TY 2018 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Monty McLaurin CEO NW MKT...................................................................... Director	0.50 ................. 44.50	X				0	558,099	42,029
(2) Shane Hilton SVP Market Oper...................................................................... Director	0.50 ................. 49.50	X				0	530,280	73,798
(3) Donald Baker Chair...................................................................... Director	1.00 ................. 0.00	X	X			0	0	0
(4) Robert Leonard SecTreasurer...................................................................... Director	1.00 ................. 2.00	X	X			0	11,711	0
(5) James Manicure Vice-Chair...................................................................... Director	1.00 ................. 2.00	X	X			0	5,946	0
(6) Paul Buchanan...................................................................... Director	0.50 ................. 0.00	X				0	0	0
(7) Teddy Bailey...................................................................... Director	0.50 ................. 0.00	X				0	0	0
(8) Susan Wood...................................................................... Director	0.50 ................. 0.00	X				0	0	0
(9) Ernie Ward...................................................................... Director	0.50 ................. 1.50	X				0	1,260	0
(10) Michael Strouth...................................................................... Director	0.50 ................. 0.00	X				0	0	0
(11) Mark Leonard...................................................................... DCH/NCH CEO	22.00 ................. 23.00		X			0	302,476	51,631
(12) Stephen Sawyer...................................................................... CFO NW Region	2.00 ................. 43.00		X			0	244,949	32,397
(13) Mark Vanover...................................................................... AVP Operations	45.00 ................. 0.00			X		0	135,181	7,045
(14) Roy Deal DO...................................................................... Physician	40.00 ................. 0.00			X		0	274,377	20,970
(15) Heather Blair NP...................................................................... Nurse Practioner	40.00 ................. 0.00			X		0	138,489	3,411
(16) Justin Ivory...................................................................... Former DCH/NCH CFO	0.00 ................. 40.00				X	0	120,052	13,425

- 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 the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Part I

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

The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2018

Page 2

Part II

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2018

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2018

Page 4

Part IV

Supporting Organizations

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

Section A. All Supporting Organizations

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

10a

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

10a

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

10b

Schedule A (Form 990 or 990-EZ) 2018

Page 5

Part IV

Supporting Organizations (continued)

Yes

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

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

11a

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

11b

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

11c

Section B. Type I Supporting Organizations

Yes

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

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

Section C. Type II Supporting Organizations

Yes

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

Section D. All Type III Supporting Organizations

Yes

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

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

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

Section E. Type III Functionally-Integrated Supporting Organizations

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

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

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

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

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

Yes

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

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2018

Page 6

Part V

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

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

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

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

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

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

Schedule A (Form 990 or 990-EZ) 2018

Page 7

Part V

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

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2018 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

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

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

Schedule A (Form 990 or 990-EZ) 2018

Page 8

Part VI

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

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

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

OMB No. 1545-0047

2018

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2018)

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

Name of organization Dickenson Community Hospital

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

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

Page 3

Name of organization Dickenson Community Hospital		Employer identification number 77-0599553

Part II	Noncash Property (See instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

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

Page 4


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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

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

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990.
SchDMd Bullet

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

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2018

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No


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

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

Yes No

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

Part V

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

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

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

1a	Land .....
b	Buildings ....	959,371	430,360	529,011
c	Leasehold improvements	557,291	525,739	31,552
d	Equipment ....	3,803,087	3,010,375	792,712
e	Other .....
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				1,353,275

Schedule D (Form 990) 2018

Page 3

Part VII

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

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

Part VIII

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

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

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

Part IX

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

(a) Description				(b) Book value
(1) Due from Affiliates				873,323
(2) Other Receivables				10,568
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				883,891

Part X

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

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
Due to Third-Party Payors	133,946
Reserve for Professional Liabiliities	41,140
Retiree Health Care Benefits	157,265
Retiree Pension Payable	48,860
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	381,211
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2018

Page 4

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

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

Part XIII

Supplemental Information

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

Return Reference

Explanation

Part X : FIN48 Footnote

Dickenson Community Hospital is included in the audited consolidated financial statements of Ballad Health. The footnote explanation relative to income taxes reads: "Ballad is classified as an organization exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. As such, no provision for federal income taxes is included in the accompanying consolidated financial statements. Taxable subsidiaries are discussed in Note K. No significant uncertain tax positions exist at June 30, 2019. Tax returns for 2016 through 2018 are subject to examination by the Internal Revenue Service."

Schedule D (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other 22500.0000000 %

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 45000.0000000 %

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? . . . . . . . . .

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

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	30,974		30,974	0.320 %
b	Medicaid (from Worksheet 3, column a) . . . . .	2,093,031	1,096,352	996,679	10.320 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	2,124,005	1,096,352	1,027,653	10.640 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	32,000	2,177	29,823	0.310 %
f	Health professions education (from Worksheet 5) . . .	30,033		30,033	0.310 %
g	Subsidized health services (from Worksheet 6) . . . .	2,987,816	1,809,403	1,178,413	12.200 %
h	Research (from Worksheet 7) .	221		221
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	3,115		3,115	0.030 %
j	Total. Other Benefits . .	3,053,185	1,811,580	1,241,605	12.850 %
k	Total. Add lines 7d and 7j .	5,177,190	2,907,932	2,269,258	23.490 %

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

Schedule H (Form 990) 2018

Page

Part II

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

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

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

1,214,685

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. ......

449,433

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).....

1,422,775

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

1,381,141

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

41,634

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2018

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?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)						Other (describe)
1	Dickenson Community Hospital PO Box 1440 Clintwood,VA24228 balladhealth.org/locations H 1918	X	X	X	X	Mental Health

Schedule H (Form 990) 2018

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	Dickenson Community Hospital
Name of hospital facility or letter of facility reporting group

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

Yes

Community Health Needs Assessment

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

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The significant health needs of the community

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

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

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

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 18

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

Yes

6 a

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

Yes

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

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

Yes

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

Hospital facility’s website (list url): www.balladhealth.org/locations#hospitals

Other website (list url):

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

Other (describe in Section C)

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

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 19

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

If "Yes" (list url):

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

10b

Yes

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

12a

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

12a

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

12b

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

Schedule H (Form 990) 2018

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Dickenson Community Hospital
Name of hospital facility or letter of facility reporting group

Yes

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

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

Yes

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

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 225.0000% and FPG family income limit for eligibility for discounted care of 450.0000%

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):

www.balladhealth.org

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

www.balladhealth.org

A plain language summary of the FAP was widely available on a website (list url):
www.blladhealth.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) 2018

Page 6

Part VFacility Information (continued)

Billing and Collections

	Dickenson Community Hospital
Name of hospital facility or letter of facility reporting group

Yes

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

Yes

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

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

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

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

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

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

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

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

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

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

Processed incomplete and complete FAP applications

Made presumptive eligibility determinations

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

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

Yes

If "No," indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 7

Part VFacility Information (continued)

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

	Dickenson Community Hospital
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) 2018

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Facility: Dickenson Community Hospital - Part V, Section B, Line 3j	During FY19, DCH was operating under the CHNA approved by its board of directors at the end of FY18. Priorities established for their CHNA were determined by the most significant health needs of the community. MSHA hospitals, including DCH, conducted their fourth CHNA this tax reporting period with board approval and publication occurring during FY19. For the FY18 CHNA, Ballad Health and its hospitals and entities agreed to focus on an index of 25 active population health index measures (plus an additional 31 measures for monitoring). The population health index itself is based on the focus areas outlined in the previous FY15 CHNA and align with national health improvement efforts, such as Healthy People 2020. MSHA's affiliates, Wellmont Health System and its hospitals, focused on the same population health index measures determined by Ballad Health, our health system's parent, when completing their individual FY19 CHNA's.To understand each community's individual needs, Ballad Health conducted a community health needs assessment (CHNA) for each Ballad hospital to profile the health of the residents within its service area. Throughout the CHNA process, high priority was given to determining the health disparities and available resources within each community. Community members from each county met with Ballad representatives to discuss current health priorities and identify potential solutions.The Dickenson County CHNA community members evaluated measures that make up DCH's population health index and a few additional measures related to access to health screenings. The Dickenson County group's members completed a survey relative to what health priorities should be a focus for their specific community over the next three years. After all the details and data collection was complete and interviews with various focus groups were complete, the Dickenson County representatives identified three top focus areas:-Smoking-Physical Activity/Obesity-Substance Abuse
Facility: Dickenson Community Hospital - Part V, Section B, Line 5	As part of the FY18 CHNA process, MSHA hospitals conducted localized community focus groups with organization representatives such as those from local health departments, school systems, health clinics, emergency services, businesses, and philanthropic boards. The individuals in DCH's community were selected for participation by the hospital's CEO. The DCH focus group members were represented by Virginia Department of Health, Health Wagon of Southwestern Virginia, Mountain States Health Alliance Government Relations, Dickenson County Department of Social Services, Lenowisco Health District, Dickenson Medical Associates, Dickenson County Behavioral Health Services, Dickenson County Public Schools, Dickenson Community Board and Dickenson Community Foundation Board. Low income, minority and medically underserved populations were represented by Virginia Department of Health, Lenowisco Health District and Health Wagon of Southwestern Virginia. Also, between the foundation board and the community board, there are a number of individuals that sit on these boards that represent low income, minority populations, and medically underserved.Activities associated with the June 2018 assessment took place from fall of 2017 through the spring of 2018. Community members from Dickenson County met with Ballad Health and DCH representatives to discuss health priorities and identify potential solutions. Community members were made aware of the 25 measures that make up Ballad Health's population health index plus 3 additional measures related to access to health screening. Participants then completed a survey to indicate their opinion on what health priorities should be a focus for their community.
Facility: Dickenson Community Hospital - Part V, Section B, Line 6a	Each hospital within Mountain States Health Alliance completed a CHNA. DCHs CHNA was conducted with all MSHA hospitals to include: Johnson City Medical Center (includes Niswonger Children's Hospital and Woodridge Hospital), Franklin Woods Community Hospital, Indian Path Community Hospital, Johnson County Community Hospital, Johnston Memorial Hospital, Norton Community Hospital, Dickenson Community Hospital, Russell County Medical Center, Smyth County Community Hospital, Sycamore Shoals Hospital, and Unicoi County Hospital.
Facility: Dickenson Community Hospital - Part V, Section B, Line 11	During the year, DCH continued to focus on its CHNA priorities as identified in its FY18 CHNA report. DCHs primary areas of focus included: diabetes, obesity, mental health and substance abuse. Many additional community needs exist in our region. It is fiscally impossible for a hospital to address every health need in a community, which is why the CHNA process is used to identify and prioritize areas of focus. A thoughtful CHNA evaluates overall community health needs to determine which ones the hospital can best influence in a positive way. Consideration is given to other organizations in the hospitals geographic area that already offer services addressing specific health needs. In some cases, it is best to simply support an identified health need through a financial donation to another nonprofit organization skilled in certain areas: teen pregnancy, dental health, fighting homelessness, etc. DCH also lends support to other nonprofit organizations by serving on their boards, committees, and assisting with fundraising efforts. DCH reached out to the Dickenson County School System in partnership for education on diabetes. DCH became a member of the school systems Wellness Committee.DCH coordinated with Clintwood Elementary School for implementation of The Morning Mile, and worked to engage the other county elementary schools in the same program. The Morning Mile program is focused on encouraging elementary and middle school students to get some exercise before classes begin. Exercising before school provides numerous benefits for students such as increased oxygen flow to the brain, reduced stress and improvement in mood. DCH presented education materials to physicians, community groups, nursing homes and assisted living facilities regarding need and benefits of treatment of psychiatric issues in the community. DCH worked with the Dickenson Countys Sheriffs Department for pill round-up program for out-of-date medications and to assist with proper needle disposal. DCH became a pilot site for the Virginia Rural Health Association High Risk Patient Education Program (HRPEP) for substance abuse. The HRPEP targets rural communities in Virginia for preventative intervention regarding prescription opioids through a training and education program. The HRPEP training provided to entities such as DCH includes curriculum training to identify high-risk patients, provide training to high-risk patients and their families, provide medication assistance, refer patients to pain management clinics when appropriate, and provide public education about risks and how to respond to opioid overdose. DCH will select staff members to receive the HRPEP training.DCH provided medications and supplies to area rescue squads this year.
Facility: Dickenson Community Hospital - Part V, Section B, Line 13h	Ballad Healths financial assistance policy allows for some exceptions to strictly adhering to federal poverty guidelines when awarding financial assistance. Unique circumstances may be weighed and assessed for financial assistance consideration on a case-by-case basis. Also, there are some services where financial assistance may be provided outside of federal poverty guidelines. These are noted in Ballad Healths financial assistance policy.

Schedule H (Form 990) 2018

Page 9

Part VFacility Information (continued)

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

Schedule H (Form 990) 2018

Page 10

Part VI

Supplemental Information

Provide the following information.

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

Form and Line Reference	Explanation
Part I, Line 3c - Charity Care Eligibility Criteria (FPG Is Not Used)	Financial assistance approval can apply to an assortment of patients such as those who have exhausted their Medicaid/TennCare benefits, those who qualified for Medicaid/TennCare after the date of service, deceased patients with no estate or assets, uninsured patients, and underinsured patients. While Ballad Healths qualifications for financial assistance is based on federal poverty guidelines, asset values may also be used to determine eligibility. Unique circumstances may be assessed on a case-by-case basis. Charity approval covers current or active patient balances when they are approved and there is no limitation or cap on the amount of charity that a patient may receive. Ballad Health hospitals do not stop approving financial assistance for patient accounts if a hospitals charity write-offs exceed the hospitals charity budget. All Ballad Health hospitals provide an uninsured discount; the current uninsured discount is 85% with the exception of critical access hospitals (including DCH) that provide 62%. In addition to the uninsured discount, many patients will further qualify for additional financial assistance. All patients seeking financial assistance must submit an application for financial assistance and submit documents in support of the information on the application, unless specifically excluded according to our policy guidelines. Medicaid eligible patients will qualify for 100% financial assistance and not be required to complete the required documentation when: a) Medicaid eligibility requirements are met after the service is provided, b) non- covered charges occur on a Medicaid eligible encounter, or c) benefits have been exhausted. Deceased patients with no estate also qualify for 100% financial assistance.Financial assistance determinations may be retroactive for all outstanding balances.
Part I, Line 7 - Explanation of Costing Methodology	The cost to charge ratio (worksheet 2 "ratio of patient care cost to charges") was used to calculate line 7a financial assistance (charity care) cost. Our cost accounting system was used to determine losses from Medicaid/TennCare reported on line 7b, with the exception of our physician clinic. We used the cost to charge ratio for our physician clinic because its data is not available in our cost accounting system. Line 7e community health improvement includes costs associated with payments to an unrelated, outside organization that assisted DCH patients obtain Medicaid coverage.Line 7f health professions education is comprised of nursing and other allied health students from schools and universities, allowing their health profession students to receive hands-on training in a hospital setting. For line 7g subsidized health services, we use our cost accounting system, except for the $196,425 subsidy of our owned and operated clinic located in a rural, low income area. For our physician clinic, the departmental operating report is used to determine the subsidy. We are careful to ensure no double counting of cost.
Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense	Self-pay balances include accounts after payments and contractual adjustments (discounts) have been applied from all third-party payers such as Medicare, Medicaid, commercial insurers, and others - generally leaving the patient responsible for any remaining deductible and/or co-payment. Other self-pay accounts are from patients with no insurance or other third-party coverage. Under Ballad Healths system-wide self-pay policy, any patient who has no insurance and is ineligible for any government assistance program received an 80% discount until September 30, 2018, at which time the uninsured discount increased to 85%. Many self-pay patients will further qualify for financial assistance (sometimes referred to as charity care) if they provide the financial information we need to deem them eligible.After the normal collection process has indicated an account is uncollectible, DCH writes the account off to bad debt. The hospital's overall self-pay accounts receivable balance is evaluated on an ongoing basis to evaluate the age of accounts receivable, historical write-offs and recoveries and any unusual instances (such as local, regional or national economic conditions) which affect the collectability of receivables.
Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit	Our primary external collection agency estimates that 37% of DCHs bad debt would likely qualify for financial assistance if patients had provided our hospitals with a financial assistance application and required documentation. The agency based their likely eligible for charity assumption on individuals with a low score. An individuals score is based on an algorithm that includes data points such as FICO credit score, property value, years at current residence, number of times an individual has moved and an individuals propensity to pay score. 97% of completed financial assistance applications processed during FY19 received a full discount (complete write-off). An additional 3% received a partial discount, resulting in an overall approval rate of 100% for completed applications. Therefore, no completed financial assistance applications were denied. Unfortunately, many patients either do not submit an application for financial assistance or do not provide a complete application. A letter is sent to the patient outlining missing information on incomplete applications. The letter also provides a contact phone number patients may call for assistance in completing the application. All self-pay patients receive follow up calls from a company DCH pays to process charity care applications for uninsured patients and to offer patients enrollment assistance in Medicaid (VA) or TennCare (TN). The follow up calls are as follows: every 31 days, 31-60 days up to 3 calls are made, after 60 days up to 2 additional calls are made. Our financial counselors follow up with patients that have a balance after insurance has paid. We have many instances of patients with large account balances and no health insurance coverage that we believe would qualify for financial assistance. Although patients are encouraged to apply for assistance, many will not do so. DCH would prefer for patients to submit completed financial assistance applications given that historical data clearly indicates that most uninsured patients and many underinsured will qualify for financial assistance under our program. Without a completed application, we have no choice other than to record an unpaid account as bad debt instead of charity care.
Part III, Line 4 - Bad Debt Expense	Ballad Healths audited financial statements included a footnote on page 13 that describes bad debt. DCH is included in the June 30, 2019 audited financial statements of Ballad Health (attached).
Part III, Line 8 - Explanation Of Shortfall As Community Benefit	Excluding Medicare losses reported in Part I subsidized health, the Part III Medicare gain is reported using DCH's filed Medicare cost report (C/R). The C/R uses a cost to charge ratio based on a step-down allocation methodology.We believe Medicare losses should be allowed as a reportable community benefit, similar to governmental programs such as Medicaid. As a participating provider in the Medicare program, hospitals are required to provide the full regimen of care for the Medicare population. There are a number of care regimens that are compensated by the Medicare program at levels below cost. Therefore, it is only logical to allow hospitals to report these uncompensated services as a community benefit. By making this change, nonprofit providers will be encouraged to continue important care delivery models for our aging population in spite of the fact it may be economically injurious.
Part III, Line 9b - Provisions On Collection Practices For Qualified Patients	Requests for financial assistance are evaluated using established guidelines, while allowing for unique financial circumstances - for example, medically indigent patients with catastrophic medical costs that would threaten the patients household financial viability. When a patient requests financial assistance or when an application has been received, the patient's account is placed in a hold status to prevent further collection activities until financial assistance eligibility is determined. All Ballad Health hospitals comply with IRS 501(r) regulatory guidelines.Our collection policy clearly states that all patients are treated equally - with dignity and respect. We ensure that outside collection agencies used by our hospitals adhere to our billing and collection guidelines. Our hospitals' collection program includes communicating expected financial responsibility prior to service. Our hospital provide assistance to help underinsured and uninsured patients determine sources of payment for medical bills and to help patients determine eligibility for programs such as Medicaid or TennCare.After insurance benefit verification, the hospital bills insurance carriers. If the insurance carrier denies payment of the service/procedure as non-covered or the patient has exceeded their maximum benefits, the service/procedure will qualify for the uninsured discount.Financial counselors are available to discuss financial assistance with patients and their families. Our hospital provides a number of payment options:- a pre-service discount may be offered- a discount in excess of established discounting rates may be granted for catastrophic high dollar accounts- our hospital accepts all non-contracted and out-of- network payers and will make attempts to work with these payers regarding appropriate reimbursement and billing to their members- payment arrangements are available so long as the account is not with a collection agencyReasonable efforts are made to determine if a patient is eligible for financial assistance - see Schedule H, Part VI, line 3 for information on how patients are informed about our financial assistance policy.
Part VI, Line 2 - Needs Assessment	Focusing on 25 active population health index measures allows Ballad Health to further engage the efforts of its hospitals in partnership with communities in our service areas. It has helped Ballad to better identify health disparities that appear across the individual communities and has helped Ballad to prioritize issues that are most important in each hospitals community. Engaging local community organizations will expand partnerships so that organizations work together more to address community health needs. Ballad Health developed a comprehensive process to gather input for and draft a population health plan last year. An executive steering team was established, aided by national experts with experience in large-scale population health improvement. Because our hospitals are located in a region with many chronic disease challenges, Ballad Healths goal is to target population health issues to make lasting improvements. Ballad conducted approximately 150 interviews and held 40 meetings with external groups, including the regional health departments, United Way agencies, chambers of commerce, schools and community organizations, the regional accountable care community steering committee, as well as internal groups such as our population health and social responsibility committee of the Ballad Health board of directors, the Ballad Health population health clinical committee, and our hospital community boards.
Part VI, Line 3 - Patient Education of Eligibility for Assistance	Consistent with the Ballad Health financial assistance policy, DCH communicates with and provides education to our patients through various avenues regarding governmental assistance programs and hospital financial assistance. Various educational and application documents related to obtaining financial assistance are widely available at DCH and all documents are available on the Ballad Health website. Printed financial assistance educational materials are part of each registration packet and posters are displayed in highly visible areas of the hospital. Our financial assistance policy and documents are available in our Emergency Department and admitting areas. We are also happy to mail all documents to patients. We offer a plain language summary and all of our documents are available in English and Spanish. Financial assistance information is available during pre-registration, registration and/or during financial counseling. We offer governmental program eligibility representatives to assist patients in securing eligibility for Medicaid or TennCare, federal disability and other governmental assistance programs. Additionally, if a patient or community resident expresses an interest in the ACA-Healthcare exchange, our representatives have the qualifications and experience to assist them through the entire process. Our financial counselors offer financial assistance applications to patients who do not qualify for governmental assistance programs and are unable to pay for some or all of their healthcare. All patient billing statements have verbiage discussing financial assistance along with contact information. Our last letter to the patient displays the plain language summary. In all oral correspondences with a patient, if it is identified the patient cannot meet payment requirements on their account, financial assistance is discussed as an option.Applicants are notified of financial assistance determination in writing.
Part VI, Line 4 - Community Information	DCH is located in Clintwood, Dickenson County, which is in rural southwest Virginia. Southwest Virginia (SWVA) is located within the Appalachian Mountains, specifically the Blue Ridge mountain region. SWVA is considered rural and much different than the rest of the state. SWVA has been and remains a major coal mining region and has a high rate of uninsured adults. According to U.S. Census Bureau estimates, the Town of Clintwood has a population of 1,434, while Dickenson Countys population is 14,782. The latest census bureau data estimates the median age of residents of Dickenson County is 44.3 which is older than the median age of 38.3 in Virginia. 21.3% of Dickenson Countys residents are 65 or older compared to almost 15.5% for the state. While the overall population of Dickenson County is projected to remain relatively flat over the next five years the 65+ age group is expected to grow significantly over the same five-year period. The aging population of the county presents opportunities for earlier identification and better management of health conditions that oftentimes affect elderly populations in rural areas.The bureau estimates Dickenson County median household income at $33,400 compared to $72,577 for the state of Virginia. 31% of Dickenson County's children live in poverty compared to 14% statewide. Dickenson County is 100% rural compared with the statewide rural rate of 24.5%. This factor is a significant contributing factor in influencing health outcomes in a population. Many rural residents must travel a greater distance to access different points of the health care delivery system; however, due to geographic distance, sometimes extreme weather conditions, lack of public transportation and challenging roads, rural residents may be limited, and in some instances, even prohibited from accessing health care services. More than 50% of vehicle crash-related fatalities occur in rural areas, even though less than one-third of miles traveled in a vehicle occur there and there is an additional 22% risk of injury-related deaths in rural communities. Within our own county, injury deaths are more than double the statewide rate. And, while our area has generally unfavorable health statistics, there are far fewer primary care physicians per resident in our county than the states average. Our countys ratio of population to primary care physicians is 3,740:1 compared to the states average of 1,310:1. In other words, we have 185% more residents per physician than the overall state rate. Because of the severe primary care physician shortage in our area, DCH continues to operate a physician clinic despite financial loss.Recruiting physicians to rural areas is often challenging due to a myriad of factors, such as geography, economics, culture and education. Geographically, rural communities are often far removed from suburban and urban centers that provide access to education, cultural and economic opportunities. These limitations influence the relocation decision of the physician candidate and his/her spouse/children to locate to a rural area.A number of factors contribute to a unique and challenging environment that influence overall health standing in our county. According to the Robert Wood Johnson foundations county health rankings, 36% of the adults in DCHs home county are obese. Obesity increases the risk for many health conditions such as coronary heart disease, type 2 diabetes, hypertension, stroke, cancer, sleep apnea and respiratory problems, and osteoarthritis. Evidence indicates physical activity, independent of its effect on weight, has substantial benefits for health. Dickenson Countys adult smoking rate is 33% higher than that of Virginias 0average. According to the 2019 County Health Rankings, Dickenson County is ranked 117th out of 133 counties in Virginia for health outcomes and 116th (down from 112th in 2018) in health behaviors. As for social and economic factors, Dickenson County ranks 130th primarily due to high rates of children in poverty and above average unemployment rates.
Part VI, Line 4 - Community Building Activities	DCH leaders support and encourage all team members to volunteer time, money and skills to community service projects and charitable organizations. Senior leaders and board members set a positive example for DCH team members, serving voluntarily on committees and boards of local service and nonprofit organizations. Some also serve as members and consultants on professional committees and task forces that affect regional development in healthcare and education. We do not capture costs associated with team members that serve on other nonprofit boards or provide services to other nonprofits.DCH, in collaboration with area health agencies and providers, may offer assistance with coordination, advocacy, or contribute supplies to support groups for their program activities that serve to assist special populations within our area. Most of these organizations work to improve the lives of community members that have limited, or no, financial resources.
Part VI, Line 5 - Promotion of Community Health	DCH is dedicated to operating efficiently so that waste is minimized. In most years, DCH does not enjoy net operating surpluses and relies on subsidization from Norton Community Hospital. Various checks and balances are established to ensure that expenditures for operating expenses and capital costs are reasonable and necessary.The majority of DCH's governing body is comprised of persons who reside in the organization's primary service area. Only two directors; Shane Hilton, and Monty McLaurin, employees of Ballad Health, live outside of the area. Physicians that request privileges who are qualified and credentialed are extended privileges by DCH.
Part VI, Line 6 - Affilated Health Care System	DCH is a federally designated critical access hospital operated under the direction of a 9-member board of directors primarily comprised of local community residents. The hospital operates 1 acute bed and a 10-bed behavioral health unit. DCH is owned by Norton Community hospital (NCH). DCH has a loan agreement with NCH that provides for NCH to assist in subsidizing DCHs operating expenses. DCH is one of the hospitals within the Ballad Health system. Ballad Health operates a family of 21 hospitals, including three tertiary care facilities, a dedicated childrens hospital, community hospitals, three critical access hospitals, a behavioral health hospital, an addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, outpatient services and a comprehensive medical management corporation. DCH serves as the county's primary health service provider. Patients benefit from DCHs affiliation with a healthcare system where they can be efficiently moved along an integrated, comprehensive continuum of care as their health status dictates. If need be, patients can be moved to one of Ballad Healths tertiary care facilities providing advanced treatment options.DCH operates a 24-hour emergency department to treat patients in life threatening situations. For any patient who needs a higher level of care than DCH can provide, air medical transportation is available through Med-Trans (Wings Air Rescue), based in Jenkins, Kentucky, or Ballad Health One Air Ambulance, based in Tennessee, and can quickly respond and have any patient transported to Norton Community hospital (7 minutes), Johnson City Medical Center (20 minutes) and other regional hospitals when minutes count. Hospitals in the Ballad Health system work closely with one another to share expertise and resources.
Part VI, Line 7 - States Filing of Community Benefit Report	VA TN
Part VI - Additional Information	Ballad Health is required to report community benefit estimates on a quarterly basis with the states of Virginia and Tennessee. The reporting includes all of Ballad Health hospital organizations and is reported using IRS Form 990, Schedule H instructions for reporting community benefit. Ballad Health operates under a Cooperative Agreement (CA) in Virginia and a Certificate of Public Advantage (COPA) in Tennessee as obligated by agreements between Ballad and the two states to allow Mountain States Health Alliance and Wellmont Health System to merge.

Schedule H (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- 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

2018

Open to Public Inspection

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2018

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Justin Ivory Former DCH/NCH CFO	(i) (ii)	------------- 106,743	-------------	------------- 13,309	------------- 1,823	------------- 11,602	------------- 133,477	-------------
2Mark Leonard DCH/NCH CEO	(i) (ii)	------------- 269,210	------------- 15,000	------------- 18,266	------------- 30,434	------------- 21,197	------------- 354,107	-------------
3Monty McLaurin CEO NW MKT Director	(i) (ii)	------------- 357,053	------------- 157,624	------------- 43,422	------------- 18,299	------------- 23,730	------------- 600,128	------------- 16,160
4Roy Deal DO Physician	(i) (ii)	------------- 199,744	------------- 53,779	------------- 20,854	------------- 3,970	------------- 17,000	------------- 295,347	-------------
5Shane Hilton SVP Market Oper Director	(i) (ii)	------------- 356,020	------------- 170,760	------------- 3,500	------------- 50,554	------------- 23,244	------------- 604,078	-------------
6Stephen Sawyer CFO NW Region	(i) (ii)	------------- 182,298	------------- 47,287	------------- 15,364	------------- 10,709	------------- 21,688	------------- 277,346	-------------

Schedule J (Form 990) 2018

Page 3

Part III

Supplemental Information

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

Return Reference	Explanation

Schedule J (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Return Reference	Explanation
Form 990, Part III, Line 4d: Other Program Services Description	OTHER PROGRAM SERVICES 4: Dickenson Community Hospital (DCH) is a federally designated critical access hospital. Federal critical access hospital designation requires that a hospital be small and located in a rural area and located more than a 35-mile drive from another hospital or more than a 15-mile drive from another hospital in an area with mountainous terrain or only secondary roads, and be state-designated as a necessary provider of health care services to residents in the area. DCH is the only hospital located in Dickenson County, with the next nearest hospitals located a 45-minute drive away. DCH is a wholly-owned subsidiary of Norton Community Hospital (NCH). NCH has two members: Mountain States Health Alliance (50.1%) and Community Healthcare Foundation (49.9%). In February 2018, Mountain States Health Alliance (MSHA) and Wellmont Health System (WHS) merged to form Ballad Health, a tax-exempt entity and parent company of MSHA and WHS. Ballad operates 3,162 licensed beds in 21 hospitals, an outpatient addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, outpatient services and a comprehensive medical management corporation.During FY19, we experienced 7, 153 visits to our ER, 26,032 outpatient visits an increase of 11% over FY18, and 261 inpatient admissions.PROMOTE COMMUNITY HEALTHDickenson Community Hospital continues to subsidize a rural physician clinic to provide some relief of the physician shortage in our area. Our FY19 subsidy was just over $196,000. The primary care physician ratio in our county (number of residents to 1 primary care physician) is 185% higher than the overall state ratio. Recruiting physicians to a rural county such as ours is often challenging due to a myriad of factors, such as geography, economics, culture and education. Geographically, rural communities are often far removed from suburban and urban centers that provide access to educational, cultural and economic opportunities. These limitations influence the relocation decision of the physician candidate and his/her spouse/children to locate to a rural area. The Association of American Medical Colleges (AAMC) issued a press release dated April 11, 2018 stating that the United States could see a shortage of up to 120,000 physicians by 2030. The U.S. population is estimated to grow by nearly 11%, with those over age 65 increasing 50% by 2030. Much of the increased demand comes from a growing, aging population. The aging population will also affect physician supply since one-third of all currently active doctors will be older than 65 in the next decade and likely to retire. The AAMC points out that data conducted in 2017 indicated that an additional 31,600 physicians would have been needed if underserved populations utilized the same health care services as insured individuals. The data looked at people in non-metropolitan areas and people without insurance compared to people living in metropolitan areas. Furthermore, the study indicated nearly half of the shortage was in the South. DCH spent $3,723 during FY19 to recruit and retain physicians. DCH recruitment efforts are based on documented community need. DCH is located in a MUA (medically underserved area), as designated by the U.S. Health Resources & Services Administration (HRSA). MUA designation indicates an area as: having too few primary care providers, having a high infant mortality, a high poverty rate or a high elderly population.As the sixth leading cause of death in the United States, Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. According to the National Institute on Aging, the number of people diagnosed is increasing each year. Alzheimer's is one of the many conditions treated at our Green Oak behavioral health unit, which focuses on senior citizens and the elderly. Green Oak is the only inpatient behavioral health unit in Southwest Virginia specifically for older adults. The unit, in conjunction with our outpatient Senior Life Solutions program, treats patients over the age of 55, and some over the age of 45 (on a case-by-case basis), keeping families that would normally have to travel for these services close to home. Green Oak is a 10-bed inpatient unit. During FY19, there were 235 admissions. The population in our region is aging and with the next closest inpatient behavioral facility about two hours away, Green Oak provides care close to home for patients from Southwest Virginia and Southeastern Kentucky.Senior Life Solutions, our outpatient behavioral health program, allows seniors access to behavioral health services without having to travel outside of the area. 21% of our residents are 65 years of age or older and with mountainous terrain especially dangerous in winter months, residents needing behavioral health services previously had to leave the area or do without needed care. Similar to our Green Oak inpatient unit, the benefit of this outpatient program extends benefit to patients families and friends since they often provide transportation for seniors to medical care appointments. Despite incurring a significant operating loss to provide our Senior Life Solutions program, DCH and NCH recognizes the need in our service area for these valuable services.Another essential service we provide despite financial loss is our wound care program. Wound care patients often have multiple health issues and many times travel is very difficult for them. These hardships often caused patients the inability to access necessary care. Patients served at DCH include those with diabetic ulcers, venous stasis ulcers, arterial ulcers, non-healing traumatic and surgical wounds and other chronic wound conditions. Mountain States Health Alliance (Mountain States) is one of only 29 organizations in the country participating in the Centers for Medicare & Medicaid Services (CMS) new initiative, Accountable Health Communities Model (referred to as AHC Program), aimed at improving the health of eligible Medicare and Medicaid beneficiaries. The AHC Program is designed to integrate care for health-related social needs into usual care by implementing systematic screening, referral, and patient navigation services for needs such as food insecurity, housing instability, safety, transportation needs, and utility assistance. Mountain States serves as the Bridge Organization for the AHC Program locally, leading a collaborative of multiple organizations and clinical delivery sites to bring needed services to beneficiaries residing in Southwest Virginia. Full implementation of the AHC Program was achieved during FY19. There are nine full-time team members for the program, whose positions are financed by federal funds, (six Navigators, one Lead Navigator, one Screening and Referral Specialist, and one Program Manager), while two part-time Navigator positions remain open. Fifty-two locations serve as clinical delivery sites in Southwest Virginia and Northeast Tennessee and have processes in place to identify health-related social needs. Patients that screen positive for health-related social needs are given a Community Referral Summary, which contains contact and program information for relevant resources that assist with the needs identified by the screening. Since formal go-live of the AHC Program on November 17, 2018 through June 30, 2019 there have been 61,705 offered screenings, 35,544 answered screenings, 9,050 needs identified, 5,030 Community Referral Summaries given to patients, and 2,142 navigated patients. The stats provided are inclusive of the Ballad Health Virginia hospitals plus three Tennessee hospitals located close to Southwest Virginia. Mountain States also created an internally-produced data system for the screening, referral, and navigation services in lieu of using the CMS AHC Data System. This data system improved operational efficiency by at least five-fold over the CMS Data System. Patient Navigators have been re-deployed from five Virginia Community Services Boards in our service area to hospital emergency departments and primary care offices. This allows the Navigators to establish initial contact with a patient and complete a personal interview and action plan related to the health-related social needs identified by the patient. Laptops and cell phones were purchased for the Navigators to have the ability to work at the clinical delivery sites and from other locations, as needed. OTHER PROGRAM SERVICES 5: Ballad Health embarked on a campaign near the end of fiscal year 2018 to reduce hospital-acquired C. diff by 30% in 90 days. This was a bold undertaking by Ballad Healths new Clinical Council and our Infection Prevention Department. C. diff is a significant threat to hospital patients everywhere. It is our duty as caregivers to protect our patients from harm all of the time, so preventing C. diff i
Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder	The corporation is organized as a Virginia non-stock, nonprofit corporation. Dickenson Community Hospital IS A 100% owned subsidiary of Norton Community Hospital, Inc.
Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body	The board of directors of Norton Community Hospital annually elect members to the board of directors for Dickenson Community Hospital. A requirement of at least (1) member is to be from Dickenson County Industrial Development Authority. Norton community hospital is the sole member of Dickenson Community Hospital.
Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders	Certain decisions of the board are, pursuant to charter and Virginia stature, subject to approval of the members. These decisions include: dissolution of the corporation; merger of the corporation; non-ordinary course of business sale of assets, etc. No ordinary day-to-day decisions are subject to member approval.
Form 990, Part VI, Line 11b: Form 990 Review Process	The CFO reviewed the Form 990 with the board of directors prior to filing the return with the IRS. The return was made available to each board member in an electronic format prior to the review.
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts	Ballad Health has a conflict of interest policy for all members of the Board of Directors, the Executive Chair/President, Executive Vice Presidents, Senior Vice Presidents, and Vice Presidents, and applies to all Ballad Health organizations. All persons covered by this policy are required to complete a conflict of interest disclosure form on an annual basis. Should a conflict arise, it is the responsibility of the conflicted individual to update his or her disclosure immediately. All meetings of the board or board committees have a standing agenda item first on the agenda titled Conflicts of Interest. If a member of the board or board committee has a conflict of interest involving any issue on the board agenda, he or she must declare the conflict of interest during the period allotted for disclosure. If any issue arises during a meeting in which the board member has a conflict of interest, he or she must immediately declare the conflict. While each member of the board or board committee is responsible for disclosing conflicts of interest, it is also the responsibility of any board member aware of a conflict which has not been disclosed to ensure the board is made aware. The presiding officer of a board or board committee meeting may ask a conflicted member to excuse themselves from the meeting during the discussion related to the issue with which the conflict of interest applies. Under no circumstances shall a member vote on a matter that gives rise to a potential conflict.
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available	Governing documents and conflict of interest policy are made available upon request to the appropriate parties requesting them. Financial statements are made available upon request to appropriate parties requesting them, and they are made available to those parties who own indebtedness of the company on a quarterly basis.
Other Changes In Net Assets Or Fund Balances - Other Increases	Change in Temp. Restricted Net Assets = $5000
Other Changes In Net Assets Or Fund Balances - Other Increases	Elimination of Intercompany Receivables/Payables = $164441
Other Changes In Net Assets Or Fund Balances - Other Increases	Pension Liability Adjustment = $10556
Part V, Line 2A: W-2 Employees	Dickenson Community Hospital (DCH) team members are paid by Norton Community Hospital, DCH's sole member, except for the CEO and CFO who are paid by Ballad Health. The CEO and CFO salary and benefit costs are allocated between NCH and DCH. Norton Community Hospital bills DCH for its share of salary and benefits and the expense is recorded on DCHS books. There were three DCH team members that received reportable compensation in excess of $100,000.
Part VI, Line 15A - Compensation Process for Top Official	On an annual basis, Ballad Health's Human Resource (H/R) Department evaluates compensation for all executives at a position level of Assistant Vice President and above. The review includes DCH/NCH's CEO. H/R's evaluation is based on market data obtained from independent third-party consultants for positions with similar responsibilities at similarly situated organizations. Based on this comparable data, the President & CEO of Ballad Health evaluates the data and submits his recommendations to the Board of Directors for Ballad Health for their final review and approval. In addition, Ballad Health offers an incentive plan to executives based on targeted achievement metrics set in advance of the pay year. Established metrics include: communication with patients, patient evidence-based care scores and patient safety, value-based purchasing, etc.
Part VI, Line 15B - Compensation Process for Officers or Key Employees	Similar to DCH/NCH's CEO, DCH's CFO receives compensation that complies with salary policy of Ballad Health. His pay is set at a market percentile specific to his position as CFO of DCH and NCH.
Part Vll - Related Organizations	Director compensation: Dickenson Community Hospitals board members, Shane Hilton and Monty McLaurin, receive compensation for services provided to related organizations and do not receive compensation for services as a DCH board member.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Dickenson Community Hospital

Employer identification number

77-0599553

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)Mountain States Health Alliance 303 Med Tech Parkway Suite 220 Johnson City,TN37604 62-0476282	Hospital System	TN	501C3	3	BALLAD		No
(2)MSHA Auxiliary 400 N State of Franklin Road Johnson City,TN37604 58-1418345	Supporting Organization	TN	501C3	12a	MSHA		No
(3)Smyth County Community Hospital 245 Medical Park Drive Marion,VA24354 54-0794913	Hospital	VA	501C3	3	MSHA		No
(4)Norton Community Hospital 100 15th Street NW Norton,VA24273 54-0566029	Hospital	VA	501C3	3	NA		No
(5)Johnston Memorial Hospital 16000 Johnston Memorial Drive Abingdon,VA24211 54-0544705	Hospital	VA	501C3	3	NA		No
(6)Abingdon Physician Partners 16000 Johnston Memorial Drive Abingdon,VA24211 20-5485346	Medical Services	VA	501C3	12a	JMH		No
(7)Ballad Health 303 Med Tech Parkway Suite 220 Johnson City,TN37604 61-1771290	Supporting Organization	TN	501C3	12b	NA		No
(8)East TN Healthcare Holdings Inc 203 Gray Commons Circle Gray,TN37615 81-5475903	Opioid Treatment	TN	501C3	3	MSHA		No
(9)Wellmont Health System 1905 American Way Kingsport,TN37660 62-1636465	Hospital System	TN	501C3	3	BALLAD		No
(10)Wellmont Hawkins Co Memorial Hosp 851 Locust Street Rogersville,TN37857 62-1816368	Hospital	TN	501C3	3	WHS		No
(11)Takoma Regional Hospital Inc DBA GCH 1420 Tusculum Boulevard Greeneville,TN37745 51-0603966	Hospital	TN	501C3	3	WHS		No
(12)Wellmont Cardiology Services 1905 American Way Kingsport,TN37660 26-3557623	Medical Services	TN	501C3	10	WHS		No
(13)Wellmont Medical Associates 1905 American Way Kingsport,TN37660 27-0898372	Medical Services	TN	501C3	7	WHS		No
(14)Ballad Health Foundation 1019 West Oakland Ave Suite 2 Johnson City,TN37604 58-1594191	Fundraiser	TN	501C3	7	BALLAD		No
(15)Wellmont Madison House 2000 Greenway Street Kingsport,TN37660 62-1308216	Assisted Living	TN	501C3	10	WHS		No
(16)Wellmont Wexford House 2421 N John B Dennis Hwy Kingsport,TN37660 58-1859039	Nursing Home	TN	501C3	10	WHS		No
(17)Wellmont Imaging Services Inc 1905 American Way Kingsport,TN37660 86-1103148	Healthcare	TN	501C3	12a	WHS		No
(18)Wellmont Sleep Services 1905 American Way Kingsport,TN37660 27-3777167	Medical Services	TN	501C3	3	WHS		No
(19)Laughlin Memorial Hospital Inc 1420 Tusculum Boulevard Greeneville,TN37745 62-0701119	Hospital	TN	501C3	3	MSHA		No
(20)Laughlin Healthcare Foundation 1420 Tusculum Boulevard Greeneville,TN37745 58-2105493	Fundraiser	TN	501C3	12a	MSHA		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2018

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Emmaus Comm Hlth PLLC 6070 HWY 11E Piney Flats,TN37686 20-0577483	Medical Services	TN	NA				No			No
(2) Medl Spec of JC LLC 2528 Wesley Street Suite 2 Johnson City,TN37601 27-2199037	Medical Services	TN	NA				No			No
(3) ETn AmbSrg Cntr 701 Med Tech Parkway Suite 100 Johnson City,TN37604 62-1787537	Medical Services	TN	NA				No			No
(4) GreenevillePhySvc LLC 1905 American Way Kingsport,TN37660 45-5070419	Medical Services	TN	NA				No			No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) Blue Ridge Medical Management Corp 1905 American Way Kingsport,TN37660 62-1490616	Medical Services	TN	MSHA	C				No
(2) Mediserve Medical Equipment 1905 American Way Kingsport,TN37660 62-1212286	Durable Medical Equipment	TN	BRMMC	C				No
(3) Mountain States Properties 1905 American Way Kingsport,TN37660 62-1845895	Property Management	TN	BRMMC	C				No
(4) Mountain States Physician Grp 1905 American Way Kingsport,TN37660 62-1700412	Medical Services	TN	BRMMC	C				No
(5) Community Home Care Inc 1490 Park Avenue NW Suite B Norton,VA24273 54-1453810	Durable Medical Equipment	VA	NCH	C				No
(6) Wilson Pharmacy Inc PO Box 5289 Johnson City,TN37604 62-0329587	Pharmacy	TN	BRMMC	C				No
(7) Crestpoint Health Insurance Company 509 Med Tech Parkway Suite 100 Johnson City,TN37604 62-0381170	Insurance	TN	ISHN	C				No
(8) Wellmont Inc 1905 American Way Kingsport,TN37660 62-1320035	Medical Services	TN	NA	C				No
(9) Wellmont Collections Inc 2004 American Way Suite 101 Kingsport,TN37660 62-1325938	Business Services	TN	NA	C				No
(10) Medical Mall Pharmacy Inc 1905 American Way Kingsport,TN37660 62-1565006	Medical Services	TN	NA	C				No
(11) Wellmont Physician Services 1905 American Way Kingsport,TN37660 62-1567353	Medical Services	TN	NA	C				No
(12) WPS Providers Inc 1905 American Way Kingsport,TN37660 20-5564642	Medical Services	TN	NA	C				No
(13) Wellmont Health Services Inc 1905 American Way Kingsport,TN37660 62-1254373	Medical Services	TN	NA	C				No
(14) Nolichuckey Management Svcs Inc 1420 Tusculum Boulevard Greeneville,TN37745 62-1776681	Medical Services	TN	NA	C				No
(15) Wellmont Insurance Co SPC LTD P O Box 30600 Grand Cayman KY1-1203 CJ 98-1195624	Insurance	CJ	NA	C				No

Schedule R (Form 990) 2018

Page 3

Part V

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

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

Yes

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

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

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

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

Yes

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

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

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

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

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

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

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

Yes

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

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

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

Yes

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

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

Schedule R (Form 990) 2018

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2018

Page 5

Part VII

Supplemental Information

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

Return Reference	Explanation

Schedule R (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

1	Briefly describe the organization’s mission or most significant activities: Our mission: Honor those we serve by delivering the best possible care.Our vision: To build a legacy of superior health by listening to and caring for those we serve.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	9
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	7
5	Total number of individuals employed in calendar year 2018 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	51,758	8,785
9	Program service revenue (Part VIII, line 2g) .........	9,351,031	8,338,451
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,622	1,044
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	11,724	35,361
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	9,416,135	8,383,641
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		3,114
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	5,564,824	5,499,189
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	4,291,996	4,154,822
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	9,856,820	9,657,125
19	Revenue less expenses. Subtract line 18 from line 12.......	-440,685	-1,273,484
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	5,916,837	4,761,236
21	Total liabilities (Part X, line 26).............	914,618	852,504
22	Net assets or fund balances. Subtract line 21 from line 20.....	5,002,219	3,908,732

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 3,932,442 including grants of $ ) (Revenue $ 3,909,446 )
	Emergency Services: Our fully staffed 24-hour emergency department is available for patients in a life threatening situation. We can provide air medical transportation to a larger regional hospital for any patient needing a higher level of care. There were 7,153 ED visits during FY19. Almost half of DCH's ER visitis are Medicaid/Self Pay.

4b	(Code: ) (Expenses $ 2,963,567 including grants of $ ) (Revenue $ 1,964,892 )
	Behavioral Health: Our 10-bed inpatient behavioral health unit (Green Oak Behavioral Health) focuses on senior citizens and is the only inpatient behavioral health unit in Southwest Virginia specifically for older adults. We also continue to offer our outpatient behavioral health program, Senior Life Solutions. There were 235 inpatient admissions and 2,239 outpatient visits during FY19.

4c	(Code: ) (Expenses $ 733,033 including grants of $ ) (Revenue $ 954,376 )
	Laboratory: Our experienced staff offers complete and comprehensive services including: outpatient services, stat testing, comprehensive chemistry studies, occupational drug testing, high sensitive coumadin monitoring, transfusion services, and more. We provide lab services 24 hours a day, 7 days a week. During FY19, 68,754 lab tests were processed.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 42,330 including grants of $ ) (Revenue $ 1,522,277 )
4e	Total program service expenses7,671,372

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	2,322,820	244,706

(A) Name and business address	(B) Description of services	(C) Compensation
Western VA Regional Emergency Physicians LLC 200 Corporate Blvd Lafayette,LA70508	ED Physician Svcs	2,005,772
Psychiatric Medical Care LLC PO Box 305172 Dept 141 Nashville,TN372305172	Mgmt/Director Fees	545,681



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 2

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	8,785
e	Government grants (contributions)		1e

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

g	Noncash contributions included in lines 1a - 1f:$
h Total. Add lines 1a-1f.......		8,785

		Business Code
2a	340B Program	900099	42,264	42,264
b	Patient Services	900099	8,249,800	8,249,800
c	Peformance & MSSP Payment	900099	35,442	35,442
d	Rental Inc T/E Affiliate	900099	10,945		10,945
e
f	All other program service revenue.
g	Total. Add lines 2a–2f ....		8,338,451

3 Investment income (including dividends, interest, and othersimilar amounts) ......			2,223			2,223
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss)......			0
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses	1,179
c	Gain or (loss)	-1,179
d	Net gain or (loss).....			-1,179	-1,179
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	Hosp. Improvement Network		900099	9,644			9,644
b	Revenue from Parent		900099	20,592	20,592
c	Unclaimed Prop. Recovery		900099	4,072	4,072
d	All other revenue ....			1,053			1,053
e	Total. Add lines 11a–11d ......			35,361
12	Total revenue. See Instructions......			8,383,641	8,350,991		23,865

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	3,114	3,114
2	Grants and other assistance to domestic individuals. See Part IV, line 22	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, line 15 and 16.	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	72,403		72,403
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	4,365,768	3,473,104	892,664
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	119,441	95,440	24,001
9	Other employee benefits .......	667,365	441,344	226,021
10	Payroll taxes ...........	274,212	249,073	25,139
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	3,500		3,500
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	2,155,251	2,045,344	109,907
12	Advertising and promotion ....	13,314	4,317	8,997
13	Office expenses .......	117,527	98,629	18,898
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	161,210	117,323	43,887
17	Travel ............	29,853	24,075	5,778
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	0
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	324,906	276,155	48,751
23	Insurance ...	10,138	9,277	861
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	Management Fees to Parent	481,303	17,233	464,070
b	Medical Supplies and Drugs	442,538	442,538
c	Repairs and Maintenance	366,220	349,737	16,483
d	Dues & Subscriptions	18,388	5,878	12,510
e	All other expenses	30,674	18,791	11,883
25	Total functional expenses. Add lines 1 through 24e	9,657,125	7,671,372	1,985,753	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 ........			1,331,408	1	841,180
2	Savings and temporary cash investments .........				2	0
3	Pledges and grants receivable, net ......				3	0
4	Accounts receivable, net .............			1,484,291	4	1,463,901
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L .............
					5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L ..............
					6	0
7	Notes and loans receivable, net ....				7	0
8	Inventories for sale or use ........			170,590	8	207,815
9	Prepaid expenses and deferred charges ......			65,725	9	11,174
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	5,319,749
b	Less: accumulated depreciation	10b	3,966,474	1,451,285	10c	1,353,275
11	Investments—publicly traded securities .				11	0
12	Investments—other securities. See Part IV, line 11 .....				12	0
13	Investments—program-related. See Part IV, line 11 ..				13	0
14	Intangible assets ...............				14	0
15	Other assets. See Part IV, line 11 ...........			1,413,538	15	883,891
16	Total assets. Add lines 1 through 15 (must equal line 34)...			5,916,837	16	4,761,236

17	Accounts payable and accrued expenses .....	413,239	17	471,293
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	501,379	25	381,211
26	Total liabilities. Add lines 17 through 25..	914,618	26	852,504

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	4,995,034	27	3,896,547
28	Temporarily restricted net assets ...........	7,185	28	12,185
29	Permanently restricted net assets		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	5,002,219	33	3,908,732
34	Total liabilities and net assets/fund balances ........	5,916,837	34	4,761,236