TY 2017 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) ROBERT BENAK MD...................................................................... EX-OFFICIO	1.00 .................	X		0	0
(2) JOHN BERNARDI...................................................................... CHAIR	1.00 .................	X	X	0	0
(3) ALEXANDER EDWARDS...................................................................... TREASURER	1.00 .................	X	X	0	0
(4) BETSY VINCENCIO...................................................................... VICE CHAIR	1.00 .................	X	X	0	0
(5) DAVID ANDERSON MD...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(6) JOANN GLEESON-KREIG PHD...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(7) JOSEPH DONNERY DPM...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(8) VICTORIA ZINSER DULEY...................................................................... SECRETARY	1.00 .................	X	X	0	0
(9) PAOLA FEDI MD...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(10) NEIL FESSETTE...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(11) PAUL GRASSO...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(12) VICKI MARKING...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(13) THOMAS RECNY...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(14) AMY SENECAL...................................................................... BOARD MEMBER	1.00 .................	X		0	0
(15) STEPHENS MUNDY...................................................................... PRESIDENT /CEO	30.00 ................. 20.00		X	1,331,339	244,727
(16) WOUTER RIETSEMAMD...................................................................... CHIEF QUALITY AND INFOR.	48.00 ................. 2.00		X	426,186	43,397
(17) KENT HALL...................................................................... CHIEF MEDICAL OFFICER	50.00 .................		X	542,049	32,813

(A) Name and business address	(B) Description of services	(C) Compensation
MAYO CLINIC PO BOX 9146 MINNEAPOLIS,MN554809149	DIAGNOSTIC SERVICES	871,697
NIXON PEABODY LLP PO BOX 28012 NEW YORK,NY100878012	LEGAL	704,982
ARCHIL CHECHELASHVILI MD, 75 BEEKMAN ST PLATTSBURGH,NY12901	PHYSICIAN	294,347
AVANTAS LLC 16 DEGRANDPRE WAY SUITE 600 PLATTSBURGH,NY12901	CONSULTING	225,361
DINO SANTORO MD 75 BEEKMAN ST PLATTSBURGH,NY12901	PHYSICIAN	223,844
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 24

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

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

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

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) 2019

Page 2

Part II

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10

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 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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—2018. 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—2019. 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—2018. 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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose
3	Gross receipts from activities that are not an unrelated trade or business under section 513 .....
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge
6	Total. Add lines 1 through 5
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support. (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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—2018. 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) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

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) 2019

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) 2019

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) 2019

Page 7

Part V

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

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2019 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

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

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

Schedule A (Form 990 or 990-EZ) 2019

Page 8

Part VI

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

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- 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

2019

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER		Employer identification number 14-1338471

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER			Employer identification number 14-1338471
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) (2019)

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 instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

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 FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

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

(i)

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

(ii)

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

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

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) 2019

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 ....	34,780,589	33,237,051	30,409,963	30,540,658	38,163,316
b	Contributions ...	2,271,004			722,012	-9,453,155
c	Net investment earnings, gains, and losses	33,273	3,475,138	2,998,228	-760,034	1,994,689
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...			108,488		57,758
f	Administrative expenses ....	6,324	1,931,600	62,652	92,673	106,434
g	End of year balance ......	37,078,542	34,780,589	33,237,051	30,409,963	30,540,658

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

Board designated or quasi-endowment SchDMd Bullet

91.200 %

Permanent endowment SchDMd Bullet

3.620 %

Term endowment SchDMd Bullet

5.180 %

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)

Yes

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

Yes

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 .....	3,280,000		3,280,000
b	Buildings ....	78,914,057	29,663,235	49,250,822
c	Leasehold improvements	2,615,249	855,576	1,759,673
d	Equipment ....	97,804,714	59,360,642	38,444,072
e	Other .....	11,419,998	1,333,001	10,086,997
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				102,821,564

Schedule D (Form 990) 2019

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
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

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
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	79,254,658
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2019

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:

CERTAIN BOARD-DESIGNATED FUNDS HAVE BEEN ESTABLISHED TO MEET SPECIFIC CURRENT AND FUTURE NEEDS OF THE HOSPITAL OR TO ADEQUATELY DISCHARGE FUTURE LIABILITES. THESE FUNDS INCLUDE THE PLANT AND CAPITAL IMPROVEMENT FUNDS, WHICH ARE DESIGNATED FOR SPECIFIC PROJECTS SUCH AS THE SURGICAL CENTER CONSTRUCTION, AND DESIGNATED FUNDS FOR BOTH SELF-INSURANCE AND FOR CVPH'S VARIOUS EMPLOYEE BENEFIT PLANS. TEMPORARILY RESTRICTED NET ASSETS ARE INTENDED FOR THE PURCHASE OF PROPERTY AND EQUIPMENT. PERMANENTLY RESTRICTED NET ASSETS ARE TO BE HELD IN PERPETUITY, THE INCOME FROM WHICH IS EXPENDABLE TO SUPPORT HEALTH CARE SERVICES, INCLUDING MEDICAL SERVICES PROVIDED TO CHILDREN, AND PROVIDING FOR CHARITY CARE.

PART X, LINE 2:

THE SYSTEM CONSISTS OF NOT-FOR-PROFIT CORPORATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. AS OF SEPTEMBER 30, 2018, THE SYSTEM DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR ANY RELATED ACCRUED INTEREST OR PENALTIES. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES ARE 2015 THROUGH 2018.

Schedule D (Form 990) 2019

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

2019

Open to Public Inspection

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

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

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

Yes

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

Yes

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

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) . . .	849,506		849,506	0.240 %
b	Medicaid (from Worksheet 3, column a) . . . . .	54,436,452	27,088,912	27,347,540	7.760 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	55,285,958	27,088,912	28,197,046	8.000 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	3,804,085	2,164,288	1,639,797	0.470 %
f	Health professions education (from Worksheet 5) . . .	1,845,835		1,845,835	0.520 %
g	Subsidized health services (from Worksheet 6) . . . .	37,730,265	19,608,752	18,121,513	5.140 %
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .	43,380,185	21,773,040	21,607,145	6.130 %
k	Total. Add lines 7d and 7j .	98,666,143	48,861,952	49,804,191	14.130 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

Page

Part II

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

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

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare 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. ......

3,390,477

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

1,356,191

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).....

93,395,137

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

123,058,542

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

-29,663,405

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
11 PET SCAN LLC	IMAGING SERVICES	49.000 %	0 %	51.000 %
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2019

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED 75 BEEKMAN ST PLATTSBURGH,NY12901	X	X	X	X

Schedule H (Form 990) 2019

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED
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..................................

Yes

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

Yes

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

Yes

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

Hospital facility’s website (list url): HTTPS://WWW.CVPH.ORG/DATA/FILES/CHA%20AND%20IS%20FINAL%20V2.PDF

Other website (list url): HTTP://WWW.CLINTONHEALTH.ORG/PDF%20FILES/CHA2016_18.PDF

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): HTTPS://WWW.CVPH.ORG/DATA/FILES/CHA%20AND%20IS%20FINAL%20V2.PDF

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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED
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 150.000000000000%
and FPG family income limit for eligibility for discounted care of 400.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

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

Yes

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

Yes

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

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

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

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

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

Other (describe in Section C)

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):

HTTP://WWW.CVPH.ORG

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

HTTP://WWW.CVPH.ORG

A plain language summary of the FAP was widely available on a website (list url):
HTTP://WWW.CVPH.ORG

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) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED
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 (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

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) 2019

Page 7

Part VFacility Information (continued)

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

	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED
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? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2019

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED	PART V, SECTION B, LINE 5: THE UNIVERSITY OF VERMONT HEALTH NETWORK - CHAMPLAIN VALLEY PHYSICIANS HOSPITAL (CVPH) AND CLINTON COUNTY HEALTH DEPARTMENT (CCHD) HAVE A LONG HISTORY OF COLLABORATION TO IMPROVE THE HEALTH OF RESIDENTS IN CLINTON COUNTY. THE COMMUNITY HEALTH ASSESSMENT (CHA)/COMMUNITY SERVICE PLAN (CSP) AND IMPLEMENTATION STRATEGY (IS)/ COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) HAVE ALL BEEN CREATED COLLABORATIVELY AND, WHEN APPLICABLE, FILED JOINTLY. THIS UNIQUE EFFORT, ALSO SUPPORTED BY THE ADIRONDACK RURAL HEALTH NETWORK, DEMONSTRATES COHESIVE COMMUNITY HEALTH ASSESSMENT AND IMPROVEMENT PLANNING. THE PARTNERSHIP BETWEEN THE TWO LEAD ORGANIZATIONS ASSURES SYNERGISTIC, NON-DUPLICATIVE, MEANINGFUL STRATEGIC EFFORTS TOWARDS THE COMMON GOAL OF IMPROVING THE POPULATION'S HEALTH AND CONTRIBUTING TO THE TRIPLE AIM. INPUT WAS ALSO SOLICITED FROM COMMUNITY ORGANIZATIONS AND THE RESIDENTS OF CLINTON COUNTY FOR CONSIDERATION WITHIN THE REQUIRED DOCUMENTS TO ASSURE INCLUSION REFLECTIVE OF THE NEEDS OF OUR SHARED POPULATION. DATA REVIEW: CVPH AND CCHD OBTAINED AND EXAMINED DATA FROM A VARIETY OF SOURCES; THE DETAILS OF WHICH ARE EXPLAINED IN THEIR ENTIRETY THROUGHOUT THE CHA. IN SHORT, THE GROUP SPENT A LARGE AMOUNT OF TIME REVIEWING THE NEW YORK STATE PREVENTION AGENDA WITH PARTICULAR INTEREST IN THE COUNTY LEVEL DASHBOARDS. THE WORKGROUP REVIEWED DATA FROM HEALTHYADK.ORG, THE CENTER FOR HEALTH WORKFORCE STUDIES, COMMUNITYCOMMONS.ORG, ROBERT WOOD JOHNSON FOUNDATION'S COUNTY HEALTH RANKINGS AND LOCALLY OBTAINED PRIMARY DATA RELATED TO A NUMBER OF HEALTH CONDITIONS AND BEHAVIORS. TO DETERMINE METRICS OF MOST SIGNIFICANCE, THE LEAD ORGANIZATIONS CONSIDERED AREAS IN WHICH CLINTON COUNTY WAS IDENTIFIED AS WORSE THAN NY AND US VALUES, PERFORMANCE BELOW THE 25TH PERCENTILE, COMMON THEMES BROUGHT FORTH BY FOCUS GROUPS, AFFECTING SIGNIFICANT NUMBER OF PEOPLE, AND DISPARITIES ASSOCIATED WITH THE NEED. ADDITIONALLY, THE GROUP LOOKED FOR NEW OR CHANGING HEALTH TRENDS. STRONG CONSIDERATION WAS ALSO PAID TO QUALITATIVE DATA COLLECTED FROM COMMUNITY RESIDENTS DIRECTLY THROUGH MEETINGS, SURVEYS AND QUALITATIVE PROGRAM DATA. PARTNERSHIPS: THE COMPLETION OF THE 2016-2018 CLINTON COUNTY CHA, CSP, IS, AND CHIP WAS A COLLABORATIVE EFFORT BETWEEN CCHD AND CVPH. CCHD AND CVPH HAVE A LONG STANDING HISTORY OF COLLABORATION AND COLLECTIVELY BRING MULTIPLE COMMUNITY GROUPS TO THE TABLE TO HAVE THE GREATEST IMPACT ON THE HEALTH OF INDIVIDUALS IN CLINTON COUNTY. COMMUNITY ENGAGEMENT: THE COMMUNITY ENGAGEMENT PROCESS USED INVOLVED TWO SURVEYS (ONE TO ORGANIZATIONS AND ONE TO COMMUNITY MEMBERS) AND A PRIORITY SETTING SESSION FOR KEY COMMUNITY STAKEHOLDERS. THIS COMMUNITY SESSION RESULTED IN THE IDENTIFICATION OF TWO MAIN COMMUNITY HEALTH NEEDS OF FOCUS. A SMALLER GROUP OF COMMUNITY STAKEHOLDERS TOOK THE WORK FROM THE RETREAT, SURVEYS, AND DATA TO PRIORITIZE THE FOCUS AREAS UNDER EACH OF THE PRIORITY AREAS TO PUT THE GREATEST EFFORT TOWARDS. LASTLY, THE CHA/CSP/CHIP/IS WILL BE SHARED IN A VARIETY OF COMMUNITY SETTINGS. COMMUNITY SURVEY RESULTS WERE SHARED BACK WITH PARTNERS WHO ASSISTED IN CONNECTING RESIDENTS TO THE SURVEY AND THE COMMUNITY AT LARGE THROUGH AN OVERVIEW OF FINDINGS POSTED ON CCHD'S WEBSITE AND PROMOTED VIA SOCIAL MEDIA. THE CCHD'S ACTION FOR HEALTH AND CVPH'S COMMUNITY HEALTH ASSESSMENT STEERING COMMITTEE HAVE BEEN KEPT APPRISED AND REGULARLY CONSULTED AS THE DOCUMENTS WERE BEING DEVELOPED.ADIRONDACK RURAL HEALTH NETWORK (ARHN) COMMUNITY HEALTH ASSESSMENT (CHA) COMMITTEE MEMBERS AND MEETING SCHEDULE:NAME, ORGANIZATIONBONNIE OHMANN, ADIRONDACK HEALTHGINGER CARRIERO, ALICE HYDE MEDICAL CENTERJOSY DELANEY, ALICE HYDE MEDICAL CENTERKATI JOCK, THE UNIVERSITY OF VERMONT HEALTH NETWORK CHAMPLAIN VALLEY PHYSICIANS HOSPITALHEATHER REYNOLDS, THE UNIVERSITY OF VERMONT HEALTH NETWORK ELIZABETHTOWN COMMUNITY HOSPITALJULIE TROMBLEE, THE UNIVERSITY OF VERMONT HEALTH NETWORK ELIZABETHTOWN COMMUNITY HOSPITALKRISTIN DOOLEY, THE UNIVERSITY OF VERMONT HEALTH NETWORK ELIZABETHTOWN COMMUNITY HOSPITAL LINDA BEERS, ESSEX COUNTY PUBLIC HEALTHJESSICA DARNEY, BUEHLER ESSEX COUNTY PUBLIC HEALTHKATHLEEN STRACK, FRANKLIN COUNTY PUBLIC HEALTHERIN STREIFF, FRANKLIN COUNTY PUBLIC HEALTHIRINA GELMAN, FULTON COUNTY PUBLIC HEALTHTRACY MILLS, GLENS FALLS HOSPITALKELLY PILKEY, GLENS FALLS HOSPITALSUSAN FRANKO, HAMILTON COUNTY PUBLIC HEALTHTAMMY SMITH, INTER-LAKES HEALTHCHERYL MCGRATTAN, NATHAN LITTAUER HOSPITALPAT AUERWARREN, COUNTY HEALTH SERVICESDAN DURKEE, WARREN COUNTY HEALTH SERVICESGINELLE JONES, WARREN COUNTY HEALTH SERVICESPATTY HUNT, WASHINGTON COUNTY PUBLIC HEALTHKATHY JO MCINTYRE, WASHINGTON COUNTY PUBLIC HEALTHACTION FOR HEALTH CONSORTIUM MEMBERS:DIANA AGUGLIA, ALLIANCE FOR POSITIVE HEALTHMARIA ALEXANDER, SENIOR CITIZENS COUNCILSARA ALLEN, CLINTON COUNTY HEALTH DEPARTMENT, CONTRACTORJOY ARANA, LICENSED MEDICAL SOCIAL WORKERMARYANN BARTO, CLINTON COUNTY HEALTH DEPARTMENT, ENVIRONMENTAL HEALTH DIVISIONLAURIE BOOTH-TRUDO, CHILD CARE COORDINATING COUNCIL OF THE NORTH COUNTRYJAMES BOSLEY, CLINTON COUNTY PLANNING/CLINTON COUNTY PUBLIC TRANSITMARY BREYETTE, CORNELL COOPERATIVE EXTENSIONCRYSTAL CARTER, CLINTON COUNTY OFFICE FOR THE AGINGDOT CRAWFORD, INTERFAITH FOOD SHELFKIM CROCKETT, CLINTON COUNTY YOUTH BUREAUMELANIE DEFAYETTE, TOWN OF PLATTSBURGH RECREATION DEPARTMENTKAREN DERUSHA, CLINTON COUNTY HEALTH DEPARTMENT, HEALTH PLANNING AND PROMOTION DIVISIONBOB DICKIE, UNIVERSITY OF VERMONT HEALTH NETWORK-CHAMPLAIN VALLEY PHYSICIANS HOSPITALADELE DOUGLAS, TOWN OF PERU COMMUNITY DEVELOPMENT COORDINATORSHANNON DROWNE, KINETIC RUNNINGVICTORIA DULEY, THE DEVELOPMENT CORP. DARWYNA FACTEAU, CLINTON COUNTY HEALTH DEPARTMENT, HEALTH CARE SERVICES DIVISIONANNE-MARIE FITZGERALD, ADIRONDACK HEALTH INSTITUTESALLY GARVEY, OFFICE FOR THE AGING, CLINTON COUNTYSANDRA GEDDES, COMMUNITY DEVELOPMENT, CITY OF PLATTSBURGHKERRY HALEY, THE FOUNDATION OF CVPHMARK HAMILTON, CITY OF PLATTSBURGH HOUSING AUTHORITYELLEN HEMINGWAY, CLINTON COUNTY HEALTH DEPARTMENT, ADMINISTRATIONKAREN KALMAN, UNIVERSITY OF VERMONT HEALTH NETWORK-CHAMPLAIN VALLEY PHYSICIANS HOSPITALJOHN KANOZA, CLINTON COUNTY HEALTH DEPARTMENT, ENVIRONMENTAL HEALTH DIVISIONDOROTHY LATTA, PLATTSBURGH INTERFAITH FOOD COUNCILJODY LEAVENS, FIDELIS CARECHARLES MCCOY, STATE UNIVERSITY OF NEW YORK AT PLATTSBURGHGIZELLE MENARD, UNIVERSITY OF VERMONT HEALTH NETWORK-CHAMPLAIN VALLEY PHYSICIANS HOSPITALERIN PANGBORN, TOWN OF PLATTSBURGH RECREATION DEPARTMENTSTEVE PETERS, CITY OF PLATTSBURGH RECREATION DEPARTMENTAMY PUTNAM, FIDELIS CAREJERIE REID, CLINTON COUNTY HEALTH DEPARTMENT, ADMINISTRATIONSARA ROWDEN, CITIZENSHAWN SABELLA, BEHAVIORAL HEALTH SERVICES NORTHSHEY SCHNELL, UNIVERSITY OF VERMONT HEALTH NETWORK-CHAMPLAIN VALLEY PHYSICIANS HOSPITALMARGARET SEARING, CLINTON COUNTY HEALTH DEPARTMENT, ADMINISTRATIONCOURTNEY SMITH, ADIRONDACK HEALTH INSTITUTEMANDY SNAY, CLINTON COUNTY HEALTH DEPARTMENT, HEALTH PLANNING AND PROMOTIONKATHY SNOW, UNITED WAY OF THE ADIRONDACK REGIONSALLY SOUCIA, JOINT COUNCIL FOR ECONOMIC OPPORTUNITYJULIE STALKER, JOINT COUNCIL FOR ECONOMIC OPPORTUNITYTREVOR COLE, TOWN OF PLATTSBURGH PLANNING DEPARTMENTPETER TROUT, BEHAVIORAL HEALTH SERVICES NORTHBRITTANY TRYBENDIS, STATE UNIVERSITY OF NEW YORK AT PLATTSBURGHLEE VERA, EASTERN ADIRONDACK HEALTH CARE NETWORKLAURIE WILLIAMS, THE FOUNDATION OF CVPH, CONTRACTORSTEVE WILLIAMS, HANNAFORD SUPERMARKETKATI JOCK, UNIVERSITY OF VERMONT HEALTH NETWORK - CHAMPLAIN VALLEY PHYSICIANS HOSPITALCONTINUED ON SCHEDULE O
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED	PART V, SECTION B, LINE 6A: CVPH IS PART OF THE ADIRONDACK RURAL HEALTH NETWORK. ADIRONDACK RURAL HEALTH NETWORK: THE ADIRONDACK RURAL HEALTH NETWORK (ARHN) IS A PROGRAM OF THE ADIRONDACK HEALTH INSTITUTE, INC. (AHI). AHI IS A JOINT VENTURE OF ADIRONDACK HEALTH (ADIRONDACK MEDICAL CENTER), UNIVERSITY OF VERMONT HEALTH NETWORK - CHAMPLAIN VALLEY PHYSICIANS HOSPITAL, GLENS FALLS HOSPITAL AND HUDSON HEADWATERS HEALTH NETWORK. THE MISSION OF AHI IS TO PROMOTE, SPONSOR, AND COORDINATE INITIATIVES AND PROGRAMS THAT IMPROVE HEALTHCARE QUALITY, ACCESS, AND SERVICE DELIVERY IN THE ADIRONDACK REGION.THE ADIRONDACK RURAL HEALTH NETWORK (ARHN) PROVIDES A FORUM FOR LOCAL PUBLIC HEALTH SERVICES, COMMUNITY HEALTH CENTERS, HOSPITALS, COMMUNITY MENTAL HEALTH PROGRAMS, EMERGENCY MEDICAL SERVICES, AND OTHER COMMUNITY-BASED ORGANIZATIONS TO ADDRESS RURAL HEALTHCARE DELIVERY BARRIERS, IDENTIFY REGIONAL HEALTH NEEDS AND SUPPORT THE NYS PREVENTION AGENDA TO IMPROVE HEALTH CARE IN THE REGION. THE ARHN REGION INCLUDES NEW YORK'S CLINTON, ESSEX, FRANKLIN, FULTON, HAMILTON, WARREN, AND WASHINGTON COUNTIES.SINCE 2002, ARHN HAS BEEN RECOGNIZED AS THE LEADING SPONSOR OF FORMAL COMMUNITY HEALTH PLANNING IN THE REGION WORKING WITH SEVERAL LOCAL HEALTH DEPARTMENTS. THE COMMUNITY HEALTH ASSESSMENT (CHA) COMMITTEE, FACILITATED BY ARHN, IS MADE UP OF HOSPITALS AND COUNTY HEALTH DEPARTMENTS WORKING TOGETHER UTILIZING A SYSTEMATIC APPROACH TO COMMUNITY HEALTH PLANNING. THE CHA COMMITTEE IS MADE UP OF MEMBERS FROM ADIRONDACK HEALTH, ALICE HYDE MEDICAL CENTER, ELIZABETHTOWN COMMUNITY HOSPITAL, ESSEX COUNTY PUBLIC HEALTH, FRANKLIN COUNTY PUBLIC HEALTH, FULTON COUNTY PUBLIC HEALTH, GLENS FALLS HOSPITAL, HAMILTON COUNTY PUBLIC HEALTH SERVICES, MOSES LUDINGTON HOSPITAL & INTER-LAKES HEALTH, NATHAN LITTAUER HOSPITAL, UVM HEALTH NETWORK - CVPH, WARREN COUNTY HEALTH SERVICES, AND WASHINGTON COUNTY PUBLIC HEALTH SERVICES.
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED	PART V, SECTION B, LINE 6B: THE CHNA IS A JOINT EFFORT WITH THE CLINTON COUNTY HEALTH DEPARTMENT. IN ADDITION, CLINTON COUNTY ACTION FOR HEALTH CONSORTIUM IS A KEY PART OF THE PROCESS, AND THEIR PURPOSE IS DESCRIBED BELOW.CLINTON COUNTY ACTION FOR HEALTH CONSORTIUM: THE CLINTON COUNTY ACTION FOR HEALTH (AFH) CONSORTIUM IS A MULTI-SECTOR, MULTI-DISCIPLINARY COLLECTION OF LOCAL HEALTH SYSTEM PARTNERS WORKING TOWARDS COMMUNITY HEALTH IMPROVEMENT AND FACILITATED BY CCHD. THE PRIMARY WORK OF THE GROUP HAS BEEN BUILT AROUND DATA DRIVEN IDENTIFIED NEEDS (NYS PREVENTION AGENDA) AND AVAILABLE COMMUNITY RESOURCES. PARTNERS IN THE EFFORT INCLUDE: MUNICIPALITIES, BUSINESSES, GRASSROOTS COMMUNITY GROUPS, HEALTH CARE PROVIDERS, THE LOCAL HOSPITAL, CHAMBER OF COMMERCE, HUMAN SERVICE AGENCIES, SCHOOLS AND LOCAL NOT-FOR-PROFITS. THE GROUP HAS EXISTED FOR OVER A DECADE AND PRESENTLY HAS APPROXIMATELY FORTY MEMBERS THAT HAVE FORMALLY COMMITTED TO ITS PURPOSE BY SIGNING AFH PARTNERSHIP LETTERS. RECRUITMENT OF NEW MEMBERS IS ONGOING. THE AFH CONSORTIUM HAS INCREASED COMMUNITY OWNERSHIP AND COMMITMENT TO THE SHARED HEALTH IMPROVEMENT GOALS AND TO THE WORK CAPTURED IN THE CHIP. IN FACILITATING THESE EFFORTS, THE CCHD HAS STRENGTHENED ITS ABILITY TO LEVERAGE RESOURCES FROM PUBLIC HEALTH PARTNERS AND PRIVATE ENTITIES ALIKE. SIGNIFICANT PROGRESS ON THE COUNTY'S CHIP HAS BEEN MADE CAPITALIZING ON THIS SYSTEM OF PARTNERSHIP CREATED THROUGH THE CONSORTIUM. THE AFH CONSORTIUM MEETS PERIODICALLY FOR UPDATES, ISSUE DISCUSSION, AND INFORMATION SHARING. A MINIMUM OF SIX MEETING ARE SCHEDULED EACH YEAR, WITH ADDITIONAL GATHERINGS SCHEDULED AS NEEDED. SUBCOMMITTEES OF MEMBERS WITH EXPERTISE RELATED TO SELECTED PRIORITY AREAS MEET MORE FREQUENTLY AND KEEP THE GROUP APPRISED OF THEIR WORK. CCHD TRACKS PROGRESS ON THE CHIP CONTINUALLY AND PREPARES A YEAR-END REPORT WHICH INCLUDES UPDATES ON WORK RELATED TO THE TWO FEATURED PRIORITY AREAS AND A SUMMARY OF ACCOMPLISHMENTS BY LOCAL PARTNERS RELATED TO EACH OF THE NYSDOH PREVENTION PLAN PRIORITY AREAS. CAPTURED ACTIVITIES DEMONSTRATE WORK ON ALL TIERS OF THE PUBLIC HEALTH IMPACT PYRAMID. MORE INFORMATION ON THE PUBLIC HEALTH PYRAMID IS INCLUDED IN THE COMMUNITY HEALTH IMPROVEMENT PLAN.
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MED	PART V, SECTION B, LINE 11: THE CHNA REVEALED THAT CLINTON COUNTY HAD TWO COMMUNITY NEEDS IN THE FOLLOWING AREAS:1. CHRONIC DISEASE2. MENTAL HEALTH AND SUBSTANCE ABUSEPRIORITIZED NEEDS:AFTER A STRUCTURED PRIORITIZATION PROCESS, THE 3 SIGNIFICANT NEEDS THAT ROSE TO THE TOP WERE:1. OBESITY IN CHILDREN AND ADULTS2. ACCESS TO HIGH QUALITY CHRONIC DISEASE PREVENTATIVE CARE AND MANAGEMENT3. PREVENTION OF SUBSTANCE ABUSE AND OTHER MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERSRATIONALE:IN ORDER TO MAXIMIZE THE POSITIVE IMPACT ON COMMUNITY HEALTH, CLINTON COUNTY PARTNERS HAVE CHOSEN TO CONCENTRATE EFFORTS ON TWO PRIORITY AREAS OF HIGH NEED. NEED, RESOURCES, EXPERTISE AND MOMENTUM EXIST TO ADDRESS THE TWO CHOSEN PRIORITIES NOTED ABOVE. THERE ARE, HOWEVER, EFFORTS UNDERWAY IN THE COMMUNITY RELATED TO ALL FIVE NYSDOH PREVENTION AGENDA PRIORITY AREAS. EXAMPLES OF WORK RELATED TO THE PRIORITY AREAS NOT SELECTED ARE LISTED BELOW. THE ACTION FOR HEALTH CONSORTIUM ACKNOWLEDGES AND CAPTURES THIS PROGRESS THROUGH ITS MEMBERS' CONTRIBUTIONS AT EACH OF ITS MEETINGS AND FORMALLY IN MID-YEAR AND END-OF-YEAR COMMUNITY HEALTH IMPROVEMENT PLAN AND IS SUMMARY DOCUMENTS. THESE DOCUMENTS ALSO ANALYZE WORK FOR ALL FIVE PRIORITY AREAS UTILIZING THE CDC'S HEALTH IMPACT PYRAMID. SUMMARY OF RESPONSES FROM THE CLINTON COUNTY HEALTH PRIORITY SETTING SESSION, 6/15/16:WHAT IS BEING DONE IN THE COMMUNITY TO ADDRESS THE NOTED PRIORITY AREA?- PROMOTE HEALTH IN WOMEN, INFANTS & CHILDREN- CLINTON COUNTY BREASTFEEDING COALITION- CVPH SEEKING DESIGNATION AS "BABY FRIENDLY"- ALL THREE PEDIATRIC PRACTICES RECOGNIZED AS BREASTFEEDING FRIENDLY BY THE NYSDOH- ESTABLISHED HEALTHY FAMILIES NY AND IMPROVED PREGNANCY OUTCOMES PROGRAMS- FLUORIDE VARNISH PROGRAMS IN PEDIATRIC PRACTICES- PREVENT HIV, STDS, VACCINE PREVENTABLE DISEASES, AND HEALTHCARE ASSOCIATED INFECTIONS- FREE STD TESTING, TREATMENT, COUNSELING FOR THE UNINSURED (PLANNED PARENTHOOD & CCHD)- ESTABLISHED NEEDLE EXCHANGE PROGRAM THROUGH THE ALLIANCE FOR POSITIVE HEALTH- NEWBORN ROUNDS ADDRESSING INFORMATION ON VACCINATIONS FOR INFANTS & FAMILIES- PEDIATRICIANS SCREENING FOR STDS- COMMUNITY HANDWASHING CAMPAIGNS AND PROMOTION- PROMOTE A HEALTHY & SAFE ENVIRONMENT- SARANAC RIVER TRAIL GREENWAY EXPANSION- TRAIL AND PARK REVISIONS- HEALTHY RETAILER AND EATERY PROGRAMS- COMPLETE STREETS EFFORTS- WORKSITE WELLNESS INITIATIVESPLAN: THE FOLLOWING IS A DESCRIPTION OF CLINTON COUNTY'S IMPLEMENTATION STRATEGY. IT INCLUDES CVPH AND CCHD PLANNED ACTIONS, ANTICIPATED IMPACT, AND A PLAN TO EVALUATE THESE ACTIONS FOR THE TWO AREAS OF PRIORITIZED.NEED: OBESITY IN CHILDREN AND ADULTS AND ACCESS TO HIGH QUALITY CHRONIC DISEASE PREVENTIVE CARE AND MANAGEMENT IN CLINICAL AND COMMUNITY SETTINGS AND PREVENT SUBSTANCE ABUSE AND OTHER MENTAL, EMOTIONAL AND BEHAVIORAL DISORDERS. EVIDENCE BASED INTERVENTIONS ARE UTILIZED THROUGHOUT THE PLAN WITH SPECIFIC DATA RESOURCES THAT WILL BE TRACKED. IT SHOULD BE NOTED THAT THIS IS A THREE YEAR PLAN. WHILE THE GOALS, OBJECTIVES, AND STRATEGIES ARE LONG TERM, THE ACTIVITIES ARE PRIMARILY FOCUSED FOR THE FIRST YEAR. EACH YEAR, THE ACTIVITIES WILL BE EVALUATED AND ADJUSTED AS NEEDED. SOME OF THE ACTIVITIES COULD ROLL OVER AND REMAIN THE SAME, BE CHANGED SLIGHTLY, OR BE ADJUSTED ENTIRELY IF IT IS DETERMINED THEY ARE NOT MOVING US TOWARDS OUR GOALS AND OBJECTIVES. HEALTH PRIORITY 1: PREVENT CHRONIC DISEASETHE PURPOSE OF THIS PRIORITY IS TO ASSIST NYS IN ADDRESSING CHRONIC DISEASES AND THEIR CAUSES TO EFFECTIVELY STEM THE TIDE OF ESCALATING HEALTH CARE COSTS AND ENSURE THAT NEW YORKERS LEAD HEALTHY AND PRODUCTIVE LIVES. CHRONIC DISEASES SUCH AS CANCER, DIABETES, HEART DISEASE, STROKE AND ASTHMA ARE CONDITIONS OF LONG DURATION AND GENERALLY SLOW PROGRESSION. THEY ARE AMONG THE MOST PREVENTABLE OF ALL DISEASES. THREE MODIFIABLE RISK BEHAVIORS - LACK OF PHYSICAL ACTIVITY, UNHEALTHY NUTRITION, AND TOBACCO USE - ARE LARGELY RESPONSIBLE FOR THE INCIDENCE, SEVERITY AND ADVERSE OUTCOMES OF CHRONIC DISEASE.THE NEW YORK STATE PREVENTION AGENDA PLACES EMPHASIS ON THREE KEY AREAS IN REGARDS TO PREVENTING CHRONIC DISEASE: 1) HEALTH PROMOTION ACTIVITIES TO ENCOURAGE HEALTHY LIVING AND LIMIT THE ONSET OF CHRONIC DISEASES; 2) EARLY DETECTION OPPORTUNITIES THAT INCLUDE SCREENING POPULATIONS AT RISK; AND 3) SUCCESSFUL MANAGEMENT STRATEGIES FOR EXISTING DISEASES AND RELATED COMPLICATIONS.FOCUS AREA 1: REDUCE OBESITY IN CHILDREN AND ADULTSTHE GOAL AROUND THIS FOCUS AREA IS CREATING COMMUNITY ENVIRONMENTS THAT PROMOTE AND SUPPORT HEALTHY FOOD AND BEVERAGE CHOICES AND PHYSICAL ACTIVITY. THE TWO EVIDENCE BASED LONG TERM OBJECTIVES CHOSEN ARE AROUND DECREASING THE PERCENTAGE OF CLINTON COUNTY ADULTS WHO REPORT PARTICIPATING IN NO LEISURE TIME ACTIVITY AND INCREASE THE PERCENTAGE OF CLINTON COUNTY ADULTS REPORTING ADEQUATE DAILY FRUIT AND VEGETABLE CONSUMPTION. THE FOLLOWING STATISTICS/INFORMATION WERE USED AS SUPPORT AND RATIONALE IN THE SELECTION OF THIS AS A PRIORITY:- 26.8% OF ADULTS IN CLINTON COUNTY ARE OBESE, COMPARED TO 24.6% IN NYS. THE PREVENTION AGENDA GOAL FOR 2013-2018 IS 23.2% (HEALTHYADK)- 64.0% OF ADULTS IN CLINTON COUNTY ARE OVERWEIGHT OR OBESE, COMPARED TO 60.5% IN NYS (HEALTHYADK)- 37.5% OF ELEMENTARY STUDENTS IN CLINTON COUNTY ARE OVERWEIGHT OR OBESE, COMPARED TO 33.1% IN NYS. THIS HAS GOTTEN 0.2% WORSE IN THE LATEST MEASUREMENT PERIOD (HEALTHYADK)- 41.6% OF MIDDLE AND HIGH SCHOOL STUDENTS IN CLINTON COUNTY ARE OVERWEIGHT OR OBESE. ONLY 35.2% ARE IN THIS CATEGORY FOR NYS (HEALTHYADK)- ONLY 66.8% OF ADULTS IN CLINTON COUNTY HAVE ACCESS TO EXERCISE OPPORTUNITIES, WHILE 90.7% OF ADULTS IN NYS DO (HEALTHYADK) OF THE SUBCATEGORIES UNDER PREVENTING CHRONIC DISEASE, 53% OF SURVEY RESPONDENTS SELECTED THIS FOCUS AREA REDUCE OBESITY IN CHILDREN AND ADULTS).THERE ARE SEVERAL STRATEGIES CVPH AND CCHD WILL BE UTILIZING TO ADDRESS THIS FOCUS AREA AND ACHIEVE THE GOAL AND OBJECTIVES. THEY ARE AS FOLLOWS:- CONDUCT GENERAL EDUCATION FOR HEALTH PROFESSIONALS ON DIET AND EXERCISE WITH A FOCUS ON THE DEVELOPMENT OF A PROGRAM TARGETING NURSES IN CONJUNCTION WITH THE MAGNET APPLICATION PROCESS TO FOCUS ON DIET, EXERCISE, STRESS, COPING, OBESITY AND DISABILITIES. CURRENTLY, THERE ARE NO PROGRAMS LIKE THIS OCCURRING, BUT THE HOPE IS TO COMPLETE ONE PROGRAM PER YEAR AT CVPH WITH THE OPPORTUNITY TO OPEN THIS UP TO NURSES AT THE CCHD.- IMPLEMENTATION OF PROGRAMS TO INCREASE ACCESS TO LEISURE TIME ACTIVITIES FOR MEMBERS OF THE COMMUNITY WITH A FOCUS ON CONTINUATION OF YEAR TWO OF THE FITNESS IN THE PARKS GRANT. SIGNIFICANT PROGRESS HAS BEEN MADE IN YEAR ONE AND THE FOCUS OF YEAR TWO WILL BE AROUND SOCCER GOLF, PICKLE BALL, AND TRANSITIONING OF FITNESS IN PARKS TO THE TOWNS. CVPH WILL WORK TO MAKE TRAIL MAPS PROVIDED BY CCHD AVAILABLE IN HOSPITAL LOCATIONS. THE CCHD WILL FINALIZE ENHANCEMENTS TO ONE ADDITIONAL RECREATIONAL SPACE TO SUPPORT ACTIVITY AS WELL AS FACILITATE COMMUNITY ENTITIES TO SUBMIT PROJECTS TO THE HEALTH FOUNDATION'S MATCHING FUNDS PROGRAM. - CONTINUATION AND EXPANSION OF THE DIABETES PROGRAM WHICH CVPH HAS IMPLEMENTED AND SEEN SIGNIFICANT SUCCESS WITH.- CONTINUED USAGE OF HEALTHY MEAL AND BEVERAGE STANDARDS FOR MEALS SOLD AND SERVED IN THE HOSPITAL WITH A FOCUS ON USING HEALTHY, LOCALLY GROWN FOODS IN THE CAFETERIA AND PATIENT MEALS. THIS WILL FOCUS ON A REGULAR REVIEW OF MENUS, NO SUGAR ADDED OPTIONS, AND INCLUSION OF NUTRITIONALS ON FOOD TO EMPOWER EMPLOYEES AND PATIENTS TO TAKE CONTROL OF THEIR FOOD CHOICES. - EXPAND PARTICIPATION IN LOCAL BETTER CHOICES CERTIFICATION PROGRAM BY RECRUITING AND PROMOTING LOCALLY OWNED RESTAURANTS TO PARTICIPATE IN SEVERAL PROGRAMS. - SUPPORT AND PROMOTE USE OF LOCALLY GROWN FRUITS AND VEGETABLES THROUGHOUT THE CLINTON COUNTY FOOD ENVIRONMENT BY WORKING WITH LOCAL FARMS, INSTITUTE ENVIRONMENTAL CHANGES AT LOCAL FOOD PANTIES, AND DESIGNING AND LAUNCHING A TARGETED MEDIA CAMPAIGN AIMED AT INCREASING DONATIONS TO FOOD PANTRIES. THERE IS SIGNIFICANT OPPORTUNITY TO PROVIDE THIS SUPPORT AND PROMOTION THROUGH THE CVPH MALNUTRITION PROGRAM.CONTINUED ON SCHEDULE O

Schedule H (Form 990) 2019

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?8
Name and address		Type of Facility (describe)
1	1 - CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
2	3 - CVPH DIAGNOSTIC CENTER 89 PLAZA BLVD PLATTSBURGH,NY12901	LAB & IMAGING SERVICES
3	4 - CVPH REHABILITATION - DEGRANDPRE WAY 16 DEGRANDPRE WAY PLATTSBURGH,NY12901	PHYSICAL THERAPY
4	5 - CVPH REHABILITATION - TOM MILLER RD TOM MILLER RD PLATTSBURGH,NY12901	PHYSICAL THERAPY
5	6 - NORTH COUNTRY REGIONAL BLOOD DONOR CENTE 85 PLAZA BOULEVARD PLATTSBURGH,NY12901	BLOOD DONATION CENTER
6	7 - CVPH SPORTS MEDICAL AND REHABILITATION 295 NEW YORK RD PLATTSBURGH,NY12901	PHYSICAL AND OCCUPATIONAL THERAPY, EXERCISE AND WELLNESS
7	8 - FAMILY MEDICINE CENTER 159 MARGARET STREET SUITE 100 PLATTSBURGH,NY12901	PRIMARY CARE
8	9 - MOBILE HEALTH SCREENING VAN 75 BEEKMAN ST PLATTSBURGH,NY12901	LAB AND DIAGNOSTIC IMAGING
9
10

Schedule H (Form 990) 2019

Page 10

Part VI

Supplemental Information

Provide the following information.

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

Form and Line Reference	Explanation
PART I, LINE 7:	IN ACCORDANCE WITH THE IRS INSTRUCTIONS, CVPH USED THE RATIO OF COST TO CHARGES TO CALCULATE COSTS. SPECIFICALLY, THE FACILITY'S TOTAL EXPENSES FROM PART IX LINE 25 OF $361,864,567 LESS COMMUNITY BENEFIT EXPENSES OF $3,804,085 WAS USED TO DETERMINE THE 2018 RCC PERCENTAGE. THE GROSS CHARITY CARE WRITE OFFS WAS OBTAINED FROM OUR REVENUE REPORTS AND TO WHICH THE CALCULATED RCC APPLIED. LINE 7(E): CLINTON COUNTY NY IS DESIGNATED AS A HEALTHCARE PROFESSIONAL SHORTAGE AREA (HPSA) FOR PRIMARY CARE. TO HELP ALLEVIATE THE LACK OF ACCESS TO PRIMARY CARE IN THE COUNTY AND SURROUNDING AREA, CVPH HAS BEEN OPERATING A HEALTH CENTER CLINIC TO PROVIDE MEDICAL TREATMENT FOR THIS AT RISK POPULATION. DURING 2018, THE CLINIC HAD IN EXCESS OF 20,000 PATIENT ENCOUNTERS WITH A PAYER MIX OF 81% MEDICAID AND MEDICARE, 16% COMMERCIAL, 1% SELF PAY AND 2% OTHER. PART 1 LINE 7, COLUMN F: AMOUNT OF BAD DEBT EXPENSE INCLUDED IN FORM 990 PART IX LINE 25 COLUMN (A), BUT REMOVED FROM THIS FIGURE FOR PURPOSES OF CALCULATING THE RCC PERCENTAGE WAS $9,529,166 AS REFLECTED ON PART IX LINE 24(B)
PART I, LN 7 COL(F):	AMOUNT OF BAD DEBT EXPENSE INCLUDED IN FORM 990 PART IX LINE 25 COLUMN (A), BUT REMOVED FROM THIS FIGURE FOR PURPOSES OF CALCULATING THE RCC PERCENTAGE WAS $3,390,477 AS REFLECTED ON PART IX LINE 24(E)PART III, LINE 3:IN ACCORDANCE WITH IRS 990 INSTRUCTIONS, CVPH APPLIED THE CALCULATED RATIO OF COST TO CHARGES TO THE FACILITY'S 2018 BAD DEBT EXPENSE OF $9,529,166 IN ORDER TO CALCULATE THE BAD DEBT EXPENSE (AT COST) AS REPORTED ON PART III LINE 2. THE RCC USED WAS 35.58%. THEREFORE, THE BAD DEBT EXPENSE (AT COST) FOR 2018 WAS $3,390,477. WE ATTRIBUTE APPROXIMATELY 40% OF THIS AMOUNT TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, CAUSING THE PORTION OF BAD DEBT AS A COMMUNITY BENEFIT TO BE $1,356,191.
PART III, LINE 4:	THE BAD DEBT EXPENSE FOOTNOTE IS DISCLOSED IN ATTACHED AUDITED FINANCIAL STATEMENTS ON PAGE 14.
PART III, LINE 8:	USED MEDICARE ONLY TOTAL CHARGES FROM INSTITUTIONAL COST REPORT FOR 2018 AND APPLIED THE RATIO OF COST TO CHARGES FROM THE 2018 COST REPORT DATA. APPROXIMATELY 44% OF OUR REVENUE IS DERIVED FROM MEDICARE PATIENTS. WE FEEL THE SHORTFALL FROM THIS PROGRAM IS DIRECTLY A COMMUNITY BENEFIT IN THAT WE ARE A SOLE COMMUNITY HOSPITAL.
PART III, LINE 9B:	CVPH HAS A FORMAL CREDIT AND COLLECTION POLICY. ALL PATIENT ACCOUNTS WILL BE BILLED AND FOLLOWED UP ON IN A TIMELY FASHION. ALL DISCOUNTS WILL BE APPLIED AND OFFERED PER POLICY, UNIFORMLY AND WITHOUT PREJUDICE OR DISCRIMINATION. THE POLICY CONSISTS OF DOCUMENTED PROCEDURES FOR INSURANCE, CREDIT BALANCES, SELF PAY OUTPATIENT, AND SELF PAY INPATIENT (NO INSURANCE & AFTER INSURANCE). THERE ARE SPECIFIED PAYMENT ARRANGEMENTS THAT ARE OFFERED AND THE TIME FRAME ALLOTTED FOR REPAYMENT IS GRADUATED BASED ON THE AMOUNT OWED, RANGING FROM 30 DAYS TO 36 MONTHS. CUSTOMER SERVICE REPRESENTATIVES PLACE PHONE CALLS TO PATIENTS TO RESOLVE ACCOUNTS OR ESTABLISH PAYMENT ARRANGEMENTS. AFTER ACCOUNTS HAVE BEEN AT THE PRIMARY BAD DEBT AGENCY FOR A PERIOD OF 6 MONTHS WITHOUT PAYMENTS, THE ACCOUNTS ARE FORWARDED TO A SECOND PLACEMENT AGENCY FOR ATTEMPTED RECOVERY.
PART VI, LINE 2:	CVPH WORKS COLLABORATIVELY TO ASSESS HEALTH NEEDS AND THEN IMPLEMENT STRATEGIES TO ADDRESS THE HEALTH PRIORITIES OF THE COMMUNITY IT SERVES. CVPH HAS WORKED WITH OTHER HOSPITALS, HEALTH DEPARTMENTS, AND AGENCIES IN CLINTON, ESSEX, AND FRANKLIN COUNTIES THROUGH PARTICIPATION IN THE MAPPING OUR WAY TO A HEALTHIER COMMUNITY PROCESS WHICH IS COORDINATED BY THE NEW YORK STATE DEPARTMENT OF HEALTH. THE GOAL OF THIS GROUP IS TO ANALYZE DATA AND SEEK OPINIONS FROM THE PUBLIC TO DETERMINE THE MAJOR CHALLENGES, NEEDS AND BARRIERS TO PROVIDING SERVICES. BY BRINGING THE VARIOUS PROVIDERS TOGETHER FROM A THREE-COUNTY AREA, IT IS BELIEVED THAT THIS PROVIDES A BROADER, MORE REPRESENTATIVE DETERMINATION OF THE NEEDS THAT EXIST. A FOUR-STEP PROCESS IS USED TO ESTABLISH PRIORITIES AS PART OF THE FORMALIZED COMMUNITY HEALTH ASSESSMENT. DATA IS COMPILED AND ANALYZED, PRIORITIES ARE DETERMINED, FOCUS GROUPS SEEK CONSENSUS AND REPORT OUT, DATA IS FURTHER WEIGHTED AND A FINAL SELECTION OF PRIORITIES FOCUSING ON ACCESS TO CARE AND THE NEED TO DIRECT RESOURCES TO TREATMENT OF CHRONIC DISEASE WERE ADOPTED AS KEY NEEDS. TO THAT END, CVPH HAS DIRECTED RESOURCES TO SUPPORT OF THE ADIRONDACK REGION MEDICAL HOME, PHYSICIAN RECRUITMENT, ITS DIABETES EDUCATION CENTER AND COMMUNITY EFFORT RELATED TO THE IMPORTANCE OF PROPER NUTRITION AND EXERCISE. WORKING INDEPENDENTLY, CVPH ASSESSES NEEDS BY ENCOURAGING AN OPEN DIALOGUE WITH ITS VARIOUS COMMUNITY CONSTITUENCIES. THE MEDICAL CENTER HOSTS MEETINGS, VISITS CLUBS AND ORGANIZATIONS, SURVEYS ITS PATIENTS, ENCOURAGES FEEDBACK THROUGH ITS WEB SITE AND INVITES FORMER PATIENTS FOR LUNCH AND TO SHARE OBSERVATIONS ABOUT UNMET NEEDS AND WAYS TO IMPROVE SERVICES WITH EMPHASIS ON FILLING EXISTING GAPS IN SERVICE. AS PART OF ITS STRATEGIC PLANNING PROCESS A COORDINATED AND FORMALIZED APPROACH IS TAKEN TO ASSESS PERCEIVED NEEDS FROM THE COMMUNITY, MEDICAL STAFF, EMPLOYEES AND BOARD MEMBERS UTILIZING FULL AND HALF- DAY MEETING SESSIONS.
PART VI, LINE 3:	THE FOLLOWING INFORMATION IS LISTED ON EVERY PATIENT STATEMENT: "FINANCIAL AID MAY BE AVAILABLE TO QUALIFIED PATIENTS. PLEASE CALL OUR OFFICE AT 562-7074 TO SEE IF YOU QUALIFY." WE ALSO HAVE INFORMATIONAL FLYERS AT THE CASHIERS DESK AND SEVERAL OTHER AREAS IN THE HOSPITAL. AT TIME OF REGISTRATION FOR EVERY SELF PAY PATIENT, WE ASK PERMISSION TO HAVE THE PATIENT CONTACTED TO SEE IF THEY QUALIFY FOR MEDICAID. ALSO WHEN MAKING A CALL TO COLLECT ON PATIENT ACCOUNTS, THE PATIENT IS OFFERED TO TAKE PART IN CVPH'S CARES PROGRAM WHERE APPROPRIATE TO DO SO.
PART VI, LINE 4:	THE PRIMARY SERVICE AREA FOR CVPH IS DEFINED AS CLINTON COUNTY. CVPH'S SECONDARY SERVICE AREA FOR TERTIARY SERVICES NOT AVAILABLE IN THOSE COMMUNITIES ARE ESSEX, FRANKLIN, AND EASTERN ST. LAWRENCE COUNTIES. THE DEMOGRAPHIC CHARACTERISTICS AND HEALTH NEEDS OF THESE COUNTIES REFLECT THOSE IN CLINTON COUNTY. OUR PAYER MIX CONSINSTS OF APPROXIMATELY 53% MEDICARE AND MEDICAID PROGRAMS. CVPH IS THE ONLY HOSPITAL IN CLINTON COUNTY, WHICH HAS A POPULATION OF APPROXIMATELY 82,000 AND IS THE LARGEST EMPLOYER IN THE TRI-COUNTY AREA. CENSUS FIGURES FOR THE SERVICE AREA ARE MONITORED. HOWEVER, CHANGES IN THE CENSUS FIGURES HAVE NOT BEEN HIGHLY SIGNIFICANT IN THE PAST DECADE, AS IN MUCH OF THE NATION. MOST NOTABLE IS THE AGING POPULATION, A TREND THAT IS BEING MONITORED BECAUSE OF THE CORRELATION BETWEEN AGE AND INCREASED UTILIZATION OF HEALTH SERVICES AND BECAUSE OF THE ANTICIPATED INCREASED NEED FOR HOME HEALTH AND SKILLED NURSING FACILITIES THAT IF NOT PRESENT CREATE A BACKLOG FOR THE MEDICAL CENTER. A SNAPSHOT OF THE CENSUS IN CLINTON COUNTY AND THE SURROUNDING COUNTIES REFLECTS: A LOW POPULATION DENSITY WHEN COMPARED WITH THE REST OF NEW YORK STATE AND THE NATION, A PREDOMINANTLY WHITE/CAUCASIAN POPULATION WITH LITTLE DIVERSITY. IN CLINTON COUNTY, A POPULATION SKEWING OLDER AS ONLY 18% OF THE POPULATION IS 18 OR YOUNGER WHILE 23% OF THE POPULATION IS AGE 55 OR OLDER, MEDIAN HOUSEHOLD AND FAMILY INCOMES SUBSTANTIALLY LOWER THAN THE REST OF NEW YORK STATE, LOWER EDUCATION LEVELS THAN THE AVERAGE FOR NEW YORK STATE.
PART VI, LINE 5:	CVPH MEDICAL CENTER PLAYS AN IMPORTANT ROLE IN PROMOTING HEALTH IN THE COMMUNITY BY, FOR INSTANCE, HOSTING FREE COMMUNITY LECTURES, SUPPORT GROUPS, AND SCREENINGS. A FREE MONTHLY COMMUNITY LECTURE SERIES OFFERS A WIDE RANGE OF TOPICS FROM DIABETES AND CANCER TO RHEUMATOLOGY AND MACULAR DEGENERATION. CVPH SPONSORS A NUMBER OF FREE SUPPORT GROUPS INCLUDING PROGRAMS ON DIABETES, MULTIPLE CANCER GROUPS, AND BEREAVEMENT. AN ARRAY OF FOCUSED CLASSES ARE HELD FOR EXPECTANT MOTHERS AS PART OF AN OVERALL CHILDBIRTH EDUCATION INITIATIVE. REGULAR CAR-SEAT SAFETY CHECKS ARE HELD TO ENSURE THAT INFANTS AND TODDLERS ARE APPROPRIATELY SECURED IN THEIR VEHICLES. CVPH WORKS IN CONJUNTION WITH THE ADIRONDACK SAFE KIDS NETWORK FOR AN ANNUAL BIKE AND SKATEBOARD SAFETY FAIR THAT DISTRIBUTES HUNDREDS OF FREE SAFETY HELMETS. CVPH IS A REGULAR PARTICIPANT AT VARIOUS HEALTH FAIRS IN THE REGION DISPENSING EDUCATION INFORMATION AND PROVIDING FREE HEALTH SCREENINGS. CVPH ALSO WORKS WITH OTHER AGENCIES TO FACILITATE INSURANCE COVERAGE FOR ELIGIBLE INDIVIDUALS AND FAMILIES. CVPH MEDICAL CENTER OVERSEES THE NEW YORK STATE GRANT-FUNDED CANCER SERVICES PROGRAM (CSP) OF CLINTON COUNTY. THE PROGRAM PROVIDES CLINTON COUNTY RESIDENTS WHO HAVE NO INSURANCE OR WHO ARE UNDERINSURED WITH FREE SCREENINGS FOR BREAST, CERVICAL AND COLORECTAL CANCERS. THE SERVICES ARE PROVIDED VIA LOCAL PROVIDERS AND CLINICS. CVPH ALSO PARTICIPATES IN THE ACTION FOR HEALTH COALITION WHICH WAS CREATED AS PART OF THE MAPP/CHNA PROCESS. THIS GROUP HAS AN ACTIVE ROLE IN TRACKING PROGRESS MADE IN IMPLEMENTING CHANGES TO IMPACT THE HEALTH OF THE COMMUNITY AS WELL AS MAKING ADJUSTMENTS TO THE STRATEGIES IDENTIFIED TO ADDRESS THESE NEEDS. SOME OF THE ACCOMPLISHMENTS OF THE ACTION FOR HEALTH COALITION INCLUDE CVPH HOSTING NEW VISIONS PROGRAM FOR SELECTED COLLEGE BOUND HIGH SCHOOL SENIORS PLANNING TO MAJOR IN A HEALTH RELATED FIELD OF STUDY, MOVING TOBACCO PRODUCTS OUT OF SIGHT IN MANY RETAIL ESTABLISHMENTS, IMPROVING NUTRITION IN SCHOOLS, AND FOCUSING ON POSITIVELY IMPACTING CHRONIC DISEASE MANAGEMENT IN CLINTON COUNTY.
PART VI, LINE 6:	CVPH MEDICAL CENTER, IS A MEMBER OF THE UNIVERSITY OF VERMONT HEALTH NETWORK (FORMERLY FLETCHER ALLEN PARTNERS, INC.), ALSO COVERING THE BURLINGTON AND BERLIN, VERMONT AREAS.

Schedule H (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990.
SchJMediumBullet

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

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

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

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 on 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? ....................

Yes

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

Yes

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) 2019

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(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)
1STEPHENS MUNDY PRESIDENT /CEO	(i) (ii)	692,840 ------------- 0	371,166 ------------- 0	267,333 ------------- 0	205,492 ------------- 0	39,235 ------------- 0	1,576,066 ------------- 0	0 ------------- 0
2WOUTER RIETSEMAMD CHIEF QUALITY AND INFOR.	(i) (ii)	346,026 ------------- 0	62,962 ------------- 0	17,198 ------------- 0	0 ------------- 0	43,397 ------------- 0	469,583 ------------- 0	0 ------------- 0
3KENT HALL CHIEF MEDICAL OFFICER	(i) (ii)	400,975 ------------- 0	67,595 ------------- 0	73,479 ------------- 0	0 ------------- 0	32,813 ------------- 0	574,862 ------------- 0	0 ------------- 0
4MICHELLE LEBEAU PRESIDENT/COO	(i) (ii)	320,528 ------------- 0	65,253 ------------- 0	33,596 ------------- 0	0 ------------- 0	36,522 ------------- 0	455,899 ------------- 0	0 ------------- 0
5SCOTT ST GEORGE VICE PRESIDENT OF FINANCE	(i) (ii)	177,941 ------------- 0	10,000 ------------- 0	0 ------------- 0	0 ------------- 0	2,550 ------------- 0	190,491 ------------- 0	0 ------------- 0
6STEPHANE MULLIGAN ORTHOPEDIC SURGEON	(i) (ii)	552,574 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	35,831 ------------- 0	588,405 ------------- 0	0 ------------- 0
7TODD WHITMAN MEDICAL ONCOLOGIST	(i) (ii)	853,559 ------------- 0	37,500 ------------- 0	0 ------------- 0	0 ------------- 0	31,091 ------------- 0	922,150 ------------- 0	0 ------------- 0
8CHARLES VOLK ORTHOPEDIC SURGEON	(i) (ii)	674,885 ------------- 0	1,095 ------------- 0	0 ------------- 0	0 ------------- 0	25,102 ------------- 0	701,082 ------------- 0	0 ------------- 0
9JOHN GRIFFIN MEDICAL ONCOLOGIST	(i) (ii)	590,623 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	34,588 ------------- 0	625,211 ------------- 0	0 ------------- 0
10JAN DUUS MEDICAL ONCOLOGIST	(i) (ii)	456,350 ------------- 0	203,250 ------------- 0	0 ------------- 0	0 ------------- 0	37,946 ------------- 0	697,546 ------------- 0	0 ------------- 0
11JOYCE RAFFERTY FORMER SVP/CFO	(i) (ii)	331,055 ------------- 0	80,327 ------------- 0	0 ------------- 0	0 ------------- 0	45,772 ------------- 0	457,154 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

Page 3

Part III

Supplemental Information

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

Return Reference	Explanation
PART I, LINE 1A	TRAVEL FOR COMPANIONS: TOTAL TRAVEL COSTS FOR COMPANION OF STEPHENS MUNDY, CEO, OF LESS THAN $1,000 WERE INCURRED AND REIMBURSED BY CVPH MEDICAL CENTER. NO OTHER BOARD MEMBER, OFFICER, DIRECTOR, OR KEY EMPLOYEE RECEIVED THIS BENEFIT.
PART I, LINE 1B	TOTAL TRAVEL COSTS FOR COMPANION OF STEPHENS MUNDY, CEO, OF LESS THAN $1,000 WERE INCURRED AND REIMBURSED BY CVPH MEDICAL CENTER. NO OTHER BOARD MEMBER, OFFICER, DIRECTOR, OR KEY EMPLOYEE RECEIVED THIS BENEFIT.
PART I, LINE 3	IN ADDITION TO THE TOOLS AND PROCESSES IDENTIFIED IN PART I, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL RECEIVES GUIDANCE REGARDING ITS PRESIDENT'S COMPENSATION FROM THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE UNIVERSITY OF VERMONT HEALTH NETWORK, WHICH IS THE SOLE MEMBER OF THE HOSPITAL. THAT NETWORK COMPENSATION COMMITTEE UTILIZES THE FOLLOWING METHODS TO ESTABLISH THAT GUIDANCE: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
PART I, LINE 4B	A DISTRIBUTION TO STEPHENS MUNDY, CEO,IN THE AMOUNT OF $267,333 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MR. MUNDY'S TAXABLE COMPENSATION. A DISTRIBUTION TO WOUTER RIETSEMA IN THE AMOUNT OF $17,198 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MR. RIETSEMA'S TAXABLE COMPENSATION. A DISTRIBUTION TO MICHELLE LEBEAU IN THE AMOUNT OF $33,596 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MS. LEBEAU'S TAXABLE COMPENSATION. A DISTRIBUTION TO KENT HALL IN THE AMOUNT OF $73,480 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MR. HALL'S TAXABLE COMENSATION. IN 2012, STEPHENS MUNDY, CEO, WAS GRANTED A 457(F) DEFERRED COMPENSATION PLAN. FOR 2017, MR. MUNDY RATABLY ACCRUED $205,492 OF DEFERRED COMPENSATION IN THE PLAN AND IT WAS INCLUDED IN HIS COMPENSATION PACKAGE.
PART I, LINE 6	DURING 2018, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER CONTINUED A COMPENSATION INCENTIVE PLAN FOR MANAGEMENT OF THE ORGANIZATION. THE PLAN SETS FORTH NUMEROUS OBJECTIVES AND GOALS (16) TO BE MET IN ORDER TO EARN AN INCENTIVE AWARD. EACH OF THE GOALS ARE AIMED AT IMPROVING THE EXPANSE OF CVPH'S SERVICE OFFERINGS, QUALITY OF SERVICE AND OPERATION, AND MEETING COMMUNITY NEEDS. ONLY ONE OF THE 16 OBJECTIVES INCLUDED IN THE 2018 PLAN IS KEYED TO NET MARGIN OF THE ORGANIZATION. THIS MEASURE IS INTENDED TO MEET THE OVERALL GOAL OF MAINTAINING THE FINANCIAL HEALTH OF THE ORGANIZATION. OTHER GOALS IN THE PLAN ARE TO IMPROVE PATIENT & EMPLOYEE SATISFACTION.

Schedule J (Form 990) 2019

Additional Data

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Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

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

Attach to Form 990.
SchKMediumBullet

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

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number
14-1338471

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY	14-6035154	187476AD8	06-07-2007	19,565,000	CONSTRUCTION OF SURGICAL SVC WING		X		X		X
B	COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY	14-6035154	187476AB2	12-19-2006	12,650,000	REFINANCE SERIES 1997 BONDS		X		X		X
C	COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY	14-6035154	187476AE6	06-25-2007	12,505,000	RENOVATION OF SURGICAL AREA		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	19,565,000		12,650,000		12,505,000
4 Gross proceeds in reserve funds .............	1,172,250				727,569
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............			12,511,605
7 Issuance costs from proceeds ...............	1,340,812		138,395		811,805
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	17,051,938				10,965,626
11 Other spent proceeds .............
12 Other unspent proceeds .............
13 Year of substantial completion .............	2009		1998		2009
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2018, a current refunding issue)? ........
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2018, an advance refunding issue)? ........
16 Has the final allocation of proceeds been made? ..........	X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X		X

Part Ⅲ

Private Business Use

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

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

Cat. No. 50193E

Schedule K (Form 990) 2019

Page 2

Part Ⅲ

Private Business Use (Continued)

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

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X		X		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X		X		X
b Exception to rebate? ........		X		X		X
c No rebate due? .........	X		X		X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....	X		X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?	X		X		X
b Name of provider ..........	KEY BANK		KEY BANK		KEY BANK
c Term of hedge .........	3500.0000000000 %		1100.0000000000 %		3500.0000000000 %
d Was the hedge superintegrated? ......		X		X		X
e Was the hedge terminated? ........		X		X		X

Schedule K (Form 990) 2019

Page 3

Part Ⅳ

Arbitrage (Continued)

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

Part Ⅴ

Procedures To Undertake Corrective Action

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

Part Ⅵ

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

Return Reference	Explanation
DATE REBATE COMPUTATION PERFORMED	ISSUER NAME: COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY DATE THE REBATE COMPUTATION WAS PERFORMED: 12/16/2010 ISSUER NAME: COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY DATE THE REBATE COMPUTATION WAS PERFORMED: 07/01/2011 ISSUER NAME: COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY DATE THE REBATE COMPUTATION WAS PERFORMED: 06/25/2012

Schedule K (Form 990) 2019

Additional Data

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SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 4	IN JANUARY 2018,THE BY-LAWS OF CVPH WERE AMENDED TO CHANGE THE SOLE MEMBER OF THE MEDICAL CENTER TO UVM HEALTH NETWORK, INC.
FORM 990, PART VI, SECTION A, LINE 6	THE UNIVERSITY OF VERMONT HEALTH NETWORK, INC. (UVMHN) IS THE VOTING MEMBER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A	THE UNIVERSITY OF VERMONT HEALTH NETWORK SHALL ELECT THE DIRECTORS TO HOLD OFFICE ANNUALLY. EACH DIRECTOR SHALL HOLD OFFICE UNTIL THE EXPIRATION OF THE TERM AND UNTIL A SUCCESSOR HAS BEEN ELECTED AND SHALL HAVE QUALIFIED, OR UNTIL THE DIRECTOR'S PRIOR RESIGNATION OR REMOVAL.
FORM 990, PART VI, SECTION B, LINE 11B	CVPH PROVIDES AN ELECTRONIC COPY OF FORM 990 TO EACH BOARD MEMBER PRIOR TO THE FORM BEING FILED.
FORM 990, PART VI, SECTION B, LINE 12C	CVPH HAS A WRITTEN CONFLICT OF INTEREST POLICY AS A PART OF ITS GOVERNING DOCUMENTS. THE POLICY IS APPLICABLE TO MEMBERS OF THE GOVERNING BODY, OFFICERS AND KEY EMPLOYEES. THE ORGANIZATION REQUIRES THAT MEMBERS HAVING A CONFLICT OF INTEREST IN A TRANSACTION RECUSE THEMSELVES OF VOTING ON THE MATTER. PROPOSED AND ONGOING TRANSACTIONS ARE REVIEWED BY APPROPRIATE GROUPS OF INDIVIUALS (COMMITTEES AND/OR LEVELS OF REVIEW) TO ENSURE THE BEST INTEREST OF THE HOSPITAL. THE ORGANIZATION SOLICITS FROM EACH MEMBER OF THE GOVERNING BODY, OFFICERS, AND KEY EMPLOYEES AN ANNUAL SIGNED STATEMENT CERTIFYING COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND SELF-DISCLOSURE OF CERTAIN INTEREST FOR EACH ANNUAL PERIOD.
FORM 990, PART VI, SECTION B, LINE 15	CVPH HAS A FORMAL PROCESS THAT IS USED TO DETERMINE THE COMPENSATION OF THE CEO ON AN ANNUAL BASIS. THIS PROCESS INCLUDES A COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES, ENGAGING AN INDEPENDENT CONSULTANT, PERFORMANCE OF A COMPENSATION SURVEY OR STUDY, REVIEW OF OTHER ORGANIZATION'S 990 FORMS, AND APPROVAL BY THE BOARD OF COMPENSATION COMMITTEE. A WRITTEN EMPLOYMENT AGREEMENT IS ESTABLISHED SETTING FORTH THE COMPENSATION AND BENEFITS OF THE CEO. CVPH PAYS NON-FIXED EARNINGS BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA THAT ARE PROSPECTIVELY AGREED UPON AS GOALS FOR THE CEO. PART B: THE SAME FORMAL PROCESS NOTED IN QUESTION 15(A) ABOVE IS USED TO DETERMINE THE BASE COMPENSATION OF THE OTHER OFFICERS. NON-FIXED EARNINGS OF OTHER OFFICERS ARE BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA AND COMPARATIVE MARKET DATA. IN ADDITION TO THE TOOLS AND PROCESSES IDENTIFIED IN SCHEDULE J, PART I, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL RECEIVES GUIDANCE REGARDING ITS PRESIDENT'S COMPENSATION FROM THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE UNIVERSITY OF VERMONT HEALTH NETWORK, WHICH IS THE SOLE MEMBER OF THE HOSPITAL. THAT NETWORK COMPENSATION COMMITTEE UTILIZES THE FOLLOWING METHODS TO ESTABLISH THAT GUIDANCE: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
FORM 990, PART VI, SECTION C, LINE 19	CVPH MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. PARTIES DESIRING COPIES OF SUCH DOCUMENTS MUST PRESENT THEMSELVES AT THE ADMINISTRATIVE OFFICES OF CVPH OR BY SENDING A REQUEST IN WRITING TO CVPH ADMINISTRATIVE OFFICES. THE ORGANIZATION HAS INSTRUCTIONS POSTED ON ITS WEBSITE FOR THOSE SEEKING COPIES OF DOCUMENTS.
FORM 990, PART XI, LINE 9:	CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 2,328,483. PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COSTS 10,936,768. CHANGE IN NET INTEREST OF FOUNDATION 48,907. TRANSFERS FROM PARENT/RELATED PARTY 825,331. CHANGE IN INTEREST IN INVESTMENT POOL 126,078.
FORM 990, PART XII, LINE 2C:	THERE IS AN AUDIT COMMITTEE THAT ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.
SCHEDULE H, PART V, SECTION B, LINE 5	CVPH COMMITTEE HEALTH NEEDS ASSESSMENT STEERING COMMITTEE NAME DEPT/AREA REPRESENTED AMY O'CONNOR, ALICE HYDE MEDICAL CENTER BRENDA STILES, ADIRONDACK ACO/MEDICAL HOME CARRIE HOWARD-CANNING, CVPH NURSING DEB FLOCK, CVPH GRANT WRITING DEBRA GOOD, CVPH CASE MANAGER DR. JOSE LOPEZ, PHYSICIAN REPRESENTATIVE, FAMILY MEDICINE GINGER CARRIERO, ALICE HYDE MEDICAL CENTER GREG FREEMAN, CVPH OCCUPATIONAL HEALTH HEATHER REYNOLDS, ELIZABETHTOWN COMMUNITY HOSPITAL JULIE MARSHALL, ALICE HYDE MEDICAL CENTER KAITLYN TENTIS, ADIRONDACK REGION PLANNING KAREN ASHLINE, ADIRONDACK ACO/MEDICAL HOME KATI JOCK, ADIRONDACK REGION PLANNING KEN THAYER, CVPH EMERGENCY DEPARTMENT KERRY HALEY, CVPH FOUNDATION MAHER HANNA, CVPH ANCILLARY SERVICES MICHELE POWERS, CVPH MARKETING PATRICIA JOHNSON, CVPH FITZPATRICK CANCER CENTER ROSEMARY REIF, CVPH BEHAVIORAL HEALTH CLINTON COUNTY COMMUNITY HEALTH ASSESSMENT 2016 PRIORITY & FOCUS AREA SELECTION JUNE 15, 2016 PRIORITY SETTING EVENT PARTICIPANT LIST NAME ORGANIZATION REPRESENTED DIANA AGUGLIA, PLATTSBURGH REGIONAL DIRECTOR, ALLIANCE FOR POSITIVE HEALTH MARIA ALEXANDER, EXECUTIVE DIRECTOR, CLINTON COUNTY SENIOR CITIZENS COUNCIL SARA ALLEN, CONRACTOR, CLINTON COUNTY HEALTH DEPARTMENT KAREN ASHLINE, ADIRONDACK MEDICAL HOME, CHAMPLAIN VALLEY HEALTH NETWORK WENDIE BISHOP, DIRECTOR ,CLINTON COUNTY NURSING HOME BONNIE BLACK, EMPLOYEE ASSISTANCE SERVICES DIRECTOR, BEHAVIORAL HEALTH SERVICES NORTH JAMES BOSLEY, PLANNING TECHNICIAN, CLINTON COUNTY PLANNING /PUBLIC TRANSIT STEVEN BOWMAN, DIRECTOR ,CLINTON COUNTY VETERAN'S SERVICE AGENCY CARI BURNELL, RN, PLATTSBURGH VETERANS ADMINISTRATION CLINIC CRYSTAL CARTER, DIRECTOR, CLINTON COUNTY OFFICE FOR THE AGING TREVOR COLE, SENIOR PLANNER, TOWN OF PLATTSBURGH PLANNING KIM CROCKETT, DIRECTOR ,CLINTON COUNTY YOUTH BUREAU ADELE DOUGLAS, COORDINATOR, TOWN OF PERU COMMUNITY DEVELOPMENT NICOLE DURGAN, PROGRAM ASSISTANT ,BEHAVIORAL HEALTH SERVICES NORTH DARWYNA FACTEAU, DIRECTOR OF HEALTH CARE SERVICES, CLINTON COUNTY HEALTH DEPARTMENT ANN-MARIE FITZGERALD, EVALUATION MANAGER, ADIRONDACK HEALTH INSTITUTE DEBORAH FLOCK, GRANT WRITER ADMINISTRATOR, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH ANDY FOSTER, MARKETING MANAGER ,BEHAVIORAL HEALTH SERVICES NORTH GREG FREEMAN, OCCUPATIONAL HEALTH AND WELLNESS , UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH DEBRA GOOD, CASE MANAGEMENT DIRECTOR, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH RICHELLE GREGORY, DIRECTOR, CLINTON COUNTY CHILD ADVOCACY CENTER KERRY HALEY, EXECUTIVE DIRECTOR, FOUNDATION OF CVPH ,UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH MAHER HANNA, AVP OF PATIENT CARE OPERATIONS, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH CARRIE HOWARD-CANNING, AVP PATIENT CARE OPERATIONS, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH KATI JOCK, DIRECTOR OF STRATEGIC PLANNING , UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH DAN JOHNSON, NURSING DIRECTOR, CLINTON COUNTY CHAPTER-NYS ADVOCACY & RESOURCE CENTER PATRICIA JOHNSON, FITZPATRICK CANCER CENTER, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH JOHN KANOZA, PE, DIRECTOR OF ENVIRONMENTAL HEALTH ,CLINTON COUNTY HEALTH DEPARTMENT JEANNINE KERR, SCHOOL FOOD SERVICE DIRECTOR, PERU CENTRAL SCHOOL DISTRICT MARK LAFOUNTAIN, PUBLIC HEALTH PREPAREDNESS , CLINTON COUNTY HEALTH DEPARTMENT DOROTHY LATTA, COORDINATOR, PLATTSBURGH INTERFAITH FOOD SHELF JODY LEAVENS, MARKETING SUPERVISOR ,FIDELIS CARE NEW YORK JOSE LOPEZ, RESIDENCY PROGRAM DIRECTOR, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH NICHOLE LOUIS, SUPERVISING PUBLIC HEALTH NURSE, CLINTON COUNTY HEALTH DEPARTMENT JESSICA MAGUIRE, COMMUNITY HEALTH COORDINATOR ,ADIRONDACK HEALTH INSTITUTE GIZELLE MENARD, ASSISTANT DIRECTOR OF NURSING ,UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH STEPHENS MUNDY, PRESIDENT AND CEO, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH STEVE PETERS, SUPERINTENDENT OF RECREATION, CITY OF PLATTSBURGH RECREATION DEPARTMENT MICHELE POWERS, DIRECTOR OF COMM AND MARKETING ,UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH AMY PUTNAM, COMMUNITY RELATIONS SPECIALIST ,FIDELIS CARE JERIE REID, PUBLIC HEALTH DIRECTOR ,CLINTON COUNTY HEALTH DEPARTMENT ROSEMARY REIF, AVP PATIENT CARE OPERATIONS, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH JONI RICHTER, DIRECTOR OF PATIENT AND FAMILY SERVICES ,AMERICAN CANCER SOCIETY AMY RUGAR, RN, U.S. DEPARTMENT OF VETERANS AFFAIRS SHAWN SABELLA, PROS DIRECTOR, BEHAVIORAL HEALTH SERVICES NORTH MARGARET SEARING, QUALITY COORDINATOR, CLINTON COUNTY HEALTH DEPARTMENT NANCY SMITH ,RESIDENT MANDY SNAY, DIRECTOR HEALTH PLANNING AND PROMOTION, CLINTON COUNTY HEALTH DEPARTMENT SALLY SOUCIA, PROGRAM DIRECTOR ,JOINT COUNCIL FOR ECONOMIC OPPORTUNITY JULIE STALKER, SENIOR OUTREACH PROGRAM DIRECTOR, JOINT COUNCIL FOR ECONOMIC OPPORTUNITY JOAN STERLING, COMMUNITY MANAGER ,AMERICAN CANCER SOCIETY BRENDA STILES, DIRECTOR CARE MANAGEMENT AND QUALITY ,UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH TOM TALLON, POPULATION HEALTH IMPROVEMENT PLAN , ADIRONDACK HEALTH INSTITUTE KENNETH THAYER, RN, EMERGENCY CARE CENTER DIRECTOR, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH PETER TROUT, DIRECTOR ,CLINTON COUNTY MENTAL HEALTH JENNIFER TRUDEAU, RN ,CLINTON COUNTY HEALTH DEPARTMENT BRITTANY TRYBENDIS, DIRECTOR OF NORTH COUNTRY THRIVE, UNIVERSITY OF NEW YORK STATE COLLEGE AT PLATTSBURGH LEE VERA, PROJECT COORDINATOR, EASTERN ADIRONDACK HEALTH CARE NETWORK DARLENE WELLS, DISASTER PROGRAM SPECIALIST, RED CROSS LAURIE WILLIAMS, CONSULTANT/PROJECT MANAGER, FOUNDATION OF CVPH TARA EBERE, DIRECTOR OF MAGNET PROGRAM, UNIVERSITY OF VERMONT HEALTH NETWORK - CVPH BETTY RABIDEAU, CASE SUPERVISOR, ADULT SERVICES CLINTON COUNTY DEPARTMENT OF SOCIAL SERVICE VICTORIA DULEY, ECONOMIC DEVELOPER, THE DEVELOPMENT CORPROATION GINNY HAY, BOARD MEMBER ,CLINTON COUNTY BOARD OF HEALTH LORA HELM, NP, CHEMICAL DEPENDENCE COUNSELOR, CHAMPLAIN VALLEY FAMILY CENTER TOTAL: 65
SCHEDULE H, PART V, SECTION B, LINE 11	TYPICALLY HOSPITALS GRAVITATE TOWARDS MEDICAL INTERVENTIONS TO ADDRESS HEALTH CONCERNS. HOWEVER, AS THE TIDE SHIFTS TO A POPULATION HEALTH FOCUS, TREATING THE ENTIRE PATIENT IS AT THE FOREFRONT IN THE MINDS OF ALL HOSPITALS. HENCE, BY CHOOSING GOALS AROUND ACTIVITY AND FOOD CHOICES, THE PATIENT ENVIRONMENT HAS THE POTENTIAL TO BE IMPACTED POSITIVELY, RESULTING IN BETTER HEALTH OUTCOMES AND LOWER OBESITY RATES. FOR INSTANCE, OFTENTIMES NURSES TAKE CARE OF OTHERS ALL DAY BUT FORGET TO TAKE CARE OF THEMSELVES. AN EDUCATIONAL PROGRAM WILL BE DESIGNED FOR HEALTHCARE PROFESSIONALS TO PROVIDE EDUCATION ON DIET AND EXERCISE. THE FOUNDATION OF CVPH HAS RECEIVED A FITNESS IN THE PARKS GRANT TO PROMOTE OUTDOOR ACTIVITIES. CONTINUED FOCUS WILL BE PUT ON EXPANSION OF ACTIVITIES FOR INDIVIDUALS OF ALL SOCIOECONOMIC LEVELS. NOT ONLY DOES CVPH PRODUCE MEALS FOR PATIENTS, PUT CVPH ALSO REGULARLY FOOD TO OVER 2,000 EMPLOYEES. THROUGH CVPH'S AWARENESS OF HEALTHY FOOD AND BEVERAGE CHOICES, HIGH NUMBERS OF COMMUNITY MEMBERS CAN BE IMPACTED POSITIVELY. ALTHOUGH MUCH WORK HAS BEEN DONE BY THE CCHD TO PROMOTE USING LOCAL FRUITS AND VEGETABLES, BY COMMITTING TO WORK WITH LOCAL FARMERS TO INCREASE THE NUMBER OF FARMERS MARKETS ACCEPTING LOCAL, STATE AND NATIONAL NUTRITION INCENTIVE PROGRAM BENEFITS, THIS POSITIVE TRAJECTORY IS SLATED TO CONTINUE. IT SHOULD BE NOTED THAT WHILE SOME OF THESE ACTIVITIES ARE NEW FOR CVPH AND CCHD, BOTH ORGANIZATIONS HAVE A LONG STANDING HISTORY OF FOCUSING ON HEALTHY FOOD CHOICES AND ACTIVITIES. CVPH HAS ELIMINATED ALL FRIED FOODS FROM THE CAFETERIA, HAS A ROBUST EMPLOYEE WELLNESS PROGRAM FOR EMPLOYEES, AND PROVIDES A DISCOUNT TO EMPLOYEES AT LOCAL GYMS. CCHD HAS GREATLY IMPACTED THE OPENING OF MANY TRAILS WITHIN CLINTON COUNTY, OPENED A DISC GOLF COURSE, AND WORKED WITH LOCAL FARMERS TO ENHANCE PARTNERSHIPS. FOCUS AREA 3: INCREASE ACCESS TO HIGH QUALITY CHRONIC DISEASE PREVENTIVE CARE AND MANAGEMENT IN BOTH CLINICAL AND COMMUNITY SETTINGS THE GOAL AND ANTICIPATED IMPACT AROUND THIS FOCUS AREA IS INCREASING SCREENING RATES FOR COLORECTAL CANCER, ESPECIALLY AMONG DISPARATE POPULATIONS. THE TWO EVIDENCE BASED LONG TERM OBJECTIVES ARE AROUND INCREASE THE NUMBER OF ADULTS RECEIVING COLORECTAL CANCERS SCREENINGS AND ACHIEVING THE HEALTHY PEOPLE TARGET FOR DEATH RATES DUE TO COLORECTAL CANCER. THE FOLLOWING STATISTICS/INFORMATION WERE USED AS SUPPORT AND RATIONALE IN THE SELECTION OF THIS AS A PRIORITY: -CHRONIC DISEASES ACCOUNT FOR APPROXIMATELY 70 PERCENT OF ALL DEATHS IN NYS, AND ALSO CAUSE MAJOR LIMITATIONS IN DAILY LIVING FOR ABOUT ONE IN TEN STATE RESIDENTS -COSTS ASSOCIATED WITH CHRONIC DISEASES AND THEIR MAJOR RISK FACTORS CONSUME MORE THAN 75 PERCENT OF OUR NATION'S SPENDING ON HEALTH CARE (NYS PREVENTION AGENDA) -THE PRIMARY CARE PROVIDER RATE IN CLINTON COUNTY IS 69 PROVIDERS PER 100,000 POPULATION. NYS VALUE IS 83 PER 100,000 (HEALTHYADK) -CANCER INCIDENCE RATES AND CANCER RELATED DEATHS ARE HIGHER IN CLINTON COUNTY THAN THE STATE AND NATIONAL AVERAGES FOR MANY TYPES OF CANCERS SUCH AS COLORECTAL, LUNG, CERVICAL, BRONCHUS, AND ORAL CAVITY (HEALTHYADK) -CLINTON COUNTY DEATH RATE DUE TO DIABETES IS 21.5 PER 100,000 POPULATION, WHILE NYS IS 17.6 -AGE-ADJUSTED DEATH RATE DUE TO CORONARY HEART DISEASE IN CLINTON COUNTY IS 119.5 PER 100,000 POPULATION, COMPARED TO 102.2 FOR THE US (HEALTHYADK) -HIGH BLOOD PRESSURE PREVALENCE IN CLINTON COUNTY IS 33.9%, COMPARED TO 27.3% IN NYS (HEALTHYADK) -OF THE SUBCATEGORIES UNDER PREVENT CHRONIC DISEASE, 37% OF SURVEY RESPONDENTS SELECTED THIS FOCUS AREA AS SEEN IN THE CHART ON THE RIGHT (INCREASE ACCESS TO HIGH QUALITY CHRONIC DISEASE PREVENTIVE CARE IN BOTH CLINICAL AND COMMUNITY SETTING) THERE ARE SEVERAL STRATEGIES CVPH AND CCHD WILL BE UTILIZING TO ADDRESS THIS FOCUS AREA AND ACHIEVE THE GOAL AND OBJECTIVES. THEY ARE AS FOLLOWS: -OFFER RECOMMENDED CLINICAL PREVENTATIVE SERVICES AND CONNECT PATIENTS TO COMMUNITY BASED PREVENTATIVE SERVICE RESOURCES WITH A FOCUS ON THE PEER EDUCATION GRANT THAT HAS A GOAL OF REFERRING 100 PATIENTS FOR SCREENING THROUGH PEER EDUCATION WITH 100 MEN REFERRED TO PRIMARY CARE PROVIDERS FOR DISCUSSION OF PROSTRATE SCREENING. A CONTINUED FOCUS WILL BE ON THOSE PATIENTS FALLING BELOW THE POVERTY LINE WITH SCREENINGS OPEN TO PATIENTS OF ALL SOCIOECONOMIC STATUSES. -IMPLEMENT POLICY AND ENVIRONMENTAL APPROACHES TO INCREASE THE NUMBER OF COMMUNITY MEMBERS WITH ACCESS TO RECOMMENDED CANCER SCREENING SERVICES WITH A FOCUS ON DEVELOPING POLICIES THAT SUPPORT TIME OFF FOR SCREENINGS, PROVIDING INFORMATION REGARDING SCREENING RATES SO THAT, AS A COMMUNITY, WE ARE ABLE TO MAKE INFORMED CHOICES, AND DESIGNING INNOVATIVE APPROACHES TO INCREASE SCREENING SUCH AS CARE NAVIGATION. THE KEY TO SUCCESSFULLY ACHIEVING THIS GOAL IS SUPPORTING AND ENHANCING THE SUCCESS CVPH'S FITZPATRICK CANCER CENTER HAS HAD SINCE ITS LAUNCH. THERE ARE TWO DEDICATED EMPLOYEES WHO PROVIDE CANCER CARE NAVIGATION AND COORDINATE SCREENING PROGRAMS WITH PARTICULAR ATTENTION TO LOW INCOME PATIENTS. WITH AN ENHANCED FOCUS ON COLON CANCER SCREENING, THE SUCCESS THE FITZPATRICK CANCER CENTER HAS SEEN IN INCREASING BREAST CANCER SCREENING RATES IS EXPECTED TO EXTRAPOLATE TO COLON CANCER SCREENINGS. A PARTICULAR FOCUS WILL BE PLACED ON TARGETING MEN WHO OFTENTIMES FORGO THIS IMPORTANT SCREENING. IN ADDITION, INNOVATIVE APPROACHES SUCH AS WORKING TO IMPLEMENT A CVPH POLICY AROUND GIVING EMPLOYEES TIME OFF TO RECEIVE PREVENTATIVE SERVICES WILL BE CVPH AND CCHD'S FOCUS OVER THE NEXT FEW YEARS. HEALTH PRIORITY 2: PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE THE PURPOSE OF THIS PRIORITY IS TO CALL ATTENTION TO THE FACT THAT MENTAL AND EMOTIONAL WELL-BEING IS ESSENTIAL TO OVERALL HEALTH, AND TO AID NYS IN PROMOTING MENTAL HEALTH AND PREVENTING SUBSTANCE ABUSE DISORDERS AMONGST OUR RESIDENTS. MENTAL, EMOTIONAL, AND BEHAVIORAL (MEB) DISORDERS INCLUDE CONDUCT DISORDERS, DEPRESSION, AND SUBSTANCE ABUSE. THEY OFTEN DEVELOP BETWEEN 14 AND 24 YEARS OF AGE. IT IS MOST EFFECTIVE TO DELIVER INTERVENTIONS FOR MENTAL HEALTH BEFORE A DISORDER MANIFESTS ITSELF. MANY MEB DISORDERS, SUCH AS SUBSTANCE ABUSE AND DEPRESSION, HAVE LIFELONG EFFECTS THAT INCLUDE HIGH PSYCHOSOCIAL AND ECONOMIC COSTS FOR PEOPLE, THEIR FAMILIES, SCHOOLS AND COMMUNITIES. IN ADDITION TO THE FINANCIAL COSTS ASSOCIATED WITH MEB DISORDERS, THEY ALSO OFTEN INTERFERE WITH ONE'S ABILITY TO ESTABLISH HEALTHY INTERPERSONAL RELATIONSHIPS, SUCCEED IN SCHOOL, JOIN THE WORKFORCE AND STAY OPTIMALLY FUNCTIONAL IN OTHER AREAS. IMPROVEMENTS IN MENTAL HEALTH HELP TO IMPROVE INDIVIDUALS AND POPULATIONS' PHYSICAL HEALTH AS WELL. FOCUS AREA 2: PREVENT SUBSTANCE ABUSE AND OTHER MENTAL EMOTIONAL BEHAVIORAL DISORDERS THE GOAL AND ANTICIPATED IMPACT AROUND THIS FOCUS AREA IS PREVENTING AND REDUCING THE OCCURRENCE OF MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS AMONG YOUTH AND ADULTS. THE EVIDENCE BASED LONG TERM OBJECTIVE IS REDUCING THE PERCENTAGE OF ADULT CLINTON COUNTY RESIDENTS REPORTING 14 OR MORE POOR MENTAL HEALTH DAYS IN A MONTH. THE FOLLOWING STATISTICS/INFORMATION WERE USED AS SUPPORT AND RATIONALE IN THE SELECTION OF THIS AS A PRIORITY: -AGE-ADJUSTED RATE DUE TO SUICIDE IN CLINTON COUNTY IS 13.7 PER 100,000 POPULATION. NYS IS 8.2 AND US IS 12.7 PER 100,000. THE NYS PREVENTION AGENDA 2013-2018 GOAL IS 5.9 (HEALTHYADK) -DEPRESSION IN THE MEDICARE POPULATION OF NYS IS 18.1%, COMPARED TO 14.9% IN NYS AND 16.2% NATIONALLY (HEALTHYADK) -THE MENTAL HEALTH PROVIDER RATE IN CLINTON COUNTY IS 189 PER 100,000 POPULATION, COMPARED TO 238 PER 100,000 FOR THE REST OF THE STATE (HEALTHYADK) -20.4% OF ADULTS IN CLINTON COUNTY BINGE DRINK, WHILE ONLY 17.7% IN NYS AND 16% NATIONALLY PARTAKE. THE PREVENTION AGENDA 2013-2018 GOAL IS 18.4% (HEALTHYADK) -THE PERCENT OF ADULTS IN CLINTON COUNTY WHO SMOKE IS 22.5%, COMPARED TO 15.9% IN THE REST OF THE STATE AND 18.1% NATIONALLY. THE PREVENTION AGENDA 2013-2018 GOAL IS 12.3% (HEALTHYADK) -OF THE SUBCATEGORIES UNDER PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE, 45% OF SURVEY RESPONDENTS SELECTED THIS FOCUS AREA AS SEEN IN THE CHART ON THE RIGHT (PREVENT SUBSTANCE ABUSE AND OTHER MENTAL EMOTIONAL BEHAVIORAL DISORDERS)
SCHEDULE H, PART V, SECTION B, LINE 11 CON'T	THERE ARE SEVERAL STRATEGIES CVPH AND CCHD WILL BE UTILIZING TO ADDRESS THIS FOCUS AREA AND ACHIEVE THE GOAL AND OBJECTIVE. THEY ARE AS FOLLOWS: -IDENTIFY AND IMPLEMENT EVIDENCE BASED PRACTICES AND ENVIRONMENTAL STRATEGIES TO PREVENT UNDERAGE DRINKING, SUBSTANCE ABUSE AND MEB DISORDERS. PRESCRIPTION OPIATE, HEROIN ADDICTION, AND OPIATE RELATED OVERDOSES CONTINUE TO INCREASE IN THE NORTH COUNTRY. SEVERAL LOCAL PROFESSIONAL AND CONCERNED CITIZENS JOINED FORCES TO FORM A COALITION NAMED SUBSTANCE ABUSE PREVENTION AND RECOVERY OF CLINTON COUNTY (SPARCC). THIS GROUP HAS REPRESENTATIVES FROM CVPH AND CCHD, AS WELL AS OTHERS. THE MISSION IS TO FOSTER COMMUNITY HEALTH THROUGH EDUCATION, PREVENTION, TREATMENT, AND RECOVERY OF SUBSTANCE ABUSE. THEY HAVE HAD COMMUNITY OPEN FORUMS AND THEIR WORK WILL CONTINUE TO BE A FOCUS IN THE UPCOMING YEARS. SBIRT STANDS FOR SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT, AND IT IS A COMPREHENSIVE, INTEGRATED APPROACH TO THE DELIVERY OF EARLY INTERVENTION AND TREATMENT SERVICES FOR PERSONS WITH SUBSTANCE USE DISORDERS, AS WELL AS THOSE WHO ARE AT RISK OF DEVELOPING THESE DISORDERS. SIGNIFICANT PROGRESS HAS BEEN MADE IN IMPLEMENTING SBIRT, BUT OVER THE NEXT FEW YEARS A CONTINUED FOCUS WILL BE AROUND MAINTAINING MOMENTUM AND EXPANDING WHERE SBIRT IS BEING UTILIZED. IN ADDITION, THROUGH THE ALLIANCE FOR POSITIVE HEALTH, CVPH WAS RECENTLY SELECTED TO START PROVIDING NARCAN IN THE EMERGENCY DEPARTMENT TO OPIOID OVERDOSE PATIENTS. -INTEGRATE MEB HEALTH WITHIN CHRONIC DISEASE STRATEGIES WITH A FOCUS ON OFFERING A SERIES OF EDUCATION EVENTS THROUGH THE CCHD FOCUSING ON PRIMARY AND SECONDARY CHRONIC DISEASE PREVENTION. FOR THE LAST CYCLE, CLINTON COUNTY CHOSE MENTAL HEALTH AS A PRIORITY AREA AS WELL, AND THERE HAS BEEN SIGNIFICANT PROGRESS IN IMPROVING THE INFRASTRUCTURE IN CLINTON COUNTY. IN ADDITION, CAPITAL RESTRUCTURING FINANCE PROGRAM (CRFP) DOLLARS WERE RECEIVED IN CLINTON COUNTY WITH A FOCUS ON MENTAL HEALTH AND SUBSTANCE ABUSE AS FOLLOWS: -CHAMPLAIN VALLEY FAMILY CENTER SCHUYLER FALLS DETOX FACILITY -BEHAVIORAL HEALTH SERVICES NORTH (BHSN) RECEIVED MONEY TO BUILD A PRIMARY CARE PRACTICE IN MORRISONVILLE IN WHICH THEY WILL INTEGRATE BEHAVIORAL HEALTH -CVPH RECEIVED MONEY TO BUILD A PRIMARY CARE PRACTICE THAT HUDSON HEADWATERS HEALTH NETWORK (AN FQHC) WILL LEASE; THEY WILL HAVE EMBEDDED BEHAVIORAL HEALTH COUNSELORS -CVPH RECEIVED MONEY TO RENOVATE THE INPATIENT PSYCHIATRIC UNIT AND EMBED OUTPATIENT PROVIDERS TO ENHANCE THE CARE CONTINUUM OFTENTIMES THE ISSUE IN ACHIEVING COMMUNITY HEALTH GOALS IS THE LACK OF FUNDING. THROUGH DSRIP, CLINTON COUNTY HAS BEEN INFUSED WITH DOLLARS THAT WILL HOPEFULLY IMPACT THE CURRENT MENTAL HEALTH AND SUBSTANCE ABUSE CRISIS.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

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

2019

Open to Public Inspection

Name of the organization

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MEDICAL CENTER

Employer identification number

14-1338471

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)UVM HEALTH NETWORK MEDICAL GROUP INC 111 COLCHESTER AVE BURLINGTON,VT05401 03-0225105	PHYSICIAN SERVICES	VT	501(C)(3)	LINE 12B, II	UVMHN	Yes
(2)UNIV OF VT MEDICAL GROUP-NEW YORK 183 PARK STREET MALONE,NY12953 20-3905216	PHYSICIAN SERVICES	NY	501(C)(3)	LINE 3	UVMHNMG	Yes
(3)UNIV OF VT MED CTR FOUNDATION INC 111 COLCHESTER AVE BURLINGTON,VT05401 26-3159849	FUNDRAISING	VT	501(C)(3)	LINE 12B, II	UVMHNMG	Yes
(4)UNIV OF VT MED CTR AUXILLIARY INC 111 COLCHESTER AVE BURLINGTON,VT05401 20-8022004	SERVICE	VT	501(C)(3)	LINE 12D, III-O	N/A		No
(5)UNIV OF VT HEALTH NETWORK 111 COLCHESTER AVE BURLINGTON,VT05401 45-2880726	HOLDING COMPANY	VT	501(C)(3)	LINE 12B, II	N/A		No
(6)CENTRAL VT MEDICAL CENTER 111 COLCHESTER AVE BURLINGTON,VT05401 22-2547186	HOSPITAL	VT	501(C)(3)	LINE 3	UVMHN	Yes
(7)UNIVERSITY HEALTH CENTER 111 COLCHESTER AVE BURLINGTON,VT05401 03-0229931	HOSPITAL	VT	501(C)(3)	LINE 12D, III-O	UVMMG	Yes
(8)COMMUNITY PROVIDERS INC 75 BEEKMAN STREET PLATTSBURGH,NY12901 22-2544844	HLTH SVC COORD	NY	501(C)(3)	LINE 12B, II	UVMHN	Yes
(9)ELIZABETHTOWN COMMUNITY HOSPITAL 75 PARK STREET ELIZABETHTOWN,NY12901 14-1364513	HOSPITAL	NY	501(C)(3)	LINE 3	UVMHN	Yes
(10)EMERGENCY MEDICAL TRANSPORT OF CVPH INC 75 BEEKMAN STREET PLATTSBURGH,NY12901 06-1718419	AMBULANCE SVC	NY	501(C)(3)	LINE 12C, III-FI	CPI	Yes
(11)CVPH MEDICAL CENTER FOUNDATION 75 BEEKMAN STREET PLATTSBURGH,NY12901 14-1727048	HLTH SVC COORD	NY	501(C)(3)	LINE 12C, III-FI	CVPH	Yes
(12)LAKE CHAMPLAIN PHYSICIAN SERVICES PC 75 BEEKMAN STREET PLATTSBURGH,NY12901 27-3785445	PHYSICIAN SERVICES	NY	501(C)(3)	LINE 12B, II	CVPH	Yes
(13)UNIVERSITY MEDICAL EDUCATION ASSOCIATES 89 BEAUMONT AVENUE BURLINGTON,VT05401 23-7107832	EDUCATIONAL	VT	501(C)(3)	LINE 11	UVMMG	Yes
(14)ALICE HYDE MEDICAL CENTER 133 PARK STREET MALONE,NY12953 15-0346515	HOSPITAL	NY	501(C)(3)	LINE 3	UVMHN	Yes
(15)PORTER MEDICAL CENTER INC 115 PORTER DRIVE MIDDLEBURY,VT05753 03-0310862	SUPPORTING ORGANIZATION	VT	501(C)(3)	LINE 12C, III-FI	UVMHN	Yes
(16)HELEN PORTER NURSING HOME 37 PORTER DRIVE MIDDLEBURY,VT05753 03-0306549	NURSING HOME	VT	501(C)(3)	LINE 3	PMC	Yes
(17)AUXILLARY OF PORTER MEDICAL CENTER 37 PORTER DRIVE MIDDLEBURY,VT05753 23-7363227	SUPPORTING ORGANIZATION	VT	501(C)(3)	LINE 12C, III-FI	PMC	Yes
(18)PORTER HOSPITAL 37 PORTER DRIVE MIDDLEBURY,VT05753 03-0181058	HOSPITAL	VT	501(C)(3)	LINE 3	PMC	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2019

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) ONECARE VT ACCOUNTABLE CARE 111 COLCHESTER AVE BURLINGTON,VT05401 45-5399218	ACCOUNTABLE CARE	VT	N/A	RELATED				No			No
(2) ADIRONDACK ACO LLC 75 BEEKMAN STREET PLATTSBURGH,NY12901 46-2840926	ACCOUNTABLE CARE	NY	N/A	NA				No			No
(3) YANKEE MEDICAL INC 276 NORTH AVENUE BURLINGTON,VT05401 03-0225363	HOME MEDICAL EQUIPMENT	VT	UVMHN					No			No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) UVMHN VENTURES INC 111 COLCHESTER AVE BURLINGTON,VT05401 04-3380045	HOLDING COMPANY	VT	UVMHN	C				No
(2) VMC INDEMNITY COMPANY LTD PO BOX HM 3103 HAMILTON HM 19 BD	CAPTIVE INSURANCE	BD	UVMMC	C				No
(3) UVMHN CREDENTIALING & ENROLLMENT 111 COLCHESTER AVE BURLINGTON,VT05401 03-0333056	ADMIN SVC	VT	UVMHN VENTURES	C				No
(4) CHARITABLE REMAINDER TRUST (5) 111 COLCHESTER AVE BURLINGTON,VT05401	SUPPORT	VT	UVMMCCVMC	T				No
(5) PERPETUAL TRUST (4) 111 COLCHESTER AVE BURLINGTON,VT05401	SUPPORT	VT	UVMMC	T				No
(6) CHARITABLE IRREVOCABLE TRUST (7) 111 COLCHESTER AVE BURLINGTON,VT05401	SUPPORT	VT	UVMMCCVMC	T				No
(7) CHAMPLAIN VALLEY HEALTH NETWORK 75 BEEKMAN STREET PLATTSBURGH,NY12901 16-1586102	ADMIN SVC	NY	N/A	C				No
(8) MEDIQUEST INC PO BOX 1656 PLATTSBURGH,NY12901 14-1663061	MED OFFICE LEASE	NY	CPI	C				No

Schedule R (Form 990) 2019

Page 3

Part V

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

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

Yes

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

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

Yes

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

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

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) THE UNIVERSITY OF VERMONT MEDICAL CENTER INC	Q	1,145,343	FMV
(2) UVMMG	O	9,738,727	FMV

Schedule R (Form 990) 2019

Page 4

Part VI

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

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

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(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) 2019

Page 5

Part VII

Supplemental Information

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

Return Reference	Explanation

Schedule R (Form 990) 2019

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: CVPH MEDICAL CENTER'S MISSION IS TO PROVIDE QUALITY HEALTH CARE FOR THE NORTH COUNTRY REGION IN UPSTATE NEW YORK.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	13
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 2019 (Part V, line 2a) ......	5	2,711
6	Total number of volunteers (estimate if necessary) .............	6	350
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	873,127	1,970,499
9	Program service revenue (Part VIII, line 2g) .........	331,003,548	345,657,501
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	3,039,208	1,817,087
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	3,673,353	6,518,782
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	338,589,236	355,963,869
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
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)	203,642,676	218,518,693
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)....	129,606,543	143,345,874
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	333,249,219	361,864,567
19	Revenue less expenses. Subtract line 18 from line 12.......	5,340,017	-5,900,698
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	219,207,678	217,442,781
21	Total liabilities (Part X, line 26).............	168,706,956	158,364,583
22	Net assets or fund balances. Subtract line 21 from line 20.....	50,500,722	59,078,198

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 259,623,384 including grants of $ ) (Revenue $ 352,250,399 )
	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER (CVPH)IS A 300 BED ACUTE CARE HOSPITAL AND 54 BED SKILLED NURSING FACILITY. CVPH PROVIDES COMPREHENSIVE MEDICAL AND SURGICAL SERVICES TO THE NORTHERN NEW YORK STATE REGION, REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. DURING 2018, CVPH PROVIDED 67,637 PATIENT DAYS OF CARE TO ITS 9,326 ADMISSIONS, AND 46,504 EMERGENCY CARE CENTER VISITS. DURING THE YEAR, 19,000 SURGICAL PROCEDURES WERE PERFORMED. 803 BIRTHS OCCURRED IN CVPH FACILITIES. CVPH EMPLOYS MORE THAN 2,700 INDIVIDUALS. IN ADDITION, THE HOSPITAL HAS 173 MEMBERS OF ITS MEDICAL STAFF, 88% OF WHICH ARE BOARD CERTIFIED. THE HOSPITAL IS JOINT COMMISSION ACCREDITED AND LICENSED BY THE NEW YORK STATE DEPARTMENT OF HEALTH. IN ADDITION TO ITS MAIN CAMPUS, CVPH OPERATES SEVERAL OUTPATIENT FACILITIES WHERE SERVICES ARE PROVIDED TO ITS PATIENTS INCLUDING: AMBULATORY SURGERY, PHYSICAL AND OCCUPATIONAL THERAPY, REHABILITATION, RENAL DIALYSIS, AND DIAGNOSTIC IMAGING. CVPH ALSO OPERATES HEALTH CLINICS LOCATED IN OUTLYING GEOGRAPHIC AREAS, TO BETTER SERVE THE HEALTH NEEDS OF CVPH'S RURAL COMMUNITY SERVICE AREA. THROUGH ITS VARIOUS LOCATIONS, OUTREACH ACTIVITIES, AND SUPPORT GROUPS, CVPH IS ACTIVE IN THE COMMUNITY IN PROMOTING HEALTH AND WELLNESS OF THE BODY, MIND, AND SPIRIT. CVPH PROVIDES ONGOING MEDICAL EDUCATION TO ITS MEDICAL STAFF, IN ADDITION TO OFFERING AN X-RAY TECHNOLOGY PROGRAM FOR ENROLLED STUDENTS. CVPH MAINTAINS A COMPREHENSIVE MEDICAL LIBRARY AND HAVE MADE AVAILABLE WEB-BASED LINKS FOR THE COMMUNITY TO EASILY ACCESS HEALTH AND WELLNESS INFORMATION AND EDUCATIONAL MATERIALS. CVPH ACCEPTS NUMEROUS INSURANCE PLANS, AND IS MEDICARE AND MEDICAID APPROVED. ADDITIONALLY, CVPH HAS A CHARITY CARE POLICY TO ACCOMMODATE PATIENTS WHOSE FINANCIAL MEANS ARE WITHIN SPECIFIED GUIDELINES.

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 expenses259,623,384

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)				(D) Reportable compensation from the organization (W-2/1099-MISC)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(18) MICHELLE LEBEAU........................................................................ PRESIDENT/COO	48.00 .......................2.00	X			419,377	0	36,522
(19) SCOTT ST GEORGE........................................................................ VICE PRESIDENT OF FINANCE	30.00 .......................20.00	X			187,941	0	2,550
(20) STEPHANE MULLIGAN........................................................................ ORTHOPEDIC SURGEON	45.00 .......................		X		552,574	0	35,831
(21) TODD WHITMAN........................................................................ MEDICAL ONCOLOGIST	45.00 .......................		X		891,059	0	31,091
(22) CHARLES VOLK........................................................................ ORTHOPEDIC SURGEON	45.00 .......................		X		675,980	0	25,102
(23) JOHN GRIFFIN........................................................................ MEDICAL ONCOLOGIST	45.00 .......................		X		590,623	0	34,588
(24) JAN DUUS........................................................................ MEDICAL ONCOLOGIST	45.00 .......................		X		659,600	0	37,946
(25) JOYCE RAFFERTY........................................................................ FORMER SVP/CFO	40.00 .......................10.00			X	411,382	0	45,772

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	6,688,110	0	570,339

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	200,000
e	Government grants (contributions)		1e	1,770,499

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

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		1,970,499

		Business Code
2a	NET PATIENT SERVICE REVENUE	621990	331,948,627	331,948,627
b	340B REVENUE	611430	11,933,621	11,933,621
c	LABORATORY DIAGNOSTIC & CLINICAL	621500	880,946	880,946
d	BLOOD BANK	621500	615,579	615,579
e	DIALYSIS	621500	278,728	278,728
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		345,657,501

3 Investment income (including dividends, interest, and othersimilar amounts) ......			691,862			691,862
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		42,165	6a
b	Less: rental expenses		116,281	6b
c	Rental income or (loss)		-74,116	6c
d	Net rental income or (loss).......			-74,116			-74,116
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	3,000	1,122,225	7a
b	Less: cost or other basis and sales expenses	0	0	7b
c	Gain or (loss)	3,000	1,122,225	7c
d	Net gain or (loss).........			1,125,225			1,125,225
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	CAFETERIA SALES		900099	1,677,617	1,677,617
b	WELLNESS CENTER		900099	822,946	822,946
c	MED SURG SUPPLIES		900099	145,830	145,830
d	All other revenue ....			3,946,505	3,946,505
e	Total. Add lines 11a–11d ......			6,592,898
12	Total revenue. See instructions.....			355,963,869	352,250,399	0	1,742,971

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	3,266,901	522,704	2,744,197
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........	163,788,364	129,465,970	34,322,394
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	12,062,954	10,615,400	1,447,554
9	Other employee benefits .......	28,649,011	24,045,594	4,603,417
10	Payroll taxes ...........	10,751,463		10,751,463
11	Fees for services (non-employees):
a	Management ......	21,939,526	21,326,746	612,780
b	Legal .........	621,407		621,407
c	Accounting ...........	8,563		8,563
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	107,445		107,445
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	17,078,552	5,335,944	11,742,608
12	Advertising and promotion ....	692,750	47,190	645,560
13	Office expenses .......	600,212	388,127	212,085
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	1,651,761	1,053,731	598,030
17	Travel ............	981,126	575,763	405,363
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........	2,500,464		2,500,464
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	15,208,177		15,208,177
23	Insurance ...	3,376,822		3,376,822
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	SUPPLIES	49,970,058	47,491,520	2,478,538
b	BAD DEBTS	9,529,166	9,529,166
c	MAINTENANCE & REPAIRS	7,343,627	4,339,403	3,004,224
d	UTILITIES	2,389,706	253,903	2,135,803
e	All other expenses	9,346,512	4,632,223	4,714,289
25	Total functional expenses. Add lines 1 through 24e	361,864,567	259,623,384	102,241,183	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........				1
2	Savings and temporary cash investments .........			13,523,749	2	4,867,229
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			40,977,095	4	42,888,793
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			5,425,792	8	6,245,337
9	Prepaid expenses and deferred charges ......			2,144,740	9	1,736,663
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	194,034,018
b	Less: accumulated depreciation	10b	91,212,454	103,789,516	10c	102,821,564
11	Investments—publicly traded securities .			47,227,228	11	50,267,182
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			6,119,558	15	8,616,013
16	Total assets. Add lines 1 through 15 (must equal line 33)...			219,207,678	16	217,442,781

17	Accounts payable and accrued expenses .....	22,737,461	17	24,246,773
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........	30,615,000	20	29,470,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			22
23	Secured mortgages and notes payable to unrelated third parties ..	24,821,390	23	25,393,152
24	Unsecured notes and loans payable to unrelated third parties ..	6,482,872	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	84,050,233	25	79,254,658
26	Total liabilities. Add lines 17 through 25..	168,706,956	26	158,364,583

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........		27
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	50,500,722	32	59,078,198
33	Total liabilities and net assets/fund balances ........	219,207,678	33	217,442,781