2013-01-07T13:58:21-06:00 2011-12-31 221478099 JH COHN LLP 4 BECKER FARM ROAD ROSELAND NJ 07068 990 2011-01-01 061562701 ST CATHERINE OF SIENA MEDICAL CENTER STCA 6318623000 50 ROUTE 25A SMITHTOWN NY 11787 JAMES CALDAS 6318623000 2013-01-07 1 THOMAS LANNING P00851654 9732283500 2011 2016-03-07 17:11:31Z JAMES CALDAS 50 ROUTE 25A SMITHTOWN NY 11787 259626178 0 0928 X HTTP://STCATHERINES.CHSLI.ORG X 2000 NY ST CATHERINE OF SIENA MEDICAL CENTER, A MEMBER OF CATHOLIC HEALTH SERVICES OF LONG ISLAND (CHS), AS A MINISTRY OF THE CATHOLIC CHURCH, CONTINUES CHRIST'S HEALING MISSION, PROMOTES EXCELLENCE IN CARE, AND COMMITS ITSELF TO THOSE IN NEED, CHSLI AFFIRMS THE SANCTITY OF LIFE, AND ADVOCATES FOR THE POOR AND UNDERSERVED, AND SERVES THE COMMON GOOD. IT CONDUCTS ITS HEALTHCARE PRACTICE, BUSINESS, EDUCATION AND INNOVATION WITH JUSTICE, INTEGRITY AND RESPECT FOR THE DIGNITY OF EACH PERSON. 23 22 2426 206 0 0 453782 414936 242916127 254756670 453872 589064 2824435 2475183 246648216 258235853 155389 264159 0 0 142552535 150268177 0 0 0 96782194 98921743 239490118 249454079 7158098 8781774 169490228 170806861 226721170 220941600 -57230942 -50134739 X ST CATHERINE OF SIENA MEDICAL CENTER, A MEMBER OF CATHOLIC HEALTH SERVICES OF LONG ISLAND (CHS), AS A MINISTRY OF THE CATHOLIC CHURCH, CONTINUES CHRIST'S HEALING MISSION, PROMOTES EXCELLENCE IN CARE, COMMITTED TO THOSE IN NEED, CHSLI AFFIRMS THE SANCTITY OF LIFE, ADVOCATES FOR THE POOR AND UNDERSERVED, AND SERVES THE COMMON GOOD. IT CONDUCTS ITS HEALTHCARE PRACTICE, BUSINESS, EDUCATION AND INNOVATION WITH JUSTICE, INTEGRITY AND RESPECT FOR THE DIGNITY OF EACH PERSON. 0 0 199539704 221376709 ST. CATHERINE OF SIENA MEDICAL CENTER IS A 318 BED ACUTE CARE HOSPITAL DEVOTED TO PROVIDING ADVANCED HEALTHCARE IN AN ENVIRONMENT OF COMPASSION. IN 2011, THE MEDICAL CENTER HAD 15,488 DISCHARGES AND PROVIDED CARE FOR 33,249 EMERGENCY ROOM VISITS. IN ACCORDANCE WITH ITS MISSION AND PHILOSOPHY, THE MEDICAL CENTER PROVIDES CARE REGARDLESS OF THE INDIVIDUAL'S ABILITY TO PAY AND ALONG WITH OTHER UNCOMPENSATED CARE REPORTED, AT COST, $3,014,000 IN CHARITY CARE. COMMUNITY SERVICE AND OTHER CHARITABLE ACTIVITIES PROVIDED FOR THE COMMUNITY TOTALED, AT COST, $2,690,000 AND REPORTED, AT COST, $1,314,000 IN UNCOMPENSATED CARE AS BAD DEBTS IN 2011. 29790608 35564492 ST. CATHERINE OF SIENA NURSING HOME IS LOCATED ON THE CAMPUS OF ST. CATHERINE OF SIENA MEDICAL CENTER. CONSISTING OF 240 BEDS, THE NURSING HOME PROVIDED 84,167 DAYS OF CARE IN 2011. THE NURSING HOME PROVIDED $686,500 IN UNCOMPENSATED CARE AS BAD DEBT IN 2011. 229330312 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 156 0 1 2426 1 0 0 0 0 0 1 1 0 0 0 0 X 23 22 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHS SERVICES INC 5167051937 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 X GARY VEITH MD 2.00 X 0 0 0 GEORGE RICE 2.00 X 0 0 0 HENRY C SCHREIBER 2.00 X 0 0 0 HON JEANNE GARANT 2.00 X 0 0 0 J ROBERT GROSS DC 2.00 X 0 0 0 JAMES CALDAS 50.00 X X 0 1119792 195571 JAMES DILTS 2.00 X 0 0 0 JAMES UMBDENSTOCK 2.00 X 0 0 0 JEROME POLLER 2.00 X X 0 0 0 JERRY NINIA MD 2.00 X 0 0 0 JOHN F VAN BOURGONDIEN 2.00 X 0 0 0 JOHN HALLERON III ESQ 2.00 X 0 0 0 MICHAEL LAMBERT 2.00 X 0 0 0 RAYMOND BORSELLA 2.00 X X 0 0 0 REV MSGR JOHN ROWAN 2.00 X 0 0 0 REV MSGR JAMES MCNAMARA 2.00 X 0 0 0 RICHARD SCHMIDT 2.00 X 0 0 0 ROBERT CARLIN MD 2.00 X 0 0 0 SALVATORE SODANO 2.00 X X 0 0 0 SISTER ANN GRAY DW 2.00 X 0 0 0 SYLVIA DIAZ 2.00 X 0 0 0 THOMAS REILLY 2.00 X X 0 0 0 WILLIAM A MULLANEY 2.00 X 0 0 0 DAN MACKSOOD 50.00 X 0 189743 12563 DENNIS VERZI 50.00 X 1375744 0 153668 PATRICK O'SHAUGHNESSY 50.00 X 340796 0 19216 DAVID RIVADENEIRA 40.00 X 871568 0 50930 GARA EDELSTEIN 50.00 X 869923 0 106262 JILL GENUA 40.00 X 239020 0 44017 JUNE J LEE 40.00 X 376412 0 32309 MICHAEL QUARTARARO 50.00 X 236177 0 41472 FRANK J FOX 0.00 X 0 1756606 16424 WILLIAM ALLISON 0.00 X 0 577460 0 SHARON KENNISH 0.00 X 615485 0 1354 4925125 3643601 673786 195 1 1 0 HUNTER ROBERTS INC 2 WORLD FINANCIAL CENTER NEW YORK NY 10281 CONTRACTOR-RENOVATIONS 2042620 JVK OPERATIONS LIMITED 130 NEW HIGHWAY NORTH AMITYVILLE NY 11701 LAUNDRY SERVICES 692578 ISLAND NEONATOLOGY LLC PO BOX 272 EAST ISLIP NY 11730 MEDICAL SERVICES 450000 LAB CORP OF AMERICA HOLDGIN PO BOX 12140 BURLINGTON NY 27216 MEDICAL SERVICES 381200 HORIZON HEALTHCARE STAFFING 20 JERUSALEM AVE HICKSVILLE NY 11801 STAFFING SERVICES 284704 22 1411 272235 11589 129701 414936 NET PATIENT REV-HOSP 621990 219192178 219192178 NET PATIENT REV-NH 623000 35564492 35564492 254756670 589064 589064 1593738 1290169 303569 303569 303569 145164 272235 100156 45008 45008 CONTRACTED SVCS-SWSM 1880962 1880962 TELEPHONE 900099 96892 96892 CAFETERIA 722210 72425 72425 76327 76327 2126606 258235853 256941201 0 879716 264159 264159 5152556 2925150 2227406 106608291 103240097 3368194 7559046 7162291 396755 22240060 21072735 1167325 8708224 8251151 457073 1937662 446066 1491596 765342 765342 137296 137296 48365 48365 10319077 9898867 420210 790252 701735 88517 4218682 3778413 440269 2868667 2450040 418627 35275 31324 3951 65512 58174 7338 5256464 4667678 588786 3400900 1397633 2003267 7049495 6259869 789626 1547071 1156609 390462 MEDICAL SUPPLIES 37948816 37948816 FINANCE AND TECHNOLOGY 10280386 9075525 1204861 PROVISION FOR BAD DEBTS 4457880 4457880 MISCELLANEOUS 3366479 153980 3212499 4428122 3932120 496002 249454079 229330312 20123767 0 25188382 13440337 2960175 5984874 59918 28048406 29443219 2841429 3082660 788787 969631 146805497 58245822 84960779 88559675 22710216 6843900 1992054 22422647 169490228 170806861 25711959 25030361 76890260 68875949 28766667 1250000 95352284 125785290 226721170 220941600 X -57609932 -50555216 378990 420477 -57230942 -50134739 169490228 170806861 X 8781774 -1685571 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 48365 48365 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: AMOUNT REFLECTS PORTION OF TRADE ASSOCIATION DUES WHICH WERE USED FOR LEGISLATIVE LOBBYING ON THE BEHALF OF THE HEALTHCARE INDUSTRY THOSE TRADE ORGANIZATIONS REPRESENT. 10126496 10126496 87873496 30523373 57350123 47896670 27234663 20662007 908835 487786 421049 88559675 INSURANCE CLAIMS RECEIVABLE 20679157 OTHER ASSETS 288915 DEFERRED FINANCING COSTS, NET 1418395 DUE FROM RELATED PARTIES, NET 36180 22422647 RESIDENT FUNDS AND SECURITY DEPOSITS 384439 THIRD PARTY PAYOR LIABILITY 30511854 RETIREMENT LIABILITY-PENSION 579138 RETIREMENT LIABILITY-457B FUNDS 122184 RETIREMENT LIABILITY-POST RETIREMENT 1551000 ESTIMATED MALPRACTICE LIABILITY 22343650 SELF INSURED LIABILITY 26804885 DUE TO RELATED PARTIES 43488140 125785290 258235853 249454079 8781774 -111042 27483 -1602012 -1685571 7096203 262908279 27483 3789254 3816737 259091542 -855689 -855689 258235853 250414439 4625419 4625419 245789020 3665059 3665059 249454079 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE MEDICAL CENTER IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. THERE ARE NO TRANSACTIONS THAT MANAGEMENT HAS DEEMED TO BE "UNRELATED BUSINESS INCOME" AND THEREFORE NO TAX LIABILITY HAS BEEN RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. MANAGEMENT REVIEWS TRANSACTIONS TO ESTIMATE POTENTIAL TAX LIABILITIES USING A THRESHOLD OF MORE LIKELY THAN NOT OF BEING SUSTAINED. PART XI, LINE 8 - OTHER ADJUSTMENTS: POSTRETIREMENT BENEFIT PLAN CHANGES OTHER THAN PERIODIC BENEFIT COST -139,000. LOSS ON DEBT EXTINGUISHMENT -1,463,012. TOTAL TO SCHEDULE D, PART XI, LINE 8: -1,602,012. PART XII, LINE 2D - OTHER ADJUSTMENTS: SIENA VILLAGE REVENUE-SEPARATE ENTITY 3,726,889. NARR-OPERATIONS 62,365. PART XII, LINE 4B - OTHER ADJUSTMENTS: MEDICAL OFFICE BUILDING RENTAL EXPENSES -1,290,169. RESTRICTED CONTRIBUTIONS 427,813. GRANT INCOME FOR PURCHASE OF PPE 6,667. PART XIII, LINE 2D - OTHER ADJUSTMENTS: MEDICAL OFFICE BUILDING EXPENSES 1,290,169. SIENA VILLAGE EXPENSES-SEPARATE ENTITY 3,335,250. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHS TRANSFER 2,788,328. CHSLI TRANSFER 876,731. DINNER DANCE 282719 185950 96769 48007 4750 14688 GOLF OUTING 134680 86285 48395 2524 15602 8928 5657 417399 272235 145164 2524 15602 56935 4750 20345 100156 45008 1 1 1 X 300.000000000000 1 X 1 1 1 0 0 3795536 428928 3366608 0.01370 17199327 15770163 1429164 0.00580 69242 104674 -35432 0.00000 21064105 16303765 4760340 0.01950 630463 0 630463 0.00260 11117 0 11117 0.00000 923909 888691 35218 0.00010 1565489 888691 676798 0.00270 22629594 17192456 5437138 0.02220 1 1150133 0 78280751 90459876 -12179125 X 1 1 1 1 ST CATHERINE OF SIENA HOSPITAL

50 ROUTE 25A SMITHTOWN NY 11787

X X X PSYCHIATRIC UNIT STCATHERINE OF SIENA MEDICAL CENTER 1 0 1 1 300.000000000000 1 400.000000000000 1 X 1 1 X X X X 1 0 1 X 0 0 1 ST CATHERINE OF SIENA NURSING HOME

52 ROUTE 25A SMITHTOWN NY 11787

SKILLED NURSING FACILITY PART I, LINE 7: RATIO OF PATIENT CARE COST TO CHARGES WORKSHEET (WORKSHEET 2) AS PRESCRIBED BY THE IRS INSTRUCTIONS TO SCHEDULE H FORM 990 WAS THE METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN PART 1, LINE 7 CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST LINES 7A,7B AND 7C AND 7D. ALL OTEHR LINES INCLUDE COSTS THAT WERE DERIVED ON THE RCC METHODOLOGY OR ACTUAL COSTS FOR THE SERVICES AS TRACKED BY HOSPITAL PERSONNEL UTILIZING DIRECT HOURLY LABOR COSTS, FRINGES AND SUPPLY COSTS.PART 1, LINE 7A COLUMN DDIRECT OFFSETTING REVENUES REPRESENT DISTRIBUTIONS FROM THE NEW YORK STATE (NYS) INDIGENT CARE POOL (ICP) WHICH IS SHOWN NET OF HOSPITAL CONTRIBUTIONS TO THE STATEWIDE POOL. THE FORMULA EMPLOYED BY NYS TO DETERMINE DISTRIBUTIONS TO HOSPITALS FROM THE ICP IS COMPLEX AND IS DERIVED FROM A HOSPITAL'S "NEED" CALCULATION. THIS CALCULATION CONSIDERS 90% OF A HOSPITALS "NEED" IS BASED ON BAD DEBTS AND CHARITY CARE WRITE OFFS AND 10% IS BASED ON A "UNITS OF SERVICE" METHODOLOGY FOR UNINSURED PATIENTS. THE HOSPITAL APPORTIONED THE ICP REVENUE BETWEEN BAD DEBT AND CHARITY CARE FOR REPORTING ON LINE 7A BASED ON THE PROPORTION OF EACH TO THE TOTAL OF ACTUAL BAD DEBTS AND CHARITY CARE FOR 2011. IT IS IMPORTANT HOWEVER TO BE AWARE THAT THE COSTS OF BAD DEBTS ARE NOT INCLUDED IN LINE 7A, COLUMN C WHILE THE OFFSETTING REVENUE IS INCLUDED IN LINE 7A, COLUMN D. BAD DEBTS AT COST ARE EXCLUDED FROM LINE 7 AND REPORTED IN PART III, LINE 2 IN ACCORDANCE WITH THE INSTRUCTIONS. AS A RESULT, THE NET COST OF FINANCIAL ASSISTANCE AT COST ON LINE 7A, COLUMN F IS UNDERSTATED FOR NYS HOSPITALS WHO REPORT IN ACCORDANCE WITH THE INSTRUCTIONS AND IN SOME INSTANCES MAY SHOW A GAIN DUE TO THE MISMATCHING OF REVENUE AND EXPENSE. IT IS IMPORTANT TO CONSIDER THE BAD DEBTS AT COST AMOUNT IN PART III, LINE 2 WHEN EVALUATING THE NET COSTS OF UNCOMPENSATED CARE FOR HOSPITALS IN NYS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 4457880. PART I, LINE 7 REFLECTS HOSPITAL INFORMATION ONLY. PART II: FOOD DRIVES ST. CATHERINE CONDUCTS SEVERAL FOOD DRIVES THROUGHOUT THE YEAR INCLUDING THANKSGIVING AND CHRISTMAS TO ASSIST LOCAL FOOD PANTRIES. ALL NON-PERISHABLE ITEMS AND PERSONAL CARE ITEMS ARE DONATED TO THE LOCAL CONSORTIUM OF FOOD PANTRIES CONSISTING OF LOCAL PARISHES. IN ADDITION, FOOD DRIVES ARE HELD BEFORE EACH OF THE FIVE HEALTHY SUNDAYS (OUTREACH TO PROVIDE SERVICES TO UNDERSERVED COMMUNITIES ORGANIZED THROUGH PARISHES) AND THE ITEMS COLLECTED ARE DONATED TO THE PARISHS FOOD PANTRY WHERE HEALTHY SUNDAYS ARE HELD. IN 2011, 83 OF ST. CATHERINES STAFF MEMBERS VOLUNTEERED TO COVER FOUR HEALTHY SUNDAYS REACHING FOUR HUNDRED AND TWENTY EIGHT PARISHIONERS.APPROXIMATELY 600 POUNDS OF FOOD AND CLOTHES WERE DONATED BY STAFF.ST. CATHERINE OF SIENA ATTENDS MANY COMMUNITY EVENTS THROUGH THE YEAR, INCLUDING: HAUPPAUGE INDUSTRIAL ASSOCIATION TRADESHOW, KINGS PARK DAY, ST. JAMES DAY, SMITHTOWN DAY, SUFFOLK SENIOR EVENT, UNITED CEREBAL PALSY HEALTH FAIR, HBO HEALTH FAIR, AND PROVIDES REPRESENTATIVES FROM SEVERAL DEPARTMENTS TO ATTEND AND ANSWER HEALTH RELATED QUESTIONS AND DISTRIBUTE INFORMATIONAL MATERIALS. IN ADDITION, IN 2011, ST. CATHERINE HELD A HEALTH FAIR THAT WAS ATTENDED BY OVER 700 COMMUNITY MEMBERS, TWO COLON CANCER AWARENESS LECTURES, AND A HEART HEALTH DAY. FOUR TOTAL CONTINUING MEDICAL EDUCATION DINNER LECTURES WERE HELD FOR FIRST RESPONDERS IN THE AREA AT NO CHARGE. AND, ST. CATHERINE HELD ITS FIRST CANCER SURVIVOR DINNER, TO OFFER AN UPLIFTING EVENING OF HEALTH AND WELLNESS. THANKSGIVING MEALS FOR HOMEBOUND RESIDENTS OF SIENA VILLAGE - ST.CATHERINE DONATES A TRADITIONAL THANKSGIVING MEAL TO ALL HOMEBOUND RESIDENTS OF SIENA VILLAGE. THE MEALS ARE PREPARED BY THE HOSPITAL STAFF AND DELIVERED TO SIENA VILLAGE WHERE THEY ARE DISTRIBUTED TO INDIVIDUAL RESIDENT APARTMENTS BY A LOCAL YOUTH GROUPKINGS PARK DAY REPRESENTATIVES FROM SEVERAL DEPARTMENTS ATTEND THIS EVENT TO ANSWER HEALTH RELATED QUESTIONS AND EDUCATE ATTENDEES ON HEALTH RELATED TOPICS SUCH AS BREAST HEALTH, DIGESTIVE TRACT HEALTH AND HEALTHY LIFE STYLE/NUTRITION. EDUCATIONAL MATERIAL IS ALSO PROVIDED.THANKSGIVING MEALS FOR HOMEBOUND RESIDENTS OF SIENA VILLAGE - ST. CATHERINE DONATES A TRADITIONAL THANKSGIVING MEAL TO ALL HOMEBOUND RESIDENTS OF SIENA VILLAGE. THE MEALS ARE PREPARED BY THE HOSPITAL STAFF AND DELIVERED TO SIENA VILLAGE WHERE THEY ARE DISTRIBUTED TO INDIVIDUAL RESIDENT APARTMENTS BY A LOCAL YOUTH GROUP PART III, LINE 4: COSTING METHODOLOGYBAD DEBT AT COST WAS CALCULATED BY APPLYING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2 TO BAD DEBT EXPENSE, WHICH IS REPORTED AT CHARGES.PART III LINE 4-TEXT OF FOOTNOTE DISCUSSING BAD DEBT:THE ALLOWANCE FOR UNCOLLECTABLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS. MANAGEMENT PERIODICALLY ASSESSES THE ADEQUACY OF THIS ALLOWANCE BASED UPON HISTORICAL COLLECTION AND WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY, AS NECESSARY, THE PROVISION FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTABLE NET PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE MEDICAL CENTER FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN BALANCES WITH COLLECTION AGENCIES, SUBJECT TO CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY EACH FACILITY. ACCOUNT BALANCES ARE CHARGED OFF AGAINST THE ALLOWANCE AFTER ALL MEANS OF COLLECTION HAVE BEEN EXHAUSTED AND THE POTENTIAL FOR RECOVERY IS CONSIDERED REMOTE.PART III LINE 4-BAD DEBT AS COMMUNITY BENEFIT:AS PART OF ITS TAX EXEMPT PURPOSE THE HOSPITAL PROVIDES ACCESS TO MEDICALLY NECESSARY CARE FOR EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF AGE, GENDER, GEOGRAPHIC LOCATION, OR CULTURAL BACKGROUND. THE HOSPITAL TREATS EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF WHETHER THEY HAVE THIRD-PARTY COVERAGE OR THE ABILITY TO PAY. BY PROVIDING HEALTH CARE TO ALL WHO REQUIRE EMERGENCY OR NON ELECTIVE CARE IN A NON-DISCRIMINATORY MANNER, THE HOSPITAL IS PROVIDING HEALTH CARE TO THE BROAD COMMUNITY IT SERVES. A PATIENTS PORTION OF A BILL THAT REMAINS UNPAID FOR A CERTAIN STIPULATED TIME PERIOD IS WHOLLY OR PARTIALLY CLASSIFIED AS BAD DEBT. BAD DEBTS ASSOCIATED WITH PATIENTS WHO HAVE RECEIVED CARE FROM THE HOSPITAL SHOULD BE CONSIDERED TO BE COMMUNITY BENEFIT SINCE CHARITABLE HOSPITALS EXIST TO PROVIDE SUCH CARE IN PURSUIT OF THEIR TAX EXEMPT PURPOSE, WHICH IS MEETING THE NEED FOR EMERGENCY AND NON-ELECTIVE MEDICAL CARE SERVICES IN THE COMMUNITY. PART III, LINE 8: THE MEDICARE REVENUE AND ALLOWABLE COSTS SHOWN ON PART III SECTION B LINE 5 WERE DERIVED FROM THE AS FILED 2011 CMS-2552 (MEDICARE COST REPORT). MEDICARE REVENUE IS BASED ON THE MEDICARE PROVIDER STATISTICAL AND REIMBURSEMENT REPORT AND MEDICARE COSTS ARE DEVELOPED UTILIZING A RATIO OF MEDICARE ALLOWABLE COSTS TO CHARGES METHODOLOGY.ST. CATHERINE INCURRED A LOSS OF APPROXIMATELY $12.0 MILLION TO DELIVER CARE TO MEDICARE PATIENTS. THIS REPRESENTS THE AMOUNT BY WHICH COSTS TO DELIVER CARE TO MEDICARE RECIPIENTS EXCEEDS THE LEVEL OF PAYMENT. ST. CATHERINE BEARS THE BURDEN OF NOT ONLY PROVIDING THE BEST AND MOST ADVANCED MEDICAL CARE POSSIBLE TO THE COMMUNITY, BUT ALSO DOING SO WITH NO RECOURSE TO OBTAIN PAYMENT FOR THE COST OF PROVIDING CARE IN EXCESS OF THE MEDICARE PAYMENT. AS MEDICARE REVENUE DECLINES AND THE COST TO PROVIDE CUTTING EDGE CARE TO THE COMMUNITY INCREASES, THE HOSPITAL WILL CARRY THE BURDEN. AS A PARTICIPATING PROVIDER AND A CHARITABLE ORGANIZATION, MEDICARE PATIENTS, THE MAJORITY OF WHOM ARE ELDERLY AND DISABLED ARE NOT TURNED AWAY, SO ST. CATHERINE WILL CONTINUE TO BEAR THE LOSS IN PROVIDING THE BEST CARE POSSIBLE TO THE LOCAL COMMUNITY.LOSSES ON TREATING MEDICARE BENEFICIARIES SHOULD BE INCLUDED AS A COMMUNITY BENEFIT IN THEIR ENTIRETY. PART III, LINE 9B: THE HOSPITAL'S CHARITY CARE POLICY DESCRIBES THE POLICIES AND PROCEDURES RELATING TO THE PROVISION OF CHARITY CARE TO PERSONS WHO ARE UNABLE TO PAY FOR ALL OR A PORTION OF THEIR BILL. NO INDIVIDUAL WILL BE DENIED MEDICALLY NECESSARY HOSPITAL SERVICES BASED ON A DEMONSTRATED INANBILITY TO PAY FOR THOSE SERVICES. IN ADDITION, UPON APPLYING FOR CHARITY CARE, EACH PATIENT AND PATIENT GUARANTOR'S ABILITY TO PAY WILL BE ASSESSED.ELIGIBILITY FOR ASSISTANCE: A REASONABLE REVIEW SHALL BE PERFORMED PRIOR TO TURNING AN ACCOUNT OVER TO A THIRD-PARTY COLLECTION AGENT AND PRIOR TO INSTITUTING ANY LEGAL ACTION FOR NON-PAYMENT, TO ASSURE THAT THE PATIENT AND PATIENT GUARANTOR ARE NOT ELIGIBLE FOR ANY ASSISTANCE PROGRAM (I.E. MEDICAID) AND DO NOT QUALIFY FOR COVERAGE THROUGH THE MEDICAL CENTERS CHARITY CARE POLICY. AFTER HAVING BEEN TURNED OVER TO A THIRD-PARTY COLLECTION AGENT, ANY ACCOUNT THAT SUBSEQUENTLY IS DETERMINED TO MEET THE CHARITY CARE CRITERIA SHALL BE RETURNED IMMEDIATELY BY THE THIRD-PARTY COLLECTION AGENT FOR APPROPRIATE FOLLOW-UP.THE THIRD-PARTY COLLECTION AGENT SHALL ADVISE THE PATIENT/GUARANTOR OF THE HOSPITAL'S CHARITY CARE POLICY AND RETURN THE ACCOUNT IMMEDIATELY IF IT IS DETERMINED THAT THE QUALIFICATIONS ARE MET. PART VI, LINE 2: ASSESSMENT OF COMMUNITY NEEDS AND GOALSST. CATHERINES PROVIDES HIGH QUALITY CARE WITH COMPASSION AND RESPECT FOR EACH PATIENT REGARDLESS OF AGE, RELIGION, RACE, GENDER OR ABILITY TO PAY. THE STANDARD OF CARE IS EQUAL FOR ALL PATIENTS. ST. CATHERINES IS CONTINUOUSLY EVALUATING THE SERVICE AREA NEEDS BY REVIEWING PATIENT SURVEYS, COMMUNITY FEEDBACK, DEMOGRAPHIC DATA, COMMUNITY HEALTH INDICATORS AND PATIENT CARE TRENDS TO DEVELOP AND REFINE ITS SCOPE OF SERVICES AND DELIVERY OF CARE.THE HEALTHY SUNDAYS PROGRAM, WHICH PROVIDES FREE MEDICAL SCREENINGS AND EDUCATION TO THE UNDERSERVED FOLLOWING WORSHIP SERVICES ON A BIMONTHLY BASIS, WAS THE RESULT OF A JOINT COMMUNITY NEEDS ASSESSMENT BY CHS HOSPITALS. THESE EVENTS ARE PROMOTED VIA CALENDAR LISTINGS IN PARISH BULLETINS AND FLYERS POSTED IN PLACES OF BUSINESS AND WORSHIP IN THE COMMUNITY SURROUNDING THE OUTREACH SITE. PART VI, LINE 3: COMMUNICATION OF FINANCIAL ASSISTANCE POLICY:1. SINCE IT IS THE DUTY OF THE MEDICAL CENTER TO ENSURE THAT EVERY PATIENT IS MADE AWARE OF THE EXISTENCE OF ITS CHARITY CARE POLICY, ALL EMPLOYEES IN THE SCHEDULING, PATIENT ACCESS, PATIENT FINANCIAL SERVICES AND EMERGENCY DEPARTMENTS ARE FULLY VERSED IN THE CHARITY CARE POLICY, HAVE ACCESS TO THE CHARITY CARE APPLICATION FORMS, AND ABLE TO DIRECT QUESTIONS TO THE APPROPRIATE MEDICAL CENTER REPRESENTATIVES.2. THE MEDICAL CENTER HAS POSTED MULTILINGUAL NOTICES AS TO ANY POLICIES ON CHARITY CARE IN SEVERAL PROMINENT LOCATIONS WITHIN THE MEDICAL CENTER INCLUDING, BUT NOT LIMITED TO, THE EMERGENCY DEPARTMENT, BILLING OFFICE, WAITING ROOMS FOR PURPOSES OF ADMISSIONS, AND THE INPATIENT AND OUTPATIENT REGISTRATION AREAS. SAID NOTICES ARE PUBLISHED IN AT LEAST ENGLISH AND SPANISH, AND ARE CLEARLY VISIBLE TO THE PUBLIC FROM THE LOCATION AT WHICH THEY ARE POSTED.3. THE MEDICAL CENTER PROVIDES PATIENTS, IN A TIMELY MANNER, A SUMMARY OF ITS CHARITY CARE POLICY UPON REQUEST. THE SUMMARY, AT A MINIMUM PROVIDES SPECIFIC INFORMATION AS TO INCOME LEVELS USED TO DETERMINE ELIGIBILITY AND THE MEANS OF APPLYING FOR ASSISTANCE. THIS SUMMARY IS WRITTEN AT OR BELOW A SIXTH GRADE READING LEVEL.4. THE MEDICAL CENTER POSTS ITS CHARITY CARE POLICY SUMMARY ON THEIR INTERNET WEBSITE.5. THE MEDICAL CENTER PROVIDES ALL PATIENTS ACCESS TO INTERPRETERS TO ASSIST THEM IN UNDERSTANDING ITS CHARITY CARE PROGRAM IN THE PRIMARY LANGUAGE SPOKEN BY THE PATIENT DURING ANY PRE-ADMISSION, ADMISSION, AND DISCHARGE PROCESS. 6. ON ALL BILLS AND STATEMENTS SENT TO PATIENTS, A STATEMENT IS INCLUDED REGARDING THE AVAILABILITY OF VARIOUS FINANCIAL ASSISTANCE PROGRAMS, INCLUDING CHARITY CARE, AND A CONTACT NUMBER TO CALL TO OBTAIN FURTHER INFORMATION. THIS INFORMATION IS PROVIDED AT OR BELOW A SIXTH GRADE READING LEVEL. PART VI, LINE 4: COMMUNITY INFORMATIONST. CATHERINES SERVICE AREA CONSISTS OF 21 COMMUNITIES LOCATED IN WESTERN SUFFOLK COUNTY. ST. CATHERINES PRIMARY CATCHMENT AREA HAS A POPULATION OF APPROXIMATELY 648,000 PER 2010 CSP AND INCLUDES: SMITHTOWN, ST. JAMES, HAUPPAUGE, KINGS PARK, COMMACK, NESCONSET, NORTHPORT AND EAST NORTHPORT. THESE COMMUNITIES REPRESENT APPROXIMATELY 53% OF TOTAL ADMISSIONS.ST CATHERINES PRIMARY SERVICE AREA, DEFINED AS 75% TOTAL DISCHARGES, CONSISTS OF 13 COMMUNITIES LOCATED IN SUFFOLK COUNTY AND IN 2010 HAD A POPULATION OF APPROXIMATELY 414,000 RESIDENTS ACCORDING THE EHANYS: MARKET EXPERT. THE TOWNS INCLUDE SMITHTOWN, RONKONKOMA, KINGS PARK, COMMACK, ST. JAMES, HAUPPAUGE, NESCONSET, BRENTWOOD, CENTRAL ISLIP, EAST NORTHPORT, HOLBROOK, CENTEREACH AND BAYSHORE.FROM 2010-2015, THERE IS A PROJECTED INCREASE OF APPROXIMATELY 2% (OR 8,700) OF THOSE RESIDENTS WITHIN ST. CATHERINE OF SIENA MEDICAL CENTERS PRIMARY SERVICE AREA THAT ARE 65 YEARS OF AGE OR OLDER. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTHST. CATHERINE OF SIENA MEDICAL CENTER OFFERS A WIDE AND COMPREHENSIVE ARRAY OF COMMUNITY SERVICE PROGRAMS THAT ADDRESS CRITICAL HEALTH ISSUES TO A DIVERSITY OF PATIENTS, INCLUDING:ANNUAL COMMUNITY HEALTH FAIR: ST. CATHERINES ANNUAL COMMUNITY HEALTH FAIRIS A PIVOTAL EDUCATION PORTAL AND WAS ATTENDED BY APPROXIMATELY 700 COMMUNITY MEMBERS IN 2011. THE HEALTH FAIR OFFERS FREE HEALTH CAREEDUCATION AND SCREENINGS, WHICH INCLUDED SKIN CANCER AND PROSTATE SCREENINGS, FREE FLU SHOTS WERE ADMINISTERED AND SERVICES ON CAMPUS WERE HIGHLIGHTED.AUXILIARY VOLUNTEER DEPARTMENT: THE AUXILIARY AND VOLUNTEERS OF ST. CATHERINE OF SIENA MEDICAL CENTER ARE A GROUP OF DEDICATED AND GENEROUS INDIVIDUALS, WHO OFFER THEIR TIME, TALENT AND SERVICES TO PATIENTS AND STAFF ON A DAILY BASIS. THE AUXILIARY ALSO DONATES FUNDS TO SUPPORT THE MISSION OF THE MEDICAL CENTER, RAISED THROUGH FUNDRAISING ACTIVITIES THAT INCLUDE: MANAGING THE HOSPITAL GIFT SHOP, PLANTS SALES AND SPECIAL EVENTS.COMMUNITY BLOOD DRIVES: ST. CATHERINE HOSTS FOUR BLOOD DRIVES ANNUALLY IN COLLABORATION WITH LONG ISLAND BLOOD SERVICES, A DIVISION OF NEW YORK BLOOD CENTER.COMMUNITY NEWSLETTER: ST. CATHERINES PUBLISHES A QUARTERLY NEWSLETTER, THE VOICE. WHICH IS MAILED THROUGHOUT THE PRIMARY CATCHMENT AREA, WHICH COVERS OVER 100,000 HOUSEHOLDS. THE VOICE HAS BEEN INCREASED TO A 12-PAGE DOCUMENT AND THE VOICE IS A PRIMARY COMPONENT OF EDUCATING THE COMMUNITY ABOUT HEALTH-RELATED ISSUES AND KEEPING THEM INFORMED OF UPCOMING EVENTS AND HOSPITAL SERVICES.EMERGENCY RESPONSE APPRECIATION DINNERS: EMERGENCY RESPONSE PERSONNEL ARE AT THE FOREFRONT OF THE MEDICAL PROCESS. THEY PROVIDE IMMEDIATE MEDICAL SERVICE AND WORK COLLABORATIVELY TO OFFER TIMELY CARE. ST. CATHERINES OFFERS A QUARTERLY EMERGENCY RESPONSE APPRECIATION AND CONTINUING MEDICAL EDUCATION (CME) DINNER FOR LOCAL EMERGENCY RESPONSE PERSONNEL. THE APPRECIATION DINNERS WERE IMPLEMENTED IN 2008, AND HAVE BECOME A HIGHLIGHT FOR ST. CATHERINES AND LOCAL EMERGENCY RESPONSE TEAMS. EACH DINNER ACTS AS A REMINDER OF HOW GRATEFUL THE HOSPITAL IS FOR PROMPTNESS AND EFFICIENCY IN THE FIELD. THE DINNERS OFFER A FORUM FOR SPECIAL EDUCATIONAL PROGRAMS AND AN OPPORTUNITY FOR EMERGENCY RESPONSE PERSONNEL TO GAIN EDUCATION CREDITS.HEALTHY SUNDAY SERIES: THE HEALTHY SUNDAY PROGRAM MANIFESTS THE COMMITMENT OF CATHOLIC HEALTH SERVICES OF LONG ISLAND BY PROACTIVELY HELPING UNDERSERVED COMMUNITIES BY PROVIDING EDUCATIONAL SEMINARS AND PREVENTIVE SCREENINGS THAT MAY BE OTHERWISE UNAVAILABLE. THE PROGRAM REACHES OUT INTO COMMUNITIES OF NEED THROUGH LOCAL PARISHES TO HELP BRIDGE THE GAP BETWEEN THE INDIVIDUAL AND THE HEALTH PROVIDER TO PROVIDE QUALITY, ACCESSIBLE SERVICES ULTIMATELY BUILDING A LINK FOR THE COORDINATION OF CARE. HEALTHY SUNDAYS PROVIDES A SAFE AVENUE TO IMPROVE ACCESS TO VITAL PRIMARY CARE SERVICES.MATERNITY EDUCATION: YOU AND YOUR BABY EDUCATION SERIESTHE MATERNITY DEPARTMENT OFFERS A VARIETY OF FEE AND NON-FEE SUPPORT GROUPS AND WORKSHOPS FOR NEW MOTHERS AND FAMILY MEMBERS AS FOLLOWS: BREAST-FEEDING SUPPORT GROUPS, CHILDBIRTH EDUCATION, EARLY PREGNANCY CLASSES, FAMILY AND FRIENDS CPR: INFANT ONLY, GRANDPARENTS CLASSES, INFANT CARE CLASSES, PRENATAL BREAST-FEEDING CLASSES, SIBLING CLASSES AND MOTHERS CIRCLE OF HOPE, A POST PARTUM SUPPORT GROUP.MEDICAL COMMUNITY EDUCATION: ST. CATHERINES IS DEDICATED TO EDUCATING THE COMMUNITY AND PROUDLY OFFERS FREE LECTURES AND PRESENTATIONS ON A VARIETY OF HEALTH AND WELLNESS TOPICS TO HELP EDUCATE AND RAISE AWARENESS. WITH THE COMBINATION OF LECTURES AND PRESENTATIONS OFFERED, ST. CATHERINES HOPES TO IMPROVE THE QUALITY OF LIFE, PROMOTE WELLNESS AND HEALTHY LIVING FOR ALL THOSE WHO LIVE AND WORK IN THE COMMUNITY.PASTORAL CARE: PASTORAL CARE SERVICE IS AVAILABLE FOR PATIENTS FOR ALL DENOMINATIONS DURING THEIR HOSPITAL STAY. WE PROVIDE SPIRITUAL RESOURCES, COUNSEL AND PRAYER, AND ASSIST PATIENTS WITH INTEGRATING THEIR SPIRITUAL BELIEFS INTO THEIR HEALING PROCESS. PASTORAL CARE IS OFTEN CALLED UPON FOR ETHICAL ADVICE WITH ADVANCE DIRECTIVES IN COLLABORATION WITH THE PATIENT ADVOCATE.OTHER SUPPORT GROUPS OFFERED TO THE COMMUNITY:BARIATRIC SUPPORT GROUPSCARDIAC DEVICE SUPPORT GROUPSDIABETES CLUB (GLAD)GREEN SEMINARPARKINSONS DISEASE SUPPORT GROUPSBEREAVEMENT SUPPORT GROUPSJOINT REPLACEMENT CLASS PART VI, LINE 6: ST. CATHERINE OF SIENA MEDICAL CENTER (ST. CATHERINE OR THE HOSPITAL OR THE MEDICAL CENTER) AND ST. CATHERINE OF SIENA NURSING HOME, ARE LOCATED ON A SINGLE CAMPUS IN SMITHTOWN, NEW YORK.ALONG WITH THE AFOREMENTIONED COMMUNITY PROGRAMS ST. CATHERINE, THROUGH ITS DAILY OPERATION, PROVIDES TO THE AREA ACUTE, EMERGENT AND OUTPATIENT CARE AS WELL AS LONG TERM CARE AND HOUSING. ST. CATHERINE IS A MEMBER OF CATHOLIC HEALTH SYSTEM OF LONG ISLAND (D/B/A CATHOLIC HEALTH SERVICES OF LONG ISLAND) (CHS) WHICH IS A NEW YORK NOT-FOR-PROFIT CORPORATION ORGANIZED TO SERVE AS THE COORDINATING BODY OF AN INTEGRATED NETWORK OF PROVIDERS SERVING NASSAU AND SUFFOLK COUNTIES. CHS IS SPONSORED BY THE ROMAN CATHOLIC DIOCESE OF ROCKVILLE CENTRE.AS OF DECEMBER 31, 2011 CHS WAS COMPRISED OF SIX HOSPITALS (MERCY MEDICAL CENTER AND ST. FRANCIS HOSPITAL IN NASSAU COUNTY; GOOD SAMARITAN HOSPITAL MEDICAL CENTER, ST. CHARLES HOSPITAL AND ST. CATHERINE IN SUFFOLK COUNTY; AND AS PASSIVE PARENT TO ST.JOSEPH HOSPITAL IN NASSAU COUNTY) THREE NURSING HOMES (ST. CATHERINE NURSING HOME; GOOD SAMARITAN NURSING HOME AND OUR LADY OF CONSOLATION RESIDENCE, ALL IN SUFFOLK COUNTY), A REGIONAL HOME CARE AND HOSPICE NETWORK AND A COMMUNITY BASED AGENCY FOR PERSONS WITH SPECIAL NEEDS. WITH MORE THAN 17,500 STAFF AND 4,600 CREDENTIALED PHYSICIANS WORKING THROUGHOUT THE SYSTEM, CHS PROVIDES THE REGION'S FINEST HEALTH AND HUMAN SERVICES.MEMBER ORGANIZATIONS OF CHS OFFER VIRTUALLY EVERY MEDICAL SPECIALTY AND CLINICAL SERVICES, AND SHARE A DEDICATION TO CONTINUOUSLY UPGRADE THE SCOPE, QUALITY AND ACCESSIBILITY OF CARE. EACH OF CHS' MEMBER ORGANIZATIONS HAVE RETAINED THEIR INDIVIDUAL LINKS TO THEIR HISTORY, THEIR DISTINCTIVE PERSONALITIES, AS WELL AS THE SERVICE SPECIALTIES WHICH THEY ARE KNOWN FOR, THUS EMBEDDING THE ORGANIZATION IN THE COMMUNITY AND SERVING IT EFFECTIVELY.THE CHS SYSTEM PROVIDES AN ABUNDANCE OF EDUCATION AND SUPPORT GROUPS, FREE HEALTH SCREENINGS THROUGH THE HEALTHY SUNDAYS PROGRAM, HEALTH FAIRS AND OTHER PROGRAMS WHICH HELP THE COMMUNITIES SERVED BY CHS ACCESS CARE. SINCE 1907 CATHOLIC HEALTH CARE ON LONG ISLAND HAS BUILT A DISTINGUISHED TRADITION OF OPERATING COMMUNITY-BASED HOSPITALS AND HUMAN SERVICE ORGANIZATIONS WITH THE PRIMARY OBJECTIVE OF SERVING THE COMMUNITY.TO FURTHER THE MISSION OF BRINGING CARE TO THE COMMUNITY, CHS AND ITS MEMBER HOSPITALS, TOGETHER WITH A NUMBER OF OTHER HEALTHCARE PROVIDERS ON LONG ISLAND ENTERED INTO A PARTNERSHIP AGREEMENT WHICH OPERATES AS THE LONG ISLAND HEALTH NETWORK (LIHN). LIHN WAS CREATED TO ESTABLISH A COMPREHENSIVE AND EFFICIENT HOSPITAL NETWORK IN NASSAU AND SUFFOLK COUNTIES BY WORKING TO, AMONG OTHER THINGS, IMPROVE QUALITY OF CARE, FACILITATE CLINICAL INTEGRATION, BENCHMARK BEST PRACTICES, AND REDUCE LENGTH OF STAY AND COSTS. REPORTS FILED WITH STATES PART VI, LINE 7 NY 0 DIOCESE OF ROCKVILLE CENTRE-CATHOLIC MINISTRIES APPEAL 50 NORTH PARK AVENUE ROCKVILLE CENTRE NY 11570 111837437 264159 TO PROVIDE GENERAL SUPPORT OF THE CATHOLIC MINISTRIES OF THE DIOCESE OF ROCKVILLE CENTRE IN CONNECTION WITH THE FORMATION OF YOUTH AND ADULTS IN THE FAITH, PROMOTION OF THE DIGNITY OF LIFE, PROMOTION OF QUALITY EDUCATION FOR YOUNG PEOPLE, AND FOSTERING OF VOCATIONS FOR THE PRIESTHOOD PART 1 LINE 2:-THE DIOCESE OF ROCKVILLE CENTER PROVIDES ANNUAL UPDATES TO ALL CONTRIBUTORS TO THE CATHOLIC MINISTRIES APPEAL, WHETHER PARISHIONERS OR CORPORATE CONTRIBUTORS LIKE CHSLI. X X X X X 1 1 0 0 0 0 0 0 0 JAMES CALDAS 0 761619 0 337500 0 20673 0 169859 0 25712 0 1315363 0 0 DAN MACKSOOD 0 158205 0 0 0 31538 0 9253 0 3310 0 202306 0 0 DENNIS VERZI 423021 0 161400 0 791323 0 144997 0 8671 0 1529412 0 0 773018 PATRICK O'SHAUGHNESSY 290488 0 50000 0 308 0 0 0 19216 0 360012 0 0 0 DAVID RIVADENEIRA 693527 0 176878 0 1163 0 21644 0 29286 0 922498 0 0 0 GARA EDELSTEIN 278991 0 75000 0 515932 0 83103 0 23159 0 976185 0 503985 0 JILL GENUA 219842 0 19000 0 178 0 19242 0 24775 0 283037 0 0 0 JUNE J LEE 296821 0 75000 0 4591 0 21644 0 10665 0 408721 0 0 0 MICHAEL QUARTARARO 189665 0 45000 0 1512 0 16560 0 24912 0 277649 0 0 0 FRANK J FOX 0 170671 0 64000 0 1521935 0 0 0 16424 0 1773030 0 1756606 WILLIAM ALLISON 0 0 0 0 0 577460 0 0 0 0 0 577460 0 577460 SHARON KENNISH -175 0 0 0 615660 0 0 0 1354 0 616839 0 562223 0 PART I, LINES 4A-B PART I, LINES 4A-B: SEVERENCE PAYMENT WILLIAM ALLISON, FORMER PRESIDENT & CEO RECEIVED PAYMENT OF SEVERENCE. FRANK J FOX, FORMER SENIOR V/P & CFO RECEIVED PAYMENT OF SEVERENCE. SHARON KENNISH, FORMER EXECUTIVE DIRECTOR RECEIVED PAYMENT OF SEVERENCE. PART I, LINE 4B SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN FRANK J FOX $949,416 PAYMENT FROM PLAN JAMES CALDAS $132,354 PARTICIPATION IN PLAN DENNIS VERZI $175,554 PARTICIPATION IN PLAN; $773,018 PAYMENT FROM PLAN GARA EDELSTEIN $108,269 PARTICIPATION IN PLAN; $503,985 PAYMENT FROM PLAN SUPPLEMENTAL INFORMATION PART III THE AMOUNTS REFLECTED IN COLUMN B(III) AND COLUMN C FOR THE INDIVIDUALS INCLUDES PARTICIPATION IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("SERP"). THE AMOUNTS OUTLINED HEREIN WERE INCLUDED IN EACH INDIVIDUAL'S 2011 FORM W-2 BOX, 5 AS TAXABLE WAGES BECAUSE THEY ARE VESTED, BUT ARE NOT DISTRIBUTED UNTIL RETIREMENT. THE DEFERRED COMPENSATION AMOUNT IN COLUMN C FOR THE INDIVIDUALS INCLUDES BOTH QUALIFIED AND NONQUALIFIED RETIREMENT PLANS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF ST. CATHERINE OF SIENA MEDICAL CENTER IS CATHOLIC HEALTH SYSTEM OF LONG ISLAND (D/B/A/ CATHOLIC HEALTH SERVICES OF LONG ISLAND) (CHS). CHS IS A NEW YORK NOT-FOR-PROFIT CORPORATION ORGANIZED TO SERVE AS THE COORDINATING BODY OF AN INTEGRATED NETWORK OF PROVIDERS SERVING NASSAU AND SUFFOLK COUNTIES. CHS IS SPONSORED BY THE ROMAN CATHOLIC DIOCESE OF ROCKVILLE CENTER. FORM 990, PART VI, SECTION A, LINE 7A CHS IS THE SOLE MEMBER AND ESTABLISHED CO-OPERATOR OF ST CATHERINE OF SIENA MEDICAL CENTER, AND HAS THE RIGHT TO APPOINT THE GOVERNING BODY OF ST. CATHERINE. FORM 990, PART VI, SECTION A, LINE 7B CHS AS THE SOLE MEMBER AND CO-OPERATOR OF ST. CATHERINE IS REQUIRED TO APPROVE CERTAIN DECISIONS MADE BY ST. CATHERINE'S GOVERNING BODY FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990, AND APPROPRIATE SCHEDULES, IS COMPLETED BY THE ACCOUNTING AND FINANCE STAFF OF THE ORGANIZATION AND REVIEWED INTERNALLY BY MANAGEMENT. IT IS THEN REVIEWED BY OUTSIDE TAX ADVISORS. THE FINAL DRAFT OF THE FORM 990 IS THEN PRESENTED TO THE ORGANIZATION'S COMPLIANCE AND AUDIT COMMITTEE (THE COMMITTEE) OF THE BOARD OF TRUSTEES (THE BOARD), WHICH HAS BEEN DELEGATED THE DETAILED REVIEW FUNCTION BY THE BOARD. UPON APPROVAL OF THE COMMITTEE, THE FORM 990 IS THEN SENT TO ALL VOTING MEMBERS OF THE BOARD. ONCE APPROVED BY THE BOARD (OR THE EXECUTIVE COMMITTEE OF THE BOARD, AS APPROPRIATE), THE ORGANIZATION'S BOARD CHAIR AND CHIEF EXECUTIVE OFFICER COMMUNICATES, IN WRITING TO THE CHS COMPLIANCE AND AUDIT COMMITTEE AND CHS BOARD CHAIR. AFTER REVIEW OF ANY APPLICABLE COMMENTS FROM THE BOARD, THE COMPLIANCE AND AUDIT COMMITTEE WILL THEN RECOMMEND THE APPROVAL OF THE FORM 990 TO THE CHS BOARD OF DIRECTORS WHO WILL THEN REVIEW THE RECOMMENDATIONS AND PROVIDE THE FINAL APPROVAL OF THE FORM 990. THE FORM 990 IS THEN SUBMITTED TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C DISCLOSURE IN ACCORDANCE WITH THE CONFLICT OF INTEREST POLICY (THE POLICY) BY BOARD AND BOARD COMMITTEE MEMBERS, EMPLOYEES AND OTHERS THAT SATISFY THE CRITERIA TO BE CONSIDERED AN INTERESTED PERSON IS SUBMITTED UPON HIRE OR APPOINTMENT AND ANNUALLY THEREAFTER. SUCH INDIVIDUALS HAVE A CONTINUING OBLIGATION TO UPDATE THE INFORMATION PROVIDED DURING THE COURSE OF THE YEAR. A SUMMARY OF DISCLOSURES IS PROVIDED TO THE ORGANIZATION'S COMPLIANCE AND AUDIT COMMITTEE BY THE ORGANIZATION'S COMPLIANCE OFFICER. ALL DISCLOSURES ARE INVESTIGATED AND INFORMATION RELATED TO THE DISCLOSURE SHALL BE GATHERED AND SUMMARIZED AND INCLUDED WITH THE SUMMARY OF DISCLOSURES. UPON REVIEW OF THE SUMMARY OF DISCLOSURES, THE ORGANIZATION'S COMPLIANCE AND AUDIT COMMITTEE SHALL REPORT ITS FINDINGS TO THE BOARD OF TRUSTEES FOR REVIEW. THE BOARD SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS BASED ON THE CRITERIA CONTAINED IN THE POLICY. IF THE BOARD OR BOARD COMMITTEE DETERMINES THAT NO CONFLICT EXISTS, THE MATTER SHALL BE REFFERED FOR REVIEW BY THE CHS COMPLIANCE AND AUDIT COMMITTEE BEFORE THE DETERMINATION BECOMES FINAL. IF A CONFLICT OF INTEREST IS IDENTIFIED AND A MAJORITY OF THE BOARD OR BOARD COMMITTEE AGREES THAT THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF CHS AND WISHES TO GO FORTH WITH IT, THE CHAIR OF THE ORGANIZATION'S BOARD OF TRUSTEES SHALL PROVIDE A WRITTEN REQUEST TO THE CHAIR OF THE CHS COMPLIANCE AND AUDIT COMMITTEE, DELINEATING THE TRANSACTION AND CONFLICT AND PROVIDING REASONS WHY THE BOARD AGREES THAT THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF CHS, CERTIFIES THAT CHS CANNOT SECURE SIMILAR SERVICES FROM AN ORGANIZATION WITHOUT A CONFLICT, AND WISHES TO GO FORWARD WITH IT. UPON RECEIPT OF THE WRITTEN REQUEST AND ANY SUPPORTING DOCUMENTS, THE CHS COMPLIANCE AND AUDIT COMMITTEE SHALL MAKE THE FINAL DECISION AS TO WHETHER CHS SHALL ENTER INTO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE CHIEF EXECUTIVE OFFICER SUBMITS FOR APPROVAL TO THE CORPORATE CEO RECOMMENDATIONS FOR BASE SALARY ADJUSTMENTS AND INCENTIVE AWARDS FOR "DISQUALIFIED PERSONS" AS DEFINED IN THE POLICY. ONCE APPROVED BY THE CORPORATE CEO, THESE RECOMMENDATIONS ARE SENT TO THE EXECUTIVE COMPENSATION COMMITTEE FOR REVIEW. THE EXECUTIVE COMPENSATION COMMITTEE, WITH AN INDEPENDENT COMPENSATION CONSULTANT ENGAGED BY THE BOARD, WILL REVIEW PROPOSED SALARY ADJUSTMENTS AND INCENTIVE AWARDS TO ENSURE REASONABLENESS BY REVIEWING COMPARABLE TOTAL COMPENSATION DATA (INCLUDING INCENTIVES) PAID TO SIMILARLY SITUATED EXECUTIVES AT THE MEDIAN OF THE DEFINED MARKETPLACE WITH POSSIBLE ADJUSTMENT MADE FOR SPECIAL SKILL, EXPERIENCE, COMPETENCE AND PERFORMANCE, INCLUDING CONTRIBUTION TO THE SYSTEM AS A WHOLE. THE COMPENSATION COMMITTEE SETS STANDARDS TO ENSURE THAT THE CRITERIA USED TO DETERMINE INCENTIVE COMPENSATION ARE SPECIFIC, OBJECTIVE, MEASUREABLE AND RELATED TO INDICATORS OF PERFORMANCE. BASED ON THE INFORMATION, THE COMMITTEE WILL THEN MAKE ITS RECOMMENDATION TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS - CERTIFICATE OF INCORPORATION FILIED WITH THE NYS DEPARTMENT OF STATE; CONFLICT OF INTEREST POLICY IS NOT PUBLICLY AVAILABLE; CHS CONSOLIDATED FINANCIAL STATEMENTS ARE AVAILABLE AT DAC BOND. FORM 990, PART VII, SECTION A, LINE 1A REFLECTED IN PART VII, SECTION A, LINE 1A ARE THE ESTIMATED WEEKLY HOURS (2.0) TRUSTEES CONTRIBUTE TO THIS AND ALL OTHER RELATED ORGANIZATIONS, NOT NECESSARILY EQUALLY BUT IN THE PROPORTION NECESSARY, FOR WHICH THEY RECEIVE NO COMPENSATION. JAMES CALDAS, PRESIDENT AND CEO-THE TOTAL HOURS REPORTED REFLECTS TIME WORKED AS OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: GOOD SAMARITAN HOSPITAL (11-1888924); GOOD SAMARITAN HOSPITAL FOUNDATION (77-0611240); ST CATHERINE OF SIENA MED CENTER (06-1562701); ST CHARLES HOSPITAL & REHAB (11-1871039); ST CHARLES FOUNDATION (41-2076312); ST CHARLES CORPORATION (11-2983148); SIENA VILLAGE (06-1569129); THE SAMARITAN CORPORATION (11-2716640); SUFFOLK HEARING AND SPEECH INC (11-2110488). DAN MACKSOOD, SVP FINANCE/CFO EASTERN DIVISION-THE TOTAL HOURS REPORTED REFLECTS TIME WORKED AS OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: GOOD SAMARITAN HOSPITAL (11-1888924); GOOD SAMARITAN HOSPITAL FOUNDATION (77-0611240); ST CATHERINE OF SIENA MED CENTER (06-1562701); ST CHARLES HOSPITAL & REHAB (11-1871039); ST CHARLES FOUNDATION (41-2076312); ST CHARLES CORPORATION (11-2983148); SIENA VILLAGE (06-1569129); THE SAMARITAN CORPORATION (11-2716640); SUFFOLK HEARING AND SPEECH INC (11-2110488). CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -111,042. DONATED SERVICES AND USE OF FACILITIES: 27,483. POSTRETIREMENT BENEFIT PLAN CHANGES OTHER THAN PERIODIC BENEFIT COST -139,000. LOSS ON DEBT EXTINGUISHMENT -1,463,012. TOTAL TO FORM 990, PART XI, LINE 5: -1,685,571. ELECTION TO ALLOCATE BUSINESS ASSET EXPENSE CONTROLLED GROUP ELECTION STATEMENT THE UNDERSIGNED CORPORATIONS, COMPONENT MEMBERS OF A CONTROLLED GROUP OF CORPORATIONS, AS DEFINED IN SECTION 179(D)(7), HEREBY CONSENT TO THE APPORTIONMENT PLAN LISTED BELOW WITH RESPECT TO THE TAXABLE YEAR OF EACH CORPORATION WHICH INCLUDES DECEMBER 31, 2011 ELECTION TO ALLOCATE $40,000 ALTERNATIVE MINIMUM TAX EXEMPTION THE UNDERSIGNED CORPORATIONS, COMPONENT MEMBERS OF A CONTROLLED GROUP OF CORPORATIONS(WITHIN THE MEANING OF SECTION 1563(A)), HEREBY CONSENT UNDER REGULATION 1.58-1(C)(3) TO THE APPORTIONMENT PLAN LISTED BELOW WITH RESPECT TO THE TAXABLE YEAR OF EACH CORPORATION WHICH INCLUDES DECEMBER 31, 2011. ELECTION TO ALLOCATE $150,000 ALTERNATIVE MINIMUM TAX PHASE-OUT THE UNDERSIGNED CORPORATIONS, COMPONENT MEMBERS OF A CONTROLLED GROUP OF CORPORATIONS (WITHIN THE MEANING OF SECTION 1563(A)), HEREBY CONSENT UNDER REGULATION 1.58-1(C(3) TO THE APPOINTMENT PLAN LISTED BELOW WITH RESPECT TO THE TAXABLE YEAR OF EACH CORPORATION WHICH INCLUDES DECEMBER 31, 2011. EMPLOYER ID NO. $128,00 $40,000 $150,000 11-3403968 NONE NONE NONE 14-1801961 NONE NONE NONE 11-3594561 NONE NONE NONE 11-3555766 NONE NONE NONE 11-1888924 NONE NONE NONE 77-0611240 NONE NONE NONE 11-2537396 NONE NONE NONE 11-2958438 NONE NONE NONE 11-3434776 NONE NONE NONE 11-2861698 NONE NONE NONE 11-2861690 NONE NONE NONE 11-3638367 NONE NONE NONE 11-1635088 NONE NONE NONE 11-2126736 NONE NONE NONE 11-3284066 NONE NONE NONE 20-8067039 NONE NONE NONE 11-2499790 NONE NONE NONE 06-1569129 NONE NONE NONE 06-1562701 NONE NONE NONE 11-1871039 NONE NONE NONE 41-2076312 NONE NONE NONE 11-3613997 NONE NONE NONE 11-2050523 NONE NONE NONE 11-2916033 NONE NONE NONE 11-3090867 NONE NONE NONE 11-2110488 NONE NONE NONE 11-2983148 NONE NONE NONE 11-2716640 NONE NONE NONE 11-3559713 NONE NONE NONE 11-1635088 NONE NONE NONE 55-0813603 NONE NONE NONE 27-1459941 NONE NONE NONE IN PROCESS NONE NONE NONE 26-3169427 NONE NONE NONE 45-0517566 NONE NONE NONE 27-1531084 NONE NONE NONE 11-2798383 NONE NONE NONE 11-2801136 NONE NONE NONE 11-2838185 $128,000 $40,000 $150,000 11-3319259 NONE NONE NONE 06-1568934 NONE NONE NONE 11-3307977 NONE NONE NONE 11-2126736 NONE NONE NONE FORM 990, PART IV, LINE 12 A AND B THE HOSPITALS (GOOD SAMARITAN HOSPITAL MEDICAL CENTER, ST. CATHERINE OF SIENA MEDICAL CENTER AND ST. CHARLES HOSPITAL) HAVE BOTH SEPARATE AND CONSOLIDATED AUDITIED FINANCIAL STATEMENTS. HOWEVER, THE HOSPITALS RESPECTIVE 990'S ARE PREPARED ON THE CONSOLIDATED BASIS AND AS SUCH PART IV, LINE 12 A HAS BEEN ANSWERED "NO" AND LINE 12 B HAS BEEN ANSWERED "YES". CONTROLLED GROUP ELECTION - CONTINUED EMPLOYER NAME, ADDRESS & TAX YEAR-END ID NO. 11-3403968 CATHOLIC HEALTH SERVICES OF LONG ISLAND 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 14-1801961 CHS AMBULANCE SERVICES 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-3594561 CHS HOME SUPPORT SERVICES, INC. 15 POWER DRIVE HAUPPAUGUE, NY 11788 TAX YEAR END: 12/31/11 11-3555761 CHS SERVICES, INC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-1888924 GOOD SAMARITAN HOSPITAL MEDICAL CENTER 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 77-0611240 GOOD SAMARITAN HOSPITAL FOUNDATION 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 11-2537396 GOOD SAMARITAN HOSPITAL SELF INSURANCE AGAINST MALPRACTICE 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 11-2958438 GOOD SHEPHERD HOSPICE 245 OLD COUNTRY ROAD MELVILLE, NY 11747 TAX YEAR END: 12/31/11 11-3434776 MARYHAVEN TRANSPORTATION SERVICES 51 TERRYVILLE ROAD PORT JEFFERSON, NY 11776 TAX YEAR END: 12/31/11 11-2861698 MARYHAVEN CENTER OF HOPE 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 11-2861690 MARYHAVEN SCHOOL CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 11-3638367 THE CENTER OF HOPE FOUNDATION 51 TERRYVILLE ROAD PORT JEFFERSON, NY 11776 TAXABLE YEAR: 12/31/11 11-1635088 MERCY MEDICAL CENTER 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-2126736 CATHOLIC HOME CARE 1150 PORTION BLVD. SUITE 1 HOLTSVILLE, NY 11742 TAX YEAR END: 12/31/11 11-3284066 OUR LADY OF CONSOLATION GERIATRIC CARE CENTER 111 BEACH DRIVE WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 20-8067039 RVC INSURANCE COMPANY, INC. 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-2499790 RIVERHEAD HOSTEL HOLDING CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 06-1569129 SIENA VILLAGE 50 ROUTE 25A SMITHTOWN, NY 11787 TAX YEAR END: 12/31/11 06-1562701 ST. CATHERINE OF SIENA MEDICAL CENTER 50 ROUTE 25A SMITHTOWN, NY 11787 TAX YEAR END: 12/31/11 11-1871039 ST. CHARLES HOSPITAL AND REHABILITATION CENTER 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAX YEAR END: 12/31/11 41-2076312 ST. CHARLES HOSPITAL FOUNDATION 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAX YEAR END: 12/31/11 11-3613997 ST. FRANCIS CARDIOVASCULAR PHYSICIANS PC 100 PORT WASHINGTON BLVD. ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-2050523 ST. FRANCIS HOSPITAL 100 PORT WASHINGTON BLVD. ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-2916033 ST. FRANCIS HOSPITAL FOUNDATION 100 PORT WASHINGTON BOULEVARD ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-3090867 ST. FRANCIS RESEARCH & EDUCATIONAL CORPORATION 100 PORT WASHINGTON BOULEVARD ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-2110488 SUFFOLK HEARING & SPEECH 369 EAST MAIN STREET EAST ISLIP, NY 11730 TAX YEAR END: 12/31/11 11-2983148 THE ST. CHARLES CORPORATION 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAX YEAR END: 12/31/11 11-2716640 THE SAMARITAN CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11795 TAX YEAR END: 12/31/11 11-3559713 WISDOM GARDENS HOUSING DEVELOPMENT CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 11-1635088 ST. FRANCIS-MERCY CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11795 TAX YEAR END: 12/31/11 55-0813603 MERCY MEDICAL CENTER FOUNDATION 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11795 TAX YEAR END: 12/31/11 27-1459941 ST. CATHERINE OF SIENA MEDICAL CENTER FOUNDATION 50 ROUTE 25A SMITHTOWN, NY 11787 TAX YEAR END: 12/31/11 IN PROCESS CATHOLIC HOME CARE FOUNDATION 1150 PORTION ROAD, SUITE 1 HOLTSVILLE, NY 11742 TAX YEAR END: 12/31/11 26-3169427 CATHOLIC HOME CARE FOUNDATION 245 OLD COUNTRY ROAD MELVILLE, NY 11747 TAX YEAR END: 12/31/11 45-0517566 OUR LADY OF CONSOLATION FOUNDATION 111 BEACH DRIVE WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 27-1531084 OUR LADY OF CONSOLATION FOUNDATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-2798383 FAIRVIEW HILL MANAGEMENT CORP 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAXABLE YEAR: 12/31/11 11-2801136 HEALTHCARE TEMP SERVICES 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAXABLE YEAR: 12/31/11 11-2838185 SAMARITAN MANAGEMENT SERVICES 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAXABLE YEAR: 12/31/11 11-3319259 SAMARITAN HOME CARE AMERICA, INC. 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAXABLE YEAR: 12/31/11 06-1568934 SIENA MEDICAL REALTY 50 ROUTE 25A SMITHTOWN, NY 11787 TAXABLE YEAR: 12/31/11 11-3307977 SOUTH SHORE PRACTICE MANAGEMENT 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAXABLE YEAR: 12/31/11 11-2126736 NURSING SISTERS HOME CARE, INC 1150 PORTION ROAD, SUITE 1 HOLTSVILLE, NY 11742 TAXABLE YEAR: 12/31/11 STATEMENT OF TAX BRACKET ALLOCATION THE AMOUNTS IN EACH TAXABLE INCOME BRACKET IN THE TAX TABLE IN SECTION 11(B) HAVE BEEN ALLOCATED TO THE CORPORATIONS LISTED BELOW PURSUANT TO REGULATION 1.1561-3(A). THE ORIGINAL COPY OF THIS STATEMENT IS FILED WITH THE INTERNAL REVENUE SERVICE CENTER IN OGDEN, UTAH. AUTHORIZATION CONSENT FOR ALLOCATION ON BEHALF OF MEMBER COMPANIES ____________________________________________ EMPLOYER ID NO. $50,000 $25,000 $9,925,000 BRACKET BRACKET BRACKET 11-3403968 NONE NONE NONE 14-1801961 NONE NONE NONE 11-3594561 NONE NONE NONE 11-3555766 NONE NONE NONE 11-1888924 NONE NONE NONE 77-0611240 NONE NONE NONE 11-2537396 NONE NONE NONE 11-2958438 NONE NONE NONE 11-3434776 NONE NONE NONE 11-2861698 NONE NONE NONE 11-2861690 NONE NONE NONE 11-3638367 NONE NONE NONE 11-1635088 NONE NONE NONE 11-2126736 NONE NONE NONE 11-3284066 NONE NONE NONE 20-8067039 NONE NONE NONE 11-2499790 NONE NONE NONE 06-1569129 NONE NONE NONE 06-1562701 NONE NONE NONE 11-1871039 NONE NONE NONE 41-2076312 NONE NONE NONE 11-3613997 NONE NONE NONE 11-2050523 NONE NONE NONE 11-2916033 NONE NONE NONE 11-3090867 NONE NONE NONE 11-2110488 NONE NONE NONE 11-2983148 NONE NONE NONE 11-2716640 NONE NONE NONE 11-3559713 NONE NONE NONE 11-1635088 NONE NONE NONE 55-0813603 NONE NONE NONE 27-1459941 NONE NONE NONE IN PROCESS NONE NONE NONE 26-3169427 NONE NONE NONE 45-0517566 NONE NONE NONE 27-1531084 NONE NONE NONE 11-2798383 NONE NONE NONE 11-2801136 NONE NONE NONE 11-2838185 $50,000 $25,000 $9,925,000 11-3319259 NONE NONE NONE 06-1568934 NONE NONE NONE 11-3307977 NONE NONE NONE 11-2126736 NONE NONE NONE STATEMENT OF TAX BRACKET ALLOCATION - CONTINUED EMPLOYER NAME, ADDRESS & TAX YEAR-END ID NO. 11-3403968 CATHOLIC HEALTH SERVICES OF LONG ISLAND 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 14-1801961 CHS AMBULANCE SERVICES 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-3594561 CHS HOME SUPPORT SERVICES, INC. 15 POWER DRIVE HAUPPAUGUE, NY 11788 TAX YEAR END: 12/31/11 11-3555761 CHS SERVICES, INC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-1888924 GOOD SAMARITAN HOSPITAL MEDICAL CENTER 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 77-0611240 GOOD SAMARITAN HOSPITAL FOUNDATION 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 11-2537396 GOOD SAMARITAN HOSPITAL SELF INSURANCE AGAINST MALPRACTICE 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 11-2958438 GOOD SHEPHERD HOSPICE 245 OLD COUNTRY ROAD MELVILLE, NY 11747 TAX YEAR END: 12/31/11 11-3434776 MARYHAVEN TRANSPORTATION SERVICES 51 TERRYVILLE ROAD PORT JEFFERSON, NY 11776 TAX YEAR END: 12/31/11 11-2861698 MARYHAVEN CENTER OF HOPE 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 11-2861690 MARYHAVEN SCHOOL CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 11-3638367 THE CENTER OF HOPE FOUNDATION 51 TERRYVILLE ROAD PORT JEFFERSON, NY 11776 TAXABLE YEAR: 12/31/11 11-1635088 MERCY MEDICAL CENTER 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-2126736 CATHOLIC HOME CARE 1150 PORTION BLVD. SUITE 1 HOLTSVILLE, NY 11742 TAX YEAR END: 12/31/11 11-3284066 OUR LADY OF CONSOLATION GERIATRIC CARE CENTER 111 BEACH DRIVE WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 20-8067039 RVC INSURANCE COMPANY, INC. 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-2499790 RIVERHEAD HOSTEL HOLDING CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 06-1569129 SIENA VILLAGE 50 ROUTE 25A SMITHTOWN, NY 11787 TAX YEAR END: 12/31/11 06-1562701 ST. CATHERINE OF SIENA MEDICAL CENTER 50 ROUTE 25A SMITHTOWN, NY 11787 TAX YEAR END: 12/31/11 11-1871039 ST. CHARLES HOSPITAL AND REHABILITATION CENTER 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAX YEAR END: 12/31/11 41-2076312 ST. CHARLES HOSPITAL FOUNDATION 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAX YEAR END: 12/31/11 11-3613997 ST. FRANCIS CARDIOVASCULAR PHYSICIANS PC 100 PORT WASHINGTON BLVD. ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-2050523 ST. FRANCIS HOSPITAL 100 PORT WASHINGTON BLVD. ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-2916033 ST. FRANCIS HOSPITAL FOUNDATION 100 PORT WASHINGTON BOULEVARD ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-3090867 ST. FRANCIS RESEARCH & EDUCATIONAL CORPORATION 100 PORT WASHINGTON BOULEVARD ROSLYN, NY 11576 TAX YEAR END: 12/31/11 11-2110488 SUFFOLK HEARING & SPEECH 369 EAST MAIN STREET EAST ISLIP, NY 11730 TAX YEAR END: 12/31/11 11-2983148 THE ST. CHARLES CORPORATION 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAX YEAR END: 12/31/11 11-2716640 THE SAMARITAN CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11795 TAX YEAR END: 12/31/11 11-3559713 WISDOM GARDENS HOUSING DEVELOPMENT CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION, NY 11776 TAX YEAR END: 12/31/11 11-1635088 ST. FRANCIS-MERCY CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11795 TAX YEAR END: 12/31/11 55-0813603 MERCY MEDICAL CENTER FOUNDATION 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11795 TAX YEAR END: 12/31/11 27-1459941 ST. CATHERINE OF SIENA MEDICAL CENTER FOUNDATION 50 ROUTE 25A SMITHTOWN, NY 11787 TAX YEAR END: 12/31/11 IN PROCESS CATHOLIC HOME CARE FOUNDATION 1150 PORTION ROAD, SUITE 1 HOLTSVILLE, NY 11742 TAX YEAR END: 12/31/11 26-3169427 CATHOLIC HOME CARE FOUNDATION 245 OLD COUNTRY ROAD MELVILLE, NY 11747 TAX YEAR END: 12/31/11 45-0517566 OUR LADY OF CONSOLATION FOUNDATION 111 BEACH DRIVE WEST ISLIP, NY 11795 TAX YEAR END: 12/31/11 27-1531084 OUR LADY OF CONSOLATION FOUNDATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE, NY 11570 TAX YEAR END: 12/31/11 11-2798383 FAIRVIEW HILL MANAGEMENT CORP 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAXABLE YEAR: 12/31/11 11-2801136 HEALTHCARE TEMP SERVICES 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 TAXABLE YEAR: 12/31/11 11-2838185 SAMARITAN MANAGEMENT SERVICES 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAXABLE YEAR: 12/31/11 11-3319259 SAMARITAN HOME CARE AMERICA, INC. 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAXABLE YEAR: 12/31/11 06-1568934 SIENA MEDICAL REALTY 50 ROUTE 25A SMITHTOWN, NY 11787 TAXABLE YEAR: 12/31/11 11-3307977 SOUTH SHORE PRACTICE MANAGEMENT 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 TAXABLE YEAR: 12/31/11 11-2126736 NURSING SISTERS HOME CARE, INC 1150 PORTION ROAD, SUITE 1 HOLTSVILLE, NY 11742 TAXABLE YEAR: 12/31/11 SIENA RETIREMENT REALTY CCRC 50 ROUTE 25A SMITHTOWN NY 11787 RETIREMENT COMMUNITY NY 3507990 N/A SIENA MEDICAL REALTY 50 ROUTE 25A SMITHTOWN NY 11787 MEDICAL OFFICE BUILDING NY 1554331 7961939 N/A CATHOLIC HEALTH SYSTEM OF LONG ISLAND 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 113403968 SUPPORT ORG NY 501(C)(3) LINE 11A, I N/A 0 CHS SERVICES INC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 113555766 SUPPORT ORG NY 501(C)(3) LINE 11A, I CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 CHS AMBULANCE SERVICES INC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 141801961 DORMANT NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 GOOD SAMARITAN HOSPITAL MEDICAL CENTER 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 111888924 HOSPITAL NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 GOOD SAMARITAN SELF INSURANCE AGAINST MALPRACTICE 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112537396 SELF INSURANCE NY 501(C)(3) LINE 11A, I GOOD SAMARITAN HOSPITAL 0 MARYHAVEN TRANSPORTATION SERVICES 51 TERRYVILLE ROAD PORT JEFFERSON STATION NY 11776 113434776 TRANSPORTATION SERVICES NY 501(C)(3) LINE 9 MARYHAVEN CENTER OF HOPE 0 MARYHAVEN CENTER OF HOPE 51 TERRYVILLE ROAD PORT JEFFERSON STATION NY 11776 112861698 PROGRAMS/HOUSING FOR THE DEVELOPMENTALLY DISABLED NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 MARYHAVEN SCHOOL CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION NY 11776 112861690 SCHOOL FOR DEVELOPMENTALLY DISABLED NY 501(C)(3) LINE 9 MARYHAVEN CENTER OF HOPE 0 THE CENTER OF HOPE FOUNDATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION NY 11776 113638367 SUPPORT ORG NY 501(C)(3) LINE 11A, I MARYHAVEN CENTER OF HOPE 0 MERCY MEDICAL CENTER 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 111635088 HOSPITAL NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 CATHOLIC HOME CARE 1150 PORTION ROAD SUITE 1 HOLTSVILLE NY 11742 112126736 HOME CARE NY 501(C)(3) LINE 9 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 OUR LADY OF CONSOLATION GERIATRIC CARE CENTER 111 BEACH DRIVE WEST ISLIP NY 11795 113284066 LT NURSING CARE NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 RIVERHEAD HOSTEL HOLDING CORPORATION 51 TERRYVILLE ROAD PORT JEFFERSON STATION NY 11776 112499790 RENTING NY 501(C)(3) LINE 9 MARYHAVEN CENTER OF HOPE 0 SIENA VILLAGE INC 50 ROUTE 25A SMITHTOWN NY 11787 061569129 SENIOR HOUSING NY 501(C)(3) LINE 9 ST CATHERINE OF SIENA MEDICAL CENTER 0 ST CHARLES HOSPITAL 200 BELLE TERRE ROAD PORT JEFFERSON STATION NY 11777 111871039 HOSPITAL NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 CHS HOME SUPPORT SERVICES INC 15 POWER DRIVE HAUPPAUGE NY 11788 113594561 RESPIRATORY THERAPY SVC/MED. EQUIP. NY 501(C)(3) LINE 9 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 ST FRANCIS HOSPITAL 100 PORT WASHINGTON BLVD ROSLYN NY 11576 112050523 HOSPITAL NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 ST FRANCIS HOSPITAL FOUNDATION 100 PORT WASHINGTON BLVD ROSLYN NY 11576 112916033 SUPPORT ORG NY 501(C)(3) LINE 11A, I ST FRANCIS HOSPITAL 0 ST FRANCIS HOSPITAL RESEARCH & EDUCATIONAL CORP 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113090867 RESEARCH ORGANIZATION NY 501(C)(3) LINE 9 ST FRANCIS HOSPITAL 0 WSNCHS NORTH INC 4295 HEMPSTEAD TURNPIKE BETHPAGE NY 11714 113438973 HOSPITAL NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 SUFFOLK HEARING & SPEECH CENTER INC 369 EAST MAIN STREET EAST ISLIP NY 11730 112110488 DIAGNOSTIC TESTING NY 501(C)(3) LINE 3 GOOD SAMARITAN HOSPITAL 0 THE ST CHARLES CORPORATION 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 112983148 SUPPORT ORG NY 501(C)(3) LINE 11A, I CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 THE SAMARITAN CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 112716640 SUPPORT ORG NY 501(C)(3) LINE 11A, I CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 WISDOM GARDENS HOUSING DEVELOPMENT FUND INC 51 TERRYVILLE ROAD PORT JEFFERSON STATION NY 11776 113559713 SENIOR HOUSING NY 501(C)(3) LINE 9 MARYHAVEN CENTER OF HOPE 0 GOOD SHEPHERD HOSPICE 245 OLD COUNTRY ROAD MELVILLE NY 11747 112958438 HOSPICE SERVICES NY 501(C)(3) LINE 9 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 ST CHARLES HOSPITAL FOUNDATION 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 412076312 SUPPORT ORG NY 501(C)(3) LINE 11A, I ST CHARLES HOSPITAL 0 GOOD SAMARITAN HOSPITAL FOUNDATION 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 770611240 SUPPORT ORG NY 501(C)(3) LINE 11A, I GOOD SAMARITAN HOSPITAL 0 ST FRANCIS-MERCY CORPORATION 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 111635088 SUPPORT ORG NY 501(C)(3) LINE 11A, I CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 MERCY MEDICAL CENTER FOUNDATION 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 550813603 SUPPORT ORG NY 501(C)(3) LINE 11A, I MERCY MEDICAL CENTER 0 ST CATHERINE OF SIENA MEDICAL CENTER FOUNDATION 50 ROUTE 25A SMITHTOWN NY 11787 271459941 SUPPORT ORG NY 501(C)(3) LINE 11A, I ST CATHERINE OF SIENA MEDICAL CENTER 0 CATHOLIC HOME CARE FOUNDATION 1150 PORTION ROAD SUITE 1 HOLTSVILLE NY 11742 SUPPORT ORG NY 501(C)(3) LINE 11A, I CATHOLIC HOME CARE 0 GOOD SHEPHERD HOSPICE FOUNDATION 245 OLD COUNTRY ROAD MELVILLE NY 11747 263169427 SUPPORT ORG NY 501(C)(3) LINE 11A, I GOOD SHEPHERD HOSPICE 0 OUR LADY OF CONSOLATION FOUNDATION 111 BEACH DRIVE WEST ISLIP NY 11795 450517566 SUPPORT ORG NY 501(C)(3) LINE 11A, I OUR LADY OF CONSOLATION 0 RVC SUPPORT 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 271531084 REAL ESTATE NY 501(C)(3) LINE 11A, I CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 ST FRANCIS CARDIOVASCULAR PHYSICIANS PC 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113613997 HEALTHCARE SERVICES NY 501(C)(3) LINE 3 ST FRANCIS HOSPITAL 0 RVC INSURANCE COMPANYINC 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 208067039 CAPTIVE INSURANCE COMPANY NY 501(C)(3) LINE 11A, I CATHOLIC HEALTH SYSTEM OF LONG ISLAND 0 RADIOLOGY CONSULTING OF LONG ISLAND PLLC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 421646134 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C SAMARITAN EMERGENCY MEDICAL SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208243412 DIAGNOSTIC TESTING NY GOOD SAMARITAN HOSPITAL C SAMARITAN PEDIATRIC SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208180263 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C SAMARITAN MEDICAL SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208088453 DIAGNOSTIC TESTING NY GOOD SAMARITAN HOSPITAL C SOUTHWEST SUFFOLK MEDICAL PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 061603195 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C CARDIAC EKG INTERPRETATION PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112924518 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C LI REGIONAL ARTHRITIS & OSTEOPOROSIS CARE PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208964140 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C SAMARITAN MANAGEMENT SERVICES INC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112838185 HEALTHCARE SERVICES NY CATHOLIC HEALTH SYSTEM OF LONG ISLAND C FAIRVIEW HILL MANAGEMENT CO INC 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 112798383 SERVICES NY ST CHARLES CORPORATION C ADVANCED REHABILIATION MEDICINE PLLC 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 113640709 HEALTHCARE SERVICES NY ST CHARLES HOSPITAL C ST FRANCIS CARDIAC PREVENTION SERVICES PC 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113224885 HEALTHCARE SERVICES NY ST FRANCIS HOSPITAL C SOUTH SHORE PRACTICE MANAGEMENT 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 113307977 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C MERCY INTERNAL MEDICINE PC 992 N VILLAGE AVENUE ROCKVILLE CENTRE NY 11710 510639649 HEALTHCARE SERVICES NY MERCY MEDICAL CENTER C 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 CATHOLIC HEALTH SERVICES OF LONG ISLAND E -18686372 COST ST FRANCIS HOSPITAL O 88664 COST OUR LADY OF CONSOLATION GERIATRIC CARE N 65262 COST CHS SERVICES INC 11-3555766 O 542061 COST TRANSACTIONS WITH RELATED ORGANIZATIONS SCHEDULE R PART V LINE 2 ST. CATHERINE HAS DISCLOSED IN SCHEDULE R THE PREDOMINANT TRANSACTION TYPE WITH EACH FACILITY WITH WHICH IT HAS CONDUCTED TRANSATIONS. HOWEVER, THERE ARE ADDITIONAL TRANSACTION TYPES TO DESCRIBE THE ACTIVITIES ST. CATHERINE HAS ENGAGED IN WITH ITS RELATED PARTY ORGANIZATIONS. THE FOLLOWING IS A LIST OF ADDITIONAL TRANSACTION TYPES BY FACILITY NAME OF ORGANIZATION EIN ADD'NL TRANS TYPES CATHOLIC HEALTH SERVICES OF LONG ISLAND 11-3405968 N,O,P ST.FRANCIS HOSPITAL 11-2050523 P OUR LADY OF CONSOLATION GERIATRIC CARE 11-3284066 O,P CATHOLIC HEALTH SERVICES 11-3555766 P