TY 2018 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) BAREFOOT SAMUEL...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(2) BROWN CANDICE...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(3) CARROLL JOE...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(4) EDWARDS JOEL MD...................................................................... TRUSTEE	2.00 .................	X		548,967	0	36,480
(5) ELY JOSEPH...................................................................... CHAIR	2.00 .................	X	X	0	0	0
(6) FORIEST BRYANT...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(7) HARDING LARI...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(8) HAUSER CHARLES...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(9) JOHNSON JOIA...................................................................... VICE CHAIR	2.00 .................	X	X	0	0	0
(10) LAMBE CLARENCE...................................................................... SEC/TREAS	2.00 .................	X	X	0	0	0
(11) LATHAM LINDA...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(12) LEON CHRISTOPHER...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(13) LOBO LUIS...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(14) THOMASON JASON MD...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(15) WOLFE III JOHN...................................................................... TRUSTEE	2.00 .................	X		0	0	0
(16) MORRIS JOHN...................................................................... ASST SEC	2.00 .................		X	0	393,030	47,612
(17) SANZ SEAN...................................................................... FMR PRES & COO	60.00 .................		X	427,205	0	24,159

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) SETLIFF MICHAEL........................................................................ PRES & COO FMH INCL KMC	60.00 .......................	X				529,052	0	73,480
(19) SMITH HARRY........................................................................ SVP HOSPITAL OPERATIONS	60.00 .......................	X				0	1,131,009	154,164
(20) BRIGHT JANET........................................................................ CNO	60.00 .......................		X			246,687	0	18,101
(21) MOTEW STEPHEN........................................................................ SVP	60.00 .......................		X			867,372	0	126,435
(22) NYCUM LAWRENCE........................................................................ SVP	60.00 .......................		X			791,442	0	124,147
(23) ROYSTER KIRSTEN........................................................................ PRES & COO KMC	60.00 .......................		X			27,635	409,049	32,954
(24) BRAVO JULIO........................................................................ RHEUMATOLOGIST	40.00 .......................			X		775,154	0	61,567
(25) MCDONALD COLIN........................................................................ NEUROLOGIST	40.00 .......................			X		726,529	0	58,534
(26) NOUREDDINE NIZAR........................................................................ CARDIOLOGIST	40.00 .......................			X		719,011	0	58,909
(27) PRELI ROBERT........................................................................ CARDIOLOGIST	40.00 .......................			X		728,277	0	60,397
(28) ZEYLIKMAN YURIY........................................................................ NEUROLOGIST	40.00 .......................			X		1,008,046	0	58,811
(29) LINDSAY JEFFERY........................................................................ FMR PRES - FMH/COO WS MKT	0.00 .......................				X	0	1,905,834	54,246
(30) MIHAL DENISE........................................................................ FMR PRES - FMH/COO WS MKT	0.00 .......................				X	0	1,457,418	43,808
(31) GREGORY CHERE........................................................................ FMR SVP	0.00 .......................				X	0	743,181	110,198
(32) JARRETT-PULLIAM KIMBERLY........................................................................ FMR CNO	0.00 .......................				X	0	342,132	23,934

(A) Name and business address	(B) Description of services	(C) Compensation
LABORATORY CORPORATION OF AMERICA HOLDIN PO BOX 12140 BURLINGTON,NC27216	LAB SERVICES	14,362,411
CROSS COUNTRY STAFFING PO BOX 404674 ATLANTA,GA30384	STAFFING SERVICES	13,119,382
MORRISON HEALTHCARE PO BOX 102289 ATLANTA,GA30368	FOOD MANAGEMENT SERVICES	11,238,945
CROTHALL HEALTH CARE INC 1500 LIBERTY RIDGE DR STE 210 WAYNE,PA19087	FACILITY SERVICES	11,236,179
SPECTRUM MEDICAL GROUP PA 3001 LYNDHURST AVE WINSTON SALEM,NC27103	HEALTH SERVICES	5,969,990
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 98

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
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Attach to Form 990 or Form 990-EZ.
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Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

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.)

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

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

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

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

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

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

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

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

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

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

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

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

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

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

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

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

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

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

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2018

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv), 170(b)(1)(A)(vi), and 170(b)(1)(A)(ix)
(Complete only if you checked the box on line 5, 7, 8, or 9 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10

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

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

Section C. Computation of Public Support Percentage

Public support percentage for 2018 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2017 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2018. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2017. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2018. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2017. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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

Schedule A (Form 990 or 990-EZ) 2018

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)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose
3	Gross receipts from activities that are not an unrelated trade or business under section 513 .....
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge
6	Total. Add lines 1 through 5
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support. (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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

Section C. Computation of Public Support Percentage

Public support percentage for 2018 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2017 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2018 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2017 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2018. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2017. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

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

Schedule A (Form 990 or 990-EZ) 2018

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

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

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

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

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

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

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

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

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

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

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

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

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

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

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

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

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

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

10a

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

10a

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

10b

Schedule A (Form 990 or 990-EZ) 2018

Page 5

Part IV

Supporting Organizations (continued)

Yes

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

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

11a

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

11b

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

11c

Section B. Type I Supporting Organizations

Yes

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

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

Section C. Type II Supporting Organizations

Yes

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

Section D. All Type III Supporting Organizations

Yes

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

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

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

Section E. Type III Functionally-Integrated Supporting Organizations

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

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

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

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

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

Yes

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

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2018

Page 6

Part V

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

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

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2018

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 2018 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-2018	(iii) Distributable Amount for 2018
1 Distributable amount for 2018 from Section C, line 6
2 Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2018:
a From 2013.......
b From 2014.......
c From 2015.......
d From 2016.......
e From 2017.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2018 distributable amount
i Carryover from 2013 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2018 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2018 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2018, 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 2018. 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 2019. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2014......
b Excess from 2015.....
c Excess from 2016.....
d Excess from 2017.....
e Excess from 2018.....

Schedule A (Form 990 or 990-EZ) (2018)

Schedule A (Form 990 or 990-EZ) 2018

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) 2018

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

Caution. An organization that 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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018) Page 2

Name of organization FORSYTH MEMORIAL HOSPITAL INC

Part I	Contributors (See instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 3

Name of organization FORSYTH MEMORIAL HOSPITAL INC		Employer identification number 56-0928089

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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 4


Name of organization FORSYTH MEMORIAL HOSPITAL INC			Employer identification number 56-0928089
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

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

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

Part I-A

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

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

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2018

Page 2

Part II-A

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

A Check SchCMd Bullet

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

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

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

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

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2015	(b) 2016	(c) 2017	(d) 2018	(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) 2018

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

59,660

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

59,660

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Return Reference	Explanation
LINE 1I	DUES PAID TO CERTAIN ORGANIZATIONS WHICH INCLUDE A PORTION RELATED TO LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 2018

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990.
SchDMd Bullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

Part I

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

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2018

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No


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

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

Yes No

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

Part V

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

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

1a	Beginning of year balance ....	0
b	Contributions ...	363
c	Net investment earnings, gains, and losses	0
d	Grants or scholarships ...	0
e	Other expenditures for facilities and programs ...	0
f	Administrative expenses ....	0
g	End of year balance ......	363

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

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

100.000 %

Temporarily restricted endowment SchDMd Bullet

0 %

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

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

1a	Land .....	10,727,897		10,727,897
b	Buildings ....	158,569,260	34,187,077	124,382,183
c	Leasehold improvements	14,091,040	10,602,121	3,488,919
d	Equipment ....	341,647,490	269,273,182	72,374,308
e	Other .....	41,561,719	18,820,554	22,741,165
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				233,714,472

Schedule D (Form 990) 2018

Page 3

Part VII

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

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

Part VIII

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

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

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

Part IX

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

(a) Description				(b) Book value
(1) DUE FROM AFFILIATE				1,215,636,632
(2) FEDERAL INCOME TAX RECEIVABLE				23,502
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,215,660,134

Part X

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

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
THIRD PARTY PAYMENT PAYABLE	9,300,551
NOTES PAYABLE	16,052,025
PATIENT REFUNDS	4,881,279
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	30,233,855
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) 2018

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

PART V, LINE 4:

THE ENDOWMENT FUNDS ARE HELD FOR COMMUNITY ENGAGEMENT.

PART X, LINE 2:

PART X, LINE 2: LIABILITY UNDER FIN 48 (ASC 740) FOOTNOTE THE AUDIT FOR NOVANT HEALTH AND ITS AFFILIATES IS PREPARED ON A CONSOLIDATED BASIS. THE COMPANY IS REQUIRED TO EVALUATE UNCERTAIN TAX POSITIONS. THIS EVALUATION INCLUDES A QUANTIFICATION OF TAX RISK IN AREAS SUCH AS UNRELATED BUSINESS TAXABLE INCOME AND THE TAXATION OF OUR FOR-PROFIT SUBSIDIARIES. THIS EVALUATION DID NOT HAVE A MATERIAL EFFECT ON THE COMPANY'S CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS FOR THE YEARS ENDED DECEMBER 31, 2018 AND 2017.

Schedule D (Form 990) 2018

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other 30000.0000000000 %

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: . . . . . . . .

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

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

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

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	48,008,023		48,008,023	3.900 %
b	Medicaid (from Worksheet 3, column a) . . . . .	166,250,005	112,176,299	54,073,706	4.400 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .	2,500,181	2,271,678	228,503	0.020 %
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	216,758,209	114,447,977	102,310,232	8.320 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	976,909	83,329	893,580	0.070 %
f	Health professions education (from Worksheet 5) . . .	12,965,472	2,984,616	9,980,856	0.810 %
g	Subsidized health services (from Worksheet 6) . . . .	36,676,511	26,276,107	10,400,404	0.850 %
h	Research (from Worksheet 7) .	1,170,719	460	1,170,259	0.100 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	428,550	0	428,550	0.030 %
j	Total. Other Benefits . .	52,218,161	29,344,512	22,873,649	1.860 %
k	Total. Add lines 7d and 7j .	268,976,370	143,792,489	125,183,881	10.180 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2018

Schedule H (Form 990) 2018

Page

Part II

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

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing	15,000	15,000	0 %
2	Economic development	166,799	166,799	0.010 %
3	Community support	237,386	237,386	0.020 %
4	Environmental improvements	2,670	2,670	0 %
5	Leadership development and training for community members	8,500	8,500	0 %
6	Coalition building
7	Community health improvement advocacy	456	456	0 %
8	Workforce development	116,090	116,090	0.010 %
9	Other
10	Total	546,901	546,901	0.040 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

66,870,056

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

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

Section B. Medicare

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

216,420,737

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

215,211,037

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

1,209,700

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

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) 2018

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?3Name, 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)					Facility reporting group
1	FMH DBA NOVANT HEALTH FORSYTH MEDICAL CENTER 3333 SILAS CREEK PARKWAY WINSTONSALEM,NC27103 WWW.NOVANTHEALTH.ORG	X	X	X	A
2	FMH DBA NOVANT HEALTH KERNERSVILLE MED CENTER 1750 KERNERSVILLE MEDICAL PARKWAY KERNERSVILLE,NC27284 WWW.NOVANTHEALTH.ORG	X	X	X	A
3	FMH DBA NOVANT HEALTH CLEMMONS MEDICAL CENTER 6915 VILLAGE MEDICAL CIRCLE CLEMMONS,NC27012 WWW.NOVANTHEALTH.ORG	X	X	X	A

Schedule H (Form 990) 2018

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)

	FORSYTH MEMORIAL HOSPITAL INC
Name of hospital facility or letter of facility reporting group

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

Yes

Community Health Needs Assessment

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

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The significant health needs of the community

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

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

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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 16

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

Yes

6 a

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

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

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

Yes

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

Hospital facility’s website (list url):

Other website (list url): WWW.NOVANTHEALTH.ORG

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

Other (describe in Section C)

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

Yes

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

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

Yes

If "Yes" (list url): WWW.NOVANTHEALTH.ORG

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

10b

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

12a

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

12a

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

12b

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

Schedule H (Form 990) 2018

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	FORSYTH MEMORIAL HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Yes

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

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

Yes

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

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 300.000000000000% and FPG family income limit for eligibility for discounted care of 0.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

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

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

Yes

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

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

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

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

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

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

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

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

SEE SECTION C

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

SEE SECTION C

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

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

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

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

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

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

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 6

Part VFacility Information (continued)

Billing and Collections

	FORSYTH MEMORIAL HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Yes

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

Yes

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

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

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

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

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs

Made a reasonable effort to orally notify individuals about the FAP and FAP application process

Processed incomplete and complete FAP applications

Made presumptive eligibility determinations

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

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

Yes

If "No," indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 7

Part VFacility Information (continued)

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

	FORSYTH MEMORIAL HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Yes

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

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

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

If "Yes," explain in Section C.

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

Yes

If "Yes," explain in Section C.

Schedule H (Form 990) 2018

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, 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
PART V, SECTION B	FACILITY REPORTING GROUP A
FACILITY REPORTING GROUP A CONSISTS OF:	- FACILITY 1: FMH DBA NOVANT HEALTH FORSYTH MEDICAL CENTER, - FACILITY 2: FMH DBA NOVANT HEALTH KERNERSVILLE MED CENTER, - FACILITY 3: FMH DBA NOVANT HEALTH CLEMMONS MEDICAL CENTER
FORSYTH MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3J:	FORSYTH MEMORIAL HOSPITAL, INC.PART V, SECTION B, LINE 3E:SEVERAL SOCIAL, BEHAVIORAL, AND CLINICAL HEALTH NEEDS WERE IDENTIFIED IN THE NEEDS ASSESSMENT. ONCE THE HEALTH NEEDS WERE IDENTIFIED, SURVEYS AND COMMUNITY MEETINGS WERE CONDUCTED IN WHICH THE VARIOUS COMMUNITY STAKEHOLDERS RANKED THE HEALTH ISSUES ACCORDING TO THE YEARS OF POTENTIAL LIFE LOST AND MAGNITUDE OF IMPACT. THE INFORMATION GATHERED WAS THEN MATRIXED AND SCORED IN ORDER TO RANK THE FOCUS AREAS AND PRIORITIZE THE IDENTIFIED HEALTH NEEDS. FURTHER PRIORITIZATION OCCURRED WITH THE REVIEW BY THE ORGANIZATION'S BOARD.
FORSYTH MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5:	WHILE CONDUCTING THE CHNA, THE HOSPITAL FACILITY(IES) SOLICITED INPUT FROM, AND CONSULTED WITH, A VARIETY OF COMMUNITY REPRESENTATIVES INCLUDING, BUT NOT LIMITED TO, REPRESENTATIVES OF CITY AND COUNTY GOVERNMENT INCLUDING HEALTH DEPARTMENTS, COMMUNITY-BASED ORGANIZATIONS, FOUNDATIONS, CHURCHES, COLLEGES/UNIVERSITIES, COMMUNITY COALITIONS AND OTHER SOCIAL SERVICE AGENCIES. INPUT WAS GATHERED THROUGH COMMUNITY MEETINGS, STAKEHOLDERS INTERVIEWS, AND SOLICITED THROUGH WRITTEN COMMENTS THROUGHOUT THE SURVEY PERIOD UNTIL THE FINAL COMMUNITY PRIORITY SETTING MEETING(S) AND SURVEY. THE SCOPE OF EXPERTISE WAS BROAD AND INCLUDED SUCH AREAS AS PUBLIC HEALTH, MINORITY POPULATIONS, HEALTH DISPARITIES, AND SOCIAL SERVICES.
FORSYTH MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 11:	THE HOSPITAL FACILITY(IES) IS/ARE A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS SUCH, NOVANT HEALTH INCLUDES MULTIPLE HOSPITAL FACILITIES AND HAS ENGAGED IN CHNAS FOR ALL OF THE COMMUNITIES BEING SERVED. THE FACILITY'S CHNA IDENTIFIED MULTIPLE NEEDS FOR THE COMMUNITY SERVED. THE NEEDS IDENTIFIED WERE REVIEWED AND PRIORITIZED BY THE CHNA RESOURCE GROUP AND SUBSEQUENTLY BY EACH FACILITY'S BOARD. THEY EVALUATED EACH DOCUMENTED NEED AND ITS INTERSECTION WITH THE ORGANIZATION'S VISION, COMMITMENTS, AND KEY STRENGTHS BEFORE FURTHER PRIORITIZING THE HEALTH NEEDS AND AGREEING UPON THE TOP HEALTH PRIORITIES TO BE ADDRESSED. WHERE POSSIBLE, WE HAVE LEVERAGED THE SYSTEM'S STRENGTHS AND RESOURCES TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NOVANT HEALTH AND EACH OF ITS HOSPITAL FACILITIES HAVE ADOPTED AND EXECUTED AN IMPLEMENTATION STRATEGY THAT ADDRESSES THE PRIORITIZED COMMUNITY HEALTH NEEDS FROM THE CHNAS. THE IMPLEMENTATION STRATEGIES OUTLINE THE PLAN THAT THE HOSPITAL FACILITY(IES) WILL UNDERTAKE TO MEET THOSE HEALTH NEEDS IN EACH OF ITS COMMUNITIES. CERTAIN NEEDS THAT WERE IDENTIFIED BY THE CHNA HAVE NOT BEEN ADDRESSED. IT WAS DETERMINED THAT THERE ARE OTHER RESOURCES IN THE COMMUNITY THAT CAN MORE APPROPRIATELY ADDRESS THESE NEEDS BASED ON SCOPE OF SERVICES AND SKILL SET. FOR MORE DETAILED INFORMATION, REFER TO THE PUBLICLY AVAILABLE IMPLEMENTATION PLAN AVAILABLE ON THE WEBSITE; REFER TO THE URL GIVEN PREVIOUSLY FOR THE POSTING OF THE PLAN.
FORSYTH MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13H:	OTHER ELIGIBILITY CRITERIA EXPLAINED IN THE FAP INCLUDE THE FOLLOWING: FREE CARE IS ONLY APPLICABLE TO MEDICALLY NECESSARY SERVICES; PROVIDER BASED PHYSICIAN CLINICS REQUIRE THAT PATIENTS MUST HAVE BEEN TREATED BY AN AFFILIATED MEDICAL GROUP PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS THREE YEARS; PATIENTS MUST BE UNABLE TO ACCESS ENTITLEMENT PROGRAMS; PATIENTS WITH SPECIAL CIRCUMSTANCES SUCH AS BANKRUPTCY MAY ALSO BE ELIGIBLE FOR CHARITY CARE. SCHEDULE H, PART V, SECTION B. FACILITY REPORTING GROUP APART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXSCHEDULE H, PART V, SECTION B. FACILITY REPORTING GROUP APART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXSCHEDULE H, PART V, SECTION B. FACILITY REPORTING GROUP APART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.NOVANTHEALTH.ORG/HOME/PATIENTS--VISITORS/YOUR-HEALTHCARE-COSTS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPX
FORSYTH MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 24:	IT IS POSSIBLE FOR A FINANCIAL ASSISTANCE POLICY (FAP) ELIGIBLE PATIENT TO BE CHARGED AN AMOUNT EQUAL TO THE GROSS CHARGE FOR A NON-EMERGENCY OR NON-MEDICALLY NECESSARY SERVICE. HOWEVER, IF THE SERVICE IS DEEMED AN EMERGENCY OR A MEDICAL NECESSITY, THEN THE FAP ELIGIBLE PATIENT WOULD NOT BE CHARGED FOR CARE AND WOULD NOT RECEIVE A BILL ONCE FAP ELIGIBILITY HAD BEEN ESTABLISHED.

Schedule H (Form 990) 2018

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?57
Name and address		Type of Facility (describe)
1	2 - NH ARCADIA FAMILY MEDICINE 12208 NC HWY 150 NORTH WINSTONSALEM,NC27127	PHYSICIAN CLINIC
2	3 - NH BREAST CENTER 2025 FRONTIS PLAZA BLVD SUITE 123 WINSTONSALEM,NC27103	IMAGING CENTER
3	4 - NH CARDIOLOGY CLEMMONS 7114 VILLAGE MEDICAL CIRCLE CLEMMONS,NC27012	PHYSICIAN CLINIC
4	5 - NH CARDIOLOGY KERNERSVILLE 1710 KVILLE MEDICAL PKWY STE 205 KERNERSVILLE,NC27284	PHYSICIAN CLINIC
5	6 - NH CARDIOLOGY MT AIRY 694 RIVERSIDE DR MOUNT AIRY,NC27030	PHYSICIAN CLINIC
6	7 - NH CARDIOLOGY WINSTON-SALEM 186 KIMEL PARK DRIVE WINSTONSALEM,NC27103	PHYSICIAN CLINIC
7	8 - NH CHAIR CITY FAMILY MEDICINE 903 RANDOLPH ST THOMASVILLE,NC27360	PHYSICIAN CLINIC
8	9 - NH CLEMMONS FAMILY MEDICINE 6301 STADIUM DRIVE CLEMMONS,NC27012	PHYSICIAN CLINIC
9	10 - NH DAVIE MEDICAL ASSOCIATES 485 VALLEY ROAD MOCKSVILLE,NC27028	PHYSICIAN CLINIC
10	11 - NH FORSYTH ENDOCRINE CONSULTANTS 755 HIGHLAND OAKS DRIVE SUITE 201 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
11	12 - NH FORSYTH FAMILY MEDICINE 400 JONESTOWN ROAD WINSTONSALEM,NC27104	PHYSICIAN CLINIC
12	13 - NH FORSYTH INTERNAL MEDICINE 1381 WESTGATE CENTER DRIVE WINSTONSALEM,NC27103	PHYSICIAN CLINIC
13	14 - NH GATEWAY FAMILY MEDICINE 390 SALEM AVENUE WINSTONSALEM,NC27101	PHYSICIAN CLINIC
14	15 - NH HAWTHORNE OUTPATIENT SURGERY 1999 S HAWTHORNE ROAD WINSTONSALEM,NC27103	AMBULATORY SURGERY CENTER
15	16 - NH HILLSDALE MEDICAL ASSOCIATES 121 MEDICAL DRIVE ADVANCE,NC27006	PHYSICIAN CLINIC
16	17 - NH IMAGING KERNERSVILLE 445 PINEVIEW DRIVE SUITE 100 KERNERSVILLE,NC27284	IMAGING CENTER
17	18 - NH IMAGING MAPLEWOOD 3155 MAPLEWOOD AVENUE WINSTONSALEM,NC27103	IMAGING CENTER
18	19 - NH INFECTIOUS DISEASE SPECIALISTS 1381 WESTGATE CENTER DRIVE WINSTONSALEM,NC27103	PHYSICIAN CLINIC
19	20 - NH INPATIENT CARE SPECIALISTS KVILLE 1750 KERNERSVILLE MEDICAL PKWY KERNERSVILLE,NC27284	PHYSICIAN CLINIC
20	21 - NH KERNERSVILLE FAMILY MEDICINE 291 BROAD STREET WINSTONSALEM,NC27284	PHYSICIAN CLINIC
21	22 - NH KERNERSVILLE OUTPATIENT SURGERY 1730 KVILLE MEDICAL PKWY STE 304 KERNERSVILLE,NC27284	AMBULATORY SURGERY CENTER
22	23 - NH LEWISVILLE FAMILY MEDICINE 1225 LEWISVILLE-CLEMMONS ROAD LEWISVILLE,NC27023	PHYSICIAN CLINIC
23	24 - NH LEXINGTON PRIMARY CARE 110 WEST MEDICAL PARK DRIVE LEXINGTON,NC27292	PHYSICIAN CLINIC
24	25 - NH MAPLEWOOD FAMILY MEDICINE ROBINHOOD MEDICAL PLAZA BLDG 100 WINSTONSALEM,NC27106	PHYSICIAN CLINIC
25	26 - NH METCALF RHEUMATOLOGY 1551 WESTBROOK PLAZA DR SUITE 200 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
26	27 - NH MOUNTAINVIEW MEDICAL 216 MOORE ROAD KING,NC27021	PHYSICIAN CLINIC
27	28 - NH NEW GARDEN MEDICAL ASSOCIATES 1941 NEW GARDEN RD SUITES 212 216 GREENSBORO,NC27410	PHYSICIAN CLINIC
28	29 - NH NORTH POINT MEDICAL ASSOCIATES 1995 BETHABARA ROAD WINSTONSALEM,NC27106	PHYSICIAN CLINIC
29	30 - NH NORTHWEST FAMILY MEDICINE 7607 NC HIGHWAY 68 N STE B OAK RIDGE,NC27310	PHYSICIAN CLINIC
30	31 - NH ONCOLOGY SPECIALISTS 1213 LEXINGTON AVENUE STE B LEXINGTON,NC27360	PHYSICIAN CLINIC
31	32 - NH ONCOLOGY SPECIALISTS 1710 KVILLE MEDICAL PKWY STE 116 KERNERSVILLE,NC27284	PHYSICIAN CLINIC
32	33 - NH ONCOLOGY SPECIALISTS 276 OLD MOCKSVILLE ROAD SUITE 800 STATESVILLE,NC28625	PHYSICIAN CLINIC
33	34 - NH ONCOLOGY SPECIALISTS 865 WESTLAKE DRIVE MOUNT AIRY,NC27030	PHYSICIAN CLINIC
34	35 - NH ORTHOPEDICS & SPORTS MEDICINE 211 OLD LEXINGTON RD THOMASVILLE,NC27360	PHYSICIAN CLINIC
35	36 - NH PFAFFTOWN FAMILY MEDICINE 4611 YADKINVILLE ROAD PFAFFTOWN,NC27040	PHYSICIAN CLINIC
36	37 - NH PILOT MOUNTAIN MEDICAL CARE 207 MEDICAL STREET PILOT MOUNTAIN,NC27041	PHYSICIAN CLINIC
37	38 - NH PREMIER MEDICAL ASSOCIATES 3333 BROOKVIEW HILLS BLVD STE 202-204 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
38	39 - NH PSYCHIATRIC MEDICINE 175 KIMEL PARK DRIVE SUITE 100 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
39	40 - NH PSYCHIATRIC MEDICINE 309 PINEYWOOD ROAD THOMASVILLE,NC27360	PHYSICIAN CLINIC
40	41 - NH RHEUMATOLOGY AND ARTHRITIS 1551 WESTBROOK PLAZA DR SUITE 200 WINSTONSALEM,NC27106	PHYSICIAN CLINIC
41	42 - NH SALEM FAMILY MEDICINE 105 VEST MILL CIRCLE WINSTONSALEM,NC27103	PHYSICIAN CLINIC
42	43 - NH SPINE SPECIALISTS 5380 US HIGHWAY 158 SUITE 110 ADVANCE,NC27006	PHYSICIAN CLINIC
43	44 - NH SPORTS MEDICINE 2337 WINTERHAVEN LANE WINSTONSALEM,NC27103	PHYSICIAN CLINIC
44	45 - NH SURRY MEDICAL ASSOCIATES 2133 ROCKFORD ST SUITE 1400 MOUNT AIRY,NC27030	PHYSICIAN CLINIC
45	46 - NH SURRY MEDICAL ASSOCIATES 865 WESTLAKE DRIVE MOUNT AIRY,NC27030	PHYSICIAN CLINIC
46	47 - NH THOMASVILLE MEDICAL ASSOCIATES 309 PINEYWOOD ROAD THOMASVILLE,NC27360	PHYSICIAN CLINIC
47	48 - NH TRIAD ENDOCRINE 500 PINEVIEW DR SUITE 101 KERNERSVILLE,NC27284	PHYSICIAN CLINIC
48	49 - NH UROLOGY 140 KIMEL PARK DR SUITE 100 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
49	50 - NH UROLOGY PARTNERS 1710 KVILLE MEDICAL PKWY STE 201 KERNERSVILLE,NC27284	PHYSICIAN CLINIC
50	51 - NH UROLOGY PARTNERS 2010 BALDWIN LANE WINSTONSALEM,NC27103	PHYSICIAN CLINIC
51	52 - NH VILLAGE POINT FAMILY MEDICINE 7130 VILLAGE MEDICAL CIRCLE CLEMMONS,NC27012	PHYSICIAN CLINIC
52	53 - NH WEST FORSYTH INTERNAL MED & PED 105 STADIUM OAKS DRIVE CLEMMONS,NC27012	PHYSICIAN CLINIC
53	54 - NH WINSTON-SALEM CARDIOLOGY 445 PINEVIEW DRIVE SUITE 220 WINSTONSALEM,NC27284	PHYSICIAN CLINIC
54	55 - NH WINSTON-SALEM HEALTH CARE 175 KIMEL PARK DRIVE SUITE 250 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
55	56 - NH WINSTON-SALEM HEALTH CARE 250 CHARLOIS BLVD WINSTONSALEM,NC27103	PHYSICIAN CLINIC
56	57 - NH WOUND CARE & HYPERBARIC MEDICINE 1901 S HAWTHORNE ROAD SUITE 220 WINSTONSALEM,NC27103	PHYSICIAN CLINIC
57	58 - NH YADKIN MEDICAL ASSOCIATES 305 EAST LEE AVENUE YADKINVILLE,NC27055	PHYSICIAN CLINIC

Schedule H (Form 990) 2018

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
PART I, LINE 3C:	OTHER CRITERIA BESIDES INCOME AND FPG USED IN DETERMINING ELIGIBILITY FOR FREE CARE INCLUDE: (1) RESIDENCY - PATIENTS MUST RESIDE WITHIN THE SERVICE AREA OF THE HOSPITAL; (2) THE KIND OF SERVICE PROVIDED - ONLY MEDICALLY NECESSARY SERVICES ARE COVERED; (3) PATIENT STATUS - IN PROVIDER BASED PHYSICIAN CLINICS, PATIENTS MUST HAVE BEEN TREATED BY AN AFFILIATED MEDICAL GROUP PRIMARY CARE PHYSICIAN WITHIN THE PREVIOUS THREE YEARS; AND (4) ACCESS TO HEALTH CARE COVERAGE - PATIENTS MUST BE UNABLE TO ACCESS EMPLOYER SPONSORED HEALTH PLANS OR ENTITLEMENT PROGRAMS. LASTLY, THE PATIENT MUST BE WITHOUT SUBSTANTIAL LIQUID ASSETS (I.E. CASH-ON-HAND). ASSETS SUCH AS HOUSES, CARS, PENALIZED RETIREMENT SAVINGS FUNDS, ETC. ARE NOT CONSIDERED LIQUID ASSETS. SUBSTANTIAL ASSETS ARE DEFINED AS ENOUGH CASH-ON-HAND TO COVER THE MEDICAL EXPENSES WITHOUT PLACING A HARDSHIP ON THE PATIENT. PATIENTS WITH SPECIAL CIRCUMSTANCES SUCH AS BANKRUPTCY MAY ALSO BE ELIGIBLE FOR CHARITY CARE; DETERMINATION IS MADE ON A CASE BY CASE BASIS UNDER THESE CIRCUMSTANCES.
PART I, LINE 6A:	PART I, LINE 6A:THE ORGANIZATION IS A PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. THE COMMUNITY BENEFIT REPORT, REFERRED TO AS A COMMUNITY IMPACT REPORT, IS PREPARED BY A RELATED ORGANIZATION. NOVANT HEALTH, INC. IS THE PARENT COMPANY AND PRODUCES A COMMUNITY BENEFIT REPORT REPRESENTING THE HEALTH SYSTEM AS A WHOLE. THE REPORT CAN BE FOUND AT HTTPS://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMMUNITY-INVOLVEMENT/COMMUNITY-BENEFIT.ASPX. PLEASE NOTE THAT THE NUMERIC DATA IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT, ITS COMMUNITY HEALTH NEEDS ASSESSMENT OR COMMUNITY BENEFIT IMPLEMENTATION STRATEGY.
PART I, LINE 7:	COSTS REPORTED IN THE TABLE FOR CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AMOUNTS ARE CALCULATED USING AN ENTITY SPECIFIC COST TO CHARGE RATIO BASED ON WORKSHEET 2 (CCR).
PART I, LN 7 COL(F):	PART I, LN 7 COL(F):THE AMOUNT OF BAD DEBT REMOVED FROM TOTAL EXPENSES (DENOMINATOR) WAS $66,870,056
PART II, COMMUNITY BUILDING ACTIVITIES:	THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES ADDRESSES THE UNDERLYING CAUSES OF HEALTH PROBLEMS AND IMPACTS THE HEALTH OF OUR COMMUNITY THROUGH PARTNERSHIPS WITH LOCAL AGENCIES DEDICATED TO IMPROVING THE LIVES OF ALL INDIVIDUALS. OUTREACH INCLUDES PROVIDING SUPPORT TO ORGANIZATIONS SUCH AS LOCAL YMCA'S, UNITED WAY PARTNER AGENCIES, CHAMBERS OF COMMERCE AND OTHER LOCAL COMMUNITY ORGANIZATIONS, ASSISTING WITH COMMUNITY AND COUNTY COALITIONS, AND PROVIDING EDUCATION SEMINARS AND TRAINING FOR COMMUNITY WORKFORCES.
PART III, LINE 2:	IMPLICIT PRICE CONCESSIONS (ANALOGOUS TO BAD DEBT EXPENSE) ARE DETERMINED BASED ON MANAGEMENT'S ASSESSMENT OF CONTRACTUAL AGREEMENTS, DISCOUNT POLICIES, AND HISTORICAL EXPERIENCE.
PART III, LINE 4:	THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS (ANALOGOUS TO BAD DEBT EXPENSE) ON LINE 2 IS CALCULATED USING THE SAME METHODOLOGY AS CHARITY CARE AND OTHER COMMUNITY BENEFITS USING AN ENTITY SPECIFIC COST TO CHARGE RATIO (CCR). FOOTNOTE 2 (ACCOUNTS RECEIVABLE) ON PAGE 7 OF THE AUDITED FINANCIAL STATEMENTS DESCRIBES PRICE CONCESSIONS.
PART III, LINE 8:	THE METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT AS REFLECTED IN THE AMOUNT REPORTED IN PART III, LINE 6 IS DETERMINED BY FOLLOWING THE MEDICARE PRINCIPLES OF ALLOWABLE COSTS. COST FOR THE OVERHEAD DEPARTMENTS ARE STEPPED DOWN TO THE REMAINING COST CENTERS BASED ON STATISTICS FOR EACH OVERHEAD COST CENTER. ONCE THE STEP-DOWN PROCESS IS COMPLETE, A COST TO CHARGE RATIO ("CCR") IS DEVELOPED FOR EACH COST CENTER. THE CCR IS THEN APPLIED TO THE MEDICARE REVENUE BY COST CENTER AND TOTALED. IT SHOULD BE NOTED THAT THE MEDICARE COST REPORTS DO NOT ADDRESS ANY MANAGED CARE MEDICARE REVENUES, COSTS, OR RELATED SHORTFALL. THE TOTAL REVENUES REPORTED AS RECEIVED FROM MEDICARE IN LINE 5 OF SECTION B ARE ONLY REPRESENTATIVE OF MEDICARE FEE FOR SERVICE PAYMENTS RECEIVED. THE ALLOWABLE COSTS ON LINE 6 ARE SIGNIFICANTLY LOWER THAN THE ACTUAL EXPENDITURES. AS SUCH, THE SHORTFALL IS UNDERESTIMATED. EVERY HOSPITAL TREATS MEDICARE PATIENTS. SOME HOSPITALS ARE LOCATED IN HIGH MEDICARE POPULATION AREAS; OTHERS PROVIDE SERVICES DISPROPORTIONATELY USED BY MEDICARE PATIENTS. MEDICARE RATES AND NUMBERS OF MEDICARE PATIENTS ARE NOT NEGOTIATED. AS REIMBURSEMENT RATES DECLINE RELATIVE TO COSTS OF CARE, HOSPITALS CONTINUE TO SERVE THE MEDICARE POPULATION. WITHOUT THIS SERVICE THESE PATIENTS WOULD BECOME AN OBLIGATION ON THE GOVERNMENT. ANY UNREIMBURSED COSTS OF THIS CARE ARE A COMMUNITY BENEFIT PROVIDED BY THE HOSPITAL TO THE COMMUNITY AND GOVERNMENT.
PART III, LINE 9B:	THE ORGANIZATION'S BILLING AND COLLECTIONS POLICY DOES EXPLAIN ACTIONS AGAINST PATIENTS WHO HAVE OUTSTANDING DELINQUENT AMOUNTS, BUT THE POLICY DOES NOT CONTAIN PROVISIONS FOR COLLECTION PRACTICES AGAINST PATIENTS WHO ARE ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY (FAP) BECAUSE FAP ELIGIBLE PATIENTS RECEIVE 100% FREE CARE AND THEREFORE DO NOT RECEIVE BILLS ONCE FAP ELIGIBILITY HAS BEEN ESTABLISHED.
PART VI, LINE 2:	PART VI, LINE 2: NEEDS ASSESSMENTTHE ORGANIZATION IS PART OF NOVANT HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM, WHICH HAS A COMMUNITY BENEFIT DEPARTMENT ("CB DEPARTMENT") COMPRISED OF COMMUNITY BENEFIT PROFESSIONALS AND AN ASSOCIATED ADVISORY WORKING GROUP ("THE COMMUNITY BENEFIT GROUP") THAT INCLUDES REPRESENTATIVES FROM INTERNAL AUDIT, LEGAL, AND TAX. THE CB DEPARTMENT IS RESPONSIBLE FOR COORDINATING THE PREPARATION OF THE COMMUNITY HEALTH NEEDS ASSESSMENTS (CHNA) FOR EACH HOSPITAL WITHIN THE SYSTEM, INCLUDING THE CHNAS REPORTED IN PART V, SECTION B. EACH HOSPITAL AND THE COMMUNITY BENEFIT GROUP WORK TOGETHER TO IDENTIFY ORGANIZATIONS AND RESOURCES WITHIN ITS COMMUNITY THAT CONTRIBUTE TO THE PROCESS. THESE ORGANIZATIONS AND RESOURCES INCLUDE PUBLIC HEALTH DEPARTMENTS, LOCAL COMMUNITY COALITIONS REPRESENTING THE MEDICALLY UNDERSERVED, UNITED WAY, LOCAL UNIVERSITIES, ETC. COMMUNITY HEALTH ASSESSMENTS PREPARED BY OTHER ORGANIZATIONS IN THE COMMUNITY ARE USED IN COMBINATION WITH INTERNAL HOSPITAL DATA AND INFORMATION COLLECTED FROM LOCAL AGENCIES TO PREPARE THE HOSPITAL'S CHNA. IN ADDITION TO ADDRESSING NEEDS IDENTIFIED THROUGH THE CHNA, EACH HOSPITAL MAY RESPOND TO REQUESTS FOR SPECIFIC COMMUNITY BENEFIT ACTIVITIES OR PROGRAMS FROM PUBLIC AGENCIES OR COMMUNITY GROUPS.
PART VI, LINE 3:	PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCETHE ORGANIZATION IS COMMITTED TO PROVIDING OUTSTANDING HEALTHCARE TO ALL MEMBERS OF OUR COMMUNITIES, REGARDLESS OF THEIR ABILITY TO PAY. OUR FINANCIAL COUNSELING TEAMS ARE CONSTANTLY WORKING WITH THE PATIENTS WITHIN OUR COMMUNITIES TO UNDERSTAND THEIR NEEDS AND ENSURE THAT OUR POLICIES AND PROCESSES ADDRESS THESE NEEDS. WE ALSO MAINTAIN CONTRACTS WITH MEDICAID ELIGIBILITY VENDORS AND THESE TEAMS OFFER ADDITIONAL SUPPORT IN PROCESSING AND ASSESSING HOW WE SERVE THE FINANCIAL NEEDS OF OUR PATIENTS. BASED ON THE ASSESSMENTS OF OUR COMMUNITIES, THE ORGANIZATION HAS DEVELOPED FINANCIAL ASSISTANCE POLICIES AND PROGRAMS THAT ADDRESS THE FINANCIAL NEEDS OF OUR PATIENTS. WE PRIDE OURSELVES ON THE TRANSPARENCY OF OUR PROGRAMS AND THE EDUCATION WE OFFER OUR PATIENTS AROUND OUR FINANCIAL ASSISTANCE POLICIES. OUR PROGRAMS ARE DOCUMENTED ON OUR WEBSITE, ALONG WITH CONTACT INFORMATION FOR OUR FINANCIAL COUNSELORS. ADDITIONALLY, OUR PROGRAMS ARE DOCUMENTED ON PATIENT FLYERS THROUGHOUT THE ORGANIZATION'S FACILITIES AND PHYSICIAN OFFICES. OUR PATIENT ACCESS SPECIALISTS, FINANCIAL COUNSELORS AND BUSINESS OFFICE TEAMS WORK WITH ALL ELIGIBLE PATIENTS TO EDUCATE THEM ON THE VARIOUS OPTIONS AVAILABLE VIA OUR FINANCIAL ASSISTANCE PROGRAMS OR GOVERNMENT SPONSORED CARE. THEY ALSO REFERENCE OUR FINANCIAL ASSISTANCE POLICY IN ALL CONVERSATIONS RELATED TO PATIENTS BILLS. FINALLY, WE WORK WITH LOCAL AREA FREE HEALTH CLINICS AND OTHER CHARITABLE ORGANIZATIONS TO PROVIDE CONTINUATION OF CARE FOR THEIR PATIENTS. IN ADDITION TO OUR FINANCIAL COUNSELING PROCESSES USED TO IDENTIFY CHARITY CARE PATIENTS, OUR COLLECTIONS PROCESSES WITHIN OUR BUSINESS OFFICES ALSO HELP IDENTIFY PATIENTS WHO ARE ALREADY ELIGIBLE FOR CHARITY OR WHO MAY BE ELIGIBLE BASED ON THEIR STATUS WITHIN THE FEDERAL POVERTY GUIDELINES ("FPG"). WE UTILIZE PREVIOUSLY SUBMITTED PATIENT DOCUMENTATION AND CREDIT AGENCY REPORTED FPG FOR DETERMINATION. SUPPORTING DOCUMENTS ARE VALID 6 MONTHS FROM THE DATE OF SUBMISSION. OUR POLICIES ARE CONSIDERED FLUID AND ARE UPDATED FREQUENTLY BASED ON LOCAL AND NATIONAL MARKET STANDARDS AND NATIONAL ECONOMIC CONDITIONS. ANY UPDATES TO OUR POLICIES REQUIRE MULTI-LEVEL LEADERSHIP APPROVAL AND ARE ULTIMATELY APPROVED BY THE ORGANIZATION'S BOARD.
PART VI, LINE 4:	PART VI, LINE 4: COMMUNITY INFORMATIONTHE FORSYTH MEMORIAL HOSPITAL, INC. FORM 990 INCLUDES THE OPERATIONS OF ONE LICENSED HOSPITAL WITH FACILITIES IN THREE LOCATIONS: FORSYTH MEMORIAL HOSPITAL, INC. DBA NOVANT HEALTH FORSYTH MEDICAL CENTER, AS NOVANT HEALTH KERNERSVILLE MEDICAL CENTER, AND AS NOVANT HEALTH CLEMMONS MEDICAL CENTER. THE ORGANIZATION DEFINES ITS COMMUNITY BY ITS PRIMARY SERVICE AREA. THE PRIMARY SERVICE AREAS OF THE FACILITIES LISTED ABOVE INCLUDE THE CITY OF WINSTON-SALEM, THE TOWNS OF BETHANIA, KERNERSVILLE, LEWISVILLE, RURAL HALL, WALKERTOWN, AND THE VILLAGE OF CLEMMONS, ALL OF WHICH ARE LOCATED IN FORSYTH COUNTY, NORTH CAROLINA. THE SECONDARY SERVICE AREA COVERS A SEVEN COUNTY RADIUS INCLUDING: DAVIDSON, DAVIE, GUILFORD, STOKES, SURRY, WILKES, AND YADKIN COUNTIES. FORSYTH COUNTY IS MORE URBAN IN NATURE. THE COUNTY CONSISTS OF A LARGE URBAN CENTER SURROUNDED BY SMALLER, MORE RURAL COMMUNITIES. ACCORDING TO THE US CENSUS BUREAU DATA, THE MEDIAN HOUSEHOLD INCOME LEVEL WAS $49,402.ACCORDING TO SG2 DATA, THE SPECIFIC POPULATION GROUPS (ETHNIC AND CULTURAL) FOR THE PRIMARY AND SECONDARY SERVICE AREAS ARE AS FOLLOWS:PRIMARY SERVICE AREAETHNICITY POPULATION % OF POPULATIONWHITE 233,910 58.76%BLACK/AFRICAN AMERICAN 94,848 23.83%HISPANIC/LATINO 50,160 12.60%ASIAN/PACIFIC ISLANDERS 9,946 2.50%OTHER 9,203 2.31%TOTAL POPULATION 398,067 100%SECONDARY SERVICE AREAETHNICITY POPULATION % OF POPULATIONWHITE 560,152 65.90%BLACK/AFRICAN AMERICAN 171,235 20.15%HISPANIC/LATINO 70,425 8.29%ASIAN/PACIFIC ISLANDERS 28,614 3.37%OTHER 19,586 2.30%TOTAL POPULATION 850,012 100%ACCORDING TO SG2 DATA, THE AGE BREAKDOWN FOR THE PRIMARY AND SECONDARY SERVICE AREAS IS AS FOLLOWS:PRIMARY SERVICE AREAETHNICITY POPULATION % OF POPULATION0-17 92,161 23.15%18-64 242,138 60.83%65+ 63,768 16.02%TOTAL POPULATION 398,067 100.00%SECONDARY SERVICE AREAETHNICITY POPULATION % OF POPULATION0-17 186,347 21.92%18-64 514,730 60.56%65+ 148,935 17.52%TOTAL POPULATION 850,012 100.00%THERE ARE FIVE NONPROFIT ACUTE CARE HOSPITAL FACILITIES IN THE COMMUNITY, FOUR OF WHICH ARE PART OF THE NOVANT HEALTH SYSTEM. THERE IS ALSO ONE ACADEMIC TEACHING HOSPITAL.
PART VI, LINE 5:	PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTHTHE ORGANIZATION FURTHERS ITS EXEMPT PURPOSES BY DOING THE FOLLOWING:1. ADOPTING A FINANCIAL ASSISTANCE POLICY;2. REMAINING CERTIFIED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES TO PROVIDE SERVICES TO ALL BENEFICIARIES OF MEDICARE, MEDICAID, AND OTHER GOVERNMENT PAYMENT PROGRAMS, AND PROVIDING SERVICES IN A NONDISCRIMINATORY MANNER TO SUCH BENEFICIARIES;3. OPERATING A FULL-TIME EMERGENCY ROOM WHICH IS OPEN TO AND ACCEPTS ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY;4. MAINTAINING AN OPEN MEDICAL STAFF, SUBJECT TO EXCLUSIVE CONTRACTS FOR HOSPITAL-BASED SERVICES SUCH AS ANESTHESIOLOGY, RADIOLOGY, PATHOLOGY, HOSPITALIST, AND EMERGENCY DEPARTMENT SERVICES, TO THE EXTENT AN EXCLUSIVE CONTRACT FOR THOSE SERVICES IS REQUIRED TO OBTAIN PROPER STAFFING COVERAGE OR TO PERMIT A MORE EFFICIENT DELIVERY OF THOSE SERVICES WITHIN THE HOSPITAL FACILITY;5. MAINTAINING A GOVERNING BOARD CONSISTING PRIMARILY OF A BROAD CROSS-SECTION OF LEADERS IN THE COMMUNITY;6. ADOPTING AND APPLYING A CONFLICT OF INTEREST POLICY, WHICH APPLIES TO THE GOVERNING BOARD AND ORGANIZATION OFFICERS;7. PROVIDING HEALTH EDUCATION LECTURES AND WORKSHOPS;8. PROVIDING HEALTH FAIRS, EDUCATION ON SPECIFIC DISEASES OR CONDITIONS, AND HEALTH PROMOTION AND WELLNESS PROGRAMS TO THE COMMUNITIES IT SERVES;9. PROVIDING SUPPORT GROUPS AND SELF HELP PROGRAMS TO THE COMMUNITIES IT SERVES;10. PROVIDING COMMUNITY-BASED CLINICAL SERVICES, INCLUDING WITHOUT LIMITATION, HEALTH SCREENINGS AND CLINICS FOR UNINSURED OR UNDERINSURED PERSONS TO THE COMMUNITIES IT SERVES;11. PROVIDING HEALTHCARE SUPPORT SERVICES, INCLUDING WITHOUT LIMITATION, INFORMATION AND REFERRAL TO COMMUNITY SERVICES, CASE MANAGEMENT OF UNDERINSURED AND UNINSURED PERSONS, TELEPHONE INFORMATION SERVICES AND ASSISTANCE TO ENROLL IN PUBLIC PROGRAMS, SUCH AS STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP) AND MEDICAID TO THE COMMUNITIES IT SERVES;12. PROVIDING SUBSIDIZED HEALTH SERVICES AND CLINICAL PROGRAMS TO THE COMMUNITIES IT SERVES;13. PROVIDING CASH AND IN-KIND CONTRIBUTIONS TO NONPROFIT COMMUNITY HEALTHCARE ORGANIZATIONS IN THE COMMUNITIES IT SERVES; AND14. GENERALLY PROMOTING THE HEALTH, WELLNESS, AND WELFARE OF THE COMMUNITIES IT SERVES BY PROVIDING QUALITY HEALTHCARE SERVICES AT REASONABLE COST.PLEASE SEE THE NOVANT HEALTH COMMUNITY BENEFIT REPORT, LOCATED AT HTTP://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMPANY-INFORMATION/FINANCIAL-PROFILE/COMMUNITY-BENEFIT-REPORT.ASPX.PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES.
PART VI, LINE 6:	PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEMTHE ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, A NOT-FOR-PROFIT INTEGRATED GROUP OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS AND OTHER HEALTHCARE SERVICE PROVIDERS. NOVANT HEALTH IS RANKED AS ONE OF OUR NATION'S TOP 20 INTEGRATED HEALTHCARE SYSTEMS - CARING FOR PATIENTS AND COMMUNITIES IN NORTH CAROLINA, SOUTH CAROLINA, AND VIRGINIA. EACH HOSPITAL PROVIDES SUBSTANTIAL COMMUNITY BENEFIT TO THE COMMUNITY IT SERVES, AS REPORTED INDIVIDUALLY ON EACH HOSPITAL'S FORM 990, SCHEDULE H. THE COMMUNITY BENEFIT OF THE SYSTEM AS A WHOLE IS DOCUMENTED IN A SYSTEM-WIDE COMMUNITY BENEFIT REPORT, LOCATED AT HTTPS://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMMUNITY-INVOLVEMENT/COMMUNITY-BENEFIT.ASPX. PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT, ITS COMMUNITY HEALTH NEEDS ASSESSMENT OR COMMUNITY BENEFIT IMPLEMENTATION STRATEGY. THERE ARE SIGNIFICANT COMMUNITY BENEFIT ACTIVITIES WITHIN NOVANT HEALTH WHICH MAY NOT BE REPORTABLE ON A SCHEDULE H BECAUSE THEY ARE NOT CONDUCTED BY AN ENTITY WHICH OWNS OR OPERATES A HOSPITAL.IN ADDITION TO HOSPITALS, NOVANT HEALTH INCLUDES A PHYSICIAN ORGANIZATION WITH PRACTICES IN NORTH CAROLINA, SOUTH CAROLINA, AND VIRGINIA AND FIVE HOSPITAL FOUNDATIONS WHICH SUPPORT AND ENHANCE THE ACTIVITIES IN THOSE HOSPITALS' COMMUNITIES. FURTHER, NOVANT HEALTH INCLUDES AMBULATORY SURGERY CENTERS, IMAGING CENTERS, REHABILITATION CENTERS, AND OTHER OUTPATIENT FACILITIES; ALL DEDICATED TO PROMOTING THE HEALTH OF THEIR RESPECTIVE COMMUNITIES.
PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORT	NOVANT HEALTH, INC. FILES A SYSTEM-WIDE COMMUNITY BENEFIT REPORT PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES WITH THE NORTH CAROLINA MEDICAL CARE COMMISSION AS PART OF THE DOCUMENTATION REQUIRED FOR THE ISSUANCE OF TAX EXEMPT BOND FINANCING.

Schedule H (Form 990) 2018

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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

2018

Open to Public
Inspection

Name of the organization
FORSYTH MEMORIAL HOSPITAL INC

Employer identification number
56-0928089

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

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

(a) Name and address of organization or government	(b) EIN	(c) IRC section (if applicable)	(d) Amount of cash grant	(e) Amount of non-cash assistance	(h) Purpose of grant or assistance
(1) ABC OF NC FOUNDATION 905 FRIEDBERG CHURCH ROAD WINSTONSALEM,NC27127	91-1963813	501(C)(3)	15,000	0	COMMUNITY OUTREACH
(2) AMERICAN HEART ASSOCIATION INC 7272 GREENVILLE AVENUE DALLAS,TX75231	13-5613797	501(C)(3)	105,000	0	COMMUNITY OUTREACH
(3) CANCER SERVICES INC 3175 MAPLEWOOD AVENUE WINSTONSALEM,NC27103	56-0656375	501(C)(3)	10,000	0	COMMUNITY OUTREACH
(4) COMMUNITY CARE CENTER FOR FORSYTH COUNTY 2135 NEW WALKERTOWN ROAD WINSTONSALEM,NC27101	58-1403699	501(C)(3)	25,000	0	COMMUNITY OUTREACH
(5) CRISIS CONTROL MINISTRY INC 200 EAST TENTH STREET WINSTONSALEM,NC27101	23-7348168	501(C)(3)	15,000	0	COMMUNITY OUTREACH
(6) DAVIE COMMUNITY FOUNDATION INC 107 N SALISBURY STREET MOCKSVILLE,NC27028	58-1850531	501(C)(3)	11,250	0	COMMUNITY OUTREACH
(7) EXPERIMENT IN SELF-RELIANCE INC PO BOX 135 WINSTONSALEM,NC27102	56-6060100	501(C)(3)	15,000	0	COMMUNITY OUTREACH
(8) FAMILY SERVICES INC 1200 SOUTH BROAD STREET WINSTONSALEM,NC27101	56-0689235	501(C)(3)	25,000	0	COMMUNITY OUTREACH
(9) FORSYTH TECHNICAL COMMUNITY COLLEGE 2100 SILAS CREEK PARKWAY WINSTONSALEM,NC27103	56-1070364	501(C)(3)	100,000	0	COMMUNITY OUTREACH
(10) GREENSBORO AREA CHAMBER OF COMMERCE 111 W FEBRUARY ONE PLACE GREENSBORO,NC27401	56-0245040	501(C)(6)	50,000	0	COMMUNITY OUTREACH
(11) HANDS ON NORTHWEST NORTH CAROLINA 751 WEST FOURTH STREET SUITE 200 WINSTONSALEM,NC27101	26-0824793	501(C)(3)	26,000	0	COMMUNITY OUTREACH
(12) HOSPICE & PALLIATIVE CARECENTER 101 HOSPICE LANE WINSTONSALEM,NC27103	58-1343313	501(C)(3)	12,500	0	COMMUNITY OUTREACH
(13) HOSPITAL HOSPITALITY HOUSE OF WINSTON-SALEM 1970 BALDWIN LANE WINSTONSALEM,NC27103	20-3604576	501(C)(3)	10,000	0	COMMUNITY OUTREACH
(14) INSIGHT HUMAN SERVICES INC 665 WEST FOURTH STREET WINSTONSALEM,NC27101	56-0951129	501(C)(3)	20,000	0	COMMUNITY OUTREACH
(15) JDRF INTERNATIONAL 26 BROADWAY 15TH FL NEW YORK,NY10004	23-1907729	501(C)(3)	15,000	0	COMMUNITY OUTREACH
(16) LEADERSHIP WINSTON-SALEM 624 W SIXTH STREET SUITE 110 WINSTONSALEM,NC27101	58-1574887	501(C)(3)	6,456	0	COMMUNITY OUTREACH
(17) MARCH OF DIMES FOUNDATION 1275 MAMARONECK AVENUE WHITE PLAINS,NY10605	13-1846366	501(C)(3)	13,000	0	COMMUNITY OUTREACH
(18) MEDASSIST OF MECKLENBURG DBA NC MEDASSIST 4428 TAGGART CREEK ROAD CHARLOTTE,NC28208	56-2018957	501(C)(3)	7,500	0	COMMUNITY OUTREACH
(19) NATIONAL CYCLING CENTER INC 145 KIMEL PARK DR WINSTONSALEM,NC27103	47-2950622	501(C)(3)	10,000	0	COMMUNITY OUTREACH
(20) OLD HICKORY COUNCIL INC 6600 SILAS CREEK PKWY WINSTONSALEM,NC27106	56-0529985	501(C)(3)	14,360	0	COMMUNITY OUTREACH
(21) PIEDMONT TRIAD PARTNERSHIP PO BOX 2672 HIGH POINT,NC27261	56-1750279	501(C)(3)	25,000	0	COMMUNITY OUTREACH
(22) RONALD MCDONALD HOUSE OF WINSTON-SALEM 419 S HAWTHORNE ROAD WINSTONSALEM,NC27103	58-1454715	501(C)(3)	10,000	0	COMMUNITY OUTREACH
(23) SAMARITAN MINISTRIES 414 E NORTHWEST BLVD WINSTONSALEM,NC27105	56-1490019	501(C)(3)	10,000	0	COMMUNITY OUTREACH
(24) SECOND HARVEST FOOD BANK OF NORTHWEST NC INC 3655 REED STREET WINSTNSALEM,NC27107	58-1457912	501(C)(3)	20,000	0	COMMUNITY OUTREACH
(25) SENIOR SERVICES INC 2895 SHOREFAIR DRIVE WINSTONSALEM,NC27105	56-1085968	501(C)(3)	45,000	0	COMMUNITY OUTREACH
(26) SUSAN G KOMEN NORTHWEST NC 1106 BURKE STREET WINSTONSALEM,NC27101	75-2891104	501(C)(3)	10,000	0	COMMUNITY OUTREACH
(27) THE SCIENCE CENTER AND ENVIRONMENTAL PARK OF FORSYTH COUNTY DBA SCIWORKS 400 W HANES MILL ROAD WINSTONSALEM,NC27105	56-0815746	501(C)(3)	9,100	0	COMMUNITY OUTREACH
(28) THE SHALOM PROJECT INC 639 SOUTH GREEN STREET WINSTONSALEM,NC27101	20-2136431	501(C)(3)	12,000	0	COMMUNITY OUTREACH
(29) THE SHEPHERD'S CENTER OF KERNERSVILLE INC PO BOX 2044 KERNERSVILLE,NC27285	56-1471510	501(C)(3)	7,500	0	COMMUNITY OUTREACH
(30) UNITED WAY OF FORSYTH COUNTY INC 301 N MAIN STREET SUITE 1700 WINSTONSALEM,NC27101	23-7357234	501(C)(3)	40,000	0	COMMUNITY OUTREACH
(31) UNIVERSITY OF NORTH CAROLINA SCHOOL OF THE ARTS FOUNDATION INC 1533 SOUTH MAIN STREET WINSTONSALEM,NC27127	56-6064850	501(C)(3)	8,300	0	COMMUNITY OUTREACH
(32) WAKE FOREST UNIVERSITY HEALTH SCIENCES MEDICAL CENTER BLVD WINSTONSALEM,NC27157	22-3849199	501(C)(3)	150,000	0	COMMUNITY OUTREACH
(33) WINSTON-SALEM ALLIANCE 100 N MAIN STREET WINSTONSALEM,NC27101	31-1726654	501(C)(6)	35,000	0	COMMUNITY OUTREACH
(34) WINSTON-SALEM FOUNDATION 751 WEST FOURTH STREET SUITE 200 WINSTONSALEM,NC27101	56-6037615	501(C)(3)	50,500	0	COMMUNITY OUTREACH
(35) WINSTON-SALEM POLICE FOUNDATION INC PO BOX 24011 WINSTONSALEM,NC27114	47-5289473	501(C)(3)	25,000	0	COMMUNITY OUTREACH
(36) WINSTON-SALEM SYMPHONY ASSOCIATION 201 NORTH BROAD STREET SUITE 200 WINSTONSALEM,NC27101	56-0692826	501(C)(3)	15,000	0	COMMUNITY OUTREACH
(37) YOUNG MEN'S CHRISTIAN ASSOCIATION OF NORTHWEST NORTH CAROLINA 301 N MAIN STREET SUITE 1900 WINSTONSALEM,NC27101	56-0530015	501(C)(3)	16,000	0	COMMUNITY OUTREACH
(38) MORAVIAN HOME INCORPORATED 1000 SALEMTOWNE DRIVE WINSTONSALEM,NC27106	56-0963926	501(C)(3)	40,000		COMMUNITY OUTREACH

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2018

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) PATIENT ASSISTANCE	22	20,840
(2) MEDICATION FOR INDIGENT PATIENTS	551		36,231	FMV	MEDICATION FOR INDIGENT PATIENTS
(3) PATIENT TRANSPORTATION	3085		47,702	FMV	CAB FARES FOR INDIGENT PATIENTS
(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

PART I, LINE 2 : PROCEDURES FOR MONITORING THE USE OF THE GRANT FUNDS

THE FILING ORGANIZATION IS PART OF THE INTEGRATED HEALTHCARE SYSTEM OPERATED BY NOVANT HEALTH, INC. ("NOVANT HEALTH"), THE PARENT ORGANIZATION. NOVANT HEALTH'S BYLAWS AUTHORIZE IT TO ESTABLISH CERTAIN POLICIES FOR ALL OF ITS SUBSIDIARIES WITHIN THE SYSTEM. NOVANT HEALTH HAS ESTABLISHED A SYSTEM-WIDE CORPORATE POLICY WITH STANDARDIZED GUIDELINES THAT ARE TO BE USED IN REVIEWING THE ELIGIBILITY AND SELECTION OF GRANTEES RECEIVING CERTAIN EXEMPT PURPOSE FUNDS. THE FILING ORGANIZATION MAINTAINS DOCUMENTATION OF THE ELIGIBILITY AND SELECTION CRITERIA AND RECORDS OF THE AMOUNTS ARE MAINTAINED VIA THE GENERAL LEDGER. FUNDS ARE GENERALLY NOT TRACKED AFTER BEING GRANTED, AS THE ORIGINAL ELIGIBILITY AND SELECTION CRITERIA HAVE ALREADY BEEN MET.

Schedule I (Form 990) 2018

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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

2018

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Yes

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

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2018

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1EDWARDS JOEL MD TRUSTEE	(i) (ii)	391,343 ------------- 0	125,621 ------------- 0	32,003 ------------- 0	16,500 ------------- 0	19,980 ------------- 0	585,447 ------------- 0	0 ------------- 0
2MORRIS JOHN ASST SEC	(i) (ii)	0 ------------- 258,746	0 ------------- 101,077	0 ------------- 33,207	0 ------------- 24,000	0 ------------- 23,612	0 ------------- 440,642	0 ------------- 7,500
3SANZ SEAN FMR PRES & COO	(i) (ii)	85,208 ------------- 0	257,849 ------------- 0	84,148 ------------- 0	15,201 ------------- 0	8,959 ------------- 0	451,365 ------------- 0	25,550 ------------- 0
4SETLIFF MICHAEL PRES & COO FMH INCL KMC	(i) (ii)	324,981 ------------- 0	168,313 ------------- 0	35,758 ------------- 0	45,450 ------------- 0	28,030 ------------- 0	602,532 ------------- 0	0 ------------- 0
5SMITH HARRY SVP HOSPITAL OPERATIONS	(i) (ii)	0 ------------- 590,928	0 ------------- 386,327	0 ------------- 153,754	0 ------------- 116,199	0 ------------- 37,965	0 ------------- 1,285,173	0 ------------- 84,750
6BRIGHT JANET CNO	(i) (ii)	185,469 ------------- 0	36,075 ------------- 0	25,143 ------------- 0	7,446 ------------- 0	10,655 ------------- 0	264,788 ------------- 0	0 ------------- 0
7MOTEW STEPHEN SVP	(i) (ii)	457,344 ------------- 0	275,852 ------------- 0	134,176 ------------- 0	95,850 ------------- 0	30,585 ------------- 0	993,807 ------------- 0	63,750 ------------- 0
8NYCUM LAWRENCE SVP	(i) (ii)	437,172 ------------- 0	268,532 ------------- 0	85,738 ------------- 0	92,949 ------------- 0	31,198 ------------- 0	915,589 ------------- 0	35,625 ------------- 0
9ROYSTER KIRSTEN PRES & COO KMC	(i) (ii)	7,398 ------------- 260,633	0 ------------- 131,192	20,237 ------------- 17,224	21,591 ------------- 0	817 ------------- 10,546	50,043 ------------- 419,595	0 ------------- 0
10BRAVO JULIO RHEUMATOLOGIST	(i) (ii)	450,437 ------------- 0	296,199 ------------- 0	28,518 ------------- 0	23,688 ------------- 0	37,880 ------------- 0	836,722 ------------- 0	7,500 ------------- 0
11MCDONALD COLIN NEUROLOGIST	(i) (ii)	390,729 ------------- 0	17,205 ------------- 0	318,595 ------------- 0	16,500 ------------- 0	42,034 ------------- 0	785,063 ------------- 0	0 ------------- 0
12NOUREDDINE NIZAR CARDIOLOGIST	(i) (ii)	461,490 ------------- 0	225,200 ------------- 0	32,321 ------------- 0	22,533 ------------- 0	36,375 ------------- 0	777,919 ------------- 0	7,500 ------------- 0
13PRELI ROBERT CARDIOLOGIST	(i) (ii)	478,472 ------------- 0	219,466 ------------- 0	30,339 ------------- 0	24,000 ------------- 0	36,397 ------------- 0	788,674 ------------- 0	7,500 ------------- 0
14ZEYLIKMAN YURIY NEUROLOGIST	(i) (ii)	358,868 ------------- 0	14,320 ------------- 0	634,858 ------------- 0	24,000 ------------- 0	34,811 ------------- 0	1,066,857 ------------- 0	0 ------------- 0
15LINDSAY JEFFERY FMR PRES - FMH/COO WS MKT	(i) (ii)	0 ------------- 915,320	0 ------------- 762,396	0 ------------- 228,118	0 ------------- 24,000	0 ------------- 30,246	0 ------------- 1,960,080	0 ------------- 7,500
16MIHAL DENISE FMR PRES - FMH/COO WS MKT	(i) (ii)	0 ------------- 676,022	0 ------------- 583,872	0 ------------- 197,524	0 ------------- 24,000	0 ------------- 19,808	0 ------------- 1,501,226	0 ------------- 7,500
17GREGORY CHERE FMR SVP	(i) (ii)	0 ------------- 406,827	0 ------------- 250,606	0 ------------- 85,748	0 ------------- 78,427	0 ------------- 31,771	0 ------------- 853,379	0 ------------- 60,000
18JARRETT-PULLIAM KIMBERLY FMR CNO	(i) (ii)	0 ------------- 132,377	0 ------------- 182,864	0 ------------- 26,891	0 ------------- 16,173	0 ------------- 7,761	0 ------------- 366,066	0 ------------- 0

Schedule J (Form 990) 2018

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
PART I, LINE 1A	FRINGE OR EXPENSE EXPLANATION FIRST-CLASS OR CHARTER TRAVEL: FIRST-CLASS OR CHARTER TRAVEL IS NOT A COVERED TRAVEL EXPENSE FOR EXECUTIVES; THEY ARE LIMITED TO BUSINESS OR COACH CLASS FARES FOR COMMERCIAL FLIGHTS. HOWEVER, CHARTER TRAVEL IS AVAILABLE TO CERTAIN EXECUTIVES, BOARD MEMBERS, AND APPROVED BUSINESS PERSONNEL MEETING APPLICABLE POLICY CRITERIA. TRAVEL FOR COMPANIONS: COMPANIONS ARE ALLOWED ON CERTAIN CHARTER FLIGHTS PAID FOR BY THE ORGANIZATION. IN THAT CASE, THE VALUE OF THE COMPANION'S FLIGHT IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. DISCRETIONARY SPENDING ACCOUNT: CERTAIN EXECUTIVES RECEIVE A DISCRETIONARY SPENDING ACCOUNT. THE DOLLAR AMOUNT IN THE ACCOUNT IS PRE-APPROVED BY THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE NOVANT HEALTH BOARD OF TRUSTEES. THE ACCOUNT CAN BE USED ONLY FOR AN APPROVED LIST OF EXPENDITURES. ALL OPTIONS OTHER THAN A DEFERRED, AT-RISK, COMPENSATION OPTION ARE CONSIDERED TAXABLE AND ARE INCLUDED IN THE EXECUTIVE'S TAXABLE INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE: WE PROVIDE TEMPORARY HOUSING ALLOWANCES IN CERTAIN EXECUTIVE RECRUITMENT AND RELOCATION PACKAGES. THE VALUE IS CALCULATED UNDER APPLICABLE TAX LAWS AND THAT AMOUNT IS INCLUDED IN THE EXECUTIVE'S INCOME AS PRESCRIBED BY THE APPLICABLE TAX LAWS.
PART I, LINE 3	THE FILING ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, AN INTEGRATED HEALTHCARE SYSTEM AND RELIES UPON NOVANT HEALTH, INC., THE PARENT ORGANIZATION, TO USE THE PROCESS DESCRIBED IN PART VI, LINE 15A/15B OF THIS RETURN TO ESTABLISH COMPENSATION FOR CERTAIN EXECUTIVES. THIS PROCESS ADHERES TO THE REQUIREMENTS SET FORTH TO SECURE THE REBUTTABLE PRESUMPTION OF REASONABLENESS AND INCLUDES A REVIEW AND APPROVAL BY INDEPENDENT AND DISINTERESTED MEMBERS OF A COMPENSATION COMMITTEE, CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, THE UTILIZATION OF THIRD-PARTY COMPARABILITY DATA SUCH AS PUBLISHED COMPENSATION SURVEYS, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION.
PART I, LINE 4B	PART I, LINES 4A-C: SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SEVERANCE NONQUALIFIED EQUITY-BASED GREGORY, CHERE MD 52,500 MOTEW, STEPHEN 56,250 NYCUM, LAWRENCE 28,125 SANZ, SEAN 25,550 SMITH, HARRY 77,250
PART I, LINE 4A - SEVERANCE PLAN:	ELIGIBLE EXECUTIVES MAY RECEIVE SEVERANCE PAY THAT IS BASED ON ANNUAL COMPENSATION FOR A SPECIFIED PERIOD OF TIME. THE SEVERANCE PAY WOULD BE PAID ONLY IN THE EVENT OF CERTAIN TYPES OF EMPLOYMENT TERMINATION, AND IS FURTHER CONTINGENT ON THE SATISFACTION OF OTHER CONDITIONS SUCH AS COMPLIANCE WITH A NON-COMPETITION COVENANT. ANY CURRENT YEAR PAYMENTS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(III) OF SCHEDULE J. THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE NOVANT HEALTH BOARD REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS SEVERANCE PLAN.
PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS:	THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("SERP") IS INTENDED TO SUPPORT RETENTION OF KEY EXECUTIVES, AND TO OFFER COMPETITIVE TOTAL COMPENSATION. ELIGIBLE EXECUTIVES WILL BE NOMINATED BY THE CEO AND APPROVED BY THE NOVANT HEALTH COMPENSATION AND LEADERSHIP COMMITTEE ("THE COMMITTEE") TO PARTICIPATE. GENERALLY, ANNUAL CONTRIBUTIONS TO THE PLAN OR PAYMENTS TO PARTICIPANTS WILL BE BASED ON A PERCENTAGE OF THE PARTICIPANT'S BASE SALARY AS OF JANUARY 1ST OF THE PREVIOUS PLAN YEAR AND ARE REPORTED IN COLUMN (C) OF SCHEDULE J. PRIOR TO MAKING THE CONTRIBUTIONS OR PAYMENTS, THE COMMITTEE WILL APPROVE THE AMOUNTS AS TO REASONABLENESS, WHEN COMBINED WITH ALL OTHER ANNUAL COMPENSATION. A 3 YEAR CLASS-YEAR VESTING PERIOD WILL APPLY UP TO AGE 62, WHEN ALL MONEY WOULD BE VESTED AND PAID OUT TO THE PARTICIPANT. OTHERWISE, VESTING WILL OCCUR ON JANUARY 1ST OF EACH YEAR FOR THE APPROPRIATE CLASS-YEAR VESTING PERIOD. THE COMMITTEE REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS.

Schedule J (Form 990) 2018

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

Return Reference	Explanation
FORM 990, PI, L1: ORGANIZATION'S MISSION OR MOST SIGNIFICANT ACTIVITIES	FORSYTH MEMORIAL HOSPITAL, INC. DOING BUSINESS AS NOVANT HEALTH FORSYTH MEDICAL CENTER ("NHFMC"), NOVANT HEALTH CLEMMONS MEDICAL CENTER ("NHCMC") AND NOVANT HEALTH KERNERSVILLE MEDICAL CENTER ("NHKMC") IS AN INTEGRAL PART OF THE NOVANT HEALTH SYSTEM (COLLECTIVELY KNOWN AS "NOVANT HEALTH"), A NOT-FOR-PROFIT INTEGRATED GROUP OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS AND OTHER HEALTHCARE SERVICE PROVIDERS. NOVANT HEALTH CONSISTS OF MORE THAN 1,600 PHYSICIANS AND OVER 28,000 EMPLOYEES WHO MAKE HEALTHCARE REMARKABLE AT OVER 640 LOCATIONS, INCLUDING 15 MEDICAL CENTERS AND HUNDREDS OF OUTPATIENT FACILITIES AND PHYSICIAN CLINICS. HEADQUARTERED IN WINSTON-SALEM, NC, NOVANT HEALTH IS COMMITTED TO MAKING HEALTHCARE REMARKABLE FOR PATIENTS AND COMMUNITIES, SERVING MORE THAN FOUR MILLION PATIENTS ANNUALLY. NOVANT HEALTH IS RANKED AS ONE OF THE NATION'S TOP 25 INTEGRATED HEALTH SYSTEMS BY SK&A. IN 2018, THE NOVANT HEALTH SYSTEM REPORTED $5 BILLION IN REVENUES. GENERAL INFORMATION NOVANT HEALTH FORSYTH MEDICAL CENTER, NOVANT HEALTH CLEMMONS MEDICAL CENTER, AND NOVANT HEALTH KERNERSVILLE MEDICAL CENTER EXIST TO IMPROVE THE HEALTH OF THE COMMUNITIES THEY SERVE WITH A VISION OF PROVIDING A REMARKABLE PATIENT EXPERIENCE IN EVERY DIMENSION, EVERY TIME. THEY ACCOMPLISH THAT MISSION BY PROVIDING HEALTHCARE SERVICES TO ALL WHO ENTRUST THEIR CARE TO THEM AND BY SUPPORTING THE GREATER WINSTON SALEM, CLEMMONS AND KERNERSVILLE, NC COMMUNITIES THROUGH PARTNERSHIPS AND OUTREACH. THE HOSPITALS SUPPORT ORGANIZATIONS THAT PROVIDE HEALTH SERVICES, EDUCATION AND ASSISTANCE TO THE UNINSURED AND THE OVERALL COMMUNITY. IN ITS SEVENTH FULL YEAR OF OPERATION, NOVANT HEALTH FORSYTH MEDICAL CENTER AFFILIATE HOSPITAL, NOVANT HEALTH KERNERSVILLE MEDICAL CENTER IN KERNERSVILLE, NC FOCUSED ON PROVIDING A REMARKABLE PATIENT EXPERIENCE VIA A FAST-ACCESS EMERGENCY DEPARTMENT, GENERAL, ORTHOPEDIC AND EYE SURGICAL SERVICES, CONSISTENT QUALITY, AND EXCELLENT SERVICE TO RESIDENTS IN THE KERNERSVILLE AREA, WESTERN GUILFORD AND ROCKINGHAM COUNTIES OF NORTH CAROLINA, AS WELL AS EASTERN STOKES AND FORSYTH COUNTIES OF NORTH CAROLINA. NOVANT HEALTH FORSYTH MEDICAL CENTER'S AFFILIATE HOSPITAL, NOVANT HEALTH CLEMMONS MEDICAL CENTER IN CLEMMONS, NC FOCUSED ON PROVIDING A REMARKABLE PATIENT EXPERIENCE VIA A FAST-ACCESS EMERGENCY DEPARTMENT, GENERAL, ORTHOPEDIC, PODIATRIC, TRANSITIONAL/INFUSION SERVICES AND EAR, NOSE AND THROAT SURGICAL SERVICES, PROVIDING CONSISTENT QUALITY AND EXCELLENT SERVICE TO RESIDENTS IN WESTERN FORSYTH COUNTY, DAVIE COUNTY AND YADKIN COUNTY OF NORTH CAROLINA. IN ADDITION TO OUR QUALITY OF SERVICES AND COMPREHENSIVE CATEGORIES OF SERVICES, WE'RE VERY PROUD OF OUR PATIENT FINANCIAL ASSISTANCE PROGRAM. WE WORK WITH PATIENTS TO HELP QUALIFY THEM FOR PUBLIC ASSISTANCE, ESTABLISH A REASONABLE PAYMENT PLAN, DISCOUNT THEIR BILL, OR PROVIDE FREE CARE FOR THOSE THAT QUALIFY FOR FINANCIAL ASSISTANCE. COMMUNITY OUTREACH COMMUNITY OUTREACH IS A CRITICAL COMPONENT TO THE MISSION OF NOVANT HEALTH FORSYTH MEDICAL CENTER, NOVANT HEALTH KERNERSVILLE MEDICAL CENTER, AND NOVANT HEALTH CLEMMONS MEDICAL CENTER. EACH YEAR, OUR PHYSICIANS, NURSES AND STAFF HOLD SCREENINGS, TEACH PROGRAMS, HOST SEMINARS AND VOLUNTEER COUNTLESS HOURS TO HELP IMPROVE THE LIVES OF THOSE IN THE TRIAD AND SURROUNDING COUNTIES IN MANY UNIQUE WAYS. A FEW EXAMPLES OF THIS ARE AS FOLLOWS: FREE COMMUNITY SCREENINGS - IN 2018, NOVANT HEALTH FORSYTH MEDICAL CENTER HELD 426 FREE SCREENING EVENTS THAT SERVED MORE THAN 4,300 SCREENING PARTICIPANTS. LOCATIONS INCLUDE NOVANT HEALTH TRIAD CAMPUSES, LOCAL PUBLIC SCHOOLS, YMCA/YWCA, HOMELESS SHELTERS, CORPORATIONS, FAITH COMMUNITIES, AND SENIOR CENTERS. THE VARIOUS EVENTS SCREENED FOR A1C, ABI, BONE DENSITY, BLOOD PRESSURE, BREAST CANCER AND HEART HEALTH. COMMUNITY EDUCATION - AS ACTIVE COMMUNITY PARTNERS, NOVANT HEALTH FORSYTH MEDICAL CENTER, NOVANT HEALTH CLEMMONS MEDICAL CENTER, AND NOVANT HEALTH KERNERSVILLE MEDICAL CENTER REGULARLY HOST AND/OR DELIVER GENERAL HEALTH EDUCATION SESSIONS AND WELLNESS PROGRAMS THROUGHOUT THE YEAR. IN 2018, 431 FREE EDUCATIONAL EVENTS SERVED MORE THAN 9,000 INDIVIDUALS. LOCATIONS INCLUDE CAMPUS FACILITIES, PUBLIC SCHOOLS, YMCA/YWCA, RECREATION CENTERS, PUBLIC LIBRARIES, SENIOR CENTERS, CORPORATIONS, HOMELESS SHELTERS, FAITH COMMUNITIES, AND NEIGHBORHOOD EVENTS. IN 2018, NEARLY 700 WELLNESS COACH SESSIONS WERE PROVIDED WITH A CERTIFIED COACH, EITHER IN 1:1 OR GROUP SETTINGS. SUPPORT GROUPS - NOVANT HEALTH FORSYTH MEDICAL CENTER AND NOVANT HEALTH KERNERSVILLE MEDICAL CENTER HOST A FULL RANGE OF SUPPORT GROUPS THAT PROVIDE EMOTIONAL SUPPORT SERVICES TO THOSE IMPACTED BY A VARIETY OF CHRONIC DISEASES AND HEALTHCARE ISSUES. FROM DIABETES AND WEIGHT MANAGEMENT, PROSTATE CANCER AND NURSING MOTHERS BREASTFEEDING, THE HOSPITALS OFFER OPPORTUNITIES FOR INDIVIDUALS TO MAKE CONNECTIONS WITH OTHERS FACING SIMILAR HEALTH ISSUES AND CHALLENGES. ALL SUPPORT GROUPS ARE FREE AND OPEN TO ANYONE IN THE COMMUNITY. IN 2018, 81 SUPPORT GROUPS WERE PROVIDED TO MORE THAN 2,000 ATTENDEES.
FORM 990, PART I, LINE 1	ARTS & HEALING - NOVANT HEALTH FORSYTH MEDICAL CENTER OFFERS HEALING THROUGH MUSIC IN THE FORM OF PARTNERSHIPS WITH THE WINSTON-SALEM SYMPHONY AS WELL AS VOLUNTEER PERCUSSIONISTS AND PIANISTS. MUSIC IS AVAILABLE WEEKLY WHERE MUSICIANS ROTATE THROUGH LOBBY AND PATIENT CARE AREAS, INCLUDING PALLIATIVE SPACES. HEALING IS ALSO AVAILABLE IN THE FORM OF ART CLASSES, WHICH ARE HELD WEEKLY FOR EXPECTANT MOTHERS IN THE ANTE-PARTUM UNIT. SCHOOL PARTNERSHIPS - NOVANT HEALTH HAS PARTNERED WITH THE DAVIE, DAVIDSON AND ROWAN-SALISBURY SCHOOL SYSTEMS TO PROVIDE ATHLETIC TRAINERS AND RAPID PHYSICIAN ACCESS TO 14 SCHOOLS. THESE ATHLETIC TRAINERS PROVIDE ONGOING SPORTS PERFORMANCE, INJURY AND SAFETY MANAGEMENT THROUGH THE SCHOOL YEAR TO STUDENT ATHLETES. AS PART OF THIS INITIATIVE, NOVANT HEALTH DONATED AUTOMATED EXTERNAL DEFIBRILLATORS TO PARTNER SCHOOLS SO THAT THEY ARE BETTER EQUIPPED TO MANAGE ON-CAMPUS MEDICAL EMERGENCIES. NOVANT HEALTH KERNERSVILLE MEDICAL CENTER, THE COMMUNITY'S FIRST HOSPITAL, OPENED IN MARCH 2011 AND IS A STATE-OF-THE-ART MEDICAL/SURGICAL FACILITY WITH 50 IN-PATIENT ROOMS, AN EMERGENCY DEPARTMENT WHICH IS OPEN 24/7, CRITICAL CARE BEDS AND SURGICAL SUITES. SOME KEY SERVICES INCLUDE: INTERMEDIATE CARE UNIT - NEWLY EXPANDED IN 2018, KERNERSVILLE MEDICAL CENTER HAS AN INTERMEDIATE CARE UNIT TO BRIDGE THE GAP BETWEEN THE INTENSIVE CARE UNIT AND THE MEDICAL/SURGICAL FLOOR. THIS UNIT HAS 12 BEDS AND PROVIDES SPECIALTY CARE FOR PATIENTS IN THE KERNERSVILLE COMMUNITY. TRANSITIONAL CARE & INFUSION SERVICES - KERNERSVILLE MEDICAL CENTER HAS ALSO ADDED TRANSITIONAL CARE, WHICH IS A NEW HEALTHCARE DELIVERY MODEL THAT ALLOWS PATIENTS TO RECEIVE CARE AT THE MEDICAL CENTER DURING THE DAY AND GO HOME AT NIGHT. THIS MODEL LEADS TO SHORTER HOSPITAL STAYS AND LOWER HEALTHCARE COSTS. DURING A TRANSITIONAL CARE APPOINTMENT, PROVIDERS EVALUATE A PATIENT'S SYMPTOMS, PROVIDE MEDICATIONS IF NEEDED, ORDER ANY NECESSARY TESTS AND ANSWER ANY QUESTIONS A PATIENT MAY HAVE. RESPIRATORY AND PULMONARY SERVICES - KERNERSVILLE MEDICAL CENTER SPECIALISTS TREAT A WIDE RANGE OF RESPIRATORY AND PULMONARY DISEASES AND CONDITIONS INCLUDING: ASTHMA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), EMPHYSEMA, LUNG CANCER, PNEUMONIA, SLEEP APNEA, SNORING AND MANY OTHERS. BREAST CENTER - NOVANT HEALTH BREAST CENTER OFFERS COMPREHENSIVE BREAST HEALTH CARE, INCLUDING MAMMOGRAPHY SCREENINGS, DIAGNOSTIC AND STEREOTACTIC PROCEDURES, BIOPSIES, CHEMOTHERAPY, RADIATION TREATMENT AND GENERAL AND PLASTIC SURGERY. NOVANT HEALTH KERNERSVILLE MEDICAL OFFICE BUILDING AND OUTPATIENT SURGERY CENTER - IN FALL 2016, NOVANT HEALTH BEGAN CONSTRUCTION ON A MEDICAL OFFICE BUILDING LOCATED ON THE CAMPUS OF NOVANT HEALTH KERNERSVILLE MEDICAL CENTER. THE NEW BUILDING, COMPLETED IN 2017, IS 60,000 SQUARE FEET AND HOUSES PHYSICIAN OFFICES AND SUITES, TWO OPERATING ROOMS AND A PROCEDURE ROOM. THE AMBULATORY SURGERY CENTER, LOCATED ON THE SECOND FLOOR OF THE MEDICAL OFFICE BUILDING WAS COMPLETED IN 2018. NOVANT HEALTH CLEMMONS MEDICAL CENTER BEGAN CONSTRUCTION ON A THREE-STORY, 60,000-SQUARE-FOOT MEDICAL OFFICE BUILDING THAT WILL SERVE AS A MULTI-SPECIALTY AMBULATORY SURGICAL CENTER FOR COMMUNITY MEMBERS. THE AMBULATORY SURGICAL CENTER MODEL LEADS TO SHORTER HOSPITAL STAYS AND LOWER HEALTHCARE COSTS FOR CLEMMONS PATIENTS. NEW TECHNOLOGY & SERVICES A CONCURRENT ELECTRONIC HEALTH RECORD (EHR) INITIATIVE HAS BEEN IMPLEMENTED BY BOTH THE ACUTE AND AMBULATORY FACILITIES IN THE NOVANT HEALTH SYSTEM. CLINICIANS CAN SHARE PATIENTS' MEDICAL INFORMATION BETWEEN PHYSICIAN OFFICES, OUTPATIENT CENTERS AND HOSPITALS. THIS SHARING OF INFORMATION IMPROVES SAFETY AND COORDINATION OF CARE AND PROMOTES CONNECTIVITY AND COMMUNICATION BETWEEN HOSPITAL CAREGIVERS, SPECIALISTS AND PRIMARY CARE PROVIDERS. EMBARKING ON THE JOURNEY TO CREATE A SHARED EHR IS THE MOST SIGNIFICANT AND IMPORTANT INVESTMENT NOVANT HEALTH HAS EVER MADE FOR ITS PATIENTS, AND TEAM MEMBERS. AWARDS, RECOGNITIONS & CERTIFICATIONS/RECERTIFICATIONS NATIONAL COMMITTEE FOR QUALITY ASSURANCE - THE HEART STROKE RECOGNITION PROGRAM (HSRP) ASSESSES KEY QUALITY PERFORMANCE MEASURES THAT ARE BASED ON NATIONAL EVIDENCE BASED GUIDELINES FOR SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE AND STROKE. PROGRAM MEASURES INCLUDE BLOOD PRESSURE CONTROL, USE OF ASPIRIN, SMOKING AND TOBACCO USE CESSATION ASSISTANCE, BODY MASS INDEX SCREENING, AND MORE. NATIONAL COMMITTEE FOR QUALITY ASSURANCE - PATIENT-CENTERED MEDICAL HOME RECOGNITION NCQA'S PATIENT-CENTERED MEDICAL HOME PREVALIDATION PROGRAM EVALUATES ELECTRONIC HEALTH RECORD (EHR) SYSTEMS, ADVANCED REGISTRIES, POPULATION HEALTH MANAGEMENT TOOLS AND OTHER RELATED TECHNOLOGY SOLUTIONS TO IDENTIFY ALIGNMENT WITH PATIENT-CENTERED MEDICAL HOME RECOGNITION STANDARDS REQUIREMENT. AWARDS INCLUDE: GET WITH THE GUIDELINES STROKE AWARDS NOVANT HEALTH FORSYTH MEDICAL CENTER: GOLD PLUS WITH TARGET STROKE ELITE PLUS HONOR ROLL GET WITH THE GUIDELINES HEART FAILURE AWARDS NOVANT HEALTH FORSYTH MEDICAL CENTER: GOLD PLUS WITH TARGET HEART FAILURE HONOR ROLL
FORM 990, PART I, LINE 1	HEALTH INFORMATION AND MANAGEMENT SYSTEMS SOCIETY (HIMSS) STAGE 7 ACUTE CARE AWARD - THIS RECOGNITION REPRESENTS NOVANT HEALTH KERNERSVILLE MEDICAL CENTER'S ACHIEVEMENT OF THE HIGHEST LEVEL ON THE ELECTRONIC MEDICAL RECORD ADOPTION MODEL (EMRAM), WHICH MEANS THAT WE ARE UTILIZING ELECTRONIC MEDICAL RECORD TECHNOLOGY TO ITS FULLEST POTENTIAL TO PROVIDE ACCESS AND CARE TO OUR PATIENTS. LEADERS IN LGBTQ HEALTHCARE EQUALITY - NOVANT HEALTH FORSYTH MEDICAL CENTER AND NOVANT HEALTH KERNERSVILLE MEDICAL CENTER HAVE BEEN RECOGNIZED AS "LEADER IN LGBTQ HEALTHCARE EQUALITY" BY THE HUMAN RIGHTS CAMPAIGN FOUNDATION, THE EDUCATIONAL ARM OF THE COUNTRY'S LARGEST LESBIAN, GAY, BISEXUAL AND TRANSGENDER CIVIL RIGHTS ORGANIZATION. FACILITIES AWARDED THIS TITLE MEET KEY CRITERIA, INCLUDING PATIENT AND EMPLOYEE NONDISCRIMINATION POLICIES, A GUARANTEE OF EQUAL VISITATION FOR SAME-SEX PARTNERS AND PARENTS, AND LGBTQ HEALTH EDUCATION FOR KEY STAFF MEMBERS. ADDITIONAL CERTIFICATIONS FOR FORSYTH MEDICAL CENTER INCLUDE: - AMERICAN ASSOCIATION FOR CARDIOVASCULAR AND PULMONARY REHABILITATION - AMERICAN DIABETES ASSOCIATION - SELF MANAGEMENT EDUCATION RECOGNITION - CENTER OF EXCELLENCE IN MINIMALLY INVASIVE GYNECOLOGY (AAGL) - INTERNATIONAL ASSOCIATION FOR HEALTHCARE SECURITY AND SAFETY - NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE - MEDICAID - ONCOLOGY REHAB PARTNERS STAR PROGRAM CERTIFICATION - THE JOINT COMMISSION - HIP FRACTURE CERTIFICATION - THE JOINT COMMISSION - TOTAL HIP JOINT REPLACEMENT CERTIFICATION - THE JOINT COMMISSION - ADVANCED PALLIATIVE CARE PROGRAM CERTIFICATION - THE JOINT COMMISSION - COMPREHENSIVE STROKE CENTER - THE JOINT COMMISSION - MINIMALLY INVASIVE COLORECTAL SURGERY CENTER ADDITIONAL CERTIFICATIONS FOR KERNERSVILLE MEDICAL CENTER INCLUDE: - INTERNATIONAL ASSOCIATION FOR HEALTHCARE SECURITY AND SAFETY - NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE - MEDICAID ADDITIONAL CERTIFICATIONS FOR EACH HOSPITAL INCLUDE: - COLLEGE OF AMERICAN PATHOLOGY - UNITED STATES DEPARTMENT OF HEALTH & HUMAN SERVICES - CLIA - UNITED STATES DEPARTMENT OF HEALTH & HUMAN SERVICES - MEDICARE ACCREDITATION THE JOINT COMMISSION - NOVANT HEALTH FORSYTH MEDICAL CENTER, NOVANT HEALTH KERNERSVILLE MEDICAL CENTER, AND NOVANT HEALTH CLEMMONS MEDICAL CENTER HAVE ALL BEEN ACCREDITED BY THE JOINT COMMISSION, AN INDEPENDENT ORGANIZATION THAT EVALUATES A HEALTHCARE ORGANIZATION'S PERFORMANCE IN AREAS THAT MOST AFFECT PATIENT HEALTH AND SAFETY. THE AMERICAN NURSES CREDENTIALING CENTER (ANCC) - THE ANCC AWARDED THE NURSING PROGRAMS AT NOVANT HEALTH FORSYTH MEDICAL CENTER AND NOVANT HEALTH KERNERSVILLE MEDICAL CENTER FOR ITS EXCELLENCE AND QUALITY IN NURSING CARE BY NAMING IT WITH MAGNET RECOGNITION. ONLY FIVE PERCENT OF ALL HOSPITALS NATIONWIDE HAVE EARNED THIS HIGH HONOR, WHICH RECOGNIZES FACILITIES THAT PROVIDE THE HIGHEST LEVEL OF NURSING CARE. THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION - NOVANT HEALTH FORSYTH MEDICAL CENTER IS RECOGNIZED AS AN ADVANCED COMPREHENSIVE STROKE CENTER, FOCUSING ON COMPREHENSIVE CARE OF THE COMPLEX STROKE PATIENT. SOCIETY OF CHEST PAIN CENTERS - NOVANT HEALTH FORSYTH MEDICAL CENTER RECEIVED THE CHEST PAIN ACCREDITATION BY THE SOCIETY OF CHEST PAIN CENTERS. THIS ACCREDITATION DEMONSTRATES A SEAMLESS AND STANDARDIZED PROCESS OF QUALITY CARE DELIVERY AT NOVANT HEALTH CHEST PAIN FACILITIES. ADDITIONAL ACCREDITATIONS FOR NOVANT HEALTH FORSYTH MEDICAL CENTER INCLUDE: - AMERICAN COLLEGE OF RADIOLOGY - AMERICAN COLLEGE OF RADIOLOGY - RADIATION ONCOLOGY - AMERICAN COLLEGE OF SURGEONS - CANCER CENTER - AMERICAN SOCIETY OF HEALTH SYSTEM PHARMACISTS - COMMISSION OF ACCREDITATION OF REHABILITATION FACILITIES - INTERSOCIETAL ACCREDITATION COMMISSION CAROTID STENTING - INTERSOCIETAL ACCREDITATION COMMISSION ECHOCARDIOGRAPHY LABORATORIES - NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS - COLLEGE OF AMERICAN PATHOLOGY ADDITIONAL ACCREDITATIONS FOR KERNERSVILLE MEDICAL CENTER INCLUDE: - AMERICAN COLLEGE OF RADIOLOGY - AMERICAN COLLEGE OF RADIOLOGY - MAMMOGRAPHY - INTERSOCIETAL ACCREDITATION COMMISSION ECHOCARDIOGRAPHY LABORATORIES - NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS - COLLEGE OF AMERICAN PATHOLOGY COMMUNITY BENEFIT REPORT HTTPS://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMMUNITY-INVOLVEMENT/COMMUNI TY-BENEFIT.ASPX THE COMMUNITY BENEFIT REPORT, REFERRED TO AS A COMMUNITY IMPACT REPORT, PREPARED BY NOVANT HEALTH IS A SYSTEM-WIDE REPORT THAT INCLUDES QUALITATIVE AND QUANTITATIVE INFORMATION. PLEASE NOTE THAT THE NUMERIC DATA IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT, ITS COMMUNITY HEALTH NEEDS ASSESSMENT OR COMMUNITY BENEFIT IMPLEMENTATION STRATEGY. IN THIS REPORT, THE NOVANT HEALTH SYSTEM'S COMMUNITY BENEFIT WAS APPROXIMATELY $884,000,000, INCLUDING $155,000,000 IN FINANCIAL ASSISTANCE FOR 2018.
FORM 990, PART III, LINE 1: MISSION, VISION, AND VALUES	MISSION NOVANT HEALTH EXISTS TO IMPROVE THE HEALTH OF COMMUNITIES, ONE PERSON AT A TIME. VISION WE, THE NOVANT HEALTH TEAM, WILL DELIVER THE MOST REMARKABLE PATIENT EXPERIENCE, IN EVERY DIMENSION, EVERY TIME. VALUES -COMPASSION: WE TREAT OUR CUSTOMERS AND THEIR FAMILIES, STAFF AND OTHER HEALTHCARE PROVIDERS AS FAMILY MEMBERS BY SHOWING THEM KINDNESS, PATIENCE, EMPATHY AND RESPECT. -DIVERSITY AND INCLUSION: WE RECOGNIZE THAT EVERY PERSON IS DIFFERENT, EACH SHAPED BY UNIQUE LIFE EXPERIENCES. THIS ENABLES US TO BETTER UNDERSTAND ONE ANOTHER AND OUR CUSTOMERS. BY ENGAGING THE STRENGTHS AND TALENTS OF EACH TEAM MEMBER, WE ENSURE A STRONG ORGANIZATION CAPABLE OF PROVIDING REMARKABLE HEALTHCARE TO OUR PATIENTS, FAMILIES AND COMMUNITIES. -PERSONAL EXCELLENCE: WE STRIVE TO GROW PERSONALLY AND PROFESSIONALLY, AND WE APPROACH EACH SERVICE OPPORTUNITY WITH A POSITIVE, FLEXIBLE ATTITUDE. HONESTY AND PERSONAL INTEGRITY GUIDE ALL THAT WE DO. -TEAMWORK: THE NEEDS AND EXPECTATIONS OF ANY ONE CUSTOMER ARE GREATER THAN THAT WHICH ONE PERSON'S SERVICE EFFORTS CAN SATISFY. WE SUPPORT EACH OTHER SO THAT TOGETHER AS A TEAM, WE CAN BE SUCCESSFUL IN THE EYE OF THE CUSTOMER AS A QUALITY SERVICE PROVIDER. -COURAGE: WE ACT BOLDLY IN MAKING THE CHANGES NECESSARY TO ACHIEVE OUR MISSION, VISION AND PROMISE OF DELIVERING REMARKABLE HEALTHCARE. OUR PEOPLE WE ARE AN INCLUSIVE TEAM OF PURPOSE-DRIVEN PEOPLE INSPIRED AND UNITED BY OUR PASSION TO CARE FOR EACH OTHER, OUR PATIENTS AND OUR COMMUNITIES. OUR PROMISE TO PATIENTS WE ARE MAKING YOUR HEALTHCARE EXPERIENCE REMARKABLE. WE WILL BRING YOU WORLD-CLASS CLINICIANS, CARE AND TECHNOLOGY - WHEN AND WHERE YOU NEED THEM. WE ARE REINVENTING THE HEALTHCARE EXPERIENCE TO BE SIMPLER, MORE CONVENIENT AND MORE AFFORDABLE, SO THAT YOU CAN FOCUS ON GETTING BETTER AND STAYING HEALTHY.
FORM 990, PART III, LINE 4A: PROGRAM SERVICE ACCOMPLISHMENTS	KMC HAS 50 LICENSED BEDS. DURING 2018 THERE WERE 10,955 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 3 DAYS, AN AVERAGE DAILY CENSUS OF 30, AND 3,251 DISCHARGES. THERE WERE 4,368 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 51,849 OUTPATIENT ENCOUNTERS AND 35,997 EMERGENCY DEPARTMENT VISITS. CMC HAS 36 LICENSED BEDS. DURING 2018 THERE WERE 4,219 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 2 DAYS, AN AVERAGE DAILY CENSUS OF 12, AND 2,118 DISCHARGES. THERE WERE 3,298 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 27,739 OUTPATIENT ENCOUNTERS AND 20,062 EMERGENCY DEPARTMENT VISITS.
FORM 990, PART VI, SECTION A, LINE 6	FORM 990, PART VI, SECTION A, LINE 6: CLASSES OF MEMBERS OR STOCKHOLDERS THE CORPORATION IS A NONPROFIT CORPORATION WITH MEMBERS (OR A MEMBER).
FORM 990, PART VI, SECTION A, LINE 7A	FORM 990, PART VI, SECTION A, LINE 7A: ELECTION OF MEMBERS AND THEIR RIGHTS NOVANT HEALTH, INC. ELECTS ALL MEMBERS OF THE GOVERNING BODY OF FORSYTH MEMORIAL HOSPITAL,INC.
FORM 990, PART VI, SECTION A, LINE 7B	FORM 990, PART VI, SECTION A, LINE 7B: DECISIONS SUBJECT TO APPROVAL OF MEMBERS NOVANT HEALTH, INC. HAS CERTAIN RESERVED POWERS, SUCH AS APPROVAL OF AMENDMENTS TO THE ARTICLES AND BYLAWS OF THE CORPORATION, AND TO ADOPT CERTAIN POLICIES WHICH SHALL BE IMPLEMENTED BY THE CORPORATION BOARD.
FORM 990, PART VI, SECTION B, LINE 11B	FORM 990, PART VI, SECTION B, LINE 11: ORGANIZATION'S PROCESS TO REVIEW FORM 990 THE BOARD HAS DELEGATED REVIEW OF THE FORM 990 TO NOVANT HEALTH'S BOARD OF TRUSTEES' AUDIT AND COMPLIANCE COMMITTEE ("THE COMMITTEE"), WHICH OVERSEES TAX MATTERS FOR ENTITIES IN THE NOVANT HEALTH SYSTEM. THE COMMITTEE IS THE REVIEW BODY FOR ALL OF THE FORM 990S FILED FOR ORGANIZATIONS WITHIN THE NOVANT HEALTH SYSTEM. THE COMMITTEE MEETS BEFORE THE FORM 990S ARE FILED WITH THE IRS AND AFTER ALL BOARD MEMBERS HAVE BEEN PROVIDED A PAPER OR ELECTRONIC COPY OF THE FORM 990 AND A SUMMARY OF ITS CONTENTS. THE VICE PRESIDENT OF TAX AND LEGAL COUNSEL FOR NOVANT HEALTH ATTEND THE MEETING TO ANSWER ANY QUESTIONS AND ADDRESS ANY SIGNIFICANT DISCLOSURES WITHIN THE FORM 990.
FORM 990, PART VI, SECTION B, LINE 12C	FORM 990, PART VI, SECTION B, LINE 12C: MONITORING AND ENFORCEMENT OF COI THE ORGANIZATION'S TRUSTEE CONFLICT OF INTEREST POLICY APPLIES TO ALL TRUSTEES, PRINCIPAL OFFICERS OR MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS INCLUDING ANY APPLICABLE DISREGARDED ENTITIES. ALL TRUSTEES ARE SENT AN ANNUAL DISCLOSURE QUESTIONNAIRE. THE TRUSTEE ANNUAL DISCLOSURE QUESTIONNAIRES ARE REVIEWED BY THE COMPLIANCE DEPARTMENT. WITH RESPECT TO PARTICULAR TRANSACTIONS THAT COME BEFORE THE BOARD, THE CONFLICT OF INTEREST POLICY WOULD BE FOLLOWED. THE POTENTIAL CONFLICT OF INTEREST WOULD BE DISCLOSED BY THE BOARD MEMBER BEFORE A VOTE ON THE TRANSACTION AND THE REST OF THE BOARD WOULD DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF THE REST OF THE BOARD DETERMINED THAT A CONFLICT OF INTEREST EXISTED THEN THE BOARD MEMBER WITH THE CONFLICT OF INTEREST WOULD NOT PARTICIPATE IN THE DELIBERATIONS AND VOTE.
FORM 990, PART VI, SECTION B, LINE 15	FORM 990, PART VI, SECTION B, LINE 15A/15B: THE FILING ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH, AN INTEGRATED HEALTHCARE SYSTEM COLLECTIVELY REFERRED TO AS "NOVANT HEALTH." NOVANT HEALTH, INC. IS THE PARENT ORGANIZATION AND INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH, INC. BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) REVIEW, APPROVE, AND OVERSEE ALL ASPECTS OF COMPENSATION AND BENEFITS FOR CERTAIN LEADERS AND EXECUTIVES ("EXECUTIVES") SERVING AS OFFICERS, INCLUDING THE TOP MANAGEMENT OFFICIAL, OR KEY EMPLOYEES FOR NOVANT HEALTH ENTITIES. THE COMMITTEE WORKS WITH AN INDEPENDENT COMPENSATION CONSULTANT AND USES THIRD PARTY COMPARABILITY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS TO ENSURE THAT TOTAL COMPENSATION AND BENEFITS FOR EACH EXECUTIVE IS REASONABLE FOR THAT EXECUTIVE'S POSITION. THE COMMITTEE REVIEWS AND APPROVES EXECUTIVE COMPENSATION AND BENEFITS ANNUALLY, CONSISTENT WITH THE WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY OF NOVANT HEALTH, AND IN A MANNER THAT QUALIFIES FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, THEREBY ASSURING THAT TOTAL COMPENSATION AND BENEFITS PROVIDED TO EACH EXECUTIVE IS REASONABLE.
FORM 990, PART VI, SECTION C, LINE 19	FORM 990, PART VI, SECTION C, LINE 19: GOVERNING DOCUMENTS DISCLOSURE THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS CONTAINING ALL ORGANIZATIONS IN THE NOVANT HEALTH SYSTEM ARE POSTED TO THE NOVANT HEALTH WEBSITE. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC.
FORM 990, PART VII, SECTION A, COLUMN B: RELATED ORGANIZATIONS	THE ORGANIZATION EMPLOYS CERTAIN EXECUTIVES WHOSE ROLES ARE SUCH THAT THEY PROVIDE SERVICES TO NOT ONLY THE ORGANIZATION, BUT ALSO TO SOME OR ALL OF THE OTHER TAX-EXEMPT ORGANIZATIONS WITHIN THE HEALTHCARE SYSTEM. FOR EXAMPLE, MANY OF THESE EXECUTIVES' ROLES FOCUS ON PARTICULAR SERVICE LINES WHICH CROSS THE VARIOUS GEOGRAPHIC MARKETS OUR ORGANIZATIONS SERVE, THUS THE SERVICES PROVIDED BY THESE EXECUTIVES MAY BENEFIT AND BE RECEIVED BY MULTIPLE ORGANIZATIONS WITHIN THE SYSTEM. THE EXECUTIVES DO NOT ALLOCATE THEIR HOURS BETWEEN THE VARIOUS ORGANIZATIONS, BUT RATHER THEIR TIME SPENT ON SERVICES TO THE ORGANIZATION IS INCLUSIVE OF SERVICES TO ALL OF THE ORGANIZATIONS THEY SERVE WITHIN THE SYSTEM.
FORM 990, PART VII, SECTION B: INDEPENDENT CONTRACTORS	THE FILING ENTITY IS PART OF THE NOT-FOR-PROFIT INTEGRATED HEALTHCARE SYSTEM KNOWN AS NOVANT HEALTH. NOVANT HEALTH, INC., THE PARENT ORGANIZATION, IS RESPONSIBLE FOR CERTAIN CORPORATE SUPPORT FUNCTIONS INCLUDING ACCOUNTS PAYABLE AND ISSUES FORMS 1099 FOR CERTAIN ENTITIES IN THE SYSTEM INCLUDING THE FILING ENTITY. INFORMATION REPORTED IN PART VII, SECTION B REPRESENTS THE EXPENSES PAID ON BEHALF OF THE FILING ENTITY TO INDEPENDENT CONTRACTORS OVER $100,000.
FORM 990, PART IX, LINE 6: COMPENSATION OF DISQUALIFIED PERSONS	THE AMOUNTS REPORTED HERE INCLUDE AMOUNTS ATTRIBUTABLE TO DISQUALIFIED PERSONS (DQP) AS DEFINED IN THE INSTRUCTIONS, BUT NOW ALSO INCLUDES AMOUNTS ATTRIBUTABLE TO INDIVIDUALS THAT MAY NOT DEFINITIVELY BE CONSIDERED DQPS UNDER THE 4958 RULES. WE HAVE OPTED TO TAKE A MORE EXPANSIVE APPROACH AS TO WHO MAY BE CONSIDERED A DQP AND REPORT THEM HERE AS WELL.
FORM 990, PART XI, LINE 9:	CONTRIBUTIONS: -1,401,008. MALPRACTICE INSURANCE: -390,232. AFFILIATE TRANSFERS: -1,510,878. PARTNERSHIP ADJUSTMENT: 16,846,580.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2018

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

FORSYTH MEMORIAL HOSPITAL INC

Employer identification number

56-0928089

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) EXCEL IMAGING LLC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 20-4253946	INACTIVE	NC			FORSYTH MEMORIAL HOSPITAL INC
(2) NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY LLC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 82-5250651	HEALTHCARE	NC	136,043	87,404	FORSYTH MEMORIAL HOSPITAL INC
(3) NOVANT HEALTH KERNERSVILLE OUTPATIENT SURGERY LLC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 82-1651821	HEALTHCARE	NC	896,924	3,673,484	FORSYTH MEMORIAL HOSPITAL INC

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)AUXILIARY OF FORSYTH MEMORIAL HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0862112	HEALTHCARE	NC	501(C)(3)	LINE 10	FORSYTH MEMORIAL HOSPITAL INC	Yes
(2)BRUNSWICK NOVANT MEDICAL CENTER FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 27-4616751	HEALTHCARE	NC	501(C)(3)	LINE 7	BRUNSWICK COMMUNITY HOSPITAL LLC		No
(3)CAROLINA MEDICORP ENTERPRISES INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1466368	HEALTHCARE	NC	501(C)(3)	LINE 12B, II	NOVANT MEDICAL GROUP INC		No
(4)COMMUNITY GENERAL HEALTH PARTNERS INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0636250	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH TRIAD REGION LLC		No
(5)COMMUNITY GENERAL HOSPITAL FOUNDATION INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1828629	HEALTHCARE	NC	501(C)(3)	LINE 7	COMMUNITY GENERAL HEALTH PARTNERS INC		No
(6)FORSYTH MEDICAL CENTER FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-2120959	HEALTHCARE	NC	501(C)(3)	LINE 7	FORSYTH MEMORIAL HOSPITAL INC	Yes
(7)FOUNDATION HEALTH SYSTEMS CORP 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1373175	HEALTHCARE	NC	501(C)(3)	LINE 10	NOVANT HEALTH INC		No
(8)MEDICAL PARK HOSPITAL INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1340424	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH TRIAD REGION LLC		No
(9)NMG SERVICES INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-2098809	HEALTHCARE	NC	501(C)(3)	LINE 10	NOVANT HEALTH INC		No
(10)NOVANT HEALTH INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1376950	HEALTHCARE	NC	501(C)(3)	LINE 12C, III-FI	N/A		No
(11)NOVANT MEDICAL GROUP INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1728803	HEALTHCARE	NC	501(C)(3)	LINE 3	NMG SERVICES INC		No
(12)PERSONAL CARE SERVICES 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1291284	HEALTHCARE	VA	501(C)(3)	LINE 10	PRINCE WILLIAM HEALTH SYSTEM		No
(13)PRESBYTERIAN HOSPITAL FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1413074	HEALTHCARE	NC	501(C)(3)	LINE 7	NOVANT HEALTH SOUTHERN PIEDMONT REGION LLC		No
(14)PRESBYTERIAN MEDICAL CARE CORPORATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1376368	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH SOUTHERN PIEDMONT REGION LLC		No
(15)PRINCE WILLIAM HEALTH SYSTEM 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1278944	HEALTHCARE	VA	501(C)(3)	LINE 12C, III-FI	NOVANT HEALTH UVA HEALTH SYSTEM		No
(16)PRINCE WILLIAM HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-0696355	HEALTHCARE	VA	501(C)(3)	LINE 3	PRINCE WILLIAM HEALTH SYSTEM		No
(17)PWHS FOUNDATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-1307595	HEALTHCARE	VA	501(C)(3)	LINE 7	PRINCE WILLIAM HEALTH SYSTEM		No
(18)ROWAN HEALTH SERVICES CORPORATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1424814	HEALTHCARE	NC	501(C)(3)	LINE 12C, III-FI	NOVANT HEALTH INC		No
(19)ROWAN REGIONAL MEDICAL CENTER AUXILIARY 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 23-7022472	HEALTHCARE	NC	501(C)(3)	LINE 10	ROWAN REGIONAL MEDICAL CENTER INC		No
(20)ROWAN REGIONAL MEDICAL CENTER FOUNDATION INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1424818	HEALTHCARE	NC	501(C)(3)	LINE 7	ROWAN REGIONAL MEDICAL CENTER INC		No
(21)ROWAN REGIONAL MEDICAL CENTER INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0547479	HEALTHCARE	NC	501(C)(3)	LINE 3	ROWAN HEALTH SERVICES CORPORATION		No
(22)SELF INSURANCE FUND - NOVANT HEALTH INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 58-1867242	HEALTHCARE	NC	501(C)(3)	LINE 12C, III-FI	NOVANT HEALTH INC		No
(23)THE PRESBYTERIAN HOSPITAL 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-0554230	HEALTHCARE	NC	501(C)(3)	LINE 3	NOVANT HEALTH SOUTHERN PIEDMONT REGION LLC		No
(24)CULPEPER MEMORIAL HOSPITAL INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 54-0622371	HEALTHCARE	VA	501(C)(3)	LINE 3	NOVANT HEALTH UVA HEALTH SYSTEM		No
(25)NOVANT HEALTH UVA HEALTH SYSTEM 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 81-0868533	HEALTHCARE	VA	501(C)(3)	LINE 12A, I	NOVANT HEALTH INC		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2018

Page 2

Part III

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

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

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) ADEPT HEALTH INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-2226937	ADMIN SERVICES	NC	N/A	C				No
(2) CHOICEHEALTH INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1896065	MANAGED CARE	NC	N/A	C				No
(3) COMMUNICARE INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1952950	RENTAL REAL ESTATE	NC	N/A	C				No
(4) KERNERSVILLE MEDICAL CENTER PARK OWNERS' ASSOCIATION 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 47-1511401	RENTAL REAL ESTATE	NC	N/A	C				No
(5) MEDQUEST INC & SUBSIDIARIES 3480 PRESTON RIDGE RD STE 600 ALPHARETTA,GA30005 22-3860764	DIAGNOSTIC IMAGING	DE	N/A	C				No
(6) NOVANT HEALTH TRINOVA INSURANCE PROTECTED CELL INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 81-2963143	INSURANCE	NC	N/A	C				No
(7) ROWAN MEDICAL FACILITIES INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1424672	MEDICAL SUPPLIES	NC	N/A	C				No
(8) SALEM DIAGNOSTICS INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1513621	HEALTH RELATED	NC	N/A	C				No
(9) SALEM HEALTH SERVICES INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 56-1342654	HEALTH RELATED	NC	N/A	C				No
(10) THE PARK AT MONROE PROPERTY OWNERS ASSOCIATION INC 2085 FRONTIS PLAZA BLVD WINSTON SALEM,NC27103 46-3910256	RENTAL REAL ESTATE	NC	N/A	C				No

Schedule R (Form 990) 2018

Page 3

Part V

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

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

Yes

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

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

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

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

Yes

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

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

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

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

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

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

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

Yes

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

Yes

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

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

Yes

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

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

Yes

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

Yes

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

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

Yes

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

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) FORSYTH MEDICAL CENTER FOUNDATION	C	2,470,495	CASH
(2) AUXILIARY OF FORSYTH MEMORIAL HOSPITAL INC	C	50,878	CASH
(3) FORSYTH MEDICAL CENTER FOUNDATION	R	1,510,878	CASH

Schedule R (Form 990) 2018

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2018

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) 2018

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: SEE SCHEDULE O
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	15
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	13
5	Total number of individuals employed in calendar year 2018 (Part V, line 2a) ......	5	7,907
6	Total number of volunteers (estimate if necessary) .............	6	769
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	254,048
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-4,983

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	5,895,007	2,758,815
9	Program service revenue (Part VIII, line 2g) .........	1,307,553,317	1,404,103,334
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	698,869	377,048
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	12,224,669	9,796,685
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	1,326,371,862	1,417,035,882
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	900,964	1,180,904
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)	486,715,719	548,238,589
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	712,590,014	747,284,720
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	1,200,206,697	1,296,704,213
19	Revenue less expenses. Subtract line 18 from line 12.......	126,165,165	120,331,669
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	1,544,644,500	1,692,009,282
21	Total liabilities (Part X, line 26).............	82,153,583	95,643,703
22	Net assets or fund balances. Subtract line 21 from line 20.....	1,462,490,917	1,596,365,579

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 1,071,982,101 including grants of $ 1,180,904 ) (Revenue $ 1,407,512,229 )
	FORSYTH MEMORIAL HOSPITAL, INC. (FMH), KERNERSVILLE MEDICAL CENTER (KMC), AND CLEMMONS MEDICAL CENTER (CMC) CARRY OUT THE PURPOSE OF THE FORSYTH COUNTY BOARD OF COMMISSIONERS BY ADVANCING AND SUPPORTING THE PROMOTION OF THE HEALTH OF THE INHABITANTS OF FORSYTH COUNTY AND THE KERNERSVILLE AREA OF NC. FMH, KMC, AND CMC MAINTAIN AN OPEN DOOR POLICY, ACCEPTING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. FMH HAS 859 LICENSED BEDS. DURING 2018 THERE WERE 235,639 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 6 DAYS, AN AVERAGE DAILY CENSUS OF 646, AND 39,834 DISCHARGES. THERE WERE 25,835 INPATIENT AND OUTPATIENT SURGERIES, A TOTAL OF 1,154,748 OUTPATIENT ENCOUNTERS AND 84,972 EMERGENCY DEPARTMENT VISITS.(CONTINUED ON SCHEDULE O)

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses1,071,982,101

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	7,395,377	6,381,653	1,167,936

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	2,521,373
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	237,442

g	Noncash contributions included in lines 1a - 1f:$
h Total. Add lines 1a-1f.......		2,758,815

		Business Code
2a	NET PATIENT REVENUE	622110	1,356,252,739	1,356,252,739
b	PHARMACY	446110	46,995,099	46,995,099
c	MOBILE MRI SERVICES	621512	2,902,974	2,902,974
d	LAB SERVICES	621511	938,695	938,695
e	VALUE BASED INCENTIVE	900099	912,860	912,860
f	All other program service revenue.		-3,899,033	-3,899,033
g	Total. Add lines 2a–2f ....		1,404,103,334

3 Investment income (including dividends, interest, and othersimilar amounts) ......			230,691			230,691
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		261,661
b	Less: rental expenses		0
c	Rental income or (loss)		261,661
d	Net rental income or (loss)......			261,661			261,661
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	316,264
b	Less: cost or other basis and sales expenses	169,907
c	Gain or (loss)	146,357
d	Net gain or (loss).....			146,357			146,357
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
	a		87,799
b	Less: cost of goods sold ..b		77,387
c	Net income or (loss) from sales of inventory..			10,412			10,412
Business Code			Miscellaneous Revenue
11a	CAFETERIA MEALS		722514	3,636,259			3,636,259
b	DIALYSIS SERVICES		621492	2,066,090	2,066,090
c	CHILD DEVELOPMENT CENTER		624410	1,684,492		254,048	1,430,444
d	All other revenue ....			2,137,771	1,342,805		794,966
e	Total. Add lines 11a–11d ......			9,524,612
12	Total revenue. See Instructions......			1,417,035,882	1,407,512,229	254,048	6,510,790

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	1,076,131	1,076,131
2	Grants and other assistance to domestic individuals. See Part IV, line 22	104,773	104,773
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, line 15 and 16.
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	3,863,572		3,863,572
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	432,761,617	419,043,074	13,718,543
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	20,670,228	20,014,982	655,246
9	Other employee benefits .......	63,026,636	61,028,692	1,997,944
10	Payroll taxes ...........	27,916,536	27,031,582	884,954
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	8,050		8,050
c	Accounting ...........	1,487		1,487
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	111,059,849	106,071,431	4,988,418
12	Advertising and promotion ....	1,015,276	1,015,276
13	Office expenses .......	5,666,625	5,267,192	399,433
14	Information technology ......	8,693,526	8,693,526
15	Royalties ..
16	Occupancy ...........	26,903,154	26,903,154
17	Travel ............	1,582,134	886,937	695,197
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	243,847		243,847
20	Interest ...........	13,904,168	13,904,168
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	25,925,258	25,925,258
23	Insurance ...	2,049,175	1,852,862	196,313
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	CORPORATE SUPPORT	183,906,642		183,906,642
b	MEDICAL SUPPLIES	133,572,306	133,572,306
c	DRUGS	119,593,919	119,593,919
d	ACCRUED UBIT	-40,438		-40,438
e	All other expenses	113,199,742	99,996,838	13,202,904
25	Total functional expenses. Add lines 1 through 24e	1,296,704,213	1,071,982,101	224,722,112	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			-35,834	1	37,164
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			152,939,255	4	160,863,070
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L .............
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L ..............
					6
7	Notes and loans receivable, net ....			11,777,628	7	13,452,882
8	Inventories for sale or use ........			22,911,348	8	23,191,358
9	Prepaid expenses and deferred charges ......			602,988	9	799,157
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	566,597,406
b	Less: accumulated depreciation	10b	332,882,934	227,353,001	10c	233,714,472
11	Investments—publicly traded securities .				11
12	Investments—other securities. See Part IV, line 11 .....			436,444	12	13,275,998
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............			31,015,047	14	31,015,047
15	Other assets. See Part IV, line 11 ...........			1,097,644,623	15	1,215,660,134
16	Total assets. Add lines 1 through 15 (must equal line 34)...			1,544,644,500	16	1,692,009,282

17	Accounts payable and accrued expenses .....	54,688,468	17	65,310,957
18	Grants payable ...		18
19	Deferred revenue .........	149,755	19	98,891
20	Tax-exempt bond liabilities .........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	27,315,360	25	30,233,855
26	Total liabilities. Add lines 17 through 25..	82,153,583	26	95,643,703

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	1,462,490,917	27	1,596,365,216
28	Temporarily restricted net assets ...........		28	0
29	Permanently restricted net assets		29	363
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	1,462,490,917	33	1,596,365,579
34	Total liabilities and net assets/fund balances ........	1,544,644,500	34	1,692,009,282