TY 2013 Form 990 Schedule O

efile Public Visual Render ObjectId: 201532249349301198 - Submission: 2015-08-12 TIN: 59-3322533

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
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Attach to Form 990 or 990-EZ.
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Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

SOUTH LAKE HOSPITAL INC

Employer identification number

59-3322533

Return Reference	Explanation
FORM 990, PAGE 6, PART VI, LINE 3	OH PROVIDES THE HOSPITAL'S PRESIDENT, CFO, COO AND CNO PURSUANT TO A MANAGEMENT AGREEMENT WITH THE HOSPITAL.
FORM 990, PAGE 6, PART VI, LINE 7A	FIFTY PERCENT OF THE BOARD MEMBERS ARE APPOINTED BY OH WHILE THE REMAINING MEMBERS ARE APPOINTED BY SOUTH LAKE MEMORIAL HOSPITAL, INC. ON BEHALF OF SOUTH LAKE COUNTY HOSPITAL DISTRICT ("DISTRICT"), A RELATED ORGANIZATION. THE DISTRICT LEVIES AD VALOREM TAXES AND HAS USED THE TAXES COLLECTED TO SUPPORT THE HOSPITAL. NEITHER RELATED ORGANIZATION HAS TECHNICAL CONTROL OF THE HOSPITAL.
FORM 990, PAGE 6, PART VI, LINE 11B	THE BOARD CHAIR WILL REVIEW THE FORM 990 WITH THE CFO WITH ALL QUESTIONS AND NEW SCHEDULES BEING REVIEWED AS WELL AS THE RECONCILIATION TO THE AUDITED FINANCIAL STATEMENTS PRIOR TO FILING WITH THE IRS.
FORM 990, PAGE 6, PART VI, LINE 12C	ANNUALLY, THE COMPLIANCE OFFICER FOR OH PROVIDES A QUESTIONNAIRE TO THE LEADERSHIP, BOARD OF DIRECTORS, DISTRICT BOARD OF TRUSTEES AND MEDICAL STAFF LEADERSHIP FOR DISCLOSURE IN REGARDS TO POTENTIAL CONFLICTS OF INTEREST. THE OH COMPLIANCE OFFICER EVALUATES EACH QUESTIONNAIRE AND WILL REQUEST ADDITIONAL INFORMATION SHOULD IT BE REQUIRED. ANY VOTING RIGHTS OR COMPENSATION RECEIVED IN RELATION TO ANY COMPETING ENTITIES IS QUESTIONED AS WELL AS OWNERSHIP IN ANY VENDOR STOCK DIRECTLY. IF ANY CONFLICT OF INTEREST OCCURS, THAT INDIVIDUAL IS RECUSED FROM THAT PORTION OF THE MEETING REGARDING THE CONFLICTED TRANSACTION.
FORM 990, PAGE 6, PART VI, LINE 19	FINANCIAL STATEMENTS ARE MADE AVAILABLE THROUGH CONTINUING DISCLOSURE AGREEMENT WITH DIGITAL ASSURANCE CORPORATION (DAC). GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST THROUGH THE SUNSHINE LAW.
FORM 990, PART IX, LINE 11G	CONTRACT SERVICE 4,474,316 915,251 0 REFERENCE LAB 744,719 0 0 PROFESSIONAL FEES 3,998,958 0 0 OTHER FEES 487,259 14,956 0 PURCHASED SERVICES 409,585 5,262,775 0 COURIER 35,408 4,548 0 CONSULTING FEES 0 493,905 0 COLLECTION 178,108 2,462,149 0 UBTI - OTHER FEES 335,468 0 0
FORM 990, PART XI, LINE 9	RENTAL EXPENSES 209,319 NET ASSETS RELEASED FROM RESTRICTIONS 40,224 CAPITAL CONTRIBUTIONS -480,743 GRANT EXPENSE NETTED AGAINST REVENUE -1,000,000 UNREALIZED IMPAIRMENT LOSS -371,833 RENTAL EXPENSE -209,319 GRANT EXPENSE NETTED AGAINST REVENUE 1,000,000 SCHOLARSHIPS FROM NET ASSETS 25,456
FORM 990, PART XI, LINE 9	NET ASSETS RELEASED FROM RESTRICTIONS -40,224 CAPITAL CONTRIBUTIONS 480,743 CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 975,001 TOTAL INCREASE IN NET ASSETS 628,624

Return Reference

Explanation

FORM 990, PAGE 6, PART VI, LINE 3

OH PROVIDES THE HOSPITAL'S PRESIDENT, CFO, COO AND CNO PURSUANT TO A MANAGEMENT AGREEMENT WITH THE HOSPITAL.

FORM 990, PAGE 6, PART VI, LINE 7A

FIFTY PERCENT OF THE BOARD MEMBERS ARE APPOINTED BY OH WHILE THE REMAINING MEMBERS ARE APPOINTED BY SOUTH LAKE MEMORIAL HOSPITAL, INC. ON BEHALF OF SOUTH LAKE COUNTY HOSPITAL DISTRICT ("DISTRICT"), A RELATED ORGANIZATION. THE DISTRICT LEVIES AD VALOREM TAXES AND HAS USED THE TAXES COLLECTED TO SUPPORT THE HOSPITAL. NEITHER RELATED ORGANIZATION HAS TECHNICAL CONTROL OF THE HOSPITAL.

FORM 990, PAGE 6, PART VI, LINE 11B

THE BOARD CHAIR WILL REVIEW THE FORM 990 WITH THE CFO WITH ALL QUESTIONS AND NEW SCHEDULES BEING REVIEWED AS WELL AS THE RECONCILIATION TO THE AUDITED FINANCIAL STATEMENTS PRIOR TO FILING WITH THE IRS.

FORM 990, PAGE 6, PART VI, LINE 12C

ANNUALLY, THE COMPLIANCE OFFICER FOR OH PROVIDES A QUESTIONNAIRE TO THE LEADERSHIP, BOARD OF DIRECTORS, DISTRICT BOARD OF TRUSTEES AND MEDICAL STAFF LEADERSHIP FOR DISCLOSURE IN REGARDS TO POTENTIAL CONFLICTS OF INTEREST. THE OH COMPLIANCE OFFICER EVALUATES EACH QUESTIONNAIRE AND WILL REQUEST ADDITIONAL INFORMATION SHOULD IT BE REQUIRED. ANY VOTING RIGHTS OR COMPENSATION RECEIVED IN RELATION TO ANY COMPETING ENTITIES IS QUESTIONED AS WELL AS OWNERSHIP IN ANY VENDOR STOCK DIRECTLY. IF ANY CONFLICT OF INTEREST OCCURS, THAT INDIVIDUAL IS RECUSED FROM THAT PORTION OF THE MEETING REGARDING THE CONFLICTED TRANSACTION.

FORM 990, PAGE 6, PART VI, LINE 19

FINANCIAL STATEMENTS ARE MADE AVAILABLE THROUGH CONTINUING DISCLOSURE AGREEMENT WITH DIGITAL ASSURANCE CORPORATION (DAC). GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST THROUGH THE SUNSHINE LAW.

FORM 990, PART IX, LINE 11G

CONTRACT SERVICE 4,474,316 915,251 0 REFERENCE LAB 744,719 0 0 PROFESSIONAL FEES 3,998,958 0 0 OTHER FEES 487,259 14,956 0 PURCHASED SERVICES 409,585 5,262,775 0 COURIER 35,408 4,548 0 CONSULTING FEES 0 493,905 0 COLLECTION 178,108 2,462,149 0 UBTI - OTHER FEES 335,468 0 0

FORM 990, PART XI, LINE 9

RENTAL EXPENSES 209,319 NET ASSETS RELEASED FROM RESTRICTIONS 40,224 CAPITAL CONTRIBUTIONS -480,743 GRANT EXPENSE NETTED AGAINST REVENUE -1,000,000 UNREALIZED IMPAIRMENT LOSS -371,833 RENTAL EXPENSE -209,319 GRANT EXPENSE NETTED AGAINST REVENUE 1,000,000 SCHOLARSHIPS FROM NET ASSETS 25,456

FORM 990, PART XI, LINE 9

NET ASSETS RELEASED FROM RESTRICTIONS -40,224 CAPITAL CONTRIBUTIONS 480,743 CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 975,001 TOTAL INCREASE IN NET ASSETS 628,624

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2013

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