2013-01-07T14:01:44-06:00 2011-12-31 221478099 COHNREZNICK LLP 4 BECKER FARM ROAD ROSELAND NJ 070681739 990 2011-01-01 111635088 MERCY MEDICAL CENTER MERC 5167052525 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 ALAN D GUERCI MD 5167052525 2013-01-07 1 THOMAS LANNING P00851654 9732283500 2011 2016-03-07 17:11:31Z ALAN D GUERCI MD 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 207141173 0 X HTTP://MERCYMEDICALCENTER.CHSLI.ORG X 1913 NY MERCY 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. CHS AFFIRMS THE SANCTITY OF LIFE, ADVOCATES FOR THE POOR AND UNDERSERVED, AND SERVES THE COMMON GOOD. CHS CONDUCTS ITS HEALTHCARE PRACTICE, BUSINESS, EDUCATION, AND INNOVATION WITH JUSTICE, INTEGRITY, AND RESPECT FOR THE DIGNITY OF EACH PERSON. 22 21 1698 1025 0 0 6783886 7474013 185289934 195083274 255531 222396 3102624 3832880 195431975 206612563 150520 233812 0 0 109640109 108767971 0 0 0 77386938 84999514 187177567 194001297 8254408 12611266 160796058 191170091 135381314 153892344 25414744 37277747 X MERCY 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, AFFIRMS THE SANCTITY OF LIFE, AND ADVOCATES FOR THE POOR AND UNDERSERVED, AND SERVES THE COMMON GOOD. CHS CONDUCTS ITS HEALTHCARE PRACTICE, BUSINESS, EDUCATION, AND INNOVATION WITH JUSTICE, INTEGRITY, AND RESPECT FOR THE DIGNITY OF EACH PERSON. 0 0 175730355 196256163 MERCY MEDICAL CENTER IS A 375 BED, NOT-FOR-PROFIT ACUTE CARE HOSPITAL SERVING THE HEALTHCARE NEEDS OF NASSAU COUNTY AND ITS SURROUNDING AREA. FOUNDED IN 1913 BY THE NURSING SISTERS OF THE CONGREGATION OF THE INFANT JESUS, MERCY MEDICAL CENTER HAS GROWN FROM A THREE FLOOR WOODEN STRUCTURE TO AN EXTENSIVE INSTITUTION OCCUPYING A 42-ACRE CAMPUS THAT HOUSES SOME OF THE MOST ADVANCED MEDICAL TECHNOLOGIES. ACCORDING TO INTERNAL DATA, OVER 32% OF MMC'S TOTAL INPATIENT DISCHARGES IN 2011 CAME FROM HEMPSTEAD, UNIONDALE, FREEPORT, AND ROOSEVELT. THESE FOUR COMMUNITIES HAVE BEEN REFERRED TO AS "COMMUNITIES AT RISK", MANY OF THE RESIDENTS LIVING IN POVERTY AND HAVING POOR HEALTH OUTCOMES. OF THE 30,989 ED TREATED & RELEASED VISITS MMC HAD IN 2011, 15,304 OR NEARLY 49% CAME FROM THESE SAME FOUR ZIP CODES. 175730355 1 1 0 1 0 0 0 0 0 1 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 0 1 0 0 0 0 1 130 0 1 1698 1 0 0 0 0 0 0 0 0 0 0 X 22 21 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHS SERVICES INC 5167051926 992 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 X PETER QUICK 2.00 X X 0 0 0 DANIEL J DENIHAN 2.00 X X 0 0 0 C JUSTIN MCCARTHY 2.00 X X 0 0 0 REV MSGR FRANCIS J CALDWELL 2.00 X X 0 0 0 JAMES DADDARIO 2.00 X 0 0 0 SR DOLORES WISNIEWSKI CIJ 2.00 X 0 0 0 SR BETTY KEEGAN 2.00 X 0 0 0 DELORES C KERSHAW 2.00 X 0 0 0 DAVID J MILLER DDS 2.00 X 0 0 0 RABBI BARRY DOV SCHWARTZ PHD 2.00 X 0 0 0 SUSAN POWERS SCHOTT 2.00 X 0 0 0 THOMAS E CHRISTMAN 2.00 X 0 0 0 KEVIN J CONWAY 2.00 X 0 0 0 EDWARD J COOK PHD 2.00 X 0 0 0 THOMAS J FANNING 2.00 X 0 0 0 JOSEPH A GRIMALDI 2.00 X 0 0 0 EUGENE F MURPHY 2.00 X 0 0 0 CHRISTOPHER S PASCUCCI 2.00 X 0 0 0 ROBERT P QUINN 2.00 X 0 0 0 MATTHEW D SERRA 2.00 X 0 0 0 EUGENE P SOUTHER ESQ 2.00 X 0 0 0 ALAN D GUERCI MD 50.00 X X 0 2258256 596927 WILLIAM C ARMSTRONG 50.00 X 0 1600307 462970 NANCY SIMMONS 50.00 X 836322 75222 91132 AARON GLATT 50.00 X 31205 498192 48911 JOHN REILLY 50.00 X 371583 0 41830 RONALD STEIMEL 50.00 X 332628 0 41685 STEPHEN TRAPANI 50.00 X 348859 11923 65395 SWARNA DEVARAJAN MD 38.00 X 325782 0 44488 ALAN WONG MD 38.00 X 394290 0 42624 RENEE MAURIELLO 38.00 X 281692 0 41752 2922361 4443900 1477714 144 0 1 0 LI EMERGENCY CARE PC 1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570 EMERGENCY MEDICINE SERVICES 1650000 VIRTUAL RADIOLOGIC PROF OF NY 11995 SINGLETREE LANE SUITE 500 MINNEAPOLIS MN 55344 RADIOLOGY SERVICES 621030 MADONNA PHYSICIANS SERVICES PC 200 OLD COUNTRY ROAD MINEOLA NY 11501 NEONATOLOGY SERVICES 386427 ALLIED UROLOGICAL SVCS LLC 205 LEXINGTON AVE NEW YORK NY 10687 SURGICAL SERVICES 193300 PATRICK E MCMANUS MD PC 303 E PARK AVE LONG BEACH NY 11561 OBSTETRICS SERVICES 180980 17 81278 6423000 568130 401605 7474013 PATIENT SERVICES 621300 195083274 195083274 195083274 222396 222396 2709121 183192 2525929 2525929 2525929 479480 81278 345418 134062 134062 CAFETERIA/COFFEE SHOP 561000 600753 600753 RADIOLOGY SCHOOL TUITI 561499 214100 214100 358036 358036 1172889 206612563 196256163 0 2882387 233812 233812 1239110 371583 867527 83676794 77903510 5773284 5168859 4764631 404228 12445014 11471757 973257 6238194 5750339 487855 347715 347715 338334 338334 181004 181004 3363066 3363066 996357 15095 981262 6661914 5721260 940654 3761383 3761383 114088 105114 8974 1126808 1126808 3051610 1344843 1706767 8784910 8784910 4984781 4984781 MEDICAL SUPPLIES 22566265 22566265 FINANCE AND TECHNOLOGY 13515038 11487782 2027256 PROVISION FOR BAD DEBT 4518009 4518009 EQUIPMENT SERVICE CONTR 2868051 2863818 4233 7820181 4591589 3228592 194001297 175730355 18270942 0 4887614 9080955 218299 248723 784765 208359 18948749 21631565 2818601 2345469 2606067 1930067 268887796 163708703 108593548 105179093 12206479 13628313 9731936 36917547 160796058 191170091 19092917 19389394 43423732 37958030 12759116 9122541 60105549 87422379 135381314 153892344 X 23259876 35029684 2154868 2248063 25414744 37277747 160796058 191170091 X 12611266 -748263 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 58461 58461 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: AMOUNT REFLECTS PORTION OF TRADE ASSOCIATION DUES WHICH WERE USED FOR LEGISLATIVE LOBBYING ON BEHALF OF THE HEALTHCARE INDUSTRY THOSE TRADE ORGANIZATIONS REPRESENT. 329471 18230 2750 23079 321872 341486 2030 2000 12045 329471 350792 1860 2000 9166 341486 360363 7910 2000 15481 350792 1.00000 0 0 8529460 8529460 161043733 80387808 80655925 397287 305206 92081 92215597 78738729 13476868 6701719 4276960 2424759 105179093 ASSETS LIMITED AS TO USE 4461357 OTHER INVESTMENTS AT COST 408392 OTHER RECEIVALBES-CURRENT 1414214 457B FUNDS 251573 INSURANCE CLAIMS RECEIVABLE 30382011 36917547 ESTIMATED THIRD PARTY PAYOR LIABILITIES 13918471 AMOUNTS DUE TO RELATED PARTIES 22166606 ESTIMATED MALPRACTICE LIABILITY 32919696 OTHER SELF INSURANCE LIABILITY 18417606 87422379 206612563 194001297 12611266 4962 -753225 -748263 11863003 200029538 0 200029538 6583025 6583025 206612563 191224352 0 191224352 2776945 2776945 194001297 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: PART V, LINE 4: MERCY MEDCIAL CENTER'S MAGOVERN FUND IS RESTRICTED FOR THE PURPOSE OF FUNDING EXPENDITURES RELATING TO THE HOSPITAL'S RADIOLOGY TRAINING PROGRAM. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MERCY 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 WHICH 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: MIMS PC CHANGE IN UNRESTRICTED NET ASSETS -40,264. POSTRETIREMENT BENEFIT PLAN CHANGES OTHER THAN NET PERIODIC BENEFIT COST -121,000. LOSS ON EXTINGUISHMENT OF DEBT -591,961. TOTAL TO SCHEDULE D, PART XI, LINE 8: -753,225. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANT FROM ST FRANCIS HOSPITAL 6,423,000. GRANT FROM DASNY FOR PURCHASES OF EQUIPMENT 209,674. RESTRICTED CONTRIBUTIONS 556,334. NET ASSETS RELEASED FROM RESTRICITION FOR OPERATIONS -97,506. MIMS PC REVENUE -508,477. PART XIII, LINE 4B - OTHER ADJUSTMENTS: ASSESSMENTS FROM RELATED PARTIES 3,285,422. MIMS PC EXPENSES -508,477. X BALL 324261 46999 277262 21271 157911 74102 GOLF 167381 24261 143120 7822 42426 9775 1 69116 10018 59098 3250 17687 11174 560758 81278 479480 3250 29093 218024 95051 345418 134062 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 4899038 3839587 1059451 0.00550 29607746 26051417 3556329 0.01830 34506784 29891004 4615780 0.02380 643867 9800 634067 0.00330 722797 210757 512040 0.00260 15661937 13716702 1945235 0.01000 68326 68326 0.00040 17036 17036 0.00010 17113963 13937259 3176704 0.01640 51620747 43828263 7792484 0.04020 150220 726 149494 0.00080 7012 7012 0.00000 109 109 0.00000 11386 11386 0.00010 5095 5095 0.00000 9956 9956 0.00010 183778 726 183052 0.00100 1 1152092 0 62621730 63065717 -443987 X 1 1 1 1 MERCY MEDICAL CENTER

1000 NORTH VILLAGE AVENUE ROCKVILLE CENTRE NY 11570

X X X X PSYCHIATRIC UNIT / REHABILITATIVE SERVICES MERCY MEDICAL CENTER 1 1 1 300.000000000000 1 400.000000000000 1 X 1 1 X X X X 1 0 1 X 0 0 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 THE METHODOLOGY WAS 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 OTHER LINES INCLUDE COSTS THAT WERE DERIVED BASED 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 I, LINE 7A, COLUMN D DIRECT 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 HOSPITAL'S "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 HAS APPOINTED 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 DEBT AND CHARITY CARE FOR 2011. PART I, L7 COL(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 $ 4,518,008. PART II: MMC'S COMMUNITY BUILDING ACTIVITIES PROMOTE THE COMMUNITY'S HEALTH IN MANY WAYS. FOR EXAMPLE, ASSISTING PATIENTS TO ENROLL IN PUBLIC PROGRAMS EXPANDS THEIR ACCESS TO CARE. DISASTER READINESS DRILLS BEYOND MINIMUM MANDATES ENSURES AVAILABILITY OF HOSPITAL SERVICES DURING TIMES OF HIGHEST NEED. COLLECTION AND DISPOSAL OF SYRINGES FOR THE COMMUNITY ELIMINATES A HEALTH HAZARD. ADVOCACY FOR BEHAVIORAL HEALTH CLIENTS PROMOTES THE INTERESTS OF A VULNERABLE POPULATION. DEFENSIVE DRIVING CLASSES PREVENT INJURY FROM CAR ACCIDENTS. PART III, LINE 4: PART III, LINE 4 - COSTING METHODOLOGY:BAD 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 UNCOLLECTIBLE 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 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 UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE MEDICAL CENTER FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT 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 MERCY MEDICAL CENTER PROVIDES ACCESS TO MEDICALLY NECESSARY CARE FOR EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF AGE, GENDER, GEOGRAPHIC LOCATION, OR CULTURAL BACKGROUND. MERCY 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, MERCY IS PROVIDING HEALTH CARE TO THE BROAD COMMUNITY IT SERVES. A PATIENT'S 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 9BTHE 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 INABILITY 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 PRIORTO TURNING AN ACCOUNT OVER TO A THIRD-PARTY COLLECTION AGENT AND PRIOR TOINSTITUTING ANY LEGAL ACTION FOR NON-PAYMENT, TO ASSURE THAT THE PATIENTAND PATIENT GUARANTOR ARE NOT ELIGIBLE FOR ANY ASSISTANCE PROGRAM (I.E.MEDICAID) AND DO NOT QUALIFY FOR COVERAGE THROUGH THE CHS CHARITY CAREPOLICY. AFTER HAVING BEEN TURNED OVER TO A THIRD-PARTY COLLECTION AGENT,ANY ACCOUNT THAT SUBSEQUENTLY IS DETERMINED TO MEET THE CHARITY CARECRITERIA SHALL BE RETURNED IMMEDIATELY BY THE THIRD-PARTY COLLECTION AGENTFOR APPROPRIATE FOLLOW-UP.THE THIRD-PARTY COLLECTION AGENT SHALL ADVISE THE PATIENT/GUARANTOR OF THEHOSPITAL'S CHARITY CARE POLICY AND RETURN THE ACCOUNT IMMEDIATELY IF IT IS DETERMINED THAT THE QUALIFICATIONS ARE MET. PART III, LINE 8: - COSTING METHODOLOGY: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.PART III, LINE 8 -MEDICARE SHORTFALL AS COMMUNITY BENEFIT:LOSSES ON TREATING MEDICARE BENEFICIARIES SHOULD BE INCLUDED AS A COMMUNITYBENEFIT IN THEIR ENTIRETY. MERCY INCURRED A LOSS OF APPROXIMATELY $444 THOUSAND TO DELIVER CARE TO MEDICARE PATIENTS. THIS REPRESENTS THE AMOUNT BY WHICH COSTS TO DELIVER CARE TO MEDICARE RECIPIENTS EXCEEDS THE LEVEL OF PAYMENT. MERCY BEARS THE BURDEN OF NOT ONLY PROVIDING THE BEST AND MOST ADVANCED MEDICAL CAREPOSSIBLE TO THE COMMUNITY, BUT ALSO DOING SO WITH NO RECOURSE TO OBTAINPAYMENT FOR THE COST OF PROVIDING CARE IN EXCESS OF THE MEDICARE PAYMENT.AS MEDICARE REVENUE DECLINES AND THE COST TO PROVIDE CUTTING EDGE CARE TOTHE 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 MERCY WILL CONTINUE TO BEAR THE LOSS IN PROVIDING THE BEST CARE POSSIBLE TO THE LOCAL COMMUNITY. PART VI, LINE 2: NEEDS ASSESSMENT:MERCY MEDICAL CENTER WORKS WITH MANY OUTSIDE PARTICIPANTS IN THE COMMUNITY IN ONGOING IDENTIFICATION OF COMMUNITY HEALTH NEEDS, INCLUDING NEIGHBORING SCHOOLS, PARISHES, BUSINESSES, COMMUNITY CENTERS, AND LOCAL CHAPTERS OF ORGANIZATIONS. MERCY STRIVES TO REACH INDIVIDUALS OF ALL AGES AND BACKGROUNDS TO PROVIDE QUALITY CARE AND HEALTH EDUCATION. THE HEALTHY SUNDAYS PROGRAM, WHICH PROVIDES FREE MEDICAL SCREENINGS ANDEDUCATION TO THE UNDERSERVED FOLLOWING WORSHIP SERVICES ON A BIMONTHLYBASIS SERVES AS A PRIMARY SOURCE OF PUBLIC PARTICIPATION AS COMMUNITY NEEDS SURVEYS (AVAILABLE IN ENGLISH AND SPANISH) ARE OFTEN DISTRIBUTED AT THESE SCREENING SITES. THUS EVERY POINT OF CONTACT DOUBLES AS AN OPPORTUNITY TO REQUEST FEEDBACK ON HOW THE HOSPITAL CAN BETTER MEET THE NEEDS OF THE COMMUNITY. 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.OVER THE YEAR, MERCY HAS WORKED WITH MANY ORGANIZATIONS TO DEVELOP HEALTH CARE PROGRAMS FOR RESIDENTS IN THE AREA: AMERICAN CANCER ASSOCIATION, AMERICAN HEART ASSOCIATION, CATHOLIC CHARITIES; DOWNSTATE NEW YORK HEALTHY START PROGRAM; ECONOMIC OPPORTUNITY CENTER; NASSAU COUNTY DEPARTMENT OF DRUG & ALCOHOL; NASSAU COUNTY DEPARTMENT OF MENTAL HEALTH; ROCKVILLE CENTRE CHAMBER OF COMMERCE, ROCKVILLE CENTRE LIONS CLUB AND DIOCESE OF ROCKVILLE CENTRE.IN SELECTING THE PREVENTION AGENDA PRIORITIES, MERCY MET IN THE PAST WITH OTHER HEALTHCARE PROVIDERS TO SELECT 2 PRIORITIES TO WORK ON TOGETHER FOR A JOINT COUNTY WIDE EFFORT. THESE OTHER PROVIDERS INCLUDED THE NASSAU COUNTY DEPARTMENT OF HEALTH, AND MANY NASSAU COUNTY HOSPITALS (LONG BEACH MEDICAL CENTER, NORTH SHORE LONG ISLAND JEWISH HEALTH CENTER, SOUTH NASSAU COMMUNITIES HOSPITAL, ST. FRANCIS HOSPITAL AND WINTHROP UNIVERSITY HOSPITAL). THE PRIORITIES SELECTED WERE PREVENTION OF INTENTIONAL INJURY FROM FALL RELATED HOSPITALIZATIONS AGE 65+ (FALLS PREVENTION) AND TOBACCO USE IN ADOLESCENT AND ADULTS (SMOKING CESSATION). MERCY CONTINUED TO WORK WITH SOME OF THE ORIGINAL HOSPITAL PARTNERS AND THE CENTER FOR TOBACCO CONTROL AND THE TOBACCO ACTION COALITION OF LONG ISLAND ON THE SMOKING CESSATION INITIATIVE, AND THE TOWN OF HEMPSTEAD DEPARTMENT OF SENIOR ENRICHMENT AND THE NASSAU COUNTY DEPARTMENT OF SENIOR AFFAIRS ON THE FALLS INITIATIVE. IN 2011 MERCY ADDED ANOTHER PREVENTION AGENDA PRIORITY , CHRONIC DISEASES SUCH AS DIABETES. IN WORKING WITH THE AMERICAN DIABETES ASSOCIATION, AMERICAN ASSOCIATION OF DIABETES EDUCATORS, HOSPITAL MEDICAL STAFF, AND CHS HOSPITALS, MERCY HOPES TO REDUCE INPATIENT HOSPITALIZATIONS BY PROMOTING DIABETES AWARENESS AND EDUCATION THROUGH COMMUNITY LECTURES, SUPPORT GROUPS AND SELF MANAGEMENT CLASSES.COMMUNITY HEALTH NEEDS ARE DISCUSSED AND ASSESSED ON A CONTINUAL BASIS AMONG THE HOSPITAL BOARD OF TRUSTEES, THE MISSION AND MINISTRY COMMITTEE AND THE PLANNING COMMITTEE OF THE BOARD, MERCY SENIOR LEADERSHIP, AND VARIOUS COMMITTEES WITHIN THE HOSPITAL SUCH AS THE COMMUNITY OUTREACH COMMITTEE AND THE CANCER COMMITTEE WHICH HAVE MULTI DISCIPLINARY REPRESENTATION OF HOSPITAL STAFF. OVER THE YEAR, MERCY CONTINUALLY SOLICITED INPUT FROM OUR AUXILIARY ORGANIZATIONS AT THE HOSPITAL - THE FRIENDS OF MERCY MEDICAL CENTER AND THE COUNCIL OF LEAGUES, REPRESENTING OVER 2000 VOICES. COMMUNITY HEALTH NEEDS ARE ALSO ASSESSED BY THE ADMINISTRATIVE STAFF AND BOARD OF TRUSTEES OF OUR PARENT CORPORATION, CATHOLIC HEALTH SERVICES OF LONG ISLAND (CHS). MERCY DISTRIBUTES A COMMUNITY NEEDS SURVEY AT ITS OUTREACH PROGRAMS. THROUGH PATIENT SATISFACTION SURVEYS, INPATIENTS AND EMERGENCY DEPARTMENT PATIENTS HAVE THE OPPORTUNITY TO MAKE COMMENTS ABOUT THEIR ONGOING AND FUTURE HEALTH CARE NEEDS. THROUGH A JOINT COMMUNITY NEEDS ASSESSMENT BY MERCY ADMINISTRATION, THE PASTORAL CARE DEPARTMENT, CHS OUTREACH COORDINATOR AND THE PARISH COMMUNITY, MERCY IS ABLE TO IDENTIFY THOSE POPULATIONS AT GREATEST RISK AND PROVIDE APPROPRIATE SERVICES (HEALTHY SUNDAYS WAS A RESULT OF THIS ASSESSMENT). PART VI, LINE 3: COMMUNICATION OF FINANCIAL ASSISTANCE 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 ARE ABLE TO DIRECT QUESTIONS TO THE APPROPRIATE HOSPITAL REPRESENTATIVES. THE HOSPITAL POSTS MULTILINGUAL NOTICES AS TO ANY POLICIES ON CHARITY CAREIN SEVERAL PROMINENT LOCATIONS WITHIN THE HOSPITAL INCLUDING, BUT NOTLIMITED TO, THE EMERGENCY DEPARTMENT, BILLING OFFICE, WAITING ROOMS FORPURPOSES OF ADMISSIONS, AND THE INPATIENT AND OUTPATIENT REGISTRATIONAREA. SAID NOTICES ARE PUBLISHED IN AT LEAST ENGLISH AND SPANISH, AND ARECLEARLY VISIBLE TO THE PUBLIC FROM THE LOCATION AT WHICH THEY ARE POSTED.THE HOSPITAL PROVIDES PATIENTS, IN A TIMELY MANNER, A SUMMARY OF ITSCHARITY CARE POLICY UPON REQUEST. THE SUMMARY, AT A MINIMUM PROVIDESSPECIFIC INFORMATION AS TO INCOME LEVELS USED TO DETERMINE ELIGIBILITY ANDTHE MEANS OF APPLYING FOR ASSISTANCE. THIS SUMMARY IS WRITTEN AT OR BELOWA SIXTH GRADE READING LEVEL.THE HOSPITAL POSTS ITS CHARITY CARE POLICY SUMMARY ON ITS INTERNETWEBSITE.THE HOSPITAL PROVIDES ALL PATIENTS INTERPRETERS TO ASSIST THEM INUNDERSTANDING ITS CHARITY CARE PROGRAM IN THE LANGUAGE SPOKEN BY THEPATIENT DURING ANY PRE-ADMISSION, ADMISSION, AND DISCHARGE PROCESS.ON ALL BILLS AND STATEMENTS SENT TO PATIENTS, A STATEMENT IS INCLUDEDREGARDING THE AVAILABILITY OF VARIOUS FINANCIAL ASSISTANCE PROGRAMS,INCLUDING CHARITY CARE, AND A CONTACT NUMBER TO CALL TO OBTAIN FURTHERINFORMATION. THIS INFORMATION IS AVAILABLE AT OR BELOW A SIXTH GRADEREADING LEVEL. PART VI, LINE 4: COMMUNITY INFORMATION:MMC'S PRIMARY SERVICE AREA CONTINUES TO INCLUDE HEMPSTEAD, ROCKVILLE CENTRE, WEST HEMPSTEAD, LYNBROOK, FREEPORT, BELLMORE/NORTH BELLMORE, MERRICK/NORTH MERRICK, VALLEY STREAM, ELMONT, UNIONDALE, ROOSEVELT, BALDWIN AND EAST MEADOW, A TOTAL POPULATION OF APPROXIMATELY 450,000. ACCORDING TO INTERNAL DATA, OVER 30% OF MMC'S TOTAL INPATIENT DISCHARGES IN 2011 CAME FROM HEMPSTEAD, UNIONDALE, FREEPORT, AND ROOSEVELT. THE NASSAU COUNTY DEPARTMENT OF HEALTH HAS REFERRED TO THESE TOWNS AS "COMMUNITIES AT RISK", WITH MANY RESIDENTS LIVING IN POVERTY AND HAVING POOR HEALTH OUTCOMES. ALMOST HALF (49%) OF MERCY'S EMERGENCY ROOM VISITS IN 2011 CAME FROM THESE 4 ZIP CODES. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH:MERCY, IN CONJUNCTION WITH OTHER CATHOLIC HEALTH SERVICES OF LONG ISLAND HOSPITALS, PARTICIPATES IN THE HEALTHY SUNDAYS PROGRAM, A COMMUNITY OUTREACH PROGRAM HELD IN PARISHES DESIGNED TO PROMOTE EDUCATION ON MANY IMPORTANT HEALTH SUBJECTS SUCH AS CANCER AWARENESS, DIABETES, BLOOD PRESSURE, HEALTHY EATING, SMOKING CESSATION AND CHOLESTEROL.MANAGING WEIGHT AND ASSOCIATED HEALTH ISSUES HAS BECOME A FACT OF LIFE AND CHALLENGE FOR MANY AMERICANS. AS A BARIATRIC CENTER OF EXCELLENCE, MERCY MEDICAL CENTER DEVELOPED THREE WEIGHT MANAGEMENT PROGRAMS THAT BEGAN IN 2009. MERCY PROVIDES A FACILITATED SUPPORT GROUP FOR POST BARIATRIC SURGERY PATIENTS, AS WELL AS CONDUCTING TWO FACILITATED WEIGHT MANAGEMENT GROUPS, ONE FOR ADULTS AND THE OTHER FOR ADOLESCENTS.IN 2011 MERCY INCREASED ITS COMMUNITY OUTREACH PROGRAMS FOR FALL PREVENTION AND SMOKING CESSATION. MERCY CONDUCTED PROGRAMS AT SENIOR CENTERS, COMMUNITY HEALTH FAIRS AND LIBRARIES, AS WELL AS WITHIN THE HOSPITAL FOR MANY OF ITS INPATIENTS AND OUTPATIENTS WITH FALL HISTORY OR WHO SMOKE. THROUGH MERCY'S NEW RISK ASSESSMENT FORM, HOSPITAL EMPLOYEES EDUCATED INPATIENTS ON RISK FACTORS AND WAYS TO AVOID FUTURE FALLS. NURSING CONTINUES TO REVIEW POTENTIAL CHANGES IN INPATIENT PROCEDURES TO REDUCE INPATIENT FALLS, SUCH AS RISK ADMISSION ASSESSMENTS, DEVELOPING A FALL PLAN OF CARE, PATIENT AND FAMILY EDUCATION, USING SPECIALTY BEDS WITH EXIT ALARMS, INITIATING SAFETY WATCHES AND OFFERING FREQUENT TOILETING IN ORDER TO AVOID A POTENTIAL FALL, WITH THE GOAL OF ENCOURAGING PATIENTS TO FOLLOW THESE PROCEDURES AT HOME. MERCY BECAME A SMOKE FREE CAMPUS ON MAY 1, 2011 (EXCEPT FOR THE PSYCHIATRIC INPATIENT UNIT WHICH HAS A CLEARLY DEFINED POLICY WHEN ITS PATIENTS MAY TO SMOKE). ALL PATIENTS ARE SCREENED UPON ADMISSION AND THOSE IDENTIFIED AS SMOKERS ARE ENTERED INTO A DATA BASE, SO NURSING STAFF CAN EDUCATE PATIENTS MOST IN NEED. IN 2011 MERCY ADDED SMOKING CESSATION DRUGS TO ITS FORMULARY. MERCY USES PHARMACY MEDICATION RECORDS TO TRACK THE NUMBER OF PATIENTS WITH PRESCRIPTIONS WRITTEN FOR A SMOKING CESSATION MEDICATION. MERCY EMPLOYEES OFFER SMOKING CESSATION INFORMATION, REFERRALS TO SMOKING CESSATION PROGRAMS AND NY-QUIT LINE CARDS AT ALL COMMUNITY OUTREACH EVENTS. MERCY ITSELF OFFERS THE GREEN SEMINAR, A MONTHLY SMOKING CESSATION PROGRAM TO PATIENTS AND OTHER COMMUNITY MEMBERS. MERCY OFFERS SMOKING CESSATION PROGRAMS TO EMPLOYEES THROUGH ITS EMPLOYEE ASSISTANCE PROGRAM AND TO PHYSICIANS THROUGH THE CENTER FOR TOBACCO CONTROL. PART VI, LINE 6: AFFILIATED HEALTHCARE SYSTEM:MERCY MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH IS LOCATED ON A SINGLE CAMPUS IN ROCKVILLE CENTRE, NEW YORK. ALONG WITH THE AFOREMENTIONED COMMUNITY PROGRAMS MERCY, THROUGH ITS DAILY OPERATION, PROVIDES TO THE AREA ACUTE, PSYCHIATRIC, REHABILITATIVE, EMERGENT AND OUTPATIENT CARE. MERCY 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 OF SIENA MEDICAL CENTER IN SUFFOLK COUNTY; AND AS PASSIVE PARENT TO ST. JOSEPH HOSPITAL IN NASSAU COUNTY); THREE NURSING HOMES (ST. CATHERINE OF SIENA 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 17,000 STAFF AND 3,800 MEDICAL STAFF 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 SERVICE, 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 HISTORY, A DISTINCTIVE PERSONALITY, 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 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 AVE ROCKVILLE CENTRE NY 11571 111837437 233812 TO FURTHER THE MISSION OF THE ROMAN CATHOLIC DIOCESE OF ROCKVILLE CENTRE. PART II, LINE 1, COLUMN (H): NAME OF ORGANIZATION OR GOVERNMENT: DIOCESE OF ROCKVILLE CENTRE - CATHOLIC MINISTRIES APPEAL (H) PURPOSE OF GRANT OR ASSISTANCE: 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. X X X X X 0 1 0 0 0 0 0 0 0 ALAN D GUERCI MD 0 760965 0 345300 0 1151991 0 567098 0 29829 0 2855183 0 0 WILLIAM C ARMSTRONG 0 487907 0 160000 0 952400 0 436336 0 26634 0 2063277 0 776631 NANCY SIMMONS 312446 73203 80000 0 443876 2019 68476 3365 16263 3028 921061 81615 427346 0 AARON GLATT 31129 377980 0 105000 76 15212 0 23201 1994 23716 33199 545109 0 0 JOHN REILLY 347177 0 20000 0 4406 0 16895 0 24935 0 413413 0 0 0 RONALD STEIMEL 300687 0 20000 0 11941 0 16895 0 24790 0 374313 0 0 0 STEPHEN TRAPANI 295932 11923 40000 0 12927 0 38771 0 26617 7 414247 11930 0 0 SWARNA DEVARAJAN MD 324848 0 0 0 934 0 16895 0 27593 0 370270 0 0 0 ALAN WONG MD 394066 0 0 0 224 0 16895 0 25729 0 436914 0 0 0 RENEE MAURIELLO 250629 0 20000 0 11063 0 16895 0 24857 0 323444 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J PART II B(III), OTHER REPORTABLE COMPENSATION INCLUDES A SERP DISTRIBUTION OF $427,346 FOR NANCY SIMMONS AND $776,631 FOR BILL ARMSTRONG, WHICH RELATES TO PRIOR YEAR CONTRIBUTIONS. SCHEDULE J PART II C, RETIREMENT AND DEFERRED COMPENSATION INCLUDES THE 2012 CONTRIBUTIONS TOWARD A SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN. THE CONTRIBUTIONS TO THE PLAN ARE AS FOLLOWS: NANCY SIMMONS = $54,427 STEPHEN TRAPANI = $21,876 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 MERCY 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 (DIOCESE). FORM 990, PART VI, SECTION A, LINE 7A CHS IS THE SOLE MEMBER AND ESTABLISHED CO-OPERATOR OF MERCY MEDICAL CENTER AND AS SUCH, HAS THE RIGHT TO APPOINT THE GOVERNING BODY OF MERCY MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7B CHS AS THE SOLE MEMBER AND ESTABLISHED CO-OPERATOR OF MERCY MEDICAL CENTER IS REQUIRED TO APPROVE CERTAIN DECISIONS MADE BY MERCY'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 IF 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 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. 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. PART VII, SECTION A, LINE 1A: ALAN GUERCI, M.D. PRESIDENT AND CEO - THE TOTAL HOURS WORKED REPORTED (50.0) REFLECTS TIME WORKED AS OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: ST. FRANCIS HOSPITAL (11-2050523); ST. FRANCIS HOSPITAL FOUNDATION (11-2916033); ST. FRANCIS RESEARCH AND EDUCATIONAL CORPORATION INC. (11-3090867); MERCY MEDICAL CENTER (11-1635088). WILLIAM ARMSTRONG, SENIOR VICE PRESIDENT AND CFO - THE TOTAL HOURS WORKED REPORTED (50.0) REFLECTS TIME WORKED AS OFFICER FOR ALL OF THE FOLLOWING RELATED ENTITIES: ST. FRANCIS HOSPITAL (11-2050523); ST. FRANCIS HOSPITAL FOUNDATION (11-2916033); ST. FRANCIS RESEARCH AND EDUCATIONAL CORPORATION INC. (11-3090867); MERCY MEDICAL CENTER (11-1635088) CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 4,962. MIMS PC CHANGE IN UNRESTRICTED NET ASSETS -40,264. POSTRETIREMENT BENEFIT PLAN CHANGES OTHER THAN NET PERIODIC BENEFIT COST -121,000. LOSS ON EXTINGUISHMENT OF DEBT -591,961. TOTAL TO FORM 990, PART XI, LINE 5: -748,263. 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 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 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 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 CATHERINE OF SIENA MEDICAL CENTER 50 ROUTE 25A SMITHTOWN NY 11787 061562701 HOSPITAL NY 501(C)(3) LINE 3 CATHOLIC HEALTH SYSTEM OF LONG ISLAND 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 11A, I 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 ADVANCED REHABILIATION MEDICINE PLLC 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 113640709 HEALTHCARE SERVICES NY ST CHARLES HOSPITAL C CARDIAC EKG INTERPRETATION PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112924518 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C FAIRVIEW HILL MANAGEMENT CO INC 200 BELLE TERRE ROAD PORT JEFFERSON NY 11777 112798383 SERVICES NY ST CHARLES CORPORATION C LI REGIONAL ARTHRITIS & OSTEOPOROSIS CARE PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208964140 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 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 MANAGEMENT SERVICES INC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 112838185 HEALTHCARE SERVICES NY CATHOLIC HEALTH SYSTEM OF LONG ISLAND C SAMARITAN MEDICAL SERVICES PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 208088453 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 SOUTH SHORE PRACTICE MANAGEMENT 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 113307977 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C SOUTHWEST SUFFOLK MEDICAL PC 1000 MONTAUK HIGHWAY WEST ISLIP NY 11795 061603195 HEALTHCARE SERVICES NY GOOD SAMARITAN HOSPITAL C ST FRANCIS CARDIAC PREVENTION SERVICES PC 100 PORT WASHINGTON BLVD ROSLYN NY 11576 113224885 HEALTHCARE SERVICES NY ST FRANCIS HOSPITAL C 0 0 1 0 0 0 0 0 1 0 0 1 0 1 1 1 0 0 CATHOLIC HEALTH SERVICES OF LONG ISLAND P -581022 COST CHS SERVICES INC P 1263958 COST MARYHAVEN CENTER OF HOPE P 474654 COST GOOD SAMARITAN HOSPITAL MEDICAL CENTER P 81947 COST PART V, TRANSACTIONS WITH RELATED PARTIES MERCY MEDICAL CENTER HAS DISCLOSED IN SCHEDULE R THE PREDOMINANT TRANSACTION TYPE WITH EACH FACILITY WITH WHICH IT HAS CONDUCTED TRANSACTIONS. HOWEVER, THERE ARE ADDITIONAL TRANSACTION TYPES TO DESCRIBE THE ACTIVITIES CHS HAS ENGAGED IN WITH ITS RELATED PARTY ORGANIZATIONS. THE FOLLOWING IS A LIST OF ADDITIONAL TRANSACTION TYPES BY FACILITY. NAME OF ADDITIONAL ORGANIZATION EIN TRANSACTION TYPES CATHOLOIC HEALTH SYSTEM OF LI 11-3403968 P CHS SERVICES, INC. 11-3555766 L,J,N,O MARYHAVEN CENTER OF HOPE 11-2861698 N,O GOOD SAMARITAN HOSPITAL MEDICAL CENTER 11-1888924 N,O