2025-11-06T14:04:15-06:00 2024-12-31 990 2024-01-01 237296923 GOOD SAMARITAN FOUNDATION - DAYTON GOOD 9374999942 110 N MAIN ST SUITE 200 DAYTON OH 45402 J MICHAEL SIMS TREASURER 9374999942 2025-11-06 0 2024 2025-03-06 01:10:19Z JENNY M LEWIS ONE WYOMING ST DAYTON OH 45402 8948864 0 X WWW.PREMIERHEALTH.COM X 1973 OH SEE PART III, LINE 1 12 11 3 29 0 0 605019 646679 0 0 830850 744837 -5741 -5834 1430128 1385682 212520 1324398 0 0 361856 393331 0 0 222701 80175 92445 654551 1810174 775577 -424492 13088472 13667705 146678 799163 12941794 12868542 X INSPIRE PHILANTHROPY TO ENHANCE THE HEALTH AND WELL-BEING OF THE GREATER DAYTON COMMUNITIES AND THE HEALTHCARE PROFESSIONALS WHO CARE FOR THEM. 0 0 155000 155000 COMMUNITY PARAMEDICINE PROGRAMSINCE 2019, GOOD SAMARITAN FOUNDATION-DAYTON HAS BEEN INSTRUMENTAL IN SUPPORTING THE COMMUNITY PARAMEDICINE PROGRAM, A COLLABORATION BETWEEN PREMIER HEALTH, THE LARGEST COMPREHENSIVE HEALTH CARE SYSTEM IN SOUTHWEST OHIO, AND THE CITY OF DAYTON FIRE DEPARTMENT. THE PROGRAM PROVIDES IN-HOME CARE TO PATIENTS WITH LIMITED ACCESS TO HEALTHCARE SERVICES, ADDRESSING THE NEEDS OF HIGH-RISK DAYTON RESIDENTS PRONE TO HOSPITAL READMISSIONS, FREQUENT EMERGENCY DEPARTMENT VISITS, AND RECURRENT EMERGENCY INTERVENTIONS. THE PROGRAM AIMS TO REDUCE PREVENTABLE HEALTH ISSUES BY ADDRESSING CLINICAL AND SOCIAL NEEDS AT HOME. REFERRALS PRIMARILY ORIGINATE FROM HOSPITALS AND EMERGENCY SERVICES. THE TEAM, COMPRISED OF A DAYTON FIRE DEPARTMENT PARAMEDIC AND EMT, CONDUCTS HOME VISITS THAT INCLUDE HEALTH AND HOME ASSESSMENTS, HEALTH EDUCATION, AND REFERRALS TO WRAPAROUND SERVICES. IN 2024, WITH GRANT SUPPORT FROM MONTGOMERY COUNTY BOARD OF COUNTY COMMISSIONERS, THE PROGRAM WAS ABLE TO IMPLEMENT AN EXPANSION FOR RESIDENTS OVER THE AGE OF 60. THIS EXPANSION INCLUDED OFFERING STEPPING ON FALL PREVENTION CLASSES, COMMUNITY OUTREACH, AND HOME ASSESSMENTS FOR SENIORS RESIDING IN THE CITY OF DAYTON. THE PROGRAM, WHICH IS FUNDED BY GIFTS FROM GOOD SAMARITAN FOUNDATION-DAYTON DONORS, ENGAGED WITH 774 CITIZENS THROUGH CLASSES AND VITALS CLINICS. THE TEAM MADE 588 CALLS AND 174 HOME AND SITE VISITS TO CITIZENS ENROLLED IN THE PROGRAM 33044 33044 ONCOLOGY PATIENT SUPPORTTHE NORTH CAMPUS IS THE BUSIEST IN THE PREMIER HEALTH SYSTEM FOR BREAST SCREENING AND DIAGNOSTICS ALONG WITH LUNG LOW DOSE CT CANCER SCREENING. GOOD SAMARITAN FOUNDATION-DAYTON PROVIDES FINANCIAL ASSISTANCE FOR ESSENTIALS, SUCH AS RENT, UTILITIES, TRANSPORTATION TO TREATMENT, AND MEDICATION TO BREAST CANCER PATIENTS EXPERIENCING FINANCIAL HARDSHIP. ONCOLOGY PATIENTS ALSO RECEIVE THERAPEUTIC PILLOWS TO COMFORT THEM POST-SURGICAL PROCEDURES AND FINANCIAL SUPPORT FOR LYMPHEDEMA GARMENTS TO AID IN THE MANAGEMENT OF THE CONDITION AS A RESULT OF CANCER TREATMENTS. IN ADDITION, ALL CANCER PATIENTS ARE GIVEN THE OPPORTUNITY TO PARTICIPATE IN SPECIALIZED EXERCISE CLASSES AT ANY POINT IN THE CANCER CARE CONTINUUM FROM DIAGNOSIS TO SURVIVORSHIP. THE CLASSES ARE DELIVERED BY A CERTIFIED EXERCISE ONCOLOGY INSTRUCTOR AND INDIVIDUALIZED FOR EACH PATIENT'S HEALTH STATUS AND GOALS. 28137 28137 MOTHERS EMPOWEREDMOTHERS EMPOWERED PROVIDES HIGH-QUALITY, COMPREHENSIVE PRENATAL CARE AND PARENTING EDUCATION TO PREGNANT WOMEN IN GREATER DAYTON WHO ARE AT RISK OF LOSING A BABY TO INFANT MORTALITY. MOTHERS EMPOWERED IS A COLLABORATION BETWEEN LIFESTAGES CENTERS FOR WOMEN, A LOCAL OB/GYN PRACTICE, AND GOOD SAMARITAN FOUNDATION-DAYTON. THE PROGRAM IS COMPRISED OF AN RN PROGRAM COORDINATOR, A PART TIME MEDICAL ASSISTANT, AND A CERTIFIED NURSE MIDWIFE. THESE HEALTH CARE PROFESSIONALS PROVIDE THE EVIDENCE-BASED, BEST-PRACTICE "CENTERINGPREGNANCY" GROUP MODEL OF PRENATAL CARE. PREGNANT MOTHERS ARE GROUPED BY DUE DATE, SO THEY GO THROUGH THE SAME STAGE OF PREGNANCY TOGETHER, LEARNING ABOUT THEIR NEW BABIES WHILE FORMING FRIENDSHIPS WITH OTHER MOMS AND BUILDING TRUSTING RELATIONSHIPS WITH THEIR MEDICAL PROVIDERS. IN 2024, 60 WOMEN WERE SERVED. 1218297 1108217 1218297 1108217 1434478 1 1 0 0 0 0 0 0 0 1 0 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 3 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 11 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 200 DAYTON OH 45402 JENNY M LEWIS PRESIDENT/SYS VP OF PHILAN 13.33 26.67 X X 0 408308 52523 JO ANNE REILING BOARD CHAIR 0.50 X X 0 0 0 PAMELA A PHELPS BOARD SECRETARY 0.50 X X 0 0 0 GEORGE T BRODERICK JR MD BOARD VICE-CHAIR (TO JAN) 0.50 X 0 113340 0 DIANE ANDERSON DO TRUSTEE (TO MAY) 0.50 X 0 0 0 ALEC CARNES TRUSTEE 0.50 X 0 0 0 SUZANNE DONOVAN SC TRUSTEE 0.50 X 0 0 0 CHARLES ELLINGTON II TRUSTEE 0.50 X 0 0 0 RICHARD T FERGUSON TRUSTEE 0.50 X 0 0 0 CHARLENE J SIMS TRUSTEE 0.50 X 0 0 0 MARIANNE WEBER TRUSTEE 0.50 X 0 0 0 KENNETH M WATSON SR BOARD VICE-CHAIR (FROM FEB) 0.50 X X 0 0 0 JEANIE KUPPER TRUSTEE (FROM AUG) 0.50 X 0 0 0 GERALDINE PEGUES TRUSTEE (FROM FEB) 0.50 X 0 0 0 J MICHAEL SIMS BOARD TREASURER 0.50 39.50 X 0 635424 50996 CHRISTINA E KNOWLES DIR-DEVELOPMENT 40.00 X 138416 0 20964 138416 1157072 124483 1 0 1 0 0 1705 47955 11500 585519 180247 646679 282960 282960 8019225 7557348 461877 461877 461877 0 47955 5834 -5834 -5834 1385682 0 0 739003 1314898 1314898 9500 9500 348187 87047 87047 174093 29773 7443 7443 14887 15371 3843 3843 7685 41475 41475 18863 4716 4716 9431 6760 1690 1690 3380 13348 3337 3337 6674 1920 1440 480 2065 2065 SPECIAL EVENTS 5834 1459 1459 2916 DUES AND SUBSCRIPTIONS 1980 495 495 990 TRAINING AND EDUCATION 200 50 50 100 1810174 1434478 152995 222701 90387 57362 261795 231153 8622885 9176308 4038405 4127882 75000 75000 13088472 13667705 30006 105007 116672 694156 146678 799163 X 2318297 2179451 10623497 10689091 12941794 12868542 13088472 13667705 X -424492 309651 32850 8739 X 0 1 X 1 0 X 802762 608096 433870 605019 653179 3102926 802762 608096 433870 605019 653179 3102926 244904 2858022 156350 153863 145044 205441 282960 943658 4046584 10402 0.70630 0.67990 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10623497 663387 692295 -1290088 10689091 9573195 565019 985690 -500406 10623497 11706800 416984 -1437430 -1113160 9573195 10656520 522412 1132315 604446 11706800 9446814 680596 1059761 530651 10656520 0.00000 0.54770 0.45230 0 0 0 SECURITIES 4127882 F 4127882 AFFILIATES PAYABLE 690826 DEFERRED ANNUITIES 3330 694156 X PART V, LINE 4: THE GOOD SAMARITAN FOUNDATION-DAYTON (GSF-DAYTON) MAKES EVERY EFFORT TO FOLLOW THE INTENT AND WISHES OF ALL ITS DONORS. THE INTENDED USES OF THE ORGANIZATION'S ENDOWMENT FUNDS AND/OR EARNINGS FROM ENDOWMENT FUNDS ARE DRIVEN BY THE WISHES/RESTRICTIONS PLACED ON THE FUNDS BY THE DONOR. A PERMANENT ENDOWMENT RESULTS WHEN A DONATION IS RECEIVED WITH A RESTRICTION THAT THE PRINCIPAL OR GIFT AMOUNT IS TO BE RETAINED IN PERPETUITY AND CANNOT BE SPENT. THE EARNINGS FROM THE PERMANENT ENDOWMENT ARE USED FOR THE PURPOSE SPECIFIED BY THE DONOR. TEMPORARY ENDOWMENTS ARE FUNDS IN WHICH ALL OR PART OF THE PRINCIPAL MAY BE EXPENDED ONLY AFTER THE EXPIRATION OF A STATED PERIOD OF TIME OR OCCURRENCE OF A SPECIFIED EVENT, DEPENDING ON THE DONOR'S WISHES. EARNINGS FROM TEMPORARILY RESTRICTED ENDOWMENTS CAN BE EITHER UNRESTRICTED OR RESTRICTED. THE GSF-DAYTON USES THE TEMPORARILY RESTRICTED ENDOWMENTS FOR THE INTENDED PURPOSE SETUP BY THE DONOR, ONLY AFTER THE PERIOD OF TIME OR SPECIFIED EVENT SET BY THE DONOR HAS BEEN MET. THE CATEGORIES OF PERMANENTLY AND TEMPORARILY RESTRICTED ENDOWMENTS ARE AS FOLLOWS: TO SUPPORT THE LOCAL COMMUNITY HOMELESS CLINIC OPERATIONS (19%); TO FUND EDUCATIONAL PROGRAMS/SCHOLARSHIPS (19%); TO FUND THE FOUNDATION OPERATIONS (17%); TO SUPPORT HEART DISEASE (10%); TO SUPPORT MOTHERS EMPOWERED (ME) TO PROVIDE FREE MEDICAL CARE AND PRENATAL AND PARENTING EDUCATION TO PREGNANT WOMEN IN NEED (6%), TO SUPPORT ELDER CARE (2%); TO BENEFIT SPECIFIC PROGRAMS FOR A SAMARITAN HEALTH PARTNER'S AFFILIATE (7%); AND MISCELLANEOUS (20%). PART X, LINE 2: THE FOLLOWING FOOTNOTE IS FROM THE 2024 CONSOLIDATED AUDITED FINANCIAL STATEMENTS FOR PREMIER HEALTH (PHP) AND AFFILIATES. PHP IS THE SOLE MEMBER OF GOOD SAMARITAN FOUNDATION-DAYTON. PHP HAS BEEN DETERMINED BY THE INTERNAL REVENUE SERVICE TO BE A TAX-EXEMPT NON-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS A TAX-EXEMPT ORGANIZATION, ITS INCOME IS EXEMPT FROM FEDERAL INCOME TAX EXCEPT TO THE EXTENT OF ANY UNRELATED BUSINESS ACTIVITIES. PHP CONSOLIDATES CERTAIN SUBSIDIARIES WHICH ARE FOR-PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. THESE ARE: * PREMIER HEALTH HOLDING COMPANY (PHHC) (WHOLLY OWNED SUBSIDIARY OF PHP) * MVHE, INC., (AND ITS WHOLLY OWNED SUBSIDARY EXTENDED CARE), SAMARITAN FAMILY CARE, INC., PREMIER HEALTH SPECIALISTS, INC. AND PREMIER HEALTH URGENT CARE, INC. (WHOLLY OWNED SUBSIDIARIES OF PHHC) MANAGEMENT ANNUALLY REVIEWS THE TAX POSITIONS AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS. RAYS OF HOPE 47955 47955 5834 47955 47955 5834 5834 -5834 1 MIAMI VALLEY HOSPITAL 110 N MAIN ST SUITE 200 DAYTON OH 45402 310537504 501(C)(3) 47849 760036 FMV MEDICAL EQUIPMENT, POPCORN OPERATIONS SAMARITAN BEHAVIORAL HEALTH 110 N MAIN ST SUITE 200 DAYTON OH 45402 020633634 501(C)(3) 178759 16848 FMV POPCORN OPERATIONS CITY OF DAYTON 101 W 3RD ST DAYTON OH 45402 316000175 GOVERNMENT 140000 0 N/A N/A SUPPORT ATRIUM MEDICAL CENTER 110 N MAIN ST SUITE 200 DAYTON OH 45402 311079309 501(C)(3) 0 100000 FMV MEDICAL EQUIPMENT SUPPORT PREMIER HEALTH PARTNERS 110 N MAIN ST SUITE 200 DAYTON OH 45402 311446699 501(C)(3) 26857 0 N/A N/A SUPPORT COMPUNET CLINICAL LABORATORIES LLC 110 N MAIN ST SUITE 200 DAYTON OH 45402 311258010 501(C)(3) 0 11295 FMV POPCORN SUPPORT FIDELITY HEALTH CARE 110 N MAIN ST SUITE 200 DAYTON OH 45402 311075381 501(C)(3) 0 7000 FMV POPCORN SUPPORT 7 0 EDUCATIONAL SCHOLARSHIPS 10 9500 PART I, LINE 2: ALL DISTRIBUTIONS (GRANTS PAID) FOLLOW THE ENTITY'S DISBURSEMENT POLICY, INCLUDING: (A) ASSUMING FUNDS AVAILABILITY, HOSPITAL DEPARTMENT PERSONNEL COMPLETE A FOUNDATION REQUEST FORM. FOR AMOUNTS IN EXCESS OF $1,000, DIRECTOR'S & VICE-PRESIDENT'S SIGNATURES ARE REQUIRED TO REQUEST FOUNDATION FUNDING. (B) FOR A REQUEST GREATER THAN $5,000, THE FOUNDATION'S DISTRIBUTION COMMITTEE REVIEWS AND APPROVES THE REQUEST. THE CHECK ALSO REQUIRES A SECOND SIGNATURE. (C) REPORTING FOR GRANTS IS THE RESPONSIBILITY OF THE OPERATIONAL UNIT. (D) BEFORE DISBURSING FUNDS, EACH REQUEST IS VERIFIED/MATCHED FOR ITS INTENDED PURPOSE. FOR EXAMPLE, SCHOLARSHIP REQUIREMENTS INCLUDE: A) GPA REQUIREMENTS; B) LENGTH OF SERVICE; C) SPECIFIC FIELDS OF STUDY. 0 1 0 0 0 0 0 0 0 J MICHAEL SIMS BOARD TREASURER 0 407084 0 165482 0 62858 0 23409 0 27587 0 686420 0 0 JENNY M LEWIS PRESIDENT/SYS VP OF PHILAN 0 299290 0 105590 0 3428 0 27031 0 25492 0 460831 0 0 CHRISTINA E KNOWLES DIR-DEVELOPMENT 109086 0 28984 0 346 0 4897 0 16067 0 159380 0 0 0 PART I, LINE 3 COMPENSATION FOR THE GSF-DAYTON CEO IS REVIEWED AND APPROVED BY PREMIER, WITH WHICH GSF-DAYTON IS AN AFFILIATE. PART I, LINE 4B DUE TO RESTRICTIONS IMPOSED BY THE INTERNAL REVENUE CODE, CERTAIN PERSONS ARE LIMITED IN THE AMOUNT OF BENEFIT THAT CAN BE EARNED UNDER A QUALIFIED RETIREMENT PLAN. LIKE MANY EMPLOYERS, GOOD SAMARITAN FOUNDATION-DAYTON (GSF-DAYTON) AND ITS AFFILIATED ORGANIZATIONS COMPENSATE FOR THIS LIMITATION AND SUPPLEMENT THE AFFECTED EXECUTIVES' QUALIFIED PENSION THROUGH CERTAIN NONQUALIFIED PLANS. GSF-DAYTON SUPPLEMENTS THE AFFECTED EXECUTIVES THROUGH A PENSION RESTORATION PLAN OR A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE BENEFITS UNDER THESE SUPPLEMENTAL NONQUALIFIED PLANS ARE SUBJECT TO MULTI-YEAR VESTING AND A PARTICIPANT CAN FORFEIT BENEFITS EARNED IF VESTING REQUIREMENTS ARE NOT SATISFIED. UNDER THE TERMS OF THE SUPPLEMENTAL PLANS, AND BECAUSE OF TAX RULES PERTAINING TO TAXATION OF THE EARNED BENEFITS UPON VESTING, CERTAIN INDIVIDUALS RECEIVED A PAYOUT OF THE CUMULATIVE VESTED BENEFITS UNDER THEIR SUPPLEMENTAL PLAN DURING 2024. THE INDIVIDUAL LISTED BELOW HAS MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE PENSION RESTORATION PLAN AND RECEIVED THE ASSOCIATED PAYMENT IN 2024: J. MICHAEL SIMS $56,017. THE FOLLOWING SERP AMOUNTS WERE DEFERRED ON THE PARTICIPANTS' BEHALF DURING THE YEAR AND WILL BE HELD UNTIL THE INCREMENTAL AMOUNTS ARE VESTED: JENNY LEWIS $4,742. BASED ON THE GUIDANCE PROVIDED IN THE INSTRUCTIONS TO THE FORM 990, ANY PAYMENTS TO THE PARTICIPANTS RELATED TO THESE PLANS THAT WERE MADE WITHIN 2-1/2 MONTHS AFTER THE END OF THE ORGANIZATION'S TAX YEAR ARE NOT TREATED AS DEFERRED COMPENSATION FOR PURPOSES OF SCHEDULE J. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES. X 2750 X GENERATOR 1 100000 FMV X EMPLOYEE FOOD 16 77097 FMV X ITEMS FOR FUNDRASING EVENTS 1 400 FMV 0 0 1 0 FORM 990, PART VI, SECTION A, LINE 2 BOARD TREASURER, J. MICHAEL SIMS HAS A FAMILIAL RELATIONSHIP WITH TRUSTEE, CHARLENE SIMS. FORM 990, PART VI, SECTION A, LINE 6 THE GOOD SAMARITAN FOUNDATION-DAYTON (GSF-DAYTON) HAS ONE CORPORATE MEMBER: PREMIER HEALTH (PREMIER), AN OHIO NON-PROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A PREMIER HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES FOR GSF-DAYTON. PREMIER HAS THE AUTHORITY TO REMOVE SUCH TRUSTEES AT ANY REGULAR OR SPECIAL MEETING OR BY WRITTEN CONSENT. FORM 990, PART VI, SECTION A, LINE 7B SEE 7A FORM 990, PART VI, SECTION B, LINE 11B THIS 990 FILING AND ATTACHED SCHEDULES (THE RETURN) ARE PREPARED BY A STAFF MEMBER IN THE TAX DEPARTMENT OF PREMIER, WITH WHICH GSF-DAYTON IS AN AFFILIATE. THE RETURN IS REVIEWED BY THE MANAGER AND DIRECTOR OF TAX COMPLIANCE OF PREMIER. AFTER ALL CHANGES FROM THE ABOVE PERSONS ARE MADE, THE RETURN IS REVIEWED BY THE VICE PRESIDENT/CONTROLLER OF PREMIER. A FINAL VERSION OF THE RETURN IS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW. AT THE BOARD OF TRUSTEES' MEETING, THE VICE PRESIDENT/CONTROLLER OF PREMIER (OR DESIGNEE) SHARES DETAILED INFORMATION ON COMPENSATION AND OTHER KEY AREAS, AS WELL AS ADDRESS ANY OTHER QUESTIONS FROM THE BOARD OF TRUSTEES, PENDING THEIR REVIEW. THE 990 FILING IS ALSO SHARED WITH THE AUDIT COMMITTEE OF PREMIER. FORM 990, PART VI, SECTION B, LINE 12C PREMIER, WITH WHICH GSF-DAYTON IS AN AFFILIATE, REQUIRES ALL BOARD MEMBERS, BOARD COMMITTEE MEMBERS, MEDICAL DIRECTORS, SUPPLY CHAIN DIVISION MEMBERS, AUTHORIZED SIGNERS, DIRECTORS, EXECUTIVES, MEDICAL EXECUTIVE COMMITTEE MEMBERS, MEDICAL DEPARTMENT AND SECTION CHAIRS, PHYSICIAN PARTNERSHIP COMMITTEE MEMBERS, PHYSICIAN GUIDANCE GROUP MEMBERS, AND ALL EMPLOYED PHYSICIANS TO ANNUALLY REVIEW THE PREMIER COMPREHENSIVE CONFLICT OF INTEREST STATEMENT, AN EXPLANATORY MEMORANDUM, THE ANTITRUST COMPLIANCE POLICY, AND COMPLETE AN INDIVIDUAL QUESTIONNAIRE DISCLOSING ANY POTENTIAL CONFLICTS AS DEFINED IN THE CONFLICT OF INTEREST POLICY. THIS IS ACCOMPLISHED EITHER BY WAY OF AN ELECTRONIC COMMUNICATION SENT OUT DIRECTLY BY THE CORPORATE COMPLIANCE DEPARTMENT OR BY WAY OF A MEMO SENT OUT FROM THE CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER OF PREMIER. IT ALSO INCLUDES AN EXPLANATORY MEMORANDUM OF SPECIFIC ACTIVITIES THAT MIGHT GIVE CAUSE TO A CONFLICT AND AN INDIVIDUAL QUESTIONNAIRE TO DISCLOSE ALL SUCH ACTIVITIES. THIS QUESTIONNAIRE MUST BE COMPLETED AND SIGNED BY THE INDIVIDUAL. THIS CORRESPONDENCE INCLUDES A COPY OF THE ANTITRUST COMPLIANCE POLICY THAT MUST BE SIGNED BY THE INDIVIDUAL. ALL OF THESE DOCUMENTS ARE SENT TO THE CORPORATE COMPLIANCE DEPARTMENT. THE CORPORATE COMPLIANCE DEPARTMENT ENSURES ALL FORMS ARE RETURNED AND RETAINS THE DOCUMENTS FOR FIVE YEARS. IN ADDITION, AT EACH MEETING OF THE BOARD OR ANY BOARD COMMITTEE, FOLLOWING APPROVAL OF THE PREVIOUS MEETING'S MINUTES, THE BOARD OR COMMITTEE CHAIR SHALL REQUEST ANY BOARD MEMBER WHO PERCEIVES A POTENTIAL CONFLICT OF INTEREST ON ANY OF THE MEETING'S AGENDA ITEMS TO DISCLOSE THE POTENTIAL CONFLICT. ADDITIONALLY, AT ANY BOARD OR BOARD COMMITTEE MEETING WHERE THE SUBJECT OF CONFLICT OF INTEREST IS DISCUSSED, THE MINUTES SHALL CONTAIN THE NAME OF THE PARTY DISCUSSING A POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE POTENTIAL CONFLICT OF INTEREST AND WHETHER A CONFLICT OF INTEREST WAS FOUND TO EXIST. IF A CONFLICT OF INTEREST IS DETERMINED BY THE BOARD TO EXIST, THE MEMBER WILL BE EXCUSED FROM PARTICIPATING IN ANY DISCUSSION OR VOTING ON THE PARTICULAR AGENDA ITEM. THE CHIEF COMPLIANCE AND ENTERPRISE RISK OFFICER REPORTS THE RESULTS OF THE PREMIER CONFLICT OF INTEREST QUESTIONNAIRES NO LESS THAN ANNUALLY TO THE BOARD OF TRUSTEES BY WAY OF THE COMPLIANCE AND AUDIT COMMITTEE. THIS REVIEW IS DOCUMENTED IN THE MINUTES OF THE MEETING. PERIODICALLY, THE INTERNAL AUDIT DEPARTMENT WILL REVIEW A SAMPLE OF COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND REPORT THE RESULTS TO THE COMPLIANCE AND AUDIT COMMITTEE. THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE INDIVIDUALLY SUMMARIZED IN A DOCUMENT AND SENT ELECTRONICALLY TO THE FINANCE DEPARTMENT FOR ANY NECESSARY DISCLOSURES REQUIRED ON THE 990 FILING. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC WHEN REQUIRED BY LAW OR FOR ACCREDITATION PURPOSES. THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: EQUITY TRANSFER 5,334. PLEDGE RESERVE 3,405. PREMIER HEALTH 110 MAIN STREET SUITE 200 DAYTON OH 45402 311446699 PARENT OH 501 (C) (3) 12B N/A 0 MEDAMERICA HEALTH SYSTEMS CO 110 MAIN STREET SUITE 200 DAYTON OH 45402 311040228 SUPPORT ORG OH 501 (C) (3) 12B N/A 0 MIAMI VALLEY HOSPITAL 110 MAIN STREET SUITE 200 DAYTON OH 45402 310537504 HOSPITAL OH 501 (C) (3) 3 PREMIER HEALTH 0 MIAMI VALLEY HOSPITAL FOUNDATION 110 MAIN STREET SUITE 200 DAYTON OH 45402 311040231 FOUNDATION OH 501 (C) (3) 7 PREMIER HEALTH 0 FIDELITY HEALTH CARE INC 110 MAIN STREET SUITE 200 DAYTON OH 45402 311075381 HOME HEALTH OH 501 (C) (3) 10 PREMIER HEALTH 0 PREMIER COMMUNITY HEALTH 110 MAIN STREET SUITE 200 DAYTON OH 45402 311122883 HEALTH EDUCATION OH 501 (C) (3) 10 FIDELITY HEALTH CARE 0 ATRIUM HEALTH SYSTEM 110 MAIN STREET SUITE 200 DAYTON OH 45402 310537492 SUPPORT ORG OH 501 (C) (3) 12B N/A 0 ATRIUM MEDICAL CENTER 110 MAIN STREET SUITE 200 DAYTON OH 45402 311079309 HOSPITAL OH 501 (C) (3) 3 PREMIER HEALTH 0 UVMC 110 MAIN STREET SUITE 200 DAYTON OH 45402 341850683 SUPPORT ORG OH 501 (C) (3) 12B N/A 0 UPPER VALLEY MEDICAL CENTER 110 MAIN STREET SUITE 200 DAYTON OH 45402 310537095 HOSPITAL OH 501 (C) (3) 3 PREMIER HEALTH 0 UPPER VALLEY PROFESSIONAL CORP 110 MAIN STREET SUITE 200 DAYTON OH 45402 311400963 HEALTH CARE OH 501 (C) (3) 10 PREMIER HEALTH HOLDING CO 0 UVPC SPECIALISTS 110 MAIN STREET SUITE 200 DAYTON OH 45402 203687536 HEALTH CARE OH 501 (C) (3) 10 PREMIER HEALTH HOLDING CO 0 UVMC NURSING CARE INC 110 MAIN STREET SUITE 200 DAYTON OH 45402 311224064 NURSING HOME OH 501 (C) (3) 10 PREMIER HEALTH 0 COMPUNET CLINICAL LABORATORIES LLC 110 MAIN STREET SUITE 200 DAYTON OH 45402 311258010 LAB OH 501 (C) (3) 12B PREMIER HEALTH 0 SAMARITAN BEHAVIORAL HEALTH INC 110 MAIN STREET SUITE 200 DAYTON OH 45402 020633634 BEHAVIORAL HEALTH OH 501 (C) (3) 7 PREMIER HEALTH 0 SWEITZER STREET LLC 110 MAIN STREET SUITE 200 DAYTON OH 45402 454700417 REAL ESTATE OH MVHE INC EXCLUDED 0 0 SWEITZER MOB LLC 110 MAIN STREET SUITE 200 DAYTON OH 45402 474554657 REAL ESTATE OH MVHE INC EXCLUDED 0 0 MVHE INC 110 MAIN STREET SUITE 200 DAYTON OH 45402 311185270 PHYSICIAN SVCS OH PREMIER HEALTH HOLDING CO C 0 PREMIER HEALTH SPECIALISTS 110 MAIN STREET SUITE 200 DAYTON OH 45402 061744704 PHYSICIAN SVCS OH PREMIER HEALTH HOLDING CO C 0 SAMARITAN FAMILY CARE 110 MAIN STREET SUITE 200 DAYTON OH 45402 311299450 PHYSICIAN SVCS OH PREMIER HEALTH HOLDING CO C 0 AFTER HOURS FAMILY CARE 110 MAIN STREET SUITE 200 DAYTON OH 45402 311269483 HEALTH CARE OH UPPER VALLEY PROFESSIONAL CORP C 0 UVMC MANAGEMENT CORP 110 MAIN STREET SUITE 200 DAYTON OH 45402 311360489 MANAGEMENT COMPANY OH PREMIER HEALTH C 0 PREMIER HEALTH URGENT CARE INC 110 MAIN STREET SUITE 200 DAYTON OH 45402 822079409 URGENT CARE OH PREMIER HEALTH HOLDING CO C 0 PREMIER HEALTH INT'L INSURANCE BUTTERFIELD BANK BLDG 6TH FLOOR 6 HAMILTON BD HM12 980548485 INSURANCE BD PREMIER HEALTH C 0 PREMIER HEALTH PLAN INC 110 MAIN STREET SUITE 200 DAYTON OH 45402 463024049 HEALTH INSURANCE OH PREMIER HEALTH INSURING CO C 0 GOOD SAMARITAN HOSPITAL 110 MAIN STREET SUITE 200 DAYTON OH 45402 310536981 HOSPITAL OH PREMIER HEALTH C 0 PREMIER HEALTH ACO OF OHIO 110 MAIN STREET SUITE 200 DAYTON OH 45402 474049773 MEDICARE ACO OH PREMIER HEALTH C 0 PREMIER HEALTH HOLDING CO 110 MAIN STREET SUITE 200 DAYTON OH 45402 812419110 HOLDING CO OH PREMIER HEALTH C 0 PREMIER HEALTH INSURING CO 110 MAIN STREET SUITE 200 DAYTON OH 45402 464766841 HEALTH INSURANCE OH PREMIER HEALTH C 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0