2023-08-12T07:03:16-05:00 2022-09-30 390859910 BAKER TILLY US LLP 225 S 6TH ST 2300 MINNEAPOLIS MN 55402 990 2021-10-01 952821104 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENR 6612002000 23845 MCBEAN PARKWAY VALENCIA CA 91355 TED D SIROTTA SENIOR VP/CFO 6612002000 2023-08-11 1 TED SIROTTA XXX-XX-XXXX LAWRENCE H MOHR CPA P00447603 6128764500 2023-08-11 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z KEVIN KLOCKENGA 23845 MCBEAN PARKWAY VALENCIA CA 91355 477163858 0 X WWW.HENRYMAYO.COM X 1972 CA BE THE TRUSTED REGIONAL LEADER TO INSPIRE AND DELIVER OPTIMAL HEALTH AND WELLNESS. 14 13 2148 192 314282 0 5775437 9178013 405891441 435164931 3644069 8005193 4415795 6269956 419726742 458618093 6193451 13597125 0 0 163819648 173982619 0 0 0 238027282 265303296 408040381 452883040 11686361 5735053 625737572 572450898 406757573 370900682 218979999 201550216 BE THE TRUSTED REGIONAL LEADER TO INSPIRE AND DELIVER OPTIMAL HEALTH AND WELLNESS. 0 0 411345646 13230272 437311073 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF SANTA CLARITA VALLEY AND SURROUNDING AREAS. THE HOSPITAL HAD 60,309 PATIENT DAYS DURING THE YEAR. WE ALSO PROVIDED SERVICES FOR 64,799 EMERGENCY VISITS. 76% OF TOTAL HOSPITAL INPATIENT ADMITS (EXCLUDING NEWBORNS) ARE ADMITTED THROUGH THE EMERGENCY ROOM. 366853 366853 TO SUPPORT GENERAL OPERATIONS OF HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION, AN AFFILIATE TO THE HOSPITAL. 411712499 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 1 1 0 0 1 249 0 1 2148 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 CA X RICHARD KIM 6612002000 23845 MCBEAN PARKWAY VALENCIA CA 91355 ROGER E SEAVER PRESIDENT/CEO 40.00 0.50 X X 962007 0 53975 CHRIS LUECHTEFELD TRUSTEE 0.50 X 0 0 0 DALE R DONOHOE TRUSTEE 0.50 X 0 0 0 DON NISHIGUCHI MD TRUSTEE (THROUGH 04/2022) 10.00 X 0 0 0 DONALD KIMBALL TRUSTEE 0.50 X 0 0 0 HOLLY SHROEDER TRUSTEE 0.50 0.50 X 0 0 0 JOHN BARSTIS MD TRUSTEE 0.50 X 0 0 0 JUDY FISH TRUSTEE 0.50 X 0 0 0 LAKHBINDER DHANDA MD TRUSTEE 2.24 X 0 0 0 MARK CHAMBERLAIN TRUSTEE 0.50 X 0 0 0 ROBERT BENJAMIN TRUSTEE 0.50 X 0 0 0 ROSCOE MARTER MD TRUSTEE 0.50 X 0 0 0 RUSSELL HANLIN TRUSTEE 0.50 X 0 0 0 SONYA ENGLE TRUSTEE 0.50 X 0 0 0 TODD STEVENS TRUSTEE 0.50 X 0 0 0 LARRY R KIDD SR VP/CCO (RETIRED 01/2022) 40.00 X 481536 0 80114 TED D SIROTTA SR VP/CFO 40.00 X 464338 0 95887 RAY B MOSS VP/CIO 40.00 X 352084 0 68390 MARK A PULEO VP/CHRO 40.00 X 317841 0 67770 ROBERT K PRETZLAFF SR VP CMO & CCO 40.00 X 330304 0 40845 CARISSA BORTUGNO VP CLINICAL SUPPORT 40.00 X 246444 0 41645 KYUNG R KIM DIRECTOR OF FINANCE 40.00 X 210053 0 33662 JOCELYN P ABUYUAN CLINICAL RN, MED SURG 1 40.00 X 239239 0 3270 KATHRYN A ORTEGA CLINICAL RN 40.00 X 206984 0 26325 JOSEPHINE J KAPLAN DIRECTOR CASE MANAGEMENT 40.00 X 206991 0 17225 JENNIFER N FITZPATRICK DIR. - CRITICAL CARE SERVICES 40.00 X 210828 0 12513 4228649 0 541621 509 0 1 0 SODEXO INC & AFFILIATES 9801 WASHINGTON BLVD GAITHERSBURG MD 20878 OTHER PURCHASED SERVICES 16007360 PROLINK HEALTHCARE LLC 4600 MONTGOMERY ROAD SUITE 300 CINCINNATI OH 45212 PROFESSIONAL SERVICES 12539315 INTERSTATE REHABILITATION LLC 333 E GLENOAKS BLVD SUITE 204 GLENDALE CA 61207 MEDICAL PURCHASED SERVICES 7636135 MEDEFIS INC 12400 HIGH BLUFF DRIVE SUITE 100 SAN DIEGO CA 92130 PROFESSIONAL SERVICES 6867328 CARE STAT INC 13355 W WASHINGTON BLVD LOS ANGELES CA 90066 PROFESSIONAL SERVICES 5448233 241 9178013 9178013 HEALTHCARE SERVICES 621110 435164931 435164931 435164931 2645357 2645357 12443 12443 1359126 743127 615999 615999 615999 23136318 13713 17802638 0 5333680 13713 5347393 5347393 FITNESS CENTER REVENUE 621110 1540378 1540378 INCOME FROM CARE NETWO 621110 600000 600000 SUPPORT SERVICES 621110 314282 314282 3199297 5764 3193533 5653957 458618093 437311073 314282 11814725 X 366853 366853 13230272 13230272 3975515 3504101 471414 124930014 111779623 13150391 4007482 3544651 462831 30442127 26937362 3504765 10627481 9611469 1016012 987215 987215 368513 368513 81095 81095 147623 147623 81251520 73473718 7777802 469704 9336 460368 1582037 1580608 1429 8708259 7868675 839584 9061658 4439148 4622510 125375 56953 68422 143452 121939 21513 9101160 7056194 2044966 22048045 22048045 2289071 2289071 MEDICAL SUPPLIES 58555804 57899674 656130 BAD DEBT 39186448 39186448 QUALITY ASSURANCE FEES 20412312 20412312 REPAIR & MAINTENANCE 4717768 3710538 1007230 6066237 2585509 3480728 452883040 411712499 41170541 0 66762900 46362926 21269535 15132377 54237213 50933178 7557468 6790718 5797981 5619814 516469072 251346043 279401629 265123029 103089886 87080265 3658870 4546861 83962090 90861730 625737572 572450898 81546657 77332275 3666047 3809813 232857418 225199111 6720053 6993164 81967398 57566319 406757573 370900682 X 209927480 192253569 9052519 9296647 218979999 201550216 625737572 572450898 X 5735053 -25025605 1860769 X X 0 1 X 1 1 1 X 0 0 0 0 0 0 0 0 0 1 81095 81095 0 PART II-B, LINE 1: FOR THE FISCAL YEAR ENDED 9/30/22, THE ORGANIZATION PARTICIPATED WITH THE CALIFORNIA HOSPITAL ASSOCIATION TO ADVOCATE POSITIVE HEALTHCARE POLICIES FOR HOSPITALS. 5838234 5838234 369930458 139595348 230335110 134012283 111750695 22261588 6688097 6688097 265123029 RECEIVABLE FROM HENRY MAYO NEWHALL FOUNDATION 9805930 RECEIVABLE FROM HENRY MAYO MSO 895117 PLEDGED LEASE 2168687 OTHER RECEIVABLES 30776960 RECEIVABLE FOR HENRY MAYO CIN -38700 OTHER CURRENT ASSETS 36703 RIGHT-OF-USE ASSET 47217033 90861730 ESTIMATED THIRD PARTY LIABILITIES 5885022 PAYABLE TO AFFILIATE 447380 OTHER LIABILITIES 8097965 LEASE OBLIGATIONS 43135952 57566319 X 383824766 -25025605 45102 -50555951 -75536454 459361220 -743127 -743127 458618093 401254549 45102 743127 788229 400466320 52416720 52416720 452883040 PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501 (C)(3) OF THE INTERNAL REVENUE CODE ("IRC") AND A SIMILAR PROVISION OF STATE LAW. ACCORDINGLY, NO PROVISION FOR INCOME TAXES FOR THIS ENTITY HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE ORGANIZATION HAS NO UNCERTAIN TAX POSITIONS AT SEPTEMBER 30, 2022 AND 2021. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -39,186,448. CHARITY CARE (GROSS CHARGES) -13,230,272. NET ASSET TRANSFER FROM HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 1,860,769. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -743,127. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 743,127. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 39,186,448. CHARITY CARE (GROSS CHARGES) 13,230,272. 1 1 X 1 X 1 X 1 1 1 0 1 1 3237847 3237847 0.00780 17651730 5030756 12620974 0.03050 20889577 5030756 15858821 0.03830 608441 608441 0.00150 2897558 2897558 0.00700 1197854 1197854 0.00290 4703853 4703853 0.01140 25593430 5030756 20562674 0.04970 1 39186448 59151992 83597417 -24445425 X 1 1 1 TOWER IMAGING VALENCIA OUTPATIENT RADIOLOGY SERVICE 0.50000 0.00000 0.50000 2 HENRY MAYO NEWHALL URGENT CARE CLINICS LLC URGENT CARE OPERATION 0.51000 0.49000 3 KECK MEDICINE OF USC AND HENRY MAYO NEWHALL MEMORIAL HOSPITAL LLC CANCER SERVICE LINE 0.50000 1 1 HENRY MAYO NEWHALL MEMORIAL HOSPITAL 23845 MCBEAN PKWY VALENCIA CA 91355 WWW.HENRYMAYO.COM 930000206 X X X TRAUMA CENTER HENRY MAYO NEWHALL MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 0 0 1 X SEE SCHEDULE H, PART V, SECTION C X 1 22 1 HTTPS://WWW.HENRYMAYO.COM/ABOUT-US/COMMUNITY-INVOLVEMENT/ 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X SEE SCHEDULE H, PART V, SECTION C X SEE SCHEDULE H, PART V, SECTION C X SEE SCHEDULE H, PART V, SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 HENRY MAYO NEWHALL MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: HENRY MAYO COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN FY22, AS REQUIRED BY STATE AND FEDERAL LAW. THE CHNA IS A PRIMARY TOOL USED BY HENRY MAYO TO DETERMINE ITS COMMUNITY BENEFIT PLAN, WHICH OUTLINES HOW IT WILL GIVE BACK TO THE COMMUNITY IN THE FORM OF HEALTH CARE AND OTHER COMMUNITY SERVICES TO ADDRESS UNMET COMMUNITY HEALTH NEEDS. THE ASSESSMENT INCORPORATED COMPONENTS OF PRIMARY DATA COLLECTION AND SECONDARY DATA ANALYSIS THAT FOCUSED ON THE HEALTH AND SOCIAL NEEDS OF THE SERVICE AREA.THE CHNA EXAMINED UP-TO-DATE DATA SOURCES FOR THE SERVICE AREA TO COMPILE COMMUNITY DEMOGRAPHICS, SOCIAL DETERMINANTS OF HEALTH, HEALTH CARE ACCESS, BIRTH INDICATORS, LEADING CAUSES OF DEATH, COVID-19, ACUTE AND CHRONIC DISEASE, HEALTH BEHAVIORS, MENTAL HEALTH, SUBSTANCE USE, AND PREVENTIVE PRACTICES. HENRY MAYO CONDUCTED TARGETED INTERVIEWS TO GATHER INFORMATION AND OPINIONS FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL. THERE WERE TWENTY-ONE (21) INTERVIEWS COMPLETED IN MARCH 2022. LEADERS AND/OR REPRESENTATIVES OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS, LOCAL HEALTH OR OTHER DEPARTMENTS OR AGENCIES THAT HAVE CURRENT DATA OR OTHER INFORMATION RELEVANT TO THE HEALTH NEEDS OF THE COMMUNITY WERE REPRESENTED IN THE SAMPLE. INPUT WAS OBTAINED FROM THE LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH. HENRY MAYO NEWHALL MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: ACCESS TO HEALTH CARE, CHRONIC DISEASES, COVID-19, HOUSING AND HOMELESSNESS AND MENTAL HEALTH WERE RANKED AS THE TOP FIVE PRIORITY NEEDS IN THE SERVICE AREA. THE CALCULATIONS OF THE COMMUNITY INPUT RESULTED IN THE FOLLOWING PRIORITY ORDERING OF THE SIGNIFICANT HEALTH NEEDS:1. ACCESS TO HEALTH CARE2. CHRONIC DISEASES (ALZHEIMER'S DISEASE, ASTHMA, CANCER, DIABETES, HEART DISEASE, HYPERTENSION)3. COVID-194. HOUSING AND HOMELESSNESS5. MENTAL HEALTH6. OVERWEIGHT/OBESITY (HEALTHY EATING AND PHYSICAL ACTIVITY)7. PREVENTIVE PRACTICES (SCREENINGS AND IMMUNIZATIONS)8. SUBSTANCE USEFOR SPECIFIC PLAN AND OTHER NEEDS NOT ADDRESSED, PLEASE REFER TO THE ATTACHED COMMUNITY BENEFIT REPORT, PAGES 8-10. SCHEDULE H, PART V, LINE 7A CHNA REPORT DIRECT LINK: HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/3F5A915D-E7CF-4A20-B329-E9EDC4593AD5/HENRY%20MAYO%202022%20CHNA%20REPORT%20FINAL.PDF SCHEDULE H, PART V, LINE 16A FINANCIAL ASSISTANCE POLICY (FAP): HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/0F751BD9-9EEB-4A09-BCCD-224995E0F5BB/FINANCIAL%20ASSISTANCE%20PROGRAM%2010.10.2022%20(2).PDF SCHEDULE H, PART V, LINE 16B FAP APPLICATION FORM: HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/D6CC943E-020F-4905-B76B-FC76D1A9917F/FINANCIAL%20ASSISTANCE%20PROGRAM%2010.10.2022%20APPLICATION.PDF SCHEDULE H, PART V, LINE 16C FAP PLAIN LANGUAGE SUMMARY: HTTPS://WWW.HENRYMAYO.COM/APP/FILES/PUBLIC/0995F2AD-7A89-48F2-8F45-C5B237B3C5C2/MR242D-%20FINAL%20COPY.PDF PART I, LINE 3C: INDIVIDUAL OR HOUSEHOLD UNIT INCOME - UP TO 400% OF THE FPL. EMPLOYMENT STATUS SHALL BE CONSIDERED WHEN DETERMINING INCOME LEVELS. PRIOR INCOME LEVELS MAY NOT MEET THE ESTABLISHED POVERTY LEVEL GUIDELINES; HOWEVER, RECENT UNEMPLOYMENT SHOULD BE CONSIDERED AS THE CURRENT SOURCE OF INCOME. INDIVIDUAL OR HOUSEHOLD UNIT NET WORTH - UP TO $250,000 (EXCLUDING NET WORTH IN PRIMARY HOMES OF UP TO $500,000 AND RETIREMENT OR DEFERRED COMPENSATION PLANS). WHEN REVIEWING NET WORTH, OTHER FINANCIAL OBLIGATIONS SUCH AS HIGH MEDICAL BILLS SHOULD BE CONSIDERED. PATIENTS WITH HIGH NET WORTH THAT WOULD OTHERWISE DISQUALIFY THEM FOR FINANCIAL ASSISTANCE MAY BE CONSIDERED FOR ELIGIBILITY IF THEY HAVE, FOR EXAMPLE, UNINSURED CATASTROPHIC HEALTH CARE COSTS THAT WOULD SIGNIFICANTLY REDUCE THEIR NET WORTH. HIGH MEDICAL COSTS SHALL MEAN:1. ANNUAL OUT-OF-POCKET COSTS INCURRED BY A PATIENT AT HMNH THAT EXCEED 10% OF THE PATIENT'S FAMILY INCOME IN THE PRIOR 12 MONTHS;2. ANNUAL OUT-OF-POCKET MEDICAL EXPENSES THAT EXCEED 10% OF THE PATIENT'S FAMILY INCOME, IF THE PATIENT PROVIDES DOCUMENTATION OF THE PATIENT'S MEDICAL EXPENSES PAID BY THE PATIENT OR THE PATIENT'S FAMILY IN THE PRIOR 12 MONTHS;SELF-PAY PATIENTS ADMITTED THROUGH THE EMERGENCY DEPARTMENT, PER EMTALA GUIDELINES, WITH INSUFFICIENT INFORMATION PROVIDED BY THE PATIENT TO FULLY EVALUATE ELIGIBILITY TESTS, AND THE ABILITY TO PAY WHICH CANNOT BE RELIABLY DETERMINED, WILL BE CLASSIFIED AS CHARITY. IF INFORMATION BECOMES AVAILABLE LATER THAT WOULD DISQUALIFY THE PATIENT FROM MEETING THE FINANCIAL ASSISTANCE CRITERIA, THEN THE PATIENT ACCOUNT WILL BE RECLASSIFIED TO THE APPROPRIATE PAYER CLASS.PATIENTS WHO QUALIFY FOR MEDI-CAL, BUT WHERE HMNH DOES NOT RECEIVE PAYMENT FOR THEIR ENTIRE STAY ARE ELIGIBLE FOR CHARITY CARE FOR DENIED STAYS, DENIED DAYS OF CARE, AND NONCOVERED SERVICES. THESE DENIALS AND ANY LACK OF PAYMENT FOR NON-COVERED SERVICES PROVIDED TO MEDI-CAL PATIENTS ARE TO BE CLASSIFIED AS CHARITY. THESE PATIENTS ARE RECEIVING THE SERVICE, AND THEY DO NOT HAVE THE ABILITY TO PAY FOR IT. IN ADDITION, MEDICARE PATIENTS WHO HAVE MEDI-CAL COVERAGE FOR THEIR CO-INSURANCE/DEDUCTIBLES, FOR WHICH MEDI-CAL DOES NOT MAKE PAYMENT, AND MEDICARE DOES NOT ULTIMATELY PROVIDE BAD DEBT REIMBURSEMENT WILL ALSO BE INCLUDED AS CHARITY. THESE PATIENTS ARE RECEIVING A SERVICE FOR WHICH A PORTION OF THE RESULTING BILL IS NOT BEING REIMBURSED.TRAUMA SERVICES RENDERED TO PATIENT MEDICAL CONDITIONS MEETING THE DEFINITION OF BILLABLE TRAUMA CARE, PER OUR TRAUMA CARE AGREEMENTS WITH THE LOS ANGELES COUNTY AND THE STATE OF CALIFORNIA, WILL BE CLASSIFIED AS CHARITY CARE. THESE PATIENTS WILL NOT BE BILLED FOR THEIR SERVICES.HMNH DEEMS PATIENTS WHO ARE ELIGIBLE FOR GOVERNMENT SPONSORED, LOW-INCOME ASSISTANCE PROGRAMS (I.E., MEDI-CAL, OUT OF STATE MEDICAID, CALIFORNIA CHILDREN'S SERVICES AND ANY OTHER APPLICABLE FEDERAL, STATE, OR LOCAL LOW-INCOME PROGRAM) TO BE INDIGENT. THEREFORE, SUCH PATIENTS MAY BE CONSIDERED AS ELIGIBLE PRESUMPTIVELY UNDER THE FAP WHEN PAYMENT IS NOT MADE BY THE GOVERNMENTAL PROGRAM. RATIONALE FOR SUCH PRESUMPTIVE DETERMINATION SHALL BE DOCUMENTED IN THE PATIENT ACCOUNT. PART III, LINE 2: THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE CARRYING AMOUNT OF PATIENT ACCOUNTS RECEIVABLE IS REDUCED BY BAD DEBT ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 4: FROM PAGE 16 OF THE AUDITED FINANCIAL STATEMENTS, ATTACHED:GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE HOSPITAL ALSO PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED OR UNDERINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FROM THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGES, BY ANY CONTRACTUAL ADJUSTMENT, DISCOUNTS, AND IMPLICIT PRICE CONCESSIONS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENT TO NET PATIENT SERVICE REVENUE IN THE PERIOD OF THE CHANGE. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. CONSISTENT WITH THE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, THE HOSPITAL HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND OTHER PATIENT BALANCES (FOR EXAMPLE, COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS THE HOSPITAL EXPECTS TO COLLECT BASED ON ITS COLLECTION HISTORY WITH THOSE PATIENTS. PART III, LINE 8: 100% INCLUDED IN THE COMMUNITY BENEFIT PACKAGE. COST METHODOLOGY IS COST ACCOUNTING SYSTEM. PART VI, LINE 2: NEEDS ASSESSMENT: HENRY MAYO COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN 2021, AS REQUIRED BY STATE AND FEDERAL LAW. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS A PRIMARY TOOL USED BY HENRY MAYO TO DETERMINE ITS COMMUNITY BENEFIT PLAN, WHICH OUTLINES HOW IT WILL GIVE BACK TO THE COMMUNITY, IN THE FORM OF HEALTH CARE AND OTHER COMMUNITY SERVICES, TO ADDRESS UNMET COMMUNITY NEEDS. THE ASSESSMENT INCORPORATED COMPONENTS OF PRIMARY DATA COLLECTION AND SECONDARY DATA ANALYSIS THAT FOCUS ON THE HEALTH AND SOCIAL NEEDS OF THE SERVICE AREA. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: HTTPS://WWW.HENRYMAYO.COM/PATIENTS-VISITORS/BILLING-INSURANCE-AND-FINANCIAL-ASSISTANCE/FINANCIAL-POLICIES/ PART VI, LINE 4: COMMUNITY INFORMATION: PAGE 3-4 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 5: PAGE 7-17 OF THE COMMUNITY BENEFIT PACKAGE WHICH IS ATTACHED. PART VI, LINE 7, REPORTS FILED WITH STATES CA 1 WILLIAM S HART UNION HIGH SCHOOL DISTRICT 21380 CENTRE POINTE PARKWAY SANTA CLARITA CA 91350 611454418 501(C)(3) 279140 0 TO PROVIDE ATHLETIC TRAINERS AT HIGH SCHOOLS IN THE COMMUNITY TO HELP REDUCE INJURIES AND KEEP STUDENT ATHLETES SAFE ID ME PROMOTIONS 18401 BURBANK BLVD SUITE 116 TARZANA CA 91356 470941148 501(C)(3) 33411 0 TO SUPPORT COMMUNITY HEALTH EDUCATION BRIDGE TO HOME SCV 23752 NEWHALL AVE SANTA CLARITA CA 91321 954587823 501(C)(3) 19167 0 CAPITAL CAMPAIGN PLEDGE SANTA CLARITA VALLEY ECONOMIC 26455 ROCKWELL CANYON ROAD UNIVERSITY CENTER 263 VALENCIA CA 91355 954133918 501(C)(3) 17925 0 TO SUPPORT LOCAL ECONOMIC DEVELOPMENT AMERICAN CANCER SOCIETY 25020 W AVENUE STANFORD SUITE170 VALENCIA CA 91355 131788491 501(C)(3) 7500 0 COMMUNITY CANCER EDUCATION 5 0 CHARITY CARE (GROSS CHARGES) - HENRY MAYO NEWHALL HOSPITAL 1339 13230272 PART I, LINE 2: THE HOSPITAL ASSISTS INDIVIDUALS WHO ARE UNINSURED OR UNDERINSURED BY PROVIDING CHARITY CARE. THIS IS APPLIED BY FOLLOWING THE HOSPITAL'S CHARITY CARE POLICY. THIS POLICY IS ADMINISTERED THROUGH THE PATIENT FINANCIAL SERVICE AND PATIENT ACCESS DEPARTMENTS OF THE HOSPITAL. PART II: THE HOSPITAL SUPPORTS (PROVIDES GRANTS TO) ORGANIZATIONS THAT EITHER DO WORK IN AREAS RELATED TO THE HEALTH NEEDS IDENTIFIED IN OUR COMMUNITY HEALTH NEEDS ASSESSMENT, AND TO ORGANIZATIONS THAT SUPPORT ECONOMIC DEVELOPMENT. FOR THE HEALTH-RELATED ACTIVITIES WE TRACK HOW MANY PEOPLE WE REACH AT PARTICULAR EVENTS, CLASSES OR SEMINARS. FOR ECONOMIC ACTIVITIES WE SUPPORT ORGANIZATIONS THAT HAVE BROAD COMMUNITY PARTICIPATION. GRANTS ARE ALSO PROVIDED TO SUPPORT GENERAL OPERATIONS OF HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION, AN AFFILIATE TO THE HOSPITAL. PART III: PATIENTS MEETING CERTAIN CRITERIA UNDER THE CHARITY CARE POLICY MAY RECEIVE HEALTHCARE SERVICES AT NO CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. 1 X X X X 0 1 0 0 0 0 0 1 0 ROGER E SEAVER PRESIDENT/CEO 567705 0 285500 0 108802 0 34000 0 19975 0 1015982 0 0 0 LARRY R KIDD SR VP/CCO (RETIRED 01/2022) 356619 0 62500 0 62417 0 73016 0 7098 0 561650 0 0 0 TED D SIROTTA SR VP/CFO 356937 0 65500 0 41901 0 71315 0 24572 0 560225 0 0 0 RAY B MOSS VP/CIO 268887 0 41000 0 42197 0 45378 0 23012 0 420474 0 0 0 MARK A PULEO VP/CHRO 237819 0 36500 0 43522 0 42258 0 25512 0 385611 0 0 0 ROBERT K PRETZLAFF SR VP CMO & CCO 262186 0 40000 0 28118 0 26438 0 14407 0 371149 0 0 0 CARISSA BORTUGNO VP CLINICAL SUPPORT 203236 0 17759 0 25449 0 13633 0 28012 0 288089 0 0 0 KYUNG R KIM DIRECTOR OF FINANCE 183201 0 15536 0 11316 0 10650 0 23012 0 243715 0 0 0 JOCELYN P ABUYUAN CLINICAL RN, MED SURG 1 217380 0 14500 0 7359 0 1300 0 1970 0 242509 0 0 0 KATHRYN A ORTEGA CLINICAL RN 189618 0 11500 0 5866 0 9100 0 17225 0 233309 0 0 0 JOSEPHINE J KAPLAN DIRECTOR CASE MANAGEMENT 172411 0 14400 0 20180 0 0 0 17225 0 224216 0 0 0 JENNIFER N FITZPATRICK DIR. - CRITICAL CARE SERVICES 165818 0 14886 0 30124 0 10543 0 1970 0 223341 0 0 0 PART I, LINE 4B HENRY MAYO NEWHALL MEMORIAL HOSPITAL HAS A SERP (SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN) OF WHICH ONLY ONE OF ITS EMPLOYEES PARTICIPATES, ROGER SEAVER. THE AMOUNT OF BENEFIT PAID IN THE CURRENT YEAR INCLUDED ON SCHEDULE J, PART II, (B)(II) IS $126,500. HENRY MAYO NEWHALL MEMORIAL HOPSITAL HAS A 457(F) PLAN, OF WHICH THE FOLLOWING EMPLOYEES LISTED ON SCHEDULE J, PART II PARTICIPATE: CARISSA BORTUGNO, LARRY R. KIDD, MARK A. PULEO, RAY B. MOSS, ROBERT K. PRETZLAFF, AND TED D. SIROTTA. NO AMOUNTS WERE PAID OUT DURING THE CURRENT YEAR. PART I, LINE 7 BONUSES ARE TIED TO QUANTITATIVE AND QUALITATIVE CRITERIA. ONE OF THE CRITERIA FOR THE BONUSES IS TIED TO FINANCIAL METRICS SUCH AS EBITDA MARGIN AND ACHIEVING COST PER UNIT OF SERVICE. A CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY 680164610 13080SCJ1 2014-02-05 70780579 FINANCE AND REFINANCE FACILITY 1 0 0 B CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EAL8 2017-02-03 115072912 FINANCE AND REFINANCE FACILITY 0 0 0 C CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EDN1 2021-03-10 33921350 REFINANCE SERIES 2013A AND 2013B BONDS 0 0 0 D CALIFORNIA PUBLIC FINANCE AUTHORITY 474447476 13057EDW1 2021-03-10 6539029 FINANCE AND REFINANCE FACILITY 0 0 0 A 6370000 59665000 70780579 1141054 1692946 29092467 38854112 2017 0 1 1 1 B 1890000 115072912 1455316 85000000 28194396 2019 1 0 1 1 C 2545000 33921350 221771 33699579 2021 1 0 1 1 D 6539029 39029 6500000 0 0 0 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 C 0 0 0 0 0 0 1 D 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 1 0 0 0 0 0 0 1 C 0 1 0 0 0 0 0 0 1 D 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 D 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CA STATEWIDE COMMUNITIES DEVELOPMENT AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 01/28/2019 DON NISHIGUCHI DON NISHIGUCHI, MD - TRUSTEE 59715 PROFESSIONAL FEES AS DETERMINED AT ARMS-LENGTH AMOUNT 0 LAKHBINDER DHANDA LAKHBINDER DHANDA, MD - TRUSTEE 17963 PROFESSIONAL FEES AS DETERMINED AT ARMS-LENGTH AMOUNT 0 KATHERINE DUNN FAMILY MEMBER OF TRUSTEE 123129 WAGES 0 PARTIKSHA DHANDA FAMILY MEMBER OF TRUSTEE 99002 WAGES 0 FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS, CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER REVIEWED THE ENTIRE FORM 990 RETURN BEFORE DISTRIBUTION TO THE BOARD AND PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO READ THE CONFLICT OF INTEREST POLICY AND COMPLETE A FORMAL CONFLICT OF INTEREST QUESTIONNAIRE AND RESULTS OF ANY CONFLICT, IF ANY, WOULD BE REPORTED TO THE FULL BOARD. BOARD MEMBERS ARE AWARE AND REMINDED OF THE HOSPITAL'S FIDUCIARY RESPONSIBILITY IN REPORTING CONFLICTS OF INTEREST. THERE HAVE BEEN CIRCUMSTANCES WHERE A CONFLICT OF INTEREST EXISTS AND IT HAS BEEN DISCLOSED TO THE BOARD OF DIRECTORS. THE CONFLICT OF INTEREST FORMS ARE REQUIRED TO BE UPDATED ON AN ANNUAL BASIS. IF A CONFLICT IS IDENTIFIED, THE BOARD MEMBER WOULD BE EXCUSED FROM VOTING ON ANY APPLICABLE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATIONS'S CEO AND EXECUTIVE MANAGEMENT COMPENSATION ARE DETERMINED THROUGH THE USE OF A COMPENSATION COMMITTEE, INDEPENDENT CONSULTANT, AND BOARD OF DIRECTOR APPROVAL. OTHER KEY EMPLOYEES AND MANAGEMENT OF THE ORGANIZATION RECEIVE PERFORMANCE REVIEWS ANNUALLY AND RATINGS ARE APPLIED THAT SUGGEST THE PERCENTAGE OF SALARY INCREASE. PERCENTAGES ARE DETERMINED THROUGH MARKET SURVEYS DONE BY HUMAN RESOURCES AND APPROVED EACH YEAR VIA THE BUDGET AND APPROVAL PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 47,322,020. MANAGEMENT AND GENERAL EXPENSES 6,434,988. TOTAL EXPENSES 53,757,008. CONSULTING AND MANAGEMENT FEES: PROGRAM SERVICE EXPENSES 170,000. TOTAL EXPENSES 170,000. REGISTRY: PROGRAM SERVICE EXPENSES 25,981,698. MANAGEMENT AND GENERAL EXPENSES 458,940. TOTAL EXPENSES 26,440,638. OTHER PURCHASED SERVICES - CIN: MANAGEMENT AND GENERAL EXPENSES 752,226. TOTAL EXPENSES 752,226. OTHER SERVICES- CLINICS: MANAGEMENT AND GENERAL EXPENSES 131,648. TOTAL EXPENSES 131,648. FORM 990, PART XI, LINE 9: NET ASSET TRANSFER FROM HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 1,860,769. FORM 990, PART XII, LINE 2C: NEITHER THE OVERSIGHT PROCESS FOR THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT CHANGED DURING THE TAX YEAR. HENRY MAYO CARE NETWORK LLC 23845 MCBEAN PKWY VALENCIA CA 91355 824876499 HEALTHCARE NETWORK CA 600000 325982 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENRY MAYO NEWHALL CLINICS LLC 23845 MCBEAN PKWY VALENCIA CA 91355 833940984 HEALTHCARE CLINICS CA 5764 716804 HENRY MAYO NEWHALL MEMORIAL HOSPITAL HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION 23845 MCBEAN PKWY VALENCIA CA 91355 953849903 RAISE FUNDS CA 501(C)(3) LINE 7 HOSPITAL 1 SANTA CLARITA HEALTHCARE ASSOCIATION 23845 MCBEAN PKWY VALENCIA CA 91355 953921194 INACTIVE CA 501(C)(3) LINE 3 HOSPITAL 0 TOWER IMAGING VALENCIA 13400 RIVERSIDE DR STE 102 SHERMAN OAKS CA 91423 201345767 RADIOLOGY SERVICES CA HOSPITAL RELATED 373897 1020351 0 0 0.50000 HENRY MAYO NEWHALL URGENT CARE CLINICS LLC 23929 MCBEAN PARKWAY STE 102 VALENCIA CA 91355 843120192 HEALTHCARE CLINICS CA HOSPITAL RELATED -64853 625667 0 0 0.51000 KECK MEDICINE OF USC AND HENRY MAYO NEWHALL 1441 EASTLAKE AVE LOS ANGELAS CA 90033 853779519 MEDICAL CENTER CA HOSPITAL RELATED -983799 6960753 0 0 0.50000 HENRY MAYO MANAGEMENT SERVICE ORGANIZATION 23845 MCBEAN PKWY VALENCIA CA 91355 475250569 MANAGEMENT CA HOSPITAL C 1129474 1195916 1.00000 1 0 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 0 1 1 TOWER IMAGING VALENCIA LLC J 546626 ACTUAL AMOUNT KECK MEDICINE OF USC AND HENRY MAYO NEWHALL J 576978 ACTUAL AMOUNT HENRY MAYO MSO D 950000 ACTUAL AMOUNT HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION B 715260 ACTUAL AMOUNT HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION C 867370 ACTUAL AMOUNT ACCRUED HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION C 993399 ACTUAL AMOUNT PAID HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION D 10942864 AMOUNT GUARANTEED HENRY MAYO NEWHALL MEMORIAL HEALTH FOUNDATION K 849738 ACTUAL AMOUNT