TY 2015 Form 990

- TIN:

Form990

Department of the TreasuryInternal Revenue Service

Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private
foundations)

Do not enter social security numbers on this form as it may be made public.

Information about Form 990 and its instructions is at www.IRS.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

A For the 2015 calendar year, or tax year beginning 07-01-2015 , and ending 06-30-2016

BCheck if applicable: Address change Name change Initial return Final return/terminated Amended return Application pending

CName of organization
Mary Hitchcock Memorial Hospital

% DANIEL JANTZEN

Doing business as

Number and street (or P.O. box if mail is not delivered to street address)
One Medical Center Drive

Room/suite

City or town, state or province, country, and ZIP or foreign postal code
Lebanon, NH03756

D Employer identification number

02-0222140

E Telephone number

G Gross receipts $ 1,067,191,105

F Name and address of principal officer:
James Weinstein DO MS
One Medical Center Drive
Lebanon,NH03756

Tax-exempt status: 501(c)(3) 501(c) ( ) LeftBullet

(insert no.) 4947(a)(1) or 527

Website:

www.dartmouth-hitchcock.org

H(a)

Is this a group return for
subordinates? Yes No

H(b)

Are all subordinates
included?

Yes No

If "No," attach a list. (see instructions)

H(c)

Group exemption number MediumBullet

K Form of organization: Corporation Trust Association Other MediumBullet

L Year of formation: 1889

M State of legal domicile: NH

Part I

Summary

1	Briefly describe the organization’s mission or most significant activities: Advancing Health Through Research, Education, Clinical Practice, Community Partnerships, providing each person the best care in the right place, at the right time, every time
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	19
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	13
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	6,003
6	Total number of volunteers (estimate if necessary) .............	6	480
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	3,716,159
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-319,154

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	5,075,715	7,326,385
9	Program service revenue (Part VIII, line 2g) .........	908,783,191	994,071,500
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	17,620,625	86,360
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	47,796,806	51,273,295
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	979,276,337	1,052,757,540
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	1,947,820	2,204,568
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	602,661,971	635,248,980
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 242,002
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	377,996,999	448,365,775
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	982,606,790	1,085,819,323
19	Revenue less expenses. Subtract line 18 from line 12.......	-3,330,453	-33,061,783
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	1,294,964,551	1,312,172,799
21	Total liabilities (Part X, line 26).............	696,007,861	787,785,889
22	Net assets or fund balances. Subtract line 21 from line 20.....	598,956,690	524,386,910

Part II

Signature Block

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign Here

	Signature of officer	Date

	Type or print name and title

Paid Preparer Use Only

Print/Type preparer's name

Preparer's signature

Date

Check if
self-employed

PTIN

Firm's name MediumBullet

Firm's EIN MediumBullet

Firm's address MediumBullet

Phone no.

May the IRS discuss this return with the preparer shown above? (see instructions) ..........YesNo

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 11282Y Form 990 (2015)

Form 990 (2015)

Page 2

Part III

Statement of Program Service Accomplishments

Check if Schedule O contains a response or note to any line in this Part III ..............

Briefly describe the organization’s mission: WE ADVANCE HEALTH THROUGH RESEARCH, EDUCATION, CLINICAL PRACTICE, AND COMMUNITY PARTNERSHIPS, PROVIDING EACH PERSON THE BEST CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, EVERY TIME.

Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ..................... Yes No

If "Yes," describe these new services on Schedule O.

Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ........................... Yes No

If "Yes," describe these changes on Schedule O.

Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.


4a	(Code: ) (Expenses $ 878,507,558 including grants of $ 2,204,568 ) (Revenue $ 1,005,285,452 )
	Mary Hitchcock Memorial Hospital (the Hospital), is an acute and tertiary care teaching hospital located in Lebanon, New Hampshire. The Hospital is a not-for-profit organization, as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from Federal income taxes on related income pursuant to Section 501(a) of the Code. The Hospital provides a broad range of patient services and health related community services, consistent with its role as a community hospital, a major teaching hospital and a tertiary care referral hospital. These include a full range of services in both acute and critical medicine, surgery, psychiatry and rehabilitation for infants, children and adults. During FY 2016 the Hospital provided 129,561 acute patient days of inpatient service and had 27,371 total acute care discharges, while the Hospital's emergency room was open to the public 24 hours per day, 7 days per week and had 30,929 discharges. The Hospital operates as an integral component of Dartmouth-Hitchcock Medical Center (DHMC), a New Hampshire nonprofit corporation organized for the exploration and coordination of matters of mutual interest among its members: the Hospital, Dartmouth-Hitchcock Clinic (the Clinic), Geisel School of Medicine (GSM), a component of Dartmouth College, and the Veterans Affairs Medical Center in White River Junction, Vermont. The Clinic provides the physician staff to the Hospital and the sophistication essential for the development of the Hospital as the largest and only teaching hospital in New Hampshire and the designation by the federal government as a Rural Referral Center for northern New England. The shared mission of the Hospital and Clinic is to advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time. Its strategic operating plan lays out a path to creating a "sustainable health system to improve the lives of the people and communities we serve, for generations to come." The focus of this work, across the Dartmouth-Hitchcock organization, i.e. all Hospital and Clinic sites, is in three main areas: Improving Population Health; Delivering Value Based Care; and Developing and Implementing New Payment Models. Consistent with this mission and in partnership with the Dartmouth-Hitchcock Clinic, the Hospital provides high quality, cost effective, comprehensive, and integrated health care to individuals, families, and the communities it serves regardless of a patient's ability to pay. The Hospital actively supports community-based health care and promotes the coordination of services among health care providers and social services organizations. The Hospital also seeks to work collaboratively with other area health care providers to improve the health status of the region. Effective with fiscal year 2000, the Hospital and the Clinic began filing an annual Community Benefit Report with the State of New Hampshire which outlines the community and charitable benefits they provide. The most recent Community Benefit Reports are available upon request or can be found on Dartmouth-Hitchcock's web site (www.dartmouth-hitchcock.org). Financial assistance, formerly called charity care, represents services provided to patients who cannot afford health care services due to inadequate financial resources which result from being uninsured or underinsured. For the year ended June 30, 2016 the Hospital provided financial assistance to 7,598 patients in the amount of $15,552,463, as measured by gross charges. The estimated cost of providing this care for the year ended June 30, 2016 was $6,127,670. The Hospital also routinely provides services to Medicaid patients at reimbursement levels that are below the cost of the care provided. The Community health activities includes the cost or value of several different types of programs including the cost of community based education, health fairs, health screenings, support groups, and programs and materials that promote wellness and prevent illness. Examples of these types of efforts include partnering with the Healthy Eating Active Living NH initiative, the Women's Health Resource Center, and smoking prevention and cessation. This category also includes financial contributions and the contribution of time and services to community programs, hospitals and agencies. The Hospital also provides a significant amount of uncompensated care to its patients reported as provision for bad debts, which is not included in the amounts reported above. During the years ended June 30, 2016, the Hospital reported a provision for bad debts of approximately $24,261,088.

4b	(Code: ) (Expenses $ 47,577,276 including grants of $ ) (Revenue $ 32,485,788 )
	As a component of New Hampshires only integrated academic medical center, the Hospital provides significant support for academic and research programs through its support of The Geisel School of Medicine at Dartmouth (GSM), the Hospital provides support for Physicians' unpaid teaching time as part of its Community Benefit Initiatives, consisting of the time physicians spend providing clinical supervision and education for residents and medical students. In addition, the Hospital provides in-kind support for research and other grants representing costs in excess of awards for numerous grant-funded health research and service initiatives awarded to the Clinic and GSM. Other community benefit initiatives include subsidizing the costs of providing medical and clinical education to professionals across New Hampshire, Vermont and beyond as well as uncompensated costs of academic and medical research activities.

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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses926,084,834

Form 990 (2015)

Page 3

Part IV

Checklist of Required Schedules

Yes

Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule A Click to see attachment

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

Yes

Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment

...

Yes

Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I Click to see attachment

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

Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II Click to see attachment

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

Yes

Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part III Click to see attachment

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

Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I Click to see attachment

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

Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II Click to see attachment

...

Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III Click to see attachment

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

Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV Click to see attachment

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

Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part V Click to see attachment

......

Yes

If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.

Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If "Yes," complete Schedule D, Part VI. Click to see attachment

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

11a

Yes

Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII Click to see attachment

.......

11b

Yes

Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII Click to see attachment

.......

11c

Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IX Click to see attachment

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

11d

Yes

Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X Click to see attachment

11e

Yes

Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X Click to see attachment

11f

12a

Did the organization obtain separate, independent audited financial statements for the tax year?
If "Yes," complete Schedule D, Parts XI and XII Click to see attachment

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

12a

Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment

12b

Yes

Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E

14a

Did the organization maintain an office, employees, or agents outside of the United States? .....

14a

Yes

Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV......... Click to see attachment

14b

Yes

Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV..... Click to see attachment

Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV... Click to see attachment

Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions) ....

Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............

Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................

20a

Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H.... Click to see attachment

20a

Yes

If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see list of attachments

20b

Yes

Form 990 (2015)

Page 4

Part IV

Checklist of Required Schedules (continued)

Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..... Click to see attachment

Yes

Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment

Yes

Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment

Yes

24a

Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a............... Click to see list of attachments

24a

Yes

Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...

24b

Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............

24c

Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...

24d

25a

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I............ Click to see attachment

25a

Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I ................... Click to see attachment

25b

Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If "Yes," complete Schedule L, Part II ................ Click to see attachment

Yes

Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III......... Click to see attachment

Yes

Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):

A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L,
Part IV ........................ Click to see attachment

28a

A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV..................... Click to see attachment

28b

Yes

An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV... Click to see attachment

28c

Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M.. Click to see attachment

Yes

Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M ............. Click to see attachment

Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I.

Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II ...........

Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I ........ Click to see attachment

Yes

Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1......................... Click to see attachment

Yes

35a

Did the organization have a controlled entity within the meaning of section 512(b)(13)?

35a

Yes

If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ... Click to see attachment

35b

Yes

Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment

Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI Click to see attachment

Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............

Yes

Form 990 (2015)

Page 5

Part V

Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........

Yes

Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..

992

Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .

Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................

Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................

6,003

If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)

Yes

Did the organization have unrelated business gross income of $1,000 or more during the year?...

Yes

If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...

Yes

At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..

Yes

If "Yes," enter the name of the foreign country: MediumBullet

BD
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).

Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..

Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?

If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............

Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...

If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................

Organizations that may receive deductible contributions under section 170(c).

Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................

Yes

If "Yes," did the organization notify the donor of the value of the goods or services provided? .....

Yes

Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................

If "Yes," indicate the number of Forms 8282 filed during the year ....

Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?

Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..

If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................

If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................

Sponsoring organizations maintaining donor advised funds.
Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? .........................

Did the sponsoring organization make any taxable distributions under section 4966?...

Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on Part VIII, line 12 ...

10a

Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities

10b

Section 501(c)(12) organizations. Enter:

Gross income from members or shareholders .........

11a

Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........

11b

12a

Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?

12a

If "Yes," enter the amount of tax-exempt interest received or accrued during the year.

12b

Section 501(c)(29) qualified nonprofit health insurance issuers.

Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.

13a

Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....

13b

Enter the amount of reserves on hand ............

13c

14a

Did the organization receive any payments for indoor tanning services during the tax year?.....

14a

If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..

14b

Form 990 (2015)

Page 6

Part VI

Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.

Check if Schedule O contains a response or note to any line in this Part VI ..............

Section A. Governing Body and Management

Yes

Enter the number of voting members of the governing body at the end of the tax year

If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.

Enter the number of voting members included in line 1a, above, who are independent

Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................

Yes

Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .

Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................

Did the organization become aware during the year of a significant diversion of the organization’s assets? .

Did the organization have members or stockholders? ................

Yes

Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................

Yes

Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................

Yes

Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:

The governing body? .......................

Yes

Each committee with authority to act on behalf of the governing body? ............

Yes

Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......

Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)

Yes

10a

Did the organization have local chapters, branches, or affiliates? ............

10a

If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?

10b

11a

Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................

11a

Yes

Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....

12a

Did the organization have a written conflict of interest policy? If "No," go to line 13.......

12a

Yes

Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................

12b

Yes

Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done...................

12c

Yes

Did the organization have a written whistleblower policy? ...............

Yes

Did the organization have a written document retention and destruction policy? .........

Yes

Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?

The organization’s CEO, Executive Director, or top management official ...........

15a

Other officers or key employees of the organization ................

15b

Yes

If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).

16a

Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................

16a

Yes

If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............

16b

Yes

Section C. Disclosure

List the States with which a copy of this Form 990 is required to be filed MediumBullet

Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.

Own website Another's website Upon request Other (explain in Schedule O)

Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.

State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBullet

DANIEL JANTZENONE MEDICAL CENTER DRIVE Lebanon,NH03756 (603) 650-5634

Form 990 (2015)

Page 7

Part VII

Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors

Check if Schedule O contains a response or note to any line in this Part VII ..............

Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees

1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet

List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

List all of the organization’s current key employees, if any. See instructions for definition of "key employee."

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.

Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(1) Vincent S Conti MHA...................................................................... Trustee	0.75 ................. 1.25	X		0	0	0
(2) Anne-Lee Verville...................................................................... Trustee/Brd Chair eff. 1/1/16	1.5 ................. 2.5	X	X	0	0	0
(3) Barbara Couch MS...................................................................... Trustee/Board Secretary	0.75 ................. 1.25	X	X	0	0	0
(4) William J Conaty...................................................................... Trustee	0.75 ................. 1.25	X		0	0	0
(5) Robert A Oden Jr PhD...................................................................... Trustee/Vice Chair eff 1/1/16	1.5 ................. 2.5	X	X	0	0	0
(6) James N Weinstein DO MS...................................................................... Trustee Ex-Officio/CEO	42.75 ................. 18.76	X	X	0	1,332,138	162,531
(7) Denis A Cortese MD...................................................................... Trustee	0.75 ................. 1.25	X		0	0	0
(8) Matthew B Dunne...................................................................... Trustee End 12/31/15	0.75 ................. 1.25	X		0	0	0
(9) Senator Judd A Gregg...................................................................... Trustee	0.75 ................. 0.75	X		0	0	0
(10) Laura K Landy MBA...................................................................... Trustee	0.75 ................. 1.25	X		0	0	0
(11) Paul P Danos PhD...................................................................... Trustee/Bd Trsrer end 12/31/15	1.5 ................. 2.5	X	X	0	0	0
(12) Barbara C Jobst MD...................................................................... Trustee	28.75 ................. 12.75	X		0	321,341	85,446
(13) Troyen Brennan MD MPH...................................................................... Trustee	0.75 ................. 1.25	X		0	0	0
(14) R William Burgess Jr MBA...................................................................... Trustee	0.75 ................. 1.25	X		0	0	0
(15) Duane A Compton PhD...................................................................... Trustee/Ex-Officio	0.75 ................. 1.56	X		0	0	0
(16) M Brooke Herndon MD MS...................................................................... Trustee	28.75 ................. 12.75	X		0	231,626	64,481
(17) Charles G Plimpton MBA...................................................................... Trustee/Bd Trsr eff 1/1/16	1.5 ................. 2.5	X	X	0	0	0

Form 990 (2015)

Page 8

Part VII

Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)					(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) Richard J Powell MD........................................................................ Trustee end 12/31/15	28.75 .......................13.55	X					0	466,328	117,201
(19) Richard Rothstein MD........................................................................ Trustee end 12/31/15	28.75 .......................12.75	X					0	556,900	71,864
(20) Steven A Paris MD........................................................................ Trustee end 12/31/15	28.75 .......................15.76	X					0	375,697	53,636
(21) Jeffrey A Cohen MD........................................................................ Trustee eff. 12/4/15	28.75 .......................13.05	X					0	402,436	136,011
(22) Timothy D Scherer MD........................................................................ Trustee eff. 12/4/15	28.75 .......................12.75	X					0	500,250	63,440
(23) Brian C Spence MD MHCDS........................................................................ Trustee eff. 12/4/15	28.75 .......................12.75	X					0	419,847	44,863
(24) Robin Kilfeather-Mackey CPA........................................................................ Chief Financial Officer	42.75 .......................19.76		X				0	550,797	175,125
(25) Daniel Jantzen CPA........................................................................ Chief Operating Officer	42.0 .......................21.0		X				676,831	0	151,921
(26) Stephen Leblanc........................................................................ Exec VP Strtgy & Ntwrk Rltns	42.75 .......................20.76		X				0	616,651	179,153
(27) Edward Merrens MD........................................................................ Chief Medical Officer	42.0 .......................18.0		X				0	469,611	67,752
(28) John Birkmeyer MD........................................................................ Chf Clncl Offr/EVP Entprs Sup	42.0 .......................20.5		X				0	791,471	59,542
(29) Maria Padin MD........................................................................ Chf Med Ofcr eff 11/9/15	42.0 .......................8.0		X				0	372,362	183,439
(30) Vincent Fusca III........................................................................ Chief of Staff	42.0 .......................19.0			X			329,987	0	40,558
(31) George Blike MD........................................................................ Chief Quality & Value Officer	42.0 .......................18.0			X			0	449,299	210,887
(32) John S Malanowski MILR........................................................................ Chief HR Officer	42.0 .......................8.0			X			506,482	0	56,423
(33) Terrence P Carroll PHD........................................................................ Chf Innvtn Offcr end 8/29/15	42.0 .......................18.0			X			654,526	0	55,371
(34) Gay Landstrom PhD RN NEA-BC........................................................................ Chief Nursing Officer	42.75 .......................18.75			X			597,242	0	44,070
(35) Robert Greene MD MHCDS FACP........................................................................ Chf Popul Mgmt Ofr	42.0 .......................18.0			X			0	557,843	38,671
(36) John Kacavas JD........................................................................ Chief Legal Officer	42.0 .......................19.0			X			242,425	0	29,942
(37) Peter D Solberg MD........................................................................ Chf Med Info Ofcr eff. 9/2/15	42.0 .......................18.0			X			0	339,723	48,738
(38) Karen Clements RN BSN MSB FACHE........................................................................ Actg Chf Nrsg Ofr eff 6/15/16	42.0 .......................18.0			X			158,313	0	18,474
(39) Thomas J Siepka........................................................................ Chief Pharmacy Offr Eff 1/4/16	42.0 .......................18.0			X			216,867	0	16,136
(40) Bruce King MSPH FHFMA........................................................................ Pres & CEO New London Hosp	0.0 .......................50.0				X		347,705	0	97,689
(41) Roderic Young........................................................................ VP Communications & Marketing	28.0 .......................12.0				X		311,382	0	45,595
(42) Martin Purcell MBA........................................................................ VP IS Operations	28.0 .......................12.0				X		331,662	0	125,676
(43) Kimberly Troland JD........................................................................ Fmr Intrm GC/Deputy Gen Cnsl	28.0 .......................12.0				X		371,724	0	38,986
(44) Kevin Donovan MHA........................................................................ CEO - WHC end 6/14/16	0.0 .......................40.5				X		308,276	0	59,783
(45) Carl Dematteo MD........................................................................ Fmr Chf Ql Compl Ofr/Physician	28.0 .......................12.0					X	0	130,501	1,482
(46) John Butterly MD........................................................................ Fmr Offr/Exec VP Med Affairs	28.0 .......................12.0					X	0	482,349	63,446
(47) Jeanine Arden-Ornt........................................................................ Fmr General Counsel	25.0 .......................0.0					X	213,499	0	0
(48) Thomas Colacchio MD........................................................................ Former Officer/Phys	28.0 .......................13.0					X	0	1,021,525	81,611
(49) Darlene A Saler MBA RN........................................................................ Frmr Actg Chf Nrsg Ofr	28.0 .......................12.0					X	193,999	0	115,514
(50) Clifford J Belden MD........................................................................ Former Chief Clinical Officer	28.0 .......................12.0					X	0	722,128	29,907
(51) Mary Oseid MHCDS........................................................................ Fmr Key Emp/VP Enterprise Svcs	28.0 .......................12.0					X	0	263,800	189,207
(52) Christine Schon MPA........................................................................ Fmr Key Emp/Adm VP Prmry Care	28.0 .......................12.01					X	0	235,521	57,261
(53) Gail Dahlstrom........................................................................ Fmr Key Emp/VP Facilities Mgmt	28.0 .......................12.0					X	165,977	0	44,038
(54) Tina Naimie CPA MHCDS........................................................................ Fmr Key Emp/VP Corp Finance	28.0 .......................13.5					X	234,879	0	23,643
(55) Wendy Fielding MBA........................................................................ Fmr Key Emp/VP Finance Plnning	28.0 .......................14.5					X	234,382	0	56,833
(56) Mary Kay Boudewyns........................................................................ Fmr Key Emp/Adm Dir Rev Mgmt	28.0 .......................12.0					X	229,591	0	141,496
(57) Thomas Dodds MD........................................................................ Former Key Emp/Dept Chr Anesth	28.0 .......................12.0					X	0	552,374	106,025
(58) Wendy Wells MD........................................................................ Fmr Key Emp/Dpt Chr Pathology	28.0 .......................12.0					X	0	448,323	124,193
(59) Jocelyn Chertoff MD........................................................................ Fmr Key Emp/Dpt Chr Dgnstc Rad	28.0 .......................12.0					X	0	544,464	179,487
(60) Edward Catherwood MD MS........................................................................ Former Key Emp/Ctr Dir Hrt/Vsc	28.0 .......................12.0					X	0	465,442	72,895
(61) Steven Boyce........................................................................ Fmr Key Emp/Adm. VP Med Spclts	28.0 .......................12.0					X	0	255,054	75,059
(62) Jeffrey OBrien MHA........................................................................ Fmr Key Emp/VP Oncology	28.0 .......................12.0					X	277,541	0	41,301

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	6,603,290	13,875,801	3,946,802

Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet

411

Yes

Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............

Yes

For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................

Yes

Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........

Section B. Independent Contractors

Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.

(A) Name and business address	(B) Description of services	(C) Compensation
TRUSTEES OF DARTMOUTH COLLEGE, 37 DEWEY FIELD HANOVER,NH03755	ADMIN & DIR SUPPORT	19,018,393
Cross Country Staffing, PO Box 404674 ATLANTA,GA303844674	Staffing Services	10,183,721
Accretive Health, 401 N Michigan Ave Ste 2700 CHICAGO,IL60611	REVENUE MGMT	14,964,524
Conifer Revenue Cycle Solutions LL, 1500 S Douglass Road Ste 200 ANAHEIM,CA92806	Revenue Mgmt	13,719,309
Turner Construction, Two Seaport Lane BOSTON,MA02210	Construction Svcs	25,439,385
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 53

Form 990 (2015)

Page 9

Part VIII

Statement of Revenue

Check if Schedule O contains a response or note to any line in this Part VIII .............

(A)
Total revenue

(B)
Related or
exempt
function
revenue

(D)
Revenue
excluded from
tax under sections
512-514

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e	2,378,499

f	All other contributions, gifts, grants, and similar amounts not included above		1f	4,947,886

g	Noncash contributions included in lines 1a-1f:$ 525,439
h Total.Add lines 1a-1f.......		7,326,385

			Business Code
2a	NET PATIENT SERVICE REVENUE	622110	987,835,649	986,647,738	1,187,911
b	RESEARCH RELATED ACTIVITIES	622110	6,235,851	6,235,851
c
d
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			994,071,500

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			3,114,602		-423,728	3,538,330
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		1,120,858
b	Less: rental expenses		569,592
c	Rental income or (loss)	0	551,266
d	Net rental income or (loss)......			551,266			551,266
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	31,306	10,804,425
b	Less: cost or other basis and sales expenses	1,834,341	12,029,632
c	Gain or (loss)	-1,803,035	-1,225,207
d	Net gain or (loss).....			-3,028,242			-3,028,242
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	PHARMACY INCOME		622110	29,007,019	28,897,933	109,086
b	CAFETERIA INCOME		622110	2,882,402			2,882,402
c	OTHER ALLOCATED INCOME		622110	9,645,850	9,645,850
d	All other revenue ....			9,186,758	6,343,868	2,842,890
e	Total. Add lines 11a–11d ......			50,722,029
12	Total revenue. See Instructions......			1,052,757,540	1,037,771,240	3,716,159	3,943,756

Form 990 (2015)

Page 10

Part IX

Statement of Functional Expenses

Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX ..............

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.		(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	825,729	825,729
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	1,378,839	1,378,839
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	11,139,844	4,619,333	6,300,316	220,195
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	5,173,529	4,236,495	915,703	21,331
7	Other salaries and wages	480,597,480	407,317,175	73,280,305
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	46,845,432	39,697,012	7,148,420
9	Other employee benefits .......	58,681,803	49,727,201	8,954,602
10	Payroll taxes ...........	32,810,892	27,804,085	5,006,807
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	2,121,110	45,251	2,075,859
c	Accounting ...........	660,654		660,654
d	Lobbying ...........	38,500		38,500
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	91,406,800	58,394,194	33,012,606
12	Advertising and promotion ....	3,001,260	31,565	2,969,695
13	Office expenses .......	13,451,721	11,429,572	2,022,149
14	Information technology ......	10,253,855	9,125,931	1,127,924
15	Royalties ..	0
16	Occupancy ...........	14,048,820	12,459,591	1,589,229
17	Travel ............	3,695,050	1,836,736	1,858,314
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	101,172	92,759	8,413
20	Interest ...........	12,828,649	11,417,498	1,411,151
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	60,735,848	54,053,546	6,682,302
23	Insurance ...	3,023,478	3,023,478
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	165,842,804	165,711,223	131,581
b	MEDICAID ENHANCEMENT TAX	46,077,549	46,077,549
c	EQUIPMENT RENTAL & MAINT	12,488,248	11,114,541	1,373,707
d	ACDMC, GME, TEACHING, & EDU	7,605,114	5,507,306	2,097,808
e	All other expenses	985,143	158,225	826,442	476
25	Total functional expenses. Add lines 1 through 24e	1,085,819,323	926,084,834	159,492,487	242,002
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).

Form 990 (2015)

Page 11

Part X

Balance Sheet

Check if Schedule O contains a response or note to any line in this Part IX ..............

				(A) Beginning of year		(B) End of year

1	Cash–non-interest-bearing ........			115,693	1	1,876,637
2	Savings and temporary cash investments .........			10,175,102	2	1,933,626
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			125,676,961	4	157,353,140
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
				313,922	5	168,957
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net ....			806,671	7	579,058
8	Inventories for sale or use ........			15,427,916	8	17,379,674
9	Prepaid expenses and deferred charges ......			7,906,477	9	9,333,121
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	1,021,194,469
b	Less: accumulated depreciation	10b	593,845,656	427,313,043	10c	427,348,813
11	Investments—publicly traded securities .			325,346,264	11	234,549,775
12	Investments—other securities. See Part IV, line 11 .....			254,702,840	12	337,361,745
13	Investments—program-related. See Part IV, line 11 ..			8,808,343	13	7,950,879
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			118,371,319	15	116,337,374
16	Total assets. Add lines 1 through 15 (must equal line 34)...			1,294,964,551	16	1,312,172,799

17	Accounts payable and accrued expenses .....	125,289,886	17	126,756,517
18	Grants payable ...	0	18	0
19	Deferred revenue .........	465,950	19	631,346
20	Tax-exempt bond liabilities .........	335,292,116	20	326,836,101
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	147,351,381	23	227,716,877
24	Unsecured notes and loans payable to unrelated third parties ..	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	87,608,528	25	105,845,048
26	Total liabilities. Add lines 17 through 25..	696,007,861	26	787,785,889

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	519,605,834	27	435,627,969
28	Temporarily restricted net assets ...........	50,053,367	28	58,764,416
29	Permanently restricted net assets	29,297,489	29	29,994,525
	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 ...........	598,956,690	33	524,386,910
34	Total liabilities and net assets/fund balances ........	1,294,964,551	34	1,312,172,799

Form 990 (2015)

Page 12

Part XI

Reconcilliation of Net Assets

Check if Schedule O contains a response or note to any line in this Part XI ..............

Total revenue (must equal Part VIII, column (A), line 12) ............

1,052,757,540

Total expenses (must equal Part IX, column (A), line 25) ............

1,085,819,323

Revenue less expenses. Subtract line 2 from line 1 ..............

-33,061,783

Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..

598,956,690

Net unrealized gains (losses) on investments ...............

-11,245,687

Donated services and use of facilities .................

Investment expenses .....................

Prior period adjustments .....................

Other changes in net assets or fund balances (explain in Schedule O) ........

-30,262,310

Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))

524,386,910

Part XII

Financial Statements and Reporting

Check if Schedule O contains a response or note to any line in this Part XII .............

Yes

Accounting method used to prepare the Form 990: Cash Accrual Other
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.

Were the organization’s financial statements compiled or reviewed by an independent accountant?

If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:

Separate basis Consolidated basis Both consolidated and separate basis

Were the organization’s financial statements audited by an independent accountant?

Yes

If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:

Separate basis Consolidated basis Both consolidated and separate basis

If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?

Yes

If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.

As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?

Yes

If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.

Yes

Form 990 (2015)

Additional Data

Software ID:
Software Version:

Form 990, Special Condition Description:

Special Condition Description

- 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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I

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

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

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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

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 Mary Hitchcock Memorial Hospital

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

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

Page 3

Name of organization Mary Hitchcock Memorial Hospital		Employer identification number 02-0222140

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

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

Page 4


Name of organization Mary Hitchcock Memorial Hospital			Employer identification number 02-0222140
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ 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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I-A

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

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)? ........

Yes

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

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

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

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

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

Yes

148,428

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

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

Yes

72,593

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

221,021

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Return Reference	Explanation
LOBBYING ACTIVITY EXPLANATION	FORM 990, SCHEDULE C, PART II B, LINES 1B & 1G MARY HITCHCOCK MEMORIAL HOSPITAL EMPLOYS TWO FULL TIME STAFF WHOSE DUTIES INCLUDE LOBBYING. TYPICAL EXPENSES ASSOCIATED WITH THE LOBBYING ACTIVITIES INCLUDE STAFF SALARY, TRAVEL, MEMBERSHIP FEES AND DUES. FROM TIME TO TIME, MARY HITCHCOCK MEMORIAL HOSPITAL, THROUGH ITS EMPLOYEES AND THE USE OF CONSULTANTS, CONTACTS GOVERNMENT OFFICIALS AND LEGISLATORS. THIS CONTACT IS FOR THE PURPOSE OF PROPOSING LEGISLATION OR EXPRESSING AN OPINION ON CHANGES IN LEGISLATION THAT AFFECT THE HOSPITAL AND ITS ABILITY TO CARRY OUT ITS MISSION. THE ACTIVITIES INCLUDE SENDING LETTERS TO, CALLING, AND MEETING WITH GOVERNMENT OFFICIALS AND LEGISLATORS. FOR THE FISCAL YEAR ENDED JUNE 30, 2016, MARY HITCHCOCK MEMORIAL HOSPITAL INCURRED $148,428 IN CONJUCTION WITH THESE ACTIVITIES.
Form 990 Schedule C, Part II B, Line 1I	MHMH pays dues to various organizations related to its exempt mission. The amount reported under other activities on line 1I refers to the amount of lobbying activities identified in dues payments to outside organizations.

Return Reference

Explanation

LOBBYING ACTIVITY EXPLANATION

FORM 990, SCHEDULE C, PART II B, LINES 1B & 1G MARY HITCHCOCK MEMORIAL HOSPITAL EMPLOYS TWO FULL TIME STAFF WHOSE DUTIES INCLUDE LOBBYING. TYPICAL EXPENSES ASSOCIATED WITH THE LOBBYING ACTIVITIES INCLUDE STAFF SALARY, TRAVEL, MEMBERSHIP FEES AND DUES. FROM TIME TO TIME, MARY HITCHCOCK MEMORIAL HOSPITAL, THROUGH ITS EMPLOYEES AND THE USE OF CONSULTANTS, CONTACTS GOVERNMENT OFFICIALS AND LEGISLATORS. THIS CONTACT IS FOR THE PURPOSE OF PROPOSING LEGISLATION OR EXPRESSING AN OPINION ON CHANGES IN LEGISLATION THAT AFFECT THE HOSPITAL AND ITS ABILITY TO CARRY OUT ITS MISSION. THE ACTIVITIES INCLUDE SENDING LETTERS TO, CALLING, AND MEETING WITH GOVERNMENT OFFICIALS AND LEGISLATORS. FOR THE FISCAL YEAR ENDED JUNE 30, 2016, MARY HITCHCOCK MEMORIAL HOSPITAL INCURRED $148,428 IN CONJUCTION WITH THESE ACTIVITIES.

Form 990 Schedule C, Part II B, Line 1I

MHMH pays dues to various organizations related to its exempt mission. The amount reported under other activities on line 1I refers to the amount of lobbying activities identified in dues payments to outside organizations.

Schedule C (Form 990 or 990EZ) 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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" 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 ....	72,720,335	74,609,411	54,935,134	57,050,185	54,023,225
b	Contributions ...	378,941	208,107	17,029,356	188,155	30,717
c	Net investment earnings, gains, and losses	-377,000	-516,882	3,029,123	-357,053	3,834,255
d	Grants or scholarships ...			16,800	5,322	15,000
e	Other expenditures for facilities and programs ...	17,967,476	1,580,301	1,648,675	1,940,831	823,012
f	Administrative expenses ....
g	End of year balance ......	54,754,800	72,720,335	73,328,138	54,935,134	57,050,185

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

Board designated or quasi-endowment SchDMd Bullet

29.860 %

Permanent endowment SchDMd Bullet

54.480 %

Temporarily restricted endowment SchDMd Bullet

15.660 %

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 ...	0	41,365,774		41,365,774
b	Buildings		507,941,964	290,401,270	217,540,694
c	Leasehold improvements		4,111,615	3,686,428	425,187
d	Equipment ...		438,422,564	299,757,958	138,664,606
e	Other ...		29,352,552	0	29,352,552
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..					427,348,813

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) FIXED INCOME	123,429,884	F
(B) PRIVATE EQUITIES	40,457,779	F
(C) HEDGE FUNDS	52,203,204	F
(D) OTHER INVESTMENTS	121,270,878	F
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	337,361,745

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) INVESTMENT IN CAPTIVE				2,878,669
(2) DUE FROM AFFILIATES				74,003,079
(3) BOND ISSUANCE COSTS				2,988,285
(4) OTHER MISC ASSETS				22,981,051
(5) CAPITAL LEASE RECEIVABLE				13,486,290
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				116,337,374

Part X

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

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
THIRD PARTY RESERVES	22,811,759
ACCRUED POST RETMNT PENS & MED	73,562,340
INTEREST RATE SWAP	9,470,949
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	105,845,048
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

Intended use of Endowment Funds

Form 990, Schedule D, Part V, Line 4 The intended use of the endowment funds is to promote and advance the following mission-related programs: healthcare services, research, charity care, and health education. ASC 740 (Fin 48) Footnote Form 990, Schedule D, Part X, Line 2 No ASC 740 (Fin 48) footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption.

Schedule D (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE F(Form 990)

Department of the Treasury
Internal Revenue Service

Statement of Activities Outside the United States

Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16. Right pointing arrow large image

Attach to Form 990. Right pointing arrow large image

See separate instructions. Right pointing arrow large image

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization
Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I

General Information on Activities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 14b.

For grantmakers.Does the organization maintain records to substantiate the amount of its grants and

other assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used

to award the grants or assistance? . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other assistance outside the United States.

Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)

(a) Region		(c) Number of employees, agents, and independent contractors in region	(d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region)	(e) If activity listed in (d) is a program service, describe specific type of service(s) in region	(f) Total expenditures for and investments in region
	Central America and the Caribbean		Program Services	Travel	20,773
	East Asia and the Pacific	1	Program Services	Medical Services	6,145
	East Asia and the Pacific		Program Services	Travel	2,228
	East Asia and the Pacific		Program Services	Research	53,632
	Europe (Including Iceland and Greenland)		Program Services	Dues and Licenses	287
	Europe (Including Iceland and Greenland)		Program Services	Insurance	105,000
	Europe (Including Iceland and Greenland)		Program Services	Software	59,632
	Europe (Including Iceland and Greenland)		Program Services	Travel	33,939
	Middle East and North Africa		Program Services	Travel	10
	North America		Program Services	Advertising	17,987
	North America		Program Services	Dues and Licenses	60
	North America		Program Services	Honorariums	1,887
	North America		Program Services	Publications	330
	North America		Program Services	Services	2,083
	North America		Program Services	Software	297,587
	North America		Program Services	Travel	21,939
	South America	3	Program Services	Medical Services	14,851
	South America		Program Services	Travel	1,115
	Sub-Saharan Africa	8	Program Services	Medical Services	441,543
	Sub-Saharan Africa		Program Services	Travel	3,245
	Central America and the Caribbean		Investments	Inv in Ins Captive	2,878,669
3a	Sub-total .....	4			638,370
b	Total from continuation sheets to Part I ...	8			3,324,572
c	Totals (add lines 3a and 3b)	12			3,962,942

For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2015

Schedule F (Form 990) 2015

Page 2

Part II

Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.

1 (a) Name of organization		(b) IRS code section and EIN (if applicable)	(a)(c) Region	(b)(d) Purpose of grant	(e) Amount of cash grant	(f) Manner of cash disbursement	(g) Amount of non-cash assistance	(h) Description of non-cash assistance	(i) Method of valuation (book, FMV, appraisal, other)

2	Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .......
3	Enter total number of other organizations or entities .......................

Schedule F (Form 990) 2015

Schedule F (Form 990) 2015Page 3

Part III

Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.

Part III can be duplicated if additional space is needed.

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

Schedule F (Form 990) 2015

Page 4

Part IV

Foreign Forms

Schedule F (Form 990) 2015

Page 5

Part V

Supplemental Information
Provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).

ReturnReference	Explanation

Schedule F (Form 990) 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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

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 225 %

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

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

Yes

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

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

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

Yes

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

Yes

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

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	6,127,670		6,127,670	0.590 %
b	Medicaid (from Worksheet 3, column a) . . . . .	181,946,139	104,152,908	77,793,231	7.480 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	188,073,809	104,152,908	83,920,901	8.070 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	4,262,106	1,803,643	2,458,463	0.240 %
f	Health professions education (from Worksheet 5) . . .	43,295,253	11,857,037	31,438,216	3.020 %
g	Subsidized health services (from Worksheet 6) . . . .	14,911,020	228,881	14,682,139	1.410 %
h	Research (from Worksheet 7) .	2,202,904	7,756	2,195,148	0.210 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	917,496		917,496	0.090 %
j	Total. Other Benefits . .	65,588,779	13,897,317	51,691,462	4.970 %
k	Total. Add lines 7d and 7j .	253,662,588	118,050,225	135,612,363	13.040 %

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.

		(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	1,504,864	669,241	835,623	0.080 %
7	Community health improvement advocacy	50,509		50,509	0.010 %
8	Workforce development	135,237		135,237	0.010 %
9	Other
10	Total	1,690,610	669,241	1,021,369	0.100 %

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? ..........................

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

24,261,088

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

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

Section B. Medicare

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

287,705,469

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

320,139,906

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

-32,434,437

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	Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon,NH03756 www.dartmouth-hitchcock.org 01799	X	X	X	X	X	X	Psych Unit and Transplant Unit Cancer Center

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)

	Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group

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

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

Yes

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

Yes

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

Hospital facility’s website (list url): Please see Section C, Supplemental Info

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 12

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

Yes

If "Yes" (list url): Please see Section C, Supplemental Info

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

10b

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

12a

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

12a

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

12b

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

Schedule H (Form 990) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group

Yes

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

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

Yes

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

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 225.% and FPG family income limit for eligibility for discounted care of 300.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

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

Yes

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

Yes

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

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

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

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

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

Other (describe in Section C)

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

Yes

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

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

See Section C, Supplemental Info

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

See Section C, Supplemental Info

A plain language summary of the FAP was widely available on a website (list url):
See Sect. C, Spplmntl Info

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)

	Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group

Yes

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

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

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

Yes

If "No," indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Section C)

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

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

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

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

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

Other (describe in Section C)

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

If "Yes," explain in Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Input From Representatives of Community Served by the Hospital Facility	Form 990, Sch H, Part V, Section B, Line 5 D-H IS ACTIVELY ENGAGED IN THE DEVELOPMENT OF AN ACTIVE UPPER VALLEY REGIONAL PUBLIC HEALTH ADVISORY COUNCIL (35+ COMMUNITY REPRESENTATIVES) AND BROADER RETHINK HEALTH INITIATIVES (100+ COMMUNITY REPRESENTATIVES). MEMBERS OF THESE TWO COMMUNITY HEALTH ADVISORY GROUPS HAVE HAD THE OPPORTUNITY TO REVIEW AND COMMENT ON DRAFTS OF DARTMOUTH-HITCHOCK'S COMMUNITY HEALTH IMPROVEMENT PLAN. THE PLAN DOCUMENT HAS ALSO BEEN CIRCULATED TO PUBLIC HEALTH OFFICIALS IN VERMONT FOR THEIR COMMENT. IN ADDITION, DARTMOUTH-HITCHCOCK REPRESENTATIVES SERVE ON NUMEROUS BOARDS, TASK FORCES, MUNICIPAL HEALTH LEADERSHIP AND PLANNING TEAMS, AND OTHER COMMUNITY HEALTH LEADERSHIP ENTITIES IN ORDER TO ENSURE THAT WE BOTH PARTICIPATE IN AND BETTER UNDERSTAND THE NEEDS OF OUR COMMUNITY. CHNA Conducted With One Or More Other Hospital Facilities Form 990, Schedule H, Part V, Section B, Line 6A During 2012, MHMH partnered with Alice Peck Day Memorial Hospital and Mount Ascutney Hospital and Health Care. CHNA Conducted With One Or More Organizations Other Than Hospital Facilities Form 990, Schedule H, Part V, Section B, Line 6B In 2012, in addition to other hospitals, the assessment was completed in partnership with Granite State United Way. Community Health Needs Assessment Form 990, Schedule H, Part V, Section B, Line 7a The Community Health Needs Assessment can be found online at http://www.dartmouth-hitchcock.org/about_dh/community_benefits_program.htm l Community Health Needs Assessment Form 990, Schedule H, Part V, Section B, Line 7c & 7d The Needs Assessment was distributed to non-profit organizations throughout the region including the Public Health Council of the Upper Valley and Granite United Way. It is also available from the Organization upon request. Community Health Needs Assessment and Implementation Strategy Form 990, Schedule H, Section B, Line 9 Mary Hitchcock Memorial Hospital Conducted a new CHNA which was approved by the board on June 28th, 2016. The CHIS was approved by the board in September of 2016. The information provided here represents the 2013 (Tax Year 2012) CHNA, which was in place for the majority of FY16. Community Health Needs Assessment Implementation Strategy Form 990, Schedule H, Part V, Section B, Line 10a The Community Health Needs Assessment Implementation Strategy can be found online at http://www.dartmouth-hitchcock.org/about_dh/community_benefits_program.htm l Community Health Needs Identified Form 990, Schedule H, Part V, Section B, Line 11 Based upon the most recent community benefits report, MHMH is increasing community benefits spending to address identified community needs, particularly, oral health, needs of older adults, substance misuse prevention, and obesity/nutrition/physical activity. In FY 2016, Mary Hitchcock Memorial Hospital's (MHMH) Community Health Improvement strategies were consistent with the intentions identified in our Community Health Improvement Plan to address identified community health needs by: a) increase investment; b) maintain similar levels of investments for services and initiatives already provided by MHMH; or c) limit investment in areas where other community organizations already provide leadership and services to address the need, or where the identified need is significantly outside the mission/services/scope of MHMH. Mary Hitchcock Memorial Hospital's Community Health Improvement Plan is a 3-year document identifying anticipated investments and activities that it will take to address needs identified in the most recent Upper Valley Community Health Needs Assessment (CHNA). In four cases, items identified in the CHNA were not adddressed by MHMH: 1) the need for more affordable housing; 2) the need for more livable wage jobs; 3) the need to reduce rural isolation; and 4) the need for improved quality of education. These needs are outside the traditional mission/services/scope of the hospital; the region looks to other entities, such as Granite United Way, Twin Pines Housing Trust, Lebanon Housing Authority; Vital Communities; and others, for leadership to address these needs. In these cases, MHMH's response may include: a) minimal investment of time, leadership, and expertise, such as serving on community committees; b) making cash investments in the lead organization or addressing smaller aspects of the identified need as part of a collaboration with community organizations, such as cash support for the Upper Valley Housing Coalition and investing in an on-site employment training program for young adults with developmental disabilities; or c) investing in the issue, but in a way that may not meet criteria for inclusion as a Community Benefit, such as investing significantly in regional jobs training activities that help individuals move to higher paying, stable jobs at Dartmouth-Hitchcock or developing pediatric clinic-community approaches to improving care for children with asthma. While these efforts address an identified community need, the cost of these efforts cannot be separated from MHMH's business model or standard of clinical care, thus do not qualify as Community Benefits. Additionally, leadership to address two community needs: cancer prevention; and prevention of unintentional injuries, is led primarily by teams who are employed by the Geisel School of Medicine at Dartmouth College. In many cases, while leadership for these efforts are provided by staff who have dual appointments to both the Geisel School of Medicine and MHMH, the cost accounting for these efforts occurs through the Geisel School, so MHMH does not claim leadership in these areas of community health improvement. In both cases, however, MHMH does provide cash support to the Geisel School of Medicine teams who do this work in our Hospital Service Area and throughout New Hampshire and Vermont. Discounted Care by income level other than FPG Form 990, Schedule H, Part V, Section B, Line 13B Patients whose family income exceeds 300% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of D-H. Residency Form 990, Schedule H, Part V, Section B, Line 13G In order to receive financial assistance, an individual must be a resident of NH or VT, or a non-resident who experiences a medical emergency. Uninsured Discount Policy Form 990, Schedule H, Part V, Section B, Line 13H D-H has a separate Uninsured Discount Policy that outlines how the discount is calculated annually and is applied prior to billing any uninsured patient. This assures a patient is not billed at an amount greater than the amount generally billed to patients with insurance. This is referenced as a link in the Financial Assistance Policy.
Measures to Publicize Financial Assistance Policy	Form 990, Schedule H, Part V, Section B Line 16 A-C The financial assistance policy, application, and plain language summary can be found at: http://www.dartmouth-hitchcock.org/billing-charges/financial_assistance.ht ml MHMH has brochures available at all admission sites as well as plain language summary posters at all locations. Additionally, MHMH provided brochures to local non-profits to distribute. Financial Assistance Policy availability within the Community Form 990, Schedule H, Part V, Section B, Line 16I MHMH financial assistance policy is posted on MHMH's website, including the verbatim policy and a shorter, more patient-friendly version. MHMH provides the patient friendly brochure version of the policy to all uninsured patients who enter the health system. MHMH continues to notify patients on the back of the billing statement about financial assistance being available to them. Additionally, MHMH posts information about the policy in public areas throughout the facilities including admission offices. MHMH has also made additional changes internally to increase awareness of the policy, including adding information to the back of the patient's statement about financial assistance available to them, posting information about the policy in public areas throughout the facilities, and ensuring financial assistance policy brochures are available in patient areas. MHMH Screens 100% of uninsured inpatient and same-day patients prior to admission. As part of this process, MHMH checks all state and federal programs to see if individuals are eligible for assistance. Patients are also screened to determine qualification for financial assistance and the application is provided and/or completed at this time. Maximum charges to financial assistance policy-eligible individuals for emergency or medically-necessary care Form 990, Schedule H, Part V, Section B, Line 22B MHMH uses the average of the three highest commerical payer discounts and applies this as a discount for all uninsured patients. The discount rate is 43% for FY16. Facility information Form 990, Schedule H, Part V, Section D The Hospital has a Cancer Treatment Center located in Saint Johnsbury, Vermont. This location is registered under the same license as the Organization's main Campus located in Lebanon, New Hampshire.

Schedule H (Form 990) 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
Other factors used in determining eligibility other than FPG	Form 990, Schedule H, Part I, Line 3c Guidelines D-H uses the FPG guidelines in determining the initial level of financial assistance provided. In addition, D-H allows for catastrophic assistance consideration based on a calculation of 10% of two years income plus 10% of amount over sheltered assets. If the projected or current selfpay balance is greater than this calculation, the selfpay balance is reduced to the sum of 10% of two years income plus 10% of assets. Each household is allowed certain sheltered assets which are not used when calculating household income or assets. Savings is sheltered up to 100% of FPL based on family size, equity in primary residence up to $200,000 up to 55 and $250,000 for aged 55 and older, and a retirement shelter of up to $100,000 in retirement assets as long as it is employer based contributions if working or IRA if self-employed. If a patient is retired, prior retirement accounts would be included as a sheltered asset. Community Benefits Report Form 990, Schedule H, Part I, Line 6a Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic (Collectively referred to as Dartmouth-Hitchcock (D-H)) share common board members and operate under an affiliation agreement. D-H performs a joint Community Health Needs Assessment (CHNA) and files a consolidated Community Benefits report with the state of New Hampshire. For purposes of IRS Form Schedule H, only Hospital numbers were used. All amounts relating to DHC were excluded. The New Hampshire Community Benefits Report filed for fiscal year 2016, DHC and MHMH combined, totaled $172,753,262.
Costing Methodology	Form 990, Schedule H, Part I, Line 7 The costing methodology used to calculate the amounts reported was a cost-to-charge ratio derived from worksheet 2, Ratio of Patient Care Cost-to-Charges.
Subsidized health services related to physician clinics	Form 990, Schedule H, Part I, Line 7G The Organization did not include any subsidized health service costs attributable to a physician clinic on Part I, line 7G.
Community Building Activities	Form 990, Schedule H, Part II COMMUNITY BUILDING ACTIVITIES INCLUDE EXPENSES RELATED TO COALITIONS THAT ADDRESS RURAL EMERGENCY/TRAUMA SERVICES, REGIONAL PUBLIC HEALTH NETWORKS; PREVENTION OF PEDIATRIC OBESITY,PREVENTION OF SUBSTANCE ABUSE, FALLS REDUCTION FOR OLDER ADULTS, PUBLIC, HEALTH NETWORKS, AND PRESCRIPTION DRUG MISUSE. THESE ALSO INCLUDE CASH SUPPORT AND/OR CONTRIBUTED IN-KIND SUPPORT FOR THE DEVELOPMENT AND MAINTENANCE OF HOUSING FOR LOW-INCOME FAMILIES, REGIONAL ECONOMIC DEVELOPMENT, AND SUPPORT FOR REGIONAL WORKFORCE DEVELOPMENT SERVICES.
Bad Debt Expense	Form 990, Schedule H, Part III, Section A, Lines 2 and 3 The amounts reported on Part III, Section A, line 2 were derived from MHMH's audited financial statements (provision for bad debt). MHMH's Policy is to exert everything in the Organization's power to obtain sufficient and adequate information to determine eligibility for financial assistance. MHMH's discount for uninsured patients is currently 43% (before financial assistance is applied). As part of MHMH's Financial Assistance Policy, MHMH makes information available to patients for eligibility and how to apply for free or discounted care. If the patient does not respond to the hospital's attempts to complete the financial assistance package, these patients may be written off to bad debt. Until 10/1/2015, when D-H changed revenue management service providers, D-H had procedures for presumptive charity review. With the transition to new revenue management providers, as of 6/30/16, presumptive charity review procedures did occur for the final six months of the fiscal year. D-H is working with the new provider to begin presumptive charity review for fiscal year 2017.
Audited Financial Stmt Disclosure for Charity Care and Bad Debt Provision	Form 990, Schedule H, Part III, Section A, Line 4 (Please note that MHMH files a consolidated audited financial statement with Dartmouth-Hitchcock Clinic and other Subsidiaries the amount reported on Schedule H represents MHMH's portion only). MHMH provides care to patients who meet certain criteria under their financial assistance policies without charge or at amounts less than their established rates. Because MHMH does not anticipate collection of amounts determined to qualify as charity care, they are not reported as revenue. MHMH grants credit without collateral to patients. Most are local residents and are insured under third-party arrangements. Additions to the allowance for uncollectible accounts are made by means of the provision for bad debts. Accounts written off as uncollectible are deducted from the allowance and subsequent recoveries are added. The amount of the provision for bad debts is based upon managements assessment of historical and expected net collections, business and economic conditions, trends in federal and state governmental healthcare coverage, and other collection indicators.
Medicare Shortfalls	Form 990, Schedule H, Part III, Section B, Line 8 The costing methodology used to calculate the amounts reported as Medicare Shortfalls was derived from the Internal Revenue Service's Worksheet B as provided for Part III calculations. MHMH had revenues of $24,037,868 and costs of $28,450,965 for services not included on the Medicare Cost Report (Ambulance Services, Laboratory and other fees screens, and Medicare Part C & D services). MHMH incurred a net loss of $4,413,097 on the provision of these services. Because of the central role of the organization in serving the healthcare needs of its community and the demographic characteristics of the community served, it is likely that a portion of the medicare shortfall should be considered community benefit expenditure. MHMH has not identified a specific amount of medicare shortfall that should be reported as such.
Credit and Collection Policy	Form 990, Schedule H, Part III, Line 9b MHMH has a Credit and Collection Policy that addresses the procedures for patients who choose not to make payment or work with MHMH to make payment arrangements for their bill. The Organization has a separate Financial Assistance Policy that addresses those patients who are unable to make payment. MHMH is a charitable health care organization who treats patients that come for medically necessary care, regardless of their financial status. MHMH offers financial assistance in the form of free or discounted care to those patients who have an inability to pay their bills. The Financial Assistance Policy outlines eligibility criteria for financial assistance; the method by which patients may apply for financial assistance; the basis for calculating amounts charged to patients eligible for financial assistance under this policy; D-H's measures to widely publicize the policy within the community served; and the limitation of charges for emergency or other medically necessary care. Patients can qualify for 25%, 50%, 75%, or 100% reduction based on Federal Poverty Levels as well as a catastrophic guideline of 10% of 2 year's income for those that may not qualify based on assets and income, but who have a bill beyond their means to pay. If a financial assistance policy eligible patient has a balance for which they are responsible after a financial assistance discount is applied, the standard practices are followed as outlined in the D-H Credit and Collections policy.
Needs Assessment	Form 990, Schedule H, Part VI, Line 2 MARY HITCHCOCK MEMORIAL HOSPITAL AND DARTMOUTH-HITCHCOCK CLINIC (COLLECTIVELY REFERRED TO AS DARTMOUTH-HITCHCOCK (D-H)) SHARE COMMON BOARD MEMBERS AND OPERATE UNDER AN AFFILIATION AGREEMENT. D-H PERFORMS A JOINT COMMUNITY NEEDS ASSESSMENT AND FILES A CONSOLIDATED COMMUNITY BENEFITS REPORT. DARTMOUTH-HITCHCOCK PARTICIPATES WITH OTHER HEALTH CARE CHARITABLE TRUSTS AND COMMUNITY PARTNERS IN EACH OF OUR SERVICE AREAS TO COMPLETE COMMUNITY HEALTH NEEDS ASSESSMENTS. DURING FY2016, MHMH PARTNERED WITH ALICE PECK DAY MEMORIAL HOSPITAL, TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT. WE ALSO WORKED TOGETHER WITH NEIGHBORING HOSPITALS, INCLUDING MOUNT ASCUTNEY HOSPITAL AND HEALTH CARE, VALLEY REGIONAL HOSPITAL, AND NEW LONDON HOSPITAL TO USE SIMILAR COMMUNITY HEALTH NEEDS ASSESSMENTS TOOLS AND APPROACH, TO ALLOW COMPARABILITY OF HEALTH DATA ACROSS A WIDER GEOGRAPHIC REGION. COLLECTIVELY D-H AND PARTNERED HOSPITALS HIRED COMMUNITY HEALTH INSTITUTE/JOHN SNOW RESEARCH AND TRAINING INSTITUTE, A PUBLIC HEALTH CONSULTING FIRM, TO PROVIDE TECHNICAL ASSISTANCE AND ANALYSIS RELATED TO OUR COMMUNITY HEALTH NEEDS ASSESSMENTS. THE NEEDS ASSESSMENT INCLUDED REVIEWING SELECTED SERVICE AREA DEMOGRAPHICS; PUBLIC HEALTH DATA AVAILABLE THROUGH NH AND VT HEALTH DEPARTMENTS, HOSPITAL DISCHARGE DATA; BEHAVIORAL RISK FACTOR SURVEILLANCE SURVEY AND YOUTH RISK BEHAVIOR SURVEYS; FOCUS GROUPS WITH EMPLOYERS AND WITH COMMUNITY MEMBERS RECEIVING SERVICES AT REGIONAL SAFETY NET SERVICE ORGANIZATIONS; ELECTRONIC SURVEYS OF PROFESSIONAL HEALTH AND SOCIAL SERVICE PROVIDERS; AS WELL AS PAPER AND ELECTRONIC CONVENIENCE SURVEYS OF COMMUNITY RESIDENTS. THE FY2016 COMMUNITY HEALTH NEEDS ASSESSMENT WAS REVIEWED AT A LARGE COMMUNITY MEETING (50+ STAKEHOLDERS) OF THE PUBLIC HEALTH COUNCIL OF THE UPPER VALLEY AND OTHER IN DECEMBER 2015 FOR FURTHER COMMENTS AND FEEDBACK. AS PART OF THE NEEDS ASSESSMENT, MHMH REVIEWED: 1. HEALTH, ECONOMIC, AND EDUCATION DATA FROM SOURCES INCLUDING YOUTH RISK BEHAVIOR SURVEYS, THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM, PUBLIC HEALTH AND HOSPITAL DISCHARGE DATA AVAILABLE IN NH HEALTH WRQS, CENSUS DATA, AND REPORTS FROM THE NEW ENGLAND COMMON ASSESSMENT PROGRAM. ADDITIONALLY, IT REVIEWED THE 2011 NH STATE HEALTH PROFILE; QUANTITATIVE AND QUALITATIVE DATA FROM LOCAL SOURCES (NEWSPAPERS, REGIONAL PLANNING OFFICES, COMMUNITY FORUMS) TO IDENTIFY CONCERNS THAT EMERGED, INTENSIFIED, OR WERE THE SOURCE OF LOCAL ATTENTION SINCE THE LAST SECONDARY DATA WAS COLLECTED. 2. OPINION DATA FROM PROFESSIONAL STAKEHOLDERS USING AN ONLINE OPINION POLL OF REGIONAL LEADERS IN HEALTH, PUBLIC HEALTH, EDUCATION, MUNICIPAL GOVERNMENTS, PUBLIC SAFETY, AND SOCIAL SERVICE PROVIDERS. 69 INFORMED STAKEHOLDERS RESPONDED TO THIS SURVEY. 3. FOCUS GROUP DATA COLLECTED FROM 4 FOCUS GROUPS LARGELY CONSISTING OF LOWER-INCOME CONSUMERS OF HEALTH/SOCIAL SERVICES. 4. OPINION DATA FROM RESIDENTS COLLECTED THROUGH COMMUNITY LIST-SERVS, ASSISTED INTERVIEWS AT HUMAN SERVICE ORGANIZATIONS, HUMAN SERVICE ORGANIZATIONS, PRIMARY CARE AND FREE CARE CLINICS, AND OTHER COMMUNITY SETTINGS. 1,566 RESIDENTS RESPONDED TO SURVEYS. DARTMOUTH-HITCHCOCK REGULARLY MONITORS NEWLY RELEASED HEALTH, ECONOMIC, AND EDUCATION DATA FROM OUR SERVICE REGION TO IDENTIFY EMERGING REGIONAL NEEDS AND CONCERNS, INCLUDING FY 2015 YOUTH RISK BEHAVIOR SURVEYS, THE 2013 NH STATE HEALTH IMPROVEMENT PLAN, NH'S EMERGING STATE PLANS TO ADDRESS SUBSTANCE MISUSE, OPIOID MISUSE, OBESITY, AND CHILDREN'S BEHAVIORAL HEALTH.
Patient Education of Eligibility for Assistance	Form 990, Schedule H, Part VI, Line 3 All uninsured inpatients, same day surgery, observation, and Emergency Department patients are pro-actively screened using paper and/or an automated tool to identify potential qualification for other federal, state, and local programs. In addition, specific outpatient activities deemed to have a higher rate of need are screened as part of regular protocol. If a patient appears to be eligible, on-site Financial Counselors assist the patient in completing the appropriate paperwork/applications and provide instruction regarding how to complete the qualification process. In some cases a Financial Counselor will act on behalf of the patient, at their signed consent, in order to complete the application process (for example, in New Hampshire a patient must be physically present at the District Office). If a patient doesn't qualify for specific programs, they are also considered for financial assistance as part of their screening. For outpatient services that are not routinely screened, staff interacting with patients are instructed to provide either a financial assistance application or contact information for a Financial Counselor when a patient expresses their inability to make payment. Every application is screened for completed income and asset documentation. Applications are also screened to assure there are no other potential options of federal, state, or local programs. The website, patient statements, and financial brochures all include information about financial assistance and how to apply. Community Information Form 990, Schedule H, Part VI, Line 4 THE ORGANIZATION DEFINES ITS SERVICE REGION AS NEW HAMPSHIRE AND EASTERN VERMONT, WITH THE LARGEST PRESENCE IN A 19-TOWN REGION ADJOINING LEBANON, NEW HAMPSHIRE, SITE OF DARTMOUTH-HITCHCOCK MEDICAL CENTER WHICH INCLUDES MARY HITCHCOCK MEMORIAL HOSPITAL AND DARTMOUTH-HITCHCOCK CLINIC'S MAIN NORTHERN CLINIC. MHMH SERVES THE GENERAL POPULATION WITH A WIDE RANGE OF SERVICES. IN ADDITION TO GENERAL HOSPITAL POPULATIONS, THE ORGANIZATION PROVIDES SERVICES TO PATIENTS WITH HIGHLY-SPECIALIZED NEEDS THAT ARE NOT AVAILABLE ELSEWHERE IN NEW HAMPSHIRE. MHMH IS THE STATE'S ONLY TERTIARY REFERRAL CENTER, PROVIDES THE STATE'S ONLY COMPREHENSIVE CANCER CENTER (NORRIS COTTON CANCER CENTER - NCCC), OPERATES THE ONLY LEVEL I TRAUMA CENTER IN NEW HAMPSHIRE, OPERATES THE ONLY COMPREHENSIVE CHILDREN'S HOSPITAL AND ACCREDITED PEDIATRIC TRAUMA CENTER IN NEW HAMPSHIRE (CHILDREN'S HOSPITAL AT DARTMOUTH - CHAD), HOSTS THE ONLY LEVEL IV NEONATAL INTENSIVE CARE NURSERY AND ONE OF TWO PEDIATRIC INTENSIVE CARE UNITS IN NEW HAMPSHIRE, AND OPERATES THE ONLY HELICOPTER TRANSPORT SERVICE IN THE STATE. AS SUCH, THE SERVICE POPULATION IS BOTH THE GENERAL PUBLIC SEEKING PRIMARY HEALTH CARE SERVICES AS WELL AS RESIDENTS WITH UNIQUE AND HIGHLY-SPECIALIZED HEALTH CARE NEEDS.
Promotion of Community Health	Form 990, Schedule H, Part VI, Line 5 MHMH SUPPORTS ORGANIZATIONS AND INITIATIVES THAT FURTHER HEALTH BY STRENGTHENING AND DEVELOPING KEY COMMUNITY CAPACITIES TO ADDRESS IDENTIFIED COMMUNITY HEALTH NEEDS. THIS INCLUDES HOSTING OR LEADING COMMUNITY PARTNERSHIPS TO ADDRESS SUBSTANCE MISUSE AND TREATMENT AND TO IMPROVE PUBLIC HEALTH; PROVIDING FUNDING FOR OBESITY REDUCTION AND CHILDREN'S ORAL HEALTH INITIATIVES, AND PARTICIPATION OF OUR STAFF IN OTHER PARTNERSHIPS INCLUDING THE OUTPATIENT FALLS PREVENTION TASK FORCE; THE TRANSPORTATION MANAGEMENT ASSOCIATION, AND THE UPPER VALLEY HOUSING AUTHORITY. IN ADDITION, MHMH OPERATES HEALTH EDUCATION AND SUPPORT SERVICES SUCH AS A WOMEN'S HEALTH RESOURCE CENTER, THE AGING RESOURCE CENTER; AND A HEALTH EDUCATION CENTER. MHMH USES CASH CONTRIBUTIONS, CONTRACTED SERVICES, AND IN-KIND CONTRIBUTION OF STAFF TIME AND EXPERTISE, TO SUPPORT THESE STRATEGIES WHICH IMPROVE COMMUNITY HEALTH. AT MHMH'S LEBANON, NH CAMPUS, THE HOSPITAL EXTENDS PROFESSIONAL STAFF PRIVILEGES TO QUALIFIED AND APPROPRIATE PHYSICIANS WHO ARE EMPLOYEES OF DARTMOUTH-HITCHCOCK CLINIC, MARY HITCHCOCK MEMORIAL HOSPITAL, AND DARTMOUTH COLLEGE, WHO ALSO HOLD A FACULTY APPOINTMENT AT GEISEL SCHOOL OF MEDICINE. MARY-HITCHCOCKS'S TRUSTEES ANNUALLY SET STRATEGIC PRIORITIES FOR THE INSTITUTION AND APPROVE OPERATING AND CAPITAL BUDGETS WHICH SUPPORT IMPROVEMENTS PATIENT CARE, MEDICAL EDUCATION, AND RESEARCH. EXAMPLES OF THESE INVESTMENTS INCLUDE THE DEVELOPMENT OF MARY HITCHCOCKS'S PATIENT SAFETY AND TRAINING CENTER, ONGOING QUALITY AND PATIENT SAFETY INITIATIVES; PURCHASES OF NEW AND EMERGING MEDICAL TECHNOLOGIES, SUPPORT TRANSLATIONAL RESEARCH, AND MEDICAL EDUCATION. OF THE 19 VOTING MEMBERS OF MARY HITCHCOCK BOARD OF TRUSTEES, 13 ARE NEITHER CONTRACTORS NOR EMPLOYEES OF MHMH.
Affiliated Health Care System Community	Form 990, Schedule H, Part VI, Line 6 BENEFITS ARE PROVIDED BY THE DARTMOUTH-HITCHCOCK HEALTH CARE SYSTEM, WHICH INCLUDES MARY HITCHCOCK MEMORIAL HOSPITAL, DARTMOUTH-HITCHCOCK CLINIC, AND OTHER RELATED ORGANIZATIONS WHOSE PRIMARY MISSION IS HEALTH CARE. MARY HITCHCOCK MEMORIAL HOSPITAL (MHMH) IN LEBANON IS NEW HAMPSHIRE'S LARGEST HOSPITAL. IN FISCAL YEAR 2016 MHMH HAD 396 LICENSED INPATIENT BEDS. THE DARTMOUTH-HITCHCOCK CLINIC (DHC) IS A MULTI-SPECIALTY PHYSICIAN PRACTICE WITH A NETWORK OF PROVIDERS ACROSS NEW HAMPSHIRE AND VERMONT. WHILE DHC'S MAIN OFFICES ARE LOCATED IN LEBANON, THE CLINIC ALSO HAS MULTI-SPECIALTY PRACTICES IN MANCHESTER, NASHUA, CONCORD, AND KEENE, NH AREAS AS WELL AS BENNINGTON, VT. IN ADDITION, THE CLINIC PROVIDES PRIMARY CARE IN RURAL COMMUNITIES IN VERMONT AND NORTHERN NEW HAMPSHIRE. MHMH, DHC, AND THE GEISEL SCHOOL OF MEDICINE FACULTY AND STUDENTS MAKE UP THE DARTMOUTH-HITCHCOCK (D-H) HEALTH CARE SYSTEM. THE HOSPITAL AND CLINIC OPERATE JOINTLY THROUGH INTERLOCKING DIRECTORATES, STRATEGIC PLANNING AND MANAGEMENT AND SHARE IDENTICAL MISSIONS. THE MEDICAL SCHOOL, WHICH WORKS CLOSELY WITH THE HOSPITAL AND CLINIC, IS FOCUSED ON MEDICAL EDUCATION AND RESEARCH.
State filing of Community Benefit Report	Form 990, Schedule H, Part VI, Line 7 MHMH files a Community Benefit Report with the State of New Hampshire jointly with Dartmouth-Hitchcock Clinic.

Schedule H (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990.
lBullet

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization
Mary Hitchcock Memorial Hospital

Employer identification number
02-0222140

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient

that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance

(1) The Trustees of Dartmouth College 1 Rope Ferry Road Hanover,NH03755	02-0222111	501(C)(3)	356,301	FMV	Educ and Prog Suppt
(2) Advance Transit PO Box 1027 Wilder,VT05088	22-2558708	501(C)(3)	78,327	FMV	Transportn Subsidy
(3) Vital Communities Inc 195 No Main St White River Jct,VT05001	03-0355283	501(C)(3)	15,750	FMV	Transportn Subsidy
(4) Indian Stream Health Center 2 Corliss Ln Rr2 Box 14 Colebrook,NH03576	20-0999212	501(c)(3)	35,000	FMV	Program Sponsor
(5) American Cancer Society 250 Williams Street NW Atlanta,GA30303	13-1788491	501(c)(3)	15,750	FMV	Program Support
(6) American Heart Association 7272 Greenville Avenue Dallas,TX75231	13-5613797	501(c)(3)	28,000	FMV	Program Support
(7) CT River Transit Inc 706 Rockingham Road Bellows Falls,VT05101	86-1069523	501(c)(3)	21,000	FMV	Transportn Subsidy
(8) Girl Scouts of the Green and White Mountains PO Box 10832 Bedford,NH03110	02-0243160	501(c)(3)	5,915	FMV	GENERAL SUPPORT
(9) Hitchcock Foundation One Medical Center Drive Lebanon,NH03756	02-0222139	501(c)(3)	8,050	FMV	PROGRAM SUPPORT
(10) Upper Valley Haven Inc 713 Hartford Avenue White River Jct,VT05001	03-0277908	501(c)(3)	15,050	FMV	General Support
(11) Good Beginnings Inc PO Box 5054 West Lebanon,NH03784	22-3096726	501(c)(3)	5,600	FMV	General Support
(12) Family Place Inc 319 US Route 5 S Norwich,VT05055	03-0305264	501(c)(3)	22,400	FMV	General Support
(13) New Hampshire Professionals Health Program 199 State Route 101 Unit 4D 6274 Amherst,NH03031	20-8986771	501(c)(3)	7,000	FMV	Program Support
(14) Upper Valley Business and Education Partnership PO Box 350 Hanover,NH03755	02-0505585	501(c)(3)	7,000	FMV	Program Support
(15) Upper Valley Housing Coalition PO Box 17 Lebanon,NH03766	20-0363702	501(c)(3)	14,000	FMV	Program Support
(16) Twin Pines Housing Trust 240 South Main Street 4 White River Jct,VT05001	22-2809527	501(c)(3)	14,000	FMV	Program Support
(17) Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon,NH03766	02-0222791	501(c)(3)	7,000	FMV	Program Support
(18) Windsor Hospital Corporation 289 County Road Windsor,VT05089	03-0183721	501(c)(3)	10,500	FMV	Program Support

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2015

Page 2

Part III

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

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

(1) Employee Awards and Educational Assistance	133	797,448	FMV
(2) D-H Tuition Reimbursement Program	357	558,612	FMV
(3) Cash Assistance to Patients	193	22,779	FMV
(3)
(4)
(5)
(6)
(7)

Part IV

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

Return Reference

Explanation

Description of Organization's Procedures for Monitoring the Use of Grants

Form 990, Schedule I, Part I, Line 1 Each award established by Mary Hitchcock Memorial Hospital has written established guidelines and procedures. Award payments are processed in accordance with the specific terms of each of the awards. The Dartmouth Institute Scholarships (TDI) are paid directly to the College on the behalf of the individuals receiving the award. The coordinators of the program(s) are responsible for assuring that all terms are met, including proper documentation of expenses with receipts.

Schedule I (Form 990) 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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

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 .........

Yes

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

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

Yes

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

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)
1Carl Dematteo MDFmr Chf Ql Compl Ofr/Physician	(i) (ii)	0 ------------- 128,215	0 ------------- 0	0 ------------- 2,286	0 ------------- 355	0 ------------- 1,127	0 ------------- 131,983	0 ------------- 0
2Robin Kilfeather-Mackey CPAChief Financial Officer	(i) (ii)	0 ------------- 513,562	0 ------------- 0	0 ------------- 37,235	0 ------------- 154,998	0 ------------- 20,127	0 ------------- 725,922	0 ------------- 0
3Daniel Jantzen CPAChief Operating Officer	(i) (ii)	514,015 ------------- 0	0 ------------- 0	162,816 ------------- 0	136,497 ------------- 0	15,424 ------------- 0	828,752 ------------- 0	0 ------------- 0
4Stephen LeblancExec VP Strtgy & Ntwrk Rltns	(i) (ii)	0 ------------- 480,623	0 ------------- 0	0 ------------- 136,028	0 ------------- 159,027	0 ------------- 20,126	0 ------------- 795,804	0 ------------- 0
5John Butterly MDFmr Offr/Exec VP Med Affairs	(i) (ii)	0 ------------- 433,100	0 ------------- 0	0 ------------- 49,249	0 ------------- 62,386	0 ------------- 1,060	0 ------------- 545,795	0 ------------- 0
6Bruce King MSPH FHFMAPres & CEO New London Hosp	(i) (ii)	323,841 ------------- 0	0 ------------- 0	23,864 ------------- 0	77,609 ------------- 0	20,080 ------------- 0	445,394 ------------- 0	0 ------------- 0
7Mary Oseid MHCDSFmr Key Emp/VP Enterprise Svcs	(i) (ii)	0 ------------- 251,570	0 ------------- 0	0 ------------- 12,230	0 ------------- 177,906	0 ------------- 11,301	0 ------------- 453,007	0 ------------- 0
8Christine Schon MPAFmr Key Emp/Adm VP Prmry Care	(i) (ii)	0 ------------- 231,714	0 ------------- 0	0 ------------- 3,807	0 ------------- 42,036	0 ------------- 15,225	0 ------------- 292,782	0 ------------- 0
9Gail DahlstromFmr Key Emp/VP Facilities Mgmt	(i) (ii)	160,834 ------------- 0	0 ------------- 0	5,143 ------------- 0	34,912 ------------- 0	9,126 ------------- 0	210,015 ------------- 0	0 ------------- 0
10James N Weinstein DO MSTrustee Ex-Officio/CEO	(i) (ii)	0 ------------- 1,239,023	0 ------------- 0	0 ------------- 93,115	0 ------------- 148,835	0 ------------- 13,696	0 ------------- 1,494,669	0 ------------- 0
11Tina Naimie CPA MHCDSFmr Key Emp/VP Corp Finance	(i) (ii)	234,308 ------------- 0	100 ------------- 0	471 ------------- 0	21,824 ------------- 0	1,819 ------------- 0	258,522 ------------- 0	0 ------------- 0
12Wendy Fielding MBAFmr Key Emp/VP Finance Plnning	(i) (ii)	234,112 ------------- 0	0 ------------- 0	270 ------------- 0	36,901 ------------- 0	19,932 ------------- 0	291,215 ------------- 0	0 ------------- 0
13Jeanine Arden-OrntFmr General Counsel	(i) (ii)	213,499 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	213,499 ------------- 0	0 ------------- 0
14Vincent Fusca IIIChief of Staff	(i) (ii)	319,756 ------------- 0	0 ------------- 0	10,231 ------------- 0	39,074 ------------- 0	1,484 ------------- 0	370,545 ------------- 0	0 ------------- 0
15Mary Kay BoudewynsFmr Key Emp/Adm Dir Rev Mgmt	(i) (ii)	211,673 ------------- 0	0 ------------- 0	17,918 ------------- 0	133,729 ------------- 0	7,767 ------------- 0	371,087 ------------- 0	0 ------------- 0
16Edward Merrens MDChief Medical Officer	(i) (ii)	0 ------------- 453,422	0 ------------- 0	0 ------------- 16,189	0 ------------- 56,876	0 ------------- 10,876	0 ------------- 537,363	0 ------------- 0
17George Blike MDChief Quality & Value Officer	(i) (ii)	0 ------------- 408,955	0 ------------- 0	0 ------------- 40,344	0 ------------- 190,750	0 ------------- 20,137	0 ------------- 660,186	0 ------------- 0
18Thomas Colacchio MDFormer Officer/Phys	(i) (ii)	0 ------------- 612,710	0 ------------- 0	0 ------------- 408,815	0 ------------- 64,362	0 ------------- 17,249	0 ------------- 1,103,136	0 ------------- 0
19Barbara C Jobst MDTrustee	(i) (ii)	0 ------------- 244,137	0 ------------- 66,525	0 ------------- 10,679	0 ------------- 65,024	0 ------------- 20,422	0 ------------- 406,787	0 ------------- 0
20Darlene A Saler MBA RNFrmr Actg Chf Nrsg Ofr	(i) (ii)	192,969 ------------- 0	0 ------------- 0	1,030 ------------- 0	100,360 ------------- 0	15,154 ------------- 0	309,513 ------------- 0	0 ------------- 0
21John S Malanowski MILRChief HR Officer	(i) (ii)	487,478 ------------- 0	0 ------------- 0	19,004 ------------- 0	38,575 ------------- 0	17,848 ------------- 0	562,905 ------------- 0	0 ------------- 0
22Clifford J Belden MDFormer Chief Clinical Officer	(i) (ii)	0 ------------- 512,238	0 ------------- 0	0 ------------- 209,890	0 ------------- 20,575	0 ------------- 9,332	0 ------------- 752,035	0 ------------- 0
23Terrence P Carroll PHDChf Innvtn Offcr end 8/29/15	(i) (ii)	423,049 ------------- 0	0 ------------- 0	231,477 ------------- 0	44,889 ------------- 0	10,482 ------------- 0	709,897 ------------- 0	0 ------------- 0
24Roderic YoungVP Communications & Marketing	(i) (ii)	306,032 ------------- 0	0 ------------- 0	5,350 ------------- 0	25,544 ------------- 0	20,051 ------------- 0	356,977 ------------- 0	0 ------------- 0
25Martin Purcell MBAVP IS Operations	(i) (ii)	277,035 ------------- 0	25,000 ------------- 0	29,627 ------------- 0	110,042 ------------- 0	15,634 ------------- 0	457,338 ------------- 0	0 ------------- 0
26Thomas Dodds MDFormer Key Emp/Dept Chr Anesth	(i) (ii)	0 ------------- 520,687	0 ------------- 0	0 ------------- 31,687	0 ------------- 85,898	0 ------------- 20,127	0 ------------- 658,399	0 ------------- 0
27Wendy Wells MDFmr Key Emp/Dpt Chr Pathology	(i) (ii)	0 ------------- 426,814	0 ------------- 0	0 ------------- 21,509	0 ------------- 104,066	0 ------------- 20,127	0 ------------- 572,516	0 ------------- 0
28Jocelyn Chertoff MDFmr Key Emp/Dpt Chr Dgnstc Rad	(i) (ii)	0 ------------- 494,914	0 ------------- 19,500	0 ------------- 30,050	0 ------------- 159,349	0 ------------- 20,138	0 ------------- 723,951	0 ------------- 0
29Edward Catherwood MD MSFormer Key Emp/Ctr Dir Hrt/Vsc	(i) (ii)	0 ------------- 464,561	0 ------------- 0	0 ------------- 881	0 ------------- 54,196	0 ------------- 18,699	0 ------------- 538,337	0 ------------- 0
30Steven BoyceFmr Key Emp/Adm. VP Med Spclts	(i) (ii)	0 ------------- 244,566	0 ------------- 0	0 ------------- 10,488	0 ------------- 55,141	0 ------------- 19,918	0 ------------- 330,113	0 ------------- 0
31Jeffrey OBrien MHAFmr Key Emp/VP Oncology	(i) (ii)	274,194 ------------- 0	0 ------------- 0	3,347 ------------- 0	21,298 ------------- 0	20,003 ------------- 0	318,842 ------------- 0	0 ------------- 0
32M Brooke Herndon MD MSTrustee	(i) (ii)	0 ------------- 213,411	0 ------------- 17,801	0 ------------- 414	0 ------------- 46,496	0 ------------- 17,985	0 ------------- 296,107	0 ------------- 0
33Richard J Powell MDTrustee end 12/31/15	(i) (ii)	0 ------------- 383,501	0 ------------- 60,750	0 ------------- 22,077	0 ------------- 99,353	0 ------------- 17,848	0 ------------- 583,529	0 ------------- 0
34Richard Rothstein MDTrustee end 12/31/15	(i) (ii)	0 ------------- 553,973	0 ------------- 0	0 ------------- 2,927	0 ------------- 52,990	0 ------------- 18,874	0 ------------- 628,764	0 ------------- 0
35Steven A Paris MDTrustee end 12/31/15	(i) (ii)	0 ------------- 349,732	0 ------------- 0	0 ------------- 25,965	0 ------------- 39,937	0 ------------- 13,699	0 ------------- 429,333	0 ------------- 0
36John Birkmeyer MDChf Clncl Offr/EVP Entprs Sup	(i) (ii)	0 ------------- 790,937	0 ------------- 0	0 ------------- 534	0 ------------- 39,415	0 ------------- 20,127	0 ------------- 851,013	0 ------------- 0
37Gay Landstrom PhD RN NEA-BCChief Nursing Officer	(i) (ii)	544,531 ------------- 0	50,000 ------------- 0	2,711 ------------- 0	26,823 ------------- 0	17,247 ------------- 0	641,312 ------------- 0	0 ------------- 0
38Kimberly Troland JDFmr Intrm GC/Deputy Gen Cnsl	(i) (ii)	351,563 ------------- 0	20,000 ------------- 0	161 ------------- 0	21,239 ------------- 0	17,747 ------------- 0	410,710 ------------- 0	0 ------------- 0
39Robert Greene MD MHCDS FACPChf Popul Mgmt Ofr	(i) (ii)	0 ------------- 544,537	0 ------------- 0	0 ------------- 13,306	0 ------------- 20,823	0 ------------- 17,848	0 ------------- 596,514	0 ------------- 0
40John Kacavas JDChief Legal Officer	(i) (ii)	242,170 ------------- 0	0 ------------- 0	255 ------------- 0	18,978 ------------- 0	10,964 ------------- 0	272,367 ------------- 0	0 ------------- 0
41Maria Padin MDChf Med Ofcr eff 11/9/15	(i) (ii)	0 ------------- 362,321	0 ------------- 0	0 ------------- 10,041	0 ------------- 165,640	0 ------------- 17,799	0 ------------- 555,801	0 ------------- 0
42Peter D Solberg MDChf Med Info Ofcr eff. 9/2/15	(i) (ii)	0 ------------- 333,774	0 ------------- 0	0 ------------- 5,949	0 ------------- 37,139	0 ------------- 11,599	0 ------------- 388,461	0 ------------- 0
43Kevin Donovan MHACEO - WHC end 6/14/16	(i) (ii)	303,563 ------------- 0	0 ------------- 0	4,713 ------------- 0	39,743 ------------- 0	20,040 ------------- 0	368,059 ------------- 0	0 ------------- 0
44Karen Clements RN BSN MSB FACActg Chf Nrsg Ofr eff 6/15/16	(i) (ii)	158,112 ------------- 0	0 ------------- 0	201 ------------- 0	10,694 ------------- 0	7,780 ------------- 0	176,787 ------------- 0	0 ------------- 0
45Thomas J SiepkaChief Pharmacy Offr Eff 1/4/16	(i) (ii)	196,691 ------------- 0	15,000 ------------- 0	5,176 ------------- 0	14,891 ------------- 0	1,245 ------------- 0	233,003 ------------- 0	0 ------------- 0
46Jeffrey A Cohen MDTrustee eff. 12/4/15	(i) (ii)	0 ------------- 382,972	0 ------------- 0	0 ------------- 19,464	0 ------------- 115,884	0 ------------- 20,127	0 ------------- 538,447	0 ------------- 0
47Timothy D Scherer MDTrustee eff. 12/4/15	(i) (ii)	0 ------------- 485,809	0 ------------- 0	0 ------------- 14,441	0 ------------- 45,581	0 ------------- 17,859	0 ------------- 563,690	0 ------------- 0
48Brian C Spence MD MHCDSTrustee eff. 12/4/15	(i) (ii)	0 ------------- 315,850	0 ------------- 89,300	0 ------------- 14,697	0 ------------- 24,812	0 ------------- 20,051	0 ------------- 464,710	0 ------------- 0

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

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

Return Reference	Explanation
Chartered Travel Services	Form 990, Schedule J, Part I - Line 1a FROM TIME TO TIME, THE ORGANIZATION PROVIDES CHARTERED TRAVEL SERVICES TO THE CEO. THE COST OF PROVIDING THE CHARTERED SERVICE HAS BEEN DEEMED A COST-EFFICIENT MANNER TO ALLOW THE OFFICER TO WORK WHILE TRAVELING VERSUS THE TIME LOST DRIVING, ETC. THIS EXPENSE HAS BEEN DEEMEND AN ORDINARY AND NECESSARY BUSINESS EXPENSE AND NON-TAXABLE TO THE RECIPIENT. ALL REQUESTS ARE APPROVED BEFORE PAYMENT TO ENSURE COMPLIANCE WITH INTERNAL POLICIES. Health or Social Club Dues & Fees Form 990, Schedule J, Part I - Line 1a The Organization has in place a Management Self Development Plan (MSDP) designed to promote professional and personal development. The MSDP is capped at 2% of gross pay and may be utilized for expenses such as professional dues, meetings and seminars, tuition reimbursement, and other miscellaneous items that promote professional knowledge. The monies may also be used for up to a 50% reimbursement of the cost of a fitness/wellness program designed to maintain the health of management personnel. All expenses are submitted for approval before reimbursement.
Severance Payments	Form 990, Schedule J, Part I, Line 4a The following listed individuals received Severance and/or change in control payments during calendar year 2015: DURING CALENDAR YEAR 2015, FORMER CHIEF INNOVATION OFFICER TERRENCE CARROLL RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $169,229 FROM DARTMOUTH-HITCHCOCK. THESE MONTHLY PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2015, FORMER CHIEF CLINICAL OFFICER CLIFFORD BELDEN RECEIVED A ONE-TIME $123,333 SEVERANCE PAYMENT FROM DARTMOUTH-HITCHCOCK. THE PAYMENT IS INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. FORM 990, SCHEDULE J, PART I LINE 4A DURING 2012, THOMAS COLACCHIO TRANSITIONED FROM AN OFFICER ROLE TO A STAFF PHYSICIAN ROLE. AS PART OF THIS TRANSITION, THOMAS COLACCHIO RECEIVED A $320,000 CHANGE OF CONTROL PAYMENT FROM DARTMOUTH-HITCHCOCK IN 2015. THE PAYMENT IS INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. Supplemental Nonqualified Retirement Plan SCHEDULE J, PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (WHICH ARE REFLECTED IN SCHEDULE J, PART II, COLUMN B (III)): James Weinstein $90,829 Robin Kilfeather-Mackey $16,500 Daniel Jantzen $75,081 Stephen Leblanc $109,692 John Butterly $41,875 Edward Merrens $15,775 George Blike $39,930 Mary Oseid $11,722 Bruce King $6,342 Thomas Colacchio $88,815 Clifford Belden $43,010 Richard Rothstein $1,307 Thomas Dodds $30,913 Wendy Wells $19,679 Jocelyn Chertoff $28,862 Edward Catherwood $881 Jeffrey OBrien $1,815 Martin Purcell $17,439 Roderic Young $4,576 Vincent Fusca III $5,587 John Malanowski $18,230 Terrence Carroll $60,398 Richard Powell $20,775 Steven Paris $17,319 Gay Landstrom $1,211 Robert Greene $11,212 Maria Padin $9,531 Peter Solberg $5,679 Kevin Donovan $4,713 Barbara C. Jobst $10,409 Dartmouth-Hitchcock Supplemental Retirement Plan Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the Plans for the plan year, but are limited by IRC Section 401(a)(17) and/or 415. For eligible employees, the Employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. MHMH sponsors a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen in 1998 and therefore no further costs of the individual employee insurance premiums have been funded by the organization. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization.
Note regarding compensation	Schedule J, part II Column B, parts I, II, and III represent actual amounts paid to employees by MHMH. These amounts are reported to employees on their annual W-2 forms as compensation. Columns C and D represent items earned, however, not paid directly to the employee as cash payments during the calendar year. Column C includes retirement benefits as well as any changes in pension actuarial value (if applicable) in a calendar year. Column D represents nontaxable benefits such as the cost of healthcare coverage provided by D-H on behalf of its employees.

Schedule J (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization
Mary Hitchcock Memorial Hospital

Employer identification number
02-0222140

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	644614YU7	08-19-2009	134,661,088	CURRENT REFUND 2008 (A),(B),(C)		X		X		X
B	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	644614G29	06-16-2010	73,647,839	CONSTR. OF FACILITY AND EQUIP		X		X		X
C	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	000000000	11-28-2012	116,170,000	CURRENT REFUND 2002		X		X		X
D	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	000000000	08-13-2014	41,242,990	REFUNDED PORTION OF 2009 ISSUE DAT		X		X		X
	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	000000000	09-01-2015	35,785,218	REFUND ISSUE DATED 8/31/2011		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	71,550,000		0		3,550,000		0
2 Amount of bonds legally defeased ..............	0		0		0		0
3 Total proceeds of issue ..................	134,661,088		73,666,926		116,170,000		41,242,990
4 Gross proceeds in reserve funds .............	0		0		0		0
5 Capitalized interest from proceeds .............	0		3,766,049		0		0
6 Proceeds in refunding escrows ...............	0		0		0		0
7 Issuance costs from proceeds ...............	2,273,111		1,168,560		520,000		352,990
8 Credit enhancement from proceeds .............	0		0		0		0
9 Working capital expenditures from proceeds .............	0		0		0		0
10 Capital expenditures from proceeds .............	0		68,732,317		0		0
11 Other spent proceeds .............	132,387,977		0		115,650,000		40,890,000
12 Other unspent proceeds .............	0		0		0		0
13 Year of substantial completion .............	2010		2012		2013
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? ....	X			X	X		X
15 Were the bonds issued as part of an advance refunding issue? .....		X		X		X		X
16 Has the final allocation of proceeds been made? ..........	X		X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X		X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X		X				X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X		X				X

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

Cat. No. 50193E

Schedule K (Form 990) 2015

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............		X		X				X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? .............		X		X				X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0 %		0 %		0 %		0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........
6 Total of lines 4 and 5 .............
7 Does the bond issue meet the private security or payment test? ...		X		X				X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X				X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............		X		X				X
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X		X				X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X		X		X		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X		X	X		X
b Exception to rebate? ........	X			X		X		X
c No rebate due? .........		X	X			X		X
If "Yes" to line 2c, provide in Part VI the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....		X		X		X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X		X		X
b Name of provider ..........	0		0		0		0
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2015

Page 3

Part IV

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X		X		X		X
b Name of provider ..........	0		0		0		0
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X		X		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...	X		X		X		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?	X		X		X		X

Part VI

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

Return Reference	Explanation
IRS FORM 990, SCHEDULE K, PART I, COLUMN F, ADDITIONAL INFORMATION	LINE A: CURRENT REFUND 2008 (A), ISSUED 9/4/08, WHICH ADVANCE REFUNDS 1985 CURRENT REFUND 2008 (B), ISSUED 10/31/08, WHICH ADVANCED REFUNDS 1993 CURRENT REFUND 2008 (C), ISSUED 12/19/08 IRS FORM 990, SCHEDULE K, PART II, LINE 11, COLUMN B
OTHER SPENT PROCEEDS	IRS FORM 990, PART II, COLUMN A, LINE 11 THE OTHER SPENT PROCEEDS ARE THE REFUNDING PROCEEDS OF THE ISSUE THAT ARE NO LONGER IN ESCROW PRIVATE BUSINESS USE IRS FORM 990, SCHEDULE K, PART III, COLUMN A THE 2015 SERIES, THROUGH OF A SERIES OF REFUNDINGS, REFUNDS ISSUES DATED PRIOR TO 12/31/2002 AND THEREFORE IS EXEMPT FROM PART III REPORTING

Schedule K (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization
Mary Hitchcock Memorial Hospital

Employer identification number
02-0222140

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	644614YU7	08-19-2009	134,661,088	CURRENT REFUND 2008 (A),(B),(C)		X		X		X
B	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	644614G29	06-16-2010	73,647,839	CONSTR. OF FACILITY AND EQUIP		X		X		X
C	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	000000000	11-28-2012	116,170,000	CURRENT REFUND 2002		X		X		X
D	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	000000000	08-13-2014	41,242,990	REFUNDED PORTION OF 2009 ISSUE DAT		X		X		X
	NH HEALTH & ED FACILITIES AUTHORITY	02-0279866	000000000	09-01-2015	35,785,218	REFUND ISSUE DATED 8/31/2011		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	71,550,000		0		3,550,000		0
2 Amount of bonds legally defeased ..............	0		0		0		0
3 Total proceeds of issue ..................	134,661,088		73,666,926		116,170,000		41,242,990
4 Gross proceeds in reserve funds .............	0		0		0		0
5 Capitalized interest from proceeds .............	0		3,766,049		0		0
6 Proceeds in refunding escrows ...............	0		0		0		0
7 Issuance costs from proceeds ...............	2,273,111		1,168,560		520,000		352,990
8 Credit enhancement from proceeds .............	0		0		0		0
9 Working capital expenditures from proceeds .............	0		0		0		0
10 Capital expenditures from proceeds .............	0		68,732,317		0		0
11 Other spent proceeds .............	132,387,977		0		115,650,000		40,890,000
12 Other unspent proceeds .............	0		0		0		0
13 Year of substantial completion .............	2010		2012		2013
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? ....	X			X	X		X
15 Were the bonds issued as part of an advance refunding issue? .....		X		X		X		X
16 Has the final allocation of proceeds been made? ..........	X		X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X		X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X		X				X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X		X				X

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

Cat. No. 50193E

Schedule K (Form 990) 2015

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............		X		X				X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? .............		X		X				X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0 %		0 %		0 %		0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........
6 Total of lines 4 and 5 .............
7 Does the bond issue meet the private security or payment test? ...		X		X				X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X				X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............		X		X				X
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X		X				X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X		X		X		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X		X	X		X
b Exception to rebate? ........	X			X		X		X
c No rebate due? .........		X	X			X		X
If "Yes" to line 2c, provide in Part VI the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....		X		X		X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X		X		X
b Name of provider ..........	0		0		0		0
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2015

Page 3

Part IV

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X		X		X		X
b Name of provider ..........	0		0		0		0
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X		X		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...	X		X		X		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?	X		X		X		X

Part VI

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

Return Reference	Explanation
IRS FORM 990, SCHEDULE K, PART I, COLUMN F, ADDITIONAL INFORMATION	LINE A: CURRENT REFUND 2008 (A), ISSUED 9/4/08, WHICH ADVANCE REFUNDS 1985 CURRENT REFUND 2008 (B), ISSUED 10/31/08, WHICH ADVANCED REFUNDS 1993 CURRENT REFUND 2008 (C), ISSUED 12/19/08 IRS FORM 990, SCHEDULE K, PART II, LINE 11, COLUMN B
OTHER SPENT PROCEEDS	IRS FORM 990, PART II, COLUMN A, LINE 11 THE OTHER SPENT PROCEEDS ARE THE REFUNDING PROCEEDS OF THE ISSUE THAT ARE NO LONGER IN ESCROW PRIVATE BUSINESS USE IRS FORM 990, SCHEDULE K, PART III, COLUMN A THE 2015 SERIES, THROUGH OF A SERIES OF REFUNDINGS, REFUNDS ISSUES DATED PRIOR TO 12/31/2002 AND THEREFORE IS EXEMPT FROM PART III REPORTING

Schedule K (Form 990) 2015

Additional Data

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Software Version:

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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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I

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

1(a) Name of disqualified person	(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
(1) DANIEL JANTZEN	Officer	SPLIT DOLLAR LIFE		X	113,178	113,178		No	Yes		Yes
(2) Deborah Jantzen	Family Member	Split Dollar Life		X	55,779	55,779		No	Yes		Yes








Total ............... $						168,957

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
(1) Christine Schon	Key Employee	35,298	Scholarship	Masters degree program
(2) Jeffrey Obrien	Former Key Employee	68,748	Scholarship	Masters degree program

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) Vincent Fusca III	Officer Fusca II	112,381	Family member employed by MHMH		No
(2) Linda Billings	Former KE Mary Oseid	92,247	Family member employed by MHMH		No
(3) Richard Alfred Powell	Trustee Powell	15,784	Family member employed by MHMH		No

Part V

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

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

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SCHEDULE M
(Form 990)

Department of the Treasury

Internal Revenue Service

Noncash Contributions

Complete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image

Attach to Form 990.
Right pointing arrow large image

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I

Types of Property

	(a) Check if applicable	(b) Number of contributions or items contributed	(c) Noncash contribution amounts reported on Form 990, Part VIII, line 1g	(d) Method of determining noncash contribution amounts
1 Art—Works of art ....
2 Art—Historical treasures .
3 Art—Fractional interests ..
4 Books and publications ..
5 Clothing and household goods .......
6 Cars and other vehicles ..
7 Boats and planes ....
8 Intellectual property ...
9 Securities—Publicly traded .	X	10	525,439	Fair Market Value
10 Securities—Closely held stock .
11 Securities—Partnership, LLC, or trust interests ....
12 Securities—Miscellaneous ..
13 Qualified conservation contribution—Historic structures .....
14 Qualified conservation contribution—Other ...
15 Real estate—Residential .
16 Real estate—Commercial ..
17 Real estate—Other ...
18 Collectibles .....
19 Food inventory ...
20 Drugs and medical supplies .
21 Taxidermy ......
22 Historical artifacts ....
23 Scientific specimens ..
24 Archeological artifacts ...
25 Other ( )
26 Other ( )
27 Other ( )
28 Other ( )

Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement

Yes

30a

During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that

it must hold for at least three years from the date of the initial contribution, and which is not required to be used

for exempt purposes for the entire holding period? ..................

30a

If "Yes," describe the arrangement in Part II.

Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?

Yes

32a

Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash

contributions? ..........................

32a

Yes

If "Yes," describe in Part II.

If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,

describe in Part II.

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

Cat. No. 51227J

Schedule M (Form 990) (2015)

Page 2

Part II

Supplemental Information. Provide the information required by Part I, lines 30b, 32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.

Return Reference	Explanation
Schedule M, Part I, Column B	The organization reported the number of contributions received in column (b). Use of related organizations to solicit noncash donations Schedule M, Part I, Line 32B The organization uses Dartmouth-Hitchcock Health, MHMH's Parent Organization, for solicitation of contributions and annual fund activities. From time to time, the Hospital may receive non-cash contributions directly from its donors.

Schedule M (Form 990) (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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Return Reference	Explanation
Business relationships	Form 990, Part VI, Section A, Line 2 Mary Hitchcock Memorial Hospital owns for-profit subsidiaries that provide services and support the mission of the organization. The following are current officers, directors, trustees, or key employees of MHMH and officers of related for-profit entities: Daniel Jantzen - Hamden Assurance, ImagineCare, and Pompanoosuc Investment Corporation James Weinstein - Dartmouth Hitchcock Master Investment Plan John Kacavas - Dartmouth Hitchcock Master Investment Plan and Hamden Assurance Robert Greene - ImagineCare Robin Kilfeather-Mackey - Hamden Assurance, ImagineCare, and Pompanoosuc Investment Corporation Vincent Fusca III - ImagineCare Description of classes of members, persons, and the nature of their rights Form 990, Part VI, Section A, Line 6 & 7a Dartmouth-Hitchcock Health (D-HH) is the sole corporate Member of Mary Hitchcock Memorial Hospital (MHMH). D-HH has specific authority and reserved powers, including the power to confirm the election of members of MHMH's Board of Trustees and the power to approve significant governance, financial and operational decisions of MHMH's Trustees. Governance decisions reserved to or subject to approval by persons other than the governing body Form 990, Part VI, Section A, Line 7B In addition to reserved powers, Dartmouth-Hitchcock Health (D-HH) shall have the authority to take actions to establish, manage, and govern the System as an integrated health care delivery system in furtherance of the mission of the Hospital and other Organizations. These powers include but are not limited to items such as the ability to approve, disapprove or modify all material governance, programmatic and financial decisions of MHMH's Board of Trustees, to appoint or remove a member of the Hospital's Board of Trustees, assess the Hospital a monetary amount for the payment of the expenses of D-HH, approve the Hospital's budget, approve the borrowings or dispositions of assets by the Hospital, approve key strategic relationships, approve the elimination or addition of any material health care service or program, and other authority to take action on behalf of the Hospital.
Process used by management and/or Governing Body to Review 990	Form 990, Part VI, Section B, Line 11b THE FORMS 990 AND 990-T ARE REVIEWED BY THE DIRECTOR OF CORPORATE FINANCE, VICE PRESIDENT OF CORPORATE FINANCE, AND THE CHIEF FINANCIAL OFFICER BEFORE THE FILING OF THE RETURN. ONCE THE RETURN HAS BEEN FULLY PREPARED A FINAL 990 AND 990-T COMPLETE ELECTRONIC VERSION IS SENT OUT TO EACH BOARD MEMBER AND TIME IS ALLOCATED FOR COMMENTS/RESPONSES PRIOR TO OFFICIAL FILING.
Conflict of Interest Policy	Form 990, Part VI, Section B, Line 12C The Mary Hitchcock Memorial Hospital BOARD OF TRUSTEES APPROVED A POLICY CONCERNING A VOLUNTARY SELF-DISCLOSURE OF ANY POTENTIAL CONFLICT OF INTEREST. THE DARTMOUTH-HITCHCOCK OFFICE OF POLICY SUPPORT, COMPLIANCE AND AUDIT SERVICES CONDUCTS AN ANNUAL SURVEY OF ALL OFFICERS, TRUSTEES, AND KEY EMPLOYEES AND PERFORMS OTHER PROCEDURES AS CONSIDERED NECESSARY TO REPORT ON COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT THEN REPORTS TO EACH BOARD ANY POTENTIAL CONFLICTS FOR THEIR REVIEW. PER THE POLICY, ANY CONFLICTS OR OTHERWISE PERCEIVED CONFLICTS ARE REQUIRED TO BE ADDRESSED BY THE BOARD OF TRUSTEEES ON AN ONGOING BASIS. IN THE EVENT A CONFLICT ARISES, THE INDIVIDUAL MAY BE REMOVED FROM PARTICIPATING IN ANY DECISION MAKING REGARDING THE IDENTIFIED CONFLICT AND/OR ITS CORRESPONDING TRANSACTIONS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION.
OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR UNDERTAKEN	Form 990, Part VI, Line 15a Although paid by a related organization, Dartmouth-Hitchcock Clinic, the Compensation for the President is evaluated by an independent third party firm for reasonableness and national data benchmarking. The Compensation Committee, along with Independent Trustees, approve the final compensation in consideration with the independent third party firm's recommendations and suggestions. This process was contemporaneously documented and last undertaken in 2016.
Offices & Positions for Which Process was Used & Year Undertaken	Form 990, Part VI, Line 15b Compensation for officers and key employees are evaluated by internal HR staff using national benchmarking data, along with ongoing evaluations by an independent third party firm for reasonableness, with the last formal process in 2012 (2016 for VP's and above). External benchmarking from an independent third party has been used for any Officer who was hired or received a compensation adjustment since the last formal process. Compensation rates are determined by following the guidelines of the compensation committee charter and philosophy documents and/or a formal review by compensation committee members.
Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public	Form 990, Part VI, Line 19 MHMH's governing documents are available through the New Hampshire Secretary of State. Certain financial information is disclosed through the Community Benefits Annual Report. The audited financial statements, governing documents, and conflict of interest policy are available upon request either in electronic or hardcopy form. Average Hours Per Week Form 990, Part VII, Section A, Line 1A, Column B As part of Dartmouth-Hitchcock Clinic and Mary Hitchcock Memorial Hospital's affiliation agreement, the two organizations share officers. As such, the average hours per week are allocated between the two organizations' 990's even though compensation reported in part VII is based on the entity issuing the W-2. In addition, certain officers spend time on Dartmouth-Hitchcock Health, the sole corporate member of both MHMH and DHC, along with three supporting organizations Dartmouth-Hitchcock Medical Center, Everwell, Inc., Hamden Risk Retention Group, and related entities: Alice Peck Day Memorial Hospital, Windsor Hospital Corporation (dba Mt Ascutney Hospital and Health Center), Mt Ascutney Hospital Community Health Foundation, Historic Homes of Runnemede, Cheshire Medical Center, Cheshire Health Foundation, Cheshire Health Services, The New London Hospital Association, and The Hitchcock Foundation. Statement of Functional Expenses Form 990, Part IX Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic operate under an affiliation agreement as directed by Dartmouth-Hitchcock Health, the sole Corporate Member of both entities. Due to the integrated operating structure, related mission, and close relationship of the two tax-exempt organizations, expenses are shared between the two entities. All expenses reported within this 990 are the organization's share of expenses as designated by the affiliation agreement.
Financial Statements and Reporting	Form 990, Part XI, Line 9 Other Changes in Net Assets Include: Pension-related changes: ($14,402,956) Unrealized Gain/Loss on Hedge and other ($1,924,482), Net Asset Transfer to Affiliates ($13,934,872) Total changes in net assets: ($30,262,310) Audited Financial Statements Form 990, Part XII, Line 2d The organization's financial information is included in the audited financial statements of Dartmouth-Hitchcock Health and Subsidiaries, which consists of the following organizations and their related subsidiaries: Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, Mt Ascutney Hospital and Health Center, Cheshire Medical Center, The New London Hospital Association, and Alice Peck Day Memorial Hospital.
A-133 Audit	Form 990 Part XII, Line 3A DURING FISCAL YEAR 2016, MARY HITCHCOCK MEMORIAL HOSPITAL EXPENDED FUNDS FROM FEDERAL AWARDS IN EXCESS OF THE $750,000 THRESHOLD SET FORTH IN THE OMB UNIFORM GUIDANCE, THEREFORE REQUIRING AN AUDIT.

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

Mary Hitchcock Memorial Hospital

Employer identification number

02-0222140

Part I

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

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity
(1) NEW ENGLAND ALLIANCE FOR HEALTH LLC ONE MEDICAL CENTER DRIVE LEBANON,NH03756 26-4232401	HLTH IMPROVMT	NH	6,879	1,729,900	MHMH
(2) D-H Specialty Services LLC One Medical Center Drive Lebanon,NH03756 46-0876427	Shd Svgs Prgm	NH	0	0	MHMH

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(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)DARTMOUTH-HITCHCOCK CLINIC ONE MEDICAL CENTER DRIVE LEBANON,NH03756 22-2519596	PHYSICIAN SVC	NH	501(c)(3)	9	D-HH	Yes
(2)DARTMOUTH-HITCHCOCK MEDICAL CENTER ONE MEDICAL CENTER DRIVE LEBANON,NH03756 22-2715483	SUPPORTNG ORG	NH	501(c)(3)	11 TYPE I	NA	Yes
(3)DARTMOUTH - HITCHCOCK HEALTH One Medical Center Drive Lebanon,NH03756 26-4812335	PARENT ORG	NH	501(C)(3)	7	NA		No
(4)HAMDEN RISK RETENTION GROUP INC 30 MAIN STREET STE 330 BURLINGTON,VT05401 20-8530788	Self Ins	VT	501(c)(3)	11 TYPE I	DHC	Yes
(5)The Hitchcock Foundation One Medical Center Drive Lebanon,NH03756 02-0222139	HLTHCRE RSRCH	NH	501(c)(3)	7	DHC	Yes
(6)EverWell Inc One Medical Center Drive Lebanon,NH03756 35-2506275	Supportng Org	NH	501(c)(3)	11 Type I	NA	Yes
(7)The New London Hospital Association Inc 273 County Rd New London,NH03257 02-0222171	Hospital	NH	501(c)(3)	3	D-HH	Yes
(8)Windsor Hospital Corporation 289 County Road Windsor,VT05089 03-0183721	Hospital	VT	501(C)(3)	3	D-HH	Yes
(9)Cheshire Medical Center 580 Court Street Keene,NH03431 02-0354549	Hospital	NH	501(C)(3)	3	D-HH	Yes
(10)Cheshire Health Foundation 580 Court Street Keene,NH03431 02-0202220	SUPPORTNG ORG	NH	501(C)(3)	11 TYPE I	CMC	Yes
(11)Mt Ascutney Hosp Cmmty Hlth Found 289 Country Road Windsor,VT05089 03-0300481	Foundation	VT	501(c)(3)	3	WHA	Yes
(12)Historic Homes of Runnemede 289 County Road Windsor,VT05089 23-7396147	Healthcare	VT	501(c)(3)	9	WHA	Yes
(13)Cheshire Health Services 580 Court Street Keene,NH03431 47-3379283	HEALTHCARE	NH	501(c)(3)	3	CMC	Yes
(14)Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon,NH03766 02-0222791	Hospital	NH	501(c)(3)	3	D-HH	Yes
(15)Surgery Center of Greater Nashua 10 Prospect Street Ste 101 Nashua,NH03060 46-1084049	Surgery Ctr	NH	501(c)(3)	3	N/A		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	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(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) D-H Mster Invst Prg 1 Med Ctr Dr LEBANON,NH03756 02-0205863	POOLED INVEST	NH	MHMH	EXCLUDED	10,286,001	515,113,296		No	-423,728	Yes		93.346 %
(2) KEENE HLTH ALLIANCE 580 Court St Keene,NH03431 30-0179297	Healthcare	NH	NA
(3) Obnet Services LLC 1 Med Ctr Dr Lebanon,NH03756 04-3746287	Database Serv	NH	NA
(4) One Care VT ACOLLC 111 COLCHESTER AVE Burlington,VT05401 45-5399218	Shared Saving	VT	NA

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(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) Charit Remndr Unitrusts (4) One Medical Center Drive Lebanon,NH03756	Chart. Trust	NH	MHMH	TRUST
(2) Pompanoosuc Investment Corp 1 Medical Ctr Dr Lebanon,NH03756 02-0352330	Real Est Hldg	NH	DHC	C Corporation				Yes
(3) Hamden Assurance Co Ltd 44 Church St Hamilton HM 12 BD 98-0121409	Liab. Insuanc	BD	DHC	Foreign Corp	0	2,878,669	25.800 %	Yes
(4) Hitchcock Health Connect 1 Medical Ctr Dr Lebanon,NH03756 80-0908979	Telehealth	DE	D-HH	C Corp				Yes
(5) Kearsarge Community Services Inc 273 County Road New London,NH03257 02-0460136	Real Est Hldg	NH	NLH	C Corp				Yes
(6) New London Physician Group Inc 273 County Road New London,NH03257 02-0494420	Physician Gro	NH	NLH	C Corp				Yes
(7) New London Medical Center East 273 County Road New London,NH03257 02-0480857	Real Est Hldg	NH	NLH	C Corp
(8) Keene Health Services 580 Court Street Keene,NH03431 02-0374997	Real Est Hldg	NH	CMC	C Corp				Yes
(9) Keene Health Realty 580 Court Street Keene,NH03431 02-0374998	Real Est Hldg	NH	CMC	C Corp				Yes
(10) Keene Health Enterprises 580 Court Street Keene,NH03431 02-0374999	Real Est Hldg	NH	CMC	C Corp				Yes

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

Yes

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

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

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

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

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

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) Dartmouth-Hitchcock Clinic	JKLMN	3,799,702	FMV
(2) Dartmouth-Hitchcock Medical Center	Q	130,690	FMV
(3) Hamden Risk Retention Group	O	3,254,274	FMV
(4) The Hitchcock Foundation	Q	1,318,408	FMV
(5) The New London Hospital Association	Q	1,466,451	FMV
(6) Windsor Hospital Association	Q	1,941,742	FMV
(7) Cheshire Medical Center	Q	6,472,034	FMV
(8) The New London Hospital Association	L	1,382,651	FMV
(9) Alice Peck Day Memorial Hospital	Q	232,203	FMV

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	Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes,"the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
2	Did the organization have an interest in a foreign trust during the tax year? If "Yes," the organization may be required to separately file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
3	Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471). . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
4	Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If “Yes,” the organization may be required to file Form 8621, Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621) .	Yes	No
5	Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
6	Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to separately file Form 5713, International Boycott Report (see Instructions for Form 5713).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No