2015-05-11T15:05:59-05:00 2014-06-30 440160260 BKD LLP 312 WALNUT STREET SUITE 3000 CINCINNATI OH 45202 990 2013-07-01 310537486 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI OHIO GOOD 5135696575 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 BRIAN KRAUSE VP-FINANCE 5135695126 2015-05-11 1 P00961884 5136218300 2013 2016-02-25 16:41:14Z JOHN PROUT 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 553205006 0 0928 X WWW.TRIHEALTH.COM X 1852 OH THE ORGANIZATION'S MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY IT SERVES. 11 6 3952 1687 147055 -200930 2693838 665475 486547135 512216127 30228597 30571227 12594030 7966874 532063600 551419703 461765 1469691 0 0 224865431 244243507 0 0 0 226863114 220457730 452190310 466170928 79873290 85248775 773878136 846515340 234246732 205216681 539631404 641298659 X SEE SCHEDULE O 0 0 372725112 1469691 512258089 SEE SCHEDULE H 372725112 1 1 0 1 0 0 0 0 0 1 1 1 1 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 310 0 1 3952 1 1 1 0 0 0 0 0 0 0 0 0 X 11 6 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 X BRIAN KRAUSE - VP FINANCE 5135695126 619 OAK STREET - ACCOUNTING 3 WEST CINCINNATI OH 45206 MICHAEL HAVERKAMP TRUSTEE 1.00 3.00 X 0 0 0 ROBERT WALKER SECRETARY 1.00 3.00 X X 0 0 0 JOHN PROUT PRESIDENT/CEO 15.00 45.00 X X 0 1455153 328652 PAUL EDGETT III TRUSTEE 1.00 3.00 X 0 1126594 94198 MYRTIS POWELL TRUSTEE 1.00 3.00 X 0 0 0 SR SALLY DUFFY TRUSTEE 1.00 3.00 X 0 0 0 MICHAEL MCGRAW CHAIRMAN 1.00 3.00 X X 0 0 0 STEPHEN BLATT MD MED STAFF PRES-GOOD SAM (END 12/13) 18.00 3.00 X 45000 394556 59073 STUART DONOVAN MD MED STAFF PRES-BETHESDA (END 12/13) 3.00 8.00 X 0 598218 11255 JOANN LOHR MD MED STAFF PRES-GOOD SAM (START 1/14) 18.00 3.00 X 84621 0 25845 ALAN ALTMAN MD MED STAFF PRES-BETHESDA (START 1/14) 3.00 8.00 X 0 284591 91628 CRAIG EISENTROUT MD TRUSTEE 1.00 3.00 X 0 111149 8503 WAYNE SHIRCLIFF VICE CHAIRMAN/TREASURER 1.00 3.00 X X 0 0 0 DONNA NIENABER ESQ SVP CORP COUNSEL/ASST SECRETARY 15.00 45.00 X 0 503646 159585 CRAIG RUCKER SVP CFO/ASST TREASURER 15.00 45.00 X 0 590695 138806 WILLIAM GRONEMAN EXEC VP SYSTEM DEVELOPMENT 15.00 45.00 X 0 587950 184458 GERALD OLIPHANT EXEC VP & COO 15.00 45.00 X 0 657505 152110 GEORGES FEGHALI MD CHIEF MEDICAL OFFICER 15.00 45.00 X 0 580831 174618 JOHN ROBINSON MD SVP-HOSPITAL OPERATIONS 15.00 45.00 X 0 386049 94986 JAIME EASTERLING EXEC DIRECTOR- GOOD SAM HOSPITAL 60.00 0.00 X 0 202384 36798 DAVID DHANRAJ MD PHYSICIAN 60.00 0.00 X 330580 0 43861 ROBERT ROHS MD PHYSICIAN 60.00 0.00 X 296779 0 41057 DEVIN NAMAKY MD PHYSICIAN 60.00 0.00 X 246688 0 38787 JOHN SPRAGUE MD PHYSICIAN 60.00 0.00 X 184906 0 34268 GARY HESS PHARMACIST 60.00 0.00 X 160069 0 39998 MICHAEL CROFTON FORMER 25.00 35.00 X 0 296442 75394 1348643 7775763 1833880 92 1 1 0 CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 CLINICAL ENGINEERING 5811601 AMERICAN NURSING CARE INC 1700 EDISON DRIVE SUITE 300 MILFORD OH 45150 NURSING 1269001 PATIENT TRANSPORT SERVICES INC 1700 EDISON DRIVE SUITE 300 MILFORD OH 45150 PATIENT TRANSPORTATION 1077336 MORRISON MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 30368 FOOD SERVICE 769274 DVA RENAL HEALTHCARE INC PO BOX 8500-1607 PHILADELPHIA PA 191781607 RENAL 619210 37 665475 665475 PATIENT SERVICES 621990 498960426 498787794 172632 JOA REVENUE 990009 8369059 8369059 AFFILIATED ORG. RENTAL 532000 2711117 2711117 MEDICAL RESEARCH 900099 1451275 1451275 JV REVENUE 900099 724250 724250 512216127 8783807 8783807 1840857 1284687 556170 556170 556170 21125991 681255 0 19826 21125991 661429 21787420 21787420 773180 480790 292390 292390 CAFETERIA 722100 2652829 2652829 EHR MEANINGFUL USE 900099 1910951 1910951 PHARMACY 446110 1565351 1565351 989183 1014760 -25577 7118314 551419703 512258089 147055 38349084 1469691 1469691 2934127 2934127 188747744 156197892 32549852 12023042 8392619 3630423 26609187 20855879 5753308 13929407 11463355 2466052 1726557 1667074 59483 2338824 1857 2336967 495478 1000 494478 1301508 1301508 18081768 11489865 6591903 3766690 394856 3371834 5996932 3372127 2624805 9341270 785510 8555760 10795964 8890702 1905262 638174 318214 319960 6615729 6615729 6199176 6199176 30056482 20372584 9683898 4339656 3552540 787116 MEDICAL/DIETARY SUPPLY 100115447 99825827 289620 OHIO HOSPITAL FEE 8619279 8619279 EQUIPMENT AND REPAIR 6729828 6265889 463939 DUES AND SUBSCRIPTIONS 308703 308703 2990265 1863920 1126345 466170928 372725112 93445816 0 19431731 51279 50093511 59201876 3420461 3313304 95030 578230635 384084289 198232255 194146346 23998853 17744476 341866209 367372884 23440617 110752831 113299469 93932344 773878136 846515340 35357073 36146048 1002560 991948 45173865 43561300 152713234 124517385 234246732 205216681 X 534122770 635745839 5508634 5552820 539631404 641298659 773878136 846515340 X 85248775 30067339 -13648859 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11006 11006 0 PART II-B, LINE 1: DURING THE TAX YEAR, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") PAID ANNUAL MEMBERSHIP DUES TO VARIOUS NATIONAL, STATE AND LOCAL ORGANIZATIONS, A PORTION ($1,479) OF WHICH RELATED TO LOBBYING ACTIVITIES. IN ADDITION, TRIHEALTH, INC., A RELATED ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL, PAID ANNUAL MEMBERSHIP DUES TO VARIOUS NATIONAL, STATE AND LOCAL ORGANIZATIONS A PORTION OF WHICH RELATED TO LOBBYING ACTIVITIES. A PORTION OF THE AFOREMENTIONED ADMINISTRATIVE SUPPORT SERVICES ARE ALLOCATED TO HOSPITAL AND $4,232 OF THE AMOUNT SHOWN ON LINE 1I REPRESENTS HOSPITAL'S SHARE OF THESE LOBBYING EXPENSES. FINALLY, HOSPITAL'S CONTROLLING ORGANIZATION, CATHOLIC HEALTH INITIATIVES, PAYS ANNUAL DUES TO THE AMERICAN HOSPITAL ASSOCIATION ("AHA") AND CATHOLIC HOSPITAL ASSOCIATION ("CHA"), A PORTION OF WHICH IS ALLOCATED TO LOBBYING ACTIVITIES. FOR THE TAX YEAR, THE AMOUNT SHOWN ON LINE 1I ABOVE REPRESENTS HOSPITAL'S SHARE OF ALLOCATED LOBBYING EXPENSES: AHA $3,935; CHA $1,360. 11117985 75468 1989550 471904 12711099 10779284 117390 528844 307533 11117985 10449966 124844 307886 103412 10779284 9912083 46487 491396 10449966 9440827 187161 284095 9912083 0.79000 0.21000 0 1 1 14180409 14180409 347978524 213962849 134015675 3931498 3156469 775029 201156848 164802570 36354278 10983356 2162401 8820955 194146346 CHI OPERATING INVESTMENT PROGRAM 367372884 F 367372884 INVESTMENT IN JOINT VENTURES 110752831 C 110752831 INVESTMENT IN DIRECT AFFILIATES 36784495 MALPRACTICE INSURANCE/WORKERS COMPENSATION RECEIVABLE 20221767 NETWORK AFFILIATION RECEIVABLE 19203390 DUE FROM RELATED ORGANIZATIONS 8318798 PENSION ASSET 9403894 93932344 ENVIRONMENTAL REMEDIATION LIABILITY 1452368 MALPRACTICE INSURANCE/WORKERS COMPENSATION LIABILITY 20221767 ACCRUED EIB 6533175 THIRD PARTY SETTLEMENTS 5799418 DEBT PAYABLE TO RELATED ORGANIZATION 90510657 124517385 X PART V, LINE 4: INVESTMENT PROCEEDS FROM ENDOWMENT FUNDS ARE USED TO SUPPORT PROGRAMS AT THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. PART X, LINE 2: THE FINANCIAL STATEMENTS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ARE AUDITED AS PART OF TRIHEALTH AND ITS SUBSIDIARIES AND AFFILIATES ("TRIHEALTH"). FOLLOWING IS THE TEXT OF THE FOOTNOTE TO THE AUDITED COMBINED FINANCIAL STATEMENTS OF TRIHEALTH THAT REPORTS ITS AND ITS SUBSIDIARIES AND AFFILIATES LIABILITY, IF APPLICABLE, FOR UNCERTAIN TAX POSITIONS UNDER ASC 740-10-25: TRIHEALTH COMPLETED AN ANALYSIS OF UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH APPLICABLE ACCOUNTING GUIDANCE AT JUNE 30, 2014 AND 2013, AND DETERMINED NO AMOUNTS WERE REQUIRED TO BE RECOGNIZED IN THE COMBINED FINANCIAL STATEMENTS AT JUNE 30, 2014 AND 2013. IN ADDITION, HOSPITAL'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION. CHI'S FIN 48 (ASC 740) FOOTNOTE FOR THE YEAR ENDED JUNE 30, 2014 READS AS FOLLOWS: CHI IS A TAX-EXEMPT COLORADO CORPORATION AND HAS BEEN GRANTED AN EXEMPTION FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CHI OWNS CERTAIN TAXABLE SUBSIDIARIES AND ENGAGES IN CERTAIN ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE AND THEREFORE SUBJECT TO INCOME TAX. MANAGEMENT REVIEWS ITS TAX POSITIONS ANNUALLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 12751079 7032126 5718953 0.01230 91859935 71323039 20536896 0.04410 104611014 78355165 26255849 0.05640 1062822 56637 1006185 0.00220 25636178 9564455 16071723 0.03450 3054890 2007914 1046976 0.00220 3292153 3292153 0.00710 262110 262110 0.00060 33308153 11629006 21679147 0.04660 137919167 89984171 47934996 0.10300 290000 290000 0.00060 290000 290000 0.00060 1 26697055 0 98042133 99041783 -999650 X 1 1 1 1 GOOD SAMARITAN HOSPITAL 375 DIXMYTH AVENUE CINCINNATI OH 45220 WWW.TRIHEALTH.COM 1191 X X X X X GOOD SAMARITAN HOSPITAL 1 1 X X X X X X X X 12 1 1 1 X HTTP://WWW.TRIHEALTH.COM X X X X 0 0 1 1 100.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X 1 0 X X X 1 X 0 0 GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 3: INPUT WAS RECEIVED FROM INDIVIDUALS REPRESENTING UNDERSERVED POPULATIONS USING THE THREE SURVEY APPROACHES DESCRIBED BELOW -CHNA GROUP LEVEL ASSESSMENTS (GLAS): THE UNIVERSITY OF CINCINNATIS ACTION RESEARCH CENTER FACILITATED LARGE GROUP COMMUNITY DISCUSSIONS (GROUP LEVEL ASSESSMENTS) WITH SERVICE PROVIDERS IN EACH OF THE COUNTIES COVERED BY THE CHNA. THE TOTAL NUMBER OF SERVICE PROVIDERS AT THE COUNTY GLAS RANGED FROM AS FEW AS NINE PEOPLE TO AS MANY AS 30 PEOPLE. OVERALL, APPROXIMATELY 200 SERVICE PROVIDERS ACROSS THE COUNTIES PARTICIPATED. THE RESULTS OF THE GLAS WERE PRESENTED BACK TO THE SERVICE PROVIDERS AND COMMUNITY AT LARGE THROUGH A SERIES OF PUBLIC PRESENTATIONS.CHNA COMMUNITY HEALTH SURVEY: THE ACTION RESEARCH CENTER ALSO SURVEYED POPULATIONS IN THE GREATER CINCINNATI REGION THAT ARE MORE OFTEN UNDERSERVED WITH A PARTICULAR FOCUS ON HEALTH CARE CONSUMERS WHO ARE UNINSURED, UNDERINSURED, LOW SOCIOECONOMIC STATUS, MINORITY, AGE 65 PLUS OR WHO HAVE BEEN DIAGNOSED WITH MENTAL ILLNESS. SURVEYS WERE ADMINISTERED TO MORE THAN 1,000 COMMUNITY RESIDENTS ACROSS THE NINE COUNTIES WITH OVERSAMPLING OF VULNERABLE GROUPS INCLUDING:MENTAL ILLNESS: RESPONDENTS WHO REPORTED BEING DIAGNOSED WITH OR HAVING EXPERIENCE WITH MENTAL ILLNESS (214 RESPONDENTS)SENIORS: THOSE 65 YEARS OF AGE OR OLDER (126 RESPONDENTS) HISPANIC/LATINOS: THOSE OF LATIN AMERICAN ORIGIN (154 RESPONDENTS)AFRICAN IMMIGRANTS: WEST AFRICAN AND CENTRAL AFRICAN IMMIGRANTS TO THE CINCINNATI AREA (48 RESPONDENTS)LOW INCOME: RESPONDENTS REPORTING COMBINED HOUSEHOLD INCOME OF $24,999 OR LESS (472 RESPONDENTS)FAMILIES AT RISK: FAMILIES WITH CHILDREN UNDER THE AGE OF 18 LIVING IN THE HOUSE REPORTING A COMBINED HOUSEHOLD INCOME OF $24,999 OR LESS(257 RESPONDENTS)THE INTERVIEW QUESTIONS WERE DRAFTED AND NARROWED TO A TOTAL OF 17 QUESTIONS IN FIVE CATEGORIES INCLUDING DEFINING HEALTH AND CONCERNS, ORGANIZATIONAL OPERATIONS PERTAINING TO COMMUNITY IMPROVEMENT, COLLABORATION AND ASSISTANCE, MEASUREMENT AND CLOSING QUESTIONS. THE SURVEYS CONTAINED QUESTIONS REGARDING BARRIERS TO HEALTH CARE, USAGE OF HEALTH CARE, HEALTH CARE NEEDS AND DEMOGRAPHIC INFORMATION.CHNA STAKEHOLDER INTERVIEWS WITH COUNTY LEADERS: FURTHER INDIVIDUAL INPUT WAS OBTAINED THROUGH ONE-ON-ONE INTERVIEWS WITH COUNTY LEADERS LASTING 45-60 MINUTES EACH. THIRTY INTERVIEWS WERE CONDUCTED IN PERSON; THREE OUT OF SIX REQUESTS TO COMPLETE THE ONLINE VERSION WERE FULFILLED; THREE INDIVIDUALS DECLINED; AND EIGHT INDIVIDUALS WERE UNABLE TO BE SCHEDULED DUE TO LACK OF RESPONSE. FOLLOWING ARE ORGANIZATIONS AND GROUPS CONSULTED WHILE CONDUCTING THE CHNA:GROUP LEVEL ASSESSMENTS REPRESENTATIONBUTLER COUNTY: BUTLER 211, BUTLER COUNTY FAMILY CHILDREN FIRST COUNCIL, BUTLER COUNTY SUCCESS, EDUCATIONAL SERVICE CENTER - SUCCESS, FAIRFIELD CITY SCHOOLS, LIFESPAN, MIDDLETOWN HEALTH DEPARTMENT, PRIMARY HEALTH SOLUTIONS, SERVE CITY, TALAWANDA SCHOOL DISTRICT BOARD, BUTLER COUNTY HEALTH DEPARTMENT AND OXFORD COLLEGE CORNER FREE CLINICCLERMONT COUNTY: AMERICAN CANCER SOCIETY, CHILD FOCUS, INC., CLERMONT COUNTY HEALTH DISTRICT, LIFEPOINT SOLUTIONS, MERCY CLERMONT, MERCY CLERMONT OUTREACH, SISTERS OF MERCY CLERMONTHAMILTON COUNTY: CENTERPOINT HEALTH, CINCINNATI CHILDRENS HOSPITAL MEDICAL CENTER, CINCINNATI HEALTH DEPARTMENT, CROSSROAD HEALTH CENTER, EVERYBODY RIDES METRO, HAMILTON COUNTY PUBLIC HEALTH, HEALTH CARE ACCESS NOW, PRO SENIORS, INC, SINCERE HOME HEALTH CARE, SINCERE HOME HEALTH CARE, TALBERT HOUSE, THE GREATER CINCINNATI FOUNDATION, THE HEALTH FOUNDATION OF GREATER CINCINNATI, THE HEALTH COLLABORATIVE, THE HEALTHCARE CONNECTION, THE HEALTHCARE CONNECTION LINCOLN HEIGHTS, UNIVERSITY OF CINCINNATI FAMILY RESIDENCYWARREN COUNTY: ABUSE RAPE CRISIS SHELTER, FAMILY & CHILDREN FIRST COUNCIL, HEALTH DISTRICT (HEALTH DEPARTMENT), OHIO STATE UNIVERSITY EXTENSION, TRIHEALTH, WARREN COUNTY CAREER CENTER, WARREN COUNTY COMMUNITY SERVICES, WARREN COUNTY UNITED WAYSTAKEHOLDER INTERVIEWS REPRESENTATIONALL COUNTIES: CHATFIELD COLLEGE, GREATER CINCINNATI FOUNDATION, HEALTHSOURCE OF OHIO, SOUTHERN STATE COMMUNITY COLLEGE, UNIVERSITY OF CINCINNATI INSTITUTE FOR POLICY RESEARCHBUTLER COUNTY: BUTLER COUNTY SUPPORTS TO ENCOURAGE LOW-INCOME FAMILIES, HAMILTON COMMUNITY FOUNDATION, MIDDLETOWN AREA UNITED WAY, MIDDLETOWN CITY HEALTH DEPARTMENT, MIDDLETOWN COMMUNITY FOUNDATIONCLERMONT COUNTY: CLERMONT COUNTY COMMUNITY SERVICES, CLERMONT COUNTY MENTAL HEALTH AND RECOVERY BOARD, UNITED WAY OF GREATER CINCINNATIHAMILTON COUNTY: CINCINNATI/HAMILTON COMMUNITY ACTION AGENCY, HAMILTON COUNTY MENTAL HEALTH AND RECOVERY SERVICES BOARD, HAMILTON COUNTY PUBLIC HEALTH, SANTA MARIA COMMUNITY SERVICES, UNITED WAY OF GREATER CINCINNATIWARREN COUNTY: MENTAL HEALTH AND RETARDATION SERVICES OF WARREN AND CLINTON COUNTIES, WARREN COUNTY COMBINED HEALTH DISTRICT, WARREN COUNTY COMMUNITY SERVICES INC. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 4: ADAMS COUNTY REGIONAL MEDICAL CENTER, ATRIUM MEDICAL CENTER, DEARBORN COUNTY HOSPITAL, FORT HAMILTON HOSPITAL, GREATER CINCINNATI FOUNDATION, GREATER CINCINNATI HEALTH COUNCIL, HAMILTON COUNTY PUBLIC HEALTH, HIGHLAND COUNTY HEALTH DEPARTMENT, LINDNER CENTER OF HOPE, MARGARET MARY COMMUNITY HOSPITAL, MCCULLOUGH-HYDE MEMORIAL HOSPITAL, MERCY HEALTH, MIDDLETOWN HEALTH DEPARTMENT, UC HEALTH, UNITED WAY OF GREATER CINCINNATI, BETHESDA NORTH HOSPITAL, BETHESDA BUTLER COUNTY GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 7: OBESITY - GOOD SAMARITAN HOSPITAL WILL ADDRESS THIS NEED IN HAMILTON AND BUTLER COUNTIES, HOWEVER, IT WILL NOT, AT THIS TIME, ENTER INTO SPECIFIC PROGRAMS IN WARREN AND CLERMONT COUNTIES. THESE COUNTIES HAVE POPULATIONS THAT ARE SIGNIFICANTLY SMALLER AND LESS DENSE THAN HAMILTON AND BUTLER COUNTIES, THEREBY PRESENTING ADDITIONAL CHALLENGES FOR AN EFFECTIVE AND COMPREHENSIVE STRATEGY.LATINO-LOW INCOME - WITH CHRONIC HEALTH CONDITIONS - GOOD SAMARITAN HOSPITAL WILL NOT ADDRESS THIS NEED SPECIFICALLY AS ITS AFFILIATED HOSPITAL, BETHESDA HOSPITAL, INC., WHICH IS IN THE TRIHEALTH, INC. SYSTEM AND THE GOOD SAMARITAN HOSPITAL FREE CLINIC, AN AFFILATED ORGANIZATION ALSO WITHIN THE TRIHEALTH, INC. SYSTEM SERVE LOW INCOME LATINOS IN HAMILTON COUNTY AND HAVE TARGETED THIS NEED. THE EXISTENCE OF AN ALTERNATIVE MEANS OF ADDRESSING THIS PARTICULAR NEED ALLOWS GOOD SAMARITAN HOSPITAL TO ALLOCATE RESOURCES TO ADDRESS OTHER SIGNIFICANT HEALTH NEEDS.SUBSTANCE ABUSE/MENTAL HEALTH - THIS NEED WILL BE ADDRESSED BY GOOD SAMARITAN HOSPITAL THROUGH ITS GERIATRIC AND ADULT BEHAVIORAL HEALTH PATIENT UNITS. IT WILL NOT ADDRESS MENTAL HEALTH NEEDS OTHERWISE AS THERE IS A COMPREHENSIVE OUTPATIENT PROGRAM FOR SUBSTANCE ABUSE ELSEWHERE IN THE TRIHEALTH, INC. SYSTEM, TO WHICH GOOD SAMARITAN HOSPITAL BELONGS. GOOD SAMARITAN HOSPITAL BELIEVES THAT IT CAN LEVERAGE THE TRIHEALTH NETWORK TO ASSIST IN ADDRESSING PORTIONS OF THIS SIGNIFICANT NEED, THEREBY PERMITTING IT TO ALLOCATE RESOURCES TO OTHER SIGNIFICANT NEEDS. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 12I: SELECT CLINIC DISCOUNT - ELIGIBLE SERVICES RENDERED IN OR ORDERED BY PHYSICIANS AT SELECT CLINICS MAY BE DISCOUNTED IN AN AMOUNT NOT TO EXCEED 85%.O/B CLINIC DISCOUNT - O/B CLINIC PATIENTS RECEIVING ELIGIBLE SERVICES WHO DO NOT QUALIFY FOR FREE CARE AND FOR WHOM THE CHARITY CARE DISCOUNT IS NOT SUFFICIENT MAY RECEIVE A DISCOUNTED FLAT FEE PRICE FOR SUCH SERVICES.UNIQUE CIRCUMSTANCES ALLOWANCE - ALLOWANCES MAY BE GRANTED TO PATIENTS WITH UNIQUE CIRCUMSTANCES WHO DO NOT QUALIFY FOR ANY OTHER FINANCIAL ASSISTANCE. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 14G: GOOD SAMARITAN HOSPITAL DOES NOT PROVIDE A DETAILED COPY OF ITS FINANCIAL ASSISTANCE POLICY TO PATIENTS HOWEVER IT DOES PROVIDE A SUMMARY OF THE POLICY IN A MANNER LISTED IN LINES 13A-13E.IN ADDITION, SUCH INFORMATION SHALL BE PROVIDED IN LANGUAGES CONSIDERED TO BE COMMONLY SPOKEN BY THE POPULATION GOOD SAMARITAN HOSPITAL SERVES. IF TRANSLATION OR OTHER ASSISTANCE IS NEEDED TO FACILITATE COMPLETION AND/OR UNDERSTANDING OF THE FINANCIAL ASSISTANCE POLICY AND/OR APPLICATION TRANSLATION AND OTHER REASONABLE REQUESTS FOR ASSISTANCE WILL BE PROVIDED. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 20D: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") ISSUES A BILLING STATEMENT TO ALL FAP ELIGIBLE INDIVIDUALS THAT STATES GROSS CHARGES FOR THE CARE RECEIVED AS THE STARTING POINT FOR APPLYING THE DISCOUNTS AND DEDUCTIONS THE FAP ELIGIBLE INDIVIDUAL IS ENTITLED TO UNDER ITS FAP, SUCH THAT THE AMOUNT THAT AN FAP ELIGIBLE INDIVIDUAL IS REQUIRED TO PAY IS (I) LESS THAN THE GROSS CHARGES FOR SUCH CARE, AND (II) TYPICALLY LESS THAN THE AMOUNTS GENERALLY BILLED TO PERSONS WITH INSURANCE. CURRENTLY, AS PART OF THE TRIHEALTH SYSTEM, GSH PROVIDES FREE CARE TO PATIENTS WHOSE INCOME FALLS BELOW 100% OF THE FEDERAL POVERTY GUIDELINES. IN ADDITION, IT PROVIDES DISCOUNTED CARE ON A SLIDING SCALE TO PATIENTS WITH INCOMES ALL THE WAY UP TO 400% OF THE FEDERAL POVERTY GUIDELINES. ANY UNINSURED PATIENT THAT FILLS OUT A FINANCIAL ASSISTANCE FORM AUTOMATICALLY RECEIVES A 40% DISCOUNT REGARDLESS OF INCOME WHILE OTHER PATIENTS RECEIVE A 45% DISCOUNT (INCOME BETWEEN 300% AND 400% OF POVERTY GUIDELINES), 60% DISCOUNT (INCOME BETWEEN 200% AND 300% OF POVERTY GUIDELINES), OR AN 80% DISCOUNT (INCOME BETWEEN 100% AND 200% OF POVERTY GUIDELINES). THE CURRENT AVERAGE DISCOUNT WITH COMMERCIAL INSURANCE COMPANIES IS 63% SO VIRTUALLY ALL PATIENTS QUALIFYING FOR FINANCIAL ASSISTANCE WITH INCOME UP TO 300% OF THE POVERTY GUIDELINES ARE RECEIVING DISCOUNTS EQUAL TO OR GREATER THAN THE AVERAGE COMMERCIAL INSURANCE DISCOUNT. IN ADDITION, GSH BELIEVES THE TRIHEALTH FINANCIAL ASSISTANCE POLICY IS GENEROUS AS MANY HOSPITALS DO NOT OFFER ANY FINANCIAL ASSISTANCE TO PATIENTS WITH INCOME OVER 300% OF THE POVERTY GUIDELINE. HOWEVER, IT PREFERS TO EXTEND DISCOUNTS TO SUCH INDIVIDUALS RATHER THAN DENY THEM ELIGIBILITY UNDER THE POLICY SO THAT SUCH INDIVIDUALS RECEIVE SOME FINANCIAL ASSISTANCE RATHER THAN NONE. 10 GOOD SAMARITAN MEDICAL CENTER 6949 GOOD SAMARITAN DRIVE CINCINNATI OH 45247 EMERGENCY DEPARTMENT/OUTPATIENT SERVICES GOOD SAMARITAN PHYSICAL THERAPY 8748 UNION CENTRE DRIVE WEST CHESTER OH 45069 PHYSICAL THERAPY GOOD SAMARITAN HOSPITAL OUTPATIENT CTR 6350 GLENWAY AVENUE CINCINNATI OH 45211 OUTPATIENT PHYSICIAN CLINIC GOOD SAMARITAN HOSPITAL WEIGHT MGMT CTR 3219 CLIFTON AVENUE SUITE 225 CINCINNATI OH 45220 WEIGHT MANAGEMENT SERVICES GOOD SAMARITAN HOSPITAL WOMEN'S CENTER 3219 CLIFTON AVENUE SUITE 100 CINCINNATI OH 45220 WOMEN'S HEALTH SERVICES TRIHEALTH OUTPATIENT CENTER 7777 BEECHMONT AVE CINCINNATI OH 45255 OUTPATIENT PHYSICIAN/PATIENT SERVICES TRIHEALTH INFUSION CENTER - WESTSIDE 5520 CHEVIOT RD SUITE A CINCINNATI OH 45247 INFUSION CENTER TRIHEALTH INFUSION CENTER - NORTH 10550 MONTGOMERY RD STE 22 CINCINNATI OH 45242 INFUSION CENTER/RADIATION THERAPY TRIHEALTH SLEEP MEDICINE 6350 GLENWAY AVENUE CINCINNATI OH 45211 SLEEP MEDICINE GOOD SAMARITAN HOSPITAL WEIGHT MGMT CTR 6200 PFEIFFER ROAD CINCINNATI OH 45242 WEIGHT MANAGEMENT SERVICES PART I, LINE 3C: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO UTILIZES THE FEDERAL POVERTY GUIDELINES ("FPG") IN DETERMINING CHARITY CARE ELIGIBILITY. SEE THE RESPONSES TO PART I, LINE 3A AND 3B.AN INDIVIDUAL'S INCOME UNDER FPG IS A SIGNIFICANT FACTOR IN DETERMINING ELIGIBILITY FOR CHARITY CARE. ADDITIONALLY, AN INDIVIDUAL'S INCOME IN RELATION TO HIS/HER MEDICAL EXPENSES IS ALSO TAKEN INTO ACCOUNT AND SUCH A PATIENT MAY BE EXTENDED DISCOUNTED OR FREE CARE BASED UPON THE FACTS AND CIRCUMSTANCES. PART I, LINE 6A: IN 1995, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND BETHESDA HOSPITAL, INC. FORMED A PARTNERSHIP CALLED TRIHEALTH, INC. TO CREATE AN INTEGRATED HEALTH DELIVERY SYSTEM WHOSE MISSION IS TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE, WITH AN EMPHASIS ON PREVENTION, WELLNESS AND EDUCATION. THE COMMUNITY BENEFIT PROVIDED BY THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO IS TRACKED ON A STANDALONE BASIS, HOWEVER ITS COMMUNITY BENEFIT IS REPORTED IN COMBINATION WITH BETHESDA HOSPITAL, INC.'S COMMUNITY BENEFIT IN A REPORT PREPARED BY TRIHEALTH, INC. PART I, LINE 7: FOR THE AMOUNTS REPORTED AT COST IN PART I, LINE 7, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO UTILIZED WORKSHEET 2 - RATIO OF PATIENT CARE COST-TO-CHARGES, WHICH WAS PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H, TO CALCULATE THE COST-TO-CHARGE RATIO. PART I, LINE 7G: THE SUBSIDIZED HEALTH SERVICES COMMUNITY BENEFIT AMOUNT REPORTED IN PART I, LINE 7(G) DOES NOT INCLUDE COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS. PART I, LN 7 COL(F): BAD DEBT EXPENSE IS NOT INCLUDED ON FORM 990, PART IX, LINE 25. IT IS PRESENTED ON FORM 990, PART VIII, LINE 2 AS A DEDUCTION FROM PATIENT SERVICE REVENUE WHICH CORRESPONDS TO ITS FINANCIAL STATEMENT PRESENTATION. SEE RESPONSE TO PART III, LINE 4. THEREFORE, NO ADJUSTMENT TO TOTAL EXPENSES SHOWN ON FORM 990, PART IX, LINE 25 IS NECESSARY. PART II, COMMUNITY BUILDING ACTIVITIES: THE UPTOWN CONSORTIUM ("CONSORTIUM") IS RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). IT IS MADE UP OF THE FIVE LARGEST EMPLOYERS OF CINCINNATI'S "UPTOWN" INCLUDING THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. "UPTOWN" GENERALLY INCLUDES THE NEIGHBORHOODS OF AVONDALE, CLIFTON, CLIFTON HEIGHTS, CORRYVILLE, FAIRVIEW, MT. AUBURN AND UNIVERSITY HEIGHTS. THE CONSORTIUM IS DEDICATED TO BUILDING THE HUMAN, SOCIAL AND PHYSICAL IMPROVEMENT OF UPTOWN CINCINNATI. IT WILL UNDERTAKE A VARIETY OF INVESTMENT AND PROGRAM ACTIVITIES IN UPTOWN TO HELP PROVIDE HOUSING, HEALTH CARE AND JOB OPPORTUNITIES. PART III, LINE 2: SEE SCHEDULE H, PART III, LINE 4. PART III, LINE 3: SEE SCHEDULE H, PART III, LINE 4. PART III, LINE 4: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S FINANCIAL STATEMENTS ARE AUDITED AS PART OF THE TRIHEALTH AUDIT REPORT.NET PATIENT ACCOUNTS RECEIVABLE (PART OF FOOTNOTE B)NET PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT SERVICE REVENUE HAVE BEEN ADJUSTED TO THE ESTIMATED AMOUNTS EXPECTED TO BE COLLECTED. THESE ESTIMATED AMOUNTS ARE SUBJECT TO FURTHER ADJUSTMENTS UPON REVIEW BY THIRD-PARTY PAYORS.THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY AS NECESSARY THE PROVISIONS FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE. SIGNIFICANT PROVISION IS MADE FOR SELF-PAY PATIENT ACCOUNTS RECEIVABLE IN THE PERIOD OF SERVICE BASED UPON HISTORICAL WRITE-OFF EXPERIENCE.AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, TRIHEALTH FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY TRIHEALTH. OVERALL, THE TOTAL WRITE-OFFS OF UNCOLLECTIBLE ACCOUNTS AND ALLOWANCES ON SELF-PAY PATIENT ACCOUNTS RECEIVABLE HAS NOT SIGNIFICANTLY CHANGED SINCE JUNE 30, 2013. TRIHEALTH HAS NOT EXPERIENCED SIGNIFICANT CHANGES IN WRITE-OFF TRENDS AND HAS NOT CHANGED ITS CHARITY CARE POLICY SINCE JUNE 30, 2013. THE OVERALL ALLOWANCE PERCENTAGE FOR UNCOLLECTIBLE ACCOUNTS WENT FROM 52% AT JUNE 30, 2013 TO 37% AT JUNE 30, 2014 AS A RESULT OF CHANGES IN PAYOR MIX DUE TO THE AFFORDABLE CARE ACT.FINANCIAL INSTRUMENTS THAT POTENTIALLY SUBJECT TRIHEALTH TO CONCENTRATIONS OF CREDIT RISK CONSIST PRIMARILY OF NON-GOVERNMENTAL PATIENT ACCOUNTS RECEIVABLE. TRIHEALTH GRANTS CREDIT WITHOUT COLLATERAL TO ITS PATIENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE PERCENTAGES OF GROSS PATIENT ACCOUNTS RECEIVABLE FROM PATIENTS AND THIRD-PARTY PAYORS AT JUNE 30 APPROXIMATED THE FOLLOWING: 2014 - MEDICARE 18%, MEDICAID 4%, MANAGED CARE 26%, SELF PAY 20%, COMMERCIAL AND OTHER 32%2013 - MEDICARE 19%, MEDICAID 3%, MANAGED CARE 22%, SELF PAY 23%, COMMERCIAL AND OTHER 33%TRIHEALTH HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. THE BASIS FOR PAYMENT UNDER THESE AGREEMENTS INCLUDES PROSPECTIVELY DETERMINED RATES, COST REIMBURSEMENT, NEGOTIATED DISCOUNTS FROM ESTABLISHED RATES, AND PER DIEMPAYMENTS. PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS DUE TO FUTURE AUDITS, REVIEW AND INVESTIGATIONS. THE DIFFERENCES BETWEEN THE ESTIMATED AND ACTUAL ADJUSTMENTS ARE RECORDED AS PART OF NET PATIENT SERVICE REVENUE IN FUTURE PERIODS, AS THE AMOUNTS BECOME KNOWN, OR AS YEARS ARE NO LONGER SUBJECT TO SUCH AUDITS, REVIEWS AND INVESTIGATIONS. TRIHEALTH RECOGNIZES A SIGNIFICANT AMOUNT OF PATIENT SERVICE REVENUE AT THE TIME THE SERVICES ARE RENDERED EVEN THOUGH IT DOES NOT ASSESS THE PATIENT'S ABILITY TO PAY. AS A RESULT, THE PROVISION FOR BAD DEBT IS PRESENTED AS A DEDUCTION FROM PATIENT SERVICE REVENUE NET OF CONTRACTUAL PROVISIONS AND DISCOUNTS.AS FOR THE AMOUNT OF BAD DEBT THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S CHARITY CARE POLICY, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO DOES NOT REPORT ACTUAL BAD DEBT EXPENSE AS COMMUNITY BENEFIT. IF UPON FURTHER RESEARCH, IT IS ULTIMATELY DETERMINED THAT A PORTION OF BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS WHO WOULD LIKELY QUALIFY FOR FINANCIAL ASSISTANCE UNDER TRIHEALTH'S CHARITY CARE POLICY, THOSE COSTS WOULD BE RECLASSIFIED, AS APPROPRIATE, TO COMMUNITY BENEFIT AT THAT TIME.PLEASE NOTE THAT BAD DEBT EXPENSE IS NOT DETERMINED UNTIL AFTER ALL DISCOUNTS AND ANY ASSOCIATED PAYMENTS ARE TAKEN INTO ACCOUNT. IF ANY PAYMENTS ARE RECEIVED AFTER A PATIENT ACCOUNT IS DETERMINED TO BE BAD DEBT, THE ACCOUNT WILL BE ADJUSTED ACCORDINGLY AT THAT TIME. PART III, LINE 8: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO USES THE "STEPDOWN METHODOLOGY" IN DETERMINING THE MEDICARE ALLOWABLE COSTS REPORTED ON THE MEDICARE COST REPORT. THIS METHOD OF COST FINDING PROVIDES FOR THE ALLOCATION OF THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS WHICH UTILIZE SUCH SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO DID NOT REPORT ANY MEDICARE SHORTFALL AS COMMUNITY BENEFIT IN PART III, LINE 7 OF THIS SCHEDULE. PART III, LINE 9B: AS OF THE FILING OF THIS RETURN, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO, AS PART OF TRIHEALTH, INC., MAINTAINS A WRITTEN DEBT COLLECTION POLICY. TRIHEALTH, INC., WHO PERFORMS THE BILLING SERVICES FOR ALL AFFILIATED HOSPITALS, WILL NOT INITIATE COLLECTION PRACTICES ON PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. BEFORE COLLECTION ACTIONS ARE TAKEN, TRIHEALTH, INC. WILL MAKE REASONABLE EFFORTS, GENERALLY AS EARLIER IN THE BILLING PROCESS AS POSSIBLE, TO DETERMINE WHETHER A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE. AFTER SUCH EFFORTS HAVE BEEN MADE AND A BALANCE REMAINS THAT IS THE RESPONSIBILITY OF THE PATIENT OR GUARANTOR, TRIHEALTH, INC. MAY PURSUE, IN ITS SOLE DISCRETION, WHATEVER ACTIONS IT MAY BE ENTITLED TO TAKE UNDER LAW. PART VI, LINE 2: IN 1852, THE SISTERS OF CHARITY ESTABLISHED GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") IN AN EFFORT TO ADDRESS THE NEEDS OF THE GROWING CITY OF CINCINNATI. IN 1995, GSH & BETHESDA HOSPITAL, INC. ("BETHESDA") FORMED A PARTNERSHIP TO CREATE A LOCAL HEALTH SYSTEM: TRIHEALTH, INC. ("TRIHEALTH"). TRIHEALTH'S MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THROUGH A FULL RANGE OF HEALTH RELATED SERVICES (E.G. PREVENTION, WELLNESS & EDUCATION)THE SERVICES DESCRIBED BELOW, & OTHERS NOT LISTED, PROMOTE A HEALTHY COMMUNITY AND SEEK TO REDUCE THE BURDENS ON THE GOVERNMENT. FOR EXAMPLE, IF GSH DID NOT ADDRESS THE ROOT CAUSES OF LOW BIRTH WEIGHT & PREMATURITY, THE BURDEN TO GOVERNMENT MEDICAL PROGRAMS SUCH AS MEDICAID WOULD BE EVEN GREATER.GSH, AS PART OF TRIHEALTH, PARTICIPATED IN AND WAS A FUNDER OF THE WORK OF A COLLABORATIVE, REGIONAL EFFORT, THE A.I.M. FOR BETTER HEALTH COMMUNITY HEALTH NEEDS ASSESSMENT (A.I.M). IN THE AREAS ASSESSED THE POPULATIONS SURVEYED WERE MORE OFTEN UNDERSERVED, INCLUDING THE UNINSURED, UNDERINSURED, LOW SOCIOECONOMIC STATUS, MINORITIES, AND OVER AGE SIXTY-FIVE, OR WITH A DIAGNOSIS OF MENTAL ILLNESS. THE A.I.M., PUBLISHED IN THE SPRING OF 2012, WAS THE BASIS FOR THE DEVELOPMENT OF GSH' COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN THAT WAS APPROVED DURING FISCAL YEAR 2013.FREE & DISCOUNTED SERVICES ARE PROVIDED FOR THOSE UNABLE TO PAY & MEETING ELIGIBILITY CRITERIA. THROUGH THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP), GSH SERVES PATIENTS MEETING CRITERIA SET FORTH BY THE STATE OF OHIO. GSH POLICY IS TO PROVIDE CHARITY CARE ON A SLIDING SCALE DISCOUNTING WHEN THE FAMILY INCOME IS UP TO 400 % OF THE ANNUALLY ESTABLISHED FEDERAL POVERTY GUIDELINE. IT OFFERS AN UNINSURED DISCOUNT FOR MEDICALLY NECESSARY SERVICES FOR THOSE WHO HAVE NO INSURANCE & WHO DO NOT QUALIFY FOR OTHER FINANCIAL ASSISTANCE OPTIONS. FINANCIAL COUNSELORS ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION WHICH IS AVAILABLE ON TRIHEALTH'S WEBSITE & BROCHURES ABOUT FINANCIAL ASSISTANCE ARE VISIBLE & AVAILABLE IN HOSPITAL REGISTRATION & ADMITTING AREAS.GSH FUNDS THE TRIHEALTH OUTREACH MINISTRIES & COMMUNITY HEALTH WORKER PROGRAMS. THESE PROGRAMS PROVIDE, AT NO CHARGE, HOME VISITS TO LOW INCOME CLIENTS IN 9 NEIGHBORHOODS. CLIENTS INCLUDE SENIORS & FRAIL ELDERLY IN THEIR HOMES OR IN CONGREGATE SUBSIDIZED HOUSING, THE MENTALLY & PHYSICALLY HANDICAPPED LIVING ALONE OR IN GROUP HOMES, & MOTHERS WHO ARE PREGNANT OR WHO HAVE RECENTLY DELIVERED A BABY. REFERRALS COME FROM HOSPITAL CARE COORDINATORS, OTHER HOSPITALS & AGENCIES. THE TEAM PROVIDES HEALTH SCREENINGS, EDUCATION ON MANAGING CHRONIC ILLNESSES, & CONNECTIONS TO ASSISTANCE. HEALTHY WOMEN HEALTHY LIVES IS A PROGRAM BASED ON THE PREMISE THAT PREVENTION, EARLY DETECTION, TREATMENT & ACCESS TO HEALTH CARE SERVICES IMPROVE INDIVIDUAL & COMMUNITY HEALTH OUTCOMES. THE FOCUS IS ON HEALTH RISKS ASSOCIATED WITH THE ONSET OF MENOPAUSE. WELL ORGANIZED SCREENING & EDUCATION EVENTS BRING THE SERVICES TO AT RISK POPULATIONS OF AFRICAN AMERICAN, APPALACHIAN, HISPANIC, UNINSURED & UNDERINSURED WOMEN FORTY YEARS OF AGE OR OLDER. SCREENING INCLUDES OSTEOPOROSIS, MAMMOGRAPHY, CHOLESTEROL, HYPERTENSION, & OBESITY. EVERY WOMAN RECEIVES A NURSE CONSULTATION, A COPY OF THEIR RESULTS & A WRITTEN PRIMARY CARE REFERRAL. WOMEN WITH ABNORMAL RESULTS ARE CONTACTED & ASSISTED IN ACCESSING PRIMARY CARE. THIS PROGRAM SERVES AS AN ENTRY POINT TO HEALTH CARE SERVICES FOR MANY WOMEN IN THE COMMUNITY.HAMILTON COUNTY'S INFANT MORTALITY RATE IS THE HIGHEST IN OHIO AND HAS LED GSH TO FOCUS ON MATERNAL & INFANT HEALTH PROGRAMS. STRATEGIES INCLUDE INVESTIGATING THE ROOT CAUSES OF PREMATURITY & LOW BIRTH WEIGHT. IN RESPONSE, GSH PROVIDES AND SUPPORTS A DIVERSITY OF PROGRAMS OF PRENATAL CARE FOR AT RISK MOTHERS. PERINATAL CARE COORDINATION NURSES & SOCIAL WORKERS FROM GSH ASSIST MOTHERS IN THE GSH FACULTY MEDICAL CENTER AND TRIHEALTH MIDWIVES LOCATIONS. THEY ALSO TRAVEL TO OUTSIDE CLINICS IN ORDER TO REACH OUT & HELP UNINSURED & UNDERINSURED MOTHERS ACCESS PUBLIC PROGRAMS, REFERRALS, EDUCATION, ASSESSMENT & RESOURCES.THE B4 (BEFORE, BETWEEN, AND BEYOND PREGNANCY FOR YOUR BABY AND YOU) IS A PREMATURITY PREVENTION PROGRAM THAT PROVIDES INTERCONCEPTION HEALTH EDUCATION, TARGETED CASE MANAGEMENT, AND SUPPORT TO MOTHERS WHOSE INFANTS ARE BORN AT LESS THAN 32 COMPLETED WEEKS OF GESTATION AND RECEIVE CARE IN GSHS NICU. THE GOAL OF THE PROGRAM IS TO PROMOTE A CONTINUUM OF WELLNESS CARE FOR WOMEN IN ORDER TO IMPROVE THEIR OWN HEALTH AND REDUCE THEIR RISK FOR RECURRING POOR BIRTH OUTCOMES, INCLUDING PREMATURITY AND NEONATAL MORTALITY. ALSO, IN COLLABORATION WITH WINTON HILLS HEALTH CENTER, GSH FUNDS THE SALARIES OF AN OB/GYN PHYSICIAN AND A NURSE MIDWIFE AT THE CENTER AND ITS SATELLITE EXTENSION. THIS AFFORDS HEALTH CARE ACCESS TO WOMEN IN THE AREA SURROUNDING THE CENTER.GSH CONTINUES A COMMITMENT TO EDUCATING THE NEXT GENERATION OF HEALTH CARE PROVIDERS, PHYSICIANS & ALLIED HEALTH PROFESSIONALS. GSH, AS PART OF TRIHEALTH, INC., SPONSORS MEDICAL RESIDENCIES. THERE WERE 26 RESIDENTS IN INTERNAL MEDICINE & 21 GENERAL SURGERY RESIDENTS AT GSH IN FISCAL YEAR 2014. 5 RESIDENTS/FELLOWS IN VASCULAR SURGERY RECEIVED EXTENDED LEARNING & PREPARATION AT GSH. 32 TOTAL RESIDENTS IN OBSTETRICS & GYNECOLOGY LEARNED IN A JOINT RESIDENCY AT BOTH BETHESDA & GSH.IN THE GSH FACULTY MEDICAL CENTER ("FMC"), A MULTI-SPECIALTY CENTER, MEDICAL RESIDENTS PROVIDE CARE TO PATIENTS UNDER THE GUIDANCE OF ATTENDING PHYSICIANS. FMC SERVICES INCLUDE OBSTETRICS & GYNECOLOGY, INTERNAL MEDICINE, VASCULAR & GENERAL SURGERY, DYSPLASIA, HIGH-RISK PREGNANCY, URO-GYNECOLOGY & GASTRO-INTESTINAL. THE FMC PHARMACIST HELPS ELIGIBLE CLIENTS COMPLETE THE MEDICATION ASSISTANCE PROGRAMS APPLICATIONS. THE GSH ON-SITE PHARMACY PROVIDES PRESCRIPTIONS FOR THOSE IN NEED, AT REDUCED OR NO COST. GSH FUNDS THE SALARIES OF STAFF SUPPORTING THE CLIENTS AND PHYSICIANS OF THE FACULTY MEDICAL CENTER. THIS STAFF INCLUDES CARE COORDINATORS, SOCIAL WORKERS, DIETITIANS, PHARMACISTS, AND FINANCIAL COUNSELORS.GSH COLLABORATES WITH LOCAL & REGIONAL COLLEGES, UNIVERSITIES & TRAINING CENTERS TO PROVIDE MENTORING, INTERNSHIPS, CLERKSHIPS, SUPERVISED EDUCATION & CLINICAL ROTATIONS TO STUDENTS IN HEALTH FIELDS. THESE PARTNERSHIPS HELP STUDENTS LEARN ABOUT & PREPARE FOR PROFESSIONS IN NURSE PRACTITIONER, RESPIRATORY THERAPY, RADIOLOGY TECHNOLOGY, STERILE PROCESSING, PHLEBOTOMY, MEDICAL LABORATORY, CLINICAL DIETETICS, PHARMACY, SPEECH, AUDIOLOGY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, NURSE MIDWIFERY, & NEONATAL NURSE PRACTITIONER. PASTORAL CARE OFFERS A CLINICAL PASTORAL EDUCATION PROGRAM EDUCATING CLERGY & OTHERS IN PASTORAL SKILLS TO MINISTER EFFECTIVELY TO THE SICK & THE DYING.GSH'S RESEARCH PROGRAM MANAGES BASIC & APPLIED SCIENTIFIC STUDIES & SPONSORED CLINICAL TRIALS. IT ALSO SUPPORTS THE EDUCATION ACTIVITIES OF STAFF PHYSICIANS & SURGEONS, TEACHING FACULTY, RESIDENTS, & ALLIED HEALTH PROFESSIONALS. WHAT IS LEARNED THROUGH THE RESEARCH & EDUCATION PROGRAMS IS SHARED WITH THE LARGER COMMUNITY. THE RESEARCH PROGRAM HELPS RESEARCHERS GIVE PROFESSIONAL PRESENTATIONS AT REGIONAL & NATIONAL MEETINGS AS HAVE STUDIES & ARTICLES PUBLISHED IN PEER-REVIEWED MEDICAL JOURNALS.THROUGH THESE PROGRAMS, GSH CONTINUES ITS SPECIAL CONCERN FOR THE VULNERABLE. EMPLOYEES, PHYSICIANS & LEADERS PROVIDING & GUIDING THESE PROGRAMS FOR COMMUNITY HEALTH ARE LIVING THE CORE VALUES OF STEWARDSHIP & RESPONSE TO COMMUNITY NEEDS. PART VI, LINE 3: TRIHEALTH, INC. ("TRIHEALTH") PERFORMS THE BILLING SERVICES FOR ALL AFFILIATED HOSPITALS INCLUDING THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. BROCHURES/APPLICATIONS, PROVIDED IN MULTIPLE LANGUAGES, ARE VISIBLE AND AVAILABLE IN THE REGISTRATION AND ADMITTING AREAS OF ALL TRIHEALTH AFFILIATED HOSPITALS. IN ADDITION, THE APPLICATION IS PRINTED ON THE REVERSE SIDE OF A PATIENT'S BILL WITH INSTRUCTIONS ON HOW TO COMPLETE THE APPLICATION AS WELL AS HOW TO RETURN IT. FINANCIAL COUNSELORS ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION. FINALLY, TRIHEALTH INC.'S WEBSITE CONTAINS INFORMATION REGARDING ITS CHARITY CARE AND FINANCIAL ASSISTANCE PROGRAMS WITH DIRECTIONS ON HOW TO CONTACT THE APPROPRIATE PERSONNEL TO INITIATE AN APPLICATION OR ASK QUESTIONS ABOUT THE PROCESS. PART VI, LINE 4: LOCATED IN CINCINNATI, OHIO, GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND THE TRIHEALTH SYSTEM SERVE HAMILTON, BUTLER, WARREN AND CLERMONT COUNTIES, AS WELL AS PERSONS FROM INDIANA AND KENTUCKY. OHIO'S THIRD LARGEST CITY, CINCINNATI HAS AN ESTIMATED POPULATION OF 300,000. THE POPULATION WITHIN THE FOUR OHIO COUNTIES SERVED BY TRIHEALTH IS ESTIMATED TO BE 1,600,000 AND 11% PERCENT OF THIS POPULATION IS UNINSURED. THE GEOGRAPHIC AREA SERVED BY THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO IS PREDOMINANTLY URBAN WITH A LARGE SEGMENT OF ITS PATIENTS UNINSURED, UNDERINSURED OR MEDICAID RECIPIENTS. PART VI, LINE 5: THE ONGOING PURPOSE OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("GSH") IS TO PROVIDE CARE WITH COMPASSION. ITS MISSION IS TO IMPROVE THE HEALTH STATUS OF THE COMMUNITY THROUGH HEALTH RELATED SERVICES--PREVENTION, WELLNESS AND EDUCATION. ITS BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY REPRESENTATIVES. GSH IS AN ACUTE TERTIARY TEACHING HOSPITAL. AS PART OF TRIHEALTH A SYSTEM OF SERVICES SPANNING ACUTE CARE TO HOME CARE, BABIES TO SENIORS. IT PROVIDES A 24-HOUR EMERGENCY ROOM, FOUR INTENSIVE CARE UNITS FOR NEONATES AND ADULTS, ADULT AND GERIATRIC INPATIENT PSYCHIATRIC CARE, AND AN ACCREDITED REHABILITATION MEDICINE PROGRAM. SERVICES ARE OPEN TO ALL INDIVIDUALS REGARDLESS OF ABILITY TO PAY. GSH HAS AN OPEN MEDICAL STAFF AND A HISTORY OF TRAINING AND EDUCATING MEDICAL RESIDENTS AND HEALTH CARE PROFESSIONALS. ITS MEDICAL AND SCIENTIFIC RESEARCH PROGRAMS INCLUDE STUDIES THAT ARE NOT COMMERCIALLY SPONSORED. GSH PARTICIPATES IN MEDICARE AND MEDICAID AND OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS, AND HAS AN ACTIVE CHARITY CARE PROGRAM.SEE RESPONSE TO PART VI, LINE 2 FOR ADDITIONAL INFORMATION. PART VI, LINE 6: IN 1995, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO AND BETHESDA HOSPITAL, INC. FORMED A PARTNERSHIP CALLED TRIHEALTH, INC. TO CREATE AN INTEGRATED HEALTH DELIVERY SYSTEM WHOSE MISSION IS TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE, WITH AN EMPHASIS ON PREVENTION, WELLNESS AND EDUCATION. TRIHEALTH, INC.'S SITES INCLUDE TWO HOSPITAL LOCATIONS AND VARIOUS PHYSICIAN OFFICE BUILDINGS THROUGHOUT THE GREATER CINCINNATI AREA IN ADDITION TO FITNESS, REHABILITATION, OCCUPATIONAL HEALTH, PALLIATIVE CARE SERVICES AND OUTPATIENT CENTERS. IT ALSO PROVIDES SERVICES IN HOMES AND WORKPLACES AND DELIVERS CARE AND EDUCATION COOPERATIVELY THROUGH COMMUNITY-BASED ORGANIZATIONS, SUCH AS CHURCHES, SCHOOLS, CLINICS AND SOCIAL AGENCIES. 1 UPTOWN CONSORTIUM INC 629 OAK STREET SUITE 306 CINCINNATI OH 45206 200688727 501(C)(3) 147900 GENERAL PURPOSES AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75231 135613797 501(C)(3) 65280 SPONSORSHIP CENTER FOR RESPITE CARE INC PO BOX 141301 CINCINNATI OH 45229 202544994 501(C)(3) 26010 GENERAL PURPOSES GOOD SAMARITAN HOSPITAL FOUNDATION OF CINCINNATI INC 619 OAK STREET CINCINNATI OH 45206 311206047 501(C)(3) 11120 SPONSORSHIP BETHESDA FOUNDATION INC 619 OAK STREET CINCINNATI OH 45206 237374129 501(C)(3) 60690 SPONSORSHIP THE HEALTH COLLABORATIVE 2649 ERIE AVENUE 2ND FLOOR CINCINNATI OH 45208 311449807 501(C)(3) 56100 GENERAL PURPOSES THE CHILDREN'S THEATER 5020 OAKLAWN DRSUITE 2000 CINCINNATI OH 45227 316026285 501(C)(3) 10200 SPONSORSHIP FRIARS CLUB INC 2316 HARRYWOOD COURT CINCINNATI OH 45239 310537485 501(C)(3) 5100 SPONSORSHIP JUVENILE DIABETES RESEARCH FOUNDATION 8050 HOSBROOK ROAD SUITE 314 CINCINNATI OH 45236 231907729 501(C)(3) 5100 SPONSORSHIP MARVIN LEWIS COMMUNITY FUND 700 WEST PETE ROSE WAY NO 37 CINCINNATI OH 45203 202704690 501(C)(3) 12750 SPONSORSHIP HEALTHY BEGINNINGS INC 47 E HOLLISTER STE 201 CINCINNATI OH 45219 311380939 501(C)(3) 80000 SUPPORT FUNDING HEALTHY MOM AND BABIES INC 2270 BANNING ROAD CINCINNATI OH 45239 311155292 501(C)(3) 100000 CHARITY CARE 12 PART I, LINE 2: THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") PROVIDES GRANTS TO OTHER ORGANIZATIONS AND INDIVIDUALS ON A VERY LIMITED BASIS. IN THOSE INSTANCES, THE DEPARTMENT GRANTING THE FUNDS IS RESPONSIBLE FOR OBTAINING AND STORING ALL NECESSARY INFORMATION FROM THE OTHER ORGANIZATION AND INDIVIDUALS RELATIVE TO HOW THE FUNDS WILL BE SPENT. GENERALLY, GRANTS ARE PROVIDED, ON BEHALF OF HOSPITAL THOUGH TRIHEALTH, INC. ("TRIHEALTH"), A SUPPORTING ORGANIZATION OF HOSPITAL, WHICH PROVIDES ADMINISTRATIVE SUPPORT SERVICES TO HOSPITAL. AS SUCH, TRIHEALTH IS RESPONSIBLE FOR MONITORING THE USE OF HOW THE FUNDS WILL BE SPENT. 0 1 0 0 0 0 0 1 0 JOHN PROUT PRESIDENT/CEO 0 933901 0 370000 0 151252 0 319627 0 9025 0 1783805 0 119269 PAUL EDGETT III TRUSTEE 0 496880 0 515695 0 114019 0 72192 0 22006 0 1220792 0 92265 STEPHEN BLATT MD MED STAFF PRES-GOOD SAM (END 12/13) 0 371110 0 22109 45000 1337 0 41395 0 17678 45000 453629 0 0 STUART DONOVAN MD MED STAFF PRES-BETHESDA (END 12/13) 0 457880 0 93000 0 47338 0 10783 0 472 0 609473 0 0 ALAN ALTMAN MD MED STAFF PRES-BETHESDA (START 1/14) 0 241019 0 25000 0 18572 0 67361 0 24267 0 376219 0 0 DONNA NIENABER ESQ SVP CORP COUNSEL/ASST SECRETARY 0 335667 0 142672 0 25307 0 142672 0 16913 0 663231 0 0 CRAIG RUCKER SVP CFO/ASST TREASURER 0 438712 0 128945 0 23038 0 127978 0 10828 0 729501 0 0 WILLIAM GRONEMAN EXEC VP SYSTEM DEVELOPMENT 0 398252 0 117323 0 72375 0 157712 0 26746 0 772408 0 20369 GERALD OLIPHANT EXEC VP & COO 0 490075 0 148339 0 19091 0 127101 0 25009 0 809615 0 0 GEORGES FEGHALI MD CHIEF MEDICAL OFFICER 0 395530 0 159828 0 25473 0 152458 0 22160 0 755449 0 0 JOHN ROBINSON MD SVP-HOSPITAL OPERATIONS 0 296746 0 75179 0 14124 0 71624 0 23362 0 481035 0 0 JAIME EASTERLING EXEC DIRECTOR- GOOD SAM HOSPITAL 0 163982 0 34882 0 3520 0 22944 0 13854 0 239182 0 0 DAVID DHANRAJ MD PHYSICIAN 329918 0 0 0 662 0 22162 0 21699 0 374441 0 0 0 ROBERT ROHS MD PHYSICIAN 239990 0 53384 0 3405 0 40594 0 463 0 337836 0 0 0 DEVIN NAMAKY MD PHYSICIAN 246371 0 0 0 317 0 20884 0 17903 0 285475 0 0 0 JOHN SPRAGUE MD PHYSICIAN 183715 0 0 0 1191 0 18860 0 15408 0 219174 0 0 0 GARY HESS PHARMACIST 149031 0 9901 0 1137 0 32716 0 7282 0 200067 0 0 0 MICHAEL CROFTON FORMER 0 223774 0 48955 0 23713 0 50992 0 24402 0 371836 0 0 PART I, LINE 4B ELIGIBLE EXECUTIVES (GENERALLY VICE PRESIDENTS AND ABOVE) PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. TRIHEALTH, INC., THE RELATED ORGANIZATION THAT PAID THE SALARIES OF THE FOLLOWING INDIVIDUALS LISTED IN SCHEDULE J, PART II, CONTRIBUTED, ON BEHALF OF THE FOLLOWING INDIVIDUALS, TO A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN IN THE AMOUNTS AS NOTED: JOHN PROUT - $261,496 DONNA NIENABER, ESQ. - $72,455 CRAIG RUCKER - $84,556 MICHAEL CROFTON - $18,591 GERALD OLIPHANT - $99,709 WILLIAM GRONEMAN - $89,099 GEORGES FEGHALI, MD - $92,355 JOHN ROBINSON, MD - $45,737 IN ADDITION, THE FOLLOWING INDIVIDUALS LISTED IN SCHEDULE J, PART II, RECEIVED A PAYMENT FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN WHICH WAS TREATED AS TAXABLE COMPENSATION BY THEIR RESPECTIVE EMPLOYERS: JOHN PROUT - $119,269 WILLIAM GRONEMAN - $20,369 PART I, LINE 7 A PHYSICIAN HAS A BASE SALARY BUT IS ALSO ELIGIBLE FOR A BONUS. THE BONUS IS CONTINGENT ON THE PROFITABILITY OF HIS OR HER PRACTICE. ESSENTIALLY, THE PROFITABILITY OF HIS OR HER PRACTICE GETS PAID TO THE PHYSICIAN AS A BONUS UP TO A MAXIMUM OF $100,000. PART I, LINE 3: TRIHEALTH, INC., A RELATED ORGANIZATION OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO, WHO PAID THE INDIVIDUAL, USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE FILING ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: * COMPENSATION COMMITTEE; * INDEPENDENT COMPENSATION CONSULTANT; * COMPENSATION SURVEY OR STUDY; AND * APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4A: THE REPORTABLE INDIVIDUALS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ARE PAID BY TRIHEALTH, INC., A RELATED ORGANIZATION, RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). THESE INDIVIDUALS DO NOT HAVE EMPLOYMENT AGREEMENTS SO NO SPECIAL ARRANGEMENTS EXIST BEYOND TRIHEALTH, INC.'S STANDARD EMPLOYEE SEVERANCE PACKAGE. GENERAL SEVERANCE PAY IS BASED ON LENGTH OF SERVICE. IN ADDITION, NOTICE PAY, IF APPLICABLE UNDER TRIHEALTH, INC. POLICY, MAY BE ADDED TO THE SEVERANCE PACKAGE AND THE AMOUNT OF NOTICE PAY WILL BE DETERMINED BY HUMAN RESOURCES IN ACCORDANCE WITH TRIHEALTH, INC. POLICY. PAYMENTS OF SEVERANCE ARE CONDITIONED UPON SIGNING A SEPARATION AND RELEASE AGREEMENT. NO REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FROM TRIHEALTH, INC. DURING THE 2013 CALENDAR YEAR. FORM 990, PART III, LINE 1 THE ORGANIZATION'S MISSION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY AND VIABILITY IN THE 21ST CENTURY. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES. FORM 990, PART VI, SECTION A, LINE 2 THE OFFICERS, DIRECTORS AND TRUSTEES OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO LISTED IN PART VII, SECTION A HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARDS OF BETHESDA HOSPITAL, INC., TRIHEALTH, INC. AND TRIHEALTH HOSPITAL, INC., ALL RELATED/AFFILIATED ENTITIES. WAYNE SHIRCLIFF, STUART DONOVAN, MD, ALAN ALTMAN, MD, ROBERT L. WALKER, MICHAEL HAVERKAMP, CRAIG EISENTROUT, MD AND MYRTIS POWELL HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARD OF BETHESDA, INC., THE SINGLE CORPORATE MEMBER OF BETHESDA HOSPITAL, INC., AN AFFILIATED ENTITY. JOHN PROUT AND MYRTIS POWELL HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON THE BOARD OF THE GOOD SAMARITAN COLLEGE OF NURSING AND HEALTH SCIENCE, A RELATED ENTITY. JOHN PROUT, DONNA NIENABER, ESQ., CRAIG RUCKER, WILLIAM GRONEMAN, GERALD OLIPHANT, GEORGES FEGHALI, MD, STUART DONOVAN, MD, STEPHEN BLATT, MD, JOHN ROBINSON, MD, JAMIE EASTERLING, JOANN LOHR, MD AND ALAN ALTMAN, MD HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF SITTING ON RELATED ENTITY BOARDS OF TRIHEALTH, INC. AND ITS SUBSIDIARIES AND AFFILIATES AS WELL AS BEING EMPLOYED BY TRIHEALTH, INC. OR ITS AFFILIATES/SUBSIDIARIES. SR. SALLY DUFFY AND MICHAEL MCGRAW HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER VIA AN UNRELATED TAX-EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO HAS TWO (2) CORPORATE MEMBERS. CATHOLIC HEALTH INITIATIVES, A COLORADO NON-PROFIT CORPORATION, IS THE SOLE VOTING MEMBER AND TRIHEALTH, INC., AN OHIO NON-PROFIT CORPORATION, IS THE SOLE NON-VOTING MEMBER. FORM 990, PART VI, SECTION A, LINE 7A IN ACCORDANCE WITH THE CORPORATE BYLAWS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"), THE TRUSTEES OF THE HOSPITAL (OTHER THAN THE CHIEF EXECUTIVE OFFICER AND THE PRESIDENTS OF THE MEDICAL STAFFS OF GOOD SAMARITAN HOSPITAL AND BETHESDA NORTH HOSPITAL WHO SERVE BY VIRTUE OF THEIR OFFICES) SHALL BE NOMINATED AND ELECTED BY THE VOTING MEMBER NO LATER THAN JUNE 30 OF EACH YEAR IN THE MANNER PROVIDED IN THE NETWORK AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 7B CATHOLIC HEALTH INITIATIVES ("CHI") IS THE SOLE CORPORATE VOTING MEMBER OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"). PURSUANT TO SECTION 5.4.2 OF THE HOSPITAL'S BYLAWS AND THE NETWORK AFFILIATION AGREEMENT, THE VOTING MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX, THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF THE HOSPITAL, * AMENDMENT OF THE CORPORATE DOCUMENTS OF THE HOSPITAL, * APPROVAL OF MEMBERS OF THE HOSPITAL'S BOARD, * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE HOSPITAL, * APPROVAL OF ISSUANCE OF DEBT BY THE HOSPITAL, * APPROVAL OF PARTICIPATION OF THE HOSPITAL IN A JOINT VENTURE, * APPROVAL OF FORMATION OF A NEW CORPORATION BY THE HOSPITAL, * APPROVAL OF A MERGER INVOLVING THE HOSPITAL, * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE HOSPITAL, * AUTHORITY TO REQUIRE THE TRANSFER OF ASSETS BY THE HOSPITAL TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS, AND * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR THE HOSPITAL. PURSUANT TO SECTION 5.5.2 OF THE HOSPITAL'S BYLAWS AND THE NETWORK AFFILATION AGREEMENT, CHI MAY, IN EXERCISE OF ITS APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE HOSPITAL, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. FORM 990, PART VI, SECTION B, LINE 11 MEMBERS OF THE BOARD ARE PROVIDED AN ELECTRONIC COPY OF THIS FORM 990 PRIOR TO FILING. HOWEVER, FOR THE PROTECTION OF DONOR PRIVACY, SCHEDULE B - SCHEDULE OF CONTRIBUTORS WAS REMOVED FROM THE COPY PROVIDED TO THE BOARD. SUBSEQUENT TO PRESENTATION TO THE BOARD, THE ORGANIZATION FILES THE RETURN MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE CERTAIN FINANCIAL INTERESTS AND FIDUCIARY RELATIONSHIPS. THE EXECUTIVE COMMITTEE AND CORPORATE COUNSEL REVIEW RESPONSES, CONDUCT FURTHER INVESTIGATION, IF NECESSARY, AND DETERMINE WHEN A CONFLICT EXISTS WITH RESPECT TO A CERTAIN TRANSACTION. IF A CONFLICT EXISTS, THE TRANSACTION IS NOT TO BE ENTERED INTO UNLESS ALTERNATIVES ARE FULLY INVESTIGATED AND, IN THEIR ABSENCE, THE BOARD, WITHOUT PARTICIPATION OF THE INTERESTED MEMBER(S), DETERMINES THAT THE TRANSACTION IS IN THE BEST INTEREST OF THE ORGANIZATION. PLANS TO MANAGE THE CONFLICT DURING THE RELATIONSHIP ARE IMPLEMENTED. ALL DISCUSSIONS ARE APPROPRIATELY DOCUMENTED. FORM 990, PART VI, SECTION B, LINE 15 IN DETERMINING COMPENSATION OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S OFFICERS AND DIRECTORS, THE ANNUAL PROCESS PERFORMED BY TRIHEALTH, INC. (A RELATED ORGANIZATION WHO PAID THE INDIVIDUALS) INCLUDED: * COMPENSATION COMMITTEE; * INDEPENDENT COMPENSATION CONSULTANT; * COMPENSATION SURVEY OR STUDY; AND * APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. ADDITIONALLY, ALL DISCUSSIONS AND DECISIONS ARE CONTEMPORANEOUSLY DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. IN ADDITION, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO'S FINANCIAL STATEMENTS ARE INCLUDED IN THE CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINT.ORG OR AT HTTP://WWW.DACBOND.COM. FORM 990, PART XI, LINE 9: CHANGE PENSION PLAN/SERP FUNDED STATUS 18,226,294. TRANSFER TO CHI CAPITAL RESOURCE POOL -3,030,132. LOSS ON UNCONSOLIDATED ORGANIZATIONS -28,811,749. MISCELLANEOUS ADJUSTMENT -33,272. FORM 990, PART I, LINE 6 DURING THE TAX YEAR, THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO WAS ASSISTED BY 1,687 VOLUNTEERS WHO DONATED OVER 153,000 HOURS. FORM 990, PART VI, LINE 1 PURSUANT TO ARTICLE SECTION 8.1.1 OF THE BYLAWS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL"), THE BOARD OF TRUSTEES MAY ESTABLISH AN THE EXECUTIVE COMMITTEE WHICH MAY EXERCISE SUCH POWER AND AUTHORITY OF THE BOARD OF TRUSTEES IN INTERVALS BETWEEN MEETINGS OF THE BOARD AS AUTHORIZED BY THE BOARD. THE EXECUTIVE COMMITTEE IS COMPOSED OF THE BOARD CHAIR, THE BOARD VICE CHAIR, THE PRESIDENT AND THE CHIEF EXECUTIVE OFFICER, THE SECRETARY AND TWO OTHER BOARD MEMBERS IN ACCORDANCE WITH THE NETWORK AFFILIATION AGREEMENT. PURSUANT TO SECTION 8.1.5 OF THE HOSPITAL'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS SHALL CONSIST OF AT LEAST THREE MEMBERS OF THE BOARD OF TRUSTEES. FURTHER, PURSUANT TO SECTION 8.1.1 OF THE HOSPITAL'S BYLAWS, FOUR MEMBERS OF THE EXECUTIVE COMMITTEE SHALL CONSTITUTE A QUORUM FOR THE TRANSACTIONS OF BUSINESS AND THE ACT OF THE FOUR OF THEM SHALL CONSTITUTE THE ACT OF THE COMMITTEE. FORM 990, PART VII, SECTION A - AVERAGE HOURS PER WEEK THE OFFICERS AND DIRECTORS FOR THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO THAT SHOW AT LEAST 60 HOURS PER WEEK PROVIDE SERVICES TO TRIHEALTH, INC. (A RELATED ORGANIZATION WHO PAID THE INDIVIDUALS) AND ITS SUBSIDIARIES/AFFILIATES ("TRIHEALTH") AS AN ENTIRE SYSTEM. HOURS WORKED, INCLUDING THEIR DUTIES AS OFFICERS AND DIRECTORS OF THE FILING ORGANIZATION, ARE NOT TRACKED ON AN ENTITY BY ENTITY BASIS, THUS THE AVERAGE HOURS PER WEEK DISCLOSED ARE ESTIMATES TO SHOW THAT THE TIME SPENT BY THESE INDIVIDUALS RELATE TO THEM FULFILLING THEIR DUTIES AS FULL-TIME, 60 HOURS-PER-WEEK EMPLOYEES OF TRIHEALTH VERSUS THEIR DUTIES AS OFFICERS AND DIRECTORS OF THE FILING ORGANIZATION. IN ADDITION, THE COMPENSATION REPORTED ON FORM 990, PART VII WAS PAID TO THESE INDIVIDUALS IN FULFILLMENT OF THEIR DUTIES AS EMPLOYEES OF TRIHEALTH. DIRECTORS (AS NOTED WITH A "MED STAFF PRES" REFERENCE) FOR BETHESDA HOSPITAL, INC. SERVE ON THE BOARD IN THEIR CAPACITY AS MEDICAL STAFF PRESIDENT FOR EITHER BETHESDA HOSPITAL, INC. OR THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO. IN ADDITION, THESE INDIVIDUALS PROVIDE SERVICES AS EMPLOYEES OF VARIOUS RELATED ENTITIES FOR WHICH THEY RECEIVE COMPENSATION. NONE OF THE COMPENSATION SHOWN IS FOR SERVING AS A DIRECTOR. FORM 990, PART XII, LINE 2C THE FINANCIAL STATEMENTS OF THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO ("HOSPITAL") ARE AUDITED AS PART OF TRIHEALTH, INC. AND ITS SUBSIDIARIES AND AFFILIATES ("TRIHEALTH"). TRIHEALTH HAS A COMMITTEE THAT ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF BOTH ITS AND ITS SUBSIDIARIES AND AFFILIATES FINANCIAL STATEMENTS AS WELL AS THE SELECTION OF THE INDEPENDENT AUDITOR. DURING THE TAX YEAR, THERE WAS NOT A CHANGE IN THE PROCESS OF AUDIT OVERSIGHT AND/OR SELECTION OF AN INDEPENDENT AUDITOR BY TRIHEALTH. FORM 990, PART VI, LINE 16B THE GOOD SAMARITAN HOSPITAL OF CINCINNATI, OHIO HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR PROCEDURE REGARDING JOINT VENTURES. HOWEVER, CATHOLIC HEALTH INITIATIVES, A RELATED ORGANIZATION, HAS A SYSTEM-WIDE JOINT VENTURE MODEL OPERATING AGREEMENT WHICH INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; (4) RETURNS OF CAPITAL, ALLOCATIONS, AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS; AND (5) ALL CONTRACTS ENTERED INTO BY THE PARTNERSHIP WITH THE EXEMPT ORGANIZATION MUST BE AT ARM'S-LENGTH, WITH PRICES SET AT FAIR MARKET VALUE. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL. 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