SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2017
Open to Public
Inspection
Name of the organization
JOHN D ARCHBOLD MEMORIAL
HOSPITAL INC
Employer identification number

58-0566121
Return Reference Explanation
FORM 990, PAGE 2, PART III, LINE 3 ON NOVEMBER 1, 2017, ARCHBOLD MEDICAL CENTER, THE SOLE MEMBER, ENTERED INTO AN ASSET PURCHASE AGREEMENT WITH A THIRD PARTY FOR THE SALE OF ITS FIVE OUTPATIENT DIALYSIS CENTERS AND ITS HOME DIALYSIS PROGRAM FOR A TOTAL CONSIDERATION OF 30 MILLION.
FORM 990, PAGE 2, PART III, LINE 4A COMMUNITY TO EDUCATE THEM ON IMPORTANT HEALTH NEEDS. JDAMH, INC. ALSO MAINTAINS HOSPITALS IN GRADY COUNTY, BROOKS COUNTY, AND MITCHELL COUNTY, FILING UNDER EIN 58-0566121.
FORM 990, PAGE 2, PART III, LINE 4D MITCHELL COUNTY HOSPITAL AND NURSING HOMES OPERATE IN CAMILLA, GEORGIA AS A CRITICAL ACCESS HOSPITAL WITH 25 ACUTE CARE BEDS AND 156 NURSING HOME BEDS. IT SERVES MITCHELL COUNTY AND 64% OF ITS PATIENTS WERE MEDICARE/MEDICAID. IN 2018, OVER 4.2 MILLION OF INDIGENT CARE WAS PROVIDED TO THE COMMUNITY. IN ADDITION, MITCHELL COUNTY HOSPITAL PROVIDED OVER 5.1 MILLION ADDITIONAL UNCOMPENSATED CARE. EIN 58-6001207 FILED UNDER EIN 58-0566121.
FORM 990, PAGE 6, PART VI, LINE 2 JAMES FALCONER III, MD VICTOR MCMILLAN, MD TRUSTEE TRUSTEE BUSINESS RELATIONSHIP NATHANIEL ABRAMS, JR HAILE MCCOLLUM TRUSTEE TRUSTEE BUSINESS RELATIONSHIP NATHANIEL ABRAMS, JR RICHARD L. SINGLETARY, JR. TRUSTEE TRUSTEE BUSINESS RELATIONSHIP HAILE MCCOLLUM RICHARD L. SINGLETARY, JR. TRUSTEE TRUSTEE BUSINESS RELATIONSHIP
FORM 990, PAGE 6, PART VI, LINE 6 THE ORGANIZATION HAS A SOLE MEMBER, ARCHBOLD MEDICAL CENTER, INC. (AMC) WITH THE POWER TO ELECT OR REPLACE AND TO REMOVE THE TRUSTEES OF THE GOVERNING BODY, AS WELL AS THE AUTHORITY TO APPROVE THE DECISIONS OF THE GOVERNING BODY.
FORM 990, PAGE 6, PART VI, LINE 7A THE BOARD OF TRUSTEES OF THE FILING ENTITY ARE ELECTED ANNUALLY BY THE SOLE MEMBER, AMC. IN ADDITION, AMC HAS THE POWER TO ELECT OR REPLACE AND TO REMOVE THE TRUSTEES OF THE GOVERNING BODY. THE CEO OF AMC SHALL BE A MEMBER OF THE BOARD WITH THE POWER TO VOTE.
FORM 990, PAGE 6, PART VI, LINE 7B THE SOLE MEMBER, AMC HAS THE AUTHORITY TO APPROVE THE DECISIONS OF THE GOVERNING BODY, INCLUDING BUT NOT LIMITED TO, CAPITAL AND OPERATING BUDGETS, MERGERS OR ACQUISITIONS, CONTRACTS AND TRANSACTIONS OVER A CERTAIN AMOUNT, DISSOLUTION, ETC.
FORM 990, PAGE 6, PART VI, LINE 11B A COPY OF THE FORM 990 IS PROVIDED TO TRUSTEES ELECTRONICALLY THROUGH A SECURE WEBSITE PRIOR TO FILING THE RETURN WITH THE IRS. ADDITIONALLY, AN OVERVIEW OF THE RETURN IS PROVIDED TO TRUSTEES IN ATTENDANCE AT A BOARD MEETING GIVING EACH AN OPPORTUNITY TO ASK QUESTIONS AND MAKE COMMENTS.
FORM 990, PAGE 6, PART VI, LINE 12C ON AN ANNUAL BASIS, THE ORGANIZATION DISTRIBUTES A CONFLICT OF INTEREST QUESTIONNAIRE AND DISCLOSURE STATEMENT TO EACH TRUSTEE. THIS QUESTIONNAIRE INCLUDES QUESTIONS RELATED TO FINANCIAL INTERESTS, OUTSIDE INTERESTS OR ACTIVITIES, AND GIFTS, MEALS, AND ENTERTAINMENT. IN ADDITION TO DISCLOSING ANY APPLICABLE INFORMATION ON THE QUESTIONNAIRE, THE TRUSTEE ACKNOWLEDGES THAT (S)HE HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ, UNDERSTANDS, AND AGREES TO COMPLY WITH IT, AND UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. RESPONSES ARE SUMMARIZED AND COLLECTIVELY REVIEWED BY THE AUDIT & COMPLIANCE COMMITTEE OF AMC, THE SOLE MEMBER. DURING EACH BOARD MEETING, THE CHAIRMAN INQUIRES IF ANY TRUSTEE HAS AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST RELATED TO ANY AGENDA ITEM. IF THE TRUSTEE DISCLOSES ANY SUCH INTEREST, THE TRUSTEE IS EXCUSED FROM THE MEETING WHILE THE DETERMINATION AS TO WHETHER AN ACTUAL CONFLICT OF INTEREST EXISTS IS DISCUSSED AND VOTED UPON BY DISINTERESTED MEMBERS OF THE BOARD AND COMMITTEE. IF INVITED TO DO SO, THE TRUSTEE WITH A POTENTIAL CONFLICT MAY RESPOND TO QUESTIONS PUT FORTH BY FELLOW DISINTERESTED TRUSTEES REGARDING ANY PROPOSED TRANSACTION OR ARRANGEMENT. THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS DOCUMENTS THE NAME OF ANY INTERESTED PERSON/TRUSTEE WHO DISCLOSED OR WAS FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH A TRANSACTION OR ARRANGEMENT RESULTING IN AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; AND THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATED TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSIONS, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH.
FORM 990, PAGE 6, PART VI, LINE 15A ARCHBOLD MEDICAL CENTER'S (AMC) COMPENSATION COMMITTEE (COMMITTEE) OF THE AMC BOARD OF TRUSTEES MAKES RECOMMENDATIONS TO THE FULL AMC BOARD ON THE FOLLOWING POSITIONS: THE PRESIDENT OF AMC AND THE PRESIDENT OF THE ARCHBOLD FOUNDATION. AMC'S PRESIDENT PRESENTS RECOMMENDATIONS FOR ALL SENIOR VICE PRESIDENTS, VICE PRESIDENTS, AND OTHER KEY EMPLOYEES OF AMC AND ALL RELATED ARCHBOLD ENTITIES TO THE COMMITTEE. SINCE AMC HAS RESERVE POWERS FOR ARCHBOLD RELATED ENTITIES, THE COMMITTEE SERVES AS THE COMPENSATION COMMITTEE FOR EACH APPLICABLE ARCHBOLD ENTITY. THE COMMITTEE CONSIDERS THE AMC PRESIDENT'S RECOMMENDATIONS, BUT IT ALSO CONSIDERS RECOMMENDATIONS AND INDEPENDENT MARKET DATA ANALYSIS FROM AN INDEPENDENT COMPENSATION CONSULTANT. THE AMC BOARD UTILIZES AN INDEPENDENT COMPENSATION CONSULTANT TO REVIEW THE EXECUTIVE COMPENSATION PROGRAM AND MAKE RECOMMENDATIONS REGARDING PLAN DESIGN AND ACTUAL COMPENSATION INCLUDING BENEFITS.
FORM 990, PAGE 6, PART VI, LINE 15B SEE 15A ABOVE.
FORM 990, PAGE 6, PART VI, LINE 19 NO DOCUMENTS ARE OR WILL BE MADE AVAILABLE TO THE PUBLIC.
FORM 990, PART IX, LINE 11G CONSULTANT FEES JDAMH 0 255,069 0 CONTRACT SERVICES JDAMH 14,878,106 1,128,136 0 CONTRACT SERVICES BROOKS 349,886 0 0 CONTRACT SERVICES GRADY 2,407,729 0 0 CONTRACT SERVICES MITCHELL 2,243,195 0 0 OUTSIDE LAB REFERRAL FEES JDA 1,102,467 0 0 OUTSIDE LAB REFERRAL GRADY 171,094 0 0 OUTSIDE LAB REFERRAL BROOKS 2,972 0 0 PROFESSIONAL FEES JDAMH 17,106,135 2,903,127 0 PROFESSIONAL FEES GRADY 2,332,705 0 0 PROFESSIONAL FEES BROOKS 806,243 0 0 PROFESSIONAL FEES MITCHELL 1,459,937 0 0 TOTAL 42,860,469 4,286,332 0
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2017


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