Form990
Click to see attachment
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)
MediumBullet Do not enter social security numbers on this form as it may be made public.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
A For the 2019 calendar year, or tax year beginning 07-01-2017 , and ending 06-30-2018
BCheck if applicable:
CName of organization
Mary Hitchcock Memorial Hospital
 
% DANIEL P JANTZEN CPA
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 $ 1,472,986,592
F Name and address of principal officer:
Joanne M Conroy MD
One Medical Center Drive
Lebanon,NH03756
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.dartmouth-hitchcock.org
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:  
L Year of formation: 1889
M State of legal domicile: NH
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: Advancing Health Through Research, Education, Clinical Practice, Community Partnerships, providing each person the best care in the right place, at the right time,every time.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 19
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 14
5 Total number of individuals employed in calendar year 2019 (Part V, line 2a) ...... 5 5,988
6 Total number of volunteers (estimate if necessary) ............. 6 647
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 6,061,228
b Net unrelated business taxable income from Form 990-T, line 39 ......... 7b -788,673
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 41,242,528 29,386,191
9 Program service revenue (Part VIII, line 2g) ......... 1,095,054,593 1,152,052,585
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 20,952,650 33,767,195
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 25,430,069 45,841,245
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 1,182,679,840 1,261,047,216
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 2,744,685 3,236,772
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) 679,834,438 679,850,538
16a Professional fundraising fees (Part IX, column (A), line 11e) ..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet160,800    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 469,945,438 527,386,727
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 1,152,524,561 1,210,474,037
19 Revenue less expenses. Subtract line 18 from line 12....... 30,155,279 50,573,179
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 1,322,008,676 1,448,110,334
21 Total liabilities (Part X, line 26)............. 737,988,485 820,807,995
22 Net assets or fund balances. Subtract line 21 from line 20..... 584,020,191 627,302,339
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2019)
Form 990 (2019)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III..............
1
Briefly describe the organization’s mission: WE ADVANCE HEALTH THROUGH RESEARCH, EDUCATION, CLINICAL PRACTICE, AND COMMUNITY PARTNERSHIPS, PROVIDING EACH PERSON THE BEST CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, EVERY TIME.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? .....................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ...........................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 939,434,129 including grants of $ 3,236,772 ) (Revenue $ 1,153,048,582 )
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 major teaching hospital, a tertiary care referral hospital, and as a Prospective Payment System hospital (as defined by CMS). These include a full range of services in both acute and critical medicine, surgery, psychiatry and rehabilitation for infants, children and adults. During FY 2018 the Hospital provided 128,060 acute patient days of inpatient service and had 27,495 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 30,417 discharges. Dartmouth-Hitchcock 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. 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. Through formal affiliations and other clinical collaborations, the Hospital also seeks to partner with other area health care providers to improve the health status of the region. The Jack Byrne Center for Palliative & Hospice Care, coordinates the clinical, educational, and research efforts of the Hospital and visiting nurse alliances around the region, to offer much-needed care for patients at the end of life, in a clinical setting that meets the needs of patients and their families. The Hospital also continues to build its telemedicine program to provide care across its rural region and in particular to make specialist consultation and care available to community hospitals. This allows caregivers at remote locations to access specialists at Dartmouth-Hitchcock and bring them "virtually" to the patient's bedside. D-H's Connected Care Center in Lebanon offers a 24/7 team of physicians, pharmacists, and nurses supporting care in 40+ specialties to 11 facilities in New Hampshire and Vermont. Acute care telehealth service lines, currently include TeleEmergency, TelePharmacy, TeleNeurology, TeleICU, TelePsychiatry and TeleUrgentCare, and in FY18 a major partnership with Philips helped implement TeleICU services within intensive care units at Dartmouth-Hitchcock Medical Center and Cheshire Medical Center in Keene, NH. In an effort to integrate behavioral health and primary care, the Hospital continues to be the lead convener for the State of New Hampshire Delivery System Reform Incentive Program ("DSRIP") for the Region 1 Integrated Delivery Network. This program is funded through a section 1115 Waiver Research and Demonstration Transformation Waiver that the State of New Hampshire received from CMS. The Waiver Enables health care providers and community partners within a region to form relationships focused on transforming care, to combat the opioid crisis, and strengthen the state's strained mental health system. This work began in July 2016 and will continue through December 31, 2020. In addition to the Hospital, Dartmouth-Hitchcock Clinic and Cheshire Medical Center are playing leadership roles in this initiative. The Hospital files an annual Community Benefits Report with the State of New Hampshire which outlines the community and charitable benefits they provide. The most recent Community Benefits Reports are available upon request or can be found on Dartmouth-Hitchcock's website. 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, 2018 the Hospital provided financial assistance to 5,417 patients in the amount of $17,303,324 as measured by gross charges. The estimated cost of providing this care for the year ended June 30, 2018 was $6,760,409. 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 debt, which is not included in the amounts reported above. During the year ended June 30, 2018, the Hospital reported a provision for bad debt of $15,586,818.
4b (Code:   ) (Expenses $ 53,652,814 including grants of $   ) (Revenue $ 35,345,645 )
As a component of New Hampshire's only integrated academic medical center, the Hospital provides the Geisel School of Medicine at Dartmouth (GSM) 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. In FY18, Dartmouth-Hitchcock continued the transition of research activities and management from the Geisel School to D-H, under the leadership of the Vice President for Research Operations, developing the research enterprise.
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet993,086,943
Form 990 (2019)
Form 990 (2019)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part IClick to see attachment.............
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part IIClick to see attachment.........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part IIIClick to see attachment..
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part IClick to see attachment.........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part IIClick to see attachment....
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part IIIClick to see attachment..............
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part V......
10
 
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete
Schedule D, Part VI. Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIClick to see attachment.......
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XIIClick to see attachment......................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States? .....
14a
Yes
 
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....Click to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I(see instructions) ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see list of attachments
20b
Yes
 
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....Click to see attachment
21
Yes
 
Form 990 (2019)
Form 990 (2019)
Page 4
Part IV
Checklist of Required Schedules (continued)
Yes
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........Click to see attachment
22
Yes
 
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............
24c
 
No
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I .... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I.......................Click to see attachment
25b
 
No
26
Did the organization report any amount on Part X, line 5 or 22 for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part IIClick to see attachment...........
26
Yes
 
27
Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?
If "Yes," complete
Schedule L, Part IIIClick to see attachment.........................
27
Yes
 
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................Click to see attachment
28a
Yes
 
b
A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....Click to see attachment
28b
Yes
 
c
A 35% controlled entity of one or more individuals and/or organizations described in lines 28a or 28b? If "Yes," complete Schedule L, Part IV.....................
28c
 
 
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..Click to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M .................Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II........................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I............Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1.........................Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ...Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable ..
1a
1,104
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
Form 990 (2019)
Form 990 (2019)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance (continued)
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
5,988
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..
4a
Yes
 
b
If "Yes," enter the name of the foreign country: MediumBulletBD
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................
7a
Yes
 
b
If "Yes," did the organization notify the donor of the value of the goods or services provided? .....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?........
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state? .........
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
15
Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see instructions and file Form 4720, Schedule N.
15
 
 
16
Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.
16
 
 
Form 990 (2019)
Form 990 (2019)
Page 6
Part VI
Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
1a
19
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
1b
14
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? .
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .......................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done...................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
Yes
 
Section C. Disclosure
17
List the states with which a copy of this Form 990 is required to be filedMediumBullet
NH
18
Section 6104 requires an organization to make its Form 1023 (or 1024-A if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletDANIEL P JANTZEN CPAONE MEDICAL CENTER DRIVE   Lebanon,NH03756 (603) 650-5634
Form 990 (2019)
Form 990 (2019)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

See instructions for the order in which to list the persons above.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) Vincent S Conti MHA......................................................................
Trustee
 0.75
.................
1.25 		X           0 0 0
(2) Anne-Lee Verville......................................................................
Trustee/Board Chair
 1.5
.................
2.5 		X   X       0 0 0
(3) Barbara Couch MS......................................................................
Trustee/Board Secretary
 1.5
.................
2.5 		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
 1.5
.................
2.5 		X   X       0 0 0
(6) James N Weinstein DO MS......................................................................
Trstee Ex-Off/CEO end 7/2/17
 38.55
.................
22.96 		X   X       0 3,173,507 113,137
(7) Denis A Cortese MD......................................................................
Trustee ends 6/23/18
 0.75
.................
1.25 		X           0 0 0
(8) Senator Judd A Gregg......................................................................
Trustee
 0.75
.................
0.75 		X           0 0 0
(9) Laura K Landy MBA......................................................................
Trustee
 0.75
.................
1.25 		X           0 0 0
(10) Paul P Danos PhD......................................................................
Trustee
 0.75
.................
1.25 		X           0 0 0
(11) Troyen Brennan MD MPH......................................................................
Trustee ends 7/31/17
 0.75
.................
1.25 		X           0 0 0
(12) Duane A Compton PhD......................................................................
Trustee/Ex-Officio
 0.75
.................
1.56 		X           0 0 0
(13) M Brooke Herndon MD MS......................................................................
Trustee/Physician end 12/31/17
 28.0
.................
12.0 		X           0 208,792 63,175
(14) Charles G Plimpton MBA......................................................................
Trustee/Board Treasurer
 1.5
.................
2.5 		X   X       0 0 0
(15) Jeffrey A Cohen MD......................................................................
Trustee/VP Service Line
 28.0
.................
15.0 		X           0 437,776 88,112
(16) Timothy D Scherer MD......................................................................
Trustee end 12/13/17 Physician
 28.0
.................
12.0 		X           0 519,777 81,712
(17) Brian C Spence MD MHCDS......................................................................
Trustee/Staff Physician
 28.0
.................
12.0 		X           0 461,954 49,478
Form 990 (2019)
Form 990 (2019)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) Kari M Rosenkranz MD........................................................................
Trustee/Physician
 28.0
.......................12.0 		X           0 545,731 29,955
(19) Cherie Holmes MD........................................................................
Trustee eff 3/15/18
 28.0
.......................13.0 		X           0 422,507 144,417
(20) Edward H Stansfeild III MA........................................................................
Trustee eff 7/1/17
 0.75
.......................1.75 		X           0 0 0
(21) Joanne M Conroy MD........................................................................
Ttee eff 8/7/17 Ex-Officio CEO
 37.8
.......................22.21 		X   X       0 412,873 6,750
(22) Pamela Thompson MS RNCENP FAAN........................................................................
Trustee eff 7/1/17
 0.75
.......................1.25 		X           0 0 0
(23) Jon Wahrenberger MD FAHA FACC........................................................................
Trustee eff 1/1/18
 0.75
.......................0.75 		X           0 0 0
(24) Marc B Wolpow JD MBA........................................................................
Trustee eff 1/1/18
 0.75
.......................1.25 		X           0 0 0
(25) Daniel P Jantzen CPA........................................................................
Chief Financial Officer
 39.0
.......................24.01 		    X       719,087 0 138,886
(26) Stephen Leblanc........................................................................
Chief Strategy Officer
 39.0
.......................23.01 		    X       0 790,399 221,976
(27) Edward Merrens MD........................................................................
Chief Clinical Officer
 42.0
.......................20.0 		    X       0 672,063 66,216
(28) Maria Padin MD........................................................................
Chief Medical Officer
 42.0
.......................20.0 		    X       0 399,509 275,686
(29) Sowmya Viswanathan MD........................................................................
Chief ACO Officer end 12/2/17
 42.0
.......................18.0 		    X       0 362,126 38,957
(30) Susan A Reeves EdD RN........................................................................
Chief Nursing Officer
 42.0
.......................18.0 		    X       197,910 0 28,709
(31) Patrick Jordan III MBA........................................................................
Chief Oper Offcr eff 11/20/17
 39.0
.......................22.0 		    X       46,154 0 2,396
(32) Vincent Fusca III........................................................................
Chief of Staff
 28.0
.......................13.0 		      X     151,957 0 7,742
(33) George Blike MD........................................................................
Chief Quality & Value Officer
 28.0
.......................14.0 		      X     0 479,654 354,998
(34) John S Malanowski MILR........................................................................
Chief HR Officer
 42.0
.......................18.0 		      X     603,227 0 28,569
(35) Jocelyn Chertoff MD........................................................................
Vp Srvc Ln /Dpt Chr Dgnstc Rad
 28.0
.......................12.0 		      X     0 575,548 112,602
(36) Jeffrey OBrien MHA........................................................................
Vp Clinical Operations
 28.0
.......................13.0 		      X     316,013 0 42,316
(37) John Kacavas JD........................................................................
Chief Legal Officer
 28.0
.......................13.0 		      X     540,763 0 39,936
(38) Peter D Solberg MD........................................................................
Chf Medical Information Ofcr
 28.0
.......................12.0 		      X     0 375,458 47,473
(39) Karen Clements RN BSN MSB FACHE........................................................................
Chief Nursing Officer
 28.0
.......................12.0 		      X     364,122 0 29,270
(40) Thomas J Siepka........................................................................
Chief Pharm Offcr end 4/7/18
 28.0
.......................12.0 		      X     308,821 0 22,578
(41) Aimee M Giglio........................................................................
Chief HR Officer
 28.0
.......................13.0 		      X     296,409 0 33,978
(42) Sandra Wong MD........................................................................
Chief ACO Officer
 28.0
.......................12.0 		      X     0 714,002 29,956
(43) Staci Hermann PharmD MS........................................................................
Int Chief Pharm Off eff 4/8/18
 28.0
.......................12.0 		      X     170,080 0 14,644
(44) Simon Hillier........................................................................
Dept Chair - Anesthesiology
 28.0
.......................12.0 		      X     0 512,380 43,349
(45) Bruce King MSPH FHFMA........................................................................
Pres & CEO New London Hosp
 0.0
.......................50.0 		        X   358,188 0 72,711
(46) Martin Purcell MBA........................................................................
VP IS Operations
 28.0
.......................12.0 		        X   352,706 0 142,253
(47) Kimberly Troland JD........................................................................
Deputy Gen Counsel
 28.0
.......................12.0 		        X   377,488 0 39,937
(48) David Gladstone MD........................................................................
Chf Clncl Physcn - Radiology
 28.0
.......................12.0 		        X   334,544 0 91,837
(49) Leigh Burgess........................................................................
VP Research Ops
 28.0
.......................12.0 		        X   310,409 0 30,005
(50) Robin Kilfeather-Mackey CPA........................................................................
Former CFO
 0.0
.......................0.0 		          X 0 313,945 0
(51) Darlene A Saler MBA RN........................................................................
Frmr Actg Chf Nrsg Ofr
 28.0
.......................13.0 		          X 121,330 0 71,702
(52) Richard Rothstein MD........................................................................
Dept Chair/Srvc Ln Ldr - Med
 0.0
.......................40.0 		          X 0 559,912 77,875
(53) John Birkmeyer MD........................................................................
Former CCO/EVP Entprs Sp
 42.0
.......................19.0 		          X 0 488,625 0
(54) Mary Oseid MHCDS........................................................................
Fmr Key Emp/VP Enterprise Svcs
 28.0
.......................13.0 		          X 0 259,438 362,997
(55) Christine Schon MPA........................................................................
Fmr Key Emp/Adm VP Prmry Care
 0.0
.......................40.0 		          X 0 274,101 42,542
(56) Tina Naimie CPA MHCDS........................................................................
Fmr Key Emp/VP Corp Finance
 28.0
.......................13.01 		          X 252,623 0 21,010
(57) Wendy Fielding MBA........................................................................
Fmr Key Emp/VP Finance Plnning
 28.0
.......................13.0 		          X 244,771 0 40,257
(58) Thomas Dodds MD........................................................................
Former Key Emp/Dept Chr Anesth
 28.0
.......................12.0 		          X 0 269,748 142,174
(59) Wendy Wells MD........................................................................
Fmr Key Emp/Dpt Chr Pathology
 28.0
.......................12.0 		          X 0 496,818 165,100
(60) Edward Catherwood MD MS........................................................................
Former Key Emp/Ctr Dir Hrt/Vsc
 28.0
.......................12.0 		          X 0 328,372 58,389
(61) Steven Boyce........................................................................
Fmr Key Emp/Adm. VP Med Spclts
 28.0
.......................12.0 		          X 0 243,090 72,123
(62) Robert Greene MD MHCDS FACP........................................................................
Fmr Chf Popul Mgmt Ofr
 28.0
.......................12.0 		          X 0 480,015 14,827
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)...........MediumBullet 6,066,602 14,778,120 3,602,712
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet426
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
TRUSTEES OF DARTMOUTH COLLEGE,
37 DEWEY FIELD
HANOVER,NH03755 		ADMIN & DIR SUPPORT 8,762,503
Conifer Revenue Cycle Solutions LL,
1500 S Douglass Road Ste 200
ANAHEIM,CA92806 		Revenue Mgmt 31,957,770
American Healthcare Services Associ,
PO Box 945
TRAVERSE CITY,MI49685 		Staffing Services 7,980,163
PC Contruction Company,
193 Tilley Drive
SOUTH BURLINGTON,VT05403 		Contruction Services 14,184,366
Cross Country Staffing,
PO BOX 404674
ATLANTA,GA303844674 		Staffing Services 4,168,083
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet122
Form 990 (2019)
Form 990 (2019)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII.............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512 - 514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues..1b  
c Fundraising events..1c  
d Related organizations1d  
e Government grants (contributions)1e 18,403,057
f All other contributions, gifts, grants, and similar amounts not included above1f 10,983,134
g Noncash contributions included in lines 1a - 1f:$ 1g 258,450
h Total. Add lines 1a-1f.......MediumBullet 29,386,191
Program Service RevenueAmt Business Code
2a NET PATIENT SERVICE REVENUE 621110 1,079,812,804 1,078,610,276 1,202,528  
b RESEARCH RELATED ACTIVITIES 621110 9,576,531 9,576,531    
c PHARMACY INCOME 621110 62,663,250 62,524,127 139,123  
d
e
f All other program service revenue.        
g Total. Add lines 2a–2f .....MediumBullet 1,152,052,585
OtherAmtRevenueAmt 3 Investment income (including dividends, interest, and othersimilar amounts) ......MediumBullet 10,628,372   -213,709 10,842,081
4 Income from investment of tax-exempt bond proceedsMediumBullet 0      
5 Royalties...........MediumBullet 0      
(ii) Personal (i) Real
6a Gross rents   819,623 6a
b Less: rental expenses   580,171 6b
c Rental income or (loss) 0 239,452 6c
d Net rental income or (loss).......MediumBullet 239,452     239,452
(ii) Other (i) Securities
7a Gross amount from sales of assets other than inventory   234,498,048 7a
b Less: cost or other basis and sales expenses 2,335 211,356,870 7b
c Gain or (loss) -2,335 23,141,178 7c
d Net gain or (loss).........MediumBullet 23,138,823     23,138,823
8a Gross income from fundraising events (not including $   of contributions reported on line 1c). See Part IV, line 18 ....
8a 0
b Less: direct expenses ... 8b 0
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
9a 0
b Less: direct expenses ... 9b 0
c Net income or (loss) from gaming activities..MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances ..
10a 0
b Less: cost of goods sold .. 10b 0
c Net income or (loss) from sales of inventory..MediumBullet 0      
Business Code Miscellaneous Revenue
11a MEANINGFUL USE 621110 326,256 326,256    
b NEAH AND PROGRAM RELATED INVESTMENTS 621110 2,167,383 1,000,644 1,166,739  
c CAFETERIA 621110 2,985,214     2,985,214
d All other revenue .... 40,122,940 36,356,393 3,766,547  
e Total. Add lines 11a–11d ...... MediumBullet 45,601,793
12 Total revenue. See instructions.....MediumBullet 1,261,047,216 1,188,394,227 6,061,228 37,205,570
Form 990 (2019)
Form 990 (2019)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX..............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising
expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 1,852,250 1,852,250
2 Grants and other assistance to domestic individuals. See Part IV, line 22 ........... 1,384,522 1,384,522
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. ............. 0  
4 Benefits paid to or for members ....... 0  
5 Compensation of current officers, directors, trustees, and key employees ........... 11,710,343 3,801,559 7,748,579 160,205
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ......... 8,537,758   8,537,758  
7 Other salaries and wages........ 532,245,573 463,756,570 68,489,003  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 31,429,952 27,385,567 4,044,385  
9 Other employee benefits ....... 60,790,493 52,968,013 7,822,480  
10 Payroll taxes ........... 35,136,419 30,615,088 4,521,331  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 1,686,541 130,602 1,555,939  
c Accounting ........... 577,500   577,500  
d Lobbying ........... 27,650   27,650  
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) 82,489,409 70,152,967 12,336,442  
12 Advertising and promotion .... 2,823,921 79,797 2,744,124  
13 Office expenses ....... 11,970,834 9,260,895 2,709,939  
14 Information technology ...... 13,100,139 9,698,258 3,401,881  
15 Royalties .. 0      
16 Occupancy ........... 16,148,901 16,148,901    
17 Travel ............ 3,649,537 2,052,682 1,596,855  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials . 0      
19 Conferences, conventions, and meetings .... 129,897 128,817 1,080  
20 Interest ........... 11,939,439 1,193,944 10,745,495  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization .. 63,759,109 18,930,171 44,828,938  
23 Insurance ... 6,635,324 4,892,650 1,742,674  
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 202,529,306 202,237,124 292,182  
b MEDICAID ENHANCEMENT TAX 53,043,764 53,043,764    
c EQUIPMENT RENTAL & MAINT 14,962,088 10,512,257 4,449,831  
d BOND-RELATED EXPENSES 28,192,089 2,819,209 25,372,880  
e All other expenses 13,721,279 10,041,336 3,679,348 595
25 Total functional expenses. Add lines 1 through 24e 1,210,474,037 993,086,943 217,226,294 160,800
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2019)
Form 990 (2019)
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
Assets 1 Cash–non-interest-bearing ........ 24,826,278 1 22,093,437
2 Savings and temporary cash investments ......... 650,122 2 637,853
3 Pledges and grants receivable, net ...... 0 3 0
4 Accounts receivable, net ............. 161,698,558 4 165,736,371
5 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
175,723 5 357,428
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
0 6 0
7 Notes and loans receivable, net ........... 10,597,854 7 10,970,000
8 Inventories for sale or use ............ 17,883,224 8 19,449,482
9 Prepaid expenses and deferred charges ...... 10,667,649 9 12,380,174
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 1,140,508,645
b Less: accumulated depreciation 10b 719,724,345 423,959,374 10c 420,784,300
11 Investments—publicly traded securities . 279,958,184 11 293,202,103
12 Investments—other securities. See Part IV, line 11 ..... 326,211,369 12 341,687,033
13 Investments—program-related. See Part IV, line 11 .. 1,970,881 13 7,382,716
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 63,409,460 15 153,429,437
16 Total assets. Add lines 1 through 15 (must equal line 33)... 1,322,008,676 16 1,448,110,334
Liabilities 17 Accounts payable and accrued expenses ..... 121,123,993 17 141,043,055
18 Grants payable ... 0 18 0
19 Deferred revenue ......... 3,864,030 19 5,835,994
20 Tax-exempt bond liabilities ......... 325,850,834 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D 0 21 0
22 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 188,220,589 23 581,255,207
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 98,929,039 25 92,673,739
26 Total liabilities. Add lines 17 through 25.. 737,988,485 26 820,807,995
Net Assets or Fund Balance Organizations that follow FASB ASC 958, check here MediumBullet and complete lines 27, 28, 32, and 33.
27 Net assets without donor restrictions ..........   27  
28 Net assets with donor restrictions ...........   28  
Organizations that do not follow FASB ASC 958, check here MediumBullet and complete lines 29 through 33.
29 Capital stock or trust principal, or current funds .....   29  
30 Paid-in or capital surplus, or land, building or equipment fund ...   30  
31 Retained earnings, endowment, accumulated income, or other funds   31  
32 Total net assets or fund balances ........... 584,020,191 32 627,302,339
33 Total liabilities and net assets/fund balances ........ 1,322,008,676 33 1,448,110,334
Form 990 (2019)
Form 990 (2019)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
1,261,047,216
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
1,210,474,037
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
50,573,179
4
Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..
4
584,020,191
5
Net unrealized gains (losses) on investments ...............
5
9,111,084
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-16,402,115
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))
10
627,302,339
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII.............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
Yes
 
Form 990 (2019)
Form 990 (2019)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
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 Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
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 12, check only one box.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations ...............................  
g
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 10 above (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
Yes No
Total
 
   
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
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 failed to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..  
6 Public support. Subtract line 5 from line 4.  
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..            
11 Total support. Add lines 7 through 10  
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose            
3 Gross receipts from activities that are not an unrelated trade or business under section 513 .....            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge            
6 Total. Add lines 1 through 5            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public support. (Subtract line 7c from line 6.)  
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
1
 
 
2
Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.
3a
 
 
b
Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.
3b
 
 
c
Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.
3c
 
 
4a
Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.
4a
 
 
b
Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.
4b
 
 
c
Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.
4c
 
 
5a
Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).
5a
 
 
b
Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (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.
6
 
 
7
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) .
7
 
 
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).
8
 
 
9a
Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.
9a
 
 
b
Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
 
 
c
Did a disqualified person (as defined in line 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.
9c
 
 
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
 
 
b
Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).
10b
 
 
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?
11a
 
 
b
A family member of a person described in (a) above?
11b
 
 
c
A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.
11c
 
 
Section B. Type I Supporting Organizations
Yes
No
1
Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.
1
 
 
2
Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (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?
1
 
 
2
Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).
2
 
 
3
By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer (a) and (b) below.
Yes
No
a
Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.
2a
 
 
b
Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.
2b
 
 
3
Parent of Supported Organizations. Answer (a) and (b) below.
a
Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.
3a
 
 
b
Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.
3b
 
 
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
Section A - Adjusted Net Income (A) Prior Year (B) Current Year
(optional)
1 Net short-term capital gain 1    
2 Recoveries of prior-year distributions 2    
3 Other gross income (see instructions) 3    
4 Add lines 1 through 3 4    
5 Depreciation and depletion 5    
6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6    
7 Other expenses (see instructions) 7    
8 Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) 8    
Section B - Minimum Asset Amount (A) Prior Year (B) Current Year
(optional)
1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): 1
a Average monthly value of securities 1a    
b Average monthly cash balances 1b    
c Fair market value of other non-exempt-use assets 1c    
d Total (add lines 1a, 1b, and 1c) 1d    
e Discount claimed for blockage or other factors
(explain in detail in Part VI):  
2 Acquisition indebtedness applicable to non-exempt use assets 2    
3 Subtract line 2 from line 1d 3    
4 Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). 4    
5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5    
6 Multiply line 5 by .035 6    
7 Recoveries of prior-year distributions 7    
8 Minimum Asset Amount (add line 7 to line 6) 8    
Section C - Distributable Amount Current Year
1 Adjusted net income for prior year (from Section A, line 8, Column A) 1  
2 Enter 85% of line 1 2  
3 Minimum asset amount for prior year (from Section B, line 8, Column A) 3  
4 Enter greater of line 2 or line 3 4  
5 Income tax imposed in prior year 5  
6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 6  
7
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
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 2019 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-2019 		(iii)
Distributable
Amount for 2019
1 Distributable amount for 2019 from Section C, line 6  
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI).
See instructions.		  
3 Excess distributions carryover, if any, to 2019:
a From 2014.......  
b From 2015.......  
c From 2016.......  
d From 2017.......  
e From 2018.......  
fTotal of lines 3a through e  
g Applied to underdistributions of prior years  
h Applied to 2019 distributable amount  
i Carryover from 2014 not applied (see
instructions) 		 
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.  
4Distributions for 2019 from Section D, line 7:
$  
a Applied to underdistributions of prior years  
b Applied to 2019 distributable amount  
c Remainder. Subtract lines 4a and 4b from 4.  
5 Remaining underdistributions for years prior to
2019, if any. Subtract lines 3g and 4a from line 2.
If the amount is greater than zero, explain in Part VI.
See instructions.		  
6 Remaining underdistributions for 2019. Subtract
lines 3h and 4b from line 1. If the amount is greater
than zero, explain in Part VI. See instructions.		  
7 Excess distributions carryover to 2020. Add lines
3j and 4c.		  
8 Breakdown of line 7:
a Excess from 2015.....  
b Excess from 2016.....  
c Excess from 2017.....  
d Excess from 2018.....  
e Excess from 2019.....  
Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019
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) 2019


Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors

Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number

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






Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......... Arrow Bullet $  
Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2019)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2
Name of organization
Mary Hitchcock Memorial Hospital
  		Employer identification number
02-0222140
Part I
Contributors
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
 
 
 
 

$  


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

$  


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

$  


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

$  


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

$  


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

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)
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) (2019)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)
Page 4
Name of organization
Mary Hitchcock Memorial Hospital
  		Employer identification number

02-0222140
Part III
Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Additional Data


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

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

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

SchCMd Bullet Complete if the organization is described below. SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd BulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
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.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

2
Political campaign activity expenditures (see instructions) ....................................................................SchCMd Bullet
$  
3
Volunteer hours for political campaign activities (see instructions) ..................................................................
 

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

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

$  
4
Did the filing organization file Form 1120-POL for this year? ...................................................................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
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) 2019

Schedule C (Form 990 or 990-EZ) 2019
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................    
b Total lobbying expenditures to influence a legislative body (direct lobbying) ........................    
c Total lobbying expenditures (add lines 1a and 1b) ............................................................    
d Other exempt purpose expenditures ...............................................................................    
e Total exempt purpose expenditures (add lines 1c and 1d) ..................................................    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
Not over $500,00020% of the amount on line 1e.
Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
Over $17,000,000$1,000,000.
g Grassroots nontaxable amount (enter 25% of line 1f) .................................................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ...................................................................................................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year
beginning in) 		(a) 2016 (b) 2017 (c) 2018 (d) 2019 (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) 2019


Schedule C (Form 990 or 990-EZ) 2019
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|No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? ...........................................................................................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........
Yes
 
c
Media advertisements? ...................................................................................................
 
No
 
d
Mailings to members, legislators, or the public? .............................................................................
 
No
 
e
Publications, or published or broadcast statements? ...........................................................
 
No
 
f
Grants to other organizations for lobbying purposes? ..........................................................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? .......................
Yes
 
179,588
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................
 
No
 
i
Other activities? ...................................................................................................................
Yes
 
84,304
j
Total. Add lines 1c through 1i ....................................................................................................
263,892
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 ...........................................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ...............................................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members ......................................................................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).
a
Current year .............................................................................................................................
2a
 
b
Carryover from last year ............................................................................................................
2b
 
c
Total ...........................................................................................................................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) .........................................
5
 
Part IV
Supplemental Information
Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.
Return Reference Explanation
LOBBYING ACTIVITY EXPLANATION FORM 990, SCHEDULE C, PART II B, LINES 1B & 1G MARY HITCHCOCK MEMORIAL HOSPITAL EMPLOYS TWO FULL TIME STAFF WHOSE DUTIES INCLUDE LOBBYING. TYPICAL EXPENSES ASSOCIATED WITH THE LOBBYING ACTIVITIES INCLUDE STAFF SALARY, TRAVEL, MEMBERSHIP FEES AND DUES. FROM TIME TO TIME, MARY HITCHCOCK MEMORIAL HOSPITAL, THROUGH ITS EMPLOYEES AND THE USE OF CONSULTANTS, CONTACTS GOVERNMENT OFFICIALS AND LEGISLATORS. THIS CONTACT IS FOR THE PURPOSE OF PROPOSING LEGISLATION OR EXPRESSING AN OPINION ON CHANGES IN LEGISLATION THAT AFFECT THE HOSPITAL AND ITS ABILITY TO CARRY OUT ITS MISSION. THE ACTIVITIES INCLUDE SENDING LETTERS TO, CALLING, AND MEETING WITH GOVERNMENT OFFICIALS AND LEGISLATORS. FOR THE FISCAL YEAR ENDED JUNE 30, 2018, MARY HITCHCOCK MEMORIAL HOSPITAL INCURRED $179,588 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) 2019


Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," 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.
SchDMd Bullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
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 ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ...................... 2a  
b Total acreage restricted by conservation easements .................... 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............
6
Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under FASB 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 $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:
a
Revenue included on Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2019

Schedule D (Form 990) 2019
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b If "Yes," explain the arrangement in Part XIII and complete the following table: Amount
c Beginning balance ............................. 1c  
d Additions during the year ............................ 1d  
e Distributions during the year .......................... 1e  
f Ending balance ................................ 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....
Part V
Endowment Funds.
Complete if the organization answered "Yes" 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 .... 56,795,299 54,754,800 72,720,335 74,609,411 54,935,134
b Contributions ... 338,335 137,888 378,941 208,107 17,029,356
c Net investment earnings, gains, and losses 2,065,129 2,553,792 -377,000 -516,882 3,029,123
d Grants or scholarships ...         16,800
e Other expenditures for facilities
and programs ... 		1,185,924 651,181 17,967,476 1,580,301 1,648,675
f Administrative expenses ....          
g End of year balance ...... 58,012,839 56,795,299 54,754,800 72,720,335 73,328,138
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet28.250 %
b
Permanent endowment SchDMd Bullet53.840 %
c
Term endowment SchDMd Bullet17.910 %
The percentages on lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) Unrelated organizations .................
3a(i)
 
No
(ii) Related organizations .................
3a(ii)
 
No
b
If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment.
Complete if the organization answered "Yes" 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 .....   50,350,802 50,350,802
b Buildings ....   559,593,902 331,824,327 227,769,575
c Leasehold improvements   4,111,615 3,830,754 280,861
d Equipment ....   506,576,297 384,069,264 122,507,033
e Other .....   19,876,029   19,876,029
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..SchDMdBullet 420,784,300
Schedule D (Form 990) 2019

Schedule D (Form 990) 2019
Page 3
Part VII
Investments—Other 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		 185,385,278 F

(B) PRIVATE EQUITIES		 50,179,251 F

(C) HEDGE FUNDS		 29,490,751 F

(D) OTHER INVESTMENTS		 76,631,753 F
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet 341,687,033
Part VIII
Investments—Program 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
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1)INVESTMENT IN CAPTIVE 23,060,627
(2)DUE FROM AFFILIATES 115,079,500
(3)CAPITAL LEASE RECEIVABLE 10,390,823
(4)OTHER MISC ASSETS 4,898,487
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 153,429,437
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
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 92,673,739
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) 2019

Schedule D (Form 990) 2019
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, community outreach and advocacy, equipment purchases, 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) 2019


Additional Data


Software ID:  
Software Version:  




SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990, Part IV, line 14b, 15, or 16.Right pointing arrow large image Attach to Form 990.Right pointing arrow large image Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
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" on Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of its grants and
other assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used
to award the grants or assistance? . . . . . . . . . . . . . . . . . . . . . . . . .
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other assistance outside the United States.
3
Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in the region (d) Activities conducted in region (by type) (such as, 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 the region		 (f) Total expenditures
for and investments
in the region
North America     Program Services Advertising 10,406
North America     Program Services Honorariums 368
Europe (Including Iceland and Greenland)     Program Services Honorariums 245
Sub-Saharan Africa   6 Program Services Medical Services 120,913
Central America and the Caribbean   5 Program Services Medical Services 25,817
South Asia   4 Program Services Medical Services 185,662
Europe (Including Iceland and Greenland)     Program Services Software 105,952
North America     Program Services Software 258,096
East Asia and the Pacific     Program Services Software 497
South Asia     Program Services Travel 2,182
Central America and the Caribbean     Program Services Travel 12,067
North America     Program Services Travel 55,607
East Asia and the Pacific     Program Services Travel 3,795
Europe (Including Iceland and Greenland)     Program Services Travel 53,383
Middle East and North Africa     Program Services Travel 1,524
South America     Program Services Travel 1,064
Sub-Saharan Africa     Program Services Travel 3,666
Central America and the Caribbean     Investments Investment in Captive 23,060,627
3a Sub-total ....   15 841,244
b Total from continuation sheets to Part I ...     23,060,627
c Totals (add lines 3a and 3b)   15 23,901,871
For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2019
Schedule F (Form 990) 2019
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" on 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)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount
of noncash
assistance 		(h) Description
of noncash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .......MediumBullet
 
3 Enter total number of other organizations or entities .......................MediumBullet
 
Schedule F (Form 990) 2019
Schedule F (Form 990) 2019Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" on 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
noncash
assistance 		(g) Description
of noncash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2019
Schedule F (Form 990) 2019
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Did the organization have an interest in a foreign trust during the tax year? If "Yes," the organization may be required to 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; don't file with Form 990). . . . . . . . . . . . . . . . . . . . . . . .
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471). . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If “Yes,” the organization may be required to file Form 8621, Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621) .
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships (see Instructions for Form 8865). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to separately file Form 5713, International Boycott Report (see Instructions for Form 5713; don't file with Form 990).. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Schedule F (Form 990) 2019
Schedule F (Form 990) 2019
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
MONITORING USE OF GRANT FUNDS FORM 990, SCHEDULE F, PART I, LINE 2 THE HOSPITAL PROVIDES UNRESTRICTED PROGRAM SUPPORT FOR CERTAIN FOREIGN ORGANIZATIONS. PROGRAM SUPPORT TO SPECIFIC ORGANIZATIONS IS CHOSEN AND DIRECTED BY THE PHYSICIANS AND/OR RESEARCHERS WORKING DIRECTLY WITH THE CHARITY.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule F (Form 990) 2019
Additional Data


Software ID:  
Software Version:  



SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Go to www.irs.gov/Form990EZ for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

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

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . . 		    6,760,409   6,760,409 0.560 %
b Medicaid (from Worksheet 3, column a) . . . . .     156,821,890 73,290,661 83,531,229 6.900 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     163,582,299 73,290,661 90,291,638 7.460 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     8,261,413 5,379,306 2,882,108 0.230 %
f Health professions education (from Worksheet 5) . . .     45,520,431 13,252,739 32,267,692 2.670 %
g Subsidized health services (from Worksheet 6) . . . .     8,141,233 6,237,360 1,903,873 0.540 %
h Research (from Worksheet 7) .     6,338,191 2,308,557 4,029,633 0.330 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     1,410,947   1,410,947 0.120 %
j Total. Other Benefits . .     69,672,215 27,177,962 42,494,253 3.890 %
k Total. Add lines 7d and 7j .     233,254,514 100,468,623 132,785,891 11.350 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing     185,500   185,500 0.020 %
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and
training for community members		            
6 Coalition building     933,031 73,819 859,212 0.070 %
7 Community health improvement advocacy     56,095   56,095 0 %
8 Workforce development     118,106   118,106 0.010 %
9 Other            
10 Total     1,292,732 73,819 1,218,913 0.100 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
15,586,818
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
 
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
331,863,907
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
342,108,967
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-10,245,060
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
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?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 Mary Hitchcock Memorial Hospital
One Medical Center Drive
Lebanon,NH03756
www.dartmouth-hitchcock.org
01799 		X X X X   X X   Psych Unit and Transplant Unit Cancer Center  
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
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): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 15
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
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.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 16
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): Please see Section C, Supplemental Info
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c 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) 2019
Schedule H (Form 990) 2019
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 No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Section C, Supplemental Info
b
See Section C, Supplemental Info
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 6
Part VFacility Information (continued)

Billing and Collections
Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 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?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Mary Hitchcock Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 8
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, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 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
Impact of actions taken to address significant health needs in prior CHNAs Form 990, Schedule H, Part V, Section B, Line 1(i) Although MHMH does review the impact of its CHNA activities within its community, the current CHNA did not explicitly address the impact of the actions taken by the hospital. The FY19 CHNA was updated to describe the impact of actions taken on previous CHNAs. Input From Representatives of the Community Served by Hospital Facility Form 990, Schedule H, Part V, Section B, Line 5 MHMH AND DHC COLLECTIVELY KNOWN AS D-H IS ACTIVELY ENGAGED IN THE DEVELOPMENT OF AN ACTIVE UPPER VALLEY REGIONAL PUBLIC HEALTH ADVISORY COUNCIL (40+ 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 NEW HAMPSHIRE AND 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. MHMH CONTRACTED WITH COMMUNITY HEALTH INSTITUTE(JSI) TO PROVIDE CONSULTATION AND TECHNICAL EXPERTISE TO OUR ASSESSMENT PROCESS. JSI IS A PUBLIC HEALTH MANAGEMENT CONSULTING AND RESEARCH ORGANIZATION DEDICATED TO IMPROVING THE HEALTH OF INDIVIDUALS AND COMMUNITIES THROUGHOUT THE WORLD. During the period March through August 2015, a Community Health Needs Assessment was conducted by Dartmouth-Hitchcock and Alice Peck Day Memorial Hospital in partnership with New London Hospital, Valley Regional Hospital, and Mt. Ascutney Hospital and Health Center. The purpose of the assessment was to identify community health concerns, priorities and opportunities for community health and health care delivery systems improvement. While Dartmouth-Hitchcock Medical Center serves as a tertiary referral medical center for a large, multi-state area, the geographic area of interest for the purposes of this assessment was the primary service area of Mary Hitchcock Memorial Hospital and Alice Peck Day Memorial Hospital. This primary service area was defined as 19 municipalities comprising the Upper Valley of New Hampshire and Vermont with a total resident population of approximately 70,000 people. Methods employed in the assessment included a survey of area residents made available through direct mail and website links, a survey of key community stakeholders who are agency, municipal or community leaders, a series of community discussion groups convened in the primary service area, and a review of available population demographics and health status indicators. In this Community Health Needs Assessment (CHNA), populations experiencing health disparities or vulnerable to poor health outcomes are primarily defined as those populations facing significant income and social determinants challenges, which in this region are more strongly associated with negative impacts on health than race or ethnicity. Enhanced efforts were made to understand the needs of these populations through targeted surveys and community conversations, including facilitated surveys and discussions at community suppers, a regional free clinic, homeless programs, and other community settings serving economically vulnerable residents. In addition, a concerted effort was made to convene a focus group of local individuals representing both documented and undocumented immigrant populations, with the assistance of a legal aid organization. However, scheduling challenges precluded our ability to convene the group. Findings of this assessment have been shared with public health officials in NH and VT, as well as with the Public Health Council of the Upper Valley. During this assessment, Mary Hitchcock Memorial Hospital used surveys from March 2015 through August 2015 to generate input from 1,566 residents, including 1,185 residents from the 19 towns defined as our Hospital Service Area. Surveys were made available through primary care clinics, free care clinics, a shelter for the homeless, a free community dinner, and numerous other community locations. Residents completing surveys included members of African-American, Hispanic, Native American, and Asian populations. Surveys were distributed through regional health clinics, the region's shelter for homeless populations; the region's low-income housing trust; the Lebanon Housing Authority; senior centers, and other locations where populations most affected by health disparities congregate. Mary Hitchcock Memorial Hospital disseminated the survey together with multiple community organizations that serve low-income, frail, and health disparity populations, including the Public Health Council of the Upper Valley, whose membership includes community mental health services, substance use services, mental health peer leaders, WIC providers, senior services advocates, services working with people with physical and developmental disabilities, community nursing, Visiting Nurses, and other core human services. In addition to assisting in survey dissemination, these providers advocated for underserved and vulnerable populations in our region as a part of the CHNA process. Based on discussions with a wide variety of community service organization leaders, town officials, and public health officials, there is general agreement that in the region covered by this CHNA, health disparity is far more likely to be driven by household median income, insurance status, and other indicators of poverty than by racial and ethnic minority characteristics. The Upper Valley region is overwhelmingly Caucasian (Grafton County NH; 93.6% white; 0.9% African American, 0.4% Native American, 1.8% Hispanic/Latino, 3.0% Asian, 2014 as per American Factfinder). Compared to other regions, racial and ethnic minority residents in our CHNA region are employed with academic and health care systems, and have relatively high socio-economic status. By comparison, the percent of households with income below 200% of federal poverty level reaches 20.7% in some of the towns in our CHNA area. Through the course of the FY2016 Community Health Needs Assessment, we attempted to, but were unable to identify any advocacy group or other representative leadership serving in an organizing or leadership role for minority populations. Similarly, we scanned for, but were unable to find any neighborhood or geographic region with a high density of racial or ethnic minority populations in our region. In May 2015, our CHNA partner, Alice Peck Day Memorial Hospital, contacted a representative of a regional group representing immigrant residents and had a conversation with that representative, but were not successful in arranging a conversation group with members represented by this organization due to lack of geographic convenience. Additionally, in May 2015 we spoke with a regional English as a Second Language coordinator regarding the challenges impacting the families served by that program. During our assessment process, Mary Hitchcock Memorial Hospital and Alice Peck Day Memorial Hospital made specific efforts to contact and receive input from members of income vulnerable populations, including holding community discussion groups with: -Pregnant and parenting teens participating in an alternative high school environment at The Family Place Parent Child Center (6/2/15). -Residents of The Haven, a shelter for homeless individuals and families (6/8/2015) -Frail older adults and advocates of the Upper Valley Interfaith Project (6/23/15) CHNA Conducted With One Or More Other Hospital Facilities Form 990, Schedule H, Part V, Section B, Line 6A During December of 2015, MHMH partnered with Alice Peck Day Memorial Hospital to complete a community health needs assessment. We also partnered with neighboring hospitals including Valley Regional Hospital, New London Hospital, and Mount Ascutney Hospital and Health Center, using similar community health needs assessment tools and approaches, allowing us to compare community health needs across a broad geographic, multi-hospital region. CHNA Conducted With One Or More Organizations Other Than Hospital Facilities Form 990, Schedule H, Part V, Section B, Line 6B During December 2015, in addition to working with Dartmouth-Hitchcock Clinic, MHMH worked closely with the member organizations of the Public Health Council of the Upper Valley (40+ member organizations) to disseminate surveys, serve as key informants, and to provide overall review and feedback re: findings identified in the community health needs assessment. 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.html Community Health
Measures to Publicize Financial Assistance Policy Form 990, Schedule H, Part V, Section B, Lines 16 A-C The financial assistance policy, application, and plain language summary can be found at: https://www.dartmouth-hitchcock.org/billing-charges/financial_assistance.h tml. MHMH has plain language summary brochures available at all admission sites as well as plain language summary posters at all physical locations. Financial Assistance Policy availability within the Community Form 990, Schedule H, Part V, Section B, Line 16J The financial assistance policy is posted on MHMH's website, including the verbatim policy and a shorter, more patient-friendly plain language summary. MHMH provides the plain language summary brochure to all uninsured patients. MHMH continues to notify patients on the back of the billing statement about financial assistance available to them. Additionally, MHMH posts information about the policy in public areas throughout the facilities including admission offices, public area boards throughout the facilities, the emergency rooms, and financial assistance policy brochures 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. Facility information Form 990, Schedule H, Part V, Section D The Hospital has a 2nd 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) 2019
Schedule H (Form 990) 2019
Page 9
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) 2019
Schedule H (Form 990) 2019
Page 10
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 MHMH uses the FPG guidelines in determining the initial level of financial assistance provided. In addition, MHMH 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 self-pay balance is greater than this calculation, the self-pay 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 990, Schedule H, only MHMH Hospital numbers were used. All amounts relating to DHC were excluded. The New Hampshire Community Benefits Report filed for fiscal year 2018, DHC and MHMH combined, totaled $179,709,257.
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 REGIONAL PUBLIC HEALTH NETWORKS, IMPROVEMENT IN SYSTEMS OF CARE FOR SUBSTANCE USE AND MENTAL HEALTH DISORDERS, PREVENTION OF SUBSTANCE ABUSE, FALLS REDUCTION FOR OLDER ADULTS, AND PRESCRIPTION DRUG MISUSE.
Bad Debt Expense Form 990, Schedule H, Part III, Section A, Line 2 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 62.8% (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. In October 2017, D-H began using a Presumptive Charity Review for bad debt patients. This review is the last step prior to transferring unpaid balances to bad debt.
Audited Financial Stmt Disclosure for Charity Care and Bad Debt Provision Form 990, Schedule H, Part III, Section A, Line 4 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 debt. 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 management's 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 $39,187,927 and costs of $48,802,676 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 $9,614,749 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 that treats patients that come for medically necessary care, regardless of their financial status or ability to pay. 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 OTHERS 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, 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. The region has a population of 70,000 people, with towns ranging in population from 300-13,000 people. These towns are generally considered rural, though the Hanover, and Lebanon, NH and Hartford, VT communities are considered to be a micropolitan area. Among the region's 19 towns, median household income varies widely, from $46K-$108K annually. 15.6% of the population is over the age of 65; 4.5% of the population is under the age of 5; 9.7% of children live in households whose median household income is less than 100% of Federal Poverty Level; 27% of children live in households with income less than 200% of Federal Poverty Level; 1.6% of the region's residents have Limited English Proficiency; and 8.2% lacked health insurance. 13% of NH residents and 20% of Vermont residents are Medicaid Beneficiaries. The region is served by MHMH and by Alice Peck Day Memorial Hospitals. There are no Federally Qualified Health Centers operating within the region. The Good Neighbor Health Clinic, in Hartford, VT, offers care to uninsured community members. Two minor civil divisions in our region, Dorchester NH and Piermont NH, are considered Medically Underserved Areas. 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 CHILD AND ADULT 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 COALITION. 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 20 VOTING MEMBERS OF THE MARY HITCHCOCK BOARD OF TRUSTEES AT FY18 END, 14 ARE NEITHER CONTRACTORS NOR EMPLOYEES OF MHMH.
Affiliated Health Care System Community Form 990, Schedule H, Part VI, Line 6 COMMUNITY BENEFITS ARE PROVIDED BY THE DARTMOUTH-HITCHCOCK HEALTH CARE SYSTEM, WHICH INCLUDES MARY HITCHCOCK MEMORIAL HOSPITAL, DARTMOUTH-HITCHCOCK CLINIC, AND OTHER RELATED ORGANIZATIONS WHOSE PRIMARY MISSION IS HEALTH CARE. MARY HITCHCOCK MEMORIAL HOSPITAL (MHMH) IN LEBANON IS NEW HAMPSHIRE'S LARGEST HOSPITAL. IN FISCAL YEAR 2018 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. 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 Benefits Report Form 990, Schedule H, Part VI, Line 7 MHMH files a Community Benefits Report with the State of New Hampshire jointly with Dartmouth-Hitchcock Clinic.
Schedule H (Form 990) 2019
Additional Data


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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 Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number
02-0222140
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" 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
noncash assistance		 (h) Purpose of grant
or assistance
(1) Advance Transit
PO Box 1027
Wilder,VT05088 		22-2558708 501(C)(3) 76,412   FMV   Transportn Subsidy
(2) American Cancer Society
2 Commerce Drive
Bedford,NH03110 		13-1788491 501(c)(3) 15,750   FMV   Program Support
(3) American Heart Association
PO Box 50075
Prescott,AZ863045075 		13-5613797 501(c)(3) 18,550   FMV   Program Support
(4) Good Neighbor Health Clinic
70 N MAIN ST
WHITE RIVER JCT,VT05001 		03-0346949 501(c)(3) 45,500   FMV   Program Support
(5) Grafton County Senior Citizens Council
PO Box 433
LEBANON,NH03766 		23-7248316 501(c)(3) 16,800   FMV   Program Support
(6) Riverbend Community Mental Health
3 N State St
Concord,NH03301 		02-0264383 501(c)(3) 17,500   FMV   Program Support
(7) Foundation for Healthy Communities
125 AIRPORT RD
CONCORD,NH03301 		02-0275078 501(c)(3) 381,915   FMV   Program Support
(8) Southwestern Vermont Health Care Foundation
100 Hospital Dr
Bennington,VT05201 		45-3362785 501(c)(3) 17,500   FMV   Program Support
(9) Albert Schweitzer Fellowship
25 Larkspur Lane
WRJ,VT05001 		13-1982786 501(c)(3) 15,400   FMV   Program Support
(10) March of Dimes Foundation
PO Box 673667
Marietta,GA30006 		13-1846366 501(c)(3) 7,000   FMV   Program Support
(11) Southeast Vermont Transit
45 Mill St
Wilmington,VT05363 		03-0353976 501(c)(3) 21,000   FMV   Transportn Subsidy
(12) Upper Valley Haven
713 Hartford Ave
Hartford,VT05001 		03-0277908 501(c)(3) 27,780   FMV   Program Support
(13) Windsor Hospital Corporation
289 County Rd
Windsor,VT05089 		03-0183721 501(c)(3) 28,000   FMV   Program Support
(14) Manchester Community Health Center
145 Hollis Street
Manchester,NH03101 		02-0458174 501(c)(3) 35,000   FMV   Program Support
(15) Ottauquechee Health Foundation
PO Box 784
Woodstock,VT05091 		03-0197766 501(c)(3) 24,576   FMV   Program Support
(16) Granite United Way
22 Concord St Fl 2
Manchester,NH03101 		02-6006033 501(c)(3) 14,000   FMV   Program Support
(17) Public health Council of the Upper Valley
1 Court St Suite 378
Waltham,MA02451 		75-2991608 501(c)(3) 14,000   FMV   Program Support
(18) Southwestern Community Services
PO Box 603
Keene,NH03431 		02-6013808 501(c)(3) 14,000   FMV   Program Support
(19) TLC Family Rescource Center
PO Box 1098
Claremont,NH03743 		52-2439830 501(c)(3) 23,800   FMV   Program Support
(20) Granite State Fit Kids
2300 Southwood Drive
Nashua,NH03063 		02-0519379 501(c)(3) 12,390   FMV   Program Support
(21) Women's Information Services WISE
38 Bank Street
Lebanon,NH03766 		02-0346512 501(c)(3) 8,199   FMV   Program Support
(22) The Family Place
319 US Route 5 South
Norwich,VT05055 		75-1590896 501(c)(3) 13,300   FMV   Program Support
(23) Friends of Recovery New Hampshire
239 Wilson Street
Manchester,NH03103 		02-0521502 501(c)(3) 5,751   FMV   Program Support
(24) Easter Seals Vermont Veterans Count
555 Auburn Street
Manchester,NH03103 		27-2867988 501(c)(3) 14,000   FMV   Program Support
(25) HIVHCV Resource Center
2 Blacksmith Street
Lebanon,NH03766 		22-3104237 501(c)(3) 11,200   FMV   Program Support
(26) Vital Communities
195 N Main St
White River Jct,VT05001 		03-0355283 501(c)(3) 12,338   FMV   Program Support
(27) NH Charitable Foundation
37 Pleasant Street
Concord,NH03301 		02-6005625 501(c)(3) 42,000   FMV   Program Support
(28) National Academy of Applied Sciences
500 5th St NW
Washington,DC20001 		53-0196932 501(c)(3) 52,500   FMV   Program Support
(29) Alice Peck Day Hospital
10 Alice Peck Day Drive
Lebanon,NH03766 		02-0222791 501(c)(3) 17,500   FMV   Program Support
(30) New London Hospital
273 County Road
New London,NH03257 		02-0222171 501(c)(3) 17,500   FMV   Program Support
(31) Cheshire Medical Center
580-590 Court St
Keene,NH03431 		02-0354549 501(c)(3) 101,500   FMV   Program Support
(32) St Joseph's Hospital
172 Kinsley Street
Nashua,NH03060 		02-0222215 501(c)(3) 17,500   FMV   Program Support
(33) The Granite YMCA
117 Market St
Manchester,NH03101 		02-0222248 501(c)(3) 13,650   FMV   Program Support
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
33
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2019

Schedule I (Form 990) 2019
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
noncash assistance		 (e) Method of valuation (book,
FMV, appraisal, other)		 (f) Description of noncash assistance
(1) Awards and Educational Assistance 64 525,163   FMV  
(2) D-H Tuition Reimbursement Program 431 764,119   FMV  
(3) Patient Assistance 840 95,239   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 2 Each award established by Mary Hitchcock Memorial Hospital has written guidelines and procedures. Award payments are processed in accordance with the specific terms of each award. The Dartmouth Institute Scholarships (TDI) are paid directly to Dartmouth College on 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) 2019



Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
SchJMediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number

02-0222140
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .........
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ..
2
Yes
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? .............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ....................
5a
 
No
b
Any related organization? .......................
5b
 
No
If "Yes," on line 5a or 5b, describe in Part III.
6
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:
a
The organization? ..................
6a
 
No
b
Any related organization? ......................
6b
 
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
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 ..........................
8
 
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2019

Schedule J (Form 990) 2019
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
(i) Base
compensation 		(ii) Bonus & incentive
compensation 		(iii) Other reportable compensation
1Robin Kilfeather-Mackey CPA
Former CFO 		(i)

(ii)		 0
-------------
0 		0
-------------
0 		0
-------------
313,945 		0
-------------
0 		0
-------------
0 		0
-------------
313,945 		0
-------------
0
2Daniel P Jantzen CPA
Chief Financial Officer 		(i)

(ii)		 638,681
-------------
0 		0
-------------
0 		80,406
-------------
0 		122,242
-------------
0 		16,644
-------------
0 		857,973
-------------
0 		0
-------------
0
3Stephen Leblanc
Chief Strategy Officer 		(i)

(ii)		 0
-------------
637,177 		0
-------------
0 		0
-------------
153,222 		0
-------------
200,238 		0
-------------
21,738 		0
-------------
1,012,375 		0
-------------
0
4Bruce King MSPH FHFMA
Pres & CEO New London Hosp 		(i)

(ii)		 327,284
-------------
0 		0
-------------
0 		30,904
-------------
0 		56,104
-------------
0 		16,607
-------------
0 		430,899
-------------
0 		0
-------------
0
5Mary Oseid MHCDS
Fmr Key Emp/VP Enterprise Svcs 		(i)

(ii)		 0
-------------
258,929 		0
-------------
0 		0
-------------
509 		0
-------------
343,760 		0
-------------
19,237 		0
-------------
622,435 		0
-------------
0
6Christine Schon MPA
Fmr Key Emp/Adm VP Prmry Care 		(i)

(ii)		 0
-------------
264,798 		0
-------------
0 		0
-------------
9,303 		0
-------------
26,040 		0
-------------
16,502 		0
-------------
316,643 		0
-------------
0
7James N Weinstein DO MS
Trstee Ex-Off/CEO end 7/2/17 		(i)

(ii)		 0
-------------
1,575,236 		0
-------------
750,000 		0
-------------
848,271 		0
-------------
97,679 		0
-------------
15,458 		0
-------------
3,286,644 		0
-------------
0
8Tina Naimie CPA MHCDS
Fmr Key Emp/VP Corp Finance 		(i)

(ii)		 252,087
-------------
0 		0
-------------
0 		536
-------------
0 		19,147
-------------
0 		1,863
-------------
0 		273,633
-------------
0 		0
-------------
0
9Wendy Fielding MBA
Fmr Key Emp/VP Finance Plnning 		(i)

(ii)		 244,357
-------------
0 		0
-------------
0 		414
-------------
0 		18,692
-------------
0 		21,565
-------------
0 		285,028
-------------
0 		0
-------------
0
10Vincent Fusca III
Chief of Staff 		(i)

(ii)		 107,871
-------------
0 		0
-------------
0 		44,086
-------------
0 		7,554
-------------
0 		188
-------------
0 		159,699
-------------
0 		0
-------------
0
11Edward Merrens MD
Chief Clinical Officer 		(i)

(ii)		 0
-------------
637,949 		0
-------------
0 		0
-------------
34,114 		0
-------------
53,885 		0
-------------
12,331 		0
-------------
738,279 		0
-------------
0
12George Blike MD
Chief Quality & Value Officer 		(i)

(ii)		 0
-------------
437,202 		0
-------------
0 		0
-------------
42,452 		0
-------------
333,250 		0
-------------
21,748 		0
-------------
834,652 		0
-------------
0
13Darlene A Saler MBA RN
Frmr Actg Chf Nrsg Ofr 		(i)

(ii)		 86,130
-------------
0 		0
-------------
0 		35,200
-------------
0 		67,401
-------------
0 		4,301
-------------
0 		193,032
-------------
0 		0
-------------
0
14John S Malanowski MILR
Chief HR Officer 		(i)

(ii)		 197,472
-------------
0 		0
-------------
0 		405,755
-------------
0 		23,958
-------------
0 		4,611
-------------
0 		631,796
-------------
0 		0
-------------
0
15Martin Purcell MBA
VP IS Operations 		(i)

(ii)		 314,995
-------------
0 		0
-------------
0 		37,711
-------------
0 		141,269
-------------
0 		984
-------------
0 		494,959
-------------
0 		0
-------------
0
16Thomas Dodds MD
Former Key Emp/Dept Chr Anesth 		(i)

(ii)		 0
-------------
244,818 		0
-------------
0 		0
-------------
24,930 		0
-------------
122,566 		0
-------------
19,608 		0
-------------
411,922 		0
-------------
0
17Wendy Wells MD
Fmr Key Emp/Dpt Chr Pathology 		(i)

(ii)		 0
-------------
468,879 		0
-------------
0 		0
-------------
27,939 		0
-------------
142,696 		0
-------------
22,404 		0
-------------
661,918 		0
-------------
0
18Jocelyn Chertoff MD
Vp Srvc Ln /Dpt Chr Dgnstc Rad 		(i)

(ii)		 0
-------------
539,060 		0
-------------
0 		0
-------------
36,488 		0
-------------
103,286 		0
-------------
9,316 		0
-------------
688,150 		0
-------------
0
19Edward Catherwood MD MS
Former Key Emp/Ctr Dir Hrt/Vsc 		(i)

(ii)		 0
-------------
263,816 		0
-------------
0 		0
-------------
64,556 		0
-------------
48,821 		0
-------------
9,568 		0
-------------
386,761 		0
-------------
0
20Steven Boyce
Fmr Key Emp/Adm. VP Med Spclts 		(i)

(ii)		 0
-------------
224,093 		0
-------------
0 		0
-------------
18,997 		0
-------------
50,582 		0
-------------
21,541 		0
-------------
315,213 		0
-------------
0
21Jeffrey OBrien MHA
Vp Clinical Operations 		(i)

(ii)		 311,569
-------------
0 		0
-------------
0 		4,444
-------------
0 		20,640
-------------
0 		21,676
-------------
0 		358,329
-------------
0 		0
-------------
0
22M Brooke Herndon MD MS
Trustee/Physician end 12/31/17 		(i)

(ii)		 0
-------------
208,018 		0
-------------
0 		0
-------------
774 		0
-------------
43,701 		0
-------------
19,474 		0
-------------
271,967 		0
-------------
0
23Richard Rothstein MD
Dept Chair/Srvc Ln Ldr - Med 		(i)

(ii)		 0
-------------
553,552 		0
-------------
0 		0
-------------
6,360 		0
-------------
60,872 		0
-------------
17,003 		0
-------------
637,787 		0
-------------
0
24John Birkmeyer MD
Former CCO/EVP Entprs Sp 		(i)

(ii)		 0
-------------
0 		0
-------------
0 		0
-------------
488,625 		0
-------------
0 		0
-------------
0 		0
-------------
488,625 		0
-------------
0
25Kimberly Troland JD
Deputy Gen Counsel 		(i)

(ii)		 367,482
-------------
0 		0
-------------
0 		10,006
-------------
0 		20,640
-------------
0 		19,297
-------------
0 		417,425
-------------
0 		0
-------------
0
26Robert Greene MD MHCDS FACP
Fmr Chf Popul Mgmt Ofr 		(i)

(ii)		 0
-------------
89,688 		0
-------------
0 		0
-------------
390,327 		0
-------------
7,491 		0
-------------
7,336 		0
-------------
494,842 		0
-------------
0
27John Kacavas JD
Chief Legal Officer 		(i)

(ii)		 522,566
-------------
0 		0
-------------
0 		18,197
-------------
0 		20,640
-------------
0 		19,296
-------------
0 		580,699
-------------
0 		0
-------------
0
28Maria Padin MD
Chief Medical Officer 		(i)

(ii)		 0
-------------
386,729 		0
-------------
0 		0
-------------
12,780 		0
-------------
253,282 		0
-------------
22,404 		0
-------------
675,195 		0
-------------
0
29Peter D Solberg MD
Chf Medical Information Ofcr 		(i)

(ii)		 0
-------------
363,669 		0
-------------
0 		0
-------------
11,789 		0
-------------
25,541 		0
-------------
21,932 		0
-------------
422,931 		0
-------------
0
30Karen Clements RN BSN MSB FAC
Chief Nursing Officer 		(i)

(ii)		 363,113
-------------
0 		0
-------------
0 		1,009
-------------
0 		20,640
-------------
0 		8,630
-------------
0 		393,392
-------------
0 		0
-------------
0
31Thomas J Siepka
Chief Pharm Offcr end 4/7/18 		(i)

(ii)		 305,051
-------------
0 		0
-------------
0 		3,770
-------------
0 		20,640
-------------
0 		1,938
-------------
0 		331,399
-------------
0 		0
-------------
0
32Jeffrey A Cohen MD
Trustee/VP Service Line 		(i)

(ii)		 0
-------------
411,216 		0
-------------
0 		0
-------------
26,560 		0
-------------
65,523 		0
-------------
22,589 		0
-------------
525,888 		0
-------------
0
33Timothy D Scherer MD
Trustee end 12/13/17 Physician 		(i)

(ii)		 0
-------------
504,115 		0
-------------
0 		0
-------------
15,662 		0
-------------
61,745 		0
-------------
19,967 		0
-------------
601,489 		0
-------------
0
34Brian C Spence MD MHCDS
Trustee/Staff Physician 		(i)

(ii)		 0
-------------
433,472 		0
-------------
0 		0
-------------
28,482 		0
-------------
27,374 		0
-------------
22,104 		0
-------------
511,432 		0
-------------
0
35Kari M Rosenkranz MD
Trustee/Physician 		(i)

(ii)		 0
-------------
523,082 		0
-------------
0 		0
-------------
22,649 		0
-------------
20,640 		0
-------------
9,315 		0
-------------
575,686 		0
-------------
0
36Sowmya Viswanathan MD
Chief ACO Officer end 12/2/17 		(i)

(ii)		 0
-------------
319,775 		0
-------------
0 		0
-------------
42,351 		0
-------------
20,640 		0
-------------
18,317 		0
-------------
401,083 		0
-------------
0
37Susan A Reeves EdD RN
Chief Nursing Officer 		(i)

(ii)		 196,911
-------------
0 		0
-------------
0 		999
-------------
0 		17,640
-------------
0 		11,069
-------------
0 		226,619
-------------
0 		0
-------------
0
38Aimee M Giglio
Chief HR Officer 		(i)

(ii)		 275,256
-------------
0 		0
-------------
0 		21,153
-------------
0 		12,384
-------------
0 		21,594
-------------
0 		330,387
-------------
0 		0
-------------
0
39David Gladstone MD
Chf Clncl Physcn - Radiology 		(i)

(ii)		 313,451
-------------
0 		3,250
-------------
0 		17,843
-------------
0 		76,621
-------------
0 		15,216
-------------
0 		426,381
-------------
0 		0
-------------
0
40Sandra Wong MD
Chief ACO Officer 		(i)

(ii)		 0
-------------
673,002 		0
-------------
0 		0
-------------
41,000 		0
-------------
20,640 		0
-------------
9,316 		0
-------------
743,958 		0
-------------
0
41Cherie Holmes MD
Trustee eff 3/15/18 		(i)

(ii)		 0
-------------
405,322 		0
-------------
0 		0
-------------
17,185 		0
-------------
135,097 		0
-------------
9,320 		0
-------------
566,924 		0
-------------
0
42Joanne M Conroy MD
Ttee eff 8/7/17 Ex-Officio CEO 		(i)

(ii)		 0
-------------
352,889 		0
-------------
50,000 		0
-------------
9,984 		0
-------------
6,750 		0
-------------
0 		0
-------------
419,623 		0
-------------
0
43Staci Hermann PharmD MS
Int Chief Pharm Off eff 4/8/18 		(i)

(ii)		 165,356
-------------
0 		0
-------------
0 		4,724
-------------
0 		6,403
-------------
0 		8,241
-------------
0 		184,724
-------------
0 		0
-------------
0
44Simon Hillier
Dept Chair - Anesthesiology 		(i)

(ii)		 0
-------------
481,165 		0
-------------
0 		0
-------------
31,215 		0
-------------
26,040 		0
-------------
17,309 		0
-------------
555,729 		0
-------------
0
45Leigh Burgess
VP Research Ops 		(i)

(ii)		 300,409
-------------
0 		10,000
-------------
0 		0
-------------
0 		20,640
-------------
0 		9,365
-------------
0 		340,414
-------------
0 		0
-------------
0
Schedule J (Form 990) 2019

Schedule J (Form 990) 2019
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference Explanation
Health or Social Club Dues & 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. COMPENSATION OF THE CEO FORM 990, SCHEDULE J, PART I, LINE 3 THE CEO IS PAID BY DARTMOUTH-HITCHCOCK CLINIC, A RELATED ORGANIZATION, WHICH USES A COMPENSATION COMMITTEE, AN INDEPENDENT CONSULANT, A COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO ESTABLISH THE CEO'S COMPENSATION.
Severance Payments Form 990, Schedule J, Part I, Line 4a THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE PAYMENTS DURING CALENDAR YEAR 2017: DURING CALENDAR YEAR 2017, FORMER INTERIM CHIEF NURSING OFFICER DARLENE SALER RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $34,830 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF CLINICAL OFFICER JOHN BIRKMEYER RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $488,625 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF HR OFFICER JOHN MALANOWSKI RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $376,352 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF POPULATION MANAGEMENT OFFICER ROBERT GREENE RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $334,519 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF FINANCIAL OFFICER ROBIN KILFEATHER-MACKEY RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $313,945 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF OF STAFF VINCENT FUSCA RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $30,770 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF ACO OFFICER SOWMYA VISWANATHAN RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $13,462 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF OF STAFF VINCENT FUSCA III RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $30,770 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE INCLUDED ON SCHEDULE J, PART II, COLUMN (B)III. DURING CALENDAR YEAR 2017, FORMER CHIEF HUMAN RESOURCE OFFICER JOHN MALANOWSKI RECEIVED SEVERANCE PAYMENTS MONTHLY TOTALING $376,352 FROM DARTMOUTH-HITCHCOCK. THESE PAYMENTS ARE 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)): BRIAN SPENCE $24,622 CHERIE HOLMES $15,997 DANIEL JANTZEN $54,632 DAVID GLADSTONE $4,570 EDWARD MERRENS $33,700 GEORGE BLIKE $40,874 JAMES WEINSTEIN $95,986 JEFFREY COHEN $17,913 JEFFREY OBRIEN $2,426 JOCELYN CHERTOFF $35,300 JOHN KACAVAS $17,423 JOHN MALANOWSKI $29,038 KAREN CLEMENTS $595 KARI ROSENKRANZ $22,379 KIMBERLY TROLAND $9,871 MARIA PADIN $10,686 MARTIN PURCELL $24,408 PETER SOLBERG $11,375 ROBERT GREENE $39,900 SANDRA WONG $41,000 SIMON HILLIER $26,167 STEPHEN LEBLANC $126,128 THOMAS DODDS $23,742 THOMAS SIEPKA $3,500 TIMOTHY SCHERER $15,537 VINCENT FUSCA $12,602 WENDY WELLS $26,109 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. Other Payments Form 990, Schedule J, Part II James Weinstein received a $750,000 bonus payment as part of a transition agreement. This amount is included on Schedule J, Column B(ii). James Weinstein received a $750,000 deferred compensation payment as part of an executive retention agreement. This amount is included on Schedule J, Column B(iii). 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 Form 990, Schedule J, Part II Column B, parts I, II, and III represent actual amounts paid to employees by MHMH and related organizations. 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) 2019

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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax-Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet Attach to Form 990.
SchKMediumBulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
Name of the organization
Mary Hitchcock Memorial Hospital
 
Employer identification number
02-0222140
Part Ⅰ
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer		 (i) Pool
financing
Yes No Yes No Yes No
A NH HEALTH & ED FACILITIES AUTHORITY
  		02-0279866 000000000 08-13-2014 41,242,290 REFUND ISSUE DATED 8/19/2009   X   X   X
B NH HEALTH & ED FACILITIES AUTHORITY
  		02-0279866 000000000 07-01-2016 35,575,000 SEE PART VI   X   X   X
Part Ⅱ
Proceeds
A B C D
1 Amount of bonds retired .................. 0 24,605,000    
2 Amount of bonds legally defeased .............. 0 0    
3 Total proceeds of issue .................. 41,242,990 35,575,000    
4 Gross proceeds in reserve funds ............. 0 0    
5 Capitalized interest from proceeds ............. 0 0    
6 Proceeds in refunding escrows ............... 0 0    
7 Issuance costs from proceeds ............... 352,990 408,058    
8 Credit enhancement from proceeds ............. 0 0    
9 Working capital expenditures from proceeds ............. 0 0    
10 Capital expenditures from proceeds ............. 0 15,936,616    
11 Other spent proceeds ............. 40,890,000 19,230,326    
12 Other unspent proceeds ............. 0 0    
13 Year of substantial completion ............. 2014 2017
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue of tax-exempt
bonds (or, if issued prior to 2018, a current refunding issue)? ........ 		               
15 Were the bonds issued as part of an advance refunding issue of taxable
bonds (or, if issued prior to 2018, an advance refunding issue)? ........ 		               
16 Has the final allocation of proceeds been made? .......... X   X          
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .................. X   X          
Part Ⅲ
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............   X   X        
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............   X X          
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2019

Schedule K (Form 990) 2019
Page 2
Part Ⅲ
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............   X X          
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?     X          
c Are there any research agreements that may result in private business use of bond-financed property? .............   X   X        
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?       X        
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....SchKMediumBullet 0 % 0 %    
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government ......... SchKMediumBullet 0 % 0 %    
6 Total of lines 4 and 5 ............. 0 % 0 %    
7 Does the bond issue meet the private security or payment test? ...   X   X        
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............   X   X        
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..        
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............   X   X        
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2? ........ 		X   X          
Part Ⅳ
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...   X   X        
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? ....... X   X          
b Exception to rebate? ........   X   X        
c No rebate due? .........   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          
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X   X        
b Name of provider .......... 0
  		0
  		 
  		 
 
c Term of hedge .........        
d Was the hedge superintegrated? ......                
e Was the hedge terminated? ........                
Schedule K (Form 990) 2019

Schedule K (Form 990) 2019
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        
b Name of provider .......... 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        
7 Has the organization established written procedures to monitor the requirements of section 148? ... 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          
Part Ⅵ
Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).
Return Reference Explanation
DESCRIPTION OF PURPOSE FORM 990, PART I, LINE B, COLUMN F THE PURPOSE OF THE ISSUE WAS TO REFUND AN ISSUE DATED 10/24/2013 AND FINANCE CAPITAL PROJECTS. 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.
Schedule K (Form 990) 2019

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Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ.
MediumBulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
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 section 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No
2
Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e) Original principal amount (f) Balance due (g) In default? (h) Approved by board or committee? (i) Written agreement?
To From Yes No Yes No Yes No
(1) DANIEL JANTZEN OFFICER SPLIT DOLLAR LIFE   X 122,003 122,003   No Yes   Yes  
(2) Deborah Jantzen FAMILY MEMBER Split Dollar Life   X 60,487 60,487   No Yes   Yes  
(3) Bruce King Officer Split Dollar Life   X 149,614 149,614   No Yes   Yes  
(4) Mary King Family Member Split Dollar Life   X 25,324 25,324   No Yes   Yes  
Total ...............Small Bullet $ 357,428
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) Karen Clements Key Employee 36,628 Scholarship Master's 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) 2019
Schedule L (Form 990 or 990-EZ) 2019
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Victoria LeBlanc Family member of Officer Stephen LeBlanc 77,079 Employment Compensation   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) 2019


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SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
Noncash Contributions
Right pointing arrow large imageComplete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
Right pointing arrow large imageGo to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
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 5 258,450 Fair Market Value
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image ( )
27 Other Right pointing arrow large image ( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that it must hold for at least three years from the date of the initial contribution, and which isn't required to be used for exempt purposes for the entire holding period? ...................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any nonstandard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ..........................
32a
Yes
 
b
If "Yes," describe in Part II.
33
If the organization didn't 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) (2019)
Schedule M (Form 990) (2019)
Page 2
Part IISupplemental 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) (2019)

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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 Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
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 Trustees, officers and key employees also hold trustee, officer or key employee positions at Dartmouth Hitchcock Clinic (DHC), a related organization. Individuals who received related organization compensation (as reported in Part VII) are paid employees of DHC. 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 Hamden Assurance, LTD., a related for-profit entity: - Daniel Jantzen - Edward Merrens - John Kacavas - George Blike Description of classes of members, persons, and the nature of their rights Form 990, Part VI, Section A, Lines 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 EXTERNAL TAX ADVISORS, 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 Compliance and Audit Services Department 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 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 Trustees 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, Section B, Line 15a Although paid by a related organization, Dartmouth-Hitchcock Clinic, the Compensation for the CEO is evaluated by an independent third party firm for reasonableness and national data benchmarking. The Talent Development and 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 2017.
Offices & Positions for Which Process was Used & Year Undertaken Form 990, Part VI, Section B, 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 2017. 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 a formal review by compensation committee members.
Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Section C, 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), Dartmouth-Hitchcock Clinic, 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, VNA & Hospice of VT and NH, 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: Net Asset Transfer to Affiliates $10,470,394, Net Assets Released from Restriction ($27,614,290), Pension-related and other changes $741,781, Total changes in net assets: ($16,402,115). Audited Financial Statements Form 990, Part XII, Line 2c The organization's financial information is included in the consolidated 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, Alice Peck Day Memorial Hospital, and VNA & Hospice of VT and NH.
Circular A-133 Audit Requirement Form 990 Part XII, Line 3A DURING FISCAL YEAR 2018, 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) 2019


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SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2019
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 -58,121 514,183 MHMH
 
(2) D-H Specialty Services LLC
One Medical Center Drive
Lebanon,NH03756
46-0876427 		Shd Svgs Prgm NH   0 MHMH
 








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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1)DARTMOUTH-HITCHCOCK CLINIC
ONE MEDICAL CENTER DRIVE

LEBANON,NH03756
22-2519596 		PHYS SVCS NH 501(c)(3) 10 D-HH
 
Yes
 
(2)DARTMOUTH-HITCHCOCK MEDICAL CENTER
ONE MEDICAL CENTER DRIVE

LEBANON,NH03756
22-2715483 		SUPPORTNG ORG NH 501(c)(3) 12 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) 12 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) 12 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) 12 TYPE I CMC
 
Yes
 
(11)Mt Ascutney Hosp Cmmty Hlth Found
289 County 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) 10 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
(16)VNA & Hospice of VT and NH
205 Billings Farm Road 5

Wilder,VT05088
03-6006494 		Hospice VT 501(c)(3) 10 D-HH
 
Yes
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



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

1 Med Ctr Dr
LEBANON,NH03756
02-0205863 		POOLED INVEST NH MHMH
  		excluded 40,088,413 585,715,206   No -213,709 Yes   90.752 %
(2) OneCare VT ACOLLC

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










Part IV
Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Charit Remndr Unitrusts (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 Company Limited

3 Gorham Road
Hamilton   08
BD
98-0121409 		Liab Insur. BD DHC
  		Foreign Corp 0 23,060,627 25.800 % Yes  
(4) Hitchcock Health Connect

ONE MEDICAL CENTER DRIVE
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       Yes  
(8) Keene Health Services

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

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

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

One Medical Center Drive
Lebanon,NH03756
81-3105071 		Sftwre tchnlg NH D-HH
  		C Corp       Yes  
Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
Page 3
Part V
Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................
1a
 
No
b Gift, grant, or capital contribution to related organization(s) ............................
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) ............................
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) ............................
1d
 
No
e Loans or loan guarantees by related organization(s) ............................
1e
Yes
 
f Dividends from related organization(s) ............................
1f
 
No
g Sale of assets to related organization(s) ............................
1g
 
No
h Purchase of assets from related organization(s) ............................
1h
 
No
i Exchange of assets with related organization(s) ............................
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) .......................
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) ......................
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) .....................
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) .................
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................
1n
Yes
 
o Sharing of paid employees with related organization(s) ............................
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses ............................
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses ............................
1q
Yes
 
r Other transfer of cash or property to related organization(s) ............................
1r
Yes
 
s Other transfer of cash or property from related organization(s) ............................
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) Dartmouth-Hitchcock Clinic

 JKLMN 55,111,967 FMV
(2) Hamden Risk Retention Group

 P 4,215,574 FMV
(3) The New London Hospital Association

 Q 2,197,181 FMV
(4) Windsor Hospital Corporation

 Q 2,009,709 FMV
(5) Cheshire Medical Center

 Q 1,135,875 FMV
(6) Cheshire Medical Center

 L 29,984,964 FMV
(7) Alice Peck Day Memorial Hospital

 Q 972,800 FMV
(8) Dartmouth-Hitchcock Health

 P 5,815,807 FMV
(9) The Hitchcock Foundation

 Q 1,116,836 FMV
(10) Windsor Hospital Corporation

 R 138,585 FMV
(11) Dartmouth Hitchcock Health

 E 527,346,357 FMV
(12) Dartmouth Hitchcock Medical Center

 C 64,575 FMV
(13) Dartmouth Hitchcock Medical Center

 P 787,904 FMV
(14) The Hitchcock Foundation

 B 395,187 FMV
(15) Dartmouth Hitchcock Health Center

 R 8,308,296 FMV
Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

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




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






























Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
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) 2019

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