efile Public Visual Render
Submission Date - 2013-08-14
TIN: 03-0185556
Form
990
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
20
11
Open to Public Inspection
A
For the
2011
calendar year, or tax year beginning
10-01-2011
and ending
09-30-2012
B
Check if applicable:
Address change
Name change
Initial return
Terminated
Amended return
Application pending
C
Name of organization
NORTH COUNTRY HOSPITAL & HEALTH CENTER INC
Doing Business As
Number and street (or P.O. box if mail is not delivered to street address)
189 PROUTY DRIVE
Room/suite
City or town, state or country, and ZIP + 4
NEWPORT
,
VT
05855
D Employer identification number
03-0185556
E Telephone number
(802) 334-7331
G
Gross receipts $
92,448,472
F
Name and address of principal officer:
CLAUDIO FORT
189 PROUTY DRIVE
NEWPORT
,
VT
05855
I
Tax-exempt status:
501(c)(3)
501(c)
(
)
(insert no.)
4947(a)(1)
or
527
J
Website:
WWW.NCHSI.ORG
H(a)
Is this a group return for
affiliates?
Yes
No
H(b)
Are all affiliates included?
Yes
No
If "No," attach a list. (see instructions)
H(c)
Group exemption number
K
Form of organization:
Corporation
Trust
Association
Other
L
Year of formation:
1919
M
State of legal domicile:
VT
Part I
Summary
1
Briefly describe the organizations mission or most significant activities:
TO PROVIDE HEALTH CARE SERVICES TO THE RESIDENTS OF ORLEANS AND ESSEX COUNTIES, ENSURING THAT HEALTH CARE IS AVAILABLE TO ALL PEOPLE.
2
Check this box
3
Number of voting members of the governing body (Part VI, line 1a)
.....
3
15
4
Number of independent voting members of the governing body (Part VI, line 1b)
....
4
12
5
Total number of individuals employed in calendar year 2011 (Part V, line 2a)
...
5
651
6
Total number of volunteers (estimate if necessary)
....
6
40
7a
Total unrelated business revenue from Part VIII, column (C), line 12
..
7a
6,765
b
Net unrelated business taxable income from Form 990-T, line 34
..
7b
4,863
Prior Year
Current Year
8
Contributions and grants (Part VIII, line 1h)
.........
222,893
299,191
9
Program service revenue (Part VIII, line 2g)
.........
74,988,618
79,113,354
10
Investment income (Part VIII, column (A), lines 3, 4, and 7d )
....
1,221,524
680,060
11
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)
8,658
45,037
12
Total revenueadd lines 8 through 11 (must equal Part VIII, column (A), line 12)
...................
76,441,693
80,137,642
13
Grants and similar amounts paid (Part IX, column (A), lines 13 )
...
65,495
0
14
Benefits paid to or for members (Part IX, column (A), line 4)
.....
0
0
15
Salaries, other compensation, employee benefits (Part IX, column (A), lines 510)
44,360,110
47,058,082
16a
Professional fundraising fees (Part IX, column (A), line 11e)
.....
0
0
b
Total fundraising expenses (Part IX, column (D), line 25)
0
17
Other expenses (Part IX, column (A), lines 11a11d, 11f24f)
....
30,812,790
33,888,208
18
Total expenses. Add lines 1317 (must equal Part IX, column (A), line 25)
75,238,395
80,946,290
19
Revenue less expenses. Subtract line 18 from line 12
.......
1,203,298
-808,648
Beginning of Current Year
End of Year
20
Total assets (Part X, line 16)
.............
70,905,679
73,717,207
21
Total liabilities (Part X, line 26)
.............
35,058,543
36,182,392
22
Net assets or fund balances. Subtract line 21 from line 20
.....
35,847,136
37,534,815
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
2013-07-22
Signature of officer
Date
ANDRE BISSONNETTE
VICE PRESIDENT OF FINANCE
Type or print name and title.
Paid preparer use only
Print/type preparer's name
Preparer's signature
Brian D Todd
Date
Check
if
self-employed
PTIN
Firm's name
BKD LLP
Firm's EIN
Firm's address
910 E ST LOUIS 200/PO BOX 1190
SPRINGFIELD
,
MO
658062523
Phone no.
(417) 865-8701
May the IRS discuss this return with the preparer shown above? See instructions
.........
Yes
No
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form
990
(2011)
Form 990 (2011)
Page
2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III
.........
1
Briefly describe the organizations mission:
QUALITY PATIENT CARE IS OUR GREATEST COMMITMENT, EMPLOYEES ARE OUR GREATEST ASSET, EXCELLENT PATIENT EXPERIENCE IS OUR GREATEST ACCOMP- LISHMENT, & THE HLTH OF OUR COMMUNITY IS OUR GREATEST RESPONSIBILITY.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ?
....................
Yes
No
If Yes, describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services?
..........................
Yes
No
If Yes, describe these changes on Schedule O.
4
Describe the organizations program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a
(Code:
) (Expenses $
35,174,988
including grants of $
) (Revenue $
47,046,308
)
THE HOSPITAL OFFERS OUTPATIENT SERVICES INCLUDING EMERGENCY ROOM, LAB WORK, DIAGNOSTIC IMAGING (X-RAY, CT SCAN, MRI, MAMMOGRAMS, NUCLEAR IMAGING, ULTRASOUND), OUTPATIENT SURGERIES, ONCOLOGY TREATMENTS, PULMONARY, CARDIAC CARE AND THERAPY SERVICES (PHYSICAL, SPEECH, & REHABILITATIVE) TOTALING 77,650 REGISTRATIONS FOR THE YEAR.
4b
(Code:
) (Expenses $
21,808,493
including grants of $
) (Revenue $
14,490,937
)
THE HOSPITAL'S PHYSICIAN PRACTICES CLINICS PROVIDE INTERNAL MEDICINE, RADIOLOGY PROGRAM, PSYCHIATRIC, OB/GYN, NEUROLOGY, ORTHOPEDICS, OCCUPATIONAL HEALTH, PULMONARY-SLEEP, SURGICAL SERVICES AND HEMATOLOGY ONCOLOGY PRACTICES. THE PHYSICIAN PRACTICE CLINICS OF THE HOSPITAL SERVICED 91,438 PATIENT VISITS FOR THE YEAR.
4c
(Code:
) (Expenses $
13,366,496
including grants of $
) (Revenue $
17,576,109
)
INPATIENT HOSPITAL CARE WAS PROVIDED AT A CRITICAL ACCESS HOSPITAL TOTALING 6,050 PATIENT DAYS FOR THE YEAR. THE HOSPITAL'S INPATIENT CARE SERVICES INCLUDE A 24 HOUR EMERGENCY DEPARTMENT, MEDICAL AND SURGICAL SERVICES, INTENSIVE CARE UNITS, BIRTHING CENTER, CLINICAL LABORATORY, MRI & ULTRASOUND, NEUROLOGY, ORTHOPAEDICS, PHARMACY, REHABILITATION SERVICES, OCCUPATIONAL THERAPY, AND PHYSICAL THERAPY, AMONG OTHERS.
4d
Other program services (Describe in Schedule O.)
(Expenses $
including grants of $
) (Revenue $
)
4e
Total program service expenses
$
70,349,977
Form
990
(2011)
Form 990 (2011)
Page
3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)?
If Yes, complete Schedule A
.....................
1
Yes
2
Is the organization required to complete
Schedule B, Schedule of Contributors
?
........
2
Yes
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office?
If Yes, complete Schedule C, Part I
..........
3
No
4
Section 501(c)(3) organizations.
Did the organization engage in lobbying activities?
If Yes, complete Schedule C,
Part II
.........................
4
Yes
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19?
If Yes, complete Schedule C, Part III
........................
5
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts?
If Yes, complete Schedule D, Part I
....................
6
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures?
If Yes, complete Schedule D, Part II
...
7
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets?
If Yes, complete Schedule D, Part III
....................
8
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services?
If Yes,
complete Schedule D, Part IV
...................
9
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments?
If Yes, complete Schedule D, Part V
10
Yes
11
If the organizations answer to any of the following questions is Yes, then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10?
If Yes, complete Schedule D, Part VI.
11a
Yes
b
Did the organization report an amount for investmentsother securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part VII.
11b
No
c
Did the organization report an amount for investmentsprogram related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part VIII.
11c
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part IX.
11d
No
e
Did the organization report an amount for other liabilities in Part X, line 25?
If Yes, complete Schedule D, Part X.
11e
Yes
f
Did the organizations separate or consolidated financial statements for the tax year include a footnote that addresses the organizations liability for uncertain tax positions under FIN 48 (ASC 740)?
If Yes, complete Schedule D, Part X.
11f
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If Yes, complete Schedule D, Parts XI, XII, and XIII
12a
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year?
If Yes, and if the organization answered No to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional
12b
Yes
13
Is the organization a school described in section 170(b)(1)(A)(ii)?
If Yes, complete Schedule E
13
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?
....
14a
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more?
If Yes, complete Schedule F, Part I
.........
14b
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.?
If Yes, complete Schedule F, Part II
..
15
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.?
If Yes, complete Schedule F, Part III
..
16
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e?
If Yes, complete Schedule G, Part I
17
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a?
If Yes, complete Schedule G, Part II
..........
18
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a?
If Yes, complete Schedule G, Part III
...................
19
No
20a
Did the organization operate one or more hospitals?
If Yes, complete Schedule H
.....
20a
Yes
b
If Yes to line 20a, did the organization attach a copy of its audited financial statement to this return?
Note.
All Form 990 filers that operated one or more hospitals must attach audited financial statements.
20b
Yes
Form
990
(2011)
Form 990 (2011)
Page
4
Part IV
Checklist of Required Schedules
(continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1?
If Yes, complete Schedule I, Parts I and II
..
21
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2?
If Yes, complete Schedule I, Parts I and III
.....
22
No
23
Did the organization answer Yes to Part VII, Section A, questions 3, 4, or 5, about compensation of the organizations current and former officers, directors, trustees, key employees, and highest compensated employees?
If Yes, complete Schedule J
................
23
Yes
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002?
If Yes, answer questions 24b24d and complete Schedule K. If No, go to line 25
................
24a
Yes
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?
...
24b
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
......................
24c
No
d
Did the organization act as an on behalf of issuer for bonds outstanding at any time during the year?
...
24d
No
25a
Section 501(c)(3) and 501(c)(4) organizations.
Did the organization engage in an excess benefit transaction with a disqualified person during the year?
If Yes, complete Schedule L, Part I
......
25a
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organizations prior Forms 990 or 990-EZ?
If Yes, complete Schedule L, Part I
................
25b
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organizations tax year?
If Yes, complete Schedule L,
Part II
.........................
26
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons?
If Yes, complete Schedule L, Part III
.........
27
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee?
If Yes, complete Schedule L, Part IV
.........................
28a
No
b
A family member of a current or former officer, director, trustee, or key employee?
If Yes,
complete Schedule L, Part IV
...................
28b
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner?
If Yes, complete Schedule L, Part IV
..
28c
No
29
Did the organization receive more than $25,000 in non-cash contributions?
If Yes, complete Schedule M
29
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions?
If Yes, complete Schedule M
............
30
No
31
Did the organization liquidate, terminate, or dissolve and cease operations?
If Yes, complete Schedule N,
Part I
...........................
31
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets?
If Yes, complete Schedule N, Part II
.......................
32
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3?
If Yes, complete Schedule R, Part I
........
33
No
34
Was the organization related to any tax-exempt or taxable entity?
If Yes, complete Schedule R, Parts II, III, IV, and V, line 1
.....................
34
Yes
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
No
b
If Yes to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)?
If Yes, complete Schedule R, Part V, line 2
...
35b
No
36
Section 501(c)(3) organizations.
Did the organization make any transfers to an exempt non-charitable related organization?
If Yes, complete Schedule R, Part V, line 2
...........
36
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes?
If Yes, complete Schedule R, Part VI
37
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19?
Note.
All Form 990 filers are required to complete Schedule O.
............
38
Yes
Form
990
(2011)
Form 990 (2011)
Page
5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V
.........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable.
.......
1a
62
b
Enter the number of Forms W-2G included in line 1a.
Enter -0-
if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners?
..................
1c
Yes
2a
Enter the number of employees reported on Form W-3,
Transmittal of Wage and Tax Statements
filed for the calendar year ending with or within the year covered by this return
.....................
2a
651
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note.
If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?
.............................
3a
Yes
b
If Yes, has it filed a Form 990-T for this year?
If No, provide an explanation in Schedule O
.....
3b
Yes
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?
.......................
4a
No
b
If "Yes," enter the name of the foreign country:
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
..
5a
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
No
c
If Yes to line 5a or 5b, did the organization file Form 8886-T?
........
5c
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?
..........
6a
No
b
If Yes, did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?
........................
6b
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?
....................
7a
No
b
If Yes, did the organization notify the donor of the value of the goods or services provided?
.....
7b
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?
...........................
7c
No
d
If Yes, indicate the number of Forms 8282 filed during the year
....
7d
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
..........................
7e
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
..
7f
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
...................
7g
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
...............
7h
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations.
Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?
................
8
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?
.........
9a
b
Did the organization make a distribution to a donor, donor advisor, or related person?
......
9b
10
Section 501(c)(7) organizations.
Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12
...
10a
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
11
Section 501(c)(12) organizations.
Enter:
a
Gross income from members or shareholders
.........
11a
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them)
........
11b
12a
Section 4947(a)(1) non-exempt charitable trusts.
Is the organization filing Form 990 in lieu of Form 1041?
12a
b
If Yes, enter the amount of tax-exempt interest received or accrued during the year.
12b
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note.
All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
c
Enter the aggregate amount of reserves on hand.
13c
14a
Did the organization receive any payments for indoor tanning services during the tax year?
.....
14a
b
If "Yes," has it filed a Form 720 to report these payments?
If No, provide an explanation in Schedule O
..
14b
Form
990
(2011)
Form 990 (2011)
Page
6
Part VI
Governance, Management, and Disclosure
For each Yes response to lines 2 through 7b below, and for a No response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI
.........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
15
b
Enter the number of voting members included in line 1a, above, who are independent
.................
1b
12
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee?
.................
2
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person?
.
3
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
No
5
Did the organization become aware during the year of a significant diversion of the organizations assets?
.
5
No
6
Did the organization have members or stockholders?
................
6
Yes
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body?
.................
7a
Yes
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body?
............
7b
Yes
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body?
.........................
8a
Yes
b
Each committee with authority to act on behalf of the governing body?
..........
8b
Yes
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organizations mailing address? If Yes, provide the names and addresses in Schedule O
.....
9
No
Section B. Policies
(This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates?
............
10a
No
b
If Yes, did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
....
10b
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990.
.....
12a
Did the organization have a written conflict of interest policy?
If No, go to line 13
.......
12a
Yes
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts?
........................
12b
Yes
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If Yes, describe in Schedule O how this was done
....................
12c
Yes
13
Did the organization have a written whistleblower policy?
...............
13
Yes
14
Did the organization have a written document retention and destruction policy?
.........
14
Yes
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organizations CEO, Executive Director, or top management official
...........
15a
Yes
b
Other officers or key employees of the organization
................
15b
Yes
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year?
......................
16a
No
b
If Yes, did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organizations exempt status with respect to such arrangements?
............
16b
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filed
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
Own website
Another's website
Upon request
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
ANDRE BISSONNETTE
189 PROUTY DRIVE
NEWPORT
,
VT
05855
(802) 334-7331
Form
990
(2011)
Form 990 (2011)
Page
7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII
.........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a
Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organizations tax year.
List all of the organizations
current
officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and
current
key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.
List all of the organizations
current
key employees, if any. See instructions for definition of "key employee."
List the organizations five
current
highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.
List all of the organizations
former
officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.
List all of the organizations
former directors or trustees
that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title
(B)
Average hours per week (describe hours for related organizations in Schedule O)
(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
(1)
KATHRYN AUSTIN
CHAIR
10.0
X
X
0
0
(2)
SCOTT PERRY
TRUSTEE
5.0
X
0
0
(3)
GARY GILLESPIE
TRUSTEE BEG 1/12
5.0
X
0
0
(4)
MELISSA PETTERSSON
SECRETARY/CLERK
5.0
X
X
0
0
(5)
RICHARD BARAW
TRUSTEE
5.0
X
0
0
(6)
ALAN WING
VICE CHAIR - BOARD
5.0
X
X
0
0
(7)
BILL STENGER
TRUSTEE
5.0
X
0
0
(8)
BONNIE NASH
VICE CHAIR - FINANCE THRU 1/12
5.0
X
X
0
0
(9)
MARC BOUCHARD MD
MED STAFF VP, PRES. BEG 10/11
40.0
X
317,076
0
44,120
(10)
JEANE KADMIRI
TRUSTEE
5.0
X
0
0
(11)
DAVE LAFORCE
TRUSTEE, VICE CHR FIN BEG 2/12
5.0
X
X
0
0
(12)
MARK BEAMS
TRUSTEE BEG 1/12
5.0
X
0
0
(13)
BOB WILSON
TRUSTEE
5.0
X
0
0
(14)
CHRISTOPHER RICKMAN MD
TRUSTEE/PHYSICIAN
40.0
X
246,609
0
41,808
(15)
CLAUDIO D FORT
CEO
40.0
X
X
282,769
0
48,501
(16)
ROBERT PRIMEAU
VP MEDICAL STAFF BEG 1/12
5.0
X
0
0
(17)
ANDRE BISSONNETTE
VP OF FINANCE
40.0
X
145,522
0
31,192
Form
990
(2011)
Form 990 (2011)
Page
8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
(continued)
(A)
Name and Title
(B)
Average hours per week (describe hours for related organizations in Schedule O)
(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
(18)
SHERYL WASHBURN
VP PATIENT CARE
40.0
X
156,291
0
6,389
(19)
PETER STUART MD
PHYSICIAN
40.0
X
419,114
0
44,345
(20)
CHRISTOPHER PEER MD
PHYSICIAN
40.0
X
434,259
0
27,980
(21)
GREG WALKER MD
PHYSICIAN
40.0
X
623,232
0
44,345
(22)
VERONIKA JEDLOVSZKY
PHYSICIAN
40.0
X
418,095
0
54,345
(23)
LARRY SISSON MD
PHYSICIAN
40.0
X
475,667
0
45,595
(24)
KIM CAMPBELL
VP MEDICAL GROUP OPERATIONS
40.0
X
151,859
0
23,217
1b
Sub-Total
................
c
Total from continuation sheets to Part VII, Section A
....
d
Total (add lines 1b and 1c)
............
3,670,493
0
411,837
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization
48
Yes
No
3
Did the organization list any
former
officer, director or trustee, key employee, or highest compensated employee on line 1a?
If Yes, complete Schedule J for such individual
.............
3
Yes
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000?
If Yes, complete Schedule J for such individual
...........................
4
Yes
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization?
If Yes, complete Schedule J for such person
.....
5
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organizations tax year.
(A)
Name and business address
(B)
Description of services
(C)
Compensation
MEDICUS HOSPITALISTS SERVICES LLC
PHYSICIAN FEES
1,014,942
NORTH COUNTRY RADIOLOGY PC
PHYSICIAN FEES
798,982
MORRISON MGMT SPECIALIST
CAFETERIA MGMT
567,963
CPS INC
PHARMACY MGMT
315,514
FLETCHER ALLEN
LAB/PHYSICIAN FEES
447,769
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization
15
Form
990
(2011)
Form 990 (2011)
Page
9
Part VIII
Statement of Revenue
(A)
Total revenue
(B)
Related or
exempt
function
revenue
(C)
Unrelated
business
revenue
(D)
Revenue
excluded from
tax under sections
512, 513, or 514
1a
Federated campaigns
..
1a
b
Membership dues
....
1b
c
Fundraising events
....
1c
d
Related organizations
...
1d
20,828
e
Government grants (contributions)
1e
192,614
f
All other contributions, gifts, grants, and
similar amounts not included above
1f
85,749
g
Noncash contributions included in lines 1a-1f:$
h
Total.
Add lines 1a-1f
.......
299,191
Business Code
2a
PATIENT SERVICE REVENUE
624,100
73,343,312
73,343,312
b
OTHER PATIENT SERVICE REVENUE
624,100
3,071,256
3,071,256
c
EHR REVENUE
624,100
1,238,476
1,238,476
d
340B PHARMACY
446,110
1,198,869
1,198,869
e
CAFETERIA
722,210
261,441
261,441
f
All other program service revenue .
g
Total.
Add lines 2a2f
........
79,113,354
3
Investment income (including dividends, interest
and other similar amounts)
.....
557,695
557,695
4
Income from investment of tax-exempt bond proceeds
..
0
5
Royalties
............
0
(i) Real
(ii) Personal
6a
Gross rents
2,397
b
Less: rental expenses
c
Rental income or (loss)
2,397
d
Net rental income or (loss)
.......
2,397
2,397
(i) Securities
(ii) Other
7a
Gross amount from sales of assets other than inventory
12,379,145
54,050
b
Less: cost or other basis and sales expenses
12,295,339
15,491
c
Gain or (loss)
83,806
38,559
d
Net gain or (loss)
..........
122,365
122,365
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
Miscellaneous Revenue
Business Code
11a
HOUSEKEEPING SERVICES
812,900
1,344
1,344
b
ADMINISTRATIVE SERVICES
561,000
5,421
5,421
c
GAIN ON INVEST IN EQUITY INVESTEE
900,099
35,875
35,875
d
All other revenue
....
e
Total.
Add lines 11a11d
......
42,640
12
Total revenue.
See Instructions.
...
80,137,642
79,113,354
6,765
718,332
Form
990
(2011)
Form 990 (2011)
Page
10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns.
All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX.
.........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII.
(A)
Total expenses
(B)
Program service
expenses
(C)
Management and
general expenses
(D)
Fundraising
expenses
1
Grants and other assistance to governments and organizations in the United States. See Part IV, line 21
0
2
Grants and other assistance to individuals in the United States. See Part IV, line 22
0
3
Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
0
4
Benefits paid to or for members
0
5
Compensation of current officers, directors, trustees, and key employees
....
1,495,352
987,368
507,984
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
33,716,695
29,620,863
4,095,832
8
Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions)
....
1,479,649
1,300,970
178,679
9
Other employee benefits
.......
8,072,873
7,182,707
890,166
10
Payroll taxes
...........
2,293,513
1,991,670
301,843
11
Fees for services (non-employees):
a
Management
......
814,074
814,074
b
Legal
.........
69,716
69,716
c
Accounting
...........
66,546
66,546
d
Lobbying
...........
0
e
Professional fundraising.
See Part IV, line 17
..
0
f
Investment management fees
......
198,505
198,505
g
Other
..........
5,896,047
4,912,260
983,787
12
Advertising and promotion
....
295,799
4,000
291,799
13
Office expenses
.......
3,842,127
3,171,097
671,030
14
Information technology
......
111,675
109,977
1,698
15
Royalties
..
0
16
Occupancy
...........
1,146,218
1,053,338
92,880
17
Travel
............
171,706
125,715
45,991
18
Payments of travel or entertainment expenses for any federal, state, or local public officials
......
0
19
Conferences, conventions, and meetings
....
265,367
205,262
60,105
20
Interest
...........
657,070
572,315
84,755
21
Payments to affiliates
.......
0
22
Depreciation, depletion, and amortization
.....
4,361,028
3,917,747
443,281
23
Insurance
..............
884,439
620,796
263,643
24
Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a
MEDICAL SUPPLIES & DRUGS
5,865,854
5,865,854
b
PROVIDER TAX
4,218,074
4,218,074
c
BAD DEBT
2,874,150
2,874,150
d
REPAIRS & MAINTENANCE
2,107,484
1,615,814
491,670
0
e
f
All other expenses
42,329
42,329
25
Total functional expenses.
Add lines 1 through 24f
80,946,290
70,349,977
10,596,313
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).
Form
990
(2011)
Form 990 (2011)
Page
11
Part X
Balance Sheet
(A)
Beginning of year
(B)
End of year
1
Cashnon-interest-bearing
..........
0
1
0
2
Savings and temporary cash investments
.......
5,366,378
2
4,086,513
3
Pledges and grants receivable, net
.........
0
3
37,919
4
Accounts receivable, net
.........
6,805,101
4
9,581,334
5
Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L
..........
0
5
0
6
Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L
..........
0
6
0
7
Notes and loans receivable, net
.............
0
7
0
8
Inventories for sale or use
..............
1,427,476
8
1,453,455
9
Prepaid expenses and deferred charges
............
845,969
9
825,095
10a
Land, buildings, and equipment: cost or other basis.
Complete Part VI of Schedule D
10a
72,578,547
b
Less: accumulated depreciation.
.....
10b
41,950,922
31,732,672
10c
30,627,625
11
Investmentspublicly traded securities
..........
20,601,621
11
24,873,728
12
Investmentsother securities. See Part IV, line 11
......
48,910
12
95,875
13
Investmentsprogram-related. See Part IV, line 11
..
355,731
13
383,366
14
Intangible assets
.........
0
14
0
15
Other assets. See Part IV, line 11
...........
3,721,821
15
1,752,297
16
Total assets.
Add lines 1 through 15 (must equal line 34)
...
70,905,679
16
73,717,207
17
Accounts payable and accrued expenses
.
9,193,788
17
9,611,330
18
Grants payable
..........
0
18
0
19
Deferred revenue
..........
68,839
19
44,115
20
Tax-exempt bond liabilities
..........
22,260,000
20
21,655,000
21
Escrow or custodial account liability.
Complete Part IV of Schedule D
..
0
21
0
22
Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons.
Complete Part II of Schedule L
..........
0
22
0
23
Secured mortgages and notes payable to unrelated third parties
..
696,073
23
770,233
24
Unsecured notes and loans payable to unrelated third parties
....
0
24
0
25
Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24).
Complete Part X of Schedule D
.....
2,839,843
25
4,101,714
26
Total liabilities.
Add lines 17 through 25
.....
35,058,543
26
36,182,392
Organizations that follow SFAS 117,
check here
and complete lines 27 through 29, and lines 33 and 34.
27
Unrestricted net assets
.....
32,786,218
27
34,399,282
28
Temporarily restricted net assets
.....
2,266,209
28
2,340,824
29
Permanently restricted net assets
.....
794,709
29
794,709
Organizations that do not follow SFAS 117,
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
.....
35,847,136
33
37,534,815
34
Total liabilities and net assets/fund balances
.....
70,905,679
34
73,717,207
Form
990
(2011)
Form 990 (2011)
Page
12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI
.........
1
Total revenue (must equal Part VIII, column (A), line 12)
...
1
80,137,642
2
Total expenses (must equal Part IX, column (A), line 25)
....
2
80,946,290
3
Revenue less expenses. Subtract line 2 from line 1
...
3
-808,648
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A))
..
4
35,847,136
5
Other changes in net assets or fund balances (explain in Schedule O)
...
5
2,496,327
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B))
....
6
37,534,815
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII
.........
Yes
No
1
Accounting method used to prepare the Form 990:
Cash
Accrual
Other
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organizations financial statements compiled or reviewed by an independent accountant?
....
2a
No
b
Were the organizations financial statements audited by an independent accountant?
........
2b
Yes
c
If Yes, to 2a or 2b, does the organization have a committee that assumes responsibility for oversight
of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
...........................
2c
Yes
d
If Yes to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
Separate basis
Consolidated basis
Both consolidated and separated basis
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
................
3a
No
b
If Yes, did the organization undergo the required audit or audits?
If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
..
3b
Form
990
(2011)
Additional Data
Software ID:
Software Version:
Form 990, Special Condition Description:
Special Condition Description