFTER THE FACILITIES SELECTED A REASONABLE NUMBER OF HEALTH PRIORITIES THEY FELT THEY COULD ADEQUATELY IMPACT, AN IMPLEMENTATION PLAN WAS CREATED FOR EACH HOSPITAL, AND EACH HOSPITAL'S BOARD APPROVED THE IMPLEMENTATION PLAN DURING THE MONTHS OF NOVEMBER AND DECEMBER 2015. MSHA ANNUALLY TRACKS PROGRESS OF IMPLEMENTATION STRATEGIES FOR EACH HOSPITAL. THE FACILITIES HAVE BEEN CONDUCTING ACTIVITIES CONSISTENT WITH THEIR RESPECTIVE IMPLEMENTATION PLANS. FOR EXAMPLE, DCH HAS IMPLEMENTED SURVIVAL KITS WITH EDUCATION FOR NEWLY DIAGNOSED DIABETES PATIENTS PROVIDED IN LOCAL CLINICS AND PHYSICIAN PRACTICES. NCH WORKS WITH LOCAL PHYSICIANS TO PROVIDE A SUPPORT PROGRAM FOR PREGNANT WOMEN WITH SUBSTANCE ABUSE ISSUES. RCMC SUPPORTS THE RUSSELL COUNTY SCHOOL BACKPACK PROGRAM WHICH PROVIDES HEALTHY FOOD FOR KIDS IN NEED TO HELP ADDRESS CHILDHOOD OBESITY. JCCH MEETS WITH THE LOCAL SCHOOLS TO PROVIDE EDUCATION ON THE DANGERS OF SMOKING. IPMC HAS BEEN SUPPORTING SUGAR FREE INITIATIVES AT THE LOCAL BOYS AND GIRLS CLUB TO HELP REDUCE OBESITY IN CHILDREN. FWCH PROVIDES COOKING AND PHYSICAL ACTIVITY CLASSES TO THE COMMUNITY TO ADDRESS OBESITY AND DIABETES. UCMH PARTNERS WITH THE LOCAL YMCA TO PROVIDE DIABETES EDUCATION CLASSES AND SUPPORT FOR THE COMMUNITY. THESE ARE JUST A FEW EXAMPLES OF THE EFFORTS MADE BY MSHA HOSPITALS TO SUPPORT THEIR IMPLEMENTATION PLANS.

Schedule H (Form 990) 2015

Page 8

Part VFacility Information (continued)

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

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

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

Form and Line Reference	Explanation
PART I, LINE 3C - OTHER INCOME BASED CRITERIA FOR FREE OR DISCOUNTED CARE	FINANCIAL ASSISTANCE APPROVAL CAN APPLY TO AN ASSORTMENT OF PATIENTS SUCH AS THOSE WHO HAVE EXHAUSTED THEIR MEDICAID BENEFITS, THOSE WHO QUALIFIED FOR MEDICAID AFTER THE DATE OF SERVICE, DECEASED PATIENTS WITH NO ESTATE OR ASSETS, UNINSURED PATIENTS, AND UNDERINSURED PATIENTS. MSHA CHARITY QUALIFICATION IS BASED ON FEDERAL POVERTY GUIDELINES BUT ALSO USES ASSET VALUES TO DETERMINE FINANCIAL ASSISTANCE ELIGIBILITY. CHARITY APPROVAL COVERS ALL DATES OF SERVICE FOR THE PATIENT WHEN THEY ARE APPROVED AND THERE IS NO LIMITATION OR CAP ON THE AMOUNT OF CHARITY THAT THEY CAN RECEIVE. MSHA ALWAYS ATTEMPTS TO FULFILL ITS OBLIGATION TO PROVIDE FINANCIAL ASSISTANCE TO THOSE PATIENTS WITHOUT THE ABILITY TO PAY. THE MAJORITY OF MSHA HOSPITALS ARE LOCATED IN TENNESSEE AND PURSUANT TO TENNESSEE LAW ALL PATIENTS WITHOUT THIRD-PARTY PAYER COVERAGE RECEIVE A DISCOUNT. ALTHOUGH VIRGINIA DOES NOT HAVE A LAW THAT REQUIRES HOSPITALS TO PROVIDE DISCOUNTS TO UNINSURED PATIENTS, MSHA EXTENDS ITS TENNESSEE UNINSURED DISCOUNT RATES TO ITS VIRGINIA HOSPITALS AS WELL. THE DISCOUNT RATE FOR CRITICAL ACCESS HOSPITALS, INCLUDING DCH, IS 58%.
PART I, LINE 6A - RELATED ORGANIZATION INFORMATION	MSHA'S COMMUNITY BENEFIT REPORT COMPLETED IN FY15 INCLUDED DCH. OUR NEXT COMMUNITY BENEFIT REPORT WILL BE ISSUED DURING FY17.
PART I, LINE 7 - COSTING METHODOLOGY EXPLANATION	THE COST TO CHARGE RATIO (WORKSHEET 2 "RATIO OF PATIENT CARE COST TO CHARGES") WAS USED TO CALCULATE LINE 7A FINANCIAL ASSISTANCE COST. OUR COST ACCOUNTING SYSTEM PROVIDED MEDICAID/TENNCARE LOSSES REPORTED ON LINE 7B, WITH THE EXCEPTION OF OUR PHYSICIAN CLINIC. WE USED COST TO CHARGE RATIO FOR OUR PHYSICIAN CLINIC BECAUSE ITS DATA IS NOT AVAILABLE IN OUR COST ACCOUNTING SYSTEM. LINE 7E COMMUNITY HEALTH IMPROVEMENT INCLUDES COSTS ASSOCIATED WITH PAYMENTS TO AN UNRELATED, OUTSIDE ORGANIZATION THAT ASSISTED DCH PATIENTS OBTAIN MEDICAID COVERAGE. LINE 7F HEALTH PROFESSIONS EDUCATION IS COMPRISED OF NURSING STUDENTS FROM SCHOOLS AND UNIVERSITIES, ALLOWING THEIR STUDENTS TO GET HANDS-ON TRAINING AT A HOSPITAL AS PART OF THEIR EDUCATION AND TRAINING. OUR ORGANIZATIONAL DEVELOPMENT DEPARTMENT KEEPS DETAILED RECORDS OF HOURS SPENT ON THESE STUDENT ACTIVITIES, THE NUMBER OF STUDENTS THAT ROTATE THROUGH OUR HOSPITAL, ETC. INFORMATION IS MAINTAINED FOR EACH HOSPITAL UNIT THAT PARTICIPATES. WE ONLY INCLUDE LABOR COSTS AND WE ONLY ASSUME A PERCENTAGE OF OUR INVOLVED TEAM MEMBERS' TIME IS DEVOTED TO THESE STUDENTS. FOR LINE 7G SUBSIDIZED HEALTH SERVICES, WE USE OUR COST ACCOUNTING SYSTEM, EXCEPT FOR THE 60,434 SUBSIDY OF OUR OWNED AND OPERATED CLINIC LOCATED IN A RURAL, LOW INCOME AREA. WE ARE CAREFUL TO ENSURE NO DOUBLE COUNTING OF COST (FOR EXAMPLE, WE DO NOT INCLUDE CHARITY AND MEDICAID ALREADY REPORTED ON LINES 7A AND 7B). AND, PURSUANT TO IRS INSTRUCTIONS, WE DO NOT INCLUDE BAD DEBT LOSSES. ALTHOUGH WE HAVE MANY SERVICE LINES WITHIN OUR HOSPITAL THAT LOSE MONEY, WE DO NOT REPORT SERVICES THAT HOSPITALS ARE REQUIRED BY STATE LICENSURE TO PROVIDE. FOR THE SERVICE LINES WE DO REPORT, SUCH AS INPATIENT AND OUTPATIENT PSYCH FOR SENIORS, WE USED OUR COST ACCOUNTING SYSTEM SINCE THESE SERVICES HAVE ESTABLISHED, STANDARD FINANCIAL REPORTS.
PART II - COMMUNITY BUILDING ACTIVITIES	DCH LEADERS SUPPORT AND ENCOURAGE ALL TEAM MEMBERS TO VOLUNTEER TIME, MONEY AND SKILLS TO COMMUNITY SERVICE PROJECTS AND CHARITABLE ORGANIZATIONS. SENIOR LEADERS AND BOARD MEMBERS SET A POSITIVE EXAMPLE FOR TEAM MEMBERS, SERVING VOLUNTARILY ON COMMITTEES AND BOARDS OF LOCAL SERVICE AND NONPROFIT ORGANIZATIONS. SOME ALSO SERVE AS MEMBERS AND CONSULTANTS ON PROFESSIONAL COMMITTEES AND TASK FORCES THAT AFFECT REGIONAL DEVELOPMENT IN HEALTHCARE AND EDUCATION. WE DO NOT CAPTURE COSTS ASSOCIATED WITH TEAM MEMBERS THAT SERVE ON OTHER NONPROFIT BOARDS OR PROVIDE SERVICES TO OTHER NONPROFITS.
PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGY	SELF-PAY BALANCES INCLUDE ACCOUNTS AFTER PAYMENTS AND CONTRACTUAL ADJUSTMENTS (DISCOUNTS) HAVE BEEN POSTED FROM ALL THIRD-PARTY PAYERS- GENERALLY LEAVING THE PATIENT RESPONSIBLE FOR ANY REMAINING DEDUCTIBLE AND/OR CO-PAYMENT. OTHER SELF-PAY ACCOUNTS ARE FROM PATIENTS WITH NO INSURANCE OR OTHER THIRD-PARTY COVERAGE. AFTER THE NORMAL COLLECTION PROCESS HAS INDICATED AN ACCOUNT IS UNCOLLECTIBLE, DCH WRITES THE ACCOUNT OFF TO BAD DEBT. THE HOSPITAL'S OVERALL SELF-PAY ACCOUNTS RECEIVABLE BALANCE IS EVALUATED ON AN ONGOING BASIS TO GATHER HISTORICAL INFORMATION TO APPLY TO THE CURRENT BALANCE. IN OTHER WORDS, THE HOSPITAL EVALUATES PAST COLLECTION HISTORY ON ACCOUNTS WRITTEN OFF TO BAD DEBT AND APPLIES THE HISTORICAL UNPAID RATE TO THE CURRENT SELF-PAY ACCOUNTS RECEIVABLE BALANCE.
PART III, LINE 3 BAD DEBT EXPENSE, PATIENTS ELIGIBLE FOR ASSISTANCE	DCH'S PATIENT FINANCIAL SERVICES MANAGEMENT ESTIMATE THAT 68% OF BAD DEBT EXPENSE IS ASSUMED ATTRIBUTABLE TO PATIENTS LIKELY ELIGIBLE FOR FINANCIAL ASSISTANCE. WE BASE THIS PERCENTAGE ON THE COMPOSITION OF BAD DEBTS ATTRIBUTABLE TO PEOPLE WITH NO FORM OF INSURANCE OR OTHER THIRD-PARTY COVERAGE, WHICH REPRESENTS THE MAJORITY OF BAD BEBT ACCOUNTS. WE ALSO ESTIMATE A MUCH SMALLER PERCENTAGE OF LIKELY CHARITY-ELIGIBLE ACCOUNTS TO PEOPLE WITH BALANCES AFTER INSURANCE/THIRD-PARTY COVERAGE HAS PAID (E.G. DEDUCTIBLES AND CO-PAYMENT BALANCES). IT IS IMPLAUSIBLE TO DETERMINE WITH EXACTITUDE THE AMOUNT OF DCH'S BAD DEBT ASSOCIATED WITH THOSE PATIENTS WHO MAY HAVE MET THE CRITERIA SET FORTH IN OUR FINANCIAL ASSISTANCE POLICY WITHOUT HAVING A COMPLETED FINANCIAL ASSESSMENT. WE ARE UNABLE TO DETERMINE OUR PATIENTS' FINANCIAL CIRCUMSTANCES UNLESS A COMPLETED FINANCIAL ASSISTANCE FORM IS VOLUNTARILY PROVIDED TO US. WE CAN ASSERT THAT 95% OF OUR PATIENTS WHO COMPLETED OUR FINANCIAL ASSISTANCE APPLICATION WERE APPROVED FOR AT LEAST PARTIAL FINANCIAL ASSISTANCE. IN FACT 83% OF COMPLETED APPLICATIONS RECEIVED A COMPLETE WRITE-OFF OF ALL CHARGES (FREE CARE). ANOTHER 12% RECEIVED A PARTIAL DISCOUNT. DURING FY16, ONLY 5% OF COMPLETED FINANCIAL ASSISTANCE APPLICATIONS WERE DENIED. UNFORTUNATELY, 33% OF SUBMITTED APPLICATIONS ARE INCOMPLETE. WE RETURN INCOMPLETE APPLICATIONS TO PATIENTS ALONG WITH A NOTICE OF MISSING INFORMATION. THE NOTICE ALSO PROVIDES A CONTACT PHONE NUMBER PATIENTS MAY CALL. WE HAVE MANY INSTANCES OF PATIENTS WITH LARGE ACCOUNT BALANCES AND NO HEALTH INSURANCE COVERAGE THAT WE ARE SURE WOULD QUALIFY FOR CHARITY CARE. ALTHOUGH HOSPITAL TEAM MEMBERS ENCOURAGE THESE INDIVIDUALS TO COMPLETE OUR FINANCIAL ASSISTANCE APPLICATION, MANY WILL NOT DO SO. OUR TEAM MEMBERS VOLUNTEER TO ASSIST PATIENTS WITH COMPLETION OF THE APPLICATION.MSHA WOULD PREFER FOR PATIENTS TO SUBMIT COMPLETED FINANCIAL ASSISTANCE APPLICATIONS GIVEN HISTORICAL DATA THAT MANY WOULD QUALIFY FOR THIS PROGRAM. WITHOUT A COMPLETED APPLICATION, MSHA MUST REPORT AN UNPAID ACCOUNT AS BAD DEBT INSTEAD OF CHARITY.
BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTS	THE TEXT OF MSHA'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE APPEARS ON PAGE 13 IN OUR MOST RECENT AUDITED FINANCIAL STATEMENTS (ATTACHED).
PART III, LINE 8 - MEDICARE EXPLANATION	MEDICARE ALLOWABLE COSTS ARE REPORTED USING DCH'S FILED MEDICARE COST REPORT (C/R). THE C/R USES A COST TO CHARGE RATIO BASED ON A STEP-DOWN ALLOCATION METHODOLOGY. IN CARING FOR THE PATIENT, THERE ARE SEVERAL SERVICES THAT ARE CONSIDERED NON-ALLOWABLE SUCH AS TRANSPORTATION OF A PATIENT, COMFORT ITEMS TO INCLUDE A TELEVISION AND A TELEPHONE. THE RECRUITMENT OF PHYSICIANS AND PHYSICIAN GUARANTEES ARE NON-ALLOWED COSTS BY THE MEDICARE PROGRAM EVEN THOUGH PHYSICIANS ARE RECRUITED BASED ON DOCUMENTED COMMUNITY NEED. ALSO, A PORTION OF THE BAD DEBT ASSOCIATED WITH THE CARE OF THE PATIENT IS NOT AN ALLOWED COST BY MEDICARE. MEDICARE LOSSES, INCLUDING SOME NON-ALLOWABLE COSTS SUCH AS THOSE NOTED ABOVE, SHOULD BE COUNTED AS A COMMUNITY BENEFIT AS THIS IS THE COST OF CARE FOR SERVING THE AGING POPULATION. WHILE WE AGREE THAT COSTS SUCH AS MARKETING TO ATTRACT PATIENTS AND LOBBYING ARE REASONABLE TO EXCLUDE, IT DOES NOT SEEM REASONABLE TO EXCLUDE RECRUITMENT OF PHYSICIANS AND BASIC ITEMS SUCH AS TELEVISIONS IN PATIENT ROOMS. AS A NONPROFIT ORGANIZATION, WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF THE COMMUNITY AND THE INDIVIDUAL WHILE MAINTAINING A HIGH LEVEL OF HEALTH CARE SERVICES WITHOUT LOSSES. SINCE LOSSES DO OCCUR THROUGH THE CMS SYSTEM OF REIMBURSEMENT, THESE LOSSES ARE A COST OF DOING BUSINESS FOR OUR COMMUNITY AND SHOULD BE CONSIDERED A COMMUNITY BENEFIT. AS A PARTICIPATING PROVIDER IN THE MEDICARE PROGRAM, DCH IS REQUIRED TO PROVIDE THE FULL REGIMEN OF CARE FOR OUR MEDICARE POPULATION. THERE ARE A NUMBER OF CARE REGIMENS THAT ARE COMPENSATED BY THE MEDICARE PROGRAM AT LEVELS BELOW OUR COST. THEREFORE, IT IS ONLY LOGICAL TO ALLOW HOSPITALS TO REPORT THESE UNCOMPENSATED SERVICES AS A COMMUNITY BENEFIT. BY MAKING THIS CHANGE, NONPROFIT PROVIDERS WILL BE ENCOURAGED TO SUSTAIN IMPORTANT CARE DELIVERY MODELS FOR OUR AGING POPULATION IN SPITE OF THE FACT IT IS SOMETIMES ECONOMICALLY INJURIOUS. PART III, LINE 9B - COLLECTION PRACTICES EXPLANATION DCH HAS ESTABLISHED A STRONG COMMITMENT TO MEET THE MEDICAL NEEDS OF THE COMMUNITIES WE SERVE. ALL REQUESTS FOR FINANCIAL ASSISTANCE ARE EVALUATED USING ESTABLISHED GENERAL GUIDELINES, WHILE ALLOWING FOR UNIQUE FINANCIAL CIRCUMSTANCES. DCH RECOGNIZES ITS OBLIGATION TO PROVIDE QUALITY HEALTHCARE TO THOSE WHO ARE UNABLE TO PAY. DCH CHARITY GUIDELINES ARE BASED ON NATIONAL POVERTY GUIDELINES. HOWEVER, FINANCIAL ASSISTANCE IS NOT BASED SOLELY ON INCOME. UNIQUE FINANCIAL CIRCUMSTANCES ARE CONSIDERED, WHICH CAN CHANGE THE CATEGORY OF ELIGIBILITY. IN ADDITION, CHARITY DETERMINATION MAY BE RETROACTIVE FOR ALL DATES OF SERVICE. WHEN A PATIENT REQUESTS FINANCIAL ASSISTANCE OR WHEN AN APPLICATION HAS BEEN RECEIVED, THE PATIENT ACCOUNT IS PLACED IN A HOLD STATUS TO PREVENT FURTHER COLLECTION ACTIVITIES UNTIL FINANCIAL ASSISTANCE ELGIBILITY IS DETERMINED.
PART VI, LINE 2 - NEEDS ASSESSMENT	MSHA INCLUDED AMERICA'S HEALTH RANKINGS (AHR) IN ITS ASSESSMENT IN ORDER TO BETTER DEFINE THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES. IN 2016, VIRGINIA'S OVERALL HEALTH RANKING MOVED UP TO 19TH, WHILE TENNESSEE IS RANKED 44TH. HOWEVER, IT SHOULD BE NOTED THAT SOUTHWEST VIRGINIA (WHERE DCH IS LOCATED) CLOSELY RESEMBLES THE HEALTH RANKINGS FOR TENNESSEE. AMERICA'S HEALTH RANKINGS ARE BASED ON A SERIES OF MEASURES INCLUDING SEVERAL HEALTH OUTCOMES AND HEALTH FACTORS. A SURVEY WAS GIVEN TO 106 INDIVIDUALS REPRESENTING THE TEN COUNTIES IN WHICH MSHA OWNS A FACILITY. THESE INDIVIDUALS INCLUDED PHYSICIANS, PUBLIC HEALTH LEADERS, NON-PROFIT DIRECTORS, SCHOOL NURSES AND OFFICIALS, AND BUSINESS LEADERS. A SURVEY WAS GIVEN TO EACH INDIVIDUAL SEEKING FEEDBACK REGARDING AVAILABLE RESOURCES IN EACH AREA, THE PERCEIVED HEALTH STATUS, HEALTH PRIORITIES (DISEASE CONDITIONS, HEALTH BEHAVIORS AND SOCIOECONOMIC FACTORS), AND SUGGESTIONS FOR IMPROVEMENT. THE MAJORITY OF RESPONSES SUGGESTED FOCUSING ON EDUCATION IN ORDER TO PROMOTE HEALTHY HABITS AND INCREASED ACCESS TO RESOURCES. OTHER RESPONSES INCLUDED: MAKE PHYSICAL EDUCATION A REQUIREMENT AS PART OF SCHOOL CURRICULUM, IMPROVE NATURAL TRAILS AND WALKWAYS, INCREASE COMMUNITY SUPPORT FOR SMOKE-FREE AREAS, PARTNER WITH LOCAL FARMER'S MARKETS, SHARE HEALTH INFORMATION BETWEEN PHARMACIES, NETWORK WITH SMALL BUSINESSES AND NON-PROFITS IN ORDER TO AVOID DUPLICATING RESOURCES, AND PROVIDE EARLY SCREENINGS FOR THE UNINSURED OR UNDERINSURED. OVERALL, THE COMMUNITY MEMBERS GAVE MSHA'S CORE SERVICE AREA A HEALTH STATUS RANKING OF 4.55 OUT OF 10 (1 BEING THE LOWEST, 10 BEING THE HIGHEST). DCH WAS GIVEN A HEALTH STATUS RANKING OF 3.8. AMONG THE 106 PARTICIPANTS, THE AREAS OF OBESITY, CANCER, HEART DISEASE, SMOKING, SUBSTANCE/PRESCRIPTION DRUG ABUSE, AND DIABETES WERE THE TOP HEALTH PRIORITIES IN OUR REGION. ACCORDING TO THE MOST RECENT AHR REPORTS, VIRGINIA AND TENNESSEE BOTH SAW AN INCREASE IN DIABETES AND OBESITY WITHIN THE PAST TEN YEARS. VIRGINIA RANKS 25TH FOR CARDIOVASCULAR DEATHS, 23RD FOR CANCER DEATHS AND 28TH FOR DIABETES. THE NATIONAL CANCER INSTITUTE REPORTS DICKENSON COUNTY CITIZENS HAVE 23% HIGHER RATE OF LUNG AND BRONCHUS INCIDENTS COMPARED TO THE STATE OF VIRGINIA. THE ROBERT WOOD JOHNSON FOUNDATION REPORTS 30% OF OUR COUNTY'S ADULTS ARE CONSIDERED OBESE AND 28% ARE PHYSICALLY INACTIVE. DICKENSON COUNTY'S HEALTH RANKING IS 122 OUT OF 134 STATEWIDE (1 BEING THE BEST AND 134 BEING THE WORST).
PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	MOUNTAIN STATES HEALTH ALLIANCE COMMUNICATES WITH AND EDUCATES OUR PATIENTS THROUGH VARIOUS AVENUES FOR GOVERNMENTAL ASSISTANCE PROGRAMS AND HOSPITAL FINANCIAL ASSISTANCE. EDUCATION IS PROVIDED TO PATIENTS THROUGH SIGNAGE AND FINANCIAL ASSISTANCE BROCHURES AT ALL HOSPITAL AND AMBULATORY ADMISSION LOCATIONS. FINANCIAL ASSISTANCE APPLICATIONS AND PLAIN LANGUAGE SUMMARIES ARE PROVIDED TO PATIENTS SHOULD THEY REQUEST ONE DURING THEIR PRE- REGISTRATION, REGISTRATION OR FINANCIAL COUNSELING PROCESS. OUR GOVERNMENTAL PROGRAM ELIGIBILITY REPRESENTATIVES ASSIST PATIENTS IN SECURING ELIGIBILITY FOR MEDICAID, FEDERAL DISABILITY AND OTHER GOVERNMENTAL ASSISTANCE PROGRAMS. ADDITIONALLY, IF A PATIENT OR COMMUNITY RESIDENT EXPRESSES AN INTEREST IN THE ACA-HEALTHCARE EXCHANGE, OUR REPRESENTATIVES HAVE THE QUALIFICATIONS AND EXPERIENCE TO ASSIST THEM THROUGH THE ENTIRE PROCESS. FINANCIAL COUNSELORS OFFER FINANCIAL ASSISTANCE APPLICATIONS TO PATIENTS WHO DO NOT QUALIFY FOR GOVERNMENTAL ASSISTANCE PROGRAMS AND ARE UNABLE TO PAY FOR THE COST OF THEIR HEALTHCARE. FINANCIAL ASSISTANCE APPLICATIONS ARE AVAILABLE ON OUR WEBSITE TO INCLUDE THE FINANCIAL ASSISTANCE APPLICATION, POLICY AND PLAIN LANGUAGE SUMMARY IN BOTH ENGLISH AND SPANISH. ALL PATIENT STATEMENTS HAVE VERBIAGE DISCUSSING FINANCIAL ASSISTANCE ALONG WITH THE CONTACT INFORMATION. OUR LAST LETTER TO THE PATIENT DISPLAYS THE PLAIN LANGUAGE SUMMARY. IN ALL ORAL CORRESPONDENCES WITH THE PATIENT, IF IT IS IDENTIFIED THEY CANNOT MEET THE PAYMENT REQUIREMENTS ON THEIR ACCOUNT, FINANCIAL ASSISTANCE IS DISCUSSED AS AN OPTION.
PART VI, LINE 4 - COMMUNITY INFORMATION	DCH IS LOCATED IN CLINTWOOD, DICKENSON COUNTY, WHICH IS IN RURAL SOUTHWEST VIRGINIA. SOUTHWEST VIRGINIA (SWVA) IS LOCATED WITHIN THE APPALACHIAN MOUNTAINS, SPECIFICALLY THE BLUE RIDGE MOUNTAIN REGION. SWVA IS CONSIDERED RURAL AND MUCH DIFFERENT THAN THE REST OF THE STATE. SWVA HAS BEEN AND REMAINS A MAJOR COAL MINING REGION AND HAS A HIGH RATE OF INDIVIDUALS WHO ARE UNINSURED. ACCORDING TO U.S. CENSUS BUREAU ESTIMATES, THE TOWN OF CLINTWOOD HAS A POPULATION OF 1,414, WHILE DICKENSON COUNTY'S POPULATION IS 15,903. THE LATEST CENSUS BUREAU DATA ESTIMATES THE MEDIAN AGE OF RESIDENTS OF DICKENSON COUNTY IS 43.4 WHICH IS OLDER THAN THE MEDIAN AGE OF 37.6 IN VIRGINIA. THE BUREAU ESTIMATES DICKENSON COUNTY MEDIAN HOUSEHOLD INCOME AT 33,624 COMPARED TO 65,015 FOR THE STATE OF VIRGINIA. 27% OF DICKENSON COUNTY'S CHILDREN LIVE IN POVERTY COMPARED TO 16% STATEWIDE. DICKENSON COUNTY'S HEALTH OUTCOMES RANK 122 OUT OF 134 IN THE STATE.
PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTH	DCH PROVIDES LOCAL ACCESS FOR DIAGNOSTIC SERVICES TO THE RESIDENTS OF THE AREA, WHO OTHERWISE WOULD HAVE TO DRIVE 45 MINUTES FOR HEALTHCARE SERVICES. OUR HOSPITAL CONTINUES TO BE A VALUABLE RESOURCE TO THE RESIDENTS OF THE AREA BY AIDING WITH TRANSPORTATION ISSUES RESOLVING ACCESS LIMITATIONS FOR SPECIALTY SERVICES, AND PROVIDING RELIEF TO THE SPECIAL HEALTH PROBLEMS OF OUR AREA. DCH OPERATES AND SUBSIDIZES A PRIMARY CARE CLINIC. POOR MENTAL HEALTH DAYS ARE WHEN A PERSON INDICATES THEIR ACTIVITIES ARE LIMITED DUE TO MENTAL HEALTH DIFFICULTIES. THIS IS A GENERAL INDICATION OF THE POPULATION'S ABILITY TO FUNCTION ON A DAY-TO-DAY BASIS. WHEN THE CHNA WAS CONDUCTED THE STATE OF VIRGINA REPORTED 3.1 DAYS COMPARED TO DICKENSON COUNTY'S 6.4 DAYS (MORE THAN DOUBLE). ALSO, THERE IS ONLY 1 MENTAL HEALTH PROVIDER FOR EVERY 3,060 RESIDENTS COMPARED TO 1 FOR EVERY 680 FOR THE STATE OF VIRGINIA. DCH HAS IMPLEMENTED PROGRAMS TO PROVIDE SERVICES TO HELP REDUCE THIS CONCERN FOR DICKENSON COUNTY. THE PSYCH SERVICES DCH PROVIDED DURING FY16 RESULTED IN A LOSS OF 1,271,984. DCH OPENED AN INPATIENT MENTAL HEALTH UNIT THIS YEAR, BEGINNING WITH 5 STAFFED BEDS. THE UNIT WAS ESTABLISHED TO MEET THE NEEDS OF SENIORS WHO PREVIOUSLY HAD TO LEAVE THE AREA OR DO WITHOUT CARE. DCH IS DEDICATED TO OPERATING EFFICIENTLY SO THAT WASTE IS MINIMIZED. DCH'S LEADERSHIP REMAINS MINDFUL OF MANAGING THE HOSPITAL'S LIMITED RESOURCES SO THAT ADEQUATE FACILITIES AND EQUIPMENT ARE AVAILABLE FOR THE CARE OF OUR PATIENTS. VARIOUS CHECKS AND BALANCES ARE ESTABLISHED TO ENSURE THAT EXPENDITURES FOR OPERATING EXPENSES AND CAPITAL COSTS ARE REASONABLE AND NECESSARY. IN MOST YEARS, DCH DOES NOT ENJOY NET OPERATING SURPLUSES AND RELIES ON SUBSIDIZATION FROM NORTON COMMUNITY HOSPITAL. THE MAJORITY OF DCH'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. ONLY TWO DIRECTORS; SHANE HILTON AND MONTY MCLAURIN, EMPLOYEES OF MSHA, LIVE OUTSIDE THE AREA. MANY OF OUR BOARD MEMBERS ARE DEEMED NON-INDEPENDENT, PER IRS FORM 990 INSTRUCTIONS: TWO EMPLOYEES OF MSHA ARE DCH DIRECTORS; THREE HAD REPORTABLE INCOME EXCEEDING 10,000 FOR HEALTH INSURANCE PAID BY NCH (DCH'S SOLE MEMBER); AND, ONE DIRECTOR HAD A FAMILY MEMBER EMPLOYED BY DCH (IN A NON-MANAGERIAL POSITION). PHYSICIANS THAT REQUEST PRIVILEGES WHO ARE QUALIFIED AND CREDENTIALED ARE EXTENDED PRIVILEGES BY DCH.
PART VI, LINE 6 - AFFILIATED HEALTH CARE SYSTEM	DCH IS LICENSED FOR 25-BEDS BUT OPERATES AS A 1-BED ACUTE CARE AND 5-BED PSYCHIATRIC CRITICAL ACCESS HOSPITAL UNDER THE DIRECTION OF AN 8-MEMBER BOARD OF DIRECTORS PRIMARILY COMPRISED OF LOCAL COMMUNITY RESIDENTS. DCH IS OWNED BY NORTON COMMUNITY HOSPITAL (NCH). DCH HAS A LOAN AGREEMENT WITH NCH THAT PROVIDES FOR NCH TO ASSIST IN SUBSIDIZING DCH'S OPERATING EXPENSES. NCH IS MAJORITY OWNED BY MOUNTAIN STATES HEALTH ALLIANCE (MSHA) BASED IN JOHNSON CITY, TENNESSEE, THE LARGEST REGIONAL HEALTHCARE SYSTEM WITH 13 HOSPITALS. MSHA PROVIDES CARE TO PEOPLE IN 29 COUNTIES IN TENNESSEE, VIRGINIA, KENTUCKY, AND NORTH CAROLINA. DCH SERVES AS ITS COUNTY'S PRIMARY HEALTH SERVICE PROVIDER. PATIENTS BENEFIT FROM DCH'S AFFILIATION WITH A HEALTHCARE SYSTEM WHERE THEY CAN BE EFFICIENTLY MOVED ALONG AN INTEGRATED, COMPREHENSIVE CONTINUUM OF CARE AS THEIR HEALTH STATUS DICTATES. IF NEED BE, PATIENTS CAN BE MOVED TO THE SYSTEM'S FLAGSHIP FACILITY, JOHNSON CITY MEDICAL CENTER, WHICH IS A TERTIARY CARE FACILITY PROVIDING ADVANCED TREATMENT OPTIONS. DCH OPERATES A 24-HOUR EMERGENCY DEPARTMENT TO TREAT PATIENTS IN LIFE THREATENING SITUATIONS. FOR ANY PATIENT WHO NEEDS A HIGHER LEVEL OF CARE THAN DCH CAN PROVIDE, AIR MEDICAL TRANSPORTATION IS AVAILABLE THROUGH WINGS AIR RESCUE. WINGS III IS BASED IN JENKINS, KENTUCKY AND CAN QUICKLY RESPOND AND HAVE ANY PATIENT TRANSPORTED TO NORTON COMMUNITY HOSPITAL (7 MINUTES), JOHNSON CITY MEDICAL CENTER (20 MINUTES) AND OTHER REGIONAL HOSPITALS WHEN MINUTES COUNT.
PART VI, LINE 7 - STATE FILING OF COMMUNITY BENEFIT REPORT	VIRGINIA

Schedule H (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

Any related organization?

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

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

The organization?

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2015

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column(B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1SHANE HILTONMSHA VP/CFO MKT OPS	(i) (ii)	------------- 330,385	------------- 65,889	------------- 10,393	------------- 34,851	------------- 24,494	------------- 462,368	-------------
2MONTY MCLAURINMSHA VP/CEO NW MKT	(i) (ii)	------------- 299,200	------------- 41,814	------------- 16,767	------------- 31,753	------------- 24,057	------------- 410,058	-------------
3MARK LEONARDDCH/NCH CEO	(i) (ii)	------------- 254,332	------------- 60,873	------------- 20,054	------------- 25,320	------------- 20,833	------------- 378,131	-------------
4ROY DEEL DOPHYSICIAN	(i) (ii)	------------- 206,270	------------- 39,177	------------- 12,250	------------- 7,872	------------- 15,625	------------- 280,121	-------------
5JOHN WRIGHTFORMER DIRECTOR	(i) (ii)	-------------	-------------	------------- 13,816	-------------	-------------	------------- 13,816	-------------
6STEPHEN SAWYER AVPCFO NW MKTIPMC CFO/FMR DCH CFO	(i) (ii)	------------- 175,344	------------- 18,495	------------- 18,029	------------- 8,934	------------- 17,994	------------- 236,797	-------------

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

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

Return Reference

Explanation

SCHEDULE J, PAGE 1, PART I, LINE 4

SHANE HILTON 0 16,331 0 MONTY MCLAURIN 0 14,905 0 MARK LEONARD 0 12,513 0

SCHEDULE J, PART III

PART I, LINE 4B SHANE HILTON, MONTY MCLAURIN, AND MARK LEONARD PARTICIPATED IN A 457(F) RETIREMENT PLAN PROVIDED BY MOUNTAIN STATES HEALTH ALLIANCE (MSHA). THE 457(F)PLAN IS A NONQUALIFIED TAX-DEFERRED COMPENSATION PLAN AVAILABLE TO A SELECT GROUP OF KEY EXECUTIVES FOR THE INTENT OF SUPPORTING RETENTION AND TO OFFER A COMPETITIVE TOTAL RETIREMENT PROGRAM. ACCOUNT BALANCES HAVE A "SUBSTANTIAL RISK OF FORFEITURE". IN ADDITION TO CREDITOR RISK, SUBSTANTIAL RISK OF FORFEITURE IS CREATED THROUGH DEFAULT RISK IF THE PARTICIPANT'S EMPLOYMENT WITH MSHA IS TERMINATED PRIOR TO AGE 65. HOWEVER, THE 457(F)PLAN CONTAINS A NON-COMPETE PROVISION THAT PROVIDES THE ACCOUNT BALANCE TO BE PAID IN A LUMP SUM AFTER THE EXECUTIVE SATISFIES THE TWO-YEAR NON-COMPETE PERIOD. THIS PROVISION APPLIES TO EMPLOYER CONTRIBUTIONS IF THE EXECUTIVE HAS PROVIDED ELIGIBLE SERVICE FOR SIX OR MORE YEARS. (ELIGIBLE SERVICE IS OFFICER SERVICE THAT PERMITTED THE EXECUTIVE TO PARTICIPATE IN THE PLAN.) THE EXECUTIVE WILL RECEIVE THE ENTIRE ACCOUNT BALANCE IF HE/SHE BECOMES DISABLED, DIES OR IF THE EXECUTIVE TERMINATES FOR "GOOD REASON- OR IS INVOLUNTARILY TERMINATED WITHOUT "GOOD CAUSE" WITHIN A 24-MONTH PERIOD AFTER A CHANGE-OF-CONTROL OCCURS. DISTRIBUTIONS FROM THIS PLAN ARE SUBJECT TO FEDERAL, STATE, AND LOCAL TAXES ON THE ENTIRE ACCOUNT BALANCE UPON DISTRIBUTION.

Schedule J (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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

Attach to Form 990 or Form 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

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

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

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

Part II

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

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










Total ............... $

Part III

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

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

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2015

Page 2

Part IV

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

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) ROY R DEEL	FAMILY MEMBER	262,393	EMPLOYMENT		No

Part V

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

Return Reference	Explanation
SCHEDULE L, PART V	1 (A) NAME OF PERSON: ROY R. DEEL 1 (B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: FAMILY MEMBER OF ROGER DEEL, DCH BOARD MEMBER 1 (D) DESCRIPTION OF TRANSACTION: ROGER DEEL, DCH BOARD MEMBER, IS A FAMILY MEMBER OF ROY DEEL, AN EMPLOYEE OF DICKENSON COMMUNITY HOSPITAL.

Schedule L (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Return Reference	Explanation
FORM 990 - ORGANIZATION'S MISSION	DICKENSON COMMUNITY HOSPITAL IS COMMITTED TO BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN OUR REGION AND TO ASSIST THEM IN ATTAINING THEIR HIGHEST POSSIBLE LEVEL OF HEALTH. PART I, LINE I - ORGANIZATION'S PRIMARY ACTIVITIES: DCH IS A FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL. FEDERAL CRITICAL ACCESS HOSPITAL DESIGNATION REQUIRES THAT A HOSPITAL BE SMALL AND LOCATED IN A RURAL AREA AND LOCATED MORE THAN A 35-MILE DRIVE FROM ANOTHER HOSPITAL OR MORE THAN A 15-MILE DRIVE FROM ANOTHER HOSPITAL IN AN AREA WITH MOUNTAINOUS TERRAIN OR ONLY SECONDARY ROADS, AND BE STATE-DESIGNATED AS A "NECESSARY PROVIDER" OF HEALTH CARE SERVICES TO RESIDENTS IN THE AREA. DCH IS LOCATED IN ONE OF THE POOREST AND MOST UNHEALTHY REGIONS OF VIRGINIA. OUT OF A STATEWIDE RANKING OF 1 TO 134 (WITH 134 BEING THE WORST), DICKENSON COUNTY IS RANKED 130 FOR LENGTH OF LIFE, 125 FOR HEALTH FACTORS (FACTORS THAT INFLUENCE THE HEALTH OF A COUNTY), AND 132 FOR CLINICAL CARE (A VERY LOW NUMBER OF PHYSICIANS AND DENTISTS AVAILABLE IN THE AREA). DCH IS THE ONLY HOSPITAL LOCATED IN DICKENSON COUNTY, WITH THE NEXT NEAREST HOSPITALS LOCATED A 45 MINUTE DRIVE AWAY. DCH IS A WHOLLY-OWNED SUBSIDIARY OF NORTON COMMUNITY HOSPITAL (NCH) AND PART OF MOUNTAIN STATES HEALTH ALLIANCE. SIMILAR TO OTHER RURAL HOSPITALS, DCH DOES NOT ENJOY NET OPERATING PROFITS. DCH IS ABLE TO CONTINUE OPERATING IN THE AREA DUE TO THE GENEROUS SUPPORT OF NCH AND MSHA.
FORM 990, PAGE 2, PART III, LINE 4D	DURING FY16, WE EXPERIENCED 7,141 VISITS TO OUR ER, 28,003 OUTPATIENT VISITS (AN INCREASE OF MORE THAN 17%) AND 114 INPATIENT ADMISSIONS. OUR NEW INPATIENT BEHAVIORAL HEALTH UNIT, GREEN OAK BEHAVIORAL HEALTH, OPENED THIS YEAR WITH FIVE STAFFED INPATIENT BEDS. THE NEW INPATIENT SERVICE FOCUSES ON SENIOR CITIZENS AND IS THE ONLY INPATIENT BEHAVIORAL HEALTH UNIT IN SOUTHWEST VIRGINIA SPECIFICALLY FOR OLDER ADULTS. WE SUSTAINED A SIGNIFICANT LOSS FROM OPERATING THE NEW UNIT. WE CONTINUED TO OFFER OUR OUTPATIENT BEHAVIORAL HEALTH PROGRAM, SENIOR LIFE SOLUTIONS. OUR NEW INPATIENT BEHAVIORAL HEALTH UNIT ALONG WITH SENIOR LIFE SOLUTIONS ALLOWS SENIORS ACCESS TO BEHAVIORAL HEALTH SERVICES WITHOUT HAVING TO TRAVEL OUTSIDE OF THE AREA. 19% OF OUR RESIDENTS ARE 65 YEARS OF AGE OR OLDER AND WITH MOUNTAINOUS TERRAIN ESPECIALLY DANGEROUS IN WINTER MONTHS, RESIDENTS NEEDING BEHAVIORAL HEALTH SERVICES PREVIOUSLY HAD TO LEAVE THE AREA OR DO WITHOUT NEEDED CARE. THE BENEFIT OF THE TWO PROGRAMS EXTENDS TO PATIENTS' FAMILIES AND FRIENDS SINCE THEY OFTEN PROVIDE TRANSPORTATION FOR SENIORS TO MEDICAL CARE APPOINTMENTS. SIMILAR TO OUR INPATIENT BEHAVIORAL HEALTH UNIT FOR SENIORS, OUR OUTPATIENT UNIT INCURRED A NET OPERATING LOSS. THE GROWTH SEEN IN OUR WOUND CARE PROGRAM CONTINUED UNABATED THIS YEAR WITH VOLUMES INCREASING BY 41% OVER PRIOR YEAR. THE PROGRAM BEGAN AS AN OUTGROWTH FROM NORTON COMMUNITY HOSPITAL IN AN EFFORT TO REACH PATIENTS THAT COULD NOT ACCESS CARE. WOUND CARE PATIENTS OFTEN HAVE MULTIPLE HEALTH ISSUES AND MANY TIMES TRAVEL IS VERY DIFFICULT FOR THEM. THESE HARDSHIPS OFTEN CAUSED PATIENTS THE INABILITY TO ACCESS NECESSARY CARE. PATIENTS SERVED AT DCH INCLUDE THOSE WITH DIABETIC ULCERS, VENOUS STASIS ULCERS, ARTERIAL ULCERS, NON-HEALING TRAUMATIC AND SURGICAL WOUNDS AND OTHER CHRONIC WOUND CONDITIONS. THE PRIMARY CARE PHYSICIAN RATIO IN OUR COUNTY IS 3,000:1 COMPARED TO 1,330:1 FOR THE STATE OF VIRGINIA. RECRUITING PHYSICIANS TO A RURAL COUNTY SUCH AS OURS IS OFTEN CHALLENGING DUE TO A MYRIAD OF FACTORS, SUCH AS GEOGRAPHY, ECONOMICS, CULTURE AND EDUCATION. GEOGRAPHICALLY, RURAL COMMUNITIES ARE OFTEN FAR REMOVED FROM SUBURBAN AND URBAN CENTERS THAT PROVIDE ACCESS TO EDUCATIONAL, CULTURAL AND ECONOMIC OPPORTUNITIES. THESE LIMITATIONS INFLUENCE THE RELOCATION DECISION OF THE PHYSICIAN CANDIDATE AND HIS/HER SPOUSE/CHILDREN TO LOCATE TO A RURAL AREA. DCH CONTINUES TO SUBSIDIZE A RURAL PHYSICIAN CLINIC TO PROVIDE SOME RELIEF OF THE PHYSICIAN SHORTAGE IN OUR AREA. RURAL LIFE OFTEN INCLUDES HAZARDOUS OCCUPATIONS, WHICH IS CERTAINLY TRUE OF DICKENSON COUNTY DUE TO THE HIGH EMPLOYMENT RATES IN THE COAL MINING INDUSTRY AND TRAUMA ACCIDENTS RELATED TO RURAL OCCUPATIONS AND ACTIVITIES. RURAL TRAUMA IS GENERALLY DIFFERENT FROM URBAN TRAUMA. RURAL TRAUMA IS MORE LIKELY TO BE FROM ACCIDENTS RELATED TO FARMING, HIKING, HORSEBACK RIDING, USE OF FOUR-WHEELERS, ETC. WHEN MORE ADVANCED CARE IS NEEDED, OUR PATIENTS CAN BE TRANSFERRED TO MOUNTAIN STATES HEALTH ALLIANCE'S FLAGSHIP FACILITY, JOHNSON CITY MEDICAL CENTER, WHICH IS A TERTIARY CARE FACILITY. OUR HOSPITAL SERVED AS A CLINICAL TRAINING HOSPITAL FOR HEALTH PROFESSIONAL EDUCATION STUDENTS. OUR DEDICATED STAFF WORKED WITH REGIONAL COLLEGES AND UNIVERSITIES TO COORDINATE THE PLACEMENT OF HEALTHCARE PROFESSIONAL STUDENTS AS PART OF THEIR EDUCATIONAL CURRICULUM. IN ADDITION TO CLINICAL TRAINING, THE HEALTHCARE STUDENTS ARE REQUIRED TO COMPLETE ORIENTATION AND COMPUTER TRAINING. PARTICIPANTS RECEIVING CLINICAL EXPERIENCE AT DCH DURING FY16 INCLUDED 26 NURSING STUDENTS FROM VARIOUS COLLEGES, UNIVERSITIES AND PROGRAMS. THIS NURSING CLINICAL EXPERIENCE REQUIRED EXTENSIVE HOSPITAL NURSING STAFF INVOLVEMENT. WE INVESTED 69,000 IN THE CLINICAL SETTING AND HANDS-ON INSTRUCTION FOR THESE STUDENTS. IN ADDITION TO NURSING STUDENTS, WE PROVIDED RESPIRATORY THERAPY TRAINING, INCURRING AN ADDITIONAL COST OF 2,100. DCH HAS PARTNERED WITH THE COMPANY ADVANCED PATIENT ADVOCACY TO WORK WITH SELF-PAYING PATIENTS WHO HAVE LIMITED FINANCIAL RESOURCES. REPRESENTATIVES WERE AVAILABLE TO DCH PATIENTS AND WERE ABLE TO DETERMINE GOVERNMENTAL MEDICAL ASSISTANCE (MEDICAID) ELIGIBILITY, AND TO HELP WITH THE APPLICATION PROCESS AND FOLLOW-UP. ONCE A PERSON IS APPROVED FOR MEDICAID THROUGH THE PROGRAM, THEY RETAIN COVERAGE FOR FUTURE MEDICAL CARE. 45 PATIENTS WERE APPROVED THIS YEAR FOR MEDICAID THROUGH THIS PROGRAM OFFERED THROUGH DCH. ADVANCED PATIENT ADVOCACY IS COMPENSATED BY DCH FOR THE SERVICE SO THIS IS A NO-CHARGE BENEFIT TO PATIENTS.
FORM 990, PART V	LINE 2A: W-2 EMPLOYEES DICKENSON COMMUNITY HOSPITAL (DCH) TEAM MEMBERS ARE PAID BY NORTON COMMUNITY HOSPITAL, SOLE MEMBER OF DCH, EXCEPT FOR THE CEO AND CFO WHO ARE PAID BY MOUNTAIN STATES HEALTH ALLIANCE. THE CEO AND CFO SALARY AND BENEFIT COSTS ARE ALLOCATED BETWEEN NCH AND DCH. NORTON COMMUNITY HOSPITAL BILLS DCH FOR ITS SHARE OF SALARY AND BENEFITS AND THE EXPENSE IS RECORDED ON DCH'S BOOKS.
FORM 990, PAGE 6, PART VI, LINE 6	THE CORPORATION IS ORGANIZED AS A VIRGINIA NON-STOCK, NONPROFIT CORPORATION. DICKENSON COMMUNITY HOSPITAL IS A 100% OWNED SUBSIDIARY OF NORTON COMMUNITY HOSPITAL,INC.
FORM 990, PAGE 6, PART VI, LINE 7A	THE BOARD OF DIRECTORS OF NORTON COMMUNITY HOSPITAL ANNUALLY ELECT MEMBERS TO THE BOARD OF DIRECTORS FOR DICKENSON COMMUNITY HOSPITAL. A REQUIREMENT OF AT LEAST (1) MEMBER IS TO BE FROM DICKENSON COUNTY INDUSTRIAL DEVELOPMENT AUTHORITY. NORTON COMMUNITY HOSPITAL IS THE SOLE OWNER OF DICKENSON COMMUNITY HOSPITAL.
FORM 990, PAGE 6, PART VI, LINE 7B	CERTAIN DECISIONS OF THE BOARD ARE, PURSUANT TO CHARTER AND VIRGINIA STATUTE, SUBJECT TO APPROVAL OF THE MEMBERS. THESE DECISIONS INCLUDE: DISSOLUTION OF THE CORPORATION; MERGER OF THE CORPORATION; NON-ORDINARY COURSE OF BUSINESS SALE OF ASSETS, ETC. NO ORDINARY DAY-TO-DAY DECISIONS ARE SUBJECT TO MEMBER APPROVAL.
FORM 990, PAGE 6, PART VI, LINE 11B	THE CFO REVIEWED THE FORM 990 WITH THE BOARD OF DIRECTORS PRIOR TO FILING THE RETURN WITH THE IRS. THE RETURN WAS MADE AVAILABLE TO EACH BOARD MEMBER IN AN ELECTRONIC FORMAT PRIOR TO THE REVIEW.
FORM 990, PAGE 6, PART VI, LINE 12C	ANNUALLY, THE CORPORATE AUDIT AND COMPLIANCE DEPARTMENT OF MSHA FORWARDS THE CONFLICT OF INTEREST POLICY AND DISCLOSURE FORM TO ALL MSHA MANAGEMENT TEAM MEMBERS AND BOARD MEMBERS, INCLUDING THOSE AT DCH. EMPLOYEES AND BOARD MEMBERS MUST NOTE ANY CONFLICTS OR ATTEST THEY HAVE "NONE", AND RETURN THE FORM TO THE AUDIT AND COMPLIANCE DEPARTMENT. ANY NOTED DISCLOSURES ARE FORWARDED TO THE APPROPRIATE MANAGEMENT OR BOARD PERSONNEL TO EVALUATE AND UTILIZE WHEN A TRANSACTION INVOLVING A CONFLICTED PERSON ARISES. ADDITIONALLY, PERSONNEL WHO HAVE A CONFLICT ARISE BETWEEN THE ANNUAL DISTRIBUTION OF THE POLICY AND FORMS ARE REQUIRED TO DISCLOSE THE CONFLICT AND WOULD BE DISCIPLINED IN ANY INSTANCE WHERE THEY HAVE NOT DISCLOSED AND ENGAGED IN A CONFLICTED TRANSACTION.
FORM 990, PAGE 6, PART VI, LINE 15A	MSHA'S HUMAN RESOURCE (H/R) DEPARTMENT EVALUATES SALARY AND BENEFITS FOR DCH'S CEO ON AN ANNUAL OR NEAR-ANNUAL BASIS. H/R'S EVALUATION IS BASED ON MARKET DATA OBTAINED FROM INDEPENDENT THIRD-PARTY CONSULTANTS FOR POSITIONS WITH SIMILAR RESPONSIBILITIES AT SIMILARLY SITUATED ORGANIZATIONS. BASED ON THAT REVIEW, H/R MAKES A RECOMMENDATION TO MSHA'S PRESIDENT & CEO, WHO HAS FINAL APPROVAL FOR THE COMPENSATION OF DCH'S CEO. IN ADDITION, MSHA OFFERS AN INCENTIVE PLAN TO EXECUTIVES BASED ON TARGETED ACHIEVEMENT METRICS SET IN ADVANCE OF THE PAY YEAR. ESTABLISHED METRICS INCLUDE: COMMUNICATION WITH PATIENTS, PATIENT EVIDENCE-BASED CARE SCORES AND PATIENT SAFETY, VALUE- BASED PURCHASING, ETC. THESE SAME METRICS ARE USED FOR ALL EMPLOYEES WITHIN MSHA, WITH A SMALL NUMBER OF EXCEPTIONS FOR OUR COMPANIES THAT DO NOT PROVIDE DIRECT PATIENT CARE.
FORM 990, PAGE 6, PART VI, LINE 15B	SIMILIAR TO THE CEO'S COMPENSATION, THE CFO RECEIVES COMPENSATION AND BENEFITS THAT COMPLY WITH MSHA'S SALARY POLICY. HIS PAY IS SET AT A MARKET PERCENTILE SPECIFIC TO HIS POSITION.
FORM 990, PAGE 6, PART VI, LINE 19	GOVERNING DOCUMENTS AND OUR CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE UPON REQUEST TO APPROPRIATE PARTIES REQUESTING THEM. FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST TO APPROPRIATE PARTIES REQUESTING THEM, AND THEY ARE MADE AVAILABLE TO THOSE PARTIES WHO OWN INDEBTEDNESS OF THE COMPANY ON A QUARTERLY BASIS. FORM 990, PART VII - RELATED ORGANIZATIONS DIRECTOR COMPENSATION: DICKENSON COMMUNITY HOSPITAL'S BOARD OF DIRECTOR MEMBERS, SHANE HILTON AND MONTY MCLAURIN, RECEIVE COMPENSATION FOR SERVICES PROVIDED TO RELATED ORGANIZATIONS AND DO NOT RECEIVE COMPENSATION FOR SERVICES AS A DCH BOARD MEMBER.
FORM 990, PART IX, LINE 11G	PHYSICIAN FEES 1,396,016 0 0 GEROPSYCH SERVICES 259,585 0 0 COLLECTION FEES 0 53,746 0 HEALTH INFO. & LAB TESTS 46,169 0 0 LINEN & ENVIRONMENTAL SERV. 0 75,651 0 ENGINEERING 0 27,265 0 CONTRACT LABOR 56,884 0 0 DIETARY 13,411 0 0 TRANSCRIPTION & CODING 0 21,981 0 VARIOUS FEES 21,110 68,256 0
FORM 990, PART XI, LINE 9	CHANGE IN TEMP. RESTRICTED CONTRIBUTIONS & GRANTS -1,679 ELIMINATION OF INTERCOMPANY REC/PAY 3,294,338 PENSION LIABILITY ADJUSTMENT 471,988 TOTAL 3,764,647

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

DICKENSON COMMUNITY HOSPITAL

Employer identification number

77-0599553

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)NORTON COMMUNITY HOSPITAL 100 15TH STREET NW NORTON,VA24273 54-0566029	HOSPITAL	VA	501C3	3	NA		No
(2)MOUNTAIN STATES HEALTH ALLIANCE 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604 62-0476282	HOSP. SYS.	TN	501C3	3	NA		No
(3)SMYTH COUNTY COMMUNITY HOSPITAL 245 MEDICAL PARK DRIVE MARION,VA24354 54-0794913	HOSPITAL	VA	501C3	3	MSHA		No
(4)JOHNSTON MEMORIAL HOSPITAL 16000 JOHNSTON MEMORIAL DRIVE ABINGDON,VA24211 54-0544705	HOSPITAL	VA	501C3	3	NA		No
(5)ABINGDON PHYSICIAN PARTNERS 16000 JOHNSTON MEMORIAL DRIVE ABINGDON,VA24211 20-5485346	MED. SERV	VA	501C3	11A	JMH		No
(6)MOUNTAIN STATES FOUNDATION 2335 KNOB CREEK ROAD STE 101 JOHNSON CITY,TN37604 58-1418862	FUNDRAISER	TN	501C3	11A	MSHA		No
(7)MOUNTAIN STATES HEALTH ALLIANCE AUX 400 N STATE OF FRANKLIN ROAD JOHNSON CITY,TN37604 58-1418345	SUPP. ORG.	TN	501C3	11A	MSHA		No
(8)APPALACHIAN EMERGENCY PHYSICIANS 1021 W OAKLAND AVENUE STE 207 JOHNSON CITY,TN37604 80-0592504	MED. SERV.	VA	501C3	11A	NA		No
(9)NEWCO INC 211 COMMERCE ST STE 800 NASHVILLE,TN372011817 61-1771290	SUPP. ORG	TN	501C3	11B	NA		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2015

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) INTEGRATED SOLUTIONS HEALTH NETWORK 509 MED TECH PARKWAY SUITE 100 JOHNSON CITY,TN37604 62-1711997	INVESTMENT	TN	NA				No			No
(2) EMMAUS COMMUNITY HEALTHCARE LLC 6070 HWY 11E PINEY FLATS,TN37686 20-0577483	MED. SERV.	TN	NA				No			No
(3) MEDICAL SPECIALISTS OF JC LLC 2528 WESLEY STREET SUITE 2 JOHNSON CITY,TN37601 27-2199037	MED. SERV.	TN	NA				No			No
(4) EAST TN AMBULATORY SURGERY CENTER 701 MED TECH PARKWAY SUITE 100 JOHNSON CITY,TN37604 62-1787537	MED. SERV.	TN	NA				No			No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) COMMUNITY HOME CARE INC 1460 PARK AVENUE NORTON,VA24273 54-1453810	DME	VA	NA	C CORP				No
(2) BLUE RIDGE MEDICAL MANAGEMENT CORP 1021 W OAKLAND AVENUE STE 207 JOHNSON CITY,TN37604 62-1490616	MED.SERV.	TN	NA	C CORP				No
(3) MEDISERVE MEDICAL EQUIPMENT 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1212286	DME	TN	NA	C CORP				No
(4) MOUNTAIN STATES PROPERTIES 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1845895	PROP. MGMT	TN	NA	C CORP				No
(5) MOUNTAIN STATES PHYSICIANS GRP INC 1021 W OAKLAND AVENUE SUITE 207 JOHNSON CITY,TN37604 62-1700412	HEALTHCARE	TN	NA	C CORP				No
(6) WILSON PHARMACY INC PO BOX 5289 JOHNSON CITY,TN37602 62-0329587	PHARMACY	TN	NA	C CORP				No
(7) CRESTPOINT HEALTH INSURANCE CO INC 509 MED TECH PARKWAY SUITE 100 JOHNSON CITY,TN37604 62-0381170	INSURANCE	TN	NA	C CORP				No

Schedule R (Form 990) 2015

Page 3

Part V

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

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

Yes

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

Yes

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

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

Schedule R (Form 990) 2015

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2015

Page 5

Part VII

Supplemental Information

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

Return Reference	Explanation

Schedule R (Form 990) 2015

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: DICKENSON COMMUNITY HOSPITAL IS COMMITTED TO BRINGING LOVING CARE TO HEALTH CARE. WE EXIST TO IDENTIFY AND RESPOND TO THE HEALTH CARE NEEDS OF INDIVIDUALS AND COMMUNITIES IN OUR REGION AND TO ASSIST THEM IN ATTAINING THEIR HIGHEST POSSIBLE LEVEL OF HEALTH. PART I, LINE I - ORGANIZATION'S PRIMARY ACTIVITIES: DCH IS A FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL. FEDERAL CRITICAL ACCESS HOSPITAL DESIGNATION REQUIRES THAT A HOSPITAL BE SMALL AND LOCATED IN A RURAL AREA AND LOCATED MORE THAN A 35-MILE DRIVE FROM ANOTHER HOSPITAL OR MORE THAN A 15-MILE DRIVE FROM ANOTHER HOSPITAL IN AN AREA WITH MOUNTAINOUS TERRAIN OR ONLY SECONDARY ROADS, AND BE STATE-DESIGNATED AS A "NECESSARY PROVIDER" OF HEALTH CARE SERVICES TO RESIDENTS IN THE AREA. DCH IS LOCATED IN ONE OF THE POOREST AND MOST UNHEALTHY REGIONS OF VIRGINIA. OUT OF A STATEWIDE RANKING OF 1 TO 134 (WITH 134 BEING THE WORST), DICKENSON COUNTY IS RANKED 130 FOR LENGTH OF LIFE, 125 FOR HEALTH FACTORS (FACTORS THAT INFLUENCE THE HEALTH OF
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	7
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	2
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	21,020	44,587
9	Program service revenue (Part VIII, line 2g) .........	5,690,502	6,535,243
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	84	150
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	16,599	-265,944
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	5,728,205	6,314,036
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	4,075,156	4,762,173
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	3,472,358	3,985,281
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	7,547,514	8,747,454
19	Revenue less expenses. Subtract line 18 from line 12.......	-1,819,309	-2,433,418
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	4,323,639	5,272,071
21	Total liabilities (Part X, line 26).............	1,829,656	1,446,859
22	Net assets or fund balances. Subtract line 21 from line 20.....	2,493,983	3,825,212

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 4,163,422 including grants of $ ) (Revenue $ 3,771,736 )
	EMERGENCY SERVICES: OUR FULLY STAFFED 24-HOUR EMERGENCY DEPARTMENT IS AVAILABLE FOR PATIENTS IN A LIFE THREATENING SITUATION. WE CAN PROVIDE AIR MEDICAL TRANSPORTATION TO A LARGER REGIONAL HOSPITAL FOR ANY PATIENT NEEDING A HIGHER LEVEL OF CARE. THERE WERE 7,141 ED VISITS DURING FY16.

4b	(Code: ) (Expenses $ 2,188,083 including grants of $ ) (Revenue $ 610,235 )
	BEHAVIORAL HEALTH: IN FY16 WE OPENED A NEW FIVE BED INPATIENT BEHAVIORAL HEALTH UNIT (GREEN OAK BEHAVIORAL HEALTH). THE NEW INPATIENT SERVICE FOCUSES ON SENIOR CITIZENS AND IS THE ONLY INPATIENT BEHAVIORAL HEALTH UNIT IN SOUTHWEST VIRGINIA SPECIFICALLY FOR OLDER ADULTS. WE CONTINUED TO OFFER OUR OUTPATIENT BEHAVIORAL HEALTH PROGRAM, SENIOR LIFE SOLUTIONS. THERE WERE 251 UNITS FOR BOTH PROGRAMS COMBINED DURING FY16.

4c	(Code: ) (Expenses $ 678,100 including grants of $ ) (Revenue $ 607,358 )
	LABORATORY: OUR EXPERIENCED STAFF OFFERS COMPLETE AND COMPREHENSIVE SERVICES INCLUDING: OUTPATIENT SERVICES, STAT TESTING, COMPREHENSIVE CHEMISTRY STUDIES, OCCUPATIONAL DRUG TESTING, HIGH SENSITIVE COUMADIN MONITORING, TRANSFUSION SERVICES, AND MORE. WE PROVIDE LAB SERVICES 24 HOURS A DAY, 7 DAYS A WEEK.

	(Code: ) (Expenses $ 187,580 including grants of $ ) (Revenue $ 1,273,914 )
	DURING FY16, WE EXPERIENCED 7,141 VISITS TO OUR ER, 28,003 OUTPATIENT VISITS (AN INCREASE OF MORE THAN 17%) AND 114 INPATIENT ADMISSIONS. OUR NEW INPATIENT BEHAVIORAL HEALTH UNIT, GREEN OAK BEHAVIORAL HEALTH, OPENED THIS YEAR WITH FIVE STAFFED INPATIENT BEDS. THE NEW INPATIENT SERVICE FOCUSES ON SENIOR CITIZENS AND IS THE ONLY INPATIENT BEHAVIORAL HEALTH UNIT IN SOUTHWEST VIRGINIA SPECIFICALLY FOR OLDER ADULTS. WE SUSTAINED A SIGNIFICANT LOSS FROM OPERATING THE NEW UNIT. WE CONTINUED TO OFFER OUR OUTPATIENT BEHAVIORAL HEALTH PROGRAM, SENIOR LIFE SOLUTIONS. OUR NEW INPATIENT BEHAVIORAL HEALTH UNIT ALONG WITH SENIOR LIFE SOLUTIONS ALLOWS SENIORS ACCESS TO BEHAVIORAL HEALTH SERVICES WITHOUT HAVING TO TRAVEL OUTSIDE OF THE AREA. 19% OF OUR RESIDENTS ARE 65 YEARS OF AGE OR OLDER AND WITH MOUNTAINOUS TERRAIN ESPECIALLY DANGEROUS IN WINTER MONTHS, RESIDENTS NEEDING BEHAVIORAL HEALTH SERVICES PREVIOUSLY HAD TO LEAVE THE AREA OR DO WITHOUT NEEDED CARE. THE BENEFIT OF THE TWO PROGRAMS EXTENDS TO PATIENTS' FAMILIES AND FRIENDS SINCE THEY OFTEN PROVIDE TRANSPORTATION FOR SENIORS TO MEDICAL CARE APPOINTMENTS. SIMILAR TO OUR INPATIENT BEHAVIORAL HEALTH UNIT FOR SENIORS, OUR OUTPATIENT UNIT INCURRED A NET OPERATING LOSS. THE GROWTH SEEN IN OUR WOUND CARE PROGRAM CONTINUED UNABATED THIS YEAR WITH VOLUMES INCREASING BY 41% OVER PRIOR YEAR. THE PROGRAM BEGAN AS AN OUTGROWTH FROM NORTON COMMUNITY HOSPITAL IN AN EFFORT TO REACH PATIENTS THAT COULD NOT ACCESS CARE. WOUND CARE PATIENTS OFTEN HAVE MULTIPLE HEALTH ISSUES AND MANY TIMES TRAVEL IS VERY DIFFICULT FOR THEM. THESE HARDSHIPS OFTEN CAUSED PATIENTS THE INABILITY TO ACCESS NECESSARY CARE. PATIENTS SERVED AT DCH INCLUDE THOSE WITH DIABETIC ULCERS, VENOUS STASIS ULCERS, ARTERIAL ULCERS, NON-HEALING TRAUMATIC AND SURGICAL WOUNDS AND OTHER CHRONIC WOUND CONDITIONS. THE PRIMARY CARE PHYSICIAN RATIO IN OUR COUNTY IS 3,000:1 COMPARED TO 1,330:1 FOR THE STATE OF VIRGINIA. RECRUITING PHYSICIANS TO A RURAL COUNTY SUCH AS OURS IS OFTEN CHALLENGING DUE TO A MYRIAD OF FACTORS, SUCH AS GEOGRAPHY, ECONOMICS, CULTURE AND EDUCATION. GEOGRAPHICALLY, RURAL COMMUNITIES ARE OFTEN FAR REMOVED FROM SUBURBAN AND URBAN CENTERS THAT PROVIDE ACCESS TO EDUCATIONAL, CULTURAL AND ECONOMIC OPPORTUNITIES. THESE LIMITATIONS INFLUENCE THE RELOCATION DECISION OF THE PHYSICIAN CANDIDATE AND HIS/HER SPOUSE/CHILDREN TO LOCATE TO A RURAL AREA. DCH CONTINUES TO SUBSIDIZE A RURAL PHYSICIAN CLINIC TO PROVIDE SOME RELIEF OF THE PHYSICIAN SHORTAGE IN OUR AREA. RURAL LIFE OFTEN INCLUDES HAZARDOUS OCCUPATIONS, WHICH IS CERTAINLY TRUE OF DICKENSON COUNTY DUE TO THE HIGH EMPLOYMENT RATES IN THE COAL MINING INDUSTRY AND TRAUMA ACCIDENTS RELATED TO RURAL OCCUPATIONS AND ACTIVITIES. RURAL TRAUMA IS GENERALLY DIFFERENT FROM URBAN TRAUMA. RURAL TRAUMA IS MORE LIKELY TO BE FROM ACCIDENTS RELATED TO FARMING, HIKING, HORSEBACK RIDING, USE OF FOUR-WHEELERS, ETC. WHEN MORE ADVANCED CARE IS NEEDED, OUR PATIENTS CAN BE TRANSFERRED TO MOUNTAIN STATES HEALTH ALLIANCE'S FLAGSHIP FACILITY, JOHNSON CITY MEDICAL CENTER, WHICH IS A TERTIARY CARE FACILITY. OUR HOSPITAL SERVED AS A CLINICAL TRAINING HOSPITAL FOR HEALTH PROFESSIONAL EDUCATION STUDENTS. OUR DEDICATED STAFF WORKED WITH REGIONAL COLLEGES AND UNIVERSITIES TO COORDINATE THE PLACEMENT OF HEALTHCARE PROFESSIONAL STUDENTS AS PART OF THEIR EDUCATIONAL CURRICULUM. IN ADDITION TO CLINICAL TRAINING, THE HEALTHCARE STUDENTS ARE REQUIRED TO COMPLETE ORIENTATION AND COMPUTER TRAINING. PARTICIPANTS RECEIVING CLINICAL EXPERIENCE AT DCH DURING FY16 INCLUDED 26 NURSING STUDENTS FROM VARIOUS COLLEGES, UNIVERSITIES AND PROGRAMS. THIS NURSING CLINICAL EXPERIENCE REQUIRED EXTENSIVE HOSPITAL NURSING STAFF INVOLVEMENT. WE INVESTED 69,000 IN THE CLINICAL SETTING AND HANDS-ON INSTRUCTION FOR THESE STUDENTS. IN ADDITION TO NURSING STUDENTS, WE PROVIDED RESPIRATORY THERAPY TRAINING, INCURRING AN ADDITIONAL COST OF 2,100. DCH HAS PARTNERED WITH THE COMPANY ADVANCED PATIENT ADVOCACY TO WORK WITH SELF-PAYING PATIENTS WHO HAVE LIMITED FINANCIAL RESOURCES. REPRESENTATIVES WERE AVAILABLE TO DCH PATIENTS AND WERE ABLE TO DETERMINE GOVERNMENTAL MEDICAL ASSISTANCE (MEDICAID) ELIGIBILITY, AND TO HELP WITH THE APPLICATION PROCESS AND FOLLOW-UP. ONCE A PERSON IS APPROVED FOR MEDICAID THROUGH THE PROGRAM, THEY RETAIN COVERAGE FOR FUTURE MEDICAL CARE. 45 PATIENTS WERE APPROVED THIS YEAR FOR MEDICAID THROUGH THIS PROGRAM OFFERED THROUGH DCH. ADVANCED PATIENT ADVOCACY IS COMPENSATED BY DCH FOR THE SERVICE SO THIS IS A NO-CHARGE BENEFIT TO PATIENTS.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 187,580 including grants of $ ) (Revenue $ 1,273,914 )
4e	Total program service expenses7,217,185

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,890,809	217,623

(A) Name and business address	(B) Description of services	(C) Compensation
PSYCHIATRIC MEDICAL CARE, PO BOX 30067 KNOXVILLE,TN379300067	MED. DIRECTOR	298,254




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 1

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	27,500
e	Government grants (contributions)		1e	17,087

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

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		44,587

			Business Code
2a	PATIENT SERVICES	622110	6,450,557	6,450,557
b	WELLNESS PROGRAMS	622110	84,686	84,686
c
d
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			6,535,243

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			150			150
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss)......
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss).....
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..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	REVENUE FROM PARENT		900099	5,459			5,459
b	VENDING MACHINES		900099	582			582
c	MEDICAL RECORDS		900099	15			15
d	All other revenue ....			-272,000	-272,000
e	Total. Add lines 11a–11d ......			-265,944
12	Total revenue. See Instructions......			6,314,036	6,263,243		6,206

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	59,392		59,392
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	3,865,242	3,266,723	598,519
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	93,146	80,469	12,677
9	Other employee benefits .......	492,211	401,920	90,291
10	Payroll taxes ...........	252,182	225,255	26,927
11	Fees for services (non-employees):
a	Management ......	1,834		1,834
b	Legal .........	10,161		10,161
c	Accounting ...........	1,500		1,500
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	2,040,074	1,793,175	246,899
12	Advertising and promotion ....	86,180	364	85,816
13	Office expenses .......	120,895	108,369	12,526
14	Information technology ......	200,069	193,445	6,624
15	Royalties ..
16	Occupancy ...........	181,068	116,146	64,922
17	Travel ............	60,431	55,574	4,857
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	277,629	189,007	88,622
23	Insurance ...	15,289	199	15,090
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 & DRUGS	474,454	474,454
b	REPAIRS & MAINTENANCE	307,401	295,987	11,414
c	MANAGEMENT FEES TO PARENT	133,229		133,229
d	DUES & SUBSCRIPTIONS	49,290	6,670	42,620
e	All other expenses	25,777	9,428	16,349
25	Total functional expenses. Add lines 1 through 24e	8,747,454	7,217,185	1,530,269	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			1,341,045	1	711,721
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			1,004,630	4	981,008
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net ....				7
8	Inventories for sale or use ........			99,718	8	130,960
9	Prepaid expenses and deferred charges ......			48,559	9	38,300
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	4,800,358
b	Less: accumulated depreciation	10b	3,098,453	1,675,564	10c	1,701,905
11	Investments—publicly traded securities .				11
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			154,123	15	1,708,177
16	Total assets. Add lines 1 through 15 (must equal line 34)...			4,323,639	16	5,272,071

17	Accounts payable and accrued expenses .....	779,398	17	829,424
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	1,050,258	25	617,435
26	Total liabilities. Add lines 17 through 25..	1,829,656	26	1,446,859

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	2,479,512	27	3,812,420
28	Temporarily restricted net assets ...........	14,471	28	12,792
29	Permanently restricted net assets		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	2,493,983	33	3,825,212
34	Total liabilities and net assets/fund balances ........	4,323,639	34	5,272,071