2013-11-15T15:05:41-06:00 2012-12-31 990 2012-01-01 452694620 TEXAS HEALTH HUGULEY INC TEXA 8175512704 11801 S FREEWAY BURLESON TX 76028 LYNN C ADDISCOTT 8175512704 2013-11-15 2012 2016-03-07 17:11:31Z X KENNETH FINCH 11801 S FREEWAY BURLESON TX 76028 100386293 0 X WWW.TEXASHEALTHHUGULEY.ORG X 2011 FL THE PROVISION OF MEDICAL CARE TO THE COMMUNITY THROUGH THE OPERATION OF A 223 BED HOSPITAL. 11 5 0 182 367516 51010 0 163688 0 99381899 0 134425 0 604841 0 100284853 0 20000 0 0 0 45387821 0 0 0 0 46904462 0 92312283 0 7972570 0 97618436 0 24629588 0 72988848 OUR MISSION IS TO EXTEND THE HEALING MINISTRY OF CHRIST BY IDENTIFYING AND MEETING THE HEALTH NEEDS OF OUR COMMUNITY, PROVIDING QUALITY, CUSTOMER ORIENTED AND COST EFFECTIVE SERVICES, AND ENSURING ACCESS TO THOSE SERVICES. 0 0 88349795 20000 99683736 OPERATION OF ACUTE CARE HOSPITAL TOTALING 223 BEDS WITH 7,806 PATIENT ADMISSIONS, 33,128 PATIENT DAYS, AND 75,914 OUTPATIENT VISITS IN THE CURRENT YEAR. 88349795 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 174 0 1 0 1 1 0 0 0 0 1 1 0 0 0 0 X 11 5 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X PENNY JOHNSON 8175512704 11801 S FREEWAY BURLESON TX 76028 X BARCLAY BERDAN 0.20 50.00 X 0 1089819 114670 RICHARD REINER 0.20 50.00 X 0 1681892 62430 ERIC ANDERSON PHD 0.10 0.00 X 0 0 0 HAROLD BERENZWEIG MD 0.10 50.00 X 0 524852 84562 HENRY CUNNINGHAM 0.10 0.00 X 0 0 0 BRENDA GAMMON 0.10 0.00 X 0 0 0 RONALD LONG 0.10 50.00 X 0 935511 102447 LARRY MOORE 0.10 0.00 X 0 0 0 JOSEPH PROSSER MD 0.10 50.00 X 0 462362 29210 MEHBOOB QASSAM MD 0.10 0.00 X 0 0 0 PAUL RATHBUN 0.20 50.00 X 0 788977 136571 TL TRIMBLE 0.10 50.00 X 0 633616 97611 KENNETH FINCH 50.00 0.00 X 0 728572 117420 PENNY JOHNSON 50.00 0.00 X 0 386891 68148 0 7232492 813069 0 0 1 0 NORHSTAR ANESTHESIA PO BOX 650252 DALLAS TX 75265 ANESTHESIA SERVICES 1041819 NURSEFINDERS INC PO BOX 910738 DALLAS TX 75391 NURSING PERSONNEL 423924 GENERAL ELECTRIC CO PO BOX 843553 DALLAS TX 75284 EQUIPMENT MAINTENANCE 314614 HUGULEY PATHOLOGY CONSULTANTS PO BOX 879 BURLESON TX 76028 LAB SERVICES 286681 KEY PERSONNEL PO BOX 1482 FORT WORTH TX 76101 AGENCY PERSONNEL 260392 16 135325 28363 163688 NET PATIENT REVENUE 900099 95923554 95923554 MEDICAL OFFICE BLDG 531120 1105145 1105145 LAB REVENUE 621500 804589 472311 332278 FITNESS CENTER 900099 786050 786050 CAFETERIA 900099 498402 498402 264159 228921 35238 99381899 57106 57106 7342 0 7342 7342 7342 77319 0 77319 77319 77319 29586 135325 101440 -71854 -71854 EQUITY EARNINGS FROM RELATED ENT 900099 669353 669353 669353 100284853 99683736 367516 69913 X 20000 20000 867354 867354 33311321 33170001 141320 914766 890979 23787 7535377 7459928 75449 2759003 2687260 71743 33639 33639 30214 30214 12459490 11420242 1039248 195902 195902 3228286 2719965 508321 3931564 3387392 544172 2416653 2416653 153074 153074 32236 32236 39787 39787 3537019 3537019 453140 379685 73455 MEDICAL SUPPLIES 18119425 18119425 REPAIRS & MAINTENA 2073948 2073948 DUES & SUBSCRIPTIONS 161482 161482 UNRELATED BUSINESS INCO 9197 9197 29406 18314 11092 92312283 88349795 3962488 0 4450 14036547 18135062 3895909 374818 51539875 3492527 0 48047348 462656 0 12661646 0 97618436 7105393 0 17524195 0 24629588 X 71353411 222410 1413027 0 72988848 0 97618436 X 7972570 65016278 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8722 8722 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: AMERICAN HOSPITAL ASSOCIATION AND TEXAS HOSPITAL ASSOCIATION DUES 1413027 3082 3082 1413027 0.00000 1.00000 0.00000 0 0 6888354 6888354 33095990 1717395 31378595 10184128 1708465 8475663 1371403 66667 1304736 48047348 DUE FROM AFFILIATED 914376 OTHER CURRENT RECEIVABLES 2772596 DONOR RESTRICTED ASSETS 1630345 FUNDS HELD IN TRUST 431000 INVESTMENT IN COMMUNITY HOSPICE OF 6898209 OTHER NON-CURRENT ASSETS 15120 12661646 DUE TO AFFILIATED 15210699 PAYABLE TO THIRD PARTIES 804722 OTHER CURRENT LIABILITIES 130418 LEASES PAYABLE 1378356 17524195 X 107571521 7375794 7375794 100195727 89126 89126 100284853 102118489 9831861 9831861 92286628 25655 25655 92312283 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: PART V, LINE 4: THE FILING ORGANIZATION'S ENDOWMENT CONSISTS OF TWO DONOR-RESTRICTED ENDOWMENT FUNDS ESTABLISHED TO SUPPORT A VARIETY OF PURPOSES INCLUDING THE ACQUISITION AND MAINTENANCE OF THE HOSPITAL'S EQUIPMENT, AND ASSISTANCE TO THE HELPING HAND FUND WHICH PROVIDES ASSISTANCE TO ORGANIZATIONS AND NEEDY INDIVIDUALS WITHIN THE COMMUNITY. PART V, LINE 1A, COLUMN (A), CURRENT YEAR - EXPLANATION FOR BEGINNING BALANCE: ON MAY 1, 2012 THE OPERATIONS OF ADVENTIST HEALTH SYSTEM/SUNBELT, INC. DBA HUGULEY MEMORIAL MEDICAL CENTER (HMMC) WERE TRANSFERRED TO THE FILING ORGANIZATION. THE AMOUNT REPORTED AS THE BEGINNING OF YEAR BALANCE REPRESENTS THE TOTAL ENDING BALANCE OF THE ENDOWMENTS FUNDS HELD BY HMMC AS OF APRIL 30, 2012. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS FOR THE EIGHT-MONTH PERIOD ENDED 12/31/12 INCLUDE THE FILING ORGANIZATION AND TWO OF ITS SUBSIDIARIES: HUGULEY MEDICAL ASSOCIATES (HMA), A TAXABLE NONPROFIT PHYSICIAN GROUP, AND HUGULEY COMMUNITY CARE CORPORATION (HCCC), A TEXAS NONPROFIT, TAX-EXEMPT CORPORATION. THESE CONSOLIDATED AUDITED FINANCIAL STATEMENTS CONTAIN THE FOLLOWING FIN 48 FOOTNOTE: THE COMPANY, OTHER THAN HMA, IS EXEMPT FROM STATE AND FEDERAL INCOME TAXES. ACCORDINGLY, THE COMPANY AND ITS TAX-EXEMPT AFFILIATES ARE NOT SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAXES EXCEPT FOR ANY NET UNREALIZED BUSINESS TAXABLE INCOME. FOR THE EIGHT-MONTH PERIOD ENDED DECEMBER 31, 2012, UNRELATED BUSINESS INCOME ACTIVITIES CONDUCTED BY THE COMPANY AND ITS TAX-EXEMPT AFFILIATES DID NOT GENERATE A MATERIAL AMOUNT OF COMBINED FEDERAL, STATE AND LOCAL INCOME TAX. HMA IS A WHOLLY-OWNED, FOR-PROFIT SUBSIDIARY OF THE COMPANY. HMA IS SUBJECT TO FEDERAL AND STATE INCOME TAXES AND FILES A FEDERAL AND STATE INCOME TAX RETURN. FOR THE EIGHT-MONTH PERIOD ENDED DECEMBER 31, 2012, HMA GENERATED A TAXABLE LOSS OF APPROXIMATELY $1,244,000. ACCORDINGLY, THERE IS NO PROVISION FOR CURRENT FEDERAL OR STATE INCOME TAX FOR THE EIGHT-MONTH PERIOD ENDED DECEMBER 31, 2012. HMA ALSO HAS TEMPORARY DEDUCTIBLE DIFFERENCES OF APPROXIMATELY $4,967,000 AT DECEMBER 31, 2012, PRIMARILY AS A RESULT OF NET OPERATING LOSS CARRYFORWARDS. AT DECEMBER 31, 2012, HMA HAD NET OPERATING LOSS CARRYFORWARDS OF APPROXIMATELY $4,337,000, OF WHICH APPROXIMATELY $1,244,000 WILL EXPIRE IN 2032. THE REMAINING $3,093,000 IS SUBJECT TO LIMITATION UNDER INTERNAL REVENUE CODE SECTION 382 AND WILL EXPIRE BEGINNING IN 2018 THROUGH 2031. DEFERRED TAXES HAVE BEEN PROVIDED FOR THESE AMOUNTS, RESULTING IN A NET DEFERRED TAX ASSET OF APPROXIMATELY $1,689,000 AT DECEMBER 31, 2012. A FULL VALUATION ALLOWANCE HAS BEEN PROVIDED AT DECEMBER 31, 2012 TO OFFSET THE DEFERRED TAX ASSET SINCE THE COMPANY HAS DETERMINED THAT IT IS MORE LIKELY THAN NOT THAT THE BENEFIT OF THE NET OPERATING LOSS CARRYFORWARDS WILL NOT BE REALIZED IN FUTURE YEARS. THE INCOME TAXES TOPIC OF THE ACCOUNTING STANDARDS CODIFICATION (ASC)(ASC 740) PRESCRIBES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAX POSITIONS RECOGNIZED IN FINANCIAL STATEMENTS. ASC 740 PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION OF A TAX POSITION TAKEN, OR EXPECTED TO BE TAKEN, IN A TAX RETURN. PART XI, LINE 2D - OTHER ADJUSTMENTS: REVENUE FROM HUGULEY MEDICAL ASSOC, A WHOLLY OWNED SUBSIDIARY OF THH 7,375,361. REVENUE FROM HUGULEY COMMUNITY CARE CORPORATION 430. ROUNDING 3. PART XI, LINE 4B - OTHER ADJUSTMENTS: RECLASS MANAGEMENT FEE REVENUE FROM EXPENSE 25,655. RECLASS NET SPECIAL EVENTS FROM EQUITY 63,471. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES FROM HUGULEY MEDICAL ASSOC, A WHOLLY OWNED SUBSIDIARY OF THH 9,847,089. NET EXP FROM HUGULEY COMMUNITY CARE CORPORATION -15,232. ROUNDING 4. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASS MANAGEMENT FEE REVENUE 25,655. CRYSTAL HEART GALA 164911 135325 29586 0 0 0 37514 49250 14676 164911 135325 29586 37514 49250 14676 101440 -71854 1 1 X 1 X 1 X 1 1 0 1 1 5522451 0 5522451 0.05980 10100224 6993161 3107063 0.03370 15622675 6993161 8629514 0.09350 39850 0 39850 0.00040 14133 0 14133 0.00020 53983 53983 0.00060 15676658 6993161 8683497 0.09410 1 12222839 1829243 24630335 24998238 -367903 X 1 1 1 1 TEXAS HEALTH HUGULEY HOSPITAL

11801 S FREEWAY FT WORTH TX 76028

WWW.TEXASHEALTHHUGULEY.ORG X X X TEXAS HEALTH HUGULEY HOSPITAL 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X 1 0 1 X 0 0 1 HUGULEY SURGERY CENTER

15305 DALLAS PKWY STE 1600 LB 28 ADDISON TX 75001

OUTPATIENT SURGER CENTER PART I, LINE 7: THE AMOUNTS OF COSTS REPORTED IN THE TABLE IN LINE 7 OF PART I OF SCHEDULE H WERE DETERMINED BY UTILIZING A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, CONTAINED IN THE SCHEDULE H INSTRUCTIONS. PART III, LINE 8: COSTING METHODOLOGY:MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST-TO-CHARGE RATIO.RATIONALE FOR INCLUDING A MEDICARE SHORTFALL AS COMMUNITY BENEFIT:AS A 501(C)(3) ORGANIZATION, THE FILING ORGANIZATION PROVIDES EMERGENCY AND NON-ELECTIVE CARE TO ALL REGARDLESS OF ABILITY TO PAY. ALL HOSPITAL SERVICES ARE PROVIDED IN A NON-DISCRIMINATORY MANNER TO PATIENTS WHO ARE COVERED BENEFICIARIES UNDER THE MEDICARE PROGRAM. AS A PUBLIC INSURANCE PROGRAM, MEDICARE PROVIDES A PRE-ESTABLISHED REIMBURSEMENT RATE/AMOUNT TO HEALTH CARE PROVIDERS FOR THE SERVICES THEY PROVIDE TO PATIENTS. IN SOME CASES, THE REIMBURSEMENT AMOUNT PROVIDED TO A HOSPITAL MAY EXCEED ITS COSTS OF PROVIDING A PARTICULAR SERVICE OR SERVICES TO A PATIENT. IN OTHER CASES, THE MEDICARE REIMBURSEMENT AMOUNT MAY RESULT IN THE HOSPITAL EXPERIENCING A SHORTFALL OF REIMBURSEMENT RECEIVED OVER COSTS INCURRED. IN THOSE CASES WHERE AN OVERALL SHORTFALL IS GENERATED FOR PROVIDING SERVICES TO ALL MEDICARE PATIENTS, THE SHORTFALL AMOUNT SHOULD BE CONSIDERED AS A BENEFIT TO THE COMMUNITY. TAX-EXEMPT HOSPITALS ARE REQUIRED TO ACCEPT ALL MEDICARE PATIENTS REGARDLESS OF THE PROFITABILITY, OR LACK THEREOF, WITH RESPECT TO THE SERVICES THEY PROVIDE TO MEDICARE PATIENTS. THE POPULATION OF INDIVIDUALS COVERED UNDER THE MEDICARE PROGRAM IS SUFFICIENTLY LARGE SO THAT THE PROVISION OF SERVICES TO THE POPULATION IS A BENEFIT TO THE COMMUNITY AND RELIEVES THE BURDENS OF GOVERNMENT. IN THOSE SITUATIONS WHERE THE PROVISION OF SERVICES TO THE TOTAL MEDICARE PATIENT POPULATION OF A TAX-EXEMPT HOSPITAL DURING ANY YEAR RESULTS IN A SHORTFALL OF REIMBURSEMENT RECEIVED OVER THE COST OF PROVIDING CARE, THE TAX-EXEMPT HOSPITAL HAS PROVIDED A BENEFIT TO A CLASS OF PERSONS BROAD ENOUGH TO BE CONSIDERED A BENEFIT TO THE COMMUNITY. DESPITE A FINANCIAL SHORTFALL, A TAX-EXEMPT HOSPITAL MUST AND WILL CONTINUE TO ACCEPT AND CARE FOR MEDICARE PATIENTS. TYPICALLY, TAX-EXEMPT HOSPITALS PROVIDE HEALTH CARE SERVICES BASED UPON AN ASSESSMENT OF THE HEALTH CARE NEEDS OF THEIR COMMUNITY AS OPPOSED TO THEIR TAXABLE COUNTERPARTS WHERE PROFITABILITY OFTEN DRIVES DECISIONS ABOUT PATIENT CARE SERVICES THAT ARE OFFERED. PATIENT CARE PROVIDED BY TAX-EXEMPT HOSPITALS THAT RESULTS IN MEDICARE SHORTFALLS SHOULD BE CONSIDERED AS PROVIDING A BENEFIT TO THE COMMUNITY AND RELIEVING THE BURDENS OF GOVERNMENT. PART III, LINE 9B: AT THE TIME OF PATIENT REGISTRATION, NON-ELECTIVE SELF-PAY PATIENTS ARE INFORMED OF THE MINIMUM DISCOUNT AVAILABLE UNDER THE FILING ORGANIZATION'S SELF-PAY DISCOUNT POLICY. SUCH PATIENTS ARE ALSO INFORMED OF THE FILING ORGANIZATION'S CHARITY CARE POLICY AND TOLD THAT THEY WILL BE REQUIRED TO SUBMIT NECESSARY FINANCIAL DATA IN ORDER TO POTENTIALLY RECEIVE ANY ADDITIONAL DISCOUNTS. UNDER THE FILING ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, PERCENTAGE DISCOUNTS ARE APPLIED TO A PATIENT'S ACCOUNT BASED UPON AMOUNTS GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE COVERING SUCH CARE.UNDER THE FILING ORGANIZATION'S POLICIES, PAYMENT PLANS FOR PARTIAL CHARITY ACCOUNTS WILL BE INDIVIDUALLY DEVELOPED WITH THE PATIENT. PARTIAL CHARITY ACCOUNTS RESULT WHEN A FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION ALLOWS FOR A PERCENTAGE REDUCTION BUT LEAVES THE PATIENT WITH A SELF-PAY BALANCE. IF THE PATIENT COMPLIES WITH THE AGREED-UPON PAYMENT PLAN, THE FILING ORGANIZATION DOES NOT PURSUE ANY COLLECTION ACTION WITH RESPECT TO THE PATIENT. HOWEVER, IF A PATIENT DOES NOT MAKE ANY PAYMENTS FOR THREE CONSECUTIVE MONTHS, THE ACCOUNT MAY BE REFERRED FOR FURTHER COLLECTION ACTIVITY. THE FILING ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS FROM PATIENTS DETERMINED TO QUALIFY FOR A 100% REDUCTION IN CHARGES UNDER ITS CHARITY CARE POLICY. PART III, LINE 2: THE AMOUNT OF BAD DEBT EXPENSE, REPORTED ON LINE 2 OF SECTION A OF PART III IS RECORDED IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15. DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS ARE RECORDED AS ADJUSTMENTS TO REVENUE, NOT BAD DEBT EXPENSE. PART III, LINE 3: METHODOLOGY FOR DETERMINING THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE THAT MAY REPRESENT PATIENTS WHO COULD HAVE QUALIFIED UNDER THE FILING ORGANIZATION'S CHARITY CARE POLICY:SELF-PAY PATIENTS ARE REQUIRED TO COMPLETE A PATIENT FINANCIAL ASSISTANCE APPLICATION SHORT FORM (PFAA). IF THE PFAA IS NOT COMPLETED AFTER REASONABLE ATTEMPTS TO OBTAIN IT ARE EXHAUSTED, PATIENT INFORMATION IS PROCESSED THROUGH A SCORER PRODUCT. THE SCORER PRODUCT UTILIZES PUBLICLY AVAILABLE DATA, SUCH AS CREDIT REPORTS, TO ASSESS AN INDIVIDUAL PATIENT'S FINANCIAL VIABILITY. PATIENTS WHO EARN A CERTAIN SCORE ON THE SCORER PRODUCT ARE CONSIDERED TO QUALIFY AS NON-STATE CHARITY PATIENTS. AN AMOUNT UP TO $1,000 OF SUCH A PATIENT'S BILL IS WRITTEN OFF AS BAD DEBT EXPENSE, WHILE THE REMAINING PORTION OF THE PATIENT'S BILL IS CONSIDERED TO BE NON-STATE CHARITY. THE AMOUNT WRITTEN OFF AS BAD DEBT EXPENSE FOR THOSE PATIENTS WHO POTENTIALLY QUALIFY AS NON-STATE CHARITY USING THE SCORER PRODUCT IS THE AMOUNT SHOWN ON LINE 3 OF SECTION A OF PART III. RATIONALE FOR INCLUDING CERTAIN BAD DEBTS IN COMMUNITY BENEFIT:THE FILING ORGANIZATION IS DEDICATED TO THE VIEW THAT MEDICALLY NECESSARY HEALTH CARE FOR EMERGENCY AND NON-ELECTIVE PATIENTS SHOULD BE ACCESSIBLE TO ALL, REGARDLESS OF AGE, GENDER, GEOGRAPHIC LOCATION, CULTURAL BACKGROUND, PHYSICIAN MOBILITY, OR ABILITY TO PAY. THE FILING ORGANIZATION TREATS EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF THEIR ABILITY TO PAY OR THE AVAILABILITY OF THIRD-PARTY COVERAGE. BY PROVIDING HEALTH CARE TO ALL WHO REQUIRE EMERGENCY OR NON-ELECTIVE CARE IN A NON-DISCRIMINATORY MANNER, THE FILING ORGANIZATION IS PROVIDING HEALTH CARE TO THE BROAD COMMUNITY IT SERVES. AS A 501(C)(3) HOSPITAL ORGANIZATION, THE FILING ORGANIZATION MAINTAINS A 24/7 EMERGENCY ROOM PROVIDING CARE TO ALL WHOM PRESENT. WHEN A PATIENT'S ARRIVAL AND/OR ADMISSION TO THE FACILITY BEGINS WITHIN THE EMERGENCY DEPARTMENT, TRIAGE AND MEDICAL SCREENING ARE ALWAYS COMPLETED PRIOR TO REGISTRATION STAFF PROCEEDING WITH THE DETERMINATION OF A PATIENT'S SOURCE OF PAYMENT. IF THE PATIENT REQUIRES ADMISSION AND CONTINUED NON-ELECTIVE CARE, THE FILING ORGANIZATION PROVIDES THE NECESSARY CARE REGARDLESS OF THE PATIENT'S ABILITY TO PAY. THE FILING ORGANIZATION'S OPERATION OF A 24/7 EMERGENCY DEPARTMENT THAT ACCEPTS ALL INDIVIDUALS IN NEED OF CARE PROMOTES THE HEALTH OF THE COMMUNITY THROUGH THE PROVISION OF CARE TO ALL WHOM PRESENT. CURRENT INTERNAL REVENUE SERVICE GUIDANCE THAT TAX-EXEMPT HOSPITALS MAINTAIN SUCH EMERGENCY ROOMS WAS ESTABLISHED TO ENSURE THAT EMERGENCY CARE WOULD BE PROVIDED TO ALL WITHOUT DISCRIMINATION. THE TREATMENT OF ALL AT THE FILING ORGANIZATION'S EMERGENCY DEPARTMENT IS A COMMUNITY BENEFIT. UNDER THE FILING ORGANIZATION'S CHARITY CARE POLICY, EVERY EFFORT IS MADE TO OBTAIN A PATIENT'S NECESSARY FINANCIAL INFORMATION TO DETERMINE ELIGIBILITY FOR CHARITY CARE. HOWEVER, NOT ALL PATIENTS WILL COOPERATE WITH SUCH EFFORTS AND A CHARITY CARE ELIGIBILITY DETERMINATION CAN NOT BE MADE. IN THIS CASE, A PATIENT'S PORTION OF A BILL THAT REMAINS UNPAID FOR A CERTAIN STIPULATED TIME PERIOD IS WHOLLY OR PARTIALLY CLASSIFIED AS BAD DEBT. BAD DEBTS ASSOCIATED WITH PATIENTS WHO HAVE RECEIVED CARE THROUGH THE FILING ORGANIZATION'S EMERGENCY DEPARTMENT SHOULD BE CONSIDERED TO BE COMMUNITY BENEFIT AS CHARITABLE HOSPITALS EXIST TO PROVIDE SUCH CARE IN PURSUIT OF THEIR PURPOSE OF MEETING THE NEED FOR EMERGENCY MEDICAL CARE SERVICES AVAILABLE TO ALL IN THE COMMUNITY. PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE RELATED TO ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS:THE FINANCIAL INFORMATION OF THE FILING ORGANIZATION IS INCLUDED IN A CONSOLIDATED AUDITED FINANCIAL STATEMENT FOR THE CURRENT YEAR.THE APPLICABLE FOOTNOTE FROM THE ATTACHED CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ADDRESSES ACCOUNTS RECEIVABLE, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS, AND THE PROVISION FOR BAD DEBTS CAN BE FOUND ON PAGES 6 AND 7. SUPPLEMENTAL SCHEDULE TO SCHEDULE H, PART III, SECTION B RECONCILIATION OF SCHEDULE H REPORTED MEDICARE SURPLUS/(SHORTFALL) TO UNREIMBURSED MEDICARE COSTS ASSOCIATED WITH THE PROVISION OF SERVICESTO ALL MEDICARE BENEFICIARIES:THE MEDICARE REVENUE AND ALLOWABLE COSTS OF CARE REPORTED IN SECTION B OF PART III OF SCHEDULE H ARE BASED UPON THE AMOUNTS REPORTED IN THE FILING ORGANIZATION'S MEDICARE COST REPORT IN ACCORDANCE WITH THE IRS INSTRUCTIONS FOR SCHEDULE H. ON AN ANNUAL BASIS, THE FILING ORGANIZATION ALSO DETERMINES ITS TOTAL UNREIMBURSED COSTS ASSOCIATED WITH PROVIDING SERVICES TO ALL MEDICARE PATIENTS. UNREIMBURSED COSTS ARE REPORTED AS A COMMUNITY BENEFIT TO THE ELDERLY. THE PRIMARY RECONCILING ITEMS BETWEEN THE MEDICARE SURPLUS/(SHORTFALL) SHOWN ON LINE 7 OF SECTION B OF PART III OF SCHEDULE H AND THE FILING ORGANIZATION'S UNREIMBURSED COSTS OF SERVICES PROVIDED TO MEDICARE PATIENTS ARE AS FOLLOWS:- MEDICARE SURPLUS/(SHORTFALL) SHOWN ON LINE 7 OF SECTION B OF SCHEDULE H: $ (367,903)- DIFFERENCE IN COSTING METHODOLOGY: (145,087)- UNREIMBURSED COSTS INCURRED FOR SERVICES PROVIDED TO MEDICARE PATIENTS THAT ARE NOT INCLUDED IN THE ORGANIZATION'S MEDICARE COST REPORT: (4,325,364) -------------TOTAL UNREIMBURSED COSTS OF SERVING ALL MEDICARE PATIENTS: $(4,838,354) AS INDICATED ABOVE, THE PRIMARY DIFFERENCES BETWEEN THE MEDICARE SURPLUS/(SHORTFALL) REPORTED ON SCHEDULE H, PART III, SECTION B, LINE 7 AND THE FILING ORGANIZATION'S DETERMINATION OF UNREIMBURSED COSTS REPORTED AS A BENEFIT TO THE ELDERLY IS DUE TO A DIFFERENCE IN THE COSTING METHODOLOGY AND DIFFERENCES IN THE POPULATION OF MEDICARE PATIENTS WITHIN THE CALCULATION. THE COST METHODOLOGY UTILIZED IN CALCULATING ANY MEDICARE SURPLUS/(SHORTFALL) FOR PURPOSES OF THE ANNUAL COMMUNITY BENEFIT REPORTING IS BASED UPON THE COST-TO-CHARGE RATIO OUTLINED IN WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. THE SAME COST-TO-CHARGE RATIO IS USED TO DETERMINE THE COSTS ASSOCIATED WITH SERVICES PROVIDED TO CHARITY CARE PATIENTS AND MEDICAID PATIENTS AS REPORTED IN SCHEDULE H, PART I, LINE 7. IN ADDITION, THE MEDICARE COST REPORT EXCLUDES SERVICES PROVIDED TO MEDICARE PATIENTS FOR PHYSICIAN SERVICES, SERVICES PROVIDED TO PATIENTS ENROLLED IN MEDICARE HMOS, AND CERTAIN SERVICES PROVIDED BY OUTPATIENT DEPARTMENTS OF THE FILING ORGANIZATION THAT ARE REIMBURSED ON A FEE SCHEDULE. THE COMPANY'S OWN COMMUNITY BENEFIT STATEMENT CAPTURES THE UNREIMBURSED COST OF PROVIDING SERVICES TO ALL MEDICARE BENEFICIARIES THROUGHOUT THE ORGANIZATION. TEXAS HEALTH HUGULEY HOSPITAL PART V, SECTION B, LINE 14G: THE FILING ORGANIZATION HAS DEVELOPED A PATIENT-FRIENDLY SUMMARY VERSION OF ITS FINANCIAL ASSISTANCE POLICY (FAP). THE FILING ORGANIZATION'S FAP PROVIDES THAT ITS HOSPITAL FACILITY WILL POST THE PATIENT-FRIENDLY SUMMARY VERSION OF ITS FAP ON THE HOSPITAL'S WEBSITE. IN ADDITION, THE FAP OF THE HOSPITAL FACILITY STATES THAT SIGNAGE REGARDING THE AVAILABILITY OF THE HOSPITAL FACILITY'S FAP WILL BE VISIBLE AT POINTS OF ADMISSION AND REGISTRATION, INCLUDING THE EMERGENCY DEPARTMENT. TEXAS HEALTH HUGULEY HOSPITAL PART V, SECTION B, LINE 20D: IN DETERMINING THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO FINANCIAL ASSISTANCE POLICY-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE, THE HOSPITAL USES THE FOLLOWING METHODOLOGY:THE HOSPITAL IDENTIFIES ALL COMMERCIAL PAYORS WHOSE VOLUME OF ACTIVITY WITH THE HOSPITAL EQUALS OR EXCEEDS $100,000 FOR THE TAXABLE YEAR. FOR THOSE IDENTIFIED COMMERCIAL PAYORS, AN AVERAGE OF THE NEGOTIATED COMMERCIAL INSURANCE RATES IS DETERMINED. THE AVERAGE OF ALL OF THE NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE IDENTIFIED COMMERCIAL PAYORS DETERMINES THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: IN ACCORDANCE WITH IRC SECTION 501(R)(3), THE FILING ORGANIZATION HAS ADOPTED AND IMPLEMENTED A POLICY THAT SETS FORTH THE GENERAL REQUIREMENTS, PROCESSES AND PROCEDURES WITH RESPECT TO CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT AND ASSOCIATED IMPLEMENTATION STRATEGY. DURING 2012, THE FILING ORGANIZATION WAS IN THE PROCESS OF PLANNING FOR THEIR INITIAL COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) THAT IS TO BE COMPLETED BY 12/31/2013. IN ADDITION TO THE CHNA THAT IS BEING CONDUCTED, A VARIETY OF PRACTICES AND PROCESSES ARE IN PLACE TO ENSURE THAT THE FILING ORGANIZATION IS RESPONSIVE TO THE HEALTH NEEDS OF ITS COMMUNITY. SUCH PRACTICES AND PROCESSES INVOLVE THE FOLLOWING:1. A HOSPITAL OPERATING/COMMUNITY BOARD COMPOSED OF INDIVIDUALS BROADLY REPRESENTATIVE OF THE COMMUNITY, COMMUNITY LEADERS, AND THOSE WITH SPECIALIZED MEDICAL TRAINING AND EXPERTISE;2. POST-DISCHARGE PATIENT FOLLOW-UP RELATED TO THE ON-GOING CARE AND TREATMENT OF PATIENTS WHO SUFFER FROM CHRONIC DISEASES; 3. SPONSORSHIP AND PARTICIPATION IN COMMUNITY HEALTH AND WELLNESS ACTIVITIES THAT REACH A BROAD SPECTRUM OF THE FILING ORGANIZATIONS COMMUNITY; AND 4. COLLABORATION WITH OTHER LOCAL COMMUNITY GROUPS TO ADDRESS THE HEALTH CARE NEEDS OF THE FILING ORGANIZATIONS COMMUNITY. PART VI, LINE 3: THE FILING ORGANIZATION HAS A PROCESS IN PLACE WHEREBY PATIENTS ARE INFORMED ABOUT THE HOSPITAL'S CHARITY CARE POLICY AND OTHER FORMS OF FINANCIAL ASSISTANCE, SUCH AS SELF-PAY DISCOUNTS. SIGNAGE IS POSTED IN THE EMERGENCY ROOM INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE FOR THOSE SELF-PAY PATIENTS MEETING ELIGIBILITY REQUIREMENTS. AFTER EMTALA MEDICAL SCREENING AND STABILIZATION REQUIREMENTS ARE MET, REGISTRATION PERSONNEL WILL SECURE FINANCIAL INFORMATION ON AS MANY SELF-PAY PATIENTS AS POSSIBLE AT THE TIME OF SERVICE. FOR THOSE WHO APPEAR TO QUALIFY FOR MEDICAID OR UNDER THE HOSPITAL'S CHARITY CARE POLICY, THE FINANCIAL COUNSELORS WILL CONTINUE TO WORK WITH THOSE PATIENTS UNTIL FINAL ACCOUNT RESOLUTION IS ACHIEVED. ALL OTHER SELF-PAY PATIENTS ARE COVERED UNDER THIS PROCESS. AT ANY TIME DURING THE PROCESS THAT DATA IS PROVIDED SHOWING THAT A PATIENT QUALIFIES FOR ASSISTANCE UNDER THE CHARITY CARE POLICY THE DISCOUNTS EXTENDED UNDER THAT POLICY WILL BE APPLIED.AS PART OF THE BILLING PROCESS, THE HOSPITAL INCLUDES THE APPLICATION FOR CHARITY CARE ASSISTANCE ALONG WITH THE INITIAL PATIENT BILL. THE HOSPITAL'S CHARITY CARE APPLICATION IS ALSO AVAILABLE TO PATIENTS ON THE HOSPITAL'S WEB-SITE IN BOTH AN ENGLISH AND SPANISH VERSION. ADDITIONALLY, THE HOSPITAL'S FINANCIAL COUNSELORS ARE AVAILABLE TO WORK WITH EVERY PATIENT DURING THE FIRST 120 DAYS OF THE BILLING PROCESS TO ASSIST THE PATIENT WITH COMPLETING CHARITY CARE APPLICATIONS AND INVESTIGATING OTHER POTENTIAL SOURCES OF THIRD-PARTY ASSISTANCE. THE DETERMINATION OF A PATIENT'S ELIGIBILITY FOR CHARITY CARE IS MADE ON A CASE-BY-CASE BASIS. VARIOUS FACTORS ARE CONSIDERED IN THAT DETERMINATION. EACH INDIVIDUAL PATIENT WHO IS IDENTIFIED AS POTENTIALLY BEING ELIGIBLE TO RECEIVE CHARITY CARE IS SEEN BY A FINANCIAL COUNSELOR AT THE HOSPITAL. THE FINANCIAL COUNSELOR WILL WORK WITH THE PATIENT TO MAKE SURE THAT OTHER SOURCES OF ASSISTANCE (PUBLIC OR OTHERWISE) HAVE BEEN SOUGHT TO THE FULLEST EXTENT POSSIBLE. WHEN OTHER FORMS OF ASSISTANCE ARE NOT AVAILABLE OR HAVE BEEN EXHAUSTED, THE HOSPITAL WILL GATHER CERTAIN FINANCIAL INFORMATION FROM THE PATIENT TO DETERMINE THE PATIENT'S ABILITY TO PAY BASED UPON LEVEL OF INCOME. PART VI, LINE 4: THE FILING ORGANIZATION CURRENTLY OPERATES TEXAS HEALTH HUGULEY (THH) A 223-BED ACUTE-CARE HOSPITAL IN BURLESON, TEXAS. THE HOSPITAL HOUSES TWO INTENSIVE CARE UNITS, A PROGRESSIVE CARE UNIT, AN OPEN-HEART SURGERY CENTER, A BEHAVIORAL HEALTH CENTER AND A 24/7 EMERGENCY DEPARTMENT. THH HAS A 16-BED INTENSIVE CARE UNIT FOR PATIENTS WITH MEDICAL CARE AND RESPIRATORY NEEDS AND A 12-BED INTENSIVE CARE UNIT CONCENTRATING ON CARDIOVASCULAR PATIENTS. A 4-BED DIALYSIS CENTER IS AVAILABLE FOR RENAL PATIENTS WITH CRITICAL NEEDS. ADDITIONALLY, THERE IS A 33-BED PROGRESSIVE CARE UNIT DESIGNED TO BRIDGE THE GAP BETWEEN THE INTENSIVE CARE UNIT AND THE MEDICAL-SURGICAL UNITS. PART OF THH'S PRIMARY SERVICE AREA INCLUDES A NUMBER OF SMALLER COMMUNITIES WITH LIMITED ACCESS TO HEALTHCARE SERVICES. TO MEET THE NEEDS OF THESE RESIDENTS, THH HAS A SUBSIDIARY THAT OPERATES MULTIPLE PRIMARY CARE CLINICS THROUGHOUT ITS PRIMARY SERVICE AREA. IN ADDITION, THE MOBILE HEALTH SERVICES BUS PROVIDES HEALTH SCREENINGS AND WELLNESS EDUCATION SERVICES THROUGHOUT TARRANT AND JOHNSON COUNTIES. BURLESON, TEXAS IS LOCATED IN JOHNSON COUNTY AND SERVES THE SOUTH FORT WORTH AREA. THE HOSPITAL'S PRIMARY MARKET HAS A POPULATION OF APPROXIMATELY 212,000, WITH AN ESTIMATED 25,000 OVER THE AGE OF 65. THE WEIGHTED AVERAGE HOUSEHOLD INCOME, BASED ON POPULATION, IN THE PRIMARY MARKET IS APPROXIMATELY $53,000. HIGH SCHOOL GRADUATES ACCOUNT FOR APPROXIMATELY 82% OF JOHNSON COUNTY, WITH AN ESTIMATED 16% HAVING A BACHELOR'S DEGREE OR HIGHER. IT IS ESTIMATED THAT 11% OF THE INDIVIDUALS RESIDING IN JOHNSON COUNTY LIVE BELOW THE POVERTY LEVEL AND THE UNEMPLOYMENT RATE IS ABOUT 8%. APPROXIMATELY 31% OF THE HOSPITAL'S PATIENTS DURING 2012 WERE MEDICARE PATIENTS, ABOUT 2.7% WERE MEDICAID PATIENTS, ABOUT 10.5% WERE SELF-PAY PATIENTS AND THE REMAINING PERCENTAGE WERE PATIENTS COVERED UNDER COMMERCIAL INSURANCE. IN 2012, ABOUT 15.3% OF THE HOSPITAL'S IN-PATIENTS WERE ADMITTED THROUGH THE HOSPITAL'S EMERGENCY DEPARTMENT. PART VI, LINE 5: THE PROVISION OF COMMUNITY BENEFIT IS CENTRAL TO THE FILING ORGANIZATION'S MISSION OF SERVICE AND COMPASSION. RESTORING AND PROMOTING THE HEALTH AND QUALITY OF LIFE OF THOSE IN THE COMMUNITIES SERVED BY THE FILING ORGANIZATION IS A FUNCTION OF "EXTENDING THE HEALING MINISTRY OF CHRIST" AND EMBODIES THE FIING ORGANIZATION'S COMMITMENT TO ITS VALUES AND PRINCIPLES. THE FILING ORGANIZATION COMMITS SUBSTANTIAL RESOURCES TO PROVIDE A BROAD RANGE OF SERVICES TO BOTH THE UNDERPRIVILEGED AS WELL AS THE BROADER COMMUNITY. IN ADDITION TO THE COMMUNITY BENEFIT INFORMATION PROVIDED IN PARTS I, II AND III OF THIS SCHEDULE H, THE HOSPITAL CAPTURES AND REPORTS THE BENEFITS PROVIDED TO ITS COMMUNITY THROUGH FAITH-BASED CARE. EXAMPLES OF SUCH BENEFITS INCLUDE THE COST ASSOCIATED WITH CHAPLAINCY CARE PROGRAMS AND MISSION PEER REVIEWS AND MISSION CONFERENCES. DURING THE CURRENT YEAR, THE FILING ORGANIZATION PROVIDED $141,009 OF BENEFIT WITH RESPECT TO THE FAITH-BASED AND SPIRITUAL NEEDS OF THE COMMUNITY. THE FILING ORGANIZATION ALSO PROVIDES BENEFITS TO ITS COMMUNITY'S INFRASTRUCTURE BY INVESTING IN CAPITAL IMPROVEMENTS TO ENSURE THAT FACILITIES AND TECHNOLOGY PROVIDE THE BEST POSSIBLE CARE TO THE COMMUNITY. DURING THE CURRENT YEAR, THE FILING ORGANIZATION EXPENDED $2,724,660 IN NEW CAPITAL IMPROVEMENTS. AS A FAITH-BASED MISSION-DRIVEN COMMUNITY HOSPITAL, THE FILING ORGANIZATION IS CONTINUALLY INVOLVED IN MONITORING ITS COMMUNITY, IDENTIFYING UNMET HEALTH CARE NEEDS AND DEVELOPING SOLUTIONS AND PROGRAMS TO ADDRESS THOSE NEEDS. IN ACCORDANCE WITH ITS CONSERVATIVE APPROACH TO FISCAL RESPONSIBILITY, SURPLUS FUNDS OF THE HOSPITAL ARE CONTINUALLY BEING INVESTED IN RESOURCES THAT IMPROVE THE AVAILABILITY AND QUALITY OF DELIVERY OF HEALTH CARE SERVICES AND PROGRAMS TO ITS COMMUNITY. PART VI, LINE 6: AS EXPLAINED IN OUR RESPONSE TO FORM 990, PART VI, SECTION A, LINE 6, TEXAS HEALTH HUGULEY, INC. (THH OR THE HOSPITAL) HAS TWO MEMBERS. THE MEMBERS ARE TEXAS HEALTH RESOURCES AND ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI). AHSSI IS A WHOLLY-OWNED SUBSIDIARY OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION. THH IS ABLE TO DRAW UPON THE EXPERTISE AND LEADERSHIP OF BOTH ITS HEALTH SYSTEM MEMBERS IN ITS EFFORT TO CREATE EXCELLENT PATIENT EXPERIENCES AND OFFER A BROAD SPECTRUM OF HEALTH SERVICES NEEDED IN ITS COMMUNITY.DURING ITS CURRENT TAX YEAR, THH WAS MANAGED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). AHSSHC IS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). AHSSHC AND ITS SUBSIDIARY ORGANIZATIONS OPERATE 43 HOSPITALS IN 10 STATES THROUGHOUT THE U.S., PRIMARILY IN THE SOUTHEASTERN PORTION OF THE U.S. AHSSHC AND ITS SUBSIDIARIES ALSO OPERATE 16 NURSING HOME FACILITIES AND OTHER ANCILLARY HEALTH CARE PROVIDER FACILITIES, SUCH AS AMBULATORY SURGERY CENTERS AND DIAGNOSTIC IMAGING CENTERS. PURSUANT TO A MANAGEMENT SERVICES AGREEMENT, AHSSHC PROVIDES MANAGEMENT AND CERTAIN CONSULTING SERVICES TO TEXAS HEALTH HUGULEY. MANAGEMENT AND CONSULTING SERVICES INCLUDE PERSONNEL ADMINISTRATION, PROCUREMENT, HEALTH INFORMATION MANAGEMENT, MAINTENANCE AND SECURITY, CONTRACTS, FINANCIAL ACCOUNTING SYSTEMS AND BUDGET DEVELOPMENT.THE READER OF THIS FORM 990 SHOULD KEEP IN MIND THAT THIS REPORTING ENTITY MAY DIFFER IN CERTAIN AREAS FROM THAT OF A STAND-ALONE HOSPITAL ORGANIZATION DUE TO ITS MANAGEMENT BY AHSSHC. THE FILING ORGANIZATION BENEFITS FROM REDUCED COSTS DUE TO ITS AFFILIATION WITH AHSSHC, SUCH AS LARGE GROUP PURCHASING DISCOUNTS, AND THE AVAILABILITY OF INTERNAL RESOURCES SUCH AS INTERNAL LEGAL COUNSEL. TEXAS HEALTH HUGULEY PAYS A MANAGEMENT FEE TO AHSSHC FOR THE MANAGEMENT SERVICES PROVIDED BY AHSSHC. AS A RESULT, MANAGEMENT FEE EXPENSE REPORTED BY TEXAS HEALTH HUGULEY MAY APPEAR GREATER IN RELATION TO MANAGEMENT FEE EXPENSE THAT MAY BE REPORTED BY A SINGLE STAND-ALONE HOSPITAL WITH NO SUCH AFFILIATION. THE SINGLE STAND-ALONE HOSPITAL WOULD LIKELY REPORT COSTS ASSOCIATED WITH MANAGEMENT AND OTHER PROFESSIONAL SERVICES ON VARIOUS EXPENSE LINE ITEMS IN ITS STATEMENT OF REVENUE AND EXPENSE AS OPPOSED TO REPORTING SUCH COSTS IN ONE OVERALL MANAGEMENT FEE EXPENSE. REPORTS FILED WITH STATES PART VI, LINE 7 TX 1 AMERICAN CANCER SOCIETY INC HIGH PLAINS DIVISION INC 2433 RIDGEPOINT DRIVE AUSTIN TX 78754 741185665 501(C)(3) 10000 GENERAL SUPPORT BURLESON AREA CHAMBER OF COMMERCE 1044 SW WILSHIRE BLVD BURLESON TX 76028 751228140 501(C)(6) 10000 GENERAL SUPPORT 1 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTS ARE GENERALLY MADE ONLY TO AFFILIATED ORGANIZATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAX UNDER 501(C)(3) AND TO OTHER LOCAL CHARITABLE ORGANIZATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAX UNDER 501(C)(3). ACCORDINGLY, THE FILING ORGANIZATION HAS NOT ESTABLISHED SPECIFIC PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE UNITED STATES AS THE FILING ORGANIZATION DOES NOT HAVE A GRANT MAKING PROGRAM THAT WOULD NECESSITATE SUCH PROCEDURES. X X X 1 1 0 1 0 0 0 0 0 0 0 BARCLAY BERDAN 0 588928 0 337234 0 163657 0 91374 0 23296 0 1204489 0 140760 RICHARD REINER 0 871778 0 266769 0 543345 0 13599 0 48831 0 1744322 0 0 HAROLD BERENZWEIG MD 0 366476 0 81748 0 76628 0 68470 0 16092 0 609414 0 0 RONALD LONG 0 524123 0 299659 0 111729 0 77123 0 25324 0 1037958 0 132681 JOSEPH PROSSER MD 0 337460 0 82343 0 42559 0 15000 0 14210 0 491572 0 1728 PAUL RATHBUN 0 528184 0 153327 0 107466 0 103021 0 33550 0 925548 0 52800 TL TRIMBLE 0 418461 0 126907 0 88248 0 84740 0 12871 0 731227 0 65078 KENNETH FINCH 0 429336 0 139875 0 159361 0 84366 0 33054 0 845992 0 51610 PENNY JOHNSON 0 263268 0 73305 0 50318 0 36337 0 31811 0 455039 0 0 PART I, LINE 1A AS DISCUSSED IN OUR RESPONSE TO SECTION B, PART VI, QUESTION 15A & B, THE FILING ORGANIZATION IS 49% OWNED BY ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI). AHSSI IS PART OF THE SYSTEM OF HEALTHCARE ORGANIZATIONS KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). THE FILING ORGANIZATION IS MANAGED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC), THE PARENT ORGANIZATION OF AHSSI. IN CONJUNCTION WITH THE MANAGEMENT AGREEMENT WITH AHSSHC, MEMBERS OF THE FILING ORGANIZATION'S EXECUTIVE MANAGEMENT TEAM THAT HOLD THE POSITION OF VICE-PRESIDENT OR ABOVE ARE COMPENSATED BY AND ON THE PAYROLL OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC), THE PARENT ORGANIZATION OF AHS. AHSSHC IS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). THE FILING ORGANIZATION REIMBURSES AHSSHC FOR THE SALARY AND BENEFIT COST OF THOSE EXECUTIVES ON THE PAYROLL OF AHSSHC THAT PROVIDE SERVICES AND ARE ON THE MANAGEMENT TEAM OF THE FILING ORGANIZATION. TRAVEL FOR COMPANIONS: AHSSHC HAS A CORPORATE EXECUTIVE POLICY THAT PROVIDES A BENEFIT TO ALLOW FOR A TRAVELING AHSSHC EXECUTIVE TO HAVE HIS OR HER SPOUSE ACCOMPANY THE EXECUTIVE ON CERTAIN BUSINESS TRIPS EACH YEAR. TYPICALLY, REIMBURSEMENT IS ONLY PROVIDED TO VICE PRESIDENTS AND ABOVE AND IS USUALLY LIMITED TO ONE BUSINESS TRIP PER YEAR BEYOND THE ANNUAL AHS PRESIDENT'S COUNCIL BUSINESS MEETING AND OTHER MEETINGS WHERE THE SPOUSE IS SPECIFICALLY INVITED. THE AHSSHC CORPORATE EXECUTIVE SPOUSAL TRAVEL POLICY WAS ORIGINALLY APPROVED AND REVIEWED BY THE AHSSHC BOARD STRATEGY & COMPENSATION COMMITTEE, AN INDEPENDENT BODY OF THE AHSSHC BOARD OF DIRECTORS. ALL SPOUSAL TRAVEL COSTS REIMBURSED TO THE EXECUTIVE ARE CONSIDERED TAXABLE COMPENSATION TO THE EXECUTIVE. TAX INDEMNIFICATION AND GROSS-UP PAYMENTS: AHS HAS A SYSTEM-WIDE POLICY ADDRESSING GROSS-UP PAYMENTS PROVIDED IN CONNECTION WITH EMPLOYER-PROVIDED BENEFITS/OTHER TAXABLE ITEMS. UNDER THE POLICY, CERTAIN TAXABLE BUSINESS-RELATED REIMBURSEMENTS (I.E. TAXABLE BUSINESS-RELATED MOVING EXPENSES, TAXABLE ITEMS PROVIDED IN CONNECTION WITH EMPLOYMENT) PROVIDED TO ANY EMPLOYEE MAY BE GROSSED-UP AT A 25% RATE UPON APPROVAL OF THE FILING ORGANIZATION'S CEO AND CFO. ADDITIONALLY, EMPLOYEES AT THE DIRECTOR LEVEL AND ABOVE ARE ELIGIBLE FOR GROSS-UP PAYMENTS ON GIFTS RECEIVED FOR BOARD OF DIRECTOR SERVICES. DISCRETIONARY SPENDING ACCOUNT: A NOMINAL DISCRETIONARY SPENDING AMOUNT WAS PROVIDED IN THE CURRENT YEAR TO ALL ELIGIBLE EXECUTIVES WHO ATTEND THE ANNUAL AHS PRESIDENT'S COUNCIL BUSINESS MEETING ($500 PER EXECUTIVE) OR THE ANNUAL AHS CFO CONFERENCE BUSINESS MEETING ($300 PER EXECUTIVE). WITH RESPECT TO THE AHS PRESIDENT'S COUNCIL MEETING, ELIGIBLE EXECUTIVES MAY INCLUDE AHSSHC VICE PRESIDENTS AND ABOVE AND ALL AHSSHC SUBSIDIARY ORGANIZATION CEOS AND REGIONAL CFOS. THE PAYMENT PROVIDED TO EACH EXECUTIVE WAS CONSIDERED TAXABLE COMPENSATION TO THE EXECUTIVE. PART I, LINE 4B AS DISCUSSED IN LINE 1A ABOVE, EXECUTIVES ON THE FILING ORGANIZATION'S MANAGEMENT TEAM THAT HOLD THE POSITION OF VICE-PRESIDENT OR ABOVE ARE COMPENSATED BY AND ON THE PAYROLL OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC), THE PARENT ORGANIZATION OF A HEALTHCARE SYSTEM KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). IN ADDITION, 3 OF THE INDIVIDUALS LISTED ON PART VII AS BOARD MEMBERS (RICHARD REINER, PAUL RATHBUN, AND TAMARA TRIMBLE) HOLD EXECUTIVE POSITIONS AND ARE ON THE PAYROLL OF AHSSHC. IN RECOGNITION OF THE CONTRIBUTION THAT EACH EXECUTIVE MAKES TO THE SUCCESS OF AHS, AHS PROVIDES TO ELIGIBLE EXECUTIVES PARTICIPATION IN THE AHS EXECUTIVE FLEX BENEFIT PROGRAM (THE PLAN). THE PURPOSE OF THE PLAN IS TO OFFER ELIGIBLE EXECUTIVES AN OPPORTUNITY TO ELECT FROM AMONG A VARIETY OF SUPPLEMENTAL BENEFITS, INCLUDING DEFERRED COMPENSATION BENEFITS TAXABLE UNDER INTERNAL REVENUE CODE (IRC) SECTION 457(F), TO INDIVIDUALLY TAILOR A BENEFITS PROGRAM APPROPRIATE TO EACH EXECUTIVE'S NEEDS. THE PLAN PROVIDES ELIGIBLE PARTICIPANTS A PRE-DETERMINED BENEFITS ALLOWANCE CREDIT THAT IS EQUAL TO A PERCENTAGE OF THE EXECUTIVE'S BASE PAY FROM WHICH IS DEDUCTED THE COST OF MANDATORY AND ELECTIVE EMPLOYEE BENEFITS. THE PRE-DETERMINED BENEFITS ALLOWANCE CREDIT PERCENTAGE IS APPROVED BY THE AHS BOARD STRATEGY & COMPENSATION COMMITTEE, AN INDEPENDENT COMMITTEE OF THE BOARD OF DIRECTORS OF AHSSHC. ANY FUNDS THAT REMAIN AFTER THE COST OF MANDATORY AND ELECTIVE BENEFITS ARE SUBTRACTED FROM THE ANNUAL PRE-DETERMINED BENEFITS ALLOWANCE ARE CONTRIBUTED, AT THE EMPLOYEE'S OPTION, TO EITHER AN IRC 457(F) DEFERRED COMPENSATION ACCOUNT OR TO AN IRC 457(B) ELIGIBLE DEFERRED COMPENSATION PLAN. UPON ATTAINMENT OF AGE 65, ALL PREVIOUS 457(F) DEFERRED AMOUNTS ARE PAID IMMEDIATELY TO THE PARTICIPANT AND ANY FUTURE EMPLOYER CONTRIBUTIONS ARE MADE QUARTERLY FROM THE PLAN DIRECTLY TO THE PARTICIPANT. THE PLAN DOCUMENTS DEFINE AN EMPLOYEE WHO IS ELIGIBLE TO PARTICIPATE IN THE PLAN TO GENERALLY INCLUDE THE CHIEF EXECUTIVE OFFICERS OF AHS ENTITIES AND VICE PRESIDENTS OF ALL AHS ENTITIES WHOSE BASE SALARY IS AT LEAST $210,000. THE PLAN PROVIDES FOR A CLASS YEAR VESTING SCHEDULE (2 YEARS FOR EACH CLASS YEAR) WITH RESPECT TO AMOUNTS ACCUMULATED IN THE EXECUTIVE'S 457(F) DEFERRED COMPENSATION ACCOUNT. DISTRIBUTIONS COULD ALSO BE MADE FROM THE EXECUTIVE'S 457(F) DEFERRED COMPENSATION ACCOUNT UPON ATTAINMENT OF AGE 65 OR UPON AN INVOLUNTARY SEPARATION. THE ACCOUNT IS FORFEITED BY THE EXECUTIVE UPON A VOLUNTARY SEPARATION. IN ADDITION TO THE PLAN, AHS HAS INSTITUTED A DEFINED BENEFIT, NON-TAX-QUALIFIED DEFERRED COMPENSATION PLAN FOR CERTAIN EXECUTIVES WHO HAVE PROVIDED LENGTHY SERVICE TO AHS AND/OR TO OTHER SEVENTH-DAY ADVENTIST CHURCH HOSPITALS OR HEALTH CARE INSTITUTIONS. PARTICIPATION IN THE PLAN IS OFFERED TO AHS EXECUTIVES ON A PRORATA SCHEDULE BEGINNING WITH 20 YEARS OF SERVICE AS AN EMPLOYEE OF AHS AND/OR ANOTHER HOSPITAL OR HEALTH CARE INSTITUTION CONTROLLED BY THE SEVENTH-DAY ADVENTIST CHURCH AND WHO SATISFY CERTAIN OTHER QUALIFYING CRITERIA. THIS SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) WAS DESIGNED TO PROVIDE ELIGIBLE EXECUTIVES WITH THE ECONOMIC EQUIVALENT OF AN ANNUAL INCOME BEGINNING AT NORMAL RETIREMENT AGE EQUAL TO 60% OF THE AVERAGE OF THE PARTICIPANT'S THREE, FIVE OR SEVEN HIGHEST YEARS OF BASE SALARY FROM AHS ACTIVE EMPLOYMENT INCLUSIVE OF INCOME FROM ALL OTHER SEVENTH-DAY ADVENTIST CHURCH HEALTHCARE EMPLOYER-FINANCED RETIREMENT INCOME SOURCES AND INVESTMENT INCOME EARNED ON THOSE CONTRIBUTIONS THROUGH SOCIAL SECURITY NORMAL RETIREMENT AGE AS DEFINED IN THE PLAN. THE NUMBER OF YEARS INCLUDED IN HIGHEST AVERAGE COMPENSATION IS DETERMINED BY THE INDIVIDUAL'S YEAR OF ENTRY TO THE SERP AND BY THE INDIVIDUAL'S YEAR OF ENTRY TO THE AHS EXECUTIVE FLEX BENEFIT PROGRAM. FLEX PLAN FLEX PLAN/ SERP 457(B) CY CY EMPLOYER CY CONTRIB./ DISTRIBUTIONS CONTRIB. DISTRIBUTIONS* PAYMENT ------------------------------------------------------- KENNETH FINCH $ 70,767 $ 57,487 $ 62,820 $0 PENNY JOHNSON $ 22,738 $ 0 $ 0 $0 PAUL RATHBUN $ 89,423 $ 53,175 $ 0 $0 RICHARD REINER $182,872 $167,651 $255,540 $0 T.L. TRIMBLE $ 71,141 $ 70,465 $ 0 $0 * INCLUDING INVESTMENT EARNINGS AS DISCUSSED IN OUR RESPONSE TO SECTION B, PART VI, QUESTION 15A & B, THE FILING ORGANIZATION IS 51% OWNED BY TEXAS HEALTH RESOURCES (THR). FOUR OF THE INDIVIDUALS LISTED ON PART VII AS BOARD MEMBERS (BARCLAY BERDAN, RONALD LONG, HAROLD BERENZWEIG, AND JOSEPH PROSSER) HOLD EXECUTIVE POSITIONS AND ARE ON THE PAYROLL OF THR. PARTICIPATION IN THR'S SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN IS MADE AVAILABLE TO A SELECT GROUP OF MANAGEMENT AND HIGHLY COMPENSATED EMPLOYEES, AS DETERMINED BY THE THR BOARD OF TRUSTEES, WHO ARE PROVIDING SERVICES TO AN EMPLOYER IN KEY POSITIONS OF MANAGEMENT AND RESPONSIBILITY. BENEFITS ARE CALCULATED FOR ELIGIBLE EMPLOYEES WHEN BASE PAY AND INCENTIVES EXCEED THE IRS QUALIFIED PLAN COMPENSATION LIMIT. SERP BENEFITS VEST WHILE THE PARTICIPANT IS EMPLOYED IF THE PARTICIPANT: REACHES AGE 65, BECOMES DISABLED, DIES, OR REACHES THE FOLLOWING YEARS OF SERVICE: 2 YEARS 25%; 3 YEARS -50%; 4 YEARS 75%; AND 5 OR MORE 100%. FOR FROZEN RESTORATION ACCOUNTS (ACCOUNT BALANCES PRIOR TO 1/1/2010), THE PARTICIPANT OR BENEFICIARY SHALL BE TAXED ON HIS OR HER VESTED SERP BENEFITS UPON THE EARLIEST OF: REMAINING EMPLOYED BY THR TO AGE 68 TERMINATION OF EMPLOYMENT FOR DISABILITY OR DEATH INVOLUNTARY TERMINATION OF EMPLOYMENT WITHOUT REASONABLE CAUSE; OR SATISFYING A 24 MONTH NON-COMPETE PERIOD FOLLOWING HIS OR HER TERMINATION OF EMPLOYMENT. PAYMENT IS MADE FOLLOWING THE BEFORE MENTIONED EVENTS, EXCEPT IN THE CASE OF INVOLUNTARY SEPARATIONS FOR WHICH THE PARTICIPANT MUST WAIT UNTIL AFTER 24 MONTHS TO RECEIVE THE PREVIOUSLY TAXED BENEFIT. FOR THE ACTIVE RESTORATION ACCOUNT (ACCOUNT BALANCES AFTER 12/31/2009) PARTICIPANTS MUST BE EMPLOYED ON DEC 1 TO QUALIFY FOR THE CURRENT YEARS SERP AMOUNT UNLESS SEPARATION IS DUE TO DEATH, DISABILITY, RETIREMENT (AGE 65) OR EARLY RETIREMENT (AGE 60 OR ABOVE WITH 15 OR MORE YEARS OF SERVICE). SERP AMOUNTS ARE CALCULATED EACH DEC 1; VESTED BALANCES ARE TAXED; AND THE NET BALANCES CAN BEGIN ACCRUING EARNINGS. VESTED BALANCES ARE PAID IN CASH LUMP SUMS WITHIN THE 90 DAY PERIOD COMMENCING UPON THE EARLIER OF DEATH, DISABILITY, OR SEPARATION FROM SERVICE. THR OWNS ANY INVESTMENTS PURCHASED IN CONNECTION WITH ITS OBLIGATIONS UNDER THE SERP PLAN. IF THR BECOMES INSOLVENT, EXECUTIVES ARE UNSECURED CREDITORS AND WILL HAVE NO PREFERRED CLAIM TO ANY ASSETS. NO CONTRIBUTIONS TO THE EMPLOYEES LISTED ON PART VII WERE MADE DURING THE CURRENT YEAR. SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 3: AS NOTED IN OUR RESPONSE TO QUESTION 15 OF PART VI OF FORM 990, THE INDIVIDUAL WHO SERVES AS THE CEO OF THE FILING ORGANIZATION IS COMPENSATED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC) FOR THAT INDIVIDUAL'S ROLE IN SERVING AS THE CEO. COMPENSATION AND BENEFITS PROVIDED TO THIS INDIVIDUAL ARE DETERMINED PURSUANT TO POLICIES, PROCEDURES, AND PROCESSES OF AHSSHC THAT ARE DESIGNED TO ENSURE COMPLIANCE WITH THE INTERMEDIATE SANCTIONS LAWS AS SET FORTH IN IRC SECTION 4958. AHSSHC USES ALL OF THE FOLLOWING TO ESTABLISH COMPENSATION OF THE CEO: - COMPENSATION COMMITTEE; - INDEPENDENT COMPENSATION CONSULTANT; - COMPENSATION SURVEY OR STUDY; AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION A, LINE 1 THE MEMBERS OF THE BOARD OF DIRECTORS LISTED ON PART VII OF THIS FORM 990 INCLUDE THE FILING ORGANIZATION'S GOVERNING BOARD AND THE MEMBERS OF THE FILING ORGANIZATION'S HOSPITAL BOARD. THE HOSPITAL BOARD IS PRIMARILY RESPONSIBLE FOR MATTERS OF THE HOSPITAL INVOLVING THE OVERSIGHT OF MEDICAL STAFF (INCLUDING THE REVIEW AND APPROVAL OF MEDICAL STAFF BYLAWS, AND APPROVAL OF APPOINTMENTS TO AND DISMISSALS FROM THE MEDICAL STAFF), CARE OF PATIENTS, IMPROVEMENTS TO LAND, BUILDINGS AND EQUIPMENT, QUALITY ASSESSMENT AND IMPROVEMENT PROGRAMS IMPLEMENTED AT THE HOSPITAL AND RISK MANAGEMENT FUNCTIONS. FORM 990, PART VI, SECTION A, LINE 2 RON LONG AND BARCLAY BERDAN - BUSINESS RELATIONSHIP RON LONG AND JOE PROSSER, MD - BUSINESS RELATIONSHIP BARCLAY BERDAN AND JOE PROSSER, MD - BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 4 EFFECTIVE 5/1/12, THE FILING ORGANIZATION AMENDED ITS ARTICLES OF INCORPORATION. THE PURPOSES/CORPORATE POWERS ARTICLE WAS AMENDED TO PROVIDE THAT THE PRIMARY PURPOSE OF THE FILING ORGANIZATION IS TO SUPPORT THE CHARITABLE ACTIVITIES OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORP. (AHSSHC) AND TEXAS HEALTH RESOURCES (THR) BY OPERATING HUGULEY MEMORIAL MEDICAL CENTER (THE HOSPITAL). BOTH AHSSHC AND THR ARE 501(C)(3) ORGANIZATIONS. THIS AMENDMENT WAS THE RESULT OF AN AFFILIATION BY AHSSHC WITH THR TO JOINTLY OWN AND OPERATE THE HOSPITAL. THE FILING ORGANIZATION WAS ORIGINALLY FORMED IN 2011. AHSSI WAS THE SOLE MEMBER OF THE FILING ORGANIZATION UNTIL THE 5/1/12 AFFILIATION WITH THR. AHSSI IS A 100% OWNED SUBSIDIARY OF AHSSHC. AHSSI IS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). SUBSEQUENT TO 5/1/12, THR HELD A 51% MEMBERSHIP INTEREST IN THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 FROM OCTOBER 26, 2011 TO APRIL 30, 2012 TEXAS HEALTH HUGULEY, INC. (THE FILING ORGANIZATION) HAD ONE MEMBER. THE SOLE MEMBER OF THE FILING ORGANIZATION WAS ADVENTIST HEALTH SYSTEM/SUNBELT, INC. ON MAY 1, 2012, THE ARTICLES OF INCORPORATION OF THE FILING ORGANIZATION WERE AMENDED TO PROVIDE THAT 51% OF THE MEMBERSHIP IN THE FILING ORGANIZATION SHALL BE HELD BY TEXAS HEALTH RESOURCES, THE SOLE CLASS A MEMBER, AND 49% OF THE MEMBERSHIP IN THE FILING ORGANIZATION SHALL BE HELD BY ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI), THE SOLE CLASS B MEMBER. BOTH AHSSI AND THR ARE EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). THERE ARE NO OTHER CLASSES OF MEMBERSHIP IN THH. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE BOARD OF DIRECTORS (GOVERNING BOARD) OF THE FILING ORGANIZATION ARE APPOINTED BY THR (MAJORITY MEMBER) AND AHSSI (MINORITY MEMBER). THE MAJORITY MEMBER IS ENTITLED TO ELECT THREE DIRECTORS TO THE BOARD OF THE FILING ORGANIZATION AND THE MINORITY MEMBER IS ENTITLED TO ELECT TWO DIRECTORS TO THE BOARD. IN ADDITION, THE MEMBERSHIP SHALL APPOINT FOR THE HOSPITAL A COMMUNITY HOSPITAL BOARD TO OVERSEE THE OPERATIONS OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B CERTAIN GOVERNANCE POWERS ARE RESERVED TO THE MEMBERS OF THE FILING ORGANIZATION. THE GOVERNING DOCUMENTS OF THE FILING ORGANIZATION DESCRIBE THOSE MATTERS REQUIRING ONLY AN AFFIRMITIVE VOTE OF THE CLASS A MEMBER (THR), THOSE MATTERS REQUIRING ONLY AN AFFIRMATIVE VOTE OF THE CLASS B MEMBER (AHSSI) AND THOSE MATTERS REQUIRING A SUPERMAJORITY VOTE OF THE MEMBERS. A SUPERMAJORITY VOTE REQUIRES AN AFFIRMATIVE VOTE OF NOT LESS THAN 52% OF THE OUTSTANDING MEMBERSHIP INTERESTS. THE RESERVED POWERS REQUIRING AN AFFIRMATIVE VOTE OF ONLY THE CLASS A MEMBER, THR, INCLUDE THE FOLLOWING: 1) TO APPROVE OR AMEND MANAGED CARE CONTRACTS TO WHICH THE FILING ORGANIZATION IS A PARTICIPATING PROVIDER; 2) TO APPROVE THE STRATEGIC PLANS OF THE FILING ORGANIZATION; 3) TO APPROVE THE ANNUAL OPERATING PLANS AND OPERATING AND CAPITAL BUDGET OF THE FILING ORGANIZATION; AND 4) TO APPROVE THE SELECTION, REMOVAL AND/OR MODIFICATION OF THE AUTHORITY AND RESPONSIBILITIES OF LAWYERS, ACCOUNTANTS AND OTHER ADVISORS AND CONSULTANTS TO THE FILING ORGANIZATION THAT ARE NOT OTHERWISE IDENTIFIED IN THE APPROVED ANNUAL OPERATING BUDGET. THE RESERVED POWERS REQUIRING AN AFFIRMATIVE VOTE OF ONLY THE CLASS B MEMBER, AHSSI, INCLUDE THE FOLLOWING: 1) TO APPROVE CHANGES TO THE MISSION, VISION, OR VALUES OF THE HOSPITAL; 2) TO APPROVE CHANGES TO RELIGIOUS AFFILIATION OF HOSPITAL; AND 3) TO APPROVE CHANGES TO OPERATIOINAL POLICIES, PLANS, PROCEDURES THAT ARE SPECIFICALLY RELATED TO THE HOSPITAL'S RELIGIOUS AFFILIATION WITH THE SEVENTH-DAY ADVENTIST CHURCH. BOTH THR, THE MAJORITY MEMBER, AND AHSSI, THE MINORITY MEMBER HAVE THE RESERVED POWER TO TERMINATE THE APPOINTMENT OF THE INDIVIDUAL HOLDING THE OFFICE OF PRESIDENT/CEO. THE FOLLOWING MATTERS REQUIRE A SUPERMAJORITY VOTE OF THE MEMBERSHIP: 1) TO AMEND THE ARTICLES OF INCORPORATION OR BYLAWS; 2) TO CHANGE THE NAME OF THE HOSPITAL; 3) TO ADD NEW CORPORATE MEMBERS OF THE FILING ORGANIZATION; 4) TO APPOINT AND REMOVE THE HOSPITAL BOARD; 5) TO APPROVE DISTRIBUTIONS OF CASH AND OTHER PROPERTY; 6) TO APPROVE THE BORROWING OF MONEY OR OTHERWISE COMMITTING THE CREDIT OF THE FILING ORGANIZATION FOR CORPORATE ACTIVITIES, AND THE VOLUNTARY PREPAYMENT OR EXTENSION OF DEBT IN EXCESS OF $200,000; 7) TO ADOPT AND THEREAFTER AMEND QUALITY AND/OR RISK MANAGEMENT PLANS; 8) TO APPROVE THE TRANSFER OF CORPORATE PROPERTY HAVING A VALUE IN EXCESS OF $500,000; 9) TO APPROVE ANY SALE, LEASE, TRANSFER, MERGER OR CONSOLIDATION OF THE FILING ORGANIZATION WITH A THIRD PARTY; 10) TO DISSOLVE THE FILING ORGANIZATION; 11) TO APPROVE THE FORMATION OF ANY SUBSIDIARY OF THE FILING ORGANIZATION OR APPROVE THE FILING ORGANIZATION ENTERING INTO ANY AFFILIATION OR JOINT VENTURE AGREEMENT; AND 12) TO APPROVE ANY SINGLE CAPITAL BUDGET ITEM OF $1,000,000 (OR MORE). FORM 990, PART VI, SECTION B, LINE 11 THE FILING ORGANIZATION'S CURRENT YEAR FORM 990 WAS REVIEWED BY THE CEO, CFO, BOARD VICE CHAIRMAN, AND TREASURER PRIOR TO ITS FILING WITH THE IRS. THE REVIEW CONDUCTED BY THESE INDIVIDUALS DID NOT INCLUDE THE REVIEW OF ANY SUPPORTING WORKPAPERS THAT WERE USED IN PREPARATION OF THE CURRENT YEAR FORM 990, BUT DID INCLUDE A REVIEW OF THE ENTIRE FORM 990 AND ALL SUPPORTING SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY OF THE FILING ORGANIZATION APPLIES TO MEMBERS OF ITS BOARD OF DIRECTORS AND ITS PRINCIPAL OFFICERS (TO BE KNOWN AS INTERESTED PERSONS). IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTERESTS, ANY MEMBER OF THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION OR ANY PRINCIPAL OFFICER OF THE FILING ORGANIZATION (I.E. INTERESTED PERSONS) MUST DISCLOSE THE EXISTENCE OF ANY FINANCIAL INTEREST WITH THE FILING ORGANIZATION AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS CONCERNING THE FINANCIAL INTEREST/ARRANGEMENT TO THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION OR TO ANY MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS THAT IS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. SUBSEQUENT TO ANY DISCLOSURE OF ANY FINANCIAL INTEREST/ARRANGEMENT AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE RELEVANT BOARD MEMBER OR PRINCIPAL OFFICER, THE REMAINING MEMBERS OF THE BOARD OF DIRECTORS OR COMMITTEE WITH BOARD DELEGATED POWERS SHALL DISCUSS, ANALYZE, AND VOTE UPON THE POTENTIAL FINANCIAL INTEREST/ARRANGEMENT TO DETERMINE IF A CONFLICT OF INTEREST EXISTS. ACCORDING TO THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY, AN INTERESTED PERSON MAY MAKE A PRESENTATION TO THE BOARD OF DIRECTORS (OR COMMITTEE WITH BOARD DELEGATED POWERS), BUT AFTER SUCH PRESENTATION, SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN A CONFLICT OF INTEREST. EACH INTERESTED PERSON, AS DEFINED UNDER THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY, SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTERESTS POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE FILING ORGANIZATION IS A CHARITABLE ORGANIZATION THAT MUST PRIMARILY ENGAGE IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS EXEMPT PURPOSES. THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY ALSO REQUIRES THAT PERIODIC REVIEWS SHALL BE CONDUCTED TO ENSURE THAT THE FILING ORGANIZATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES. FORM 990, PART VI, SECTION B, LINE 15 AS DESCRIBED ABOVE ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI) HOLDS A 49% MEMBER INTEREST IN THE FILING ORGANIZATION. THE TOP-TIER PARENT OF AHSSI IS ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). THE FILING ORGANIZATION HAS ENTERED INTO A MANAGEMENT SERVICES AGREEMENT WITH AHSSHC. UNDER THIS AGREEMENT, AHSSHC WILL MANAGE THE DAILY OPERATIONS OF THE FILING ORGANIZATION'S HOSPITAL. PURSUANT TO THE MANAGEMENT SERVICES AGREEMENT, AHSSHC WILL APPOINT THE KEY MEMBERS OF THE FILING ORGANIZATION'S ADMINISTRATIVE TEAM (I.E. COO, CFO, CNO). THE PRESIDENT/CEO OF THE FILING ORGANIZATION IS SUBJECT TO APPOINTMENT BY THE MEMBERSHIP OF THE FILING ORGANIZATION. THE PRESIDENT/CEO AND OTHER OFFICERS AND KEY EMPLOYEES OF THE FILING ORGANIZATION WILL BE COMPENSATED BY AHSSHC. COMPENSATION AND BENEFITS PROVIDED TO THE OFFICERS AND KEY EMPLOYEES IS DETERMINED PURSUANT TO POLICIES, PROCEDURES, AND PROCESSES OF AHSSHC THAT ARE DESIGNED TO ENSURE COMPLIANCE WITH THE INTERMEDIATE SANCTIONS LAWS AS SET FORTH IN IRC SECTION 4958. AHSSHC HAS TAKEN STEPS TO ENSURE THAT PROCESSES ARE IN PLACE TO SATISFY THE REBUTTABLE PRESUMPTION OF REASONABLENESS STANDARD AS SET FORTH IN TREASURY REGULATION 53.4958-6 WITH RESPECT TO ITS ACTIVE EXECUTIVE-LEVEL POSITIONS. THE AHSSHC BOARD STRATEGY AND COMPENSATION COMMITTEE (THE COMMITTEE) SERVES AS THE GOVERNING BODY FOR ALL EXECUTIVE COMPENSATION MATTERS. THE COMMITTEE IS COMPOSED OF CERTAIN MEMBERS OF THE BOARD OF DIRECTORS (THE BOARD) OF AHSSHC. VOTING MEMBERS OF THE COMMITTEE INCLUDE ONLY INDIVIDUALS WHO SERVE ON THE BOARD AS INDEPENDENT REPRESENTATIVES OF THE COMMUNITY, WHO HOLD NO EMPLOYMENT POSITIONS WITH AHSSHC AND WHO DO NOT HAVE RELATIONSHIPS WITH ANY OF THE INDIVIDUALS WHOSE COMPENSATION IS UNDER THEIR REVIEW THAT IMPACTS THEIR BEST INDEPENDENT JUDGMENT AS FIDUCIARIES OF AHSSHC. THE COMMITTEE'S ROLE IS TO REVIEW AND APPROVE ALL COMPONENTS OF THE EXECUTIVE COMPENSATION PLAN OF AHSSHC. AS AN INDEPENDENT GOVERNING BODY WITH RESPECT TO EXECUTIVE COMPENSATION, IT SHOULD BE NOTED THAT THE COMMITTEE WILL OFTEN CONFER IN EXECUTIVE SESSIONS ON MATTERS OF COMPENSATION POLICY AND POLICY CHANGES. IN SUCH EXECUTIVE SESSIONS, NO MEMBERS OF MANAGEMENT OF AHSSHC ARE PRESENT. THE COMMITTEE IS ADVISED BY AN INDEPENDENT THIRD PARTY COMPENSATION ADVISOR. THIS ADVISOR PREPARES ALL THE BENCHMARK STUDIES FOR THE COMMITTEE. COMPENSATION LEVELS ARE BENCHMARKED WITH A NATIONAL PEER GROUP OF OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS AND HOSPITALS OF SIMILAR SIZE AND COMPLEXITY TO AHS AND EACH OF ITS AFFILIATED ENTITIES. THE FOLLOWING PRINCIPLES GUIDE THE ESTABLISHMENT OF INDIVIDUAL EXECUTIVE COMPENSATION: - THE SALARY OF THE PRESIDENT/CEO OF AHS WILL NOT EXCEED THE 40TH PERCENTILE OF COMPARABLE SALARIES PAID BY SIMILARLY SITUATED ORGANIZATIONS; AND - OTHER EXECUTIVE SALARIES SHALL BE ESTABLISHED USING MARKET MEDIANS. THE COMPENSATION PHILOSOPHY, POLICIES, AND PRACTICES OF AHSSHC ARE CONSISTENT WITH THE ORGANIZATION'S FAITH-BASED MISSION AND CONFORM TO APPLICABLE LAWS, REGULATIONS, AND BUSINESS PRACTICES. AS A FAITH-BASED ORGANIZATION SPONSORED BY THE SEVENTH-DAY ADVENTIST CHURCH (THE CHURCH), AHSSHC'S PHILOSOPHY AND PRINCIPLES WITH RESPECT TO ITS EXECUTIVE COMPENSATION PRACTICES REFLECT THE CONSERVATIVE APPROACH OF THE CHURCH'S MISSION OF SERVICE AND WERE DEVELOPED IN COUNSEL WITH THE CHURCH'S LEADERSHIP. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS OF THE FILING ORGANIZATION, ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT GENERALLY MADE AVAILABLE TO THE PUBLIC AS A WHOLE. PART VII, SECTION A, COLUMN (B) FOR THOSE BOARD OF DIRECTOR MEMBERS WHO DEVOTE LESS THAN FULL-TIME TO THE FILING ORGANIZATION (BASED UPON THE AVERAGE NUMBER OF HOURS PER WEEK SHOWN IN COLUMN (B) ON PAGE 7 OF THE RETURN) THE COMPENSATION AMOUNTS SHOWN IN COLUMNS (E) AND (F) ON PAGE 7 WERE PROVIDED IN CONJUNCTION WITH THAT PERSON'S RESPONSIBILITIES AND ROLES IN SERVING IN AN EXECUTIVE LEADERSHIP POSITION WITHIN ADVENTIST HEALTH SYSTEM OR THR. OTHER FEES FORM 990, PART IX, LINE 11G PAYMENTS TO HEALTHCARE PROFESSIONAL : PROGRAM SERVICE EXPENSES 5,257,798. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,257,798. PROFESSIONAL FEES : PROGRAM SERVICE EXPENSES 388,598. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 388,598. PURCHASED MEDICAL SERVICES : PROGRAM SERVICE EXPENSES 1,491,156. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,491,156. ENVIRONMENTAL SERVICES : PROGRAM SERVICE EXPENSES 535,475. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 535,475. TRANSCRIPTION SERVICES : PROGRAM SERVICE EXPENSES 157,609. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 157,609. RECRUITING : PROGRAM SERVICE EXPENSES 220,720. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 220,720. MISCELLANEOUS PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 3,368,886. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,368,886. AHS MANAGEMENT FEES : PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 763,689. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 763,689. BILLING & COLLECTION SERVICES : PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 275,559. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 275,559. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TEMPORARILY RESTRICTED INCOME 18,699. TRANSFER OF NET ASSETS FROM ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI) 65,819,738. TRANSFER TO SUBSIDIARY -2,378,686. TRANSFER OF TEMPORARILY RESTRICTED ASSETS FROM AHSSI 169,463. TRANSFER OF PERMANENTLY RESTRICTED ASSETS FROM AHSSI 1,413,027. RESTRICTED GIFTS AND GRANTS 177,466. TRANSFER FROM RESTRICTED TO OPERATING -139,958. TRANSFER OF NET SPECIAL EVENTS FROM EQUITY -63,471. ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL 60440 651219504 OPERATION OF HOSPITAL & RELATED SERVICES IL 501(C)(3) 170(B)(1)(A)(III) ADVENTIST HLTH SYSTEMSUNBELT INC 0 ADVENTIST CARE CENTERS - COURTLAND INC 730 COURTLAND STREET ORLANDO FL 32804 205774723 OPERATION OF HOME FOR THE AGED/HLTHCARE DELIVERY FL 501(C)(3) 509(A)(2) SUNBELT HLTH CARE CENTERS INC 0 ADVENTIST GLENOAKS HOSPITAL 701 WINTHROP AVENUE GLENDALE HEIGHTS IL 60139 363208390 OPERATION OF HOSPITAL & RELATED SERVICES IL 501(C)(3) 170(B)(1)(A)(III) ADVENTIST HLTH SYSTEMSUNBELT INC 0 ADVENTIST HLTH MID-AMERICA INC 9100 W 74TH STREET SHAWNEE MISSION KS 66204 521347407 HLTHCARE RELATED SERVICES KS 501(C)(3) 509(A)(3) TYPE I ADVENTIST HLTH SYSTEMSUNBELT INC 0 ADVENTIST HLTH PARTNERS INC 1000 REMINGTON BLVD STE 200 BOLINGBROOK IL 60440 364138353 OPERATE OUT-PATIENT PHYSICIAN CLINICS IL 501(C)(3) 170(B)(1)(A)(III) AHS MIDWEST MANAGEMENT INC 0 ADVENTIST HLTH SYSTEM AFFILIATED BENEFIT TRUST 900 HOPE WAY ALTAMONTE 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170(B)(1)(A)(III) ADVENTIST HLTH SYSTEMSUNBELT INC 0 ADVENTIST UNIVERSITY OF HEALTH SCIENCES INC (630 YEAR END) 671 LAKE WINYAH DRIVE ORLANDO FL 32803 593069793 EDUCATION/OPERATION OF SCHOOL FL 501(C)(3) 170(B)(1)(A)(II) ADVENTIST HLTH SYSTEMSUNBELT INC 0 AHS MIDWEST MANAGEMENT INC 1000 REMINGTON BLVD STE 200 BOLINGBROOK IL 60440 363354567 OPERATION OF PHYSICIAN PRACTICE MGMT IL 501(C)(3) 509(A)(3) TYPE I ADVENTIST HLTH SYSTEMSUNBELT INC 0 AHSCENTRAL TEXAS INC 1301 WONDER WORLD DRIVE SAN MARCOS TX 78666 742621825 PROVIDE OFFICE SPACE - MEDICAL PROFESSIONALS TX 501(C)(3) 509(A)(3) TYPE III-F ADVENTIST HLTH SYSTEM SUNBELT HLTHCARE CORP 0 APOPKA HLTH CARE PROPERTIES INC 305 E OAK STREET APOPKA FL 32703 510605694 LEASE TO RELATED ORGANIZATION GA 501(C)(3) 509(A)(3) TYPE III-F SUNBELT HLTH CARE CENTERS INC 0 BATTLE CREEK ADVENTIST HOSPITAL 1000 REMINGTON BLVD STE 200 BOLINGBROOK IL 60440 381359189 INACTIVE MI 501(C)(3) 170(B)(1)(A)(III) ADVENTIST HLTH SYSTEMSUNBELT INC 0 BOLINGBROOK 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611120442 OPERATION OF HOME FOR THE ELDERLY-DISABLED KY 501(C)(3) 170(B)(1)(A)(VI) MEMORIAL HOSPITAL INC 0 CENTRAL TEXAS MEDICAL CENTER FOUNDATION 1301 WONDER WORLD DRIVE SAN MARCOS TX 78666 742259907 FUND-RAISING FOR TAX-EXEMPT HOSPITAL TX 501(C)(3) 170(B)(1)(A)(VI) ADVENTIST HLTH SYSTEMSUNBELT INC 0 CHICKASAW HLTH CARE PROPERTIES INC 250 S CHICKASAW TRAIL ORLANDO FL 32825 510605681 LEASE TO RELATED ORGANIZATION GA 501(C)(3) 509(A)(3) TYPE III-F SUNBELT HLTH CARE CENTERS INC 0 CHIPPEWA VALLEY HOSPITAL & OAKVIEW CARE CENTER INC 1220 THIRD AVENUE WEST DURAND WI 54736 391365168 OPERATION OF HOSPITAL & RELATED SERVICES WI 501(C)(3) 170(B)(1)(A)(III) ADVENTIST HLTH SYSTEMSUNBELT INC 0 COBB MEDICAL ASSOCIATES LLC 3949 SOUTH COBB DRIVE SE SMYRNA GA 300806342 582617089 OPERATION OF PHYSICIAN PRACTICES & MEDICAL SERVICES GA 501(C)(3) 170(B)(1)(A)(III) EMORY-ADVENTIST INC 0 COURTLAND HLTH CARE PROPERTIES INC 730 COURTLAND STREET ORLANDO FL 32804 510605682 LEASE TO RELATED ORGANIZATION GA 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